Every finding on record at Provo Rehabilitation and Nursing

Based on interview and record review, it was determined that the facility failed to provide respiratory care and tracheostomy care to residents who required these services. Specifically, for 3 out of 9 sampled residents, staff did not follow physician orders for changing tracheostomies; staff were not obtaining needed consultations with outside providers; staff were not accurately documenting the resident condition prior to the tracheostomy change; staff did not initiate a hospital transfer for a resident with concerns about the integrity of the tracheostomy. Additionally, staff interviews revealed knowledge of faulty equipment with a resident experiencing a broken flange which caused a dislodged tracheostomy, and subsequently going into cardiac arrest and dying. Finally, a resident found to have his BiPap (Bilevel Positive Airway Pressure) displaced was found to be unresponsive and CPR (cardiopulmonary resuscitation) was begun and the resident was unable to be resuscitated and passed away. The findings for residents 1 and 9 were determined to have resulted in immediate jeopardy (IJ). Resident identifiers: 1, 5, and 9. NOTICEOn [DATE], an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to ensure that residents who needed respiratory care, including tracheostomy care, were provided such care consistent with professional standards of practice. This notice was given verbally and in writing to the Administrator, Director of Nursing, and Regional Nurse Consultant regarding residents 1 and 9.On [DATE], the Administrator provided the following written abatement plan for the removal of the Immediate Jeopardy effective on [DATE] at 11:37 AM. [NAME] Rehabilitation & Nursing 3.11.2026Abatement Plan/Plan of Removal: Tag F6951. Immediate Corrective ActionsAudit of All Tracheostomy Supplies: A facility-wide sweep was conducted to identify and sequester any tracheostomy tubes from the faulty batch ([DATE]-Present) mentioned in staff interviews. All XLT [Extended Length] and Shiley supplies were audited and verified to be intact and safe for use.Validation of Physician Orders: A 100% audit of all residents with tracheostomies and BiPap/Ventilator needs was completed to ensure current physician orders match the Electronic Medication Administration Record (EMAR) and Respiratory Therapy (RT) flowsheets. Increased monitoring orders from Q [every]-shift to every 2 hours for residents with CPAP (Continuous Positive Airway Pressure)/BiPap to ensure appropriate placement and functioning added to MAR [Medication Administration Record].ENT [Ears, Nose,Throat] /Specialist Review: Any resident identified with High Risk; airway status (e.g.,tracheal stenosis) will be flagged on the EMAR and at the bedside with a Do Not Change Trach - ENT/Provider Only alert as indicated. Review conducted of any outstanding ENT referrals and scheduled as indicated.2. Staff Education (Competency and Communication)All Respiratory Therapists and Licensed Nurses must complete mandatory training before their next scheduled shift.Key Education Topics:Emergency Airway Management: Re-training on the Difficult Airway protocol, specifically when to cease attempts at reinsertion and initiate emergency transfer to a higher level of care (Hospital/ER [Emergency Room]).Tracheostomy Change Protocol: Education on documentation requirements prior to a change (baseline vitals, stoma integrity, and clinical justification).Equipment Failure Reporting: A new Equipment Variance form and protocol for immediate reporting of faulty flanges or defective supplies to the RT Director, Director of Nursing (DON) and Administrator.CPAP/BiPap/Oxygen Use/Monitoring: Education on CPAP, BiPap, and Oxygen use, monitoring of placement and functioning, and who and when to report faulty/broken equipment to. Education on increased monitoring, particularly for those with behaviors of pulling masks/lines off.Department Head Education:Insurance/Access Advocacy: Education for the Transportation Driver and Business Office on the facility's obligation to pay for necessary outside consultations (like ENT) regardless of Medicaid-pending status to prevent delays in care. (Department Head Team)Ad-Hoc QAP [Quality Assurance Performance Improvement]I: Review conducted of F695 findings and abatement/immediate corrective action plan.4. Systemic ChangesInvestigation Protocol: Any death involving a resident with a tracheostomy or ventilator will now trigger a formal internal investigation for each incident and mandatory reporting to the State Survey Agency, if abuse or negligence is suspected.High Risk Alert Notification: Whiteboard will no longer be utilized for High Risk alerts, formal Critical Care Alert, will populate via the Care Profile at the top of every RT and Nursing EMR as indicated for individual residents.Tracheostomy/Ventilator Equipment Audits: Monthly Equipment Audits will be conducted, along with every shift monitoring of equipment per the Respiratory Therapy EMR.Monitoring for residents with Respiratory Care: Increased monitoring orders from every shift to every 2 hours for residents with CPAP/BiPap to ensure appropriate placement and functioning added to MAR. Residents with Ventilator/Tracheostomy orders to have an assessment every shift conducted by Respiratory Staff that will be entered into the resident chart. In addition ventilator check and tracheostomy placement orders increased for monitoring every 4 hours.Date of alleged compliance: 3.11.2026 11:37am.The facility alleged abatement of the Immediate Jeopardy as of [DATE] at 11:37 AM On [DATE] at 4:13 PM, while completing the complaint survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on [DATE] at 11:37 AM.Findings included: IMMEDIATE JEOPARDY 1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. Resident 1's medical records were reviewed. Resident 1's physician orders revealed the following: a. Change Tracheostomy tube Q 45 days and PRN [as needed] every day shift every 30 day(s). The order was initiated on [DATE] and discontinued on [DATE]. The same order was initiated again on [DATE] and discontinued on [DATE]. The Medication Administration Record documented that the tracheostomy was changed on [DATE], [DATE], [DATE], and [DATE]. It should be noted that there was no order to change the tracheostomy tube after [DATE]. b. On [DATE], an order was initiated for an ENT referral related to stenosis and tracheostomy status. On [DATE], resident 1's hospital History & Physical [H & P] documented, . she had exchange of tracheostomy to Shiley by ENT due to hemoptysis. She went into respiratory arrest that night and was found to have a dislodged trach. She has some anoxic brain injury secondary to the episode where she had a PEA [Pulseless Electrical Activity] cardiac arrest Trach was changed by ENT in OR [operating room] on [DATE]. Given significant subglottic stenosis/proximal tracheal stenosis ENT recommends against trialing PMV [Passy Muir Valves]. They recommend changing trach every 3 months instead of monthly. On [DATE], resident 1's hospital H & P documented, 51 yo [year old] female admitted post out of hospital cardiac arrest at [name of nursing facility omitted]. She is s/p [status post] anoxic brain injury and is essentially in a vegetative state. She is trached and pegged. She was found unresponsive with dislodgement of her trach. 35 minutes of cpr was performed by EMS [Emergency Medical Services] when they found her in PEA. On [DATE] at 10:38 AM, the Nurse Practitioner note documented continued trach care per Respiratory Therapy protocol. F/u [follow-up] ENT for subglottic and tracheal stenosis. On [DATE] at 7:00 AM, the RT documentation revealed that the resident was alert and oriented x [times] 3 to person, place and person. The type of tracheostomy was an XLT that was cuffed and non-fenestrated. The tube size was 7 millimeters. Stoma site had redness noted. The report documented that the cuff pressure was checked, inner cannula was changed and trach tie was changed. The ventilator type was documented as VOCSN and the mode of delivery was assisted control (AC) and pressure control (PC). The ventilator settings were set for a respiratory rate of 24 and was observed at that rate. The report documented that the respiratory pattern was regular and unlabored on the ventilator. Breath sounds were rhonchi, cough effort was strong, and yellow blood tinged secretions were present. Secretions were thick in moderate amount. Resident 1's oxygen saturations were 95%. Pt [patient] `rest in bed on vent @4L [liters]. HOB [Head of Bed] elevated. Trach is midline, secure and patent. Trach and oral care provided. Tx [treatment] given and tolerated well. No s/s [signs and symptoms] of resp. [respiratory] distress noted. Will continue to monitor. On [DATE] at 11:00 AM, the RT note documented, Pt] rest in bed on vent @ACPC [Assist Control Pressure Control] 4L. HOB elevated. Trach is midline, secure and patent. BS [breath sounds] coarse. Sx [suctioned] x3 for moderate amount of yellow thick secretions. No s/s of resp. distress noted at this time. Will continue to monitor. The note documented that resident 1's heart rate was 80 beats per minute, respiratory rate was 24 and oxygen saturation was at 100%. On [DATE] at 1:55 PM, the RT note documented, RT performed trach [tracheostomy] changed as pt mentioned trach is too tight this morning. Pt was placed on 6L O2 [oxygen] for pre-oxygenated. SpO2 [oxygen saturation] 97%, HR [heart rate] 98. During removal and reinsertion of trach tube, resistance was encounter (sic) and insertion was unsuccessful. a smaller size trach tube was attempted, still unsuccessful to insertion. Pt developed acute resp. distress with pallor and cyanosis noted. Code blue was activated immediately. [Note: This note was entered by Respiratory Therapist (RT) 1.] On [DATE] at 2:32 PM, the nursing note documented Per RT report, at approximately at 1355 [1:55 PM] a scheduled tracheostomy tube change was initiated. RT [respiratory therapist 1] and RT [respiratory therapist 2] reported that during removal and attempted reinsertion of the tracheostomy tube, resistance was encountered when advancing the new trach. A second tracheostomy kit was opened and insertion was reattempted. Resistance was again met and placement was unsuccessful. RT reported the resident then exhibited signs of respiratory distress with decreasing oxygen saturation and cyanosis. A Code Blue was initiated immediately, and manual ventilation was initiated via bag-valve device. At approximately 1400 [2:00 PM], I heard the Code Blue call and responded immediately to the room. Upon arrival, both RTs were present and providing ventilatory support via bag-valve mask. Resident was observed to be unresponsive, apneic, cyanotic, and without palpable pulse. Resident was lowered to the floor with assistance for initiation of CPR per facility protocol. Chest compressions were initiated immediately. Staff were directed to: Activate EMS (911), retrieve crash cart, obtain AED [Automated External Difibrillator], and notify RT supervisor [name omitted]. AED was applied and rhythm analyzed three times. No shock was advised. Continuous CPR was performed per protocol. EMS arrived during the third AED rhythm analysis and assumed care upon arrival. Resuscitative efforts were continued by EMS. Time of death was pronounced at 1425 [2:25 PM] by EMS. Attending physician was notified. Facility administration was notified per protocol. Family was called multiple times following the event. Calls were directed to voicemail on each attempt. Messages were left requesting immediate return call. Post-mortem care was completed per facility policy. On [DATE] at 3:13 PM, a note authored by the Transportation Driver (TD) documented, Received an order on [DATE] for Resident to go to ENT R/T [related to] Stenosis and tracheostomy status. Sent the order to Ent on [DATE] was told by Ent that resident didn't have insurance and that it would be self-pay. Tried calling family on multiple occasions with no answer or call back and with not being able to confirm if family can help self-pay the clinic would not schedule. It should be noted that this note was authored 5 days after resident 1 died and 3 months after the order for the ENT referral was initiated. On [DATE] at 1:24 PM, an interview was conducted with Respiratory Therapist (RT) 1. RT 1 stated that she had become an RT in [DATE]. RT 1 stated that the policy for changing the tracheostomy was to change it if it was dislodged or coming out or if the resident was complaining. RT 1 stated that she would only change the tracheostomy if it was coming out, otherwise it was the Medical Doctor (MD) that changed the tracheostomy. RT 1 stated that the inner cannula was changed daily and if a resident was complaining that the trach was too tight she would change the entire tracheostomy out, not just the inner cannula. RT 1 stated that during the morning [[DATE]] resident 1 was complaining that the tracheostomy was too tight and RT 1 visualized that the trach was coming out. RT 1 stated that the tracheostomy was dislodged approximately 1.5 inches from the stoma. RT 1 stated that resident 1's vital signs were good and she was not in any respiratory distress. RT 1 stated that she pushed the tracheostomy back in and resident 1 continued to report that it felt tight. RT 1 stated that resident 1's complaints of the tracheostomy being too tight could indicate that it was dirty inside and needed to be changed immediately. RT 1 stated that prior to attempting to change resident 1's tracheostomy the current tracheostomy was secure, patent and midline. RT 1 stated that when she attempted to place the new tracheostomy she met resistance. RT 1 stated that she then attempted to insert a smaller size tracheostomy and also met resistance. RT 1 stated that she was being assisted by RT 2 during the tracheostomy replacement. RT 1 stated that resident 1 had stenosis and a smaller airway and she also thought resident 1 had tracheal edema. RT 1 stated that during the attempted tracheostomy change resident 1's oxygenation dropped to 75% and a code blue was called. RT 1 stated that resident 1's oxygenation dropped to 60% and the resident was turning purple at that time. RT 1 stated that while RT 2 was mechanically ventilating resident 1, RT 1 left the room to get assistance from the RT Director, which took approximately 10 seconds. Resident 1 subsequently went into cardiac arrest and was pronounced dead by EMS. On [DATE] at 2:10 PM, an interview was conducted with RT 3. RT 3 stated that resident 1 had complications of tracheal stenosis, and they were not to change her tracheostomy until she was seen by the ENT. RT 3 stated that if the trach was coming out he would readjust it. RT 3 stated that resident 1 needed to go to the ENT to determine if she needed to have the trach changed on a regular basis. RT 3 stated that they had orders to not change her trach until she was seen by the ENT. RT 3 stated that resident 1 frequently complained of tightness in her tracheostomy and he would assess the trach tie to ensure it was not too tight and then provide resident 1 with education on safety reasons for why they could not loosen the trach ties. RT 3 stated that he was told after resident 1's death that resident 1 complained of the trach being too tight and that RT 1 thought it needed to be changed. RT 3 stated that RT 1 attempted the trach change, was unsuccessful, and they lost the airway. RT 3 stated that he recalled seeing resident 1's name on the whiteboard in the manager's office with a note that stated ENT only. RT 3 stated that if the tracheostomy was patent, midline, and secure he would not change an ENT only trach. On [DATE] at 2:55 PM, a telephone interview was conducted with RT 2. RT 2 stated that he had been an RT since [DATE]. RT 2 stated that resident 1 was not supposed to have her trach changed but he was not informed of this until after the resident's death. RT 2 stated that he was not sure why the trach needed to be changed. RT 2 stated that he did not visualize resident 1's trach coming out or dislodgement prior to the attempted change. RT 2 stated that after resident 1's death he heard through one of his coworkers that the physician was supposed to change the tracheostomy, but they had orders to do it for the patient one time a month. It should be noted that those orders had expired on [DATE] and resident 1 did not have an active order for a tracheostomy change at the time of her death. RT 2 stated that he had never changed a vented patient's tracheostomy prior to resident 1's. RT 2 stated that after resident 1's death RT 1 had stated that resident 1 wanted the tracheostomy changed and that was what prompted the tracheostomy change. On [DATE] at 12:02 PM, an interview was conducted with the RT Director. The RT Director stated that she started at the facility on [DATE]. The RT Director stated that they had a standing order to change a tracheostomy every 30 days unless otherwise specified. The RT Director stated that in the beginning of February 2026 she received a Verbal Order (VO) from the provider that resident 1 should have their tracheostomy changed only by an ENT provider unless it was an emergent situation. The RT Director stated that this order was not in resident 1's chart. The RT Director stated she communicated the VO with the staff and it was also documented on the whiteboard in her office and said trach change was on hold until otherwise notified. The RT Director stated that RT 1 went in and resident 1's tracheostomy was dislodged and starting to come out. RT 1 deflated the cuff and pushed it back in. The RT Director stated that resident 1 was not in any distress, was oxygenating well, the tracheostomy was midline, and patent. The RT Director stated that the RTs could have sent resident 1 to the hospital for a tracheostomy change. The RT Director stated that she provided education to the RTs that they should work with nursing and were able to transfer the resident out if they were concerned about the integrity of the trach. The RT Director stated that she educated the staff about the accuracy of their documentation when she realized that the notes did not contain any details of resident 1's trach being dislodged. The RT Director stated that she was not informed that resident 1 was having issues with her tracheostomy until she was in cardiac arrest. On [DATE] at 3:17 PM, an interview was conducted with the DON. The DON stated that she had seen a provider note in resident 1's chart that indicated that the tracheostomy should be changed every 3 months. The DON stated that the order was never put into resident 1's medical records. The DON stated that resident 1's prior tracheostomy order to change every 45 days was initiated by the prior RT Director, and then the contracted respiratory company did an audit and changed the order to every 30 days as the new standard protocol. The DON stated that the tracheostomy order dropped off the Medication Administration Record in January and resident 1 had no order to change the tracheostomy after that. The DON stated that the admission process was for the RT Director to manage any respiratory orders and treatments and the licensed nurse would handle all other medication and treatment orders. The DON stated that the contracted respiratory company was responsible for the maintenance and upkeep of all ventilator equipment. The DON stated that the previous communication of respiratory equipment issues was through the RT Director but that was not always communicated to the DON and Administrator clearly. The DON stated that moving forward she expected the RT Director to communicate any concerns with equipment to her. The facility policy on Tracheostomy Tube Changes documented that tracheostomy tubes should be changed per doctor's orders or every 30 days to prevent the risk of tracheal stenosis. As included are emergency changes (i.e. damaged tubes, tubes that are not patent). The policy documented under Replacement of Trach Tube that If airflow is inadequate, or tube cannot be placed properly remove tube, provide ventilation* if necessary and attempt to reinsert tube. If still unable to pass a tube manually ventilate and call 911 or emergency services. The procedure further documented that if you were unable to reinsert a tube Attempt to insert a tube of smaller size, usually the next size down. If the patient's stoma suddenly closes, attempt to pass a suction catheter or tracheal tube exchanger through the stoma to thread the tracheostomy tube. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. A review of resident 9's medical record revealed the following notes: a. On [DATE] at 11:00 PM, a late entry respiratory therapy note documented, At approximately 2100 [9:00 PM] hours, I entered the patient's room to conduct my first rounds. Upon examination, I observed that the tracheostomy tube was broken and dislodged from the tracheostomy flange, with the tube approximately 1.5 inches out of position. Immediate replacement of the trach tube was necessary, as the tube was not in midline and was shifted to the right. I promptly notified the nurse to witness the situation and called for a second respiratory therapist to assist with the trach tube change.A Shiley XLT 6 and a Shiley XLT 5 were available at the bedside for use. The patient had a Shiley XLT 6 in place. After removing the old tube, I inserted the new tube, which had been tested and lubricated. During suctioning, a significant amount of bloodwas [sic] observed. A second and third pass were performed to address further blood accumulation. The SpO2 alarm signaled low oxygen saturation, prompting disconnection from the ventilator to manually bag the patient. Despite these efforts, the SpO2 levels did not improve. Two additional nurses were called in to assist as a pulse check was performed, which revealed no pulse. The patient was subsequently transferred to the floor. A Shiley XLT 5 was then placed to see if it would enhance oxygenation while continuing manual bagging, with no resistance encountered during ventilation. SpO2 did not improve; chest compressions were going on while manual ventilation continued until EMS [Emergency Medical Services] came and took over the situation. b. On [DATE] at 12:19 AM, a late entry nursing note documented, I was called into resident room by RT. RT showed residents tach [sic] was broken and needed to be replaced. Another Rt was called into room to assist with trach change, residents 02 and other V/S [vital signs] were stable at this time. RT's alerted nurse that resident was having copious amounts of bleeding while new trach was being changed out. Residents became unstable at this time and code blue was initiated, other staff arrived to assist and 911 was immediately called. [NAME] [sic] arrived and worked on resident however was unableto [sic] be revived, and time of death was called. Provider DON [Director of Nursing] and family members made away [sic] of death. On [DATE] at 2:11 PM, an interview was conducted with RT 3. RT 3 stated that he had changed out resident 9's trach ties earlier in the day and had not seen a problem with the trach. RT 3 stated that resident 9 could not move and was in a comatose state. RT 3 stated that resident 9 was unable to forcefully cough unless she was being suctioned. RT 3 stated that resident 9 used a XLT trach which twisted to lock. RT 3 stated that if the flange broke then the inner cannula would not lock and it would be loose. RT 3 stated that he asked other RTs if they had any issues with XLT trachs that broke because he was concerned for other residents in the facility that used them and the possibility that they may break. On [DATE] at 12:02 PM, an interview was conducted with the Respiratory Director. The Respiratory Director stated that she had heard that there was a batch of trachs that facilities had problems with the flange breaking. The Respiratory Director stated that she was not the director when resident 9 passed away. The Respiratory Director stated if a flange broke on a trach there was an increased risk that the trach would lose patency. The Respiratory Director stated that there have been two residents in the facility who have had flanges break, but that this was before she was the director. On [DATE] at 12:37 PM, an interview was conducted with the DON. The DON stated that the facility had a contract with an outside respiratory company and had used them for two years. The DON stated that respiratory staff identified that resident 9 had a broken trach and the respiratory staff made the decision to change out the trach when there was some increased bleeding and resident 9 went into cardiac arrest and passed away. The DON stated that she was not sure how the flange broke on the trach. The DON stated that she was unaware of any other residents that have had a flange break on the tracheostomy. On [DATE] at 3:01 PM, an interview was conducted with RT 4. RT 4 stated that on [DATE] he entered resident 9's room around 9:00 PM to perform his first assessment. RT 4 stated that resident 9's trach was broken at the flange and it had been dislodged at a 45 degree angle to the right side of the stoma. RT 4 stated that trachs should be centered and midline and if it was not then a resident could have airway obstruction or bleeding. RT 4 stated that the ventilator was not alarming and he was not sure why it was not alarming as high pressure because every breath was pressurized. RT 4 stated that resident 9's lips appeared to be cyanotic and so he replaced her oxygen sensor to another location on her body and resident 9's oxygen saturation was below 90%. RT 4 stated that he called for another RT and a nurse to come into resident 9's room because he needed to change resident 9's trach so that resident 9 would have a patent airway. RT 4 stated that he changed resident 9's trach and suctioned resident 9's airway. RT 4 stated that upon the first suctioning pass a large amount of frank blood and mucus was suctioned out. RT 4 stated that he went back in and suctioned an additional two times and continued to suction larger amounts of blood. RT 4 stated that resident 9's oxygen was showing as low. RT 4 stated that the nurse checked resident 9's pulse and found her without one. RT 4 stated that resident 9 was lowered to the floor and CPR was begun. RT 4 stated that he continued to suction large amounts of blood out of resident 9's trach. RT 4 stated that he believed that resident 9's airway was filled with blood. RT 4 stated that he notified the interim respiratory manager about the ventilator not alarming and made sure that he checked all of his residents' ventilators to make sure they were working correctly. RT 4 stated he was not sure how the flange broke on resident 9's trach because she was comatose and in a vegetative state and could not move. On [DATE] at 2:36 PM, an interview was conducted with the RT Director, and the RT contract company representative. The RT Director stated that she currently had one XLT left for a patient and it was not part of the back order. The RT Director stated that they had two trach issues with patency issues in December and [DATE], but that neither of those devices were part of a recall. The RT Director stated that they did not do an investigation because there was not a ventilator that was malfunctioning. The RT Director also stated that they looked into the issue with alarms; they were using a nipple adapter that was causing back pressure and that it wasn't alarming for a high pressure alarm. The RT Director additionally stated that was reported to her but she was not here at the time that was implemented. The RT Director stated they took the nipple adapter off the vent and they have not had any issues since, but she was not sure if it was related to this patient. The RT Director stated that the interim manager was called yesterday and the interim manager told her there were no malfunctioning alarms that were reported to her during the time with resident 9's displacement. The RT contract company representative stated that RT 4 had meant that had an alarm been going off it would have likely been a high pressure alarm and that it was not an actual equipment issue. The RT contract company representative stated the issue was that the resident had a broken trach and not an actual equipment problem. The RT contract company representative stated that RT 4 checked on his patients because it was an unusual incident. On [DATE] at 4:23 PM, a follow-up interview was conducted with RT 4. RT 4 stated that when he entered resident 9's room the ventilator was not alarming and the tracheostomy was severely deviated to the side. RT 4 stated that he would determine if a tracheostomy was occluded from the alarm. RT 4 stated the ventilator alarm should have been going off if there was an occlusion and it would have been a pressure alarm. RT 4 stated that resident 9's tracheostomy could have been partially occluded and that may have been why it was not alarming. RT 4 stated that all he could see was from the stoma out and he could not determine if it was occluded. RT 4 stated that the tracheostomy could have been partially occluded and still have adequate air movement and then it would not necessarily alarm. RT 4 stated that resident 9 coughed a lot and with those involuntary movements could have caused the tracheostomy to dislodge, especially with the broken flange. RT 4 stated that his concern was that the tracheostomy was going to come out. RT 4 then stated that he did question why it was not alarming and if it was more than 50% occluded it should have alarmed. RT 4 stated that later he spoke to the interim supervisor about some of the alarms and pulse oximeters that needed to be replaced. RT 4 stated that he was concerned about the alarm cables that were breaking, which would result in the ventilator not alarming to the call system. Additionally, some of the pulse oximeters were not working and they were separated from the supply. RT 4 stated that there was an instance when he needed a functioning pulse oximeter and he did not have one at the facility. RT 4 stated that he told the CNAs that he was taking their vital signs cart to use for a patient's pulse oximeter monitoring. RT 4 stated that he had some situations when he did not have supplies and equipment that was needed to provide care to the residents. RT 4 stated that he repeatedly asked for alarms, pulse oximeters, and cables for the pulse oximeters that did not have in supply to provide care for the resident. RT 4 stated that as soon as the current RT Director took over the supplies were available. RT 4 stated that he attributed the lack of supplies to the previous RT Director. POTENTIAL FOR HARM 3. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, anoxic brain damage, chronic respiratory failure with hypoxia, and acute and chronic respiratory failure with hypercapnia. A review of resident 5's physician orders revealed to check for proper body positioning and nasal cannula placement and BiPAP vent [ventilator] setting with humidity AVAPS [Average Volume Assured Pressure Support] Trilogy settings: VT [Tidal Volume] 550, Max [maximum] P-25 [inspiratory pressure], Max PS-10 [pressure support], Min PS-2,

Based on interview and record review the facility did not ensure that all alleged violations involving injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, if the events resulted in serious bodily injury to the administrator, State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 1 out of 9 sampled residents, the SSA and APS were not notified when a resident's tracheostomy flange broke, resulting in a dislodged tracheostomy tube. The resident subsequently went into cardiac arrest and died. This will be cited at a harm level. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. A review of resident 9's medical record revealed the following notes:a. On [DATE] at 11:00 PM, a late entry respiratory therapy note documented, At approximately 2100 [9:00 PM] hours, I entered the patient's room to conduct my first rounds. Upon examination, I observed that the tracheostomy tube was broken and dislodged from the tracheostomy flange, with the tube approximately 1.5 inches out of position. Immediate replacement of the trach [tracheostomy] tube was necessary, as the tube was not in midline and was shifted to the right. I promptly notified the nurse to witness the situation and called for a second respiratory therapist to assist with the trach tube change. A Shiley XLT [Extended Length Tracheostomy] 6 and a Shiley XLT 5 were available at the bedside for use. The patient had a Shiley XLT 6 in place. After removing the old tube, I inserted the new tube, which had been tested and lubricated. During suctioning, a significant amount of bloodwas [sic] observed. A second and third pass were performed to address further blood accumulation. The SpO2 [oxygen saturation] alarm signaled low oxygen saturation, prompting disconnection from the ventilator to manually bag the patient. Despite these efforts, the SpO2 levels did not improve. Two additional nurses were called in to assist as a pulse check was performed, which revealed no pulse. The patient was subsequently transferred to the floor. A Shiley XLT 5 was then placed to see if it would enhance oxygenation while continuing manual bagging, with no resistance encountered during ventilation. SpO2 did not improve; chest compressions were going on while manual ventilation continued until EMS [Emergency Medical Services] came and took over the situation.b. On [DATE] at 12:19 AM, a late entry nursing note documented, I was called into resident room by RT [Respiratory Therapist]. RT showed residents tach [sic] was broken and needed to be replaced. Another Rt was called into room to assist with trach change, residents 02 [oxygen] and other V/S [vital signs] were stable at this time. RT's alerted nurse that resident was having copious amounts of bleeding while new trach was being changed out. Residents became unstable at this time and code blue was initiated, other staff arrived to assist and 911 was immediately called. [NAME] [sic] arrived and worked on resident however was unableto [sic] be revived, and time of death was called. Provider DON [Director of Nursing] and family members made away [sic] of death.Review of State Survey Agency (SSA) records revealed that this incident had not been reported to the SSA. On [DATE] at 12:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that night shift respiratory staff had identified that resident 9's tracheostomy was broken and they made the decision to change the tracheostomy and while they changed it there was some increased bleeding and resident 9 went into cardiac arrest. The DON stated that this was not reported to the SSA because it was felt that the respiratory staff were following policy and there was no concern for negligence. The DON stated that she was unsure of how the tracheostomy broke. The DON stated that there was another respiratory therapist director at the time of the incident and she was unsure if the respiratory director investigated the incident. On [DATE] at 1:35 PM, a follow-up interview was conducted with the DON. The DON stated that both her and the Administrator were contacted by the Unit Manager on [DATE] and they made a determination to not report because the tracheostomy was identified to be broken and respiratory staff followed policy to change the broken tracheostomy. [Cross refer to F695]

Based on interview and record review it was determined that the facility did not ensure that the resident was free from neglect. Specifically, for 2 out of 9 sampled residents, the facility did not provide the resident with access to an outside provider appointment for the treatment and care of their tracheostomy tube and verbal orders for the tracheostomy change were not followed. In addition, a comatose resident in a vegetative state experienced a broken flange which caused a dislodged tracheostomy, and the resident subsequently went into cardiac arrest and died. This resulted in a finding of harm for 2 residents. Resident identifiers: 1 and 9. Findings included:1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. Resident 1's medical records were reviewed. Resident 1's physician orders revealed the following: a. Change Tracheostomy tube Q (every) 45 days and PRN (as needed) every day shift every 30 day(s). The order was initiated on [DATE] and discontinued on [DATE]. The same order was initiated again on [DATE] and discontinued on [DATE]. The Medication Administration Record (MAR) documented that the tracheostomy was changed on [DATE], [DATE], [DATE], and [DATE]. It should be noted that there was no order to change the tracheostomy tube after [DATE]. b. On [DATE], an order was initiated for an ENT (Ears, Nose, and Throat) referral related to stenosis and tracheostomy status. On [DATE], resident 1's hospital History & Physical (H & P) documented, . she had exchange of tracheostomy to Shiley by ENT due to hemoptysis. She went into respiratory arrest that night and was found to have a dislodged trach. She has some anoxic brain injury secondary to the episode where she had a PEA [Pulseless Electrical Activity] cardiac arrest Trach was changed by ENT in OR [operating room] on [DATE]. Given significant subglottic stenosis/proximal tracheal stenosis ENT recommends against trialing PMV [Passy Muir Valves]. They recommend changing trach every 3 months instead of monthly. On [DATE] at 10:38 AM, the Nurse Practitioner note documented continued trach care per Respiratory Therapy (RT) protocol. F/u [follow-up] ENT for subglottic and tracheal stenosis. On [DATE] at 11:00 AM, the RT note documented, Pt [patient] rest in bed on vent @ACPC [Assist Control Pressure Control] 4L [liters]. HOB [head of bed] elevated. Trach [trachestomy] is midline, secure and patent. BS [breath sounds] coarse. Sx [suctioned] x [times] 3 for moderate amount of yellow thick secretions. No s/s [signs and symptoms] of resp [respiratory]. distress noted at this time. Will continue to monitor. The note documented that resident 1's heart rate was 80 beats per minute, respiratory rate was 24 and oxygen saturation was at 100%. On [DATE] at 1:55 PM, the RT note documented, RT performed trach changed as pt mentioned trach is too tight this morning. Pt was placed on 6L O2 [oxygen] for pre-oxygenated. SpO2 [oxygen saturation] 97%, HR [heart rate] 98. During removal and reinsertion of trach tube, resistance was encounter (sic) and insertion was unsuccessful. a smaller size trach tube was attempted, still unsuccessful to insertion. Pt developed acute resp. distress with pallor and cyanosis noted. Code blue was activated immediately. [Note: This note was entered by Respiratory Therapist (RT) 1.] On [DATE] at 2:32 PM, the nursing note documented Per RT report, at approximately at 1355 [1:55 PM] a scheduled tracheostomy tube change was initiated. RT [respiratory therapist 1] and RT [respiratory therapist 2] reported that during removal and attempted reinsertion of the tracheostomy tube, resistance was encountered when advancing the new trach. A second tracheostomy kit was opened and insertion was reattempted. Resistance was again met and placement was unsuccessful. RT reported the resident then exhibited signs of respiratory distress with decreasing oxygen saturation and cyanosis. A Code Blue was initiated immediately, and manual ventilation was initiated via bag-valve device. At approximately 1400 [2:00 PM], I heard the Code Blue call and responded immediately to the room. Upon arrival, both RTs were present and providing ventilatory support via bag-valve mask. Resident was observed to be unresponsive, apneic, cyanotic, and without palpable pulse. Resident was lowered to the floor with assistance for initiation of CPR per facility protocol. Chest compressions were initiated immediately. Staff were directed to: Activate EMS (911), retrieve crash cart, obtain AED [Automated External Difibrillator], and notify RT supervisor [name omitted]. AED was applied and rhythm analyzed three times. No shock was advised. Continuous CPR [cardiopulmonary resuscitation] was performed per protocol. EMS arrived during the third AED rhythm analysis and assumed care upon arrival. Resuscitative efforts were continued by EMS. Time of death was pronounced at 1425 [2:25 PM] by EMS. Attending physician was notified. Facility administration was notified per protocol. Family was called multiple times following the event. Calls were directed to voicemail on each attempt. Messages were left requesting immediate return call. Post-mortem care was completed per facility policy. On [DATE] at 3:13 PM, a note authored by the Transportation Driver (TD) documented, Received an order on [DATE] for Resident to go to ENT R/T [related to] Stenosis and tracheostomy status. Sent the order to Ent on [DATE] was told by Ent that resident didn't have insurance and that it would be self-pay. Tried calling family on multiple occasions with no answer or call back and with not being able to confirm if family can help self-pay the clinic would not schedule. It should be noted that this note was authored 5 days after resident 1 died and 3 months after the order for the ENT referral was initiated. On [DATE] at 1:24 PM, an interview was conducted with Respiratory Therapist (RT) 1. RT 1 stated that she had become an RT in [DATE]. RT 1 stated that the policy for changing the tracheostomy was to change it if it was dislodged or coming out or if the resident was complaining. RT 1 stated that she would only change the tracheostomy if it was coming out, otherwise it was the Medical Doctor (MD) that changed the tracheostomy. RT 1 stated that the inner cannula was changed daily and if a resident was complaining that the trach was too tight she would change the entire tracheostomy out, not just the inner cannula. RT 1 stated that during the morning ([DATE]) resident 1 was complaining that the tracheostomy was too tight and RT 1 visualized that the tracheostomy was coming out. RT 1 stated that the tracheostomy was dislodged approximately 1.5 inches from the stoma. RT 1 stated that resident 1's vital signs were good and she was not in any respiratory distress. RT 1 stated that she pushed the tracheostomy back in and resident 1 continued to report that it felt tight. RT 1 stated that resident 1's complaints of the tracheostomy being too tight could indicate that it was dirty inside and needed to be changed immediately. RT 1 stated that prior to attempting to change resident 1's tracheostomy the current tracheostomy was secure, patent and midline. RT 1 stated that when she attempted to place the new tracheostomy she met resistance. RT 1 stated that she then attempted to insert a smaller size tracheostomy and also met resistance. RT 1 stated that she was being assisted by RT 2 during the tracheostomy replacement. RT 1 stated that resident 1 had stenosis and a smaller airway and she also thought resident 1 had tracheal edema. RT 1 stated that during the attempted tracheostomy change resident 1's oxygenation dropped to 75% and a code blue was called. RT 1 stated that resident 1's oxygenation dropped to 60% and the resident was turning purple at that time. RT 1 stated that while RT 2 was mechanically ventilating resident 1, RT 1 left the room to get assistance from the RT Director, which took approximately 10 seconds. Resident 1 subsequently went into cardiac arrest and was pronounced dead by EMS. On [DATE] at 2:10 PM, an interview was conducted with RT 3. RT 3 stated that resident 1 had complications of tracheal stenosis, and they were not to change her tracheostomy until she was seen by the ENT. RT 3 stated that if the trach was coming out he would readjust it. RT 3 stated that resident 1 needed to go to the ENT to determine if she needed to have the trach changed on a regular basis. RT 3 stated that they had orders to not change her trach until she was seen by the ENT. RT 3 stated that resident 1 frequently complained of tightness in her tracheostomy and he would assess the trach tie to ensure it was not too tight and then provide resident 1 with education on safety reasons for why they could not loosen the trach ties. RT 3 stated that he was told after resident 1's death that resident 1 complained of the trach being too tight and that RT 1 thought it needed to be changed. RT 3 stated that RT 1 attempted the trach change, was unsuccessful, and they lost the airway. RT 3 stated that he recalled seeing resident 1's name on the whiteboard in the manager's office with a note that stated ENT only. RT 3 stated that if the tracheostomy was patent, midline, and secure he would not change an ENT only trach. On [DATE] at 2:55 PM, a telephone interview was conducted with RT 2. RT 2 stated that he had been an RT since [DATE]. RT 2 stated that resident 1 was not supposed to have her trach changed but he was not informed of this until after the resident's death. RT 2 stated that he was not sure why the trach needed to be changed. RT 2 stated that he did not visualize resident 1's trach coming out or dislodgement prior to the attempted change. RT 2 stated that after resident 1's death he heard through one of his coworkers that the physician was supposed to change the tracheostomy, but they had orders to do it for the patient one time a month. It should be noted that those orders had expired on [DATE] and resident 1 did not have an active order for a tracheostomy change at the time of her death. RT 2 stated that he had never changed a vented patient's tracheostomy prior to resident 1's. RT 2 stated that after resident 1's death RT 1 had stated that resident 1 wanted the tracheostomy changed and that was what prompted the tracheostomy change. On [DATE] at 10:17 AM, an interview was conducted with the Transportation Driver. The TD stated he scheduled appointments for residents and if he was not able to schedule an appointment it would be documented under a progress note. The TD stated that he had a coaching session 2 weeks ago and was instructed that he needed to start documenting every time he contacted an outside provider or resident representative. The TD stated that he sent resident 1's order to the ENT on [DATE] and again on [DATE]. The TD stated that he was told that the resident did not have any insurance and therefore the ENT office would not see her. The TD stated that he was informed that resident 1 did not have insurance by the Business Office Manager (BOM). On [DATE] at 11:29 AM, a telephone interview was conducted with the Business Office Manager. The BOM stated that resident 1 had a Medicaid Pending status at the facility and that the BOM had been in contact with Medicaid since resident 1 had been admitted . The BOM stated that she had screened resident 1 prior to the resident admitting to the facility in order for resident 1 to obtain Medicaid. The BOM stated that if a Medicaid pending resident required a service from an outside provider and the provider would not accept the resident with the Medicaid pending status then the facility would be responsible for payment to the outside provider. The BOM stated that she was not informed that resident 1 could not be seen by an ENT provider because of her Medicaid pending status and if she had known she would have spoken with the Administrator about this and had resident 1 seen by the ENT provider. On [DATE] at 12:02 PM, an interview was conducted with the RT Director. The RT Director stated that she started at the facility on [DATE]. The RT Director stated that they had a standing order to change a tracheostomy every 30 days unless otherwise specified. The RT Director stated that in the beginning of February 2026 she received a Verbal Order (VO) from the provider that resident 1 should have their tracheostomy changed only by an ENT provider unless it was an emergent situation. The RT Director stated that this order was not in resident 1's chart. The RT Director stated she communicated the VO with the staff and it was also documented on the whiteboard in her office and said trach change was on hold until otherwise notified. The RT Director stated that RT 1 went in and resident 1's tracheostomy was dislodged and starting to come out. RT 1 deflated the cuff and pushed it back in. The RT Director stated that resident 1 was not in any distress, was oxygenating well, the tracheostomy was midline, and patent. The RT Director stated that the RTs could have sent resident 1 to the hospital for a tracheostomy change. The RT Director stated that she provided education to the RTs that they should work with nursing and were able to transfer the resident out if they were concerned about the integrity of the trach. The RT Director stated that she educated the staff about the accuracy of their documentation when she realized that the notes did not contain any details of resident 1's trach being dislodged. The RT Director stated that RT 1 did not inform her of any concerns with resident 1's trach prior to her code. On [DATE] at 3:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she had seen a provider note in resident 1's chart that indicated that the tracheostomy should be changed every 3 months. The DON stated that the order was never put into resident 1's medical records. The DON stated that resident 1's prior tracheostomy order to change every 45 days was initiated by the prior RT Director, and then the contracted respiratory company did an audit and changed the order to every 30 days as the new standard protocol. The DON stated that the tracheostomy order dropped off the Medication Administration Record in January and resident 1 had no order to change the tracheostomy after that. The DON stated that the admission process was for the RT Director to manage any respiratory orders and treatments and the licensed nurse would handle all other medication and treatment orders. The DON stated that the contracted respiratory company was responsible for the maintenance and upkeep of all ventilator equipment. The DON stated that the previous communication of respiratory equipment issues was through the RT Director but that was not always communicated to the DON and Administrator clearly. The DON stated that moving forward she expected the RT Director to communicate any concerns with equipment to her. The facility policy on Tracheostomy Tube Changes documented that tracheostomy tubes should be changed per doctor's orders or every 30 days to prevent the risk of tracheal stenosis. As included are emergency changes (i.e. damaged tubes, tubes that are not patent). The policy documented under Replacement of Trach Tube that If airflow is inadequate, or tube cannot be placed properly remove tube, provide ventilation* if necessary and attempt to reinsert tube. If still unable to pass a tube manually ventilate and call 911 or emergency services. The procedure further documented that if you were unable to reinsert a tube Attempt to insert a tube of smaller size, usually the next size down. If the patient's stoma suddenly closes, attempt to pass a suction catheter or tracheal tube exchanger through the stoma to thread the tracheostomy tube. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. A review of resident 9's medical record revealed that on [DATE] at 9:00 PM, respiratory staff entered resident 9's room and found the tracheostomy flange broken, the tracheostomy tube was dislodged, and approximately 1.5 inches out of position, shifted to the right and not midline. Respiratory therapy staff notified nursing and called for a second respiratory therapist to assist with the tracheostomy tube change. During suctioning, respiratory staff observed a significant amount of blood and performed additional passes to clear continued accumulation of blood. Resident 9's oxygen saturation dropped and respiratory staff initiated manual ventilation; however, oxygen levels did not improve. Nursing staff performed a pulse check and no pulse was located. Resident 9 was lowered to the floor and cardiopulmonary resuscitation was performed. Emergency Medical Services arrived and resident 9 was unable to be revived and passed away. On [DATE] at 12:37 PM, an interview was conducted with the DON. The DON stated that the facility had a contract with an outside respiratory company and had used them for two years. The DON stated that respiratory staff identified that resident 9 had a broken trach and the respiratory staff made the decision to change out the trach when there was some increased bleeding and resident 9 went into cardiac arrest and passed away. The DON stated that she was not sure how the flange broke on the trach. The DON stated that she was unaware of any other residents that have had a flange break on the tracheostomy. On [DATE] at 3:01 PM, an interview was conducted with RT 4. RT 4 stated that on [DATE] he entered resident 9's room around 9:00 PM to perform his first assessment. RT 4 stated that resident 9's trach was broken at the flange and it had been dislodged at a 45 degree angle to the right side of the stoma. RT 4 stated that trachs should be centered and midline and if it was not then a resident could have airway obstruction or bleeding. RT 4 stated that the ventilator was not alarming and he was not sure why it was not alarming as high pressure because every breath was pressurized. RT 4 stated that resident 9's lips appeared to be cyanotic and so he replaced her oxygen sensor to another location on her body and resident 9's oxygen saturation was below 90%. RT 4 stated that he called for another RT and a nurse to come into resident 9's room because he needed to change resident 9's trach so that resident 9 would have a patent airway. RT 4 stated that he changed resident 9's trach and suctioned resident 9's airway. RT 4 stated that upon the first suctioning pass a large amount of frank blood and mucus was suctioned out. RT 4 stated that he went back in and suctioned an additional two times and continued to suction larger amounts of blood. RT 4 stated that resident 9's oxygen was showing as low. RT 4 stated that the nurse checked resident 9's pulse and found her without one. RT 4 stated that resident 9 was lowered to the floor and CPR was begun. RT 4 stated that he continued to suction large amounts of blood out of resident 9's trach. RT 4 stated that he believed that resident 9's airway was filled with blood. RT 4 stated that he notified the interim respiratory manager about the ventilator not alarming and made sure that he checked all of his residents' ventilators to make sure they were working correctly. RT 4 stated he was not sure how the flange broke on resident 9's trach because she was comatose and in a vegetative state and could not move. [Cross-refer F695]

Based on interview and record review it was determined that the facility did not ensure that the services provided by the facility met professional standards of practice. Specifically, for 1 out of 9 sampled residents, the facility Respiratory Therapist Director did not ensure that a Verbal Order (VO) was entered into the resident's medical record which resulted in the respiratory staff providing a treatment that deviated from the prescribed order. This will be cited at a harm level. Resident identifier: 1.Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage.Resident 1's medical records were reviewed.Resident 1's physician orders revealed the following:a. Change Tracheostomy tube Q (every) 45 days and PRN (as needed) every day shift every 30 day(s). The order was initiated on [DATE] and discontinued on [DATE]. The same order was initiated again on [DATE] and discontinued on [DATE]. The Medication Administration Record (MAR) documented that the tracheostomy was changed on [DATE], [DATE], [DATE], and [DATE].It should be noted that there was no order to change the tracheostomy tube after [DATE].On [DATE], resident 1's hospital History & Physical [H & P] documented, . she had exchange of tracheostomy to Shiley by ENT [Ear, Nose and Throat] due to hemoptysis. She went into respiratory arrest that night and was found to have a dislodged trach. She has some anoxic brain injury secondary to the episode where she had a PEA [Pulseless Electrical Activity] cardiac arrest Trach was changed by ENT in OR [operating room] on [DATE]. Given significant subglottic stenosis/proximal tracheal stenosis ENT recommends against trialing PMV [Passy Muir Valves]. They recommend changing trach every 3 months instead of monthly.On [DATE] at 1:55 PM, the Respiratory Therapist (RT) note documented, RT performed trach changed as pt [patient] mentioned trach is too tight this morning. Pt was placed on 6L [liters] O2 for pre-oxygenated. SpO2 [oxygen saturation] 97%, HR [heart rate] 98. During removal and reinsertion of trach tube, resistance was encounter (sic) and insertion was unsuccessful. a smaller size trach tube was attempted, still unsuccessful to insertion. Pt developed acute resp. [respiratory] distress with pallor and cyanosis noted. Code blue was activated immediately. [Note: This note was entered by (RT) 1.]On [DATE] at 2:32 PM, the nursing note documented Per RT report, at approximately at 1355 [1:55 PM] a scheduled tracheostomy tube change was initiated. [RT 1] and [RT 2] reported that during removal and attempted reinsertion of the tracheostomy tube, resistance was encountered when advancing the new trach. A second tracheostomy kit was opened and insertion was reattempted. Resistance was again met and placement was unsuccessful. RT reported the resident then exhibited signs of respiratory distress with decreasing oxygen saturation and cyanosis. A Code Blue was initiated immediately, and manual ventilation was initiated via bag-valve device. At approximately 1400 [2:00 PM], I heard the Code Blue call and responded immediately to the room. Upon arrival, both RTs were present and providing ventilatory support via bag-valve mask. Resident was observed to be unresponsive, apneic, cyanotic, and without palpable pulse. Resident was lowered to the floor with assistance for initiation of CPR per facility protocol. Chest compressions were initiated immediately. Staff were directed to: Activate EMS (911), retrieve crash cart, obtain AED [Automated External Difibrillator], and notify RT supervisor [name omitted]. AED was applied and rhythm analyzed three times. No shock was advised. Continuous CPR was performed per protocol. EMS arrived during the third AED rhythm analysis and assumed care upon arrival. Resuscitative efforts were continued by EMS. Time of death was pronounced at 1425 [2:25 PM] by EMS. Attending physician was notified. Facility administration was notified per protocol. Family was called multiple times following the event. Calls were directed to voicemail on each attempt. Messages were left requesting immediate return call. Post-mortem care was completed per facility policy.On [DATE] at 1:24 PM, an interview was conducted with Respiratory Therapist (RT) 1. RT 1 stated that she had become an RT in [DATE]. RT 1 stated that the policy for changing the tracheostomy was to change it if it was dislodged or coming out or if the resident was complaining. RT 1 stated that she would only change the tracheostomy if it was coming out, otherwise it was the Medical Doctor (MD) that changed the tracheostomy. On [DATE] at 2:10 PM, an interview was conducted with RT 3. RT 3 stated that resident 1 had complications of tracheal stenosis, and they were not to change her tracheostomy until she was seen by the ENT. RT 3 stated that if the trach was coming out he would readjust it. RT 3 stated that resident 1 needed to go to the ENT to determine if she needed to have the trach changed on a regular basis. RT 3 stated that he recalled seeing resident 1's name on the whiteboard in the manager's office with a note that stated ENT only.On [DATE] at 2:55 PM, a telephone interview was conducted with RT 2. RT 2 stated that he had been an RT since [DATE]. RT 2 stated that resident 1 was not supposed to have her trach changed but he was not informed of this until after the resident's death. RT 2 stated that after resident 1's death he heard through one of his coworkers that the physician was supposed to change the tracheostomy, but they had orders to do it for the patient one time a month. It should be noted that those orders had expired on [DATE] and resident 1 did not have an active order for a tracheostomy change at the time of her death. On [DATE] at 12:02 PM, an interview was conducted with the RT Director. The RT Director stated that she started at the facility on [DATE]. The RT Director stated that they had a standing order to change a tracheostomy every 30 days unless otherwise specified. The RT Director stated that in the beginning of February 2026 she received a Verbal Order from the provider that resident 1 should have their tracheostomy changed only by an ENT provider unless it was an emergent situation. The RT Director stated that this order was not in resident 1's chart. The RT Director stated that she believed that the Medical Doctor would put the order in resident 1's medical records. The RT Director stated she had since been informed that she could enter orders into resident records. The RT Director stated she communicated the VO with the staff and it was also documented on the whiteboard in her office and said trach changes were on hold until otherwise notified. On [DATE] at 3:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she had seen a provider note in resident 1's chart that indicated that the tracheostomy should be changed every 3 months. The DON stated that the order was never put into resident 1's medical records. The DON stated that resident 1's prior tracheostomy order to change every 45 days was initiated by the prior RT Director, and then the contracted respiratory company did an audit and changed the order to every 30 days as the new standard protocol. The DON stated that the tracheostomy order dropped off the Medication Administration Record in January and resident 1 had no order to change the tracheostomy after that. The DON stated that the admission process was for the RT Director to manage any respiratory orders and treatments and the licensed nurse would handle all other medication and treatment orders. [Cross-refer F695]

Based on interview and record review it was determined that the facility did not ensure that the resident was provided access to an outside provider when the qualified professional person was not employed by the facility, and the facility assumed responsibility for obtaining those services in a timely manner. Specifically, for 1 out 9 sampled residents, the facility did not obtain an appointment with an Ear, Nose, and Throat (ENT) provider for the evaluation of a resident's tracheostomy and tracheal stenosis as ordered. This resulted in a finding of harm for resident 1. Resident identifier:1.Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage.Resident 1's medical records were reviewed.Resident 1's physician orders revealed the following:On 12/3/25, resident 1 had an order initiated for an Ear, Nose, and Throat (ENT) referral related to stenosis and tracheostomy status.On 9/25/25, resident 1's hospital History & Physical (H & P) documented, . she had exchange of tracheostomy to Shiley by ENT [Ear, Nose and Throat] due to hemoptysis. She went into respiratory arrest that night and was found to have a dislodged trach. She has some anoxic brain injury secondary to the episode where she had a PEA [Pulseless Electrical Activity] cardiac arrest Trach was changed by ENT in OR [operating room] on 9/17/ 25. Given significant subglottic stenosis/proximal tracheal stenosis ENT recommends against trialing PMV [Passy Muir Valves]. They recommend changing trach every 3 months instead of monthly.On 2/17/26 at 10:38 AM, the Nurse Practitioner note documented continued trach care per Respiratory Therapy (RT) protocol. F/u [follow-up] ENT for subglottic and tracheal stenosis.On 2/23/26 at 3:13 PM, a progress note authored by the Transportation Driver (TD) documented, Received an order on 12/3/25 for Resident to go to ENT R/T [related to] Stenosis and tracheostomy status. Sent the order to Ent on 12/8/25 was told by Ent that resident didn't have insurance and that it would be self-pay. Tried calling family on multiple occasions with no answer or call back and with not being able to confirm if family can help self-pay the clinic would not schedule.On 3/10/26 at 10:17 AM, an interview was conducted with the TD. The TD stated he scheduled appointments for residents and if he was not able to schedule an appointment it would be documented under a progress note. The TD stated that he had a coaching session 2 weeks ago and was instructed that he needed to start documenting every time he contacted an outside provider or resident representative. The TD stated that he sent resident 1's order to the ENT on 12/8/25 and again on 12/30/25. The TD stated that he was told that the resident did not have any insurance and therefore the ENT office would not see her. The TD stated that he was informed that resident 1 did not have insurance by the Business Office Manager (BOM). On 3/10/26 at 11:29 AM, an interview was conducted with the BOM. The BOM stated that resident 1 had a Medicaid Pending status at the facility and that the BOM had been in contact with Medicaid since resident 1 had been admitted . The BOM stated that she had screened resident 1 prior to the resident admitting to the facility in order for resident 1 to obtain Medicaid. The BOM stated that if a Medicaid pending resident required a service at an outside provider and the provider would not accept the resident with the Medicaid pending status then the facility would be responsible for payment to the outside provider. The BOM stated that she was not informed that resident 1 could not be seen by an ENT provider because of her Medicaid pending status and if she had known she would have spoken with the Administrator about this and had resident 1 seen by the ENT provider. [Cross-refer F695]

Based on interview and record review, it was determined that the facility did not demonstrate identification, reporting, investigation, analysis and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective action. Specifically, the facility did not identify or investigate in their Quality Assurance Performance Improvement (QAPI) three respiratory-related resident deaths. This will be cited at a harm level. Resident identifiers: 1, 5, and 9.Findings included:1. There was noncompliance identified at an IJ (Immediate Jeopardy) level for residents who were on ventilators and had a tracheostomy changed by respiratory staff when they were not supposed to and another resident's tracheostomy broke. Both of these residents went into cardiac arrest and subsequently died. Resident identifiers: 1 and 9. [Cross refer to F695] 2. Based on interview and record review it was determined that the facility did not ensure that the resident was free from neglect. Specifically, for 2 out of 9 sampled residents, the facility did not provide the resident with access to an outside provider appointment for the treatment and care of their tracheostomy tube and verbal orders for the tracheostomy change were not followed. In addition, a comatose resident in a vegetative state experienced a broken flange which caused a dislodged tracheostomy, and the resident subsequently went into cardiac arrest and died. Resident identifiers: 1 and 9. [Cross refer to F600]3. Based on interview and record review the facility did not ensure that all alleged violations involving injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, if the events resulted in serious bodily injury to the administrator, State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 1 out of 9 sampled residents, the SSA and APS were not notified when a resident's tracheostomy flange broke, resulting in a dislodged tracheostomy tube. The resident subsequently went into cardiac arrest and died. Resident identifier: 9. [Cross refer to F609]On [DATE] at 3:28 PM, an interview was conducted with the Administrator (ADM). The ADM stated that if the facility identified a process that was not working as intended this led to a quick Quality Assurance (QA) meeting. The ADM stated that in the quick QA they would identify the issue, what caused the issue, and what was the process to resolve the issue. The ADM stated that was how the process entered into the QAPI program and then it was reviewed monthly with QAPI. The ADM stated that the facility reviewed the residents' deaths in QAPI and focused on whether staff was following procedure. The ADM stated that the facility had addressed resident 1 and resident 9 in QAPI, but had not reviewed resident 5's death. The ADM stated that he was not informed of resident 9's death and the circumstances that had occurred with the broken flange until the following morning. The ADM stated that the contracted respiratory company was responsible for supplying all equipment needed for the respiratory unit. The ADM stated that the contracted respiratory company had not reported any equipment issues or equipment that was not functioning properly. The ADM stated that it was his expectation that the respiratory company report any equipment concerns that they may have.

Based on interview and record review, it was determined that the facility did not maintain all mechanical, electrical, and patient care equipment in a safe and operating condition. Specifically, a ventilator did not alarm when a resident's tracheostomy tube's flange broke and dislodged and the resident went into cardiac arrest and died. This will be cited at a harm level. Resident identifier: 9. Resident 9 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. A review of resident 9's medical record revealed that on [DATE] at 9:00 PM, respiratory staff entered resident 9's room and found the tracheostomy flange broken, the tracheostomy tube was dislodged, and approximately 1.5 inches out of position, shifted to the right and not midline. Respiratory therapy staff notified nursing and called for a second respiratory therapist to assist with the tracheostomy change. During suctioning, respiratory staff observed a significant amount of blood and performed additional passes to clear continued accumulation of blood. Resident 9's oxygen saturation dropped and respiratory staff initiated manual ventilation; however, oxygen levels did not improve. Nursing staff performed a pulse check and no pulse was located. Resident 9 was lowered to the floor and cardiopulmonary resuscitation (CPR) was performed. Emergency Medical Services (EMS) arrived and resident 9 was unable to be revived and passed away. On [DATE] at 3:01 PM, an interview was conducted with Respiratory Therapist (RT) 4. RT 4 stated that he had entered the room of resident 9 on [DATE] and found the tracheostomy flange broken and the tracheostomy was deviated significantly to the right at approximately a 45 degree angle and partially out of the stoma. RT 4 stated that resident 9's lips were blue in color. RT 4 stated that the ventilator was not alarming and it should have been alarming with at least a high pressure alarm because each ventilated breath was pressurized. RT 4 stated that he moved the continuous pulse oximeter sensor to a different location because the oxygen saturation alarm was not going off and resident 9's oxygen level was below 90%. RT 4 stated that after resident 9 passed away, he checked all the ventilators to see if they were disconnected because the ventilator had not alarmed. RT 4 stated that he gave a report about the ventilator to the interim respiratory therapist director. On [DATE] at 3:28 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the contracted respiratory company was responsible to supply all equipment needed for the respiratory unit. The ADM stated that it was his expectation that the contracted respiratory company communicate with the facility if there were any problems with equipment. The ADM stated that no equipment issues had been reported to him. On [DATE] at 3:43 PM, an interview was conducted with the Respiratory Therapist Interim Director. The Respiratory Therapist Interim Director stated that she was at the facility for a couple of days in [DATE] and then for a week at the beginning of [DATE]. The Respiratory Therapist Interim Director stated that while she was at the facility she was working on compliance with the supplies and ensuring that the respiratory therapists had all the supplies that they needed. The Respiratory Therapist Interim Director stated that she had received a text message about the flange breaking from a tracheostomy and that resident 9 had passed away after this occurred. The Respiratory Therapist Interim Director stated that she returned to the facility after this had occurred and was informed that the facility had everything handled. On [DATE] at 4:23 PM, a follow-up interview was conducted with RT 4. RT 4 stated that when he entered resident 9's room on [DATE] the ventilator was not alarming. RT 4 stated that the tracheostomy was severely deviated to the side. RT 4 stated that he questioned why the ventilator was not alarming because he was concerned that the tracheostomy was going to come out. RT 4 stated that he later spoke with the interim respiratory supervisor about his concerns with the ventilator and that some of the alarms and pulse oximeters needed to be replaced. RT 4 stated that he was concerned about the alarm cables that were breaking, which would result in the ventilator not alarming to the call system, and some of the pulse oximeters were not working. RT 4 stated that there had been an instance when he needed a functioning pulse oximeter and he did not have one. RT 4 stated that he told the Certified Nursing Assistants (CNAs) that he was taking their vital signs cart to use for patients. RT 4 stated that he had some situations where he did not have the equipment that he needed for the resident.

Based on interview and record review, the facility in response to an allegation of abuse, neglect, or mistreatment did not have evidence that the alleged violation was thoroughly investigated. Specifically, for 1 out of 9 sampled residents, an investigation into the cause of a broken tracheostomy flange in a comatose resident that was dependent on a ventilator was not investigated. This will be cited at a harm level. Resident identifier: 9.Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. A review of resident 9's medical record revealed that on [DATE] at 9:00 PM, respiratory staff entered resident 9's room and found the tracheostomy flange broken, the tracheostomy tube was dislodged, and approximately 1.5 inches out of position, shifted to the right and not midline. Respiratory therapy staff notified nursing and called for a second respiratory therapist to assist with the tracheostomy tube change. During suctioning, respiratory staff observed a significant amount of blood and performed additional passes to clear continued accumulation of blood. Resident 9's oxygen saturation dropped and respiratory staff initiated manual ventilation; however, oxygen levels did not improve. Nursing staff performed a pulse check and no pulse was located. Resident 9 was lowered to the floor and cardiopulmonary resuscitation (CPR) was performed. Emergency Medical Services (EMS) arrived and resident 9 was unable to be revived and passed away. On [DATE] at 12:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff identified the broken tracheostomy and decided to change it. The DON stated increased bleeding occurred, and Resident 9 went into cardiac arrest. The DON stated staff started CPR and called EMS. The DON stated she had not investigated how the tracheostomy broke and was unsure if the respiratory therapy director at the time had investigated it.[Cross refer to F695]

Based on observation, interview, and record review, the facility did not ensure that residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. Specifically, for 7 out of 69 sampled residents, residents were having consensual relationships per their families consent and the residents were not assessed and did not have the capacity to consent and residents were being sexually abused by other residents. Resident identifiers: 50, 70, 208, 209, 310, 311, and 409. Findings included: 1. Resident 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic kidney disease stage 2, dementia, essential hypertension, mild protein-calorie malnutrition, dysphonia, history of falling, cognitive communication deficit, major depressive disorder, and fall on same level. Resident 70's medical record was reviewed from 10/7/24 through 10/21/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 70 had a Brief Interview for Mental Status (BIMS) score of 10. A BIMS score of 8 to 12 indicated moderate cognitive impairment. On 9/1/23 at 12:12 PM, a Nursing progress note documented Note Text : Pt [patient] found by OT [Occupational Therapy] in his room with his pants off and female resident sitting beside him on the bed. OT assisted pt in getting pants on and assisted pt to the dining room. On 9/1/23 at 12:39 PM, a Nursing progress note documented Note Text : CNA [Certified Nursing Assistant] found pt standing behind the curtain with female resident. CNA brought both pt out of the room and to the dining room for lunch. On 9/6/23 at 11:24 AM, a Nursing progress note documented Note Text : Patient is being friendly and having relations with another female resident on the unit. Family is aware and patient is his own power of attorney per nursing management pt is ok to continue relations. Pt was found in his room with pants down and female resident in room. Both parties are in agreement to the situation. Since then both patients have been separate on the unit per their own accord. No concerns at this time, will continue to monitor. A care plan Focus dated 9/18/23, documented RESOLVED: I have a special friend I like to spend time with. We like to hold hands and kiss but sometimes forget that others become uncomfortable when we're in in [sic] public areas displaying affection. - Displaying affection toward resident [resident 208]. He consented with the affection and resident [resident 208] son aware and no concern. - Huddle/Inservice to facility employee in the unit. The Interventions initiated on 9/18/23, included: a. Anticipate and meet needs. b. Approach in a calm manner. c. Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. d. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. e. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. f. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. g. Provide a program of activities that is of interest and accommodates residents status. h. When displaying affection, staff to talk with parties involved to ensure all are consenting. On 10/10/24 at 4:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the resident associated with resident 70 during the incident on 9/1/23, was resident 208. The DON stated the incident was not reported because the incident was identified as a consensual relationship, between resident 208's family and resident 70 being his own power of attorney at that time. 2. Resident 208 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, essential hypertension, depression, and mild protein-calorie malnutrition. Resident 208's medical record was reviewed from 10/7/24 through 10/21/24. An admission MDS assessment dated [DATE], documented that resident 208 had a BIMS score of 99 which indicated resident 208 was unable to complete the interview. On 8/29/23 at 4:50 PM, a Nursing progress note documented Late Entry: Note Text: Resident was found in male residents room sitting on bed. Redirected resident and male resident to join day room activities. Despite the redirection, both residents continued to hold hands and have physical contact. Residents were separated during dinner time. (Note: The incident was with resident 70.) On 8/30/23 at 3:49 PM, a Nursing progress note documented Note Text: NO [new order] from provider to initiate Lexapro r/t [related to] hypersexual behavior secondary to Alzheimers [sic], as well as Pepcid 20mg [milligrams] BID [twice a day]. NO in place, representative aware. On 8/30/23 at 4:52 PM, a Nursing progress note documented Note Text: Resident was found by CNA in male residents room. Male resident did not have any pants or brief on, and female resident had her shirt pulled up some. Resident was removed from male residents room. She was then taken to the shower room, her hospice CNA came to do cares on her. DON notified of happenings. CNA staff aware to keep residents separated. (Note: The incident was with resident 70.) On 9/1/23 at 12:11 PM, a Nursing progress note documented Note Text: Pt found in fell ow residents room sitting on the bed. OT found pt this way and brought pt out of the room. (Note: The incident was with resident 70.) On 9/1/23 at 12:35 PM, a Nursing progress note documented Note Text: CNA found pt standing behind the curtain with fell ow resident. CNA brought both patients out of the room for lunch. (Note: The incident was with resident 70.) On 9/6/23 at 1:39 AM, a Nursing progress note documented Note Text: Pt was found in another pt's bed at 0130 [1:30 AM]. She was in the same pt's room that had a res [resident] to res situation on 9/4 [23]. No issues today, the other pt calmly reported to nurse that she was in his bed and asked the nurse to help her to her room. (Note: The incident was with resident 70.) On 9/6/23 at 11:21 AM, Nursing progress note documented Note Text: Patient is being flirtatous [sic] with a male resident on unit. They hold hands and pt is often found in male patients room. Earlier male pt was found on his bed with pants down while [resident name redacted] was in the room with him. Patients family is aware and per nursing management family is ok with patients behavior with this one male patient only, if she is to take a liking to any other resident we must notify her family. After pt was found with the other resident in his room they've been separate on the unit per their own accord. Will continue to monitor. (Note: The incident was with resident 70.) On 9/18/2023 at 7:19 PM, a Nursing progress note documented Note Text : patient found kissing another male resident in the male residents room patient was redirected into an activity 30 min [minute] checks started. (Note: The incident was with resident 50.) A care plan Focus created on 9/18/23 and initiated on 1/8/24, documented I have a special friend I like to spend time with. We like to hold hands and kiss but sometimes forget that others become uncomfortable when we're in in [sic] public areas displaying affection. - Resident displaying affection to resident [resident identifier redacted] and resident [resident identifier redacted]. - Son understand and aware of his mother affection with this resident. - Frequent Visual check and her whereabouts. - Huddle/Inservice staff q [every] change of shift to redirect resident. - Activities that catered to her needs to redirect her behavior. The Interventions created on 9/18/23 and initiated on 1/8/24, included: a. Anticipate and meet needs. b. Approach in a calm manner. c. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. d. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. e. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. f. Minimize potential for resident's disruptive behaviors by offering tasks which divert attention. g. Provide a program of activities that is of interest and accommodates residents status. h. Staff to ensure when I am displaying affection towards others, that all parties are consenting. i. Stop and talk with resident when passing by. On 9/21/23 at 11:24 AM, an Interdisciplinary Team (IDT) progress note documented Note Text : IDT meet today unit managers/social worker and hospice to discuss about the incident that happened last 9/18/23. Resident was found kissing with resident [resident identifier redacted]. She wanders into his room, and both was redirected. Assisted resident back to activities and she stay in activities. Reported the incident to resident son and made aware. Hospice informed and plan to review her medication. Hospice plan to discuss with the son. Resident will be on q 30 mins [minute] checks and check her whereabouts. Plan activities that catered for her needs. Huddle with staff, Inservice about redirecting resident at all times. Continue as plan. Son aware and hospice informed. 3. Resident 50 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, vascular dementia, pain, essential hypertension, need for assistance with personal care, and cognitive communication deficit. Resident 50's medical record was reviewed from 10/7/24 through 10/21/24. A quarterly MDS assessment dated [DATE], documented that resident 50 did not have a BIMS score due to resident 50 rarely or never understood. On 9/18/23 at 7:21 PM, a Nursing progress note documented Note Text : a female resident found kissing [resident name redacted] in his room the female resident was redirected into an activity 30 min checks started family attempted to call left message DON and MD notified. A care plan Focus initiated on 9/18/23, documented RESOLVED: I have a special friend I like to spend time with. We like to hold hands and kiss but sometimes forget that others become uncomfortable when we're in in [sic] public areas displaying affection - Displaying affection with resident [resident 208] and he likes the affection, and his family was aware and with no concern. The other resident family also aware with no concern - Huddle/Inservice the staff to Redirect the resident and made aware of the plan. The interventions initiated on 9/18/23 included: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Anticipate and meet needs. c. Approach in a calm manner. d. Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. e. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. f. Educate family/caregivers on successful coping and interaction strategies. Needs encouragement and active support by family/caregivers. Use these strategies. g. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. h. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. i. Provide a program of activities that is of interest and accommodates residents status. j. When I am displaying affection towards others, ensure staff stop and ensure all parties are consenting. On 9/19/23 at 11:32 AM, a Social Services progress note documented Note Text : Spoke with PT niece today about incident of pt and other female resident kissing. Pt niece was understanding and consents for pt to have relations with another resident as long as he is happy. On 9/21/23 at 12:03 PM, an IDT progress note documented Note Text : IDT meet today. Clinical resource, Unit managers, SSD [Social Services Director] and SSD to discuss the incident that happened last 9/18/23. Resident was found kissing another resident [resident identifier redacted] in his room. Both was redirected. Reported this incident to resident niece and she was laughing because the resident already told her about it. No concern at this time. Will continue to monitor. NP [Nurse Practitioner] made aware of the incident. On 10/16/24 at 11:37 AM, an interview was conducted with the Medical Director (MD). The MD stated that sometimes he was involved with the capacity to consent for residents but it would depend on the situation with the resident. The MD stated that he would get help from psychiatry if the residents were in and out or questionable. The MD stated if there was going to be something legally he would get more opinions. The MD state if the capacity to consent affected anything medical the facility staff would consult with him. The MD stated that he was not consulted on the interaction with resident 70 and resident 208. The MD stated if he was consulted he did not document on either of the residents. The MD stated if the resident had behavioral health services they would usually follow the resident and not him. The MD stated if the residents were on the dementia unit he would expect to be consulted. The MD stated if the resident had no cognitive impairment, diagnoses, disability, or a BIMS score that would have triggered the decision the residents should have the capacity to consent. The MD stated if the residents were on the regular unit and there was a question about capacity he might call in someone else. The MD stated that the residents had a personalized screening for consent. On 10/17/24 at 7:11 AM, an interview was conducted with the Social Worker (SW). The SW stated that he would do different cognitive assessments to determine if the resident had the capacity to consent. The SW stated if the BIMS score was questionable he would do a different more detailed assessment. The SW stated that he would assess if the residents understood and he would look at the residents orientation. The SW stated he would talk with the residents and do they understand what a relationship was and what that meant. The SW stated that residents had rights and they had the right to do what they want as long as it did not cause harm to others. The SW stated if the resident did not understand then he would talk with the family. The SW stated if the residents were both seeking each other he would call the family. The SW stated if the residents were not seeking each other the staff would put in interventions like staff would watch more and intervene. The SW stated if the residents wished to be together and hold hands that was fine but if the residents wanted more we would provide a private space. The SW stated if the other resident was not interested we would follow up with that party to make sure they were okay. The SW stated if the cognition was not there or the resident was on the Memory Care we would contact the family. The SW stated they would take into consideration the families opinion. The SW stated we would allow a companionship and it was all about safety. The SW stated when he met with the the residents he would document in a Social Services note. The SW stated that when the MD's or mental health did their rounds he would discuss the residents wishes with them. On 10/17/24 at 3:32 PM, an interview was conducted with the DON. The DON stated if the resident interactions had the potential to be sexual they would look at cognition and if cognition was not there they would contact the family to see if that was something that would be consensual on their end. The DON stated that until that was identified we would keep the residents separated and make sure the residents were safe and their interactions were done safely. The DON stated for the capacity to consent they would look a the residents BIMS score, diagnoses, involvement with social work, and involve therapy on determining those assessments. The DON stated the capacity to consent would be scanned in the residents medical record. The DON stated that resident 208's son stated that if resident 208 was happy he was happy, but of course the son wanted to keep resident 208 safe. The DON stated that staff were educated that resident 70's and resident 208's relationship was consensual but if it was more sexual to redirect them. The DON stated that snuggling or sitting on the couch was okay and it was more of a companionship. The DON stated that she felt the conversations with the family and redirecting of the residents that there was no need to report because it was not abuse. 48709 4. Resident 409 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, pneumonia, [NAME]-Pick Disease Type C, fracture of neck of left femur, mild cognitive impairment, and acute kidney failure. Resident 409's medical record was reviewed from 10/7/24 through 10/21/24. A quarterly MDS assessment dated [DATE], indicated resident 409 had a BIMS score of 00 which suggested severe cognitive impairment. Per facility documentation, an incident of abuse between resident 409 and resident 209 occurred on 7/31/23. The following was documented: A Nursing Progress note, dated 8/1/23 at 2:02 AM, indicated, Male CNA reported that he went to check resident [409] bc [because] he was told he didn't have a brief. Upon entering the room he noticed that his roommate, resident [209], was looking at resident [409] and was up against resident [409]'s bed. Staff rediretd [sic] resident [209] back to his side of the room, closed the curtain and proceeded to assist resident [409] with his brief. Staff notice that there was a whitish discharge noted arouind [sic] penile area. After assisting resident [sic] [409] with brief he left the room and left the door open. Staff wentback [sic] a few minutes later to check on them and saw that the bedroom door was closed. He opened the door and saw that resident [209] was by resident [409]'s bed, touching him inappropriately with his hand on resident [409]'s genitals. He intervened and redirected resident [209] away from resident [409]. CNA reported incident to nurse and resident [209] was removed from room and placed into another unoccupied room in a different area of the unit. Incident reported to administrator, DON, ADON [Assistant Director of Nursing] and Provider. Review of the Form 358: Reported Incidents, dated 8/1/23 at 12:20 AM, for resident 409 documented, .[Resident 209] was witnessed by CNA [staff name redacted], at approximately 2215 [10:15 PM] near [resident 409's] bed inappropriately touching his genital area. CNA was reported to separate residents immediately and request assistance in residents shared room. The form further documented that resident 209 was moved to a private room with staff supervision and the police department and Adult Protective Services were notified. A Social Services Summary, dated 8/1/23 at 9:39 AM, indicated, Resident has experienced trauma this last week due to a roommate. IDT was held for Resident with daughter to see additional support needed. So far rt [resident] has not shown deference from baseline. Outside support has been offered and denied multiple times from [resident 409]. Referrals were made to [Behavioral Health Service] and NP so that they are available for help. Staff have states that [resident 409] has shown no emotions that are different then from before trauma. A Social Services Progress Note, dated 8/1/23 at 3:58 PM, indicated, PSYCHOSOCIAL ASSESSEMENT [sic]: Pt has limited ability to answer questions. He is able to answer yes and no as long as he is allowed time for response. Pt was asked questions about emotional and mental health. Pt has expressed sadness about the incident from night before. Pt acknowledges he is not angry just sad. Pt has acknowledged that he would like to see someone . A Nursing Progress note, dated 8/2/23 at 11:16 AM, indicated, Resident was visited by two [city name redacted] City Detectives regarding incident with previous roommate on night of 7/31 [23]. Resident gave permission to talk to officers but appeared uncomfortable when questioning proceeded to more detailed questions. Nurse asked resident if he wanted to talk to me without them and he said yes. Resident then stated that 'He touched me. He shouldn't have done that.' I asked him if it was without his permission, if it made him uncomfortable, resident responded yes to both questions. I then asked resident if I could tell the officers what he just told me and he responded yes. Officers were informed of conversation. Wctm [will continue to monitor]. Review of the Form 359: Follow-Up Investigation Report, dated 8/7/23 at 9:20 PM, indicated, P't [sic] has limited ability to answer questions. He is able to answer yes and no as long as he is allowed time for response. Pt was asked questions about emotional and mental health. Pt has expressed sadness about the incident from night before. Pt acknowledges he is not angry just sad. Pt has acknowledged that he would like to see someone. Pt will be referred out for mental health services. [Behavioral Health Service] is 2-3 weeks referral. Psych [psychiatric] NP will be in facility next week which both referrals will be made. Follow-up conversation on 8/7/23, resident confirmed this was not a consensual act. The document further indicated, .[Resident 409] also has a history of depression. [Resident 409] capability to meaningfully answer and participate in the BIMS and PHQ9 [Patient Health Questionnaire-9] assessment process depends largely on his status on any given day; his cognitive level fluctuates. Sometimes he is able to answer the basic questions, and other times he does not answer at all. He requires extensive assist with ADL's [activities of daily living] and wheelchair use . The document further indicated, Abuse allegation verified-in follow up interviews with [resident 409], he confirmed that the incident was not consensual. The facility passed this information on to the [city name redacted] Police Department; [Resident 209] has been removed from the Facility in the custody of the police. The document further indicated, [Staff name redacted] worked the adjacent hall on the night of the incident. [Staff name redacted] re-counted the events that [Staff name redacted] reported; specifically, she confirmed that [resident 409] frequently masturbates and that the staff have been instructed to provide him privacy when he experiences that need . The document further indicated, .[resident 409] is known to masturbate often, even when staff are in the room . A Social Services Progress Note, dated 8/8/24 at 3:48 PM, indicated, Follow up with pt evening of 8/7/2023 on incident from previous week. Nursing has continually monitored Pt for change in physical, mental, or emotional health. Pt is documented to be at baseline. Met with pt this last evening to assess psychosocial wellbeing. Pt was able to discuss to verbalize multiple answers tonight. Pt has acknowledged that he is angry, sad, or frustrated over situation with roommate. He is happy that roommate is no longer in facility. Pt answered questions about daughter, birthyear [sic]. Pt laughed over a few jokes agreeing that SW [Social Worker] is able to come back to visit. Pt is selective on who he talks with it is very limited. Pt was offered mental health services which he declined. Pt was offered someone to talk to pt declined. Facility will continue to monitor for change in mental, physical, or emotional health. A Social Services Progress Note, dated 8/22/24 at 8:42 PM, indicated, Pt receive3d [sic] mail today about upcoming court procedures over past roommate. Pt does not want to know about upcoming hearings unless the court needs him. Resident 409's care plan revealed a focus of, Potential to demonstrate physical behaviors aeb [as evidenced by]: masturbation. Date Initiated: 12/04/2023. It indicated the Goal, Will not harm self or others through the review date. Date Initiated: 12/04/2023. And included the following interventions, Ensure hand hygiene is reminded and carried out frequently throughout the day. Date Initiated: 12/04/2023. Monitor/document/report to MD of danger to self and others. Date Initiated: 12/04/2023. Provide privacy via curtains and blankets/sheets as needed. Date Initiated: 12/04/2023. 5. Resident 209 was admitted to the facility on [DATE] with diagnoses which included [NAME]'s Encephalopathy, frontal lobe and executive function deficit, hypertension, alcohol use unspecified with alcohol-induced persisting amnestic disorder, major depressive disorder, cognitive communication deficit, and personal history of other mental and behavioral disorders. Resident 209's medical record was reviewed from 10/7/24 through 10/21/24. An admission MDS assessment dated [DATE], indicated resident 209 had a BIMS score of 9 which suggested moderate cognitive impairment. The Hospital History and Physical (H & P), dated 5/23/23, indicated: a. A Progress Note Generic, dated 4/24/23 at 10:05 AM, indicated, .4. History of violent behavior Mental status at baseline. He does have a history of violence, including strangling previous RN [Registered Nurse] at his facility, beating up her roommate. He is currently calm and not showing signs of agitation or aggression. Has hand [sic] several ER [emergency room ] visits and admissions in last 6 months for violent behavior at care facility. Seen by psychiatry multiple time, neuropsychiatry 10/5/22- these providers/noted indicated that patient has significant impairment, concerns about decision making . b. A Behavioral Health Progress Note, dated 4/24/23 at 1:11 PM, indicated, Based on his history, patient is likely a at chronic risk of harm due to other. Violence seems to have co-occurred with the emergency of his neurocognitive deficit . An Encounter Progress note, dated 5/24/23 at 12:00 AM, indicated, [Resident 209] isa [sic] [AGE] year-old patient who is seen today as a new patient. He was admitted from [facility name redacted] Hospital. He has known cognitive deficits, history of alcohol abuse resulting in Warnicke Korsakoff syndrome. There was mention of a TBI [traumatic brain injury], but [facility name redacted] Hospital could not find in the actual records of this. He was found wandering the streets in the rain and confused. He was taken to the emergency room by police. He had previously been in [facility name redacted] but was discharged to a facility after violent behavior to the staff. He was transferred to [facility name redacted] Hospital for psychiatric consultation if needed. He has been in and out of facilities for many years, he is alert to self only today, is unsure where he is at or the appropriate year. He is currently laying in bed and appears cooperative. He had previously been on estrogen for hypersexuality, this was stopped at the hospital as that is not an appropriate indication, he is on paroxetine which should be helpful. He does have a sister who it appears has been fairly involved in his care. He takes trazodone at night to help him sleep, psych recommended this be used for aggression. He has also been on Eliquis which appears to have been since 2018 for bilateral PEs [pulmonary embolism]. This has been maintained. He is not able or capable of making his own decisions, had previously been at facilities, will be maintained in the secure memory unit, will have low threshold to intervene with behaviors due to his violent history. A Nursing Progress note, dated 5/24/23 at 5:19 AM, indicated, ALERT CHARTING: 72 hour admit charting Pt appears to be adjusting well to change. No negative or depressive statements made this shift. Pt has made 2 sexually suggestive comments to CNAs. Will continue to monitor pt for any changes in behavior. A Social Service Summary, dated 6/5/23 at 6:06 AM, indicated, [Resident 209] is admitted to facility for long term care in memory care. [Resident 209] is a [AGE] year-old male that is poor historian with history of frontal lobe/executive function deficit, neurocognitive deficit, TBI, [NAME] Korsakoff syndrome who was brought to the EDultimately [sic] ER after found wandering streets in the rain knocking on his whole childhood home store. He has been in and out of facilities for the last few years with admits to the ER due to violence incidents. His brother is currently seeking guardianship through court order. [Resident 209] has no plans for discharge at this time. A Nursing Progress Note, dated 6/7/23 at 1:14 AM, indicated, Pt flipped off nurse after nurse redirected him to his room. A Nursing Progress Note, dated 6/11/23 at 7:28 PM, indicated, CNA reported to LN [licensed nurse] that fell ow female pt had wandered into pt's room and pt was inappropriate while touching fell ow pt's shoulder and touching her hair. CNA immediately pulled pt out of the room and closed the door told pt he was very inappropriate. A Nursing Progress Note, dated 7/1/23 at 2:15 AM, indicated, Resident to Resident. Patient hit [name redacted] on her hand with his fist. When [name redacted] was trying to reach a pencil of color. After that he insult her with sexual vulgar words and telling her the F and B word. Continue monitoring [resident 209] aggressivity to avoid harmto [sic] another patient. An IDT Progress Note, dated 7/21/23 at 4:28 AM, indicated, IDT team has met to discussed pt. IDT will hold IDT Care plan meeting with family to discuss placement to other facility with the intentions to benefit the resident to help decrease behaviors. A Nursing Progress Note, dated 7/21/23 at 10:54 PM, indicated, Resident used foul language at nurses aides when they refused to get him more ice/water. This nurse asked nicely for resident not to use such language. Resident used more foul language at me and then stood up to try to intimidate me continuing to curse. Resident directed to his room. No further incidents noted. A Nursing Progress Note, dated 7/23/23 at 1:19 AM, indicated, At 2230 [10:30 PM] hrs [hours] patient arrive to the nurse station demanding the phone because he said he needed to call his Father. The nurse kindly mentioned that it was too late to call family. Also, we mention that tomorrow morning will be a better time to try that. He got furious and stated [sic] to using foul language saying the 'F' word and insulting the nurse calling her by the 'B' word. He also flipped the middle finger to her and alluded sexual offences. Then he left back to his room. A Nursing Progress Note, dated 7/23/23 at 1:38 AM, indicated, Resident to resident: Resident continue with sexual insinuations towards female residents. He was also passing in the hall way and many times he stop outside of the female resident's door and look around if someone was watching. Since he noticed that I was keeping my eye on him he did not enter in the room. Continue monitoring. An IDT Progress Note, dated 7/25/23 at 3:00 PM, indicated, Per staff and IDT discussion on 07/25/2023, on 07/21/2023 [resident 209] had asked female resident for sexual favors in which she denied and he left her alone regarding any additional sexual acts. Female resident was safe and unharmed and did not appear to be in any emotional distress, and [resident 209] was redirected. [Resident 209] continued to be monitored over the next several shifts, and was noted by LN on shift to be making sexual insinuations towards female residents, per the LN on shift no female resident was directly spoken to or harmed, [resident 209] was using hand and mouth gestures at female residents in the hallway insinuating oral stimulation of the penis. LN was right behind [resident 209] at the time and redirected him imm[TRUNCATED]

Based on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, steam table was soiled, hood vents were dusty, the wall behind the dish machine was soiled, tile missing grout, and a fan had dust build up. Findings included: 1. On 10/7/24 at 10:36 AM, an initial tour of the kitchen was conducted. The following was observed: a. Under the steam table shelf which was above the food, the steam table was observed to be soiled. b. The hood vents were observed to have dust in it. The hood vents were above the stove, tilt stove, and oven. According to a sticker the last time the hood vents were inspected was April 6th, 2024. It revealed that hood vents were due to be cleaned 10/6/24. c. There was a wall behind the dish machine that was soiled with a yellow/brown substance with a hole in the wall. d. There was missing grout in the tile in the dish machine room. 2. On 10/21/24 at 10:32 AM, a follow-up kitchen tour was conducted. The following was observed: a. The hood vents were observed to have dust on them. The hood vents were above the stove, tilt stove, and oven. b. There was a fan observed on the floor pointed toward the food preparation area that had dust build up on it. c. There was a wall behind the dish machine that was soiled with a yellow/brown substance with a hole in the wall. d. There was missing grout in the tile in the dish machine room. On 10/21/24 at 10:39 AM, an interview was conducted with the Dietary Manager (DM). The DM stated stated staff took down vents and cleaned them. The DM stated that every quarter a company came to clean everything in the kitchen. The DM stated the fan was from an employee personal fan and she was not sure how often it was cleaned. The DM stated the shelf above the steam table was cleaned daily when the steam table was wiped down. The DM stated the shelf was stained and not soiled. The DM provided a cleaning list for the cooks and the steam table was on the list twice daily. The DM stated the shelf probably needed to be replaced because it was stained. The DM stated she had not noticed the grout was missing in the dish machine room. The DM stated the wall behind the dish machine was dirty with a hole in it and she was sending a work order to the Maintenance department.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than two hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 2 out of 69 sampled residents, notification to the SSA and APS was not done when residents with cognitive impairments and without the capacity to consent were found in a resident room and one of the residents was disrobed from the waist down. Resident identifiers: 70 and 208. Findings included: 1. Resident 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic kidney disease stage 2, dementia, essential hypertension, mild protein-calorie malnutrition, dysphonia, history of falling, cognitive communication deficit, major depressive disorder, and fall on same level. Resident 70's medical record was reviewed from 10/7/24 through 10/21/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 70 had a Brief Interview for Mental Status (BIMS) score of 10. A BIMS score of 8 to 12 indicated moderate cognitive impairment. On 9/1/23 at 12:12 PM, a Nursing progress note documented Note Text : Pt [patient] found by OT [Occupational Therapy] in his room with his pants off and female resident sitting beside him on the bed. OT assisted pt in getting pants on and assisted pt to the dining room. On 9/1/23 at 12:39 PM, a Nursing progress note documented Note Text : CNA [Certified Nursing Assistant] found pt standing behind the curtain with female resident. CNA brought both pt out of the room and to the dining room for lunch. On 9/6/23 at 11:24 AM, a Nursing progress note documented Note Text : Patient is being friendly and having relations with another female resident on the unit. Family is aware and patient is his own power of attorney per nursing management pt is ok to continue relations. Pt was found in his room with pants down and female resident in room. Both parties are in agreement to the situation. Since then both patients have been separate on the unit per their own accord. No concerns at this time, will continue to monitor. A care plan Focus dated 9/18/23, documented RESOLVED: I have a special friend I like to spend time with. We like to hold hands and kiss but sometimes forget that others become uncomfortable when we're in in [sic] public areas displaying affection. - Displaying affection toward resident [resident identifier redacted]. He consented with the affection and resident [resident identifier redacted] son aware and no concern. - Huddle/Inservice to facility employee in the unit. The Interventions initiated on 9/18/23, included: a. Anticipate and meet needs. b. Approach in a calm manner. c. Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. d. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. e. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. f. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. g. Provide a program of activities that is of interest and accommodates residents status. h. When displaying affection, staff to talk with parties involved to ensure all are consenting. On 10/10/24 at 4:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the resident associated with resident 70 during the incident on 9/1/23, was resident 208. The DON stated the incident was not reported because the incident was identified as a consensual relationship, between resident 208's family and resident 70 being his own power of attorney at that time. 2. Resident 208 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, essential hypertension, depression, and mild protein-calorie malnutrition. Resident 208's medical record was reviewed from 10/7/24 through 10/21/24. An admission MDS assessment dated [DATE], documented that resident 208 had a BIMS score of 99 which indicated resident 208 was unable to complete the interview. On 8/29/23 at 4:50 PM, a Nursing progress note documented Late Entry: Note Text: Resident was found in male residents room sitting on bed. Redirected resident and male resident to join day room activities. Despite the redirection, both residents continued to hold hands and have physical contact. Residents were separated during dinner time. On 8/30/23 at 3:49 PM, a Nursing progress note documented Note Text: NO [new order] from provider to initiate Lexapro r/t [related to] hypersexual behavior secondary to Alzheimers [sic], as well as Pepcid 20mg [milligrams] BID [twice a day]. NO in place, representative aware. On 8/30/23 at 4:52 PM, a Nursing progress note documented Note Text: Resident was found by CNA in male residents room. Male resident did not have any pants or brief on, and female resident had her shirt pulled up some. Resident was removed from male residents room. She was then taken to the shower room, her hospice CNA came to do cares on her. DON notified of happenings. CNA staff aware to keep residents separated. On 9/1/23 at 12:11 PM, a Nursing progress note documented Note Text: Pt found in fell ow residents room sitting on the bed. OT found pt this way and brought pt out of the room. On 9/1/23 at 12:35 PM, a Nursing progress note documented Note Text: CNA found pt standing behind the curtain with fell ow resident. CNA brought both patients out of the room for lunch. On 9/6/23 at 1:39 AM, a Nursing progress note documented Note Text: Pt was found in another pt's bed at 0130 [1:30 AM]. She was in the same pt's room that had a res [resident] to res situation on 9/4 [23]. No issues today, the other pt calmly reported to nurse that she was in his bed and asked the nurse to help her to her room. On 9/6/23 at 11:21 AM, Nursing progress note documented Note Text: Patient is being flirtatous [sic] with a male resident on unit. They hold hands and pt is often found in male patients room. Earlier male pt was found on his bed with pants down while [resident name redacted] was in the room with him. Patients family is aware and per nursing management family is ok with patients behavior with this one male patient only, if she is to take a liking to any other resident we must notify her family. After pt was found with the other resident in his room they've been separate on the unit per their own accord. Will continue to monitor. A care plan Focus created on 9/18/23 and initiated on 1/8/24, documented I have a special friend I like to spend time with. We like to hold hands and kiss but sometimes forget that others become uncomfortable when we're in in [sic] public areas displaying affection. - Resident displaying affection to resident [resident identifier redacted] and resident [resident identifier redacted]. - Son understand and aware of his mother affection with this resident. - Frequent Visual check and her whereabouts. - Huddle/Inservice staff q [every] change of shift to redirect resident. - Activities that catered to her needs to redirect her behavior. The Interventions created on 9/18/23 and initiated on 1/8/24, included: a. Anticipate and meet needs. b. Approach in a calm manner. c. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. d. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. e. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. f. Minimize potential for resident's disruptive behaviors by offering tasks which divert attention. g. Provide a program of activities that is of interest and accommodates residents status. h. Staff to ensure when I am displaying affection towards others, that all parties are consenting. i. Stop and talk with resident when passing by. On 10/16/24 at 11:37 AM, an interview was conducted with the Medical Director (MD). The MD stated that sometimes he was involved with the capacity to consent for residents but it would depend on the situation with the resident. The MD stated that he would get help from psychiatry if the residents were in and out or questionable. The MD stated if there was going to be something legally he would get more opinions. The MD state if the capacity to consent affected anything medical the facility staff would consult with him. The MD stated that he was not consulted on the interaction with resident 70 and resident 208. The MD stated if he was consulted he did not document on either of the residents. The MD stated if the resident had behavioral health services they would usually follow the resident and not him. The MD stated if the residents were on the dementia unit he would expect to be consulted. The MD stated if the resident had no cognitive impairment, diagnoses, disability, or a BIMS score that would have triggered the decision the residents should have the capacity to consent. The MD stated if the residents were on the regular unit and there was a question about capacity he might call in someone else. The MD stated that the residents had a personalized screening for consent. On 10/17/24 at 3:32 PM, an interview was conducted with the DON. The DON stated if the resident interactions had the potential to be sexual they would look at cognition and if cognition was not there they would contact the family to see if that was something that would be consensual on their end. The DON stated that until that was identified we would keep the residents separated and make sure the residents were safe and their interactions were done safely. The DON stated for the capacity to consent they would look a the residents BIMS score, diagnoses, involvement with social work, and involve therapy on determining those assessments. The DON stated the capacity to consent would be scanned in the residents medical record. The DON stated that resident 208's son stated that if resident 208 was happy he was happy, but of course the son wanted to keep resident 208 safe. The DON stated that staff were educated that resident 70's and resident 208's relationship was consensual but if it was more sexual to redirect them. The DON stated that snuggling or sitting on the couch was okay and it was more of a companionship. The DON stated that she felt the conversations with the family and redirecting of the residents that there was no need to report because it was not abuse.

Based on interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents. Specifically, for 2 out of 69 sampled residents, a resident with cognitive impairment eloped from the facility memory care unit. In addition, a resident with cognitive impairment was moved out of the memory care unit and eloped from the facility. Resident identifiers: 50 and 70. Findings included: 1. Resident 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic kidney disease stage 2, dementia, essential hypertension, mild protein-calorie malnutrition, dysphonia, history of falling, cognitive communication deficit, major depressive disorder, and fall on same level. Resident 70's medical record was reviewed from 10/7/24 through 10/21/24. On 3/18/23 at 9:35 AM, an Elopement/Wandering Evaluation documented that resident 70 was a Low Risk. On 3/23/23 at 7:54 AM, a Social Service Summary note documented [Resident 70] is admitted to facility for skilled nursing stay at this time. Pt [patient] was living at home with a person that recently moved in with him. Pt has one brother who is not support for him at all. The contact [name redacted] was a senior companion for him and his mother for while and is the only long term he helps. Pt needs 24 hour care due to cognition status. On 3/23/23 at 4:45 PM, a Nursing note documented Note Text : provided assistance with telehealth today with neurologist care taker was present neurologist discussed no concerns that he could see he advised if patient wants to continue to follow up with dementia dx [diagnosis] diagnostic or new dx (example parkinsons) he shouldfollow [sic] up with a general neurologist and he gave recommendations caretaker stated she would schedule and assist patient with the follow up, . On 4/5/23 at 1:28 PM, a Weekly Skilled Review note documented . Cognitive impairment makes discharge concerning, but wants to go home. On 4/13/23 at 9:51 PM, a Nursing note documented Note Text : Resident was observed walking hallway. Resident wandered in room [ROOM NUMBER] and that resident reported he appeared confused, and she called for the CNA [Certified Nursing Assistant] who helped him. Resident currently resting in bed with eyes closed. On 4/15/23 at 9:04 AM, a Nursing note documented Note Text : Alert charting r/t [related to] COC [change of condition]. Resident was recently found wandering into other residents room. Resident has had no recurring behaviors noted during this shift. Resident is alert and oriented per baseline. Vital signs are within normal limits. On 4/16/23 at 4:22 PM, a Nursing note documented Note Text : Alert charting ongoing to pt for wandered into another pt room. No episode behavior within shift noted. On 4/16/23 at 7:34 PM, a Nursing note documented Note Text : Alert Note: On alert charting d/t [due to] wandering into room [ROOM NUMBER]. Was reported to this writer by the CNA that the family of the resident in room [ROOM NUMBER] told him that the resident had wandered into room [ROOM NUMBER] naked looking for the bathroom. At the time that the CNA was told of this the resident was in his own room. This was reported to management and the Physician. Will pass onto dayshift nurse. WCTM [will continue to monitor] resident for wandering throughout the shift. On 4/17/23 12:00 AM, an Encounter note documented . He has had some issues with wandering and going into peoples rooms, he will likely need the memory care unit for his safety. He reports to be feeling fair, denies any pain, nausea, or other complaints today. Neuro [neurological] - Alert, oriented x2 [person and place]. On 4/18/23 at 11:44 PM, a Nursing note documented Note Text : Resident observed waking in the hall by RT [Respiratory Therapist] and resident stated he just wanted to go sit down in the chairs at the end of the hall. CNA came out of a room observed the resident who told the resident he had been sleeping for three hours and wanted to go fora [sic] walk. When this writer observed resident, he was in his hospital gown which was open in the back had one shoe on and appeared confused he told this writer he was looking for a thing. On 4/19/23 at 12:49 AM, a Daily Skilled Note documented . Resident is Alert, Oriented X 1 [person] No Active Symptoms or Treatments effecting Level of Consciousness, Cognition, Sleep, Mood, or Behavior. Cognitive symptoms described as Alert with confusion. On 4/19/23 at 11:14 AM, a Nursing note documented Note Text : Pt moved from room [ROOM NUMBER] to room [ROOM NUMBER]. No problems with transfer. Provider and management aware. Social work aware. WCTM. (Note: Resident 70 was moved to the memory care unit that was locked.) On 6/18/23 at 9:35 AM, an Elopement/Wandering Evaluation documented that resident 70 was a Low Risk. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 70 had a Brief Interview for Mental Status (BIMS) score of 10. A BIMS score of 8 to 12 indicated moderate cognitive impairment. On 6/29/23 at 6:20 AM, a Social Service Summary note documented Social Service Summary : [resident 70] was moved into memory care due to wandering and disrobing after his skilled stay at facility. Pt has had an increased BIMS score since admission. Pt also had a diagnosis of UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY with a history of strokes. On 8/20/23 at 3:28 PM, a Nursing note documented Note Text : At approximately 1435 [2:35 PM] the pt's brother asked the nurse where the pt is. The nurse asked the brother if he had already checked the pt's room/bathroom as he can usually be found in there and the brother said he was not in there. At this point the nurse and the pt's brother set out to find the pt. Pt was not found in the main dining hall where church was being held. The nurse asked the CNAs if they had seen the pt, one said she thought he might be at church and another one said he had been let out to spend some time outside in front of the building, which others had apparently seen him do on previous occassions [sic]. One cna took her car out driving around the facility searching for the pt. The nurse and pt's brother continued to walk around inside and outside the facility looking for the pt. While looking outside one of the facility's transport staff told the nurse that he had received a call about the pt being found and was on his way to get him. Once returned to the facility, the nurse assessed the pt before the pt's brother took the pt out for their dinner appointment. Neuros [neurological] started since the fall was unwitnessed. On 8/20/23 at 9:25 PM, a Nursing note documented Note Text : On monitoring for elopement, frequent checks done. safety precautions in place. all needs anticipated and met. call light within reach for assistance. will cont [continue] to monitor. On 8/25/23 at 7:45 PM, a Fall Committee Interdisciplinary Team (IDT) note documented LATE ENTRY Note Text : DON [Director of Nursing] and PT [Physical Therapy] present during review on 08/25/2023. Most recent fall risk assessment conducted 08/20/2023, with a score of 9, indicating resident is a medium fall risk. Most recent fall recorded 08/20/2023, fall was unwitnessed and did not result in any injuries. New interventions include; re-assess elopement risk and education to staff on memory care unit policy and procedure. Exhibit Form 359 submitted to the State Survey Agency documented on 8/21/23 at 12:00 PM, The resident was friendly and simply stated he was bored and wanted to go outside. The resident stated that he also was trying to go see his brother in Springville. I asked him if he was happy here, he said yes. The resident said he feels safe and liked living here. On 8/21/23 at 11:00 AM, CNA 2 was interviewed by a staff member [CNA 2] was the staff member that opened the door and let [resident 70] leave. While speaking with her, she said that he simply asked to go outside, and she let him out. She claims that she has seen him outside of the memory care unit before, as well as the courtyard outside. So she didn't think it was an issue letting him out. After some education, she expressed remorse in allowing him outside unsupervised, and stated that she should have checked with the floor nurse. On 10/10/24 at 11:00 AM, an interview was conducted with CNA 1. CNA 1 stated that she was not aware of any residents that were able to go outside unattended and she had never seen any resident go outside unattended. CNA 1 stated she had worked at the facility since September 2024. CNA 1 stated if a resident wanted to go outside she would ask the nurse or tell the nurse to let them know who she was taking outside. CNA 1 stated that she would stay outside with the resident. CNA 1 stated the smoking area was secured and if a resident was left out in the smoking area they would not be able to get out. On 10/17/24 at 3:36 PM, an interview was conducted with the DON. The DON stated that resident 70's brother had come to the facility to take resident 70 out and that was not uncommon. The DON stated that resident 70's brother came in looking for resident 70 and the nurse was unsure where resident 70 was and starting looking for him. The DON stated as staff were outside the transportation called to tell them they found resident 70 and they were on the way to get him. The DON stated they would determine if a resident needed to be on the unit by looking at their previous elopement history, reports from the hospital, wandering or exit seeking in the facility, and they would discuss with the family proper placement. The DON stated the elopement assessment contained resident cognition, elopement history, and statements wanting to go home. The DON stated that resident 70 was noticed missing at 2:35 PM. The DON stated a bystander called that resident 70 had fallen in the grass a couple blocks away. The DON stated CNA 2 reported she had seen resident 70 up front outside before and thought it was okay to let him out. The DON stated that education was provided to CNA 2 to clarify if a resident on the secured unit could go out. The DON stated CNA 2 was a newer employee. The DON stated when resident 70 had been outside in the past it had been with recreation therapy. The DON stated they were using consistent staff on the unit and a therapist had a desk on the unit and was on the unit daily. 2. Resident 50 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, vascular dementia, pain, essential hypertension, need for assistance with personal care, and cognitive communication deficit. Resident 50's medical record was reviewed from 10/7/24 through 10/21/24. A quarterly MDS assessment dated [DATE], documented that resident 50 did not have a BIMS score due to resident 50 rarely or never understood. On 11/7/23, the Elopement Wandering Evaluation documented that resident 50 was a high risk for elopements. On 12/12/23 at 1:47 PM, a Nursing note documented Note Text : IDT discussion on moving resident off of unit d/t todays incident, as well as lack of exit seeking behavior. Resident is observed to wander aimlessly at times but is not exit seeking. Discussed plan to move resident today to room [ROOM NUMBER]A with IDT and resident Niece [name redacted]- Niece approves of room change and will be coming to see him at the facility today. On 12/12/23, resident 50 was to room [ROOM NUMBER]-A. (Note: Resident 50 was moved to room that was not on the secured unit.) On 12/24/23 at 3:42 PM, a Nursing note documented Note Text: Resident was seen at apx [approximately] 1245 [12:45 PM] after lunch today walking with walker towards 400 hall. Nurse could not locate resident about 10 minutes later and began looking. Staff and management notified when resident could not be found. Staff looked in all rooms, outside around building and neighborhood. Nurse attemped [sic] multiple times to contact family but unable to reach anyone. Nurse called police to report resident missing. Dispatch stated that a call was made about a man outside near our building. [Name redacted] fire dept [department], ambulance, and police were seen near [name redacted] underground parking. Nurse ran over to [name redacted] with dispatch on the phone. Resident was found with police and EMTs [Emergency Medical Technicians]. EMTs reported that he may have fallen, bystanders helped him to the side of the parking garage and called police. EMTs reported that all VS [vital signs] were wnl [within normal limits], resident appeared unharmed upon assessment. A small scrape to right knee is the only skin alteration nurse noted. Nurse and EMTs brought resident back to facility in ambulance. Resident was immediately returned to 100 Hall locked unit. Will have new placement in rm [room] 103. Neuro's started on resident on 100 Hall. VSS [vital signs stable], resident happy to be back. On 12/28/23 at 4:41 PM, a Nursing note documented Note Text : patient has been wandering hallways on memory care unit. He has entered rooms that are not his. He got upset at a cna for redirecting him out of a female residents room. He is currently in a room that is not his but is unoccupied. He does not want to go to his own room and doesn't show any reason to dislike his current room. He just seems to be confused and wandering. Otherwise no issues noted. Will continue to monitor On 2/21/24 at 11:25 PM, a Nursing note documented Note Text : Alert charting. Patient is struggling with the room move and is not happy with it. He was seeking to elope and asked staff to unlock the door. He is adamant that he is leaving and is complaining about his roommate not sleeping. On 2/25/23 at 11:57 AM, a Nursing note documented Note Text : resident and family notified of room change and was agreeable to room change today resident moved with all belongings room updated in chart. On 10/17/24 at 3:49 PM, an interview was conducted with the DON. The DON stated that resident 50 had admitted to the unit initially due to cognition and elopement risk. The DON stated that resident 50 was no longer exit seeking so staff thought it was appropriate to move resident 50 off the unit. The DON stated at 12:45 PM, after lunch resident 50 was walking the back side of the hall and 10 minutes later the nurse could not locate resident 50. The DON stated that staff did a search of the building, contacted the family, called the police department, and dispatch reported they might have located resident 50.

Based on observation, interview, and record review, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences. Specifically, for 1 out of 69 sampled residents, a resident that required oxygen (O2) therapy did not have physician's orders indicating the type of oxygen delivery system, when to administer the oxygen, and the equipment settings for the prescribed flow rates. Resident identifier: 103. Findings included: Resident 103 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, pneumonia, acute posthemorrhagic anemia, hypovolemic shock, and chronic obstructive pulmonary disease. On 10/8/24 at 9:35 AM, an observation was made of Licensed Practical Nurse 5 placing resident 103's O2 tubing and positioning the nasal cannula (NC) on resident 103's face. On 10/10/24 at 10:32 AM, an observation was made of resident 103 with a NC on his face and the O2 concentrator set at 2 Liters (L). A review of resident 103's medical record was conducted on 10/7/24 through 10/21/24. On 9/6/24, a physician's order for Resident 103 documented, O2 per NC at 2L per minute to keep saturations (sats) greater than 90% every shift. The physician's order was discontinued on 9/10/24 at 9:39 AM, due to discharged to the hospital. On 9/10/24 at 2:10 AM, a Nursing Progress Note revealed the following. Resident 103 transferred to the hospital at approximately 10:00 PM on 9/9/24. Provider notified of situation and gave orders for transfer to emergency department (ED). The resident transported to the hospital via ambulance service. Nurse to nurse report was given to ED charge nurse. On 9/13/24 at 8:20 PM, a Nursing Progress Note revealed the following. Resident 103 arrived back at the facility at approximately 3:30 PM, via facility's transport from the hospital. Patient was at the hospital for a Gastrointestinal (GI) bleed and GI ulcer. On 9/13/24, a physician's order for resident 103 documented, O2 per NC at 2 Liters per minute to keep sats greater than 90% every shift. The physician's order was discontinued on 9/19/24 at 9:34 AM. On 9/18/24 at 8:08 PM, a Nursing Progress Note revealed the following. Resident 103 was sent to the hospital via ambulance service at 7:30 PM, due to low O2 sats at 79%. On 9/18/24 at 11:25 PM, a Nursing Progress Note revealed the following. Resident 103 has been admitted to the hospital with hypoxia, hypotensive, and mental status. On 9/18/24, a Care Plan was initiated and created for resident 103. The focus revealed resident 103 had O2 therapy related to ineffective gas exchange and chronic obstructive pulmonary disease (COPD). The goal being that resident 103 would have no signs and symptoms (s/sx) of poor O2 absorption through the review date of 1/1/25. With an intervention of, if the resident was allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., change from mask to a nasal cannula). Return resident to the usual oxygen delivery method after the meal. On 9/25/24 at 5:45 PM, a Nursing Progress Note revealed the following. Resident 103 arrived with the facility's transport team from the hospital at around 2:00 PM. Patient was stable. On 9/25/24, a hospital discharging order revealed the following. Discharge oxygen instructions, wear 1L of oxygen for comfort and to keep saturations above 90%. A review of physician's orders revealed no active order for oxygen therapy upon return from hospital on 9/25/24. On 9/27/24, a Care Plan was initiated and created for resident 103. The focus revealed resident 103 had COPD. The goal would to be free of s/sx of respiratory infections through review date. With the intervention, give oxygen therapy as ordered by physician. On 10/16/24 at 2:20 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated every time when entering a room, she would do a quick assessment of the resident looking for s/sx of shortness of breath, check what the O2 level was set at, and using her nursing judgement she would adjust the level as needed. RN 3 stated that there were standing orders, which was to keep the resident O2 levels maintained. RN 3 stated if O2 levels dip to low she would call the physician for additional orders. RN 3 stated resident 103 should have an active order to be on oxygen. On 10/17/24 at 3:15 PM, an interview was conducted with the Director of Nursing (DON). The DON stated oxygen should have an order, even if there were standing order, there still needed to be an order that was entered into the resident's medical record.

Based on interview and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 69 sampled residents, a resident that complained about mouth pain for approximately ten months was not provided interventions timely. Resident identifier: 64. Findings included: Resident 64 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, anoxic brain damage, antisocial personality disorder, delusional disorders, dysphagia, anxiety disorder, psychotic disorder with delusions, mood affective disorder, major depressive disorder, mild protein-calorie malnutrition, essential hypertension, and mental disorder. Resident 64's medical record was reviewed on 10/9/24 through 10/21/24. A care plan Focus initiated on 6/7/23 and revised on 9/16/24, documented PAIN [resident 64] has acute/chronic pain r/t [related to] Cervicalgia, Polyneuropathy, GERD [gastroesophageal reflux disease], mouth pain and low back pain. The Goal included Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. and Will voice a level of comfort of [sic] through the review date. The interventions included: a. Anticipate need for pain relief and respond immediately to any complaint of pain. Initiated on 6/7/23. b. Monitor/record/report to Nurse any signs and symptoms (s/sx) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Initiated on 6/19/23. c. Pain assessment every shift. Initiated on 6/19/23, d. Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or complaints of (c/o) pain or discomfort. Initiated on 6/7/23. e. Reposition for comfort as tolerated. Initiated on 6/19/23. f. Use non pharmalogical interventions to aid in treating pain. Initiated on 6/19/23. An additional care plan Focus initiated on 6/19/23 and revised on 9/16/24, documented DENTAL [resident 64] is Edentulous. The Goal included Will be free of infection, pain or bleeding in the oral cavity by/through review date. The interventions initiated on 6/19/23, included: a. RESOLVED: Administer medications as ordered. Monitor/document for side effects and effectiveness. Resolved date 9/26/14. b. Coordinate arrangements for dental care, transportation as needed/as ordered. c. Monitor/document/report to Medical Doctor (MD) as needed (PRN) signs and symptoms of oral/dental problems needing attention: Pain (gums & palate), Abscess, Debris in mouth, Lips cracked or bleeding, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. d. Requires Mechanical Soft texture. Consult with dietitian and change if chewing/swallowing problems are noted. The Order Summary was reviewed. The following medications were started for pain management on 6/6/23, a. Acetaminophen oral tablet, give 650 milligrams (mg) by mouth every six hours PRN for pain. b. Benzocaine mouth/throat Gel 10 % dental, give one application by mouth before meals and at bedtime for gum pain. c. Celecoxib oral capsule, give 100 mg by mouth every 12 hours PRN for pain. d. Gabapentin oral tablet, give 100 mg by mouth three times a day for neuropathy. e. Lidocaine external patch 4 %, apply to affected area topically two times a day for pain. f. Tylenol oral tablet, give 650 mg by mouth three times a day for pain. On 12/11/23 at 12:22 PM, a Minimum Data Set (MDS) Notes documented LATE ENTRY Note Text : resident c/o difficulty chewing and swallowing r/t mouth pain and has active mar [Medication Administration Record] for mouth numbing gel. On 12/23/23 at 10:56 AM, a Nursing note documented Note Text : Pt [patient] asking to go to the hospital because he is sick and that his mouth is burning. Pt given his med [medication] for his mouth, pt went to his room. On 1/19/24 at 9:42 AM, Nursing note documented Pt c/o that he does not feel good, he feels really sick and needs to go to the hospital. Pt states his whole face is swollen and the right side of his face hurts more. States he feels dizzy and these symptoms started about 5 days ago. States he is dying. No swelling to face noted. Pt was able to eat most of his breakfast. Pt resp [respirations] even and unlabored. Breath sounds clear all quadrants, moving air well. Heart with reg [regular] rate. Abd [abdomen] soft non tender. Bowel sounds present all quadrants. Pt mouth checked with tongue blade and flashlight. No redness, no swelling no drainage noted. Pt has Benzocaine topical scheduled before meals and at hs [at bedtime]. Pt has started smoking again. not sure when he started again. MD made aware. On 1/20/24 at 9:41 AM, a Nursing note documented Note Text : Pt reports his head hurts really bad. Pt took his medications. Pt is sitting by the nurses station and took hold of his head and began to shake and kick he feet. incident last approx [approximately] 12 seconds. Pt states he needs to see a doctor because its happening too much. On 1/21/24 at 9:07 AM, an electronic Medication Administration Record (eMAR) -Medication Administration Note documented Note Text : MONITOR LEVEL OF PAIN every shift Pt states he is in pain rubbing the right side of his face, cannot rate pain. given scheduled Tylenol already. On 1/25/24 at 10:33 AM, an eMAR-Medication Administration Note documented Note Text : Celecoxib Oral Capsule 100 MG Give 100 mg by mouth every 12 hours as needed for pain PRN Administration was: Ineffective. On 1/30/24 at 9:23 AM, a Social Services note documented Note Text : Patient is stating that they need to see the dentist. Dentist has been notified for visit with patient. On 1/30/24 at 2:09 PM, a Nursing note documented Note Text : Dentist came to facility to see resident due to the pain in his gums/jaw. After assessment by dentist, recommendation to start diflucan 100mg PO [by mouth] BID [twice a day] for the first day, then once daily for 13 days for a total of 15 tablets. Family notified of treatment. On 2/2/24 at 6:52 AM, an eMAR-Medication Administration Note documented Note Text : MONITOR LEVEL OF PAIN every shift pt reports he gets really bad pain in his brain causing his brain to wobble. Pt grabbed his head with both hands and head began to shake and groaning for several seconds. MD notified. On 2/4/24 at 10:17 PM, a Nursing note documented Note Text : Alert Charting: Resident continues on fluconazole for gum infection, no adverse side effects noted at this time. Resident with c/o gum pain this eve [evening], pain relief gel administered as ordered. On 2/5/24 at 12:48 PM, a Nursing note documented Note Text : Alert Charting: Resident continues on fluconazole for gum infection, no adverse side effects noted at this time. Resident complained of normal mouth pain and pain relief gel administered as ordered. On 2/7/24 at 11:19 AM, a Nursing note documented Note Text : Pt continues on Fluconazole 100 mg BID daily. Pt still complains that his gum hurts and asks for more soon after it has been applied. No side effects noted. On 2/8/24 at 1:25 PM, a Nursing note documented Note Text : patient continues fluconazole to treat oral fungal infection patient reported mouth pain but no other concerns noted. On 2/8/24 at 11:18 PM, a Nursing note documented Note Text : ABX [antibiotic] Fluconazole Patient continues fluconazole to treat oral fungal infection. Patient reported mouth pain and said the topical cream helped during this shift. On 2/9/24 at 1:57 PM, a Nursing note documented Note Text : alert charting patient continues fluconazole for fungal infection in mouth pain still reports some pain. On 2/10/24 at 12:25 AM, an eMar - Shift Level Administration Note documented Note Text : Pt c/o gum pain for which he received orajel for comfort. On 2/15/24 at 11:24 AM, a Nursing note documented Note Text : ALERT CHARTING: Pt has finsihed [sic] course of Fluconazole. No neg [negative] side effects noted. Pt toleratied [sic] course of medication well. c/o gum pain this morning. On 3/2/24 at 12:17 PM, an eMAR-Medication Administration Note documented Note Text : MONITOR LEVEL OF PAIN every shift Pt complained of having gum pain. On 3/4/24 at 8:32 AM, an eMAR-Medication Administration Note documented Note Text : MONITOR LEVEL OF PAIN every shift Resident c/o pain 8/10 in gums. Benzocaine cream applied per orders. On 3/6/24 at 9:29 AM, an eMAR-Medication Administration Note documented Note Text : MONITOR LEVEL OF PAIN every shift my mouth hurts. On 4/2/24, a dental visit note documented a periodic oral evaluation. 4.2.24 - Exam complete. Patient was prescribed an antifungal mouthwash at our previous visit, which appeared to be successful. Patient has a severely dry mouth, encouraged drinking plenty of fluids. On 4/8/24 at 12:43 PM, a Change in Condition note documented Change in Condition : Symptoms or signs noted of Condition change: Pain (uncontrolled) . Notifications : Reported to primary care clinician: [name of Nurse Practitioner redacted] Date and time of clinician notification: 04/08/2024 7:00 AM . On 4/8/24 at 12:50 PM, a Nursing note documented Note Text : patient reported intense gum pain given tylenol and celebrex scheduled oragel [sic] with some relief md [Medical Director] don [Director of Nursing] and [name redacted] notified. On 4/8/24 at 3:45 PM, a Condition Follow-up note documented Condition follow-up note from start of : 4/8/2024 Resident is being monitored for : pain in gums . Pnl [pain level] 3 - 4/8/2024 14:33 [2:33 PM] Pain scale: Numerical Current Conditions : pain tylenol celebrex and orajel given therapy applied heat . On 4/8/24 at 11:30 PM, a Condition Follow-up note documented Condition follow-up note from start of : 4/8/2024 Resident is being monitored for : pain in gums . Pnl 2 - 4/8/2024 19:08 [7:08 PM] Pain scale: Numerical Current Conditions : pain tylenol celebrex and orajel given therapy applied heat . On 4/9/24 at 1:00 AM, an Encounter note documented . Chief Complaint / Nature of Presenting Problem: Mouth Pain History Of Present Illness: Patient is a [AGE] year-old male with a history of anoxic brain injury and antisocial personality disorder who has been complaining of mouth and gum pain. Nursing reports that he has been complaining of mouth and gum pain for a while. He has had all of his teeth already removed. On exam it was not the patient's teeth or mouth that was hurting him, it was the patient's jaw and face on the right side.He [sic] had no evidence of rash, induration, swelling, or cellulitis. He had no signs concerning for shingles. Diagnosis, Assessment and Plan . Mouth pain Right upper jaw/gum pain. No obvious abnormality or trauma. Increase gabapentin to 300 mg by mouth 3 times a day Consider increasing Celebrex if gabapentin increased does not improve pain. Patient has all of his teeth removed. Refer to ENT [Ear, Nose, and Throat] for evaluation. The note was signed by the Nurse Practitioner (NP). (Note: On 6/18/24, the Celebrex (celecoxib) was scheduled BID but the dose was never increased.) On 4/9/24, the Order Summary Report documented ENT referral r/t right upper jaw pain. On 4/9/24 at 2:49 PM, a Nursing note documented Note Text : N/O [new order] [name redacted] NP to increase Gabapentin to 300mg for neuropathy and refer pt to ent for right upper jaw pain. orders updated. Family and management aware. On 4/9/24 at 3:33 PM, a Condition Follow-up documented Condition follow-up note from start of : 4/8/2024 Resident is being monitored for : increased gum pain . Pnl 1 - 4/9/2024 09:39 [9:39 AM] Pain scale: Numerical Current Conditions : patient continues to complain of mouth pain given prn medications with scheduled encouraged rest pain has improved but he is still very uncomfortable . On 4/9/24 at 11:25 PM, a Condition Follow-up documented Condition follow-up note from start of : 4/8/2024 Resident is being monitored for : increased gum pain . Pnl 6 - 4/9/2024 20:16 [8:16 PM] Pain scale: Numerical Current Conditions : Patient continues to complain of increased gum pain. Patient was able to sleep after administration of PRN pain medication. Patient stated not drinking a lot of water at this time because the cold ice hurts his mouth. Room temperature water was provided. On 4/10/24 at 1:25 AM, a Nursing note documented Note Text : alert charting r/t COC [change of condition]: Resident continues to complain of gum pain. Patient was able to sleep this shift after administration of PRN pain medication. On 4/10/24 at 3:55 PM, a Condition Follow-up documented Condition follow-up note from start of : 4/8/2024 Resident is being monitored for : Increased gum pain . Pnl 4 - 4/10/2024 08:26 [8:26 AM] Pain scale: PAINAD [Pain Assessment in Advanced Dementia] Current Conditions : Res [resident]Gabapentin was increased to 300mg and it has helped but res is still complaining of some pain relieved with prn Tylenol and [NAME] [sic]. On 4/11/24 at 12:01 AM, a Condition Follow-up documented Condition follow-up note from start of : 4/8/2024 Resident is being monitored for : Increased gum pain . Pnl 5 - 4/10/2024 21:34 [9:34 PM] Pain scale: Numerical Current Conditions : Res Gabapentin was increased to 300mg resident is still complaining of pain, somewhat relieved with prn [NAME] [sic]. On 4/11/24 at 2:36 AM, a Condition Follow-up documented Condition follow-up note from start of : 4/8/2024 Resident is being monitored for : Increased gum pain . Pnl 6 - 4/11/2024 01:18 [1:18 AM] Pain scale: Numerical Current Conditions : Resident up to nurses' station with C/O 'bad' pain in gums. Given PRN Tylenol with some relief. On 4/11/24 at 5:29 AM, a Nursing note documented Note Text : Alert Charting - Med Change: Resident continues on increased Gabapentin without S/S [signs and symptoms] of adverse effects. Resident up at 0118 and again at 0500 [5:00 AM] with continued C/O gum pain. Given Tylenol at 0118, and instructed resident that I could only give Tylenol againafter [sic] 0718 [7:18 AM]. On 4/11/24 at 1:14 PM, a Nursing note documented Note Text : Gum pain charting. patient has [sic]requesting an appointment for his gums. patient was notified there has been a referral put in for that. been reporting pain continuously. On 4/12/24 at 1:25 AM, a Nursing note documented Note Text : Alert charting r/t med change: Gabapentin increased to 300mg. Patient was compliant [sic] with medication this shift and tolerated well. Patient continues to complain of intense pain to gums. On 4/12/24 at 1:26 AM, a Nursing note documented Note Text : alert charting r/t COC: Patient continues to complain of intense pain to gums. Patient was able to sleep after administration of PRN pain medication. On 4/12/24 at 5:00 AM, a Nursing note documented Note Text : Patient continues to complain of increase pain. Patient was administered PRN Tylenol at 0200 [2:00 AM]. At 0500 patient requested an additional dose of Tylenol. Nurse informed patient that no more doses or pain medication were available at the moment and that the provider would be made aware of the current orders not being sufficient to alleviate pain. Patient became very distressed and aggressive, and started kicking the door to the nurses station. Management & provider notified. On 4/13/24 at 2:43 AM, a Nursing note documented Note Text : Resident C/O pain/pressure to head and extreme gum pain. Tylenol ineffective. Given Celecoxib Oral Capsule 100 MG (Celecoxib). On 4/13/24 at 8:13 AM, an eMAR-Medication Administration Note documented Note Text : Celecoxib Oral Capsule 100 MG Give 100 mg by mouth every 12 hours as needed for pain PRN Administration was: Ineffective. On 4/15/24 at 1:00 AM, an Encounter note documented . Chief Complaint / Nature of Presenting Problem: Dental Pain History Of Present Illness: Patient is seen today complaining of dental pain. Patient is not able to identify the specific tooth. Patient already has an appointment with a dentist but unknown how soon that will be. Patient will likely need some breakthrough pain management until his appointment. Diagnosis, Assessment and Plan . Mouth pain Appointment with dentist is being established. Will offer patient some low-dose oxycodone as needed until his appointment. Will also consider prophylactic antimicrobial coverage. Follow-up Plan: Oxycodone 5 mg every 6as [sic] needed x 7 days or until his dentist appointment which ever comes first. The note was signed by the NP. (Note: The prophylactic antimicrobial coverage was not started.) On 4/15/24 at 10:59 AM, a Nursing note documented Note Text : Resident was started on oxycodone 5mg Q6 [every six] hours for 7 days to assist with gum pain until he is able to go to the dentist/ ENT appointment. On 4/15/24 at 12:18 PM, an eMAR-Medication Administration Note documented Note Text : Celecoxib Oral Capsule 100 MG Give 100 mg by mouth every 12 hours as needed for pain Given for severe oral pain. On 4/16/24 at 12:00 AM, an eMAR-Medication Administration Note documented Note Text : Acetaminophen Oral Tablet Give 650 mg by mouth every 6 hours as needed for pain PRN Administration was: Ineffective Follow-up Pain Scale was: 6. On 4/16/24 at 5:48 AM, a Nursing note documented Note Text : Alert Charting: Resident started on Oxycodone 5mg prn for pain. Resident C/O pain at 0059 [12:59 AM] 15 Apr [April]. with some relief after 1 hour. Resident with no S/S of adverse effects. On 4/16/24 at 7:02 AM, an eMAR-Medication Administration Note documented Note Text : MONITOR LEVEL OF PAIN every shift pt reports his neck pain is 9/10 and 10/10 for his mouth. On 4/17/24 at 12:51 PM, a Condition Follow-up note documented Condition follow-up note from start of : 4/8/2024 Resident is being monitored for : Increased gum pain . Pnl 4 - 4/17/2024 08:58 [8:58 AM] Pain scale: Numerical Current Conditions : Pt c/o gum pain today. Asked for more after he had received a recent dose. at one point pt was getting very anxious and grimacing and calmed down after medication was given to him. Pt does not like cold water, LN [Licensed Nurse] gave warm tap water which pt drank without difficulty. On 4/17/24 at 8:50 PM, a Condition Follow-up note documented Condition follow-up note from start of : 4/8/2024 Resident is being monitored for : Increased gum pain . Pnl 0 - 4/17/2024 19:43 [7:43 PM] Pain scale: Numerical Current Conditions : Patient complained of intense gum pain this shift. Pain was well controlled with PRN medication. Patient has been able to sleep this shift. No new concerns at this time. On 4/18/24 at 2:07 AM, an eMAR-Medication Administration Note documented Note Text : oxyCODONE HCl Oral Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for pain for 7 Days PRN Administration was: Ineffective Patient continues to complain of intense pain. Follow-up Pain Scale was: 6. On 4/19/24 at 4:07 AM, an eMAR-Medication Administration Note documented Note Text : Acetaminophen Oral Tablet Give 650 mg by mouth every 6 hours as needed for pain PRN Administration was: Ineffective Follow-up Pain Scale was: 6. On 4/20/24 at 12:17 AM, an eMAR-Medication Administration Note documented Note Text : Celecoxib Oral Capsule 100 MG Give 100 mg by mouth every 12 hours as needed for pain PRN Administration was: Ineffective. On 4/22/24 at 3:36 PM, a Nursing note documented Note Text : ENT clinic referred patient to a clinic specializing in TMJ [temporomandibular joint]. On 4/27/24 at 7:42 AM, an eMAR-Medication Administration Note documented Note Text : MONITOR LEVEL OF PAIN every shift about a 9, my gums hurt real bad. On 4/29/24 at 7:15 AM, an eMAR-Medication Administration Note documented Note Text : Acetaminophen Oral Tablet Give 650 mg by mouth every 6 hours as needed for pain Oral pain 7/10. On 6/4/24 at 3:57 PM, an eMAR-Medication Administration Note documented Note Text : CP [compound] -Magic Mouthwash 1:1:1 [ratio of viscous lidocaine, Maalox, and diphenhydramine] Give 10 ml [milliliters] by mouth four times a day for Mouth pain for 14 Days Swish and spit medication still pending from pharmacy, MD aware. (Note: The physician's order was discontinued on 6/18/24.) On 6/4/24, a dental visit note documented that a limited oral exam was completed and a cancer screening. Resident 64's pain was not addressed. On 6/18/24 at 1:00 AM, an Encounter note documented . Chief Complaint / Nature of Presenting Problem: Jaw pain History Of Present Illness: Patient is seen today for follow-up of his jaw pain which has been consistent and persistent since his admission last year. Patient is edentulous and has had workups with dentistry in the past. Patient has been taking numbing gels to his gums but there are concerns for TMJ. Patient is confused and requires memory care secure unit for safety and wandering risk. Patient does have as needed orders for Celebrexbut [sic] has not been taking them as often as he could. Follow-up Plan: Increase celebrex to 100 mg BID. The note was signed by the NP. On 6/18/24 at 9:34 AM, a Nursing note documented Note Text : new order: schedule Celebrex to BID for jaw pain. On 6/21/24 at 7:05 AM, an eMAR-Medication Administration Note documented Note Text : MONITOR LEVEL OF PAIN every shift states my gums are killing me. On 6/21/24 at 7:05 AM, an eMAR-Medication Administration Note documented Note Text : Celecoxib Oral Capsule 100 MG Give 100 mg by mouth two times a day for pain pt states his gums are killing me. On 6/21/24 at 2:03 PM, an eMAR-Medication Administration Note documented Note Text : (AA [antianxiety]- MONITOR EPISODES Q [every] SHIFT OF ANXIETY AEB [as evidenced by]: anxious statements every shift for monitoring c/o pain to gums and neck. On 6/21/24 at 7:16 PM, a Nursing note documented Note Text : ALERT CHARTING: No adverse reaction noted to Celebrex. Pt complains of having more pain to gums and neck today. Pt gets some relief after meds [medications] given. Pt has been OOB [out of bed] all day watching TV then falls asleep on the couch. Enc [encourage] to go to his bed but wants to stay in the day room to watch tv. On 6/22/24 at 3:25 AM, a Nursing note documented Note Text : Alert Charting: Resident continues on Celebrex. No adverse reactions noted. Resident does C/O more breakthrough pain than before medication change. On 6/23/24 at 12:48 PM, an eMAR-Medication Administration Note documented Note Text : Acetaminophen Oral Tablet Give 650 mg by mouth every 6 hours as needed for pain Follow-up Pain Scale was: 8 PRN Administration was: Ineffective md don aware. On 6/23/24 at 12:53 PM, a Nursing note documented Note Text : Pt asking for [NAME] [sic] before he eats lunch. Pt rates gum pain at 8/10. No relief from earlier dose. Pt slept for approx 2 hours and when he woke up for lunch he began c/o gum pain. MD, don aware. On 6/25/24 at 10:01 AM, an eMAR-Medication Administration Note documented Note Text : (AA)- MONITOR EPISODES Q SHIFT OF ANXIETY AEB: anxious statements every shift for monitoring pain to gums, pt gets very anxious and demands medication. On 7/2/24 at 1:00 AM, an Encounter note documented . Chief Complaint / Nature of Presenting Problem: Mouth and neck pain History Of Present Illness: Patient is a [AGE] year-old male who is a long-term resident of our memory care unit. He is complaining of chronic mouth and neck pain. Nursing reports that he complains of mouth and neck pain specially after he smokes. He refuses to wear his dentures. They feel like his pain has been much improved since starting Celebrex. Patient denies any other acute issues or concerns. Diagnosis, Assessment and Plan . Mouth pain Nurse reports that he is complaining of his mouth and neck pain less since starting the Celebrex. I encouraged the patient to stop smoking which he stated he would not. He appears to be comfortable. He states that he is not having mouth pain currently. Continue Celebrex 100 mg twice a day . The note was signed by the NP. On 7/5/24 at 7:49 AM, an eMAR-Medication Administration Note documented Note Text : Celecoxib Oral Capsule 100 MG Give 100 mg by mouth two times a day for pain Pt took his meds with water and began shaking his head and moaning and groaning om [sic] pain. calmed down after putting oral gel on his gums. On 7/8/24 at 12:02 PM, a Nursing note documented Note Text : patient refused tums this am stated it [NAME] [sic] his gums to chew. On 7/9/24 at 7:54 AM, an eMAR-Medication Administration Note documented Note Text : MONITOR LEVEL OF PAIN every shift 'whew' my gums hurts real bad. On 7/11/24 at 7:49 AM, an eMAR-Medication Administration Note documented Note Text : Calcium Carbonate Oral Wafer Give 500 mg by mouth one time a day for supplement refused stated it hurts his gums to chew md notified. On 7/21/24 at 7:47 AM, an eMAR-Medication Administration Note documented Note Text : Celecoxib Oral Capsule 100 MG Give 100 mg by mouth two times a day for pain pt states my whole mouth hurts really bad. On 8/5/24 at 11:51 AM, a Social Services note documented Note Text : Referred out to be seen by dentist. On 8/13/24 at 8:05 AM, a Social Services note documented LATE ENTRY Note Text : Resident was seen by dental today. Dentist advise using magic mouthwash regularly. On 8/13/24, a dental visit note documented 8.13.24 - Spoke to patient about using Magic Mouthwash regularly with indefinite refills. 8/5/24 - Per SW [Social Worker], [name redacted], pt is having tooth pain. (Note: The Magic Mouthwash was initiated on 8/21/24.) On 8/15/24 at 1:21 PM, an eMAR-Medication Administration Note documented Note Text : (AA)- MONITOR EPISODES Q SHIFT OF ANXIETY AEB: anxious statements every shift for monitoring Pt came out of his room this morning stating he was tripping bad, shaking his head and c/o gum pain. LN talked to pt for a few minutes and asked pt to describewhat [sic] he meant. Pt couldn't. meds given, with tylenol. On 8/15/24 at 3:50 PM, an eMAR-Medication Administration Note documented Note Text : Acetaminophen Oral Tablet Give 650 mg by mouth every 6 hours as needed for pain just as high as you can go on the scale. On 8/15/24 at 4:39 PM, an eMAR-Medication Administration Note documented Note Text : Acetaminophen Oral Tablet Give 650 mg by mouth every 6 hours as needed for pain Follow-up Pain Scale was: 10 PRN Administration was: Ineffective md and don aware. On 8/15/24 at 4:44 PM, a Nursing note documented Note Text : poor pain control to gums today. asking for oral gel more often, tylenol given x2. pt asking if someone can go buy some oral gel for him. If not, pt states he is going to break a window and climb out. On 8/16/24 at 10:57 AM, a Nursing note documented Note Text : Pt back from smoke break. Asking for oral Gel for his gums. Pt threatening to kick the door so he can get out or to have someone open the door for him so he can leave. Wants to break a window so he can get out. Redirecting not helpful. On 8/17/24 at 11:52 AM, an eMAR-Medication Administration Note documented Note Text : Acetaminophen Oral Tablet Give 650 mg by mouth every 6 hours as needed for pain Follow-up Pain Scale was: 2 PRN Administration was: Ineffective pt states it is hard to tell. On 8/18/24 at 6:26 AM, an eMAR-Medication Administration Note documented Note Text : Celecoxib Oral Capsule 100 MG Give 100 mg by mouth two times a day for pain It hurts real bad per pt. On 8/18/24 at 7:05 AM, an eMAR-Medication Administration Note documented Note Text : Acetaminophen Oral Tablet Give 650 mg by mouth every 6 hours as needed for pain Follow-up Pain Scale was: 5 PRN Administration was: Ineffective provider on call made aware. On 8/18/24 at 8:20 AM, a Nursing note documented Note Text : asking for oral gel for his gums nonstop. States well can I just go, like leave? Pt redirected with no results. Threatens to kick the door open or break a window and go out. States his gums are very painful. NP notified. Tylenol order changed to Q4prn 650 mg. NP will see pt today. On 8/19/24 at 1:00 AM, an Encounter note documented . Chief Complaint / Nature of Presenting Problem: Mouth Pain History Of Present Illness: Patient is seen today for acute complaints of mouth pain. Appears to be related to patient's gums, primarily on his right side. Patient is edentulous and had dentures at 1 point but they have since been misplaced. Patient has also been on a pureed diet in the past due to the lack of teeth but patient continues to refuse this diet and would prefer regular meals which has been difficult for him to consume due to the lack of teeth. Patient has also recently started smoking again but unknown correlation between smoking and gum pain. Gums on the right side do appear to be slightly irritated and red. Patient is asking for more Orajel. Diagnosis, Assessment and Plan . Mouth pain Unsure if this is related to patient starting smoking again. Concerns for possible abscess given the mildly irritated nature of his right lower gums. Patient has had dental workups in the past which have been unremarkable. Will order CBC [complete blood count], CMP [comprehensive metabolic panel] for concerns of possible abscess. The note was signed by the NP. On 8/19/24 at 1:59 AM, an eMAR-Medication Administration Note documented Note Text : Acetaminophen Oral Tablet Give 650 mg by mouth every 4 hours as needed for pain c/o gum hurting.Has [sic] had multiple doses of oral gel with no efffective [sic] relief. On 8/20/24 at 1:00 AM, an Encounter note documented . Chief Complaint / Nature of Presenting Problem: Lab Follow up/Agitation History Of Present Illness: Patient is seen today for follow-up of his mouth pain, agitation, and valproic acid level which was obtained yesterday. Valproic acid level of 30.1 which is subtherapeutic. Patient likely to benefit from an increase in his Depakote. Could be related to patient's agitation but unknown correlation with patient's mouth pain. Other workup has been unremarkable for signs of infection or possible abscess. Diagnosis, Assessment and Plan . Mouth pain Unsure if this is related to patient starting smoking again. Concerns for possible abscess given the mildly irritated nature of his right lower gums, however, yesterday's CBC was unremarkable for signs of infection. Patient has had dental workups in the past which have been unremarkable. Follow-up Plan: Increase Depakote to 500 mg 3 times daily, recheck Valproic acid level 8/26. The note was signed by the NP. On 8/20/24 at 7:55 AM, an eMAR-Medication Administration Note documented Note Text : Acetaminophen Oral Tablet Give 650 mg by mouth every 4 hours as needed for pain PRN Administration was: Ineffective Follow-up Pain Scale was: 5 swearing at nurse as pt stated he needed more oralgel [sic] for his gum pain. On 8/20/24 at 8:03 AM, a Nursing note documented Note Text : Pt received all of his am meds. shortly thereafter pt asking for more [NAME] [sic] and neck rub. Pt informed that he received his meds already. Asked pt to lie down for a little while and allow the meds to work. calling LN a liar and inappropriate language toward LN. ADON [Assistant Director of Nursing] notified as to what other option to use to help pt understand that his meds have been given already. On 8/20/24 at 1:37 PM, a Nursing note documented Note Text : Noon meds given with increase dose of Depakote plus tylenol. Pt sat in his room until lunch time. Pt now asking for more [NAME] [sic]. LN informed pt that he had already had his meds plus the[TRUNCATED]

Based on interview and record review, the facility did not provide routine and emergency drugs to its residents. Specifically, for 1 out of 69 residents, a resident that was experiencing pain, agitation, and depression did not have their medications available for administration. Resident identifier: 64. Findings included: Resident 64 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, anoxic brain damage, antisocial personality disorder, delusional disorders, dysphagia, anxiety disorder, psychotic disorder with delusions, mood affective disorder, major depressive disorder, mild protein-calorie malnutrition, essential hypertension, and mental disorder. Resident 64's medical record was reviewed on 10/9/24 through 10/21/24. On 1/18/24 at 4:51 PM, an electronic Medication Administration Record (eMAR) -Medication Administration Note documented Note Text : Zoloft Oral Tablet Give 200 mg [milligrams] by mouth in the evening for depression refill request sent. The January 2024 Medication Administration Record (MAR) was reviewed. Resident 64 did not receive Zoloft on 1/18/24. On 2/18/24 at 3:54 PM, an eMAR-Medication Administration Note documented Note Text : Zoloft Oral Tablet Give 200 mg by mouth in the evening for depression refill request sent. On 2/20/24 at 5:14 PM, an eMAR-Medication Administration Note documented Note Text : Zoloft Oral Tablet Give 200 mg by mouth in the evening for depression Pharm [pharmacy] notified of need of refill of this medication, they will deliver medication this evening. On 2/21/24 at 4:27 PM, an eMAR-Medication Administration Note documented Note Text : Zoloft Oral Tablet Give 200 mg by mouth in the evening for depression [pharmacy name redacted] notified, medication to be sent out this evening. The February 2024 MAR was reviewed. Resident 64 did not receive Zoloft on 2/18/24, 2/20/24, and 2/21/24. On 5/30/24 at 8:14 PM, an eMAR-Medication Administration Note documented Note Text : busPIRone HCl [hydrochloride] Oral Tablet 5 MG Give 10 mg by mouth three times a day for anxiety Medication not available. Ordered from pharmacy. MD [Medical Director] Staff and Nurse MGMT [management] notified. On 9/16/24 at 9:56 AM, an eMAR-Medication Administration Note documented Note Text : traMADol HCl Oral Tablet 25 MG Give 1 tablet by mouth three times a day for pain related to TMJ [temporomandibular joint] unavailable pharmacy will send md [Medical Director] notified ok to give at next scheduled dose. On 9/16/24 at 2:07 PM, an eMAR-Medication Administration Note documented Note Text : traMADol HCl Oral Tablet 25 MG Give 1 tablet by mouth three times a day for pain related to TMJ unavailable pharmacy will send md notified ok to give at next scheduled dose. The September 2024 MAR was reviewed. Resident 64 did not receive two doses of Tramadol on 9/16/24. On 10/14/24 at 9:29 AM, a physician's order documented TEGretol-XR [extended release] Tablet Extended Release 12 Hour 100 MG (CarBAMazepine ER) Give 1 tablet by mouth two times a day for nerve pain. On 10/14/24 at 8:06 PM, an eMAR-Medication Administration Note documented Note Text : TEGretol-XR Tablet Extended Release 12 Hour 100 MG Give 1 tablet by mouth two times a day for nerve pain waiting for pharmacy. On 10/14/24 at 11:32 PM, a Nursing note documented Note Text : *ALERT MED [medication] CHANGE TERGATOL [sic] - PT [patient] was not administered tergatol [sic] this shift d/t [due to] waiting for pharmacy. Pt was slightly agitated earlier and his biggest complaint was receiving more benzocaine gel for his gums. On 10/16/24 at 12:59 PM, an eMAR-Medication Administration Note documented Note Text : Depakote Oral Tablet Delayed Release 250 MG Give 500 mg by mouth three times a day for unspecified mood [affective] disorder med not available, pharm notified, they will fill today and send. On 10/15/24 at 10:36 AM, an interview was conducted with resident 64. Resident 64 stated that he had really bad mouth pain. Resident 64 stated he was supposed to see the dentist and he had not seen them yet. Resident 24 stated his gums were hurting bad right now, 24 hours a day. Resident 64 stated that he could ask for oral gel but he was tired of asking for it and the staff always ran out of the oral gel. Resident 24 stated at one time he had used a mouth wash but they took me off of it. Resident 64 stated that he was not sure if the mouth wash worked because he was not on it long enough. Resident 64 ended the conversation, stood up from the couch grimacing in pain, grabbed the right side of his face, and stated that he was in pain right now and was going to ask for his oral gel. On 10/17/24 at 10:44 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she did not have issues with the pharmacy and refilling medications. LPN 4 stated if she called the pharmacy for a refill the pharmacy would tell her the refill would be to the facility by the end of shift. LPN 4 stated the facility had an emergency medication system. LPN 4 stated the system had a stock of narcotics and antibiotics. LPN 4 stated if the pill card was in the blue line of medications she could push the reorder button in the eMAR system. LPN 4 stated if it was the last pill she would call the pharmacy. LPN 4 stated the eMAR system showed when the medication was last ordered and if the refill was in progress. On 10/17/24 at 3:18 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had changed pharmacies approximately six to eight months ago. The DON stated the emergency medication system contained narcotics and antibiotics. The DON stated the staff had to fax a signed order to the pharmacy in order to access the narcotics in the emergency medication system. The DON stated that staff were able to now reorder medications through the eMAR system.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 69 sampled residents, a resident administered his own blood pressure medication, diabetes medication, and blood thinner that his family member brought from home. There was no documentation from the nurse regarding the incident, dosage of the medications, and why medications were listed as administered by the nurse. Resident identifier: 160. Findings included: Resident 160 was admitted to the facility on [DATE] and readmitted after surgery on 9/28/24 with diagnoses which included fracture of shaft of right fibula, diabetes mellitus (DM), mild protein calorie malnutrition, hypertension (HTN), atrial fibrillation, and alcohol dependence. On 10/7/24 at 11:30 AM, an interview was conducted with resident 160 and his family member. Resident 160 stated he had asked for his medications at 6:00 AM. Resident 160 stated Physical Therapy came to get him at about 10:30 AM, and he asked for his medications again. Resident 160 stated the nurse told him, his medications had been administered. Resident 160 stated his family member brought in his Metformin, blood pressure medication, and blood thinner. Resident 160 stated he had to chase down the nurses to get his medications administered. Resident 160's family member confirmed she brought medications to resident 160 that morning. Resident 160's medical record was reviewed on 10/7/24 through 10/21/24. A physician's order dated 9/28/24, revealed Apixaban Oral tablet 5 MG [milligrams]. Give 1 tablet by mouth two times a day for blood thinner. A physician's order dated 9/28/24, revealed Metformin HCl [hydrochloride] oral Tablet 1000 MG. Give 1 tablet by mouth two times a day for DM. A physician's order dated 9/28/24, revealed Metoprolol Tartrate Oral Tablet 50 MG. Give 1 tablet by mouth two times a day for HTN. The October 2024 Medication Administration Record (MAR) revealed resident 160 was administered medications on 10/7/24 at 8:25 AM. Resident 160's progress notes were reviewed and there were no notes regarding resident 160 administering their own medications. On 10/15/24 at 11:47 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated there was a flex time for medication administration. RN 1 stated nurses could administer medications an hour before and an hour after the flex time, so the nurse was able to administer morning medications as early as 6:00 AM. RN 1 stated if family members administered medications to a resident she would report it, unless there was an order in place for residents to take medications from home. RN 1 stated she would report it to the Director of Nursing (DON). RN 1 stated she would want to know which medications and how much the resident took. RN 1 stated Metformin, blood thinner, and blood pressure medications would be concerning to have the resident administer instead of being administered the medications at the facility. On 10/15/24 at 12:25 PM, a phone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she did not administer resident 160's medication. LPN 1 stated a manger was helping her with medication pass that day and that nurse was the one who administered the medications. LPN 1 was informed that her initials were on the MAR for the morning of 10/7/24. LPN 1 stated that she did administer the medications. LPN 1 stated resident 160 had told her that he took medications from home and she was not sure how resident 160 obtained the medications. LPN 1 stated resident 160 refused the medications she offered him. LPN 1 stated she wasted the medications and thought she documented that the medications had been wasted. LPN 1 stated she should have documented the medications as refused. LPN 1 stated the process for administering medication was that she pulled up the residents medical record on the computer and went through each medication, then popped out the medication and clicked on the medication. LPN 1 stated after the medication was administered, then she went back into the medical record and documented that medications were administered. LPN 1 stated she did not go back into resident 160's medical record to click that the medication was refused. LPN 1 stated she remembered that resident 160's family member brought him the medications and did not see any medication bottles or verify dosages. LPN 1 stated that resident 160 stated he took three medications. LPN 1 stated she was not sure what time the medications were taken. LPN 1 stated resident 160 was really mad he had not received his medication but then was fine with her the rest of the day. On 10/16/24 at 10:40 AM, an interview was conducted with Assistant Director of Nursing (ADON). The ADON stated the nurse did not strike out the medications and note that resident 160's family member had brought in medications. The ADON stated if medications were wasted, the medications were put into a drug buster container. On 10/17/24 at 3:23 PM, an interview was conducted with the DON. The DON stated medications should not be provided to residents from family members. The DON stated the physician should be notified immediately so that staff can identify why the resident was needing family to bring in the medications. The DON stated she was not notified until the next day. The DON stated she notified the physician and the physician discussed the concerns with the resident. On 10/17/24 at 3:25 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated the DON would need to ask the family why they were bringing medications into the resident. The RNC stated staff also needed to complete an Interdisciplinary Team Meeting to determine if medications needed to be entered into the medical record with a specific time.

Based on interview, observation and record review, the facility did not ensure that 3 of 54 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level for all three residents. Resident identifiers: 33, 47, and 244. Findings include: HARM 1. Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, osteoporosis, pseudobulbar affect, major depressive disorder, and hypertension. Resident 33's medical record was reviewed on 1/23/23. Resident 33's weights were recorded as follows: a. 7/5/22 - 179.2 pounds (lbs) b. 1/3/23 - 169.4 lbs The weight loss above is a 5.5 percent weight loss in six months. No other weights were recorded for resident 33 between 7/5/22 and 1/3/23. In addition, no weights were recorded after 1/3/23 as of 1/23/23. Review of resident 33's nursing progress notes indicated that no notes had been entered regarding resident 33's weight loss. A Nutrition/Hydration Risk Evaluation dated 1/16/23 indicated that resident 33's weight status was Stable within 3 Months. No indication was made as to how the staff member made this determination. The Evaluation indicated that the resident was at Medium Risk. The Evaluation did not indicate any interventions for resident 33 to maintain or improve his nutritional status. Review of resident 33's assessments indicated that no other nutrition assessments had been completed for resident 33. On 1/30/23 at 3:38 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was part of the Nutrition at Risk (NAR) committee. The DON stated that each week the facility Registered Dietitian (RD) provided the NAR committee members with a list of residents who had experienced weight loss. The DON stated that after a resident experienced weight loss, they were typically reweighed weekly, and evaluated in the weekly NAR meeting until their weight stabilized. The DON stated that residents' weights usually have to be stable for several weeks before the residents would be removed from the list of residents who required weekly weights. The DON confirmed that resident 33 had not been re-weighed or re-evaluated by the NAR committee after experiencing a 10 pound weight loss. The DON did not provide an explanation as to why the resident had not been weighed weekly after the identified weight loss occurred. 2. Resident 47 was admitted on [DATE] with diagnoses that included dementia, diabetes mellitus, hypertension, bipolar disorder, cognitive communication deficit, dysphagia and history of traumatic brain injury. Resident 47's medical record was reviewed on 1/23/23. Resident 47's weights were recorded as follows: a. 6/7/22 - 188 lbs b. 7/5/22 - 186 lbs c. 8/2/22 - 178 lbs d. 8/9/22 - 176 lbs e. 9/6/22 - 174 lbs f. 10/4/22 - 173 lbs g. 11/1/22 - 174 lbs h. 12/6/22 - 169 lbs i. 1/3/22 - 163 lbs No weights were recorded after 1/3/23 for resident 47 as of 1/23/23. The weight loss above is a 12.4 percent weight loss in six months. On 12/6/22, the facility NAR committee recommended to increase resident 47's supplement to 60 milliliters twice daily. On 1/5/22, the facility NAR committee recommended to increase resident 47's supplement to 120 milliliters twice daily. On 1/30/23 at 3:38 PM, an interview was conducted with the facility DON. The DON confirmed that resident 47 had not been re-weighed or re-evaluated by the NAR committee weekly after experiencing a 6 pound weight loss between 12/6/22 and 1/3/22. The DON also confirmed that the NAR committee had not re-evaluated resident 47 after 1/3/23. The DON did not provide an explanation as to why the resident had not been weighed weekly after the identified weight loss had occurred. 46232 3. Resident 244 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Resident 244's medical record was reviewed on 1/24/23. An annual Minimum Data Set (MDS) assessment dated [DATE], documented that resident 244 required supervision assistance by one person to eat his meals. In addition, a quarterly MDS assessment dated [DATE] documented that resident 244 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident 244's care plan was reviewed. The focus area of the care plan that related to Activities of Daily Living (ADLs) for resident 244 dated 1/4/17 documented that resident 244 required extensive assistance for eating. The focus area of the care plan that related to nutrition dated 1/24/17 documented that resident 244 was at nutritional risk as evidenced by periods of decreased oral intake. An intervention implemented on 1/1/18 documented that resident 244 would have weekly weights for 30 days and monthly if stable and to promptly identify signs and symptoms of weight loss and dehydration. The last update to the nutritional risk focus area was on 12/22/22 that indicated the resident will be offered food and fluids and encouraged to eat. The update also indicated that weight loss was expected, but did not indicate the reason. On 7/5/22, staff documented that resident 244 weighed 185 lbs. On 8/2/22, staff documented that resident 244 weighed 179.4 lbs. A nurse practitioner/ physician assistant progress note dated 8/25/22 documented that resident 244 had some noted weight loss recently due to food preferences. No weights were documented for resident 244 between 8/2/22 and 11/2/22. On 11/2/22, staff documented that resident 244 weighed 187 lbs. On 12/6/22, staff documented that resident 244 weighed 173.2 lbs. On 12/6/22, a physician note indicated that a follow up visit was requested due to reported weight loss. Resident has not been eating well. He does report some depression but not as bad as it was before. He does not want to get up out of bed to participate in meals in the dining room as discussed as an option. He is willing to do mirtzapine if any more wt (weight) loss. A Nutrition Interdisciplinary Team Update for resident 244 dated 12/7/22 was reviewed. The Update indicated that resident 244 had lost 7.4 percent of his body weight in one month, and that he was only eating an average of 40 percent of his meals. The Update also indicated that a family member was notified of wt (weight) change via phone call, she is concerned about the loss and would like him to receive additional supplement drinks if possible. She would also like to to (sic) ensure that he is getting the feeding assistance that he needs d/t (due to) his tremors and would like staff to encourage him to come to the dining room for meals. NAR team recommends switch supplement. No indication was made on the Update that resident 244 would received increased assistance with dining, or would be encouraged to eat in the dining room. [Note: This is the only NAR meeting note for resident 244 between 7/1/22 and 1/24/23.] On 12/7/22 a physician note indicated that the physician was visiting with resident 244 and his sister. She is at residents bedside helping him with lunch. She expressed that he has significant difficulty with eating and is taken (sic) a long time to eat the food that he has so far. On 12/13/22, staff documented that resident 244 weighed 172 lbs. A Registered Dietitian Nutritional Risk Review dated 12/22/22 documented that resident 244 had experienced an 8 percent weight loss since 11/2/22, but that a fortified diet and supplements were being given. No other interventions were listed. A nurse practitioner/ physician assistant progress note dated 12/27/22 documented that resident 244 sister expressed concerns on 12/7/22 about resident 244's difficulty eating and stated it took resident 244 a long time to eat the food that he had so far. A new patient encounter progress note dated 1/3/23 documented that resident 244 had reportedly been losing weight. November 2 he weighed 187 pounds, today he weighs 168 which is a 10% weight loss. He states his appetite has not been very good as he just has not felt well. He remains at risk for significant weight loss and malnutrition. On 1/4/22, staff documented that resident 244 weighed 168 lbs. The exact meal percentage consumption for the last 30 days from 12/28/22 through 1/25/23 documented that resident 244 had consumed 50 % or less of his meals for 46 out of 72 documented times. The snack consumption for the last 30 days from 12/2822 through 1/25/23 documented that resident 244 accepted a snack 3 times out of the 24 instances documented. On 1/23/23 at 10:25 AM, Resident 244 was observed sitting up in his bed with his eyes closed. A breakfast meal tray was observed on a bedside table in front of resident 244. Most of the food on the breakfast tray appeared to be untouched except for the cereal. On 1/25/23 at 12:05 PM, Resident 244 was observed to have his eyes closed when his lunch tray was dropped off. The lunch tray was observed on a bedside table located to the right of resident 244. Resident 244 eye's continued to appear closed until 12:16 PM when the observation ended. On 1/25/23 at 1:47 PM, Resident 244 was observed to have his eyes closed and the lunch tray at his bedside appeared untouched. On 1/26/23 at 10:00 AM, Resident 244 was observed to have his eyes closed and had napkin placed across his chest with a handful of cheerios scattered across the napkin. A breakfast meal tray was observed on a bedside table in front of the resident. The breakfast meal tray had a piece of toast with jelly, a cut up sunny side up egg and a bowel of cheerios. The cheerios were the only item of food that appeared to have been eaten by the resident. On 1/26/23 at 12:10 PM, Resident 244 was observed to be sitting up in bed and staring at his food with shaking hands. A lunch tray comprised of meat and rice was observed on a bedside table located in front of resident 244. Resident 244 was observed to stare at his food for 17 minutes before he picked up his cup of milk with a shaky hand. Resident 244 was observed to bring the cup of milk to his mouth without spilling but began to cough when he drank the milk. Resident 244 was then observed to spill the remainder of his milk as he tried to put the cup back on his bedside table. A follow up interview was conducted with resident 244. Resident 244 stated he did not like his food and he did not plan to eat it. Resident 244 stated the only thing he liked was the milk and that he was not hungry. On 1/26/23 at 1:17 PM, Resident 244 was observed to have his eyes closed and his lunch tray appeared to be untouched expected for the milk he drank. On 1/30/23 at 12:07 PM, Resident 244's sister was observed to feed resident 244 homemade soup. A follow up interview was conducted with resident 244. Resident 244 stated he needed help feeding himself. Resident 244 stated that staff took his meal trays away and had not offered him any meal substitutions when he did not like the food. On 1/26/23 at 11:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated the resident 244 was an extensive two person assist and needed to be pulled up in bed for every meal. CNA3 stated that resident 244 ate in his room and that he was capable of feeding himself. CNA 3 stated that the only help resident 244 required with meals was to have his tray set up for him. CNA3 stated they were unsure the percentage of meals that resident 244 ate. On 1/25/23 at 12:34 PM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated that resident 244 was able to feed himself and only required setup assist with his tray. The MDSC stated that resident 244 didn't always eat all his food because he didn't like what he was served. The MDSC stated that resident 244 got a supplement with his meals. On 1/26/23 at 10:46 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 244 ate about 25% of his breakfast that day. CNA 2 stated resident 244 didn't usually eat very much of his meals. CNA 2 stated that resident 244 was capable of using silverware and was able to feed himself and did not require any help that the CNA was aware of. On 1/26/23 at 12:35 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated they had not worked with resident 244 since October 2022. The OT was asked if resident 244 was able to feed himself with his shaky hands and the OT responded that they were unsure how much help resident 244 needed with meals. The OT stated they evaluated and worked with residents that needed more assistance on activities of daily living (ADLs). The OT stated they were not working with resident 244 since he didn't need help with any ADLs that he was aware of. On 1/30/23 at 11:11 AM, an interview was conducted with Licensed Practical Nurse (LPN)1. LPN 1 stated that resident 244 was able to feed himself and was able to reach for his own waters. LPN 1 stated that every once in a while, resident 244 did not eat much but stated that he always ate his cereal. On 01/30/23 at 12:21 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that resident 244 needed set up assistance for meals. The CNAC stated they made sure to sit him up in bed to eat. The CNAC stated she handed resident 244 his chocolate milk with meals and stated that resident 244 did not have problems grabbing things with his hands. The CNAC stated there were times where resident 244 did not eat his food because he did not like what was served to him. The CNAC stated that resident 244 verbalized when he did not like his meal. The CNAC stated they have asked resident 244 if he needed help with meals but stated that resident 244 had refused the help. The CNAC stated they thought it was weird that resident 244's sister was feeding him lunch today because resident 244 was able to feed himself and did not need that much help with meals. On 1/30/23 at 3:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that supervision assist meant that a staff member had to help and encourage the resident to eat during meals. The DON stated if the resident's MDS documented him as a supervision assist, she expected staff to be at bedside during meal times to help feed him. The DON that when a resident has a 10% weight loss, they were triggered for weight loss and put on weekly weights, as well as reviewed in the weekly NAR meetings.

Based on interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with activities of daily living, had untreated pain, experienced weight loss, experienced falls with injuries, and obtained wounds. The findings for all the residents listed in this deficiency were cited at a harm level. Resident identifiers: 22, 27, 33, 47, 146, 244, and 298. Findings include: HARM ASSISTANCE WITH TOILETING 1. Resident 27 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, Parkinson's disease, neurocognitive disorder with Lewy Bodies, neuropathy, and insomnia. Resident 27's medical record was reviewed on 1/23/23. Resident 27's quarterly Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The MDS indicated that resident 27 was severely cognitively impaired. The MDS indicated that resident 27 required extensive assistance of two people for bed mobility, transferring, dressing, and toilet use. The MDS indicated that resident 27 required extensive assistance of one person for personal hygiene and bathing. The MDS further indicated that resident 27 was unable to move on and off the toilet without staff assistance. The MDS also indicated that resident 27 was always incontinent of bladder, and frequently incontinent of bowel. And the MDS also indicated that resident 27 was at risk for pressure sores, and currently had Moisture Associated Skin Damage (MASD). On 2/8/22 facility staff developed a care plan for resident 27 indicating that the resident had an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Immobility secondary to Parkinson's disease, impaired cognition secondary to Dementia with Lewy bodies . The goal listed was to safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions on the care plan included Requires Extensive assistance staff participation to use toilet, Requires Extensive assistance staff participation with transfer, and Requires Extensive Assistance staff participation to reposition and turn in bed. On 11/11/22 facility staff developed a care plan for resident 27 indicating that he had MASD to his sacrum related to incontinence. The care plan goal indicated that resident 27 Will be free from MASD through the review date. Interventions included encourage good nutrition and hydration in order to promote healthier skin, identify potential causative factors and eliminate/resolve, when possible, reposition frequently, treatment as ordered, and wound nurse to follow. Resident 27's medical record indicated that from 1/1/23 through 1/29/23, resident 27 required extensive assistance or was totally dependent on staff for bed mobility 69 of 79 opportunities. On 10/20/22 a weekly skin evaluation indicated that resident 27 has reddened Non blanchable area to his LT (left) buttock. Area was cleaned and barrier cream applied. [Note: No documentation could be found to indicate that the wound nurse had observed the wound until 11/11/22, approximately 22 days later.] On 10/29/22 a nurses note documented, Coccyx with open area. Wound care tech came and treated wound. Cleaned wound Anasept applied then dressing. Wound care nurse was notified. [Note: The first wound note was not entered until 11/11/22, approximately 14 days later.] On 11/10/22 a nurses note documented, Pt (patient) continues to area (sic) to buttocks that is no (sic) blanchable. I had informed the MD in the past about this area. We have applied barrier cream and bridged him while in bed. I have informed the wound CNA (Certified Nursing Assistant) about area. On 11/11/22 a nurses note documented, Wound care team assessed sacrum, 2.3 [centimeter (cm)]x (by)3.1xUTD (unable to determine) open area with redness in surrounding tissue wound bed is 40 slough, 30 granular, 30 macerated. entire area is blanching. On 11/16/22 resident 27 was assessed by a Physician Assistant-Certified (PA-C). The PA-C documented that the resident had MASD on his sacrum that had been present longer than one week. The size of the wound was documented as 2.3 cmx3.1 cm x UTD, with 90 percent granulation and 10 percent slough. The PA-C documented that the Tissue does blanch. The PA-C indicated that with each brief change, staff were to remove resident 27's dressing, cleanse the wound, apply skin prep to periwound, apply Medihoney to wound bed, and cover with Bandage. On 11/17/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that resident 27 had MASD to his sacrum that was 2.3x3.1xUTD . Patient has new MASD that is open, initial visit with wound provider this week, debrided with a curette to remove slough and macerated edges. Patient has barriers in wound healing of cognitive impairment and incontinence. MD (medical doctor) and family notified. On 11/18/22 a nurses note documented, Wound note MASD to sacrum wound nurse to call family. On 11/23/22, a Skin Ulcer Non-Pressure Weekly assessment was initiated for resident 27 but was left blank. On 11/23/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound had increased in size and measured 2.5x3.4xUTD. On 11/28/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound had increased in size and measured 2.5x3.4xUTD. On 12/5/22, resident 27 was assessed by a PA-C. The PA-C documented that Selective debridement due to slough today; 50 [percent] granular tissue with granular buds noted post debridement. Continue with current treatment. Pt is soiled today. On 12/12/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound was unchanged in size from 11/28/22. On 12/14/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 2.4x3.6xUTD. The periwound was described as Macerated. The PA-C documented that Sizes slightly larger after last week's debridement with increased granular tissue. Continue treatment. On 12/21/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's sacrum had increased slough, so selective debridement was completed. On 12/28/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that resident 27's wound measured 2.1x2.5xUTD. On 1/1/23 a nurses note documented, Resident has ongoing pressure wound to coccyx, difficult for resident to turn on side. Has pressure reducing mattress in place. On 1/4/23, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 1x2.1x0.3. On 1/11/23, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 1.5x2.3x0.3, which indicated the wound had increased in size. On 1/27/23, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound had not changed in size since 1/11/23. No documentation was located to indicate what days and times, if any, resident 27 refused to be repositioned or have his brief changed. On 1/30/23 at 11:30 PM, an observation was made of the Wound Nurse (WN) and CNA 2. The WN and CNA 2 were observed to enter the room of resident 27. Resident 27 was lying in his bed. The WN raised the resident's bed to approximately waist height and both the WN and CNA 2 pulled resident 27 toward the edge of the bed. The WN and CNA 2 then walked out into the hallway to obtain hand sanitizer. No side rails were observed to be pulled up on the bed, as resident 27 was lying on his right side, with his back near the edge of the bed, unattended by staff. The WN and CNA 2 returned to the bedside of resident 27 and donned gloves. The WN pulled back the soiled brief, and blood was observed on the brief. No dressing was observed on the wound. The WN cleaned the wound on resident 27 with dry gauze. Resident 27 said ouch as the wound was cleaned. The wound area had different shades of red, and dark red, neither area blanched when pressed on by the WN. The WN stated, We debrided last week, that's why it hurts. No pain alleviation was offered to resident 27. The WN again left the bedside to go to the hallway to obtain hand sanitizer. CNA 2 was standing at the foot of the bed with his back to the resident. While the WN was in the hallway, the soiled brief was observed to return to the original position and touch the cleaned wound. The WN donned gloves and returned to the bedside and repositioned resident 27 using the draw sheet on the bed. Her gloves were not observed to be changed. The WN applied ointment to a gloved finger then to the wound. The WN and CNA 2 were then called away to the doorway, the soiled brief again returned to its original position and touched the wound. The WN returned to the bedside, pulled the brief away from the wound and a new dressing was applied to the wound. The WN then put the soiled brief back in place over the new dressing on resident 27. At that time, both the WN and CNA 2 were observed to have left the room to obtain hand sanitizer, resident 27 was still observed to be close to the edge of the elevated bed with no side rails in position. Both staff then returned to reposition resident 27. On 1/30/23 at 11:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 8. When asked about resident 27, LPN 8 stated that staff were instructed to help the resident turn and keep him off his bum. LPN 8 stated that resident 27 did not get out of bed or attempt to get out of bed during the nighttime hours. LPN 8 stated that resident 27's sacrum wound was old and that it was caused by staff not repositioning the resident or changing his incontinence briefs timely. LPN 8 stated that in the recent past, there would only be one CNA assigned to the memory care unit, which was not enough to ensure the safety and good care of the residents. ASSISTANCE WITH EATING 2. Resident 244 was admitted to the facility on [DATE] with diagnoses that included but not limited to gastro esophageal reflux disease, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Resident 244's medical record was reviewed on 1/24/23. An annual Minimum Data Set (MDS) assessment dated [DATE], documented that resident 244 required supervision assistance with one person. In addition, a quarterly MDS assessment dated [DATE] documented that resident 244 had a Brief Interview for Mental Status (BIMS) score of 15. A Plan of Care problem with an effective date of 1/4/17 documented that resident 244 required extensive assist with bed mobility, transfers, . eating, toilet use and personal hygiene. Another care area identified with an effective date of 1/24/17 documented that resident 244 was at nutritional risk as evidence by periods of decreased oral intake. An intervention implemented on 1/1/18, documented that resident 244 would have weekly weights x 30 days and monthly if stable and to promptly identify signs and symptoms of weight loss and dehydration; interventions initiated timely daily. [Note: no weekly weights were done.] Registered Dietician Nutritional Risk Review dated 12/22/22 documented that resident 244 had an 8% (percent) weight loss since 11/2/22. A nurse practitioner/ physician assistant progress note dated 8/25/22 documented that resident 244 had some noted weight loss recently due to food preferences. A nurse practitioner/ physician assistant progress note dated 12/27/22 documented that resident 244's sister expressed concerns on 12/7/22 about resident 244's difficulty eating and stated it took resident 244 a long time to eat the food that he had so far. A new patient encounter progress note dated 1/3/23 documented that resident 244 had reportedly been losing weight. On November 2 he weighed 187 pounds, today he weighs 168 which is a 10% weight loss. He states his appetite has not been very good as he just has not felt well. He remains at risk for significant weight loss and malnutrition. The exact meal percentage consumption for the last 30 days documented that resident 244 had consumed 50 % or less of his meals for 46 out of 72 documented encounters. The snack consumption for the last 30 days documented that resident 244 accepted a snack 3 times out of the 24 instances documented. On 1/23/23 at 10:25 AM, resident 244 was observed sitting up in his bed with his eyes closed. A breakfast meal tray was observed on a bedside table in front of resident 244. Most of the food on the breakfast tray appeared to be untouched except, for the cereal. On 1/25/23 at 12:05 PM, resident 244 was observed to have his eyes closed when his lunch tray was dropped off. The lunch tray was observed on a bedside table located to the right of resident 244. Resident 244 eye's continued to appear closed until 12:16 PM. On 1/25/23 at 1:47 PM, resident 244 was observed to have his eyes closed and lunch tray at bedside remained untouched. On 1/26/23 at 10:00 AM, resident 244 was observed to have his eyes closed and had a napkin placed across his chest with a handful of cheerios scattered across the napkin. A breakfast meal tray was observed on a bedside table in front of the resident. The breakfast meal tray had a piece of toast with jelly, a cut up sunny side up egg and a bowel of cheerios. The cheerios were the only item of food that was touched by the resident. On 1/26/23 at 12:10 PM, resident 244 was observed to be sitting up in bed and staring at his food with shaking hands. A lunch tray compromised of meat and rice was observed on a bedside table located in front of resident 244. Resident 244 continued to stare at his food for 17 minutes before he picked up his cup of milk with a shaky hand. Resident 244 was observed to bring the cup of milk to his mouth without spilling but began to cough when he drank the milk. Resident 244 was then observed to spill the remainder of his milk as he tried to put the cup back on his bedside table. A follow up interview was conducted with resident 244. Resident 244 stated he did not like his food, and he did not plan to eat it. Resident 244 stated the only thing he liked was the milk and that he was not hungry. On 1/26/23 at 1:17 PM, resident 244 was observed to have his eyes closed and his lunch tray appeared to be untouched expected for the milk he drank. On 1/30/23 at 12:07 PM, resident 244's sister was observed to feed resident 244 homemade soup. A follow up interview was conducted with resident 244. Resident 244 stated he needed help feeding himself. Resident 244 stated that staff took his meal trays away and had not offered him any meal substitutions when he did not like the food. On 1/26/23 at 11:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated the resident 244 was an extensive two person assist and needed to be pulled up in bed for every meal. CNA 3 stated that resident 244 ate in his room and that he was capable of feeding himself. CNA 3 stated that the only help resident 244 required with meals was to have his tray set up for him. CNA 3 stated they were unsure the percentage of his meals that he ate. On 1/25/23 at 12:34 PM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated that resident 244 was able to feed himself and only required setup assist with his tray. The MDSC stated that resident 244 didn't always eat all his food because he didn't like what he was served. The MDSC stated that resident 244 got a boost with all his meals as a supplement. On 1/26/23 at 10:46 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 244 ate about 25% of his breakfast today. CNA 2 stated resident 244 didn't eat very much of his meals. CNA 2 stated that resident 244 was capable of using silverware and was able to feed himself and did not require any help that he was aware of. On 1/26/23 at 12:35 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated they had not worked with resident 244 since October. The OT was asked if resident 244 was able to feed himself with his shaky hands and the OT responded that they were unsure how much help resident 244 needed with meals. The OT stated they evaluated and worked with residents that needed more assistance on ADLs. The OT stated they were not working with resident 244 since he didn't need help with any ADLs that he was aware of. On 1/30/23 at 11:11 AM, an interview was conducted with Licensed Practical Nurse (LPN)1. LPN 1 stated that resident 244 was able to feed himself and was able to reach for his own waters. LPN 1 stated that every once in a while, resident 244 did not each much but stated that he always ate his cereal. On 01/30/23 at 12:21 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that resident 244 was a set up assistance for meals. The CNAC stated they made sure to sit him up in bed and during brief changes. The CNAC stated she handed resident 244 his chocolate milk with meals and stated that resident 244 did not have problems grabbing thing with his hands. The CNAC stated there were times where he did not eat his food because he did not like what was serve to him. The CNAC stated that resident 244 verbalized when he did not like his meal. The CNAC stated they have asked resident 244 if he needed help with meals but stated that resident 244 has refused the help. The CNAC stated they thought it was weird that resident 244's sister was feeding him lunch today because resident 244 was able to feed himself and did not that much help with meals. On 1/30/23 at 3:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that supervision assist meant that a staff member had to help and encourage the resident to eat during meals. The DON stated if the resident's MDS documented him as a supervision assist, she expected staff to be at bedside during mealtimes to help feed him. The DON that when a resident has a 10% weight loss, they were triggered for weight loss and put on weekly weights, as well as reviewed in the weekly Nutrition at Risk meetings. PAIN MANAGEMENT 3. Resident 22 was admitted to the facility on [DATE] with diagnoses that included degenerative disc disease; dementia; schizoaffective disorder, bipolar type; post-traumatic stress disorder; scoliosis; and hypertension. On 1/23/23 resident 22's medical record was reviewed. A care plan for resident 22 was developed on 3/9/20 with a focus area of Has acute and chronic pain r/t (related to) Chronic Physical Disability, pain in lower back, hip and knees. Goals included: Will voice a level of comfort of (sic) through the review date, Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date, and Will not have an interruption in normal activities due to pain through the review date. Interventions included: Able to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain; anticipate need for pain relief and respond immediately to any complaint of pain; engage in daily recreation activities for distraction to manage pain; monitor/record/report any signs and symptoms of non-verbal pain; and monitor/report to nurse if resident complains of pain or has requests for pain treatment. On 10/4/22, the Director of Nursing (DON) completed a quarterly Pain Management Review for resident 22. Despite resident 22's care plan indicating that resident 22 was able to describe his pain, the DON documented that resident 22 was unable to be interviewed. The DON also indicated that no observations were made of resident 22 in pain, but in contrast, that resident 22 was receiving oxycodone as needed for pain. On 1/4/23 a quarterly Pain Management Review was completed by facility staff for resident 22. The pain review indicated that resident 22 was interviewed that day. The review also indicated that resident 22 was receiving oxycodone for pain, and that at the time of the interview, resident 22 was experiencing pain at a level of 6 out of 10. The pain review indicated that resident 22 would like to experience no pain. The pain review also indicated that resident 22 had experienced pain in the last 5 days on a daily basis or several times a day. The review specified that the pain was located in resident 22's right knee and was especially bad in the late evening. At that time, resident 22 described the pain as stabbing, and that it affected his sleep. Resident 22 also indicated that physical activity made the pain worse, but rest and repositioning relieved the pain. Staff documented on the pain review that resident 22 could be observed to have difficulty sleeping and/or make facial expressions such as grimacing when he was experiencing pain. The goal was to Encourage the resident to verbalize his needs, and pain level before medication and document effectiveness of medication. The facility Provider Notifications binder at the nurse's station in the 100 hall was reviewed. The binder indicated that on 1/23/23 resident 22 was requesting time of scheduled oxy (oxycodone) to be changed from 1600 (4:00 PM) to 1400 (2:00 PM). The facility Provider Orders binder at the nurses station in the 100 hall was reviewed. The binder indicated that on 1/23/23 an order was written to increase resident 22's oxycodone to every 4 hours as needed. The order was signed by the Nurse Practitioner (NP). On 1/24/23 at approximately 9:30 AM, resident 22 was observed to approach the facility NP at the nurse's station. Resident 22 was observed to tell the NP that he was experiencing an increased amount of pain. The NP responded to resident 22 by stating that she was aware of his request for an increased dosage of his pain medication, and had approved it, so the resident should start to experience pain relief soon. On 1/24/23, the facility Nurse Practitioner (NP) entered an encounter note in resident 22's medical record. The encounter note indicated that Patient is seen today with complaint of pain. He states this pain is mostly in his knees, though he has pain to his back as well. He states he has been taking oxycodone every 6 hours but will have to take Tylenol in between because it does not carry through long enough. He states mostly at night it is very bothersome for him and makes for a long rough night. He states that he would like his oxycodone increased to every 4 hours. He also has a scheduled dose at 4:00 in the afternoon, that he would like changed to earlier in the afternoon. The NP documented resident 22's pain level at a 6. The NP documented that resident 22 had a diagnosis of Osteoarthritis involving multiple joints on both sides of body and to Increase Oxycodone to every 4 hours as needed and Change scheduled oxycodone to 1400 (2:00 PM) from 1600 (4:00 PM). On 1/25/23 at 8:45 AM, an observation was made of resident 22. Resident 22 walked down the hallway and stopped at the nurse's station. Licensed Practical Nurse (LPN) 6 was observed to be in the nurses station standing at the medication cart. Resident 22 approached LPN 6 and stated that his knee hurt. LPN 6 did not look up from the medication cart or acknowledge resident 22. LPN 6 then stated, Well, you will just have to wait a minute I'm busy. Resident 22 nodded and went over to a chair across from the nurse's station and sat down. LPN 6 was not observed to administer any pain medication to resident 22 during the medication pass observation. On 1/25/23 at 10:50 AM, resident 22 was approached by a staff member and invited to participate in a facility activity. Resident 22 responded by saying that he could not go to the activity because his knees hurt too much. Resident 22 also stated that he thought he could not have more medications until 3:00 PM, and that was too far away. On 1/25/23 at 11:10 AM, resident 22 was observed to approach LPN 6 at the nurse's station, and ask for a pain pill, stating that his knee is really hurting. Resident 22 was observed to be bending over at the waist and rubbing his right knee while grimacing. LPN 6 stated, Ya, I know I'm sorry. LPN 6 did not make any other comments to the resident, and turned away from the resident while the resident was standing at the nursing station. On 1/25/23 at 11:12 AM, LPN 6 approached resident 22 and handed him a cup of water, and a cup containing a pill. LPN 6 immediately turned around and walked back to her medication cart without observing if resident 22 swallowed the pill. In addition, LPN 6 did not assess resident 22's pain level. On 1/25/23 at 11:35 AM, resident 22's Controlled Drug Record was reviewed. The record did not have any oxycodone listed as having been signed out by LPN 6 that day. Resident 22's Medication Administration Record (MAR) did not indicate any as needed pain medications given on 1/25/22 at 11:12 AM by LPN 6. On 1/25/23 at 12:14 PM, resident 22 was observed to ask LPN 6 if she could put some cream on his knee because it was still hurting. LPN 6 responded by asking if the pain medications had helped, and resident 22 stated Not totally. On 1/25/23 at 12:45 PM, an interview was conducted with resident 22. Resident 22 stated that not last night but the night before, indicating the evening of 1/23/23, his pain had increased to a 9 out of 10. Resident 22 stated that at that time facility staff put ice and aspercreme on his knee and had given him some oxycodone. Resident 22 stated that after those interventions he was able to get another 2 hours of sleep. On 1/25/23 at 2:20 PM, an interview was conducted with LPN 6. LPN 2 stated that she had given oxycodone to resident 22 at 11:11 AM and had documented it. When asked about the Provider Notification and Provider Orders binders, LPN 6 stated that one binder was to let the providers know of any concerns, and the other binder was for providers to record their responses. LPN 6 stated that she checked the binder at the beginning of each shift, but that there really isn't a process in place yet. LPN 6 reviewed the binder and confirmed that resident 22 was to have his oxycodone increased as of 1/23/23. A nurses note dated 1/26/23 indicated that resident 22's Oxycodone 5mg increased to q4 (every four hours) prn (as needed) from q6 (every six hours) prn per NP on 1/25/23. New increased dose started today, resident aware of new changes. The entry was made by Assistant Director of Nursing (ADON) 2, not LPN 6 even though LPN 6 was made aware on 1/25/23. Resident 22's January 2023 MAR was reviewed. On 1/25/23, resident 22 did not receive his 4:00 PM scheduled dose of oxycodone. The MAR also indicated that resident 22's increased oxycodone orders did not go into effect until the morning of 1/26/23. On 1/30/23 at 11:02 AM, a follow up interview was conducted with resident 22. Resident 22 was asked about his pain management. Resident 22 produced a notepaper and stated that he had spoken with the NP on 1/23/23, and that the NP agreed to increase his pain medications. Resident 22 stated that it took time for the orders to get processed so he was without the increased dose for a day or longer. Resident 22 also stated that the oxycodone only covered his pain for 4 hours, and before his pain medication dose was increased, he was using lidocaine ointment to help get him through the remaining two hours before he could have more oxycodone. Resident 22 stated that by the end of the 4 hours his pain level was a 4 to 5, but at the end of 6 hours without pain medication his pain level increased to a 6. Resident 22 stated that he had a diagnosis of scoliosis, so it put his hip out, causing pain. Resident 22 stated that the majority of his pain was from his right knee which he injured in a fall. On 1/30/23 at 11:25 AM, an interview was conducted with the NP. The NP stated that she spoke with resident 22 two weeks ago at which time resident 22 talked about the pain with me. The NP stated that on 1/23/23 she had spoken with resident 22 about his pain again, at which time she approved the increase in pain medication. The NP stated that she wrote the order for the increased pain medication in the binder at the nurse's station. The NP stated that whenever she wrote an order in the binder, she always verbally informed the nurse on duty about the new order as well. On 1/30/23 at 11:35 AM, an interview was conducted with the Medical Director (MD). The MD stated that approximately three weeks ago, he and the NP had started a new process of writing down the new orders in a binder at the nurses station. The MD stated that when there was a verbal order given, the MD or NP would tell the nurse on duty, and write it in the binder so there was a record of the verbal order. The MD stated that he expected nurses to put the verbal order into effect ASAP, at most an hour. 4. Resident 298 was admitted on [DATE] with diagnoses which included femur fracture, history of falling, chronic respiratory failure with hypoxia, cognitive communication deficit, dysphagia, need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). On 1/23/23 at 12:00 PM, an interview was conducted with resident 298's family member (FM). The FM stated the resident was admitted on [DATE] at 8:00 AM and went almost an entire day without his pain being controlled. The FM stated the facility would not give resident 298 any pain medication because they didn't have an order (air quotes used when the FM said this). The FM stated on her arrival she demanded the nurse get resident 298 something for pain and the nurse went straight to the facility supply and got resident 298 a pain medication. The FM stated it did help resident 298 but he wouldn't have gotten anything if she had not come in. On 1/24/23, resident 298's medical record was reviewed. Resident 298 was admitted to the facility in the morning on 1/21/23, the first vital sign check was documented at 9:53 AM. A physician order dated 1/20/23 revealed an order for Tramadol 50 mg give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. A physician order dated 1/21/23 revealed an order for Percocet tablet 5-325 milligrams (mg) give 1 tablet by mouth every 4 hours as needed for pain. The Medication Treatment Record (MAR) for January 2023 revealed, at 1:56 PM resident 298 had pain at a level 5 on a 0-10 pain scale with 0 being no pain and 10 being immense pain. A Non-pharmalogical Intervention (NPI) was documented at 1:56 PM as, speak to/approach in a calm manner. No pain medication was documented as administered to resident 298. No documentation was found in the medical record of Tramadol being administered to resident 298 on 1/21/23. On 1/21/23 at 9:59 PM, the MAR documented resident 298 continued to complain of pain at a level 5 on the 0-10 pain scale and was administered Percocet 5mg. Note: This was 8 hours after resident 298 complained about pain. The pain medication was administered by the oncoming night shift nurse not the admitting day shift nurse. On 1/30/23 at 1:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) 9. LPN 9 stated she was the nurse who admitted resident 298 to the facility on [DATE]. LPN 9 stated the resident, and his family were upset because all she could give him was Tramadol for pain because the provider had already been into the facility to see the residents for the day, so the resident's orders didn't get sent to the pharmacy until the next day. LPN 9 stated she could have gotten the narcotic pain medication out of the house supply with a verbal order from the provider. LPN 9 stated that she probably should have done that sooner and that the family was upset she didn't give the resident anything for his pain except [TRUNCATED]

Based on interview, record review, and observation, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, residents experienced neglect, did not receive assistance with activities of daily living, experienced pain without timely intervention, developed wounds, experienced falls with injuries, and experienced weight loss without timely intervention. This resulted in seven deficiencies cited at a harm level. In addition, multiple deficiencies that were cited on the previous recertification survey and complaint surveys were re-cited on the current survey. Resident identifiers: 22, 27, 33, 41, 47, 60, 146, 244, 295, 298, and 349. Findings include: 1. Based on interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with activities of daily living, had untreated pain, experienced weight loss, and experienced falls with injuries. The findings for all the residents listed in this deficiency were cited at a harm level. Resident identifiers: 22, 27, 33, 47, 146, 244, and 298. [Cross refer to F600] 2. Based on interview and record review it was determined, for 1 of 54 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs). Specifically, a resident did not receive help with feeding assistance and cueing. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. [Cross refer to F676] 3. Based on interview, observation and record review, the facility did not ensure that 4 of 54 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, residents were not assisted with toileting or bathing as needed. This resulted in a finding of harm for one resident. Resident identifiers: 27, 60, 295 and 349. [Cross refer to F677] 4. Based on interview and record review it was determined that the facility did not ensure, for 1 of 54 sample residents, that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices. Specifically, one resident developed a penile wound and did not promptly receive appropriate wound care follow up and no investigation was done on the cause of the wound. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. [Cross refer to F684] 5. Based on observation, interview and record review, for 3 of 54 sampled residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as is possible. Specifically, one resident with a history of falls was left unattended and subsequently fell out of bed, receiving an eye laceration. The deficient practice for this resident was cited at a harm level. In addition, one resident with a history of falls was observed to not have interventions in place, and one resident was left unattended at the side of his bed. Resident identifiers: 27, 41 and 146. [Cross refer to F689] 6. Based on interview, observation and record review, the facility did not ensure that 3 of 54 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level for all three residents. Resident identifiers: 33, 47, and 244. [Cross refer to F692] 7. Based on interview, observation and record review, the facility did not ensure that pain management was provided to 2 of out 54 residents. Specifically, residents complained of pain but were not provided with pain relief medication in a timely manner. These findings resulted in harm for both residents. Resident identifiers: 22 and 298. [Cross refer to F697] 8. On 5/28/21 an annual recertification survey was conducted. Among the deficiencies cited included F550, F584, F600 (at a harm level), F609, F656, F677, F689 (at a harm level), F690 (at a harm level), F695, F697 (at a harm level), F756, and F835. The deficiencies listed were cited again during the current recertification survey. 9. On 6/1/22 a complaint survey was conducted. F880 was cited at that time. F880 was also cited again during the current recertification survey. 10. On 11/3/22 a complaint survey was conducted F550, F677, and F689 were cited. These deficiencies were cited again during the current recertification survey. On 1/30/23 at 3:37 PM, an interview was conducted with the facility Director of Nursing (DON). The DON was asked about the Quality Assurance program, and specifically what had been implemented with regard to brief changes for example. The DON stated that facility CNAs were provided a sheet to document if a resident received a brief change, and how often they should be checked. The DON stated that facility staff should be checking residents' incontinence briefs every couple of hours. When asked how the facility management was ensuring that briefs were being changed timely, the DON stated that facility staff were asking the [CNAs] if they have done their brief changes. On 1/30/23 at 3:17 PM, an interview was conducted with the facility Administrator (ADM). The ADM was asked about the Quality Assurance program, and specifically what had been implemented with regard to brief changes for example. The AM was asked what interventions had been put into place since November 2022 when the facility was cited for F677 after multiple residents were identified as not having their incontinence briefs changed in a timely manner. The ADM stated that they the CNA Coordinator was reviewing the electronic health record documentation to ensure the staff were documenting brief changes. When asked if there was a specific auditing process in place, the ADM stated there was not. When asked if observations were being made by facility management to ensure brief changes were occurring versus being documented, the ADM stated that intervention had not been put into place.

Based on interview, record review, and observation, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies; and regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. Specifically, residents experienced neglect, did not receive assistance with activities of daily living, experienced pain without timely intervention, developed wounds, experienced falls with injuries, and experienced weight loss without timely intervention. This resulted in seven deficiencies cited at a harm level. In addition, multiple deficiencies that were cited on the previous recertification survey and complaint surveys were re-cited on the current survey. Resident identifiers: 22, 27, 33, 41, 47, 60, 146, 244, 295, 298, and 349. Findings include: 1. Based on interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with activities of daily living, had untreated pain, experienced weight loss, and experienced falls with injuries. The findings for all the residents listed in this deficiency were cited at a harm level. Resident identifiers: 22, 27, 33, 47, 146, 244, and 298. [Cross refer to F600] 2. Based on interview and record review it was determined, for 1 of 54 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs). Specifically, a resident did not receive help with feeding assistance and cueing. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. [Cross refer to F676] 3. Based on interview, observation and record review, the facility did not ensure that 4 of 54 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, residents were not assisted with toileting or bathing as needed. This resulted in a finding of harm for one resident. Resident identifiers: 27, 60, 295 and 349. [Cross refer to F677] 4. Based on interview and record review it was determined that the facility did not ensure, for 1 of 54 sample residents, that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices. Specifically, one resident developed a penile wound and did not promptly receive appropriate wound care follow up and no investigation was done on the cause of the wound. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. [Cross refer to F684] 5. Based on observation, interview and record review, for 3 of 54 sampled residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as is possible. Specifically, one resident with a history of falls was left unattended and subsequently fell out of bed, receiving an eye laceration. The deficient practice for this resident was cited at a harm level. In addition, one resident with a history of falls was observed to not have interventions in place, and one resident was left unattended at the side of his bed. Resident identifiers: 27, 41 and 146. [Cross refer to F689] 6. Based on interview, observation and record review, the facility did not ensure that 3 of 54 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level for all three residents. Resident identifiers: 33, 47, and 244. [Cross refer to F692] 7. Based on interview, observation and record review, the facility did not ensure that pain management was provided to 2 of out 54 residents. Specifically, residents complained of pain but were not provided with pain relief medication in a timely manner. These findings resulted in harm for both residents. Resident identifiers: 22 and 298. [Cross refer to F697] 8. On 5/28/21 an annual recertification survey was conducted. Among the deficiencies cited included F550, F584, F600 (at a harm level), F609, F656, F677, F689 (at a harm level), F690 (at a harm level), F695, F697 (at a harm level), F756, and F835. The deficiencies listed were cited again during the current recertification survey. 9. On 6/1/22 a complaint survey was conducted. F880 was cited at that time. F880 was also cited again during the current recertification survey. 10. On 11/3/22 a complaint survey was conducted F550, F677, and F689 were cited. These deficiencies were cited again during the current recertification survey. On 1/30/23 at 3:37 PM, an interview was conducted with the facility Director of Nursing (DON). The DON was asked about the Quality Assurance program, and specifically what had been implemented with regard to brief changes for example. The DON stated that facility CNAs were provided a sheet to document if a resident received a brief change, and how often they should be checked. The DON stated that facility staff should be checking residents' incontinence briefs every couple of hours. When asked how the facility management was ensuring that briefs were being changed timely, the DON stated that facility staff were asking the [CNAs] if they have done their brief changes. On 1/30/23 at 3:17 PM, an interview was conducted with the facility Administrator (ADM). The ADM was asked about the Quality Assurance program, and specifically what had been implemented with regard to brief changes for example. The AM was asked what interventions had been put into place since November 2022 when the facility was cited for F677 after multiple residents were identified as not having their incontinence briefs changed in a timely manner. The ADM stated that they the CNA Coordinator was reviewing the electronic health record documentation to ensure the staff were documenting brief changes. When asked if there was a specific auditing process in place, the ADM stated there was not. When asked if observations were being made by facility management to ensure brief changes were occurring versus being documented, the ADM stated that intervention had not been put into place.

Based on interview, observation and record review, the facility did not ensure that pain management was provided to 2 of out 54 residents. Specifically, residents complained of pain but were not provided with pain relief medication in a timely manner. These findings resulted in harm for both residents. Resident identifiers: 22 and 298. Findings include: HARM 1. Resident 22 was admitted to the facility on [DATE] with diagnoses that included degenerative disc disease; dementia; schizoaffective disorder, bipolar type; post-traumatic stress disorder; scoliosis; and hypertension. On 1/23/23 resident 22's medical record was reviewed. A care plan for resident 22 was developed on 3/9/20 with a focus area of Has acute and chronic pain r/t (related to) Chronic Physical Disability, pain in lower back, hip and knees. Goals included: Will voice a level of comfort of (sic) through the review date, Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date, and Will not have an interruption in normal activities due to pain through the review date. Interventions included: Able to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain; anticipate need for pain relief and respond immediately to any complaint of pain; engage in daily recreation activities for distraction to manage pain; monitor/record/report any signs and symptoms of non-verbal pain; and monitor/report to nurse if resident complains of pain or has requests for pain treatment. On 10/4/22, the Director of Nursing (DON) completed a quarterly Pain Management Review for resident 22. Despite resident 22's care plan indicating that resident 22 was able to describe his pain, the DON documented that resident 22 was unable to be interviewed. The DON also indicated that no observations were made of resident 22 in pain, but in contrast, that resident 22 was receiving oxycodone as needed for pain. On 1/4/23 a quarterly Pain Management Review was completed by facility staff for resident 22. The pain review indicated that resident 22 was interviewed that day. The review also indicated that resident 22 was receiving oxycodone for pain, and that at the time of the interview, resident 22 was experiencing pain at a level of 6 out of 10. The pain review indicated that resident 22 would like to experience no pain. The pain review also indicated that resident 22 had experienced pain in the last 5 days on a daily basis or several times a day. The review specified that the pain was located in resident 22's right knee and was especially bad in the late evening. At that time, resident 22 described the pain as stabbing, and that it affected his sleep. Resident 22 also indicated that physical activity made the pain worse, but rest and repositioning relieved the pain. Staff documented on the pain review that resident 22 could be observed to have difficulty sleeping and/or make facial expressions such as grimacing when he was experiencing pain. The goal was to Encourage the resident to verbalize his needs, and pain level before medication and document effectiveness of medication. The facility Provider Notifications binder at the nurse's station in the 100 hall was reviewed. The binder indicated that on 1/23/23 resident 22 was requesting time of scheduled oxy (oxycodone) to be changed from 1600 (4:00 PM) to 1400 (2:00 PM). The facility Provider Orders binder at the nurses station in the 100 hall was reviewed. The binder indicated that on 1/23/23 an order was written to increase resident 22's oxycodone to every 4 hours as needed. The order was signed by the Nurse Practitioner (NP). On 1/24/23 at approximately 9:30 AM, resident 22 was observed to approach the facility NP at the nurse's station. Resident 22 was observed to tell the NP that he was experiencing an increased amount of pain. The NP responded to resident 22 by stating that she was aware of his request for an increased dosage of his pain medication, and had approved it, so the resident should start to experience pain relief soon. On 1/24/23, the facility Nurse Practitioner (NP) entered an encounter note in resident 22's medical record. The encounter note indicated that Patient is seen today with complaint of pain. He states this pain is mostly in his knees, though he has pain to his back as well. He states he has been taking oxycodone every 6 hours but will have to take Tylenol in between because it does not carry through long enough. He states mostly at night it is very bothersome for him and makes for a long rough night. He states that he would like his oxycodone increased to every 4 hours. He also has a scheduled dose at 4:00 in the afternoon, that he would like changed to earlier in the afternoon. The NP documented resident 22's pain level at a 6. The NP documented that resident 22 had a diagnosis of Osteoarthritis involving multiple joints on both sides of body and to Increase Oxycodone to every 4 hours as needed and Change scheduled oxycodone to 1400 (2:00 PM) from 1600 (4:00 PM). On 1/25/23 at 8:45 AM, an observation was made of resident 22. Resident 22 walked down the hallway and stopped at the nurse's station. Licensed Practical Nurse (LPN) 6 was observed to be in the nurses station standing at the medication cart. Resident 22 approached LPN 6 and stated that his knee hurt. LPN 6 did not look up from the medication cart or acknowledge resident 22. LPN 6 then stated, Well, you will just have to wait a minute I'm busy. Resident 22 nodded and went over to a chair across from the nurse's station and sat down. LPN 6 was not observed to administer any pain medication to resident 22 during the medication pass observation. On 1/25/23 at 10:50 AM, resident 22 was approached by a staff member and invited to participate in a facility activity. Resident 22 responded by saying that he could not go to the activity because his knees hurt too much. Resident 22 also stated that he thought he could not have more medications until 3:00 PM, and that was too far away. On 1/25/23 at 11:10 AM, resident 22 was observed to approach LPN 6 at the nurse's station, and ask for a pain pill, stating that his knee is really hurting. Resident 22 was observed to be bending over at the waist and rubbing his right knee while grimacing. LPN 6 stated, Ya, I know I'm sorry. LPN 6 did not make any other comments to the resident, and turned away from the resident while the resident was standing at the nursing station. On 1/25/23 at 11:12 AM, LPN 6 approached resident 22 and handed him a cup of water, and a cup containing a pill. LPN 6 immediately turned around and walked back to her medication cart without observing if resident 22 swallowed the pill. In addition, LPN 6 did not assess resident 22's pain level. On 1/25/23 at 11:35 AM, resident 22's Controlled Drug Record was reviewed. The record did not have any oxycodone listed as having been signed out by LPN 6 that day. Resident 22's Medication Administration Record (MAR) did not indicate any as needed pain medications given on 1/25/22 at 11:12 AM by LPN 6. On 1/25/23 at 12:14 PM, resident 22 was observed to ask LPN 6 if she could put some cream on his knee because it was still hurting. LPN 6 responded by asking if the pain medications had helped, and resident 22 stated Not totally. On 1/25/23 at 12:45 PM, an interview was conducted with resident 22. Resident 22 stated that not last night but the night before, indicating the evening of 1/23/23, his pain had increased to a 9 out of 10. Resident 22 stated that at that time facility staff put ice and aspercreme on his knee and had given him some oxycodone. Resident 22 stated that after those interventions he was able to get another 2 hours of sleep. On 1/25/23 at 2:20 PM, an interview was conducted with LPN 6. LPN 2 stated that she had given oxycodone to resident 22 at 11:11 AM and had documented it. When asked about the Provider Notification and Provider Orders binders, LPN 6 stated that one binder was to let the providers know of any concerns, and the other binder was for providers to record their responses. LPN 6 stated that she checked the binder at the beginning of each shift, but that there really isn't a process in place yet. LPN 6 reviewed the binder and confirmed that resident 22 was to have his oxycodone increased as of 1/23/23. A nurses note dated 1/26/23 indicated that resident 22's Oxycodone 5mg increased to q4 (every four hours) prn (as needed) from q6 (every six hours) prn per NP on 1/25/23. New increased dose started today, resident aware of new changes. The entry was made by Assistant Director of Nursing (ADON) 2, not LPN 6 even though LPN 6 was made aware on 1/25/23. Resident 22's January 2023 MAR was reviewed. On 1/25/23, resident 22 did not receive his 4:00 PM scheduled dose of oxycodone. The MAR also indicated that resident 22's increased oxycodone orders did not go into effect until the morning of 1/26/23. On 1/30/23 at 11:02 AM, a follow up interview was conducted with resident 22. Resident 22 was asked about his pain management. Resident 22 produced a notepaper and stated that he had spoken with the NP on 1/23/23, and that the NP agreed to increase his pain medications. Resident 22 stated that it took time for the orders to get processed so he was without the increased dose for a day or longer. Resident 22 also stated that the oxycodone only covered his pain for 4 hours, and before his pain medication dose was increased, he was using lidocaine ointment to help get him through the remaining two hours before he could have more oxycodone. Resident 22 stated that by the end of the 4 hours his pain level was a 4 to 5, but at the end of 6 hours without pain medication his pain level increased to a 6. Resident 22 stated that he had a diagnosis of scoliosis, so it put his hip out, causing pain. Resident 22 stated that the majority of his pain was from his right knee which he injured in a fall. On 1/30/23 at 11:25 AM, an interview was conducted with the NP. The NP stated that she spoke with resident 22 two weeks ago at which time resident 22 talked about the pain with me. The NP stated that on 1/23/23 she had spoken with resident 22 about his pain again, at which time she approved the increase in pain medication. The NP stated that she wrote the order for the increased pain medication in the binder at the nurse's station. The NP stated that whenever she wrote an order in the binder, she always verbally informed the nurse on duty about the new order as well. On 1/30/23 at 11:35 AM, an interview was conducted with the Medical Director (MD). The MD stated that approximately three weeks ago, he and the NP had started a new process of writing down the new orders in a binder at the nurses station. The MD stated that when there was a verbal order given, the MD or NP would tell the nurse on duty, and write it in the binder so there was a record of the verbal order. The MD stated that he expected nurses to put the verbal order into effect ASAP, at most an hour. 44640 2. Resident 298 was admitted on [DATE] with diagnoses which included femur fracture, history of falling, chronic respiratory failure with hypoxia, cognitive communication deficit, dysphagia, need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). On 1/23/23 at 12:00 PM, an interview was conducted with resident 298's family member (FM). The FM stated the resident was admitted on [DATE] at 8:00 AM and went almost an entire day without his pain being controlled. The FM stated the facility would not give resident 298 any pain medication because they didn't have an order (air quotes used when the FM said this). The FM stated on her arrival she demanded the nurse get resident 298 something for pain and the nurse went straight to the facility supply and got resident 298 a pain medication. The FM stated it did help resident 298 but he wouldn't have gotten anything if she had not come in. On 1/24/23, resident 298's medical record was reviewed. Resident 298 was admitted to the facility in the morning on 1/21/23, the first vital sign check was documented at 9:53 AM. A physician order dated 1/20/23 revealed an order for Tramadol 50 mg give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. A physician order dated 1/21/23 revealed an order for Percocet tablet 5-325 milligrams (mg) give 1 tablet by mouth every 4 hours as needed for pain. The Medication Treatment Record (MAR) for January 2023 revealed, at 1:56 PM resident 298 had pain at a level 5 on a 0-10 pain scale with 0 being no pain and 10 being immense pain. A Non-pharmalogical Intervention (NPI) was documented at 1:56 PM as, speak to/approach in a calm manner. No pain medication was documented as administered to resident 298. No documentation was found in the medical record of Tramadol being administered to resident 298 on 1/21/23. On 1/21/23 at 9:59 PM, the MAR documented resident 298 continued to complain of pain at a level 5 on the 0-10 pain scale and was administered Percocet 5mg. Note: This was 8 hours after resident 298 complained about pain. The pain medication was administered by the oncoming night shift nurse not the admitting day shift nurse. On 1/30/23 at 1:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) 9. LPN 9 stated she was the nurse who admitted resident 298 to the facility on [DATE]. LPN 9 stated the resident, and his family were upset because all she could give him was Tramadol for pain because the provider had already been into the facility to see the residents for the day, so the resident's orders didn't get sent to the pharmacy until the next day. LPN 9 stated she could have gotten the narcotic pain medication out of the house supply with a verbal order from the provider. LPN 9 stated that she probably should have done that sooner and that the family was upset she didn't give the resident anything for his pain except Tramadol. LPN 9 stated the resident had been restless and upset, but he then settled down after his oxygen was put on and his pain medication was given. Note: There is no documented administration of Tramadol to resident 298 in the January MAR. The first dose was documented as given at 10:37 AM on 1/22/23 by LPN 9. On 1/30/23 at 3:02 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) 1. The ADON 1 stated the admitting nurse should get the resident settled in the room, assess their needs, if the resident is in pain the nurse should check the orders and provide the pain medication that is ordered. The ADON 1 stated the facility does have a supply of medications, including narcotic pain medication, in a locked machine. If the resident is in need of a pain medication the nurses can get one from the machine while they wait for the resident's medications to arrive from the pharmacy. The ADON 1 stated a resident should not sit in pain while staff wait for a medication to come from the pharmacy if it is available in the facility.

Based on interview and record review it was determined, for 1 of 54 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs). Specifically, a resident did not receive help with feeding assistance and cueing. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. Findings include: Resident 244 was admitted to the facility on [DATE] with diagnoses that included but not limited to gastro esophageal reflux disease, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Resident 244's medical record was reviewed on 1/24/23. An annual Minimum Data Set (MDS) assessment dated [DATE], documented that resident 244 required supervision assistance with one person. In addition, a quarterly MDS assessment dated [DATE] documented that resident 244 had a Brief Interview for Mental Status (BIMS) score of 15. A Plan of Care problem with an effective date of 1/4/17 documented that resident 244 required extensive assist with bed mobility, transfers, . eating, toilet use and personal hygiene. Another care area identified with an effective date of 1/24/17 documented that resident 244 was at nutritional risk as evidence by periods of decreased oral intake. An intervention implemented on 1/1/18, documented that resident 244 would have weekly weights x 30 days and monthly if stable and to promptly identify signs and symptoms of weight loss and dehydration; interventions initiated timely daily. [Note: no weekly weights were done.] Registered Dietician Nutritional Risk Review dated 12/22/22 documented that resident 244 had an 8% (percent) weight loss since 11/2/22. A nurse practitioner/ physician assistant progress note dated 8/25/22 documented that resident 244 had some noted weight loss recently due to food preferences. A nurse practitioner/ physician assistant progress note dated 12/27/22 documented that resident 244's sister expressed concerns on 12/7/22 about resident 244's difficulty eating and stated it took resident 244 a long time to eat the food that he had so far. A new patient encounter progress note dated 1/3/23 documented that resident 244 had reportedly been losing weight. On November 2 he weighed 187 pounds, today he weighs 168 which is a 10% weight loss. He states his appetite has not been very good as he just has not felt well. He remains at risk for significant weight loss and malnutrition. The exact meal percentage consumption for the last 30 days documented that resident 244 had consumed 50 % or less of his meals for 46 out of 72 documented encounters. The snack consumption for the last 30 days documented that resident 244 accepted a snack 3 times out of the 24 instances documented. On 1/23/23 at 10:25 AM, resident 244 was observed sitting up in his bed with his eyes closed. A breakfast meal tray was observed on a bedside table in front of resident 244. Most of the food on the breakfast tray appeared to be untouched except, for the cereal. On 1/25/23 at 12:05 PM, resident 244 was observed to have his eyes closed when his lunch tray was dropped off. The lunch tray was observed on a bedside table located to the right of resident 244. Resident 244 eye's continued to appear closed until 12:16 PM. On 1/25/23 at 1:47 PM, resident 244 was observed to have his eyes closed and lunch tray at bedside remained untouched. On 1/26/23 at 10:00 AM, resident 244 was observed to have his eyes closed and had a napkin placed across his chest with a handful of cheerios scattered across the napkin. A breakfast meal tray was observed on a bedside table in front of the resident. The breakfast meal tray had a piece of toast with jelly, a cut up sunny side up egg and a bowel of cheerios. The cheerios were the only item of food that was touched by the resident. On 1/26/23 at 12:10 PM, resident 244 was observed to be sitting up in bed and staring at his food with shaking hands. A lunch tray compromised of meat and rice was observed on a bedside table located in front of resident 244. Resident 244 continued to stare at his food for 17 minutes before he picked up his cup of milk with a shaky hand. Resident 244 was observed to bring the cup of milk to his mouth without spilling but began to cough when he drank the milk. Resident 244 was then observed to spill the remainder of his milk as he tried to put the cup back on his bedside table. A follow up interview was conducted with resident 244. Resident 244 stated he did not like his food, and he did not plan to eat it. Resident 244 stated the only thing he liked was the milk and that he was not hungry. On 1/26/23 at 1:17 PM, resident 244 was observed to have his eyes closed and his lunch tray appeared to be untouched expected for the milk he drank. On 1/30/23 at 12:07 PM, resident 244's sister was observed to feed resident 244 homemade soup. A follow up interview was conducted with resident 244. Resident 244 stated he needed help feeding himself. Resident 244 stated that staff took his meal trays away and had not offered him any meal substitutions when he did not like the food. On 1/26/23 at 11:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated the resident 244 was an extensive two person assist and needed to be pulled up in bed for every meal. CNA 3 stated that resident 244 ate in his room and that he was capable of feeding himself. CNA 3 stated that the only help resident 244 required with meals was to have his tray set up for him. CNA 3 stated they were unsure the percentage of his meals that he ate. On 1/25/23 at 12:34 PM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated that resident 244 was able to feed himself and only required setup assist with his tray. The MDSC stated that resident 244 didn't always eat all his food because he didn't like what he was served. The MDSC stated that resident 244 got a boost with all his meals as a supplement. On 1/26/23 at 10:46 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 244 ate about 25% of his breakfast today. CNA 2 stated resident 244 didn't eat very much of his meals. CNA 2 stated that resident 244 was capable of using silverware and was able to feed himself and did not require any help that he was aware of. On 1/26/23 at 12:35 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated they had not worked with resident 244 since October. The OT was asked if resident 244 was able to feed himself with his shaky hands and the OT responded that they were unsure how much help resident 244 needed with meals. The OT stated they evaluated and worked with residents that needed more assistance on ADLs. The OT stated they were not working with resident 244 since he didn't need help with any ADLs that he was aware of. On 1/30/23 at 11:11 AM, an interview was conducted with Licensed Practical Nurse (LPN)1. LPN 1 stated that resident 244 was able to feed himself and was able to reach for his own waters. LPN 1 stated that every once in a while, resident 244 did not each much but stated that he always ate his cereal. On 01/30/23 at 12:21 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that resident 244 was a set up assistance for meals. The CNAC stated they made sure to sit him up in bed and during brief changes. The CNAC stated she handed resident 244 his chocolate milk with meals and stated that resident 244 did not have problems grabbing thing with his hands. The CNAC stated there were times where he did not eat his food because he did not like what was serve to him. The CNAC stated that resident 244 verbalized when he did not like his meal. The CNAC stated they have asked resident 244 if he needed help with meals but stated that resident 244 has refused the help. The CNAC stated they thought it was weird that resident 244's sister was feeding him lunch today because resident 244 was able to feed himself and did not that much help with meals. On 1/30/23 at 3:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that supervision assist meant that a staff member had to help and encourage the resident to eat during meals. The DON stated if the resident's MDS documented him as a supervision assist, she expected staff to be at bedside during mealtimes to help feed him. The DON that when a resident has a 10% weight loss, they were triggered for weight loss and put on weekly weights, as well as reviewed in the weekly Nutrition at Risk meetings. [Cross refer to F692]

Based on interview, observation and record review, the facility did not ensure that 4 of 54 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, residents were not assisted with toileting or bathing as needed. This resulted in a finding of harm for one resident. Resident identifiers: 27, 60, 295 and 349. Findings include: HARM 1. Resident 27 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, Parkinson's disease, neurocognitive disorder with Lewy Bodies, neuropathy, and insomnia. Resident 27's medical record was reviewed on 1/23/23. Resident 27's quarterly Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The MDS indicated that resident 27 was severely cognitively impaired. The MDS indicated that resident 27 required extensive assistance of two people for bed mobility, transferring, dressing, and toilet use. The MDS indicated that resident 27 required extensive assistance of one person for personal hygiene and bathing. The MDS further indicated that resident 27 was unable to move on and off the toilet without staff assistance. The MDS also indicated that resident 27 was always incontinent of bladder, and frequently incontinent of bowel. And the MDS also indicated that resident 27 was at risk for pressure sores, and currently had Moisture Associated Skin Damage (MASD). On 2/8/22 facility staff developed a care plan for resident 27 indicating that the resident had an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Immobility secondary to Parkinson's disease, impaired cognition secondary to Dementia with Lewy bodies . The goal listed was to safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions on the care plan included Requires Extensive assistance staff participation to use toilet, Requires Extensive assistance staff participation with transfer, and Requires Extensive Assistance staff participation to reposition and turn in bed. On 11/11/22 facility staff developed a care plan for resident 27 indicating that he had MASD to his sacrum related to incontinence. The care plan goal indicated that resident 27 Will be free from MASD through the review date. Interventions included encourage good nutrition and hydration in order to promote healthier skin, identify potential causative factors and eliminate/resolve, when possible, reposition frequently, treatment as ordered, and wound nurse to follow. Resident 27's medical record indicated that from 1/1/23 through 1/29/23, resident 27 required extensive assistance or was totally dependent on staff for bed mobility 69 of 79 opportunities. On 10/20/22 a weekly skin evaluation indicated that resident 27 has reddened Non blanchable area to his LT (left) buttock. Area was cleaned and barrier cream applied. [Note: No documentation could be found to indicate that the wound nurse had observed the wound until 11/11/22, approximately 22 days later.] On 10/29/22 a nurses note documented, Coccyx with open area. Wound care tech came and treated wound. Cleaned wound Anasept applied then dressing. Wound care nurse was notified. [Note: The first wound note was not entered until 11/11/22, approximately 14 days later.] On 11/10/22 a nurses note documented, Pt (patient) continues to area (sic) to buttocks that is no (sic) blanchable. I had informed the MD in the past about this area. We have applied barrier cream and bridged him while in bed. I have informed the wound CNA (Certified Nursing Assistant) about area. On 11/11/22 a nurses note documented, Wound care team assessed sacrum, 2.3 [centimeter (cm)]x (by)3.1xUTD (unable to determine) open area with redness in surrounding tissue wound bed is 40 slough, 30 granular, 30 macerated. entire area is blanching. On 11/16/22 resident 27 was assessed by a Physician Assistant-Certified (PA-C). The PA-C documented that the resident had MASD on his sacrum that had been present longer than one week. The size of the wound was documented as 2.3 cmx3.1 cm x UTD, with 90 percent granulation and 10 percent slough. The PA-C documented that the Tissue does blanch. The PA-C indicated that with each brief change, staff were to remove resident 27's dressing, cleanse the wound, apply skin prep to periwound, apply Medihoney to wound bed, and cover with Bandage. On 11/17/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that resident 27 had MASD to his sacrum that was 2.3x3.1xUTD . Patient has new MASD that is open, initial visit with wound provider this week, debrided with a curette to remove slough and macerated edges. Patient has barriers in wound healing of cognitive impairment and incontinence. MD (medical doctor) and family notified. On 11/18/22 a nurses note documented, Wound note MASD to sacrum wound nurse to call family. On 11/23/22, a Skin Ulcer Non-Pressure Weekly assessment was initiated for resident 27 but was left blank. On 11/23/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound had increased in size and measured 2.5x3.4xUTD. On 11/28/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound had increased in size and measured 2.5x3.4xUTD. On 12/5/22, resident 27 was assessed by a PA-C. The PA-C documented that Selective debridement due to slough today; 50 [percent] granular tissue with granular buds noted post debridement. Continue with current treatment. Pt is soiled today. On 12/12/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound was unchanged in size from 11/28/22. On 12/14/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 2.4x3.6xUTD. The periwound was described as Macerated. The PA-C documented that Sizes slightly larger after last week's debridement with increased granular tissue. Continue treatment. On 12/21/22, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's sacrum had increased slough, so selective debridement was completed. On 12/28/22, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that resident 27's wound measured 2.1x2.5xUTD. On 1/1/23 a nurses note documented, Resident has ongoing pressure wound to coccyx, difficult for resident to turn on side. Has pressure reducing mattress in place. On 1/4/23, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 1x2.1x0.3. On 1/11/23, resident 27 was assessed by a PA-C. The PA-C documented that resident 27's wound measured 1.5x2.3x0.3, which indicated the wound had increased in size. On 1/27/23, a Skin Ulcer Non-Pressure Weekly assessment was completed for resident 27. The assessment indicated that the wound had not changed in size since 1/11/23. No documentation was located to indicate what days and times, if any, resident 27 refused to be repositioned or have his brief changed. On 1/30/23 at 11:30 PM, an observation was made of the Wound Nurse (WN) and CNA 2. The WN and CNA 2 were observed to enter the room of resident 27. Resident 27 was lying in his bed. The WN raised the resident's bed to approximately waist height and both the WN and CNA 2 pulled resident 27 toward the edge of the bed. The WN and CNA 2 then walked out into the hallway to obtain hand sanitizer. No side rails were observed to be pulled up on the bed, as resident 27 was lying on his right side, with his back near the edge of the bed, unattended by staff. The WN and CNA 2 returned to the bedside of resident 27 and donned gloves. The WN pulled back the soiled brief, and blood was observed on the brief. No dressing was observed on the wound. The WN cleaned the wound on resident 27 with dry gauze. Resident 27 said ouch as the wound was cleaned. The wound area had different shades of red, and dark red, neither area blanched when pressed on by the WN. The WN stated, We debrided last week, that's why it hurts. No pain alleviation was offered to resident 27. The WN again left the bedside to go to the hallway to obtain hand sanitizer. CNA 2 was standing at the foot of the bed with his back to the resident. While the WN was in the hallway, the soiled brief was observed to return to the original position and touch the cleaned wound. The WN donned gloves and returned to the bedside and repositioned resident 27 using the draw sheet on the bed. Her gloves were not observed to be changed. The WN applied ointment to a gloved finger then to the wound. The WN and CNA 2 were then called away to the doorway, the soiled brief again returned to its original position and touched the wound. The WN returned to the bedside, pulled the brief away from the wound and a new dressing was applied to the wound. The WN then put the soiled brief back in place over the new dressing on resident 27. At that time, both the WN and CNA 2 were observed to have left the room to obtain hand sanitizer, resident 27 was still observed to be close to the edge of the elevated bed with no side rails in position. Both staff then returned to reposition resident 27. On 1/30/23 at 11:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 8. When asked about resident 27, LPN 8 stated that staff were instructed to help the resident turn and keep him off his bum. LPN 8 stated that resident 27 did not get out of bed or attempt to get out of bed during the nighttime hours. LPN 8 stated that resident 27's sacrum wound was old and that it was caused by staff not repositioning the resident or changing his incontinence briefs timely. LPN 8 stated that in the recent past, there would only be one CNA assigned to the memory care unit, which was not enough to ensure the safety and good care of the residents. POTENTIAL FOR HARM 2. Resident 60 was admitted to the facility on [DATE] with diagnoses that included dementia, cognitive communication deficit, diabetes mellitus, anxiety disorder, right hand contracture and muscle weakness. Resident 60's medical record was reviewed on 1/23/23. Resident 60's annual MDS assessment dated [DATE] was reviewed. The MDS indicated that resident 60 was severely cognitively impaired. The MDS indicated that resident 60 required extensive assistance with one staff member for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The MDS also indicated that resident 60 required extensive assistance with two staff members for transfers. The MDS indicated that resident 60 did not ambulate independently and required the use of a wheelchair. The MDS further indicated that resident 60 was unable to move on and off the toilet without staff assistance. The MDS also indicated that resident 60 was always incontinent of bladder, and frequently incontinent of bowel. The MDS also indicated that resident 60 was at risk for pressure sores, and currently had MASD. On 12/6/20 facility staff developed a care plan for resident 60 indicating that the resident had an ADL Self Care Performance Deficit r/t Immobility secondary to dementia . The goal listed was to safely perform bed mobility, transfers, eating, dressing, grooming toilet use and personal hygiene through the review date. Interventions on the care plan included Requires Extensive assistance 1-2 staff participation to . use toilet, Requires Extensive assistance 1-2 staff participation with transfers, and Requires Extensive Assistance 1-2 staff participation to reposition and turn in bed. On 1/6/21 facility staff developed a care plan for resident 60 indicating that resident 60 had bowel and bladder incontinence. Interventions included the use of disposable briefs for resident 60, and that the briefs should be changed with rounds, cares and as needed. On 1/25/23 the following observations were made of resident 60: a. At 10:02 AM, the resident was seated in her wheelchair by the main nurse's station in the 100 hall. b. At 11:10 AM, staff wheeled resident 60 into the day room. c. At 12:23 PM, staff wheeled resident 60 from the day room directly to the dining room. d. At 1:42 PM, staff wheeled resident 60 from the dining room directly to the day room. e. At 1:51 PM, the observation ended. At no time during the continuous observation was resident 60's incontinence brief changed, nor was resident 60 repositioned. On 1/25/23 at 1:51 PM, an interview was conducted with CNA 14. CNA 14 stated that she was paired with CNA 15 that day. CNA 14 stated that they showered resident 60 at 6:45 AM that morning, but that they had not changed resident 60's incontinence brief after that. On 1/25/23 at 1:54 PM, an interview was conducted with CNA 13. CNA 13 stated that she and CNA 16 had changed resident 60's incontinence brief that morning before breakfast. CNA 13 confirmed that she had not changed resident 60's incontinence brief since that time. CNA 13 stated that she was about to do rounds again with CNA 16, and they would change resident 60's incontinence brief. On 1/25/23 at 1:57 PM, an interview was conducted with CNA 15. CNA 15 stated that resident 60 required extensive assistance of staff to change her incontinence brief. CNA 15 stated that the typical schedule was to change the residents' incontinence briefs when she arrived for her shift at 6:00 AM, then at 9:00 AM, before lunch, after lunch, and at 2:00 PM before she left her shift. CNA 15 stated that she and CNA 14 had changed resident 60's incontinence brief when they first arrived for their shift at 6:00 AM, but had not changed it since then. CNA 15 stated that CNAs assigned on the 100 hall did not have assigned residents, we just help each other and we communicate. On 1/25/23 at 2:19 PM, an interview was conducted with CNA 16. CNA 16 confirmed that he did not change resident 60's incontinence brief after the initial brief change that morning. On 1/25/23 at 2:11 PM, resident 60 was observed to be wheeled to her room by CNAs 14 and 15. 3. Resident 349 was admitted to the facility on [DATE] with diagnoses that included dementia, vascular dementia, diabetes mellitus, chronic kidney disease muscle weakness, cognitive communication deficit, history of transient ischemic attack, and chronic obstructive pulmonary disease. Resident 349's medical record was reviewed on 1/23/23. Resident 349's annual MDS assessment dated [DATE] was reviewed. The MDS indicated that resident 349 was severely cognitively impaired. The MDS indicated that resident 349 required extensive assistance with one staff member for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The MDS also indicated that resident 349 required extensive assistance with two staff members for transfers. The MDS indicated that resident 349 did not ambulate independently and required the use of a wheelchair. The MDS further indicated that resident 349 was unable to move on and off the toilet without staff assistance. The MDS also indicated that resident 349 was always incontinent of bladder, and always incontinent of bowel. The MDS also indicated that resident 349 was at risk for pressure sores. On 2/9/18 facility staff developed a care plan for resident 349 indicating that the resident had an ADL Self Care Performance Deficit r/t functional mobility, strength and reduced balance, dementia . The goal listed was to maintain current level of function in bed mobility, transfers, eating, dressing, grooming toilet use and personal hygiene through the review date. Interventions on the care plan included requires assistance (one person extensive) to . use toilet, Requries (sic) (one person extensive staff participation with transfers, and Requires extensive assistance staff participation to reposition and turn in bed. On 6/30/21 facility staff developed a care plan for resident 349 indicating that resident 349 had bowel and bladder incontinence. Interventions included the use of disposable briefs for resident 349, and that the briefs should be changed with rounds, cares and as needed. On 1/25/23 the following observations were made of resident 349: a. At 10:02 AM, the resident was seated in her wheelchair in the day room. b. At approximately 12:30 PM, staff wheeled resident 349 from the day room directly to the dining room. d. At 1:44 PM, staff wheeled resident 349 from the dining room directly to the day room. e. At 1:51 PM, the observation ended. At no time during the continuous observation was resident 349's incontinence brief changed, nor was resident 349 repositioned. On 1/25/23 at 1:51 PM, an interview was conducted with CNA 14. CNA 14 stated that she was paired with CNA 15 that day. CNA 14 stated that they showered resident 349 at approximately 6:25 AM that morning, but that they had not changed resident 60's incontinence brief after that. On 1/25/23 at 1:54 PM, an interview was conducted with CNA 13. CNA 13 stated that she and CNA 16 had changed resident 349's incontinence brief that morning before breakfast. CNA 13 confirmed that she had not changed resident 349's incontinence brief since that time. CNA 13 stated that she was about to do rounds again with CNA 16, and they would change resident 349's incontinence brief. On 1/25/23 at 1:57 PM, an interview was conducted with CNA 15. CNA 15 stated that resident 349 required extensive assistance of staff to change her incontinence brief. CNA 15 stated that the typical schedule was to change the residents' incontinence briefs when she arrived for her shift at 6:00 AM, then at 9:00 AM, before lunch, after lunch, and at 2:00 PM before she left her shift. CNA 15 stated that she and CNA 14 had changed resident 349's incontinence brief when they first arrived for their shift at 6:00 AM, but had not changed it since then. CNA 15 stated that CNAs assigned on the 100 hall did not have assigned residents, we just help each other and we communicate. On 1/25/23 at 2:19 PM, an interview was conducted with CNA 16. CNA 16 confirmed that he did not change resident 349's incontinence brief after the initial brief change that morning. On 1/30/23 at 3:37 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that facility CNAs were provided a sheet to document if a resident received a brief change, and how often they should be checked. The DON stated that facility staff should be checking residents' incontinence briefs every couple of hours. When asked how the facility management was ensuring that briefs were being changed timely, the DON stated that facility staff were asking the [CNAs] if they have done their brief changes. On 1/30/23 at 3:17 PM, an interview was conducted with the facility Administrator (ADM). The ADM was asked what interventions had been put into place since November 2022 when the facility was cited for F677 after multiple residents were identified as not having their incontinence briefs changed in a timely manner. The ADM stated that they the CNA Coordinator was reviewing the electronic health record documentation to ensure the staff were documenting brief changes. When asked if there was a specific auditing process in place, the ADM stated there was not. When asked if observations were being made by facility management to ensure brief changes were occurring versus being documented, the ADM stated that intervention had not been put into place. 44640 4. Resident 295 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis, urinary tract infection, extended spectrum beta lactamase resistance, quadriplegia, hypertension, gastroparesis, malnutrition, ileostomy status and cachexia. On 1/23/23 at 10:00 AM, an interview was conducted with resident 295. Resident 295 stated he wished he could have a more thorough bed bath when he got one. Resident 295 stated he didn't get one very often, maybe once a week. Resident 295 stated a bed bath more often might be nice. An observation was made of resident 295. Resident 295's hair was oily, combed back, and large amounts of dandruff were observed in resident's 295's hair. On 1/24/23, resident 295's medical record was reviewed. Review of resident 295's bathing task for the last 30 days revealed resident 295 was not available on 12/28/22 (resident was in the local hospital), resident refused on 1/4/23, and resident refused on 1/23/23. All other dates were marked with not applicable (N/A) which meant per the certified nurses aides (CNA's) this task was not performed. On 3/12/22 a baseline care plan documented that resident 295 was at risk for alterations in Activities of Daily Living (ADLs) due to weakness, decline in function and mobility, bowel obstruction, status post-surgery and quadriplegia. An intervention documented resident required staff participation with bathing. An MDS dated [DATE] revealed resident 295 was totally dependent on staff with the bathing task and required substantial/maximal assistance with showering/bathing. Review of resident 295's bathing task revealed the residents bathing preference was day (AM), evening (PM) with as needed (PRN) night (NOC). Resident 295 had a shower schedule of Mondays, Wednesdays, and Fridays. Resident 295's shower/bathing history for the month of October 2022 revealed: a. 10/5/22 Sponge bath b. 10/7/22 Resident refusal c. 10/12/22 Sponge bath d. 10/19/22 Sponge bath e. 10/26/22 Resident refusal No resident refusal forms were provided by the facility for the 10/7/22 or 10/26/22. Resident 295 went 13 days from when a bath refusal was documented on 10/26/22 to when another bath was offered on 11/8/22. Resident 295's shower/bathing history for the month of November 2022 revealed: a. 11/8/22 Resident refusal b. 11/16/22 Resident refusal c. 11/23/23 Sponge bath d. 11/30/22 Resident refusal No resident refusal forms were provided by the facility for the month of November. Resident 295 went 14 days from when a bath refusal was documented on 11/30/22 to when a bath was documented on 12/14/22. Resident 295's shower/bathing history for the month of December 2022 revealed: a. 12/14/22 Sponge bath b. 12/21/22 Resident refusal c. 12/28/22 Resident unavailable (resident hospitalized ) No resident refusal forms were provided by the facility for the month of December. Resident 295's shower/bathing history for the month of January 2023, up until the survey date, revealed: a. 1/4/23 Resident refusal b. 1/23/23 Resident refusal A resident refusal form for 1/23/23 was not provided by the facility. On 1/26/23 at 12:40 PM, an interview was conducted with CNA 2. CNA 2 stated resident 295 was always good with cares and taking his bath, he was cooperative. CNA 2 stated he thought resident 295 was scheduled 2 or 3 times a week for a bath. CNA 2 stated resident 295 usually wouldn't ask for things so they had to anticipate his needs. On 1/30/23 at 1:10 PM, an interview was conducted with the CNA Coordinator (CNAC). The CNAC stated the CNAs were assigned to an area when they come on shift, and some CNAs did showers and some did resident care. The CNAC stated that the CNAs had a shift sheet which gave them information on the residents, and it included if residents were an every 2 or 4 hour turn, when their bath was and other needed information. The CNAC stated that the facility had a concierge service that did not do resident care but helped with getting waters, cleaning equipment and other things so the CNAs had more time with the residents. The CNAC stated that CNAs were expected to complete the tasks, including baths, that they were assigned for their shift and if they were unable to do this they were supposed to pass this information on to the oncoming shift. On 1/30/23 at 3:27 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) 1. The DON stated the CNAs were supposed to shower the residents on their scheduled shower days, unless the resident refused then the CNA was supposed to offer another day. The CNAs were supposed to have the residents sign a refusal form every time they refused a shower. The ADON 1 stated the residents' shower days were in the care plan so the CNAs and the nurses knew when they were and treatments could be coordinated if needed. [Cross refer to F867]

Based on observation, interview and record review, for 3 of 54 sampled residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as is possible. Specifically, one resident with a history of falls was left unattended and subsequently fell out of bed, receiving an eye laceration. The deficient practice for this resident was cited at a harm level. In addition, one resident with a history of falls was observed to not have interventions in place, and one resident was left unattended at the side of his bed. Resident identifiers: 27, 41 and 146. Findings include: HARM 1 . Resident 146 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, polyneuropathy, Parkinson's disease and generalized anxiety disorder. Resident 146's medical record was reviewed on 1/23/23. On 1/6/23 a Fall Committee note indicated that resident 146 had experienced 3 falls where she was found on the floor mat next to her bed. No injuries occurred . already in a low bed and a floor mat has been added. She has dementia and is not aware of her own safety. Will continue to try and keep her from having an injury but she will climb out of bed. An incident report dated 1/8/23 at 11:30 PM stated that, Pt (Patient) found lying face flat on the floor at 2330 (11:30 PM) yelling for help. When turned over to back pt (patient) had blood all over face two gashes found above and under right eye Gashes were heavily bleeding. Bruising on rt (right) eye and chin. Wound treated. Neuro status at baseline, awake and responsive with pupils dilating wnr (within normal range). Family contacted without success. Provider [Medical Director] notified and acknowledged. Pt to be sent to hospital for stitches and CT [computerized tomography] scan. On 1/11/23 a Fall Committee note indicated that resident 146 was found with two gashes . above and below right eye. Bruising noted on right eye and chin. Resident had rotator cuff injury to left arm with sling in place . Right eye laceration was treated and closed with glue. On 1/30/23 at 10:09 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN1 stated that the day of Resident 146's fall on 1/8/23, resident 146 had received an x-ray. LPN 1 stated after the x-ray tech finished working with Resident 146, the x-ray tech left Resident 146's bed in the high position and did not replace the floor mat, which was moved so the x-ray could be taken. On 1/30/23 at 12:07 PM, LPN 2 was interviewed. LPN 2 stated she was the staff member that found resident 146 after the fall on 1/8/23. LPN 2 stated that the bed was in the high position, that the bed mat was not in place when the fall on this date occurred, and that the bed rails were not in place when this fall occurred. LPN 2 stated that the x-ray tech left the bed in the high position and did not replace the floor mat. An incident report dated 1/13/23 at 11:50 PM stated that, . was found on the floor in her room on floor mat. Bed was in lowest position. Removed air mattress d/t (due to) every time . gets close to the edge of the bed she rolls out with the air mattress. Record review of Resident 146's Minimum Data Set (MDS) Annual assessment dated [DATE] documented that resident 146 has a Brief Interview for Mental Status (BIMS) score of 3, indicating that resident 146 has a severe cognitive impairment. This MDS Annual Assessment also documented that resident 146 requires assistance to complete Activities of Daily Living (ADLs). On 01/25/2023 at 10:22 AM, Resident 146 was observed laying in her bed. The bed was placed low to the ground and there was a fall mat next to her bed. POTENTIAL FOR HARM 2 . Resident 41 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, insomnia, and dementia. Resident 41's medical record was reviewed on 1/23/23. An incident report dated 12/29/2022 at 6:55 AM stated, CNAs (certified nursing assistants) were doing their rounds around 0430 (4:30 AM) and walked into Res (resident) room and found her on the floor. Her head was on the opposite side of the headboard laying on her blanket. Her legs were under her bed and she had a small skin tear and bruise on her right upper front hip area. She was awake and responding but was having a hard time breathing. She was put back on her bed. Resident unable to give Description. Her vitals were taken and we started neuro checks. Her BP (blood pressure) was 134/100, P (pulse) 89, O2 (oxygen) 77, RR (respiratory rate) 20. She seemed to have some trouble breathing so I started her on 2L (liters) of oxygen and tested her or [sic] covid. Her O2 (oxygen) went up to 88 and her covid test came back positive. Her pupils were reactive and she has some weakness on her left arm compared to her right arm. She was reacting to her name and was Ox3. Neuro checks are being done according to the times on sheet. A tiger text was sent to provider [Medical Director] and DON (Director of Nursing). An incident report dated 1/20/23 at 4:05 PM stated, The CNA reported that resident was trying to fight with brief change and trying to hit/kick him and then fell out of bed and hit her head on the floor. The bleeding from corner of R (right) eye laceration. The nursing staff helped her back in bed, assessed, the bleed from corner of R (right) eye laceration. The laceration site seen by wound nurse and ADON (Assistant Director of Nursing) , new order to send her out to ER (emergency room ). Resident has sent to ER. The care plan, orders, and Minimum Data Set (MDS) Assessments for resident 41 were reviewed. Resident 41 had orders for a fall mat to be next to her bed and for her bed to be in the low position since 9/15/22. Resident 41's Quarterly MDS dated [DATE] documented that Resident 41 has Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the interview. The MDS also documented that Resident 41 required assistance to complete Activities of Daily Living (ADLs). On 1/25/23 at 10:24 AM, Resident 41's room was observed. There was no fall mat next to her bed, and the bed was not in a low position. On 1/25/23 at 1:44 PM, CNA 1 was interviewed. CNA1 stated that Resident 41 fell down sometimes, so there should be cushioning on the floor next to Resident 41's bed and the bed should be in a low position. 44640 3. On 1/30/23 at 11:30 PM, an observation was made of the Wound Nurse (WN) and CNA 2. The WN and CNA 2 were observed to enter the room of resident 27. Resident 27 was lying in his bed, the WN raised the resident's bed to approximately waist height and both the WN and CNA 2 pulled resident 27 toward the edge of the bed. The WN and CNA 2 then walked out into the hallway to obtain hand sanitizer. No side rails were observed to be pulled up on the bed. The WN and CNA 2 returned to the bedside of resident 27, gloves were donned. The WN pulled back the soiled brief, blood was observed on the brief. No dressing was observed on the wound. The WN cleaned the wound on resident 27 with dry gauze. Resident 27 said ouch as the wound was cleaned. The wound area had different shades or red, and dark red, neither area blanched when pressed on by the WN. The WN stated, We debrided last week, that's why it hurts. No pain alleviation offered to resident 27. The WN again left the bedside to go to the hallway to obtain hand sanitizer. CNA 2 was standing at the foot of the bed with his back to the resident. While the WN was in the hallway, the soiled brief was observed to return to the original position and touch the cleaned wound. The WN donned gloves and returned to the bedside and repositioned resident 27 using the draw sheet on the bed. Gloves were not observed to be changed. The WN applied ointment to a gloved finger then to the wound. The WN and CNA 2 were then called away to the doorway, the soiled brief again returned to its original position and touched the wound. The WN returned to the bedside, pulled the brief away from the wound and a new dressing was applied to the wound. The WN then put the soiled brief back in place over the new dressing on resident 27. At that time, both the WN and CNA 2 were observed to have left the room to obtain hand sanitizer, resident 27 was still observed to be close to the edge of the elevated bed with no side rails in position. Both staff then returned to reposition resident 27.

Based on interview and record review it was determined that the facility did not ensure, for 1 of 54 sample residents, that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices. Specifically, one resident developed a penile wound and did not promptly receive appropriate wound care follow up and no investigation was done on the cause of the wound. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. Findings include: Resident 244 was admitted to the facility on [DATE] with diagnoses that included but not limited to gastro esophageal reflux disease, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Resident 244's medical record was reviewed on 1/24/23. A Plan of Care problem with an effective date of 1/4/17 documented that resident 244 required extensive assist for bed mobility, transfers, eating, toilet use and personal hygiene. An intervention implemented on 1/4/17, documented that resident 244 required skin inspections such as observing for redness, open areas, scratches, cuts and bruises. Another intervention implemented on 1/23/23 documented that resident 244 had actual impairment to his skin integrity related to trauma to penis. An intervention implemented on 1/23/23 documented resident 244 needed to be encouraged to have good nutrition and hydration in order to promote healthier skin. A physician order with a start date of 11/6/22 documented as followed, Wound care to top of penis, betadine and open to air every shift for trauma to penis. A nursing progress note dated 10/13/22 documented, Resident 244's sores around his penis are getting much worse. On the dorsal side it now looks like a hematoma has formed and he is complaining of extreme pain with brief changes . Needs to be followed up with wound care. [Note: Resident 244 was seen by wound care 13 days later on 10/26/22.] A physician progress note dated 12/1/22 documented that on 10/13/22 resident 244 had a dark red lesion to the lateral right aspect of his glans penis. There was no open lesion or drainage noted. The physician documented that lesions/sore appeared to be from friction and positioning. Wound care provider progress notes documented: a. Resident 244 was first seen by the wound care provider on 10/26/22 and identified resident wound was caused by trauma and stated the resident's penis had dark discoloration. b. Wound notes on 11/9/22, 11/16/22, 11/23/22, 11/30/22, and 12/7/22 stated that the wound was stable and the discoloration was lightening up. c. Wound note on 12/19/22 stated, Wound is getting smaller and there seems to be some hemosiderin staining without any open area. Continue current treatment plan. d. Wound notes for 12/28/22, 1/2/23, and 1/11/23 documented that the wound was stable and had improved as well as had decreased in size. Skin Ulcer non pressure weekly assessments revealed: a. On 11/6/22 it was documented that the onset of the penile wound was on 10/26/22. It stated that there was a dark discoloration to the trauma site at the top of the penis and that the wound was stable and there were no signs of infection. b. On 11/18/22 resident 244's penile wound was described as epithelial tissue that was dark red/purple and lightening up. c. On 12/12/22 it was documented that, wound continues to improve in discoloration continue iodine and open to air. Patient has barriers in wound healing of limited mobility, incontinence and wearing briefs due to incontinence. Weekly Skin evaluations dated 9/26/22, 10/10/22 and 10/31/22 revealed that resident 244's scrotal area was excoriated. No documentation could be located to indicate an investigation was completed regarding how resident 244 obtained the penile wound. On 1/30/23 at 8:55 AM, a wound observation was done on resident 244 while he got his brief changed. Resident was observed to be thin, no lines on the skin were noted from the brief being too tight. Resident 244's penis was noted to be in the center of peri area, pointing downward and the scrotal sac laid flat against the perineum. Resident 244's penis did not appear to have enough length to have been pinched in between either thigh. Certified Nursing Assistant (CNA) 4 was observed to hold the penis in his left hand and pulled the skin back, away from the head of the penis with his right hand. A ruby red area was noted on the resident's right side of the head of the penis; around the penis rim, the area had a center spot with spindles that came from the center area in every direction. The area was uniform in color. No drainage was noted and no open area noted to the penis. The same red discoloration was noted on the base of the scrotum in three different areas, one larger and two smaller areas. This was seen when resident 244 was rolled onto his left side and the buttocks area was viewed. The resident was rolled back to his back and the scrotum was lifted up; no other reddened areas were noted on the scrotum. Paste was applied to resident 244's buttocks and a brief was put under the resident. On 1/25/23 at 10:45 AM, an interview was conducted with CNA 7. CNA 7 stated that resident obtained his penile wound because he slid down in bed and sat on his penis. CNA 7 stated resident 244 has had this wound since November. On 1/25/23 at 10:48 AM, an interview was conducted with the Wound Physician Assistant (WPA). The WPA stated that resident 244 obtained his penis wound because the resident sat on it. The WPA stated when he first saw the penile wound, there was discoloration on it but stated that the color of it had improved. The WPA stated it was never an open wound but they applied betadine to protect his skin. The WPA stated resident 244's wound was stable enough that the nurses were applying betadine. On 1/30/23 at 8:55 AM, an interview was conducted with CNA 4 while he completed a brief change on resident 244. CNA 4 stated resident 244's penile wound happened because of the way resident 244 bent his legs that caused his penis to be pinched. CNA 4 was told it was a bruise and stated that resident 244's penis was black when he first saw it. CNA 4 stated he was unsure how long the penis was left in any certain position for it to have turned black. CNA 4 stated it was a significantly worse bruise when they discovered it back in December and stated the bruise was heading in the right direction since it had improved. CNA 4 stated they were told to keep a close eye on resident 244's penis and was told to notify the nurse if there were any concerns. CNA 4 stated they came in every 2 hours and repositioned resident 244. CNA 4 stated when a new brief was put on resident 4, they pulled the scrotum and the penis up in the center of the peri area and then put the brief in place. CNA 4 stated this was how the scrotum and penis were protected from being pinched. On 1/30/23 at 10:53 AM, an interview was conducted with the Wound Nurse (WN). The WN stated that resident 244's penile wound was due to a catheter he had while he was hospitalized . The WN stated that was what the wound care provider said at the initial evaluation of 244's penile wound on 10/26/22. The WN stated resident 244's wound had gotten smaller and the discoloration had lightened up. The WN stated the current wound care orders were to apply iodine to resident 244 penis. The WN stated the iodine helped lighten the bruising and it created a barrier that helped protect the skin. On 1/30/23 at 11:02 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 244 has had the penile wound for several for months. LPN 1 stated that it looked really bad when it was first discovered. LPN 1 stated that initially the resident's penis wound was tomato red in color. LPN 1 stated that resident 244 complained of a lot of pain when his wound was first discovered but stated he no longer complained of pain. LPN 1 stated the wound care nurse did the wound care on Mondays, Wednesdays and Fridays. LPN 1 stated the wound care orders were to apply betadine to resident 244's penis. On 1/30/23 at 12:26 PM, an interview was conducted with the Certified Nursing Aid Coordinator (CNAC). The CNAC stated that resident 244's skin appeared to be really thin and they were careful during brief changes to avoid any skin issues. The CNAC stated that resident 244 sometimes got a sore underneath his penis because of how sensitive and delicate his skin was. The CNAC stated she was not aware that resident 244 had a sore on his penis. The CNAC stated that when a new skin issue was discovered on any resident, their protocol was to notify the resident's nurse and wound nurse right away. The CNAC stated that resident 244 was able to reposition himself if he was uncomfortable but stated facility staff repositioned him every two hours. On 1/30/23 at 4:13 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 244's penile wound happened because the resident's penis was long and the resident sat on it. The DON stated that staff had to constantly go back and pull resident 244's penis out from underneath him. The DON stated wound care should have evaluated resident 244 sooner than 10/26/22. The DON stated that staff knew the protocol for getting the wound care nurse involved. The DON stated that if any staff noticed a wound, they notified the wound care nurse that same day. The DON stated she was unsure why there was a 13-day delay for wound care to see resident 244 and that no investigation was done on his penile wound. [Cross refer to F692]

Based on observation, interview and record review it was determined, for 7 out of 51 residents, that the facility did not ensure that the residents were free from abuse and neglect. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute [CONDITION(S)], a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . These examples of neglect were cited at a harm level. Additionally, a resident reported an allegation of verbal and physical abuse from a licensed nurse with medication administration, a resident reported an allegation of physical abuse from a Certified Nurse Assistant (CNA) during incontinence care, and a resident reported an allegation of rough treatment during incontinence care in September 2020 followed by an allegation of verbal abuse with cares by the same nurse in May 2021. Resident identifiers: 1, 17, 84, 101, 105, 108 and 112. Findings include: A. The following examples were cited at harm level for neglect. According to the interpretive guidance neglect was defined as the failure of the facility, it's employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Resident 84 was admitted to the facility 1/1/21. He has a history of traumatic subdural hemorrhage, nontraumatic subarachnoid hemorrhage, falls, [CONDITION(S)], neuromuscular dysfunction of the bladder, chronic respiratory failure, [CONDITION(S)], dependence on respirator, [CONDITION(S)], [CONDITION(S)] and dementia. Resident 84's medical record was reviewed on 5/23/21. On 5/20/21 at 10:23 PM, a nursing progress note indicated that resident 84's Foley cath (catheter) is patent and draining well at this time. On 5/22/21 at 7:48 PM, a nursing progress note indicated that res (resident) continued with no urine output since cath change to collect UA (urinalysis) and diaphoresis. MD order received at 1850 (6:50 PM) to transport resident to [name of local emergency room ]. [Name of local city paramedics] arrived at 1910 (7:10 PM) to transport and left at 1930 (7:30 PM). The nurses note did not indicate the date or time the catheter had been changed. On 5/22/21 the emergency room Report for resident 84 indicated that the facility staff note that they went to change the patients Foley catheter today for source control and had not had urine output since. They also note change in [CONDITION(S)] ([CONDITION(S)]) sputum upon suctioning from clear to green. emergency room Physician diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The emergency room Report also documented that a urinalysis indicated red colored urine, turbid in nature, nitrites present in abnormal nature, large amount of hemoglobin, proteins present at greater than 3000, Large abnormal White Blood Cells and bacteria 3 plus. On 5/22/21, a Computerized Tomography scan was performed in the emergency room . The impression from the radiologist included prominently distended bladder. The Foley catheter is malpositioned, the balloon is just inferior to the prostal gland. There is bilateral hydroureter with bilateral hydronephrosis, likely secondary to bladder outlet obstruction. On 5/25/21 at 10:06 AM, a record review showed a late entry progress note for 5/23/21 regarding resident 84. The nursing progress note stated that resident 84 was hospitalized on [DATE]. The note also stated that patient was reported to be tachy (tachycardic) with a HR (heart rate) reaching 145 and a low grade fever. Patient was assessed and on call was notified of the change at 1000 (10:00 AM). Orders were received to do CBC (complete blood count) and CRP (C-Reactive Protein). Due to patient being very dehydrated and all staff efforts being without good outcome, [primary physician]had to be contacted to get a PIV (peripheral intravenous) to draw from as well as have a line in place. [Primary physician] placed PIV at 1715 (5:15 PM) and sample was taken to the lab. No urine output had been seen since midmorning and RN (Registered Nurse) suspected it clogged and was told to change it to get culture. catheter was changed at 1500 (3:00 PM) and no urine was produced. RN notified on call. On call at 1845 (6:45 PM) called and told the night RN to send patient out. [Note: It should be noted that resident 84's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .] On 5/23/21 a confidential staff interview was conducted with Staff Member (SM) 2. SM 2 stated that resident 84 should have been rounded on every two hours. SM 2 stated that the facility was so short staffed on multiple occasions that the staff wasn't able to check the fullness of residents' catheter bags. SM 2 stated that he/she frequently saw resident catheter bags filled to capacity, as well as residents' catheter bags not being emptied timely. SM 2 stated that on the day of hospitalization , resident 84's catheter was not flowing and the catheter bag was full. SM 2 stated the resident's physician was notified, and the catheter was changed to get clean urine for a urinalysis. SM 2 stated that the new catheter was not draining, and resident 84 then had a bladder scan with no reading. SM 2 then stated that resident 84's physician requested that resident 84 be sent to the local emergency room . SM 2 stated that he/she felt the resident was septic because no one changed resident 84's catheter bag in a timely manner. 2 . Resident 1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's medical record was reviewed on 5/23/21. Resident 1's quarterly Minimum Data Set (MDS) admission assessment dated [DATE] was reviewed. The MDS indicated that resident 1 required extensive assistance with 2 staff members for bed mobility, and was totally dependent on 2 staff members for transferring. Nurses notes for resident 1 revealed the following: a. On 5/12/21 at 8:00 PM, CNA found RN and alerted her that patient had fallen out of bed during a brief change and was on the floor. CNA states she was changing the resident when she ran out of wipes. She told the resident to go ahead and roll back while she went and got more wipes. The resident then rolled forward rolling off the bed and onto the floor instead of rolling backwards onto her back. CNA returned to the room to find the resident on the floor. Resident head was resting on the stand holding the ventilator and posterior head was actively bleeding . Res (Resident) c/o (complains of) pain all over body and especially her head. Res was assisted back into Bed and Posterior head was clean and area assessed. 1.5 inch laceration and goose bump noted to posterior head . NP (Nurse Practitioner) notified and gave orders to transport Res to [name of local emergency room ] . b. On 5/13/21 at 1:20 AM, Resident was transferred back to facility via [name of ambulance company] 3 staples noted to laceration on posterior head. Res Noted to have bruised ribs. Staples to be removed 5/19/21. Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 5/13/21 at 12:46 PM for pain 10/10 b. On 5/14/21 at 7:57 AM for pain 2/10 c. On 5/14/21 at 7:48 PM for pain 5/10 [Note: Resident 1 did not receive any other [MEDICATION(S)] during the month of May 2021 as of 5/26/21.] The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical therapy notes dated 5/12/21 documented that resident 1 required maximum assistance for bed mobility training. Physical therapy notes dated 5/14/21 documented that resident 1 was still not feeling like herself after falling out of bed; body aches due to fall. Physical therapy notes dated 5/18/21 documented that resident 1 was extremely anxious and did not want to attempt sitting EOB (end of bed) today either; has taken a big step back since her fall a week ago. On 5/23/21 at 7:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after the incident on 5/12/21 with resident 1, we took all agency staff off that hall. Now all staff that are up there are our people or are agency who have trained for that hall and know how to reposition those residents. The DON also stated that the CNA left the resident on her side when she left the room and that the CNA should not have left the resident on her side. She should have laid her (the resident) back down on her back and taken all of the supplies in with her. On 5/24/21 at 10:30 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 1 needs two people to change her. She's a total assist. CNA 3 further stated that when he changed resident 1's briefs, he always used two people because the bed is kind've small so I can pull her over to the side to give me enough space, so in case she falls forward she falls into the bed. On 5/24/21 at 10:55 AM, an interview was conducted with resident 1. Resident 1 stated that she was unable to move herself around in bed. When asked about the incident on 5/12/21, resident 1 stated that there were usually two people that changed her brief, but on 5/12/21 it was only one. Resident 1 stated that the lone staff member had rolled the resident to her right side on the edge of the bed and left the room. Resident 1 stated that she had subsequently fallen out of the bed and hit her head on the equipment next to her bed. Resident 1 stated that it was scary. On 5/23/21, a confidential staff interview was conducted with SM 2. SM 2 stated that the facility was poorly staffed. SM 2 stated that all the residents on the 500 hall should be 2 person assistance with brief changes. SM 2 stated that it's dangerous how low the staffing was for the 500 hall. SM 2 stated that there was one agency CNA for the 500 hall one day, and that resident 1 had an accident because there was only one CNA. SM 2 stated that resident 1 was rolled to her side for a brief change. SM 2 stated that the agency CNA left the room to get wipes and resident 1 rolled out of bed. SM 2 stated that when resident 1 rolled out of bed she hit her head and ended up with stitches. SM 2 stated when Agency CNAs worked on the 500 hall there were a lot more accidents. 3. Resident 108 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 108's medical record was reviewed on 5/23/21. On 4/29/21, staff completed an Initial Admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed an Initial Admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed a document entitled Functional Performance Evaluation. The evaluation indicated that resident 108 requiredsubstantial/maximal assistance with sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed to chair transfer. On 4/30/21, staff completed a document entitled Braden Scale for Predicting Pressure Sore Risk. The document indicated that resident 108 was slightly limited in her ability to respond to pressure-related discomfort, had skin that was occasionally moist, was chairfast, and was slightly limited in her ability to change and control body position. The document also indicated that resident 108 was at low risk for developing a pressure sore. On 4/30/21 staff developed a care plan for resident 108 that indicated resident had a self care performance deficit related to immobility and weakness. The care plan indicated that resident 108 required Extensive assistance 2 staff participation to reposition and turn in bed. On 5/3/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. On 5/10/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. Nurses notes for resident 108 indicated the following note: On 5/12/21 wound team note. team notified 5/11 of sores present on admit. [Resident 108] has MASD under L (left) breast, center to L [NAME] (sic), and BL (bilateral) buttock, scaring (sic) noted on BL buttocks from old wounds. she has a fluid filled blister on her R (right) heel, 4.7x4.5xUTD (unable to determine). PI (pressure injury) unstageable. dark in color. no drainage. no s/s (signs or symptoms) of infection. [NAME] (Decubitis ulcer) noted on the L pad of foot. old and very stable, 0.5x0.7xUTD. education on offloading. On 5/12/21 staff developed a care plan for resident 108 that stated Has pressure ulcer development to R (right) heel r/t (related to) immobility. The care plan also stated that the pressure ulcer was present on admission, was unstageable, and was 4.7 centimeters by 4.5 centimeters in size. On 5/12/21 staff also developed a care plan for resident 108 that stated resident 108 Has actual impairment to skin integrity r/t MASD. [Note: The initial skin integrity care plan for resident 108 developed on 4/30/21 did not indicate that resident 108 had any impairments to her skin integrity.] Resident 108's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No orders for wound care were written prior to 5/12/21. On 5/18/21 staff completed a weekly skin evaluation. Staff documented that resident 108 had an unstageable pressure ulcer to her R heel that was present on admission. However, no notes could be located in resident 108's medical record to indicate that resident 108 had any skin issues on her R heel prior to 5/11/21. In addition, nurses notes did not indicate that the wound team was notified of any skin issues prior to 5/11/21. On 5/19/21 Wound Assessment Progress Note was completed by a wound specialist. The note indicated that resident 108 had an unstageable pressure ulcer on her right heel that was 4.7x4.5xUTD in size. The note also indicated the that wound was intact, dark discoloration [with] fluid and boggy. The note indicated that resident 108 had a skin issue on her left heel that was resolved. On 5/28/21 at 2:00 PM, an interview was conducted with the facility Wound Nurse (WN). The WN stated that resident 108's heel should not be placed directly on the bed or a pillow. The WN stated that resident 108 doesn't have a lot of mobility in her right leg. The WN stated that resident 108 would try to lift her R leg but doesn't succeed. The WN stated that resident 108 was admitted with a blister to her right heel. When asked why there was no documentation about a wound to her R heel prior to 5/11/21 or treatment implemented prior to 5/12/21, the WN stated he did not know. On 5/24/21 at 11:05 AM, an interview was conducted with resident 108. When asked about her stay, resident 108 stated I'm not getting very good care here. Resident 108 stated that she had pain a lot in my back and two sores on my butt. When asked if she could move herself around in her bed, the resident stated she did not attempt to reposition herself in bed because it hurts too much. The resident also stated that she had a sore on her right heel and it hurts like hell. I think it's because I'm just laying in bed. I can wiggle my toes but I can't move my foot off the pillows. It's damn scary to be worried about my foot . On 5/25/21 at 1:23 PM, a follow up interview was conducted with resident 108. Resident 108 stated that staff repositioned her in bed but they don't do it very often. I'll have to call for someone to help. The resident stated that she also had two painful sores on her bottom, that she was admitted with, but my butt feels like its on fire. It needs to be moved. On 5/24/21 a continuous observation was made of resident 108 as follows: a. At 11:35 AM, resident 108 was observed to be in her room in seated her bed, with the head of the bed elevated, and her legs outstretched toward the end of the bed. b. At 12:33 PM, a staff member entered the room to deliver resident 108's lunch tray. c. At 1:10 PM, the Social Services Worker (SSW) entered the room, seated herself in a chair, and spoke with resident 108 for several minutes. d. At 1:23 PM, a staff member entered resident 108's room and obtained a blood sugar sample. e. At 1:41 PM, a staff member entered resident 108's room and administered resident 108's insulin. f. At 2:22 PM, a staff member entered resident 108's room to assist resident 108 out of bed and into her wheelchair. During the duration of the observation from 11:35 AM to 2:22 PM, no staff members were observed to reposition resident 108, nor did resident 108 make any efforts to reposition her buttocks or her legs. On 5/28/21 at 12:55 PM, two staff members were observed to enter resident 108's room. They slid resident 108 up in bed, but did not reposition her right heel. The right heel was observed to be directly laying on a pillow, instead of being floated. 4. Resident 112 was admitted to the facility on [DATE] and 1/1/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/24/21 at 10:02 AM, an interview was conducted with resident 112. Resident 112 stated that he needed his brief to be changed. Resident 112 was observed to have a foul odor. Resident 112 stated that he wanted to have his brief changed every 2 hours, but not allowed to be changed until every 4 hours. Resident 112 stated that he has not been continent for most of his life. Resident 112 stated that he has a red buttocks and back from sitting in his urine for long periods of time. At 10:30 AM, a therapy staff member wheeled resident to the therapy gym. At 12:40 PM, resident 112 was observed outside the dining room in his wheelchair. Resident 112 stated he had not been changed. At 1:19 PM, an observation was made of resident 112 with CNA 12 and CNA 14 buttocks and backside. Resident 112 was observed to have red areas with small opening that were bleeding. On 5/24/21 at 1:25 PM, an interview was conducted with CNA 10. CNA 10 stated that resident 112 was compliant with brief changes. CNA 10 stated that resident 112 has set times to have his brief changed. CNA 10 stated usually after smoking he was changed. CNA 10 stated that his butt is terrible. CNA 10 stated that she slathers his buttocks with cream. CNA 10 stated that his buttocks is from sitting in a soiled brief for to long and not being changed. CNA 10 stated she thought the bleeding was from hemorrhoids. On 5/24/21 at 1:30 PM, an interview was conducted with CNA 12. CNA 12 stated that she changed resident 112's brief when he got up this morning. CNA 12 stated that therapy did not do brief changes. CNA 12 stated that resident 112 had sores and dead skin on his buttocks. CNA 12 stated that sometime his back side bleeds like it did today. CNA 12 stated that resident 112 should have been changed around his smoke break which was about 10:30 AM. CNA 12 stated that another CNA should have changed his brief before he left for therapy. CNA 12 stated resident 112 did not have a brief change until 1:30 PM. Resident 112's medical record was reviewed 5/24/21 through 5/28/21. A quarterly MDS dated [DATE] revealed resident 112 was frequently incontinent of bowel and bladder. Resident 112 had not been on a toileting program for bowel or bladder. Resident 112 had a BIMS of 11 which revealed mild cognitive impairment. A care plan dated 5/19/15 revealed, Has bowel incontinence r/t MS The goal developed were Will have less than two episodes of incontinence per day through the review date. The interventions developed were Check resident [with] rounds and prn and assist with toileting as needed and Provide pericare after each incontinent episode According to the CNA documentation in the tasks section from 4/29/21 until 5/28/21 resident 112 had 4 continent bowel episodes and 1 continent bladder episode. CNA documentation further revealed that resident 112 was documented as being toileted at 7:40 AM. Resident 112's Bowel and Bladder Evaluation dated 1/28/21 and 4/28/21 resident 112 was an unlikely candidate for bowel and bladder re-training. The evaluation dated 4/28/21 revealed that resident 112 was always incontinent of bowel and bladder which made resident an unlikely candidate for re-training. On 5/24/21 at 12:45 PM, an interview was conducted with CNA 10. CNA 10 stated resident 112 was usually changed every 2 hours. CNA 10 stated that resident 112 was able to verbalize to staff when he needed to have a brief changed. CNA 10 stated it can be difficult when staffing is low to change resident 112 because he required 2 person assist with a hoyer lift. On 5/24/21 at 2:00 PM, an interview was conducted with the DON. The DON stated resident 112 was a 2 person assist with brief changes. The DON stated that resident 112 should receive a brief change every 2 hours. On 5/27/21 at 3:43 PM, an interview was conducted with RN 3. RN 3 stated stated that resident 112 was continent but he was hard to transfer so he used briefs. RN 3 stated that resident 112 was alert and Oriented x 4 (person, place, time, and situation). RN 3 stated that resident 112 knew what he wants and where he was. RN 3 stated that resident 112 was able to tell when he had a brief change. RN 3 stated that she was no aware of any skin issues and nothing had been reported to her regarding his buttocks. RN 3 stated resident 112 was not on a bowel and bladder retraining program. On 5/28/21 at 10:52 AM, a follow up interview was conducted with the DON. The DON stated that resident 112 was alert and oriented for the most part and able to tell staff what he wanted and needed. The DON stated that he was compliant with cares as long as it was not during a smoking break. The DON stated that he talked to the Wound Nurse regarding resident 112's buttocks. The DON stated that resident 112 had MASD which was caused by sitting in his urine for to long. B. The following examples were cited at a potential for harm related to abuse allegations: 1. Resident 105 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/26/21 at 9:46 AM, an interview was conducted with resident 105. Resident 105 stated that there was a nurse who was giving me a bad time. When asked to elaborate, resident 105 stated that when RN 7 administered resident 105's [MEDICATION(S)], she sometimes doesn't clean my arm with an alcohol wipe before she gives me a [MEDICATION(S)] shot and she injects it quickly instead of slowly so it makes me bleed all over the pillowcase, my nightgown, and my pillow. Its all soaked with blood. Resident 105 stated that she asked RN 7 why she insisted on doing it that way when resident 105 had asked her to do it differently. Resident 105 stated that RN 7 responded by saying when you go to school to be a nurse, you can tell me how to give a shot. Resident 105 stated that she felt she was being verbally and physically abused. Resident 105 stated that she reported the alleged abuse to the DON the same day, as well as the next day, but nothing happened. Resident 105 stated that the DON told her he would speak to RN 7 about it, but nothing changed and she was still the same. Resident 105 stated that RN 7 had made my life miserable. On 6/8/21 at 4:00 PM, an interview was conducted with RN 7. RN 7 stated that she had had an issue with resident 105. When asked to explain, RN 7 stated that the resident would try and tell me how to giver her shots. I told her don't tell me how to do my job. I went to school to be a nurse. Unless she has a nursing degree, she can't tell me how to do my job. I'm working under my license, not hers. RN 7 then stated that the DON had approached her and stated that resident 105 was alleging that RN 7 was abusive to her. On 5/28/21 at 8:26 AM, the DON was informed of the allegations of verbal abuse toward resident 105 by RN 7. The DON stated that he was not aware of the situation, even though both RN 7 and resident 105 stated that he had spoken with them about it, and would investigate and report immediately. A review of the State Agency database revealed that the facility did not investigate or report the incident until 6/8/21, approximately 12 days after the incident was reported to the facility by the state surveyor. 2. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with left femur fracture, muscle weakness, diabetes, major depressive disorder, and major depressive disorder. On 5/26/21 at 11:56 AM, an interview was conducted with resident 17. Resident 17 was asked if he felt staff had been abusive. Resident 17 stated the other night I was messy and CNA 8 cam into his room crying. Resident 17 stated that CNA 8 told him that she did not get any respect and she was burned out. Resident 17 stated that she was very upset. Resident 17 stated that she was rough and rolled him over and changed his brief really fast. Resident 17 stated that she did not fully cover him back up and she did not fully clean him. Resident 17 stated that he reported it to the CNA coordinator. Resident 17's medical record was reviewed 5/26/21 through 5/28/21. A quarterly MDS dated [DATE] revealed that resident 17 had a BIMS score of 14 which revealed he was cognitively intact. On 5/27/21 at 9:55 AM, an interview was conducted with the CNA coordinator. The CNA coordinator stated when a resident reported any concerns or abuse from a resident, then he talked with the staff member. The CNA coordinator stated he then educated the CNAs. The CNA coordinator stated that some of the CNAs were really little so they seam a little rougher but they were not rough. The CNA coordinator stated that CNA 8 was a solid aide and he had to put her on the 300 hall rather than the 500 hall. The CNA coordinator stated that he had not received any reports regarding resident 17 and CNA 8. On 5/28/21 at 1:07 PM, a phone interview was conducted with CNA 8. CNA 8 stated there were issues with staffing. CNA 8 stated a lot of time we were running with low staff. CNA 8 stated there have been times when we have had issues and I've had to run my tail off. CNA 8 stated there had been times that I have been on a hall with 30 residents and my partner goes on break and there are 20 call lights going. CNA 8 stated I have had moments when my stress level has gotten so high that I have just shut down. CNA 8 stated At work try to keep emotions in check but several times she remembered being really stressed. CNA 8 stated that resident 17 had noticed when something with me is off and will ask me what is wrong. CNA 8 stated that resident 17 had to wait for long periods of time to be changed out of a dirty brief because someone was on break. CNA 8 stated that the CNA coordinator call her in and told her not to tell residents when she was short staffed. CNA 8 stated that she had voiced she was burnt out to the CNA coordinator and then she was assigned on the 300 hall instead of the 500 hall where she liked to work. CNA 8 stated that the CNA coordinator did not listen to her concerns. On 5/28/21 at 7:57 AM, an interview was conducted with CRN 2. CRN 2 stated that the DON and Administrator completed the abuse investigations. On 5/28/21 at 10:52 AM, an interview was conducted with the DON. The DON stated he did not have an abuse investigation for resident 17. The DON stated that he was not aware that resident 17 had complained about care from a CNA. The DON was told that resident 17 had complained a CNA treated him abusively. A review of the FRI reports through the State Survey agency on 6/7/21 revealed there were no reported abuse investigations. 3. Resident 101 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/28/21 at 1:17 PM, an interview was conducted with resident 101. When asked if he had ever felt like he was abused at the facility, resident 101 stated that on one occasion, RN 7 entered his room to provide cares, at which time resident 101 told RN 7 can you give me a minute? I'm on the phone with my girlfriend. Resident 101 stated that RN 7 responded by saying I'm here to do your cares now, your girlfriend can call you back. Resident 101 stated that RN 7 has said rude things before this incident, and that they don't treat me with the kind of respect I deserve. My bedroom is my domain. I live here. The nurses don't have the right to speak to anyone that way. Resident 101 stated that both RN 7 and LPN 4 have told him on multiple occasions that this isn't a hotel when resident 101 asked for assistance with something. Resident 101 stated that on those occasions he told the nurses that he realized he wasn't living in a hotel but its still my home. Resident 101 stated that he had reported his concerns to management with regard to how he was being treated, but they don't resolve it. I don't want to get people in trouble, I just want them educated and courteous. On 6/8/21 at 4:00 PM, an interview was conducted with RN 7. RN 7 stated that she has had conversations with resident 101 and his girlfriend regarding their phone calls. RN 7 stated that resident 101's girlfriend would call the facility and tell staff that resident 101 would like a pain pill, but when I get there he (resident 101) says to come back in five minutes. I've explained to her that she (resident 101's girlfriend) can call back in 5 minutes when we are done with his (resident 101's) care. Review of the facility grievance log revealed a grievance form for resident 101 on 9/29/2020 at 12:30 PM. The summary stated, Pt reports the p.m. nurse [RN 7] and CNA [CNA 11] handled him roughly when changing him and would not listen to him instructing them. The form documented that the SSW 1 and the Assistant Director of Nursing (ADON) met with the patient to let the patient voice their grievance, and concluded that if the patient was not turned correctly it caused him pain. The form further documented that the corrective action taken was that the ADON educated RN 7 and CNA 11 on 9/30/2020. On 5/28/21 the DON was informed of the allegations of verbal abuse toward resident 101 by RN 7. The DON stated that he was not aware of the situation, and would inve [TRUNCATED]

Based on observation, record review and interview the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, deficient practices were identified during the survey regarding abuse, neglect, falls, incontinence cares, pain, treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 1, 8, 17, 37, 56, 61, 82, 84, 85, 88, 94, 96, 98, 99, 101, 102, 103, 105, 108, and 112. Findings include: 1. The facility administration did not ensure that for 7 out of 51 residents, the residents were free from abuse and neglect. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute [CONDITION(S)], a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . These examples of neglect were cited at a harm level. Additionally, a resident reported an allegation of verbal and physical abuse from a licensed nurse with medication administration, a resident reported an allegation of physical abuse from a Certified Nurse Assistant (CNA) during incontinence care, and a resident reported an allegation of rough treatment during incontinence care in September 2020 followed by an allegation of verbal abuse with cares by the same nurse in May 2021. Resident identifiers: 1, 17, 84, 101, 105, 108 and 112. [Cross refer to F600] 2. The facility administration did not ensure that for 1 of 51 sample residents, that the facility provided care to prevent unavoidable pressure ulcers, nor did they provide timely treatment and services for the resident's pressure ulcer. Specifically, a resident developed an unstageable pressure sore and was not provided interventions to prevent the pressure sore. In addition, after the pressure sore was developed treatment and services were not provided in a timely manner to heal the pressure sore. This resulted in a finding of harm. Resident identifier: 108. [Cross refer to F686] 3. The facility administration did not ensure that for 3 of 51 sample residents, residents did not receive adequate supervision and assistance devices to prevent accidents. Specifically, one resident was assisted with a brief change with only one staff member instead of two, resulting in the resident falling out of bed and sustaining a [CONDITION(S)]. This incident was found to have occurred at a harm level. In addition, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . This incident was found to have occurred at a harm level. Another resident was not assessed to determine if he was safe to smoke independently. Resident identifiers: 1, 37, and 103. [Cross refer to F689] 4. The facility administration did not ensure that for 6 of 51 sample residents, that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, the facility failed to ensure proper care for a resident with a urinary catheter which resulted in the resident being hospitalized . This finding was cited at a harm level. In addition, a resident was not toileted timely, resulting in the resident having skin breakdown. This finding was also cited at a harm level. In addition, residents were not placed on a bowel and bladder training program despite requests and staff assessment of appropriateness Resident identifiers: 37, 82, 84, 99, 102, and 112. [Cross refer to F690] 5. The facility administration did not ensure that for 16 of 51 sampled residents, the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute [CONDITION(S)], a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . These findings were cited at a harm level for 4 residents. In addition, a resident reported attempting to hold their bowel movements at night due to safety concerns with a one person assistance with incontinence care, and a resident reported being left unattended on a commode for 90 minutes. Additionally, multiple residents reported delayed incontinence care and being left for extended periods of time in soiled and wet briefs which resulted in skin irritation, typical call light response times of two hours, and residents reported needing assistance with eating and none was provided. Furthermore, multiple staff members reported staffing shortages that resulted in unsafe conditions for residents and the inability to complete the necessary cares, medication administration, and services for residents. Resident identifiers: 1, 8, 37, 56, 61, 84, 85, 88, 94, 96, 98, 99, 101, 105, 108, 112. [Cross refer to F725] 6. The facility administration did not ensure for 1 of 51 sample residents, that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, or who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, a resident that attempted suicide was not provided mental health services. This was found to have occurred at a harm level. Resident identifier: 99. [Cross refer to F742] On 5/24/21 at 3:44 PM, an interview was conducted with the facility Administrator (Admin). The Admin stated that there was a formal QA for staffing that started on 5/12/21 after resident 1 fell and sustained a laceration. The Admin stated that as of 5/24/21 he felt that the facility was fully staffed, but the staff were newer and would need to receive additional training. The Admin stated that the facility had been short staffed for a long time and that staff were still frustrated even though the facility was now fully staffed.

Based on observation, record review and interview the facility Quality Assessment and Assurance (QAA) Committee did not develop and implement appropriate plans of action to correct identified quality deficiencies. Specifically, deficient practices were identified during the survey regarding abuse, neglect, falls, incontinence cares, pain, treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 1, 8, 17, 37, 56, 61, 82, 84, 85, 88, 94, 96, 98, 99, 101, 102, 103, 105, 108, and 112. Findings include: 1. The facility QAA Committee did not ensure that for 7 out of 51 residents, the residents were free from abuse and neglect. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute [CONDITION(S)], a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . These examples of neglect were cited at a harm level. Additionally, a resident reported an allegation of verbal and physical abuse from a licensed nurse with medication administration, a resident reported an allegation of physical abuse from a Certified Nurse Assistant (CNA) during incontinence care, and a resident reported an allegation of rough treatment during incontinence care in September 2020 followed by an allegation of verbal abuse with cares by the same nurse in May 2021. Resident identifiers: 1, 17, 84, 101, 105, 108 and 112. [Cross refer to F600] 2. The facility QAA Committee did not ensure that for 1 of 51 sample residents, that the facility provided care to prevent unavoidable pressure ulcers, nor did they provide timely treatment and services for the resident's pressure ulcer. Specifically, a resident developed an unstageable pressure sore and was not provided interventions to prevent the pressure sore. In addition, after the pressure sore was developed treatment and services were not provided in a timely manner to heal the pressure sore. This resulted in a finding of harm. Resident identifier: 108. [Cross refer to F686] 3. The facility QAA Committee did not ensure that for 3 of 51 sample residents, residents did not receive adequate supervision and assistance devices to prevent accidents. Specifically, one resident was assisted with a brief change with only one staff member instead of two, resulting in the resident falling out of bed and sustaining a [CONDITION(S)]. This incident was found to have occurred at a harm level. In addition, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . This incident was found to have occurred at a harm level. Another resident was not assessed to determine if he was safe to smoke independently. Resident identifiers: 1, 37, and 103. [Cross refer to F689] 4. The facility QAA Committee did not ensure that for 6 of 51 sample residents, that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, the facility failed to ensure proper care for a resident with a urinary catheter which resulted in the resident being hospitalized . This finding was cited at a harm level. In addition, a resident was not toileted timely, resulting in the resident having skin breakdown. This finding was also cited at a harm level. In addition, residents were not placed on a bowel and bladder training program despite requests and staff assessment of appropriateness Resident identifiers: 37, 82, 84, 99, 102, and 112. [Cross refer to F690] 5. The facility QAA Committee did not ensure that for 16 of 51 sampled residents, the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute [CONDITION(S)], a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . These findings were cited at a harm level for 4 residents. In addition, a resident reported attempting to hold their bowel movements at night due to safety concerns with a one person assistance with incontinence care, and a resident reported being left unattended on a commode for 90 minutes. Additionally, multiple residents reported delayed incontinence care and being left for extended periods of time in soiled and wet briefs which resulted in skin irritation, typical call light response times of two hours, and residents reported needing assistance with eating and none was provided. Furthermore, multiple staff members reported staffing shortages that resulted in unsafe conditions for residents and the inability to complete the necessary cares, medication administration, and services for residents. Resident identifiers: 1, 8, 37, 56, 61, 84, 85, 88, 94, 96, 98, 99, 101, 105, 108, 112. [Cross refer to F725] 6. The facility QAA Committee did not ensure for 1 of 51 sample residents, that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, or who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, a resident that attempted suicide was not provided mental health services. This was found to have occurred at a harm level. Resident identifier: 99. [Cross refer to F742] On 5/24/21 at 3:44 PM, an interview was conducted with the facility Administrator (Admin). The Admin stated that there was a formal QA for staffing that started on 5/12/21 after resident 1 fell and sustained a laceration. The Admin stated that as of 5/24/21 he felt that the facility was fully staffed, but the staff were newer and would need to receive additional training. The Admin stated that the facility had been short staffed for a long time and that staff were still frustrated even though the facility was now fully staffed. On 5/24/21 at approximately 12:00 PM, it was observed that as the Director of Nursing (DON) was obtaining average call light times, that there were no call light times recorded for the 100 hall (Memory Care Unit). When asked, he stated that the system did not record the 100 hall's call light times. Therefore, the QA program was not capturing an accurate picture of call light times in order to take to the QA committee.

Based on observation, interview and record review it was determined, for 17 of 51 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute [CONDITION(S)], a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . These findings were cited at a harm level for 4 resudents. In addition, a resident reported attempting to hold their bowel movements at night due to safety concerns with a one person assistance with incontinence care, and a resident reported being left unattended on a commode for 90 minutes. Additionally, multiple residents reported delayed incontinence care and being left for extended periods of time in soiled and wet briefs which resulted in skin irritation, typical call light response times of two hours, and residents reported needing assistance with eating and none was provided. Furthermore, multiple staff members reported staffing shortages that resulted in unsafe conditions for residents and the inability to complete the necessary cares, medication administration, and services for residents. Resident identifiers: 1, 8, 37, 56, 59, 61, 84, 85, 88, 94, 96, 98, 99, 101, 105, 108, 112. Findings include: A. The following examples were cited at a HARM level related to insufficient nursing staff: 1. Resident 84 was admitted to the facility 1/1/21. He has a history of traumatic subdural hemorrhage, nontraumatic subarachnoid hemorrhage, falls, [CONDITION(S)], neuromuscular dysfunction of the bladder, chronic [CONDITION(S)], [CONDITION(S)], dependence on respirator, [CONDITION(S)], [CONDITION(S)] and dementia. Resident 84's medical record was reviewed on 5/23/21. On 5/20/21 at 10:23 PM, a nursing progress note indicated that resident 84's Foley cath (catheter) is patent and draining well at this time. On 5/22/21 at 7:48 PM, a nursing progress note indicated that res (resident) continued with no urine output since cath change to collect UA (urinalysis) and diaphoresis. MD order received at 1850 (6:50 PM) to transport resident to [name of local emergency room ]. [Name of local city paramedics] arrived at 1910 (7:10 PM) to transport and left at 1930 (7:30 PM). The nurses note did not indicate the date or time the catheter had been changed. On 5/22/21 the emergency room Report for resident 84 indicated that the facility staff note that they went to change the patients Foley catheter today for source control and had not had urine output since. They also note change in [CONDITION(S)] ([CONDITION(S)]) sputum upon suctioning from clear to green. emergency room Physician diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The emergency room Report also documented that a urinalysis indicated red colored urine, turbid in nature, nitrites present in abnormal nature, large amount of hemoglobin, proteins present at greater than 3000, Large abnormal White Blood Cells and bacteria 3 plus. On 5/22/21, a Computerized Tomography scan was performed in the emergency room . The impression from the radiologist included prominently distended bladder. The Foley catheter is malpositioned, the balloon is just inferior to the prostal gland. There is bilateral hydroureter with bilateral hydronephrosis, likely secondary to bladder outlet obstruction. On 5/25/21 at 10:06 AM, a record review showed a late entry progress note for 5/23/21 regarding resident 84. The nursing progress note stated that resident 84 was hospitalized on [DATE]. The note also stated that patient was reported to be tachy (tachycardic) with a HR (heart rate) reaching 145 and a low grade fever. Patient was assessed and on call was notified of the change at 1000 (10:00 AM). Orders were received to do CBC (complete blood count) and CRP (C-Reactive Protein). Due to patient being very dehydrated and all staff efforts being without good outcome, [primary physician]had to be contacted to get a PIV (peripheral intravenous) to draw from as well as have a line in place. [Primary physician] placed PIV at 1715 (5:15 PM) and sample was taken to the lab. No urine output had been seen since midmorning and RN (Registered Nurse) suspected it clogged and was told to change it to get culture. catheter was changed at 1500 (3:00 PM) and no urine was produced. RN notified on call. On call at 1845 (6:45 PM) called and told the night RN to send patient out. [Note: It should be noted that resident 84's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .] On 5/23/21 a confidential staff interview was conducted with Staff Member (SM) 2. SM 2 stated that resident 84 should have been rounded on every two hours. SM 2 stated that the facility was so short staffed on multiple occasions that the staff wasn't able to check the fullness of residents' catheter bags. SM 2 stated that he/she frequently saw resident catheter bags filled to capacity, as well as residents' catheter bags not being emptied timely. SM 2 stated that on the day of hospitalization , resident 84's catheter was not flowing and the catheter bag was full. SM 2 stated the resident's physician was notified, and the catheter was changed to get clean urine for a urinalysis. SM 2 stated that the new catheter was not draining, and resident 84 then had a bladder scan with no reading. SM 2 then stated that resident 84's physician requested that resident 84 be sent to the local emergency room . SM 2 stated that he/she felt the resident was septic because no one changed resident 84's catheter bag in a timely manner. 2 . Resident 1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's medical record was reviewed on 5/23/21. Resident 1's quarterly Minimum Data Set (MDS) admission assessment dated [DATE] was reviewed. The MDS indicated that resident 1 required extensive assistance with 2 staff members for bed mobility, and was totally dependent on 2 staff members for transferring. Nurses notes for resident 1 revealed the following: a. On 5/12/21 at 8:00 PM, CNA found RN and alerted her that patient had fallen out of bed during a brief change and was on the floor. CNA states she was changing the resident when she ran out of wipes. She told the resident to go ahead and roll back while she went and got more wipes. The resident then rolled forward rolling off the bed and onto the floor instead of rolling backwards onto her back. CNA returned to the room to find the resident on the floor. Resident head was resting on the stand holding the ventilator and posterior head was actively bleeding . Res (Resident) c/o (complains of) pain all over body and especially her head. Res was assisted back into Bed and Posterior head was clean and area assessed. 1.5 inch laceration and goose bump noted to posterior head . NP (Nurse Practitioner) notified and gave orders to transport Res to [name of local emergency room ] . b. On 5/13/21 at 1:20 AM, Resident was transferred back to facility via [name of ambulance company] 3 staples noted to laceration on posterior head. Res Noted to have bruised ribs. Staples to be removed 5/19/21. Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 5/13/21 at 12:46 PM for pain 10/10 b. On 5/14/21 at 7:57 AM for pain 2/10 c. On 5/14/21 at 7:48 PM for pain 5/10 [Note: Resident 1 did not receive any other [MEDICATION(S)] during the month of May 2021 as of 5/26/21.] The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical therapy notes dated 5/12/21 documented that resident 1 required maximum assistance for bed mobility training. Physical therapy notes dated 5/14/21 documented that resident 1 was still not feeling like herself after falling out of bed; body aches due to fall. Physical therapy notes dated 5/18/21 documented that resident 1 was extremely anxious and did not want to attempt sitting EOB (end of bed) today either; has taken a big step back since her fall a week ago. On 5/23/21 at 7:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after the incident on 5/12/21 with resident 1, we took all agency staff off that hall. Now all staff that are up there are our people or are agency who have trained for that hall and know how to reposition those residents. The DON also stated that the CNA left the resident on her side when she left the room and that the CNA should not have left the resident on her side. She should have laid her (the resident) back down on her back and taken all of the supplies in with her. On 5/24/21 at 10:30 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 1 needs two people to change her. She's a total assist. CNA 3 further stated that when he changed resident 1's briefs, he always used two people because the bed is kind've small so I can pull her over to the side to give me enough space, so in case she falls forward she falls into the bed. On 5/24/21 at 10:55 AM, an interview was conducted with resident 1. Resident 1 stated that she was unable to move herself around in bed. When asked about the incident on 5/12/21, resident 1 stated that there were usually two people that changed her brief, but on 5/12/21 it was only one. Resident 1 stated that the lone staff member had rolled the resident to her right side on the edge of the bed and left the room. Resident 1 stated that she had subsequently fallen out of the bed and hit her head on the equipment next to her bed. Resident 1 stated that it was scary. On 5/23/21, a confidential staff interview was conducted with SM 2. SM 2 stated that the facility was poorly staffed. SM 2 stated that all the residents on the 500 hall should be 2 person assistance with brief changes. SM 2 stated that it's dangerous how low the staffing was for the 500 hall. SM 2 stated that there was one agency CNA for the 500 hall one day, and that resident 1 had an accident because there was only one CNA. SM 2 stated that resident 1 was rolled to her side for a brief change. SM 2 stated that the agency CNA left the room to get wipes and resident 1 rolled out of bed. SM 2 stated that when resident 1 rolled out of bed she hit her head and ended up with stitches. SM 2 stated when Agency CNAs worked on the 500 hall there were a lot more accidents. 3. Resident 108 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 108's medical record was reviewed on 5/23/21. On 4/29/21, staff completed an Initial Admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed an Initial Admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed a document entitled Functional Performance Evaluation. The evaluation indicated that resident 108 requiredsubstantial/maximal assistance with sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed to chair transfer. On 4/30/21, staff completed a document entitled Braden Scale for Predicting Pressure Sore Risk. The document indicated that resident 108 was slightly limited in her ability to respond to pressure-related discomfort, had skin that was occasionally moist, was chairfast, and was slightly limited in her ability to change and control body position. The document also indicated that resident 108 was at low risk for developing a pressure sore. On 4/30/21 staff developed a care plan for resident 108 that indicated resident had a self care performance deficit related to immobility and weakness. The care plan indicated that resident 108 required Extensive assistance 2 staff participation to reposition and turn in bed. On 5/3/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. On 5/10/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. Nurses notes for resident 108 indicated the following note: On 5/12/21 wound team note. team notified 5/11 of sores present on admit. [Resident 108] has MASD under L (left) breast, center to L [NAME] (sic), and BL (bilateral) buttock, scaring (sic) noted on BL buttocks from old wounds. she has a fluid filled blister on her R (right) heel, 4.7x4.5xUTD (unable to determine). PI (pressure injury) unstageable. dark in color. no drainage. no s/s (signs or symptoms) of infection. [NAME] (Decubitis ulcer) noted on the L pad of foot. old and very stable, 0.5x0.7xUTD. education on offloading. On 5/12/21 staff developed a care plan for resident 108 that stated Has pressure ulcer development to R (right) heel r/t (related to) immobility. The care plan also stated that the pressure ulcer was present on admission, was unstageable, and was 4.7 centimeters by 4.5 centimeters in size. On 5/12/21 staff also developed a care plan for resident 108 that stated resident 108 Has actual impairment to skin integrity r/t MASD. [Note: The initial skin integrity care plan for resident 108 developed on 4/30/21 did not indicate that resident 108 had any impairments to her skin integrity.] Resident 108's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No orders for wound care were written prior to 5/12/21. On 5/18/21 staff completed a weekly skin evaluation. Staff documented that resident 108 had an unstageable pressure ulcer to her R heel that was present on admission. However, no notes could be located in resident 108's medical record to indicate that resident 108 had any skin issues on her R heel prior to 5/11/21. In addition, nurses notes did not indicate that the wound team was notified of any skin issues prior to 5/11/21. On 5/19/21 Wound Assessment Progress Note was completed by a wound specialist. The note indicated that resident 108 had an unstageable pressure ulcer on her right heel that was 4.7x4.5xUTD in size. The note also indicated the that wound was intact, dark discoloration [with] fluid and boggy. The note indicated that resident 108 had a skin issue on her left heel that was resolved. On 5/28/21 at 2:00 PM, an interview was conducted with the facility Wound Nurse (WN). The WN stated that resident 108's heel should not be placed directly on the bed or a pillow. The WN stated that resident 108 doesn't have a lot of mobility in her right leg. The WN stated that resident 108 would try to lift her R leg but doesn't succeed. The WN stated that resident 108 was admitted with a blister to her right heel. When asked why there was no documentation about a wound to her R heel prior to 5/11/21 or treatment implemented prior to 5/12/21, the WN stated he did not know. On 5/24/21 at 11:05 AM, an interview was conducted with resident 108. When asked about her stay, resident 108 stated I'm not getting very good care here. Resident 108 stated that she had pain a lot in my back and two sores on my butt. When asked if she could move herself around in her bed, the resident stated she did not attempt to reposition herself in bed because it hurts too much. The resident also stated that she had a sore on her right heel and it hurts like hell. I think it's because I'm just laying in bed. I can wiggle my toes but I can't move my foot off the pillows. It's damn scary to be worried about my foot . On 5/25/21 at 1:23 PM, a follow up interview was conducted with resident 108. Resident 108 stated that staff repositioned her in bed but they don't do it very often. I'll have to call for someone to help. The resident stated that she also had two painful sores on her bottom, that she was admitted with, but my butt feels like its on fire. It needs to be moved. On 5/24/21 a continuous observation was made of resident 108 as follows: a. At 11:35 AM, resident 108 was observed to be in her room in seated her bed, with the head of the bed elevated, and her legs outstretched toward the end of the bed. b. At 12:33 PM, a staff member entered the room to deliver resident 108's lunch tray. c. At 1:10 PM, the Social Services Worker (SSW) entered the room, seated herself in a chair, and spoke with resident 108 for several minutes. d. At 1:23 PM, a staff member entered resident 108's room and obtained a blood sugar sample. e. At 1:41 PM, a staff member entered resident 108's room and administered resident 108's insulin. f. At 2:22 PM, a staff member entered resident 108's room to assist resident 108 out of bed and into her wheelchair. During the duration of the observation from 11:35 AM to 2:22 PM, no staff members were observed to reposition resident 108, nor did resident 108 make any efforts to reposition her buttocks or her legs. On 5/28/21 at 12:55 PM, two staff members were observed to enter resident 108's room. They slid resident 108 up in bed, but did not reposition her right heel. The right heel was observed to be directly laying on a pillow, instead of being floated. 4. Resident 112 was admitted to the facility on [DATE] and 1/1/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/24/21 at 10:02 AM, an interview was conducted with resident 112. Resident 112 stated that he needed his brief to be changed. Resident 112 was observed to have a foul odor. Resident 112 stated that he wanted to have his brief changed every 2 hours, but not allowed to be changed until every 4 hours. Resident 112 stated that he has not been continent for most of his life. Resident 112 stated that he has a red buttocks and back from sitting in his urine for long periods of time. At 10:30 AM, a therapy staff member wheeled resident to the therapy gym. At 12:40 PM, resident 112 was observed outside the dining room in his wheelchair. Resident 112 stated he had not been changed. At 1:19 PM, an observation was made of resident 112 with CNA 12 and CNA 14 buttocks and backside. Resident 112 was observed to have red areas with small opening that were bleeding. On 5/24/21 at 1:25 PM, an interview was conducted with CNA 10. CNA 10 stated that resident 112 was compliant with brief changes. CNA 10 stated that resident 112 has set times to have his brief changed. CNA 10 stated usually after smoking he was changed. CNA 10 stated that his butt is terrible. CNA 10 stated that she slathers his buttocks with cream. CNA 10 stated that his buttocks is from sitting in a soiled brief for to long and not being changed. CNA 10 stated she thought the bleeding was from hemorrhoids. On 5/24/21 at 1:30 PM, an interview was conducted with CNA 12. CNA 12 stated that she changed resident 112's brief when he got up this morning. CNA 12 stated that therapy did not do brief changes. CNA 12 stated that resident 112 had sores and dead skin on his buttocks. CNA 12 stated that sometime his back side bleeds like it did today. CNA 12 stated that resident 112 should have been changed around his smoke break which was about 10:30 AM. CNA 12 stated that another CNA should have changed his brief before he left for therapy. CNA 12 stated resident 112 did not have a brief change until 1:30 PM. Resident 112's medical record was reviewed 5/24/21 through 5/28/21. A quarterly MDS dated [DATE] revealed resident 112 was frequently incontinent of bowel and bladder. Resident 112 had not been on a toileting program for bowel or bladder. Resident 112 had a BIMS of 11 which revealed mild cognitive impairment. A care plan dated 5/19/15 revealed, Has bowel incontinence r/t MS The goal developed were Will have less than two episodes of incontinence per day through the review date. The interventions developed were Check resident [with] rounds and prn and assist with toileting as needed and Provide pericare after each incontinent episode According to the CNA documentation in the tasks section from 4/29/21 until 5/28/21 resident 112 had 4 continent bowel episodes and 1 continent bladder episode. CNA documentation further revealed that resident 112 was documented as being toileted at 7:40 AM. Resident 112's Bowel and Bladder Evaluation dated 1/28/21 and 4/28/21 resident 112 was an unlikely candidate for bowel and bladder re-training. The evaluation dated 4/28/21 revealed that resident 112 was always incontinent of bowel and bladder which made resident an unlikely candidate for re-training. On 5/24/21 at 12:45 PM, an interview was conducted with CNA 10. CNA 10 stated resident 112 was usually changed every 2 hours. CNA 10 stated that resident 112 was able to verbalize to staff when he needed to have a brief changed. CNA 10 stated it can be difficult when staffing is low to change resident 112 because he required 2 person assist with a hoyer lift. On 5/24/21 at 2:00 PM, an interview was conducted with the DON. The DON stated resident 112 was a 2 person assist with brief changes. The DON stated that resident 112 should receive a brief change every 2 hours. On 5/27/21 at 3:43 PM, an interview was conducted with RN 3. RN 3 stated stated that resident 112 was continent but he was hard to transfer so he used briefs. RN 3 stated that resident 112 was alert and Oriented x 4 (person, place, time, and situation). RN 3 stated that resident 112 knew what he wants and where he was. RN 3 stated that resident 112 was able to tell when he had a brief change. RN 3 stated that she was no aware of any skin issues and nothing had been reported to her regarding his buttocks. RN 3 stated resident 112 was not on a bowel and bladder retraining program. On 5/28/21 at 10:52 AM, a follow up interview was conducted with the DON. The DON stated that resident 112 was alert and oriented for the most part and able to tell staff what he wanted and needed. The DON stated that he was compliant with cares as long as it was not during a smoking break. The DON stated that he talked to the Wound Nurse regarding resident 112's buttocks. The DON stated that resident 112 had MASD which was caused by sitting in his urine for to long. 5. Resident 99 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/26/21 at 11:22 AM, an interview was conducted with resident 99. Resident 99 stated that she attempted suicide after an agency Certified Nursing Assistant (CNA) treated her terrible. Resident 99 stated there were not enough staff and she felt like a burden on staff. Resident 99 stated that she tried to cut my throat. Resident 99 stated that she used a knife and put a hole in my neck. Resident 99 stated she was supposed to see a counselor after she returned from the hospital. Resident 99 stated that a counselor came into her room and said he was in a hurry and would come back to talk. Resident 99 stated she wanted to talk to a counselor but the counselor had not returned. Resident 99 stated that she had attempted suicide prior to admission as well. Resident 99's medical record was reviewed 5/26/21 through 5/28/21. A care plan dated 5/11/21 revealed, Resident has a history of suicide attempts. A goal developed was Resident will have no incidents of self harm. Interventions were Administer medications as ordered. Monitor/document for side effects and effectiveness, encourage to express feelings, Monitor/record/report to MD prn (as needed) risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med (medications) or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness, provide [local] Mental Health crisis number, resident followed by [local] Mental health. The Emergency Department History and Physical Report dated 3/19/21 at 3:41 PM revealed that resident 99 was .brought in by EMS (Emergency Medical Services), VS (vital signs) normal but pt (patient) unresponsive. Superficial self inflicted abrasion on right arm and chest/neck. The report further revealed, According to caregivers at the facility patient was in her normal state this morning. Her normal state is bedbound only moves right upper extremity and is conversant. Patient had mentioned to some of the workers that she wanted to kill herself. She had a visitor at the facility today. This afternoon patient was found unresponsive with superficial cut marks to her neck. Resident 99's progress notes revealed the entries: a. On 3/19/21 at 1:00 PM, At 1205 (12:05 PM) Aid reported that she went to check in on resident and noticed that resident had a pocket knife in her left hand and noticed that she had a cut on her lower R (right) forearm and bloody smear just below the front side of her neck. She immediately called out to the nurse who was outside the door and while nurse was with the resident she alerted another nurse for help. Upon arriving in residents room, writer noted that the first nurse was holding on to left hand to prevent resident from cutting herself and talking calmly to her. Resident was not combative and was not attempting to attack the staff. She appeared withdrawn, somewhat lethargic but was still coherent to answer appropriately. Staff was able to talk resident into letting the pocket knife go. Resident refused to answer specifically why she was upset. She said repeatedly 'I just want to die', 'I want to be with [name removed]', '[name removed] wants me to be with him', 'Put me in the ground next to [name removed]'. Resident was placed on one on one watch with staff. Provider, DON (Director of Nursing) and Administrator alerted to situation. Provider ordered to send resident to [local hospital] ED (Emergency Department) for further psychiatric and medical eval (evaluation) and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . One of the daughters mentioned that resident has had suicidal ideation and attempts in the past at home and the reason why she was placed in a care center. Resident picked up by [local non-emergent ambulance company] [at] 1250 (12:50 PM) and transported to hospital via stretcher. b. On 3/22/21 at 3:42 PM, MD (Medical Doctor) recommended psych (psychological) evaluation, [local mental health company] notified and coordinating a visit for evaluation. c. On 3/26/21 at 9:43 AM, Late Entry: SW (Social Worker) spoke to [resident 99] about her SI (suicidal ideation) hospitalization and how she was feeling. [Resident 99] stated that she felt better and explained her attempt and what brought her to the ED. SW asked if she had met with the therapist and APRN (Advanced Practice Registered Nurse) that week and she said yes. SW asked if she had any SI ideation that week since returning and she said no. [Resident 99] spoke candidly with SW about her attempts.SW feels she is stable at this time. SW talk to nursing about possible plastic utensils. An Investigation regarding resident 99 suicide attempt was provided to the State Survey Agency. The undated form revealed that on 3/19/21 resident 99 had a suicide attempt. The follow up information revealed, .Resident requested a psychiatric visit to evaluate her mental state. [Local mental Health Company] Mental Health was coordinated to perform visit. Provider did write a new medication order to assist with her psychosocial well-being. House provider was updated on recommendation and order from psychiatric provider to which it was agreed to follow those recommendations. On 5/28/21 at 9:18 AM, a list was provided by the facility Discharge Planner. The list was resident names that the local mental health company was providing services to. Resident 99 was not on the list. The facility Discharge Planner responded that resident 99 was not receiving services but paperwork was being sent today to have resident 99 be on services the following week. On 5/27/21 at 12:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was no incident report for resident 99's suicide attempt. On 5/27/21 at 12:26 PM, an interview was conducted with CNA 12. CNA 12 stated that she was not working when resident 99 tried to hurt herself. CNA 12 stated that she worked the following day. CNA 12 stated that resident 99 told her that an agency CNA had told her she was a burden, like her husband always did. CNA 12 stated that resident 99 told her she had a knife or something sharp she pressed into her neck. CNA 12 stated that resident 99 told her that a nurse came in and found her. CNA 12 stated that resident 99 told CNA 12 that she was in the wrong head space. CNA 12 stated that resident 99's routine in the morning was usually an hour long and agency CNAs have been upset her routine was so long and told her she was a burden. On 5/27/21 at 2:00 PM, an interview was conducted with SSW 1. SSW 1 stated she started at the facility February 2021. SSW 1 stated resident 99 had a suicide attempt. SSW 1 stated she spoke with resident 99 after her suicide attempt. SSW 1 stated that resident 99 stated that she grabbed her knife from home after an agency CNA that was working with her was not very kind with her. SSW 1 stated that resident 99 told her she tried to stab herself with the knife. SSW 1 stated resident 99 was sent to hospital and was there for a bit and then came back. SSW 1 stated that when resident 99 returned to the facility a mental health company was contacted to work with resident 99. SSW 1 stated that resident 99 was seeing the mental health specialist weekly. SSW 1 stated she was not involved in care planning. SSW 1 stated she talked to management and the CNA coordinator about not allowing the Agency CNA back in the building. SSW 1 stated that the CNA coordinator contacted Agency CNAs. SSW 1 stated that she had discussed staffing issues with the management team. SSW 1 stated she provided some training for staff on how to deal with emotional and mental issues with residents. B. The following examples were cited at a potiental for harm related to sufficent staffing: 1. Resident 56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/25/21 [TRUNCATED]

Based on observation, interview and record review it was determined, for 1 of 51 sample residents, that the facility did not ensure that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, or who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, a resident that attempted suicide was not provided mental health services. This was found to have occurred at a harm level. Resident identifier: 99. Findings include: Resident 99 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/26/21 at 11:22 AM, an interview was conducted with resident 99. Resident 99 stated that she attempted suicide after an agency Certified Nursing Assistant (CNA) treated her terrible. Resident 99 stated there were not enough staff and she felt like a burden on staff. Resident 99 stated that she tried to cut my throat. Resident 99 stated that she used a knife and put a hole in my neck. Resident 99 stated she was supposed to see a counselor after she returned from the hospital. Resident 99 stated that a counselor came into her room and said he was in a hurry and would come back to talk. Resident 99 stated she wanted to talk to a counselor but the counselor had not returned. Resident 99 stated that she had attempted suicide prior to admission as well. Resident 99's medical record was reviewed 5/26/21 through 5/28/21. A care plan dated 5/11/21 revealed, Resident has a history of suicide attempts. A goal developed was Resident will have no incidents of self harm. Interventions were Administer medications as ordered. Monitor/document for side effects and effectiveness, encourage to express feelings, Monitor/record/report to MD prn (as needed) risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med (medications) or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness, provide [local] Mental Health crisis number, resident followed by [local] Mental health. The Emergency Department History and Physical Report dated 3/19/21 at 3:41 PM revealed that resident 99 was .brought in by EMS (Emergency Medical Services), VS (vital signs) normal but pt (patient) unresponsive. Superficial self inflicted abrasion on right arm and chest/neck. The report further revealed, According to caregivers at the facility patient was in her normal state this morning. Her normal state is bedbound only moves right upper extremity and is conversant. Patient had mentioned to some of the workers that she wanted to kill herself. She had a visitor at the facility today. This afternoon patient was found unresponsive with superficial cut marks to her neck. Resident 99's progress notes revealed the entries: a. On 3/19/21 at 1:00 PM, At 1205 (12:05 PM) Aid reported that she went to check in on resident and noticed that resident had a pocket knife in her left hand and noticed that she had a cut on her lower R (right) forearm and bloody smear just below the front side of her neck. She immediately called out to the nurse who was outside the door and while nurse was with the resident she alerted another nurse for help. Upon arriving in residents room, writer noted that the first nurse was holding on to left hand to prevent resident from cutting herself and talking calmly to her. Resident was not combative and was not attempting to attack the staff. She appeared withdrawn, somewhat lethargic but was still coherent to answer appropriately. Staff was able to talk resident into letting the pocket knife go. Resident refused to answer specifically why she was upset. She said repeatedly 'I just want to die', 'I want to be with [name removed]', '[name removed] wants me to be with him', 'Put me in the ground next to [name removed]'. Resident was placed on one on one watch with staff. Provider, DON (Director of Nursing) and Administrator alerted to situation. Provider ordered to send resident to [local hospital] ED (Emergency Department) for further psychiatric and medical eval (evaluation) and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . One of the daughters mentioned that resident has had suicidal ideation and attempts in the past at home and the reason why she was placed in a care center. Resident picked up by [local non-emergent ambulance company] [at] 1250 (12:50 PM) and transported to hospital via stretcher. b. On 3/22/21 at 3:42 PM, MD (Medical Doctor) recommended psych (psychological) evaluation, [local mental health company] notified and coordinating a visit for evaluation. c. On 3/26/21 at 9:43 AM, Late Entry: SW (Social Worker) spoke to [resident 99] about her SI (suicidal ideation) hospitalization and how she was feeling. [Resident 99] stated that she felt better and explained her attempt and what brought her to the ED. SW asked if she had met with the therapist and APRN (Advanced Practice Registered Nurse) that week and she said yes. SW asked if she had any SI ideation that week since returning and she said no. [Resident 99] spoke candidly with SW about her attempts.SW feels she is stable at this time. SW talk to nursing about possible plastic utensils. An Investigation regarding resident 99 suicide attempt was provided to the State Survey Agency. The undated form revealed that on 3/19/21 resident 99 had a suicide attempt. The follow up information revealed, .Resident requested a psychiatric visit to evaluate her mental state. [Local mental Health Company] Mental Health was coordinated to perform visit. Provider did write a new medication order to assist with her psychosocial well-being. House provider was updated on recommendation and order from psychiatric provider to which it was agreed to follow those recommendations. On 5/28/21 at 9:18 AM, a list was provided by the facility Discharge Planner. The list was resident names that the local mental health company was providing services to. Resident 99 was not on the list. The facility Discharge Planner responded that resident 99 was not receiving services but paperwork was being sent today to have resident 99 be on services the following week. On 5/27/21 at 12:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was no incident report for resident 99's suicide attempt. On 5/27/21 at 12:26 PM, an interview was conducted with CNA 12. CNA 12 stated that she was not working when resident 99 tried to hurt herself. CNA 12 stated that she worked the following day. CNA 12 stated that resident 99 told her that an agency CNA had told her she was a burden, like her husband always did. CNA 12 stated that resident 99 told her she had a knife or something sharp she pressed into her neck. CNA 12 stated that resident 99 told her that a nurse came in and found her. CNA 12 stated that resident 99 told CNA 12 that she was in the wrong head space. CNA 12 stated that resident 99's routine in the morning was usually an hour long and agency CNAs have been upset her routine was so long and told her she was a burden. On 5/27/21 at 2:00 PM, an interview was conducted with SSW 1. SSW 1 stated she started at the facility February 2021. SSW 1 stated resident 99 had a suicide attempt. SSW 1 stated she spoke with resident 99 after her suicide attempt. SSW 1 stated that resident 99 stated that she grabbed her knife from home after an agency CNA that was working with her was not very kind with her. SSW 1 stated that resident 99 told her she tried to stab herself with the knife. SSW 1 stated resident 99 was sent to hospital and was there for a bit and then came back. SSW 1 stated that when resident 99 returned to the facility a mental health company was contacted to work with resident 99. SSW 1 stated that resident 99 was seeing the mental health specialist weekly. SSW 1 stated she was not involved in care planning. SSW 1 stated she talked to management and the CNA coordinator about not allowing the Agency CNA back in the building. SSW 1 stated that the CNA coordinator contacted Agency CNAs. SSW 1 stated that she had discussed staffing issues with the management team. SSW 1 stated she provided some training for staff on how to deal with emotional and mental issues with residents.

Based on observation, interview and record the review, for 6 of 51 sample residents, it was determined that the facility did not ensure that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, the facility failed to ensure proper care for a resident with a urinary catheter which resulted in the resident being hospitalized . This finding was cited at a harm level. In addition, a resident was not toileted timely, resulting in the resident having skin breakdown. This finding was also cited at a harm level. In addition, residents were not placed on a bowel and bladder training program despite requests and staff assessment of appropriateness Resident identifiers: 37, 82, 84, 99, 102, and 112. Findings include: HARM 1. Resident 84 was admitted to the facility 1/1/21. He has a history of traumatic subdural hemorrhage, nontraumatic subarachnoid hemorrhage, falls, [CONDITION(S)], neuromuscular dysfunction of the bladder, chronic [CONDITION(S)], [CONDITION(S)], dependence on respirator, [CONDITION(S)], [CONDITION(S)] and dementia. Resident 84's medical record was reviewed on 5/23/21. On 5/20/21 at 10:23 PM, a nursing progress note indicated that resident 84's Foley cath (catheter) is patent and draining well at this time. On 5/22/21 at 7:48 PM, a nursing progress note indicated that res (resident) continued with no urine output since cath change to collect UA (urinalysis) and diaphoresis. MD order received at 1850 (6:50 PM) to transport resident to [name of local emergency room ]. [Name of local city paramedics] arrived at 1910 (7:10 PM) to transport and left at 1930 (7:30 PM). The nurses note did not indicate the date or time the catheter had been changed. On 5/22/21 the emergency room Report for resident 84 indicated that the facility staff note that they went to change the patients foley catheter today for source control and had not had urine output since. They also note change in [CONDITION(S)] ([CONDITION(S)]) sputum upon suctioning from clear to green. emergency room Physician diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The emergency room Report also documented that a urinalysis indicated red colored urine, turbid in nature, nitrites present in abnormal nature, large amount of hemoglobin, proteins present at greater than 3000, Large abnormal White Blood Cells and bacteria 3 plus. On 5/22/21, a Computerized Tomography scan was performed in the emergency room . The impression from the radiologist included prominently distended bladder. The foley catheter is malpositioned, the balloon is just inferior to the prostal gland. There is bilateral hydroureter with bilateral hydronephrosis, likely secondary to bladder outlet obstruction. On 5/25/21 at 10:06 AM, a record review showed a late entry progress note for 5/23/21 regarding resident 84. The nursing progress note stated that resident 84 was hospitalized on [DATE]. The note also stated that patient was reported to be tachy (tachycardic) with a HR (heart rate) reaching 145 and a low grade fever. Patient was assessed and on call was notified of the change at 1000 (10:00 AM). Orders were received to do CBC (complete blood count) and CRP (C-Reactive Protein). Due to patient being very dehydrated and all staff efforts being without good outcome, [primary physician]had to be contacted to get a PIV (peripheral intravenous) to draw from as well as have a line in place. [Primary physician] placed PIV at 1715 (5:15 PM) and sample was taken to the lab. No urine output had been seen since midmorning and RN (Registered Nurse) suspected it clogged and was told to change it to get culture. catheter was changed at 1500 (3:00 PM) and no urine was produced. RN notified on call. On call at 1845 (6:45 PM) called and told the night RN to send patient out. [Note: It should be noted that resident 84's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .] On 5/23/21 a confidential staff interview was conducted with Staff Member (SM) 2. SM 2 stated that resident 84 should have been rounded on every two hours. SM 2 stated that the facility was so short staffed on multiple occasions that the staff wasn't able to check the fullness of residents' catheter bags. SM 2 stated that he/she frequently saw resident catheter bags filled to capacity, as well as residents' catheter bags not being emptied timely. SM 2 stated that on the day of hospitalization , resident 84's catheter was not flowing and the catheter bag was full. SM 2 stated the resident's physician was notified, and the catheter was changed to get clean urine for a urinalysis. SM 2 stated that the new catheter was not draining, and resident 84 then had a bladder scan with no reading. SM 2 then stated that resident 84's physician requested that resident 84 be sent to the local emergency room . SM 2 stated that he/she felt the resident was septic because no one changed resident 84's catheter bag in a timely manner. 2. Resident 112 was admitted to the facility on [DATE] and 1/1/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/24/21 at 10:02 AM, an interview was conducted with resident 112. Resident 112 stated that he needed his brief to be changed. Resident 112 was observed to have a foul odor. Resident 112 stated that he wanted to have his brief changed every 2 hours, but was not allowed to be changed until 4 hours had passed. Resident 112 stated that he had not been continent for most of his life. Resident 112 stated that he had a red buttocks and back from sitting in his urine for long periods of time. At 10:30 AM, a therapy staff member wheeled resident to the therapy gym. At 12:40 PM, resident 112 was observed outside the dining room in his wheelchair. Resident 112 stated he still had not been changed. At 1:19 PM, an observation was made of resident 112's buttocks and backside, with CNA 12 and CNA 14 buttocks present. Resident 112 was observed to have red areas with a small opening that were bleeding. On 5/24/21 at 1:25 PM, an interview was conducted with CNA 10. CNA 10 stated that resident 112 was compliant with brief changes. CNA 10 stated that resident 112 had set times to have his brief changed. CNA 10 stated usually after smoking the resident was changed. CNA 10 stated that resident 112's butt is terrible. CNA 10 stated that she slathered the resident's buttocks with cream. CNA 10 stated that the resident's red buttocks were from sitting in a soiled brief for too long and not being changed. CNA 10 stated she also thought the bleeding was from hemorrhoids. On 5/24/21 at 1:30 PM, an interview was conducted with CNA 12. CNA 12 stated that she changed resident 112's brief when he got up this morning. CNA 12 stated that therapy did not do brief changes. CNA 12 stated that resident 112 had sores and dead skin on his buttocks. CNA 12 stated that sometime resident 112's back side bleeds like it did today. CNA 12 stated that resident 112 should have been changed around his smoke break which was about 10:30 AM. CNA 12 stated that another CNA should have changed his brief before the resident left for therapy. CNA 12 stated resident 112 did not have a brief change until 1:30 PM. Resident 112's medical record was reviewed 5/24/21 through 5/28/21. A quarterly MDS dated [DATE] revealed resident 112 was frequently incontinent of bowel and bladder. Resident 112 had not been on a toileting program for bowel or bladder. Resident 112 had a BIMS of 11 which revealed mild cognitive impairment. A care plan dated 5/19/15 revealed, Has bowel incontinence r/t MS (multiple [CONDITION(S)]) The goal developed was Will have less than two episodes of incontinence per day through the review date. The interventions developed were Check resident [with] rounds and prn (as needed) and assist with toileting as needed and Provide pericare after each incontinent episode. According to the CNA documentation in the tasks section from 4/29/21 until 5/28/21 resident 112 had 4 continent bowel episodes and 1 continent bladder episode. CNA documentation further revealed that resident 112 was documented as being toileted at 7:40 AM. Resident 112's Bowel and Bladder Evaluation dated 1/28/21 and 4/28/21 resident 112 was an unlikely candidate for bowel and bladder re-training. The evaluation dated 4/28/21 revealed that resident 112 was always incontinent of bowel and bladder which made resident an unlikely candidate for re-training. On 5/24/21 at 12:45 PM, an interview was conducted with CNA 10. CNA 10 stated resident 112 was usually changed every 2 hours. CNA 10 stated that resident 112 was able to verbalize to staff when he needed to have a brief changed. CNA 10 stated it can be difficult when staffing is low to change resident 112 because he required 2 person assist with a hoyer lift. On 5/24/21 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 112 was a 2 person assist with brief changes. The DON stated that resident 112 should receive a brief change every 2 hours. On 5/27/21 at 3:43 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated stated that resident 112 was continent but he was hard to transfer so he used briefs. RN 3 stated that resident 112 was alert and Oriented x 4 (person, place, time, and situation). RN 3 stated that resident 112 knew what he wanted and where he was. RN 3 stated that resident 112 was able to tell when he had a brief change. RN 3 stated that she was not aware of any skin issues and nothing had been reported to her regarding the resident's buttocks. RN 3 stated resident 112 was not on a bowel and bladder retraining program. On 5/28/21 at 10:52 AM, a follow up interview was conducted with the DON. The DON stated that resident 112 was alert and oriented for the most part and able to tell staff what he wanted and needed. The DON stated that the resident was compliant with cares as long as it was not during a smoking break. The DON stated that he talked to the Wound Nurse regarding resident 112's buttocks. The DON stated that resident 112 had Moisture Associated Skin Damage (MASD) which was caused by sitting in his urine for too long. POTENTIAL FOR HARM 3. Resident 82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/23/21 at 5:18 PM, an interview was conducted with resident 82. Resident 82 stated that one night she needed to have her brief changed but the 500 hall was short staffed. Resident 82 stated that she had wait all night to be changed. Resident 82 stated earlier today I was changed between 4:00 PM and 4:30 PM. Resident 82 stated prior to that she was changed earlier in the morning. Resident 82 stated she was soaked when she was changed between 4:00 and 4:30 PM. Resident 82 stated that she did not feel safe with Agency staff changing her brief. Resident 82 stated that Agency staff were not trained on how to change her brief safely. Resident 82's medical record was reviewed 5/23/21 through 5/28/21. A quarterly MDS dated [DATE] revealed that resident 82 had a BIMS of 15 which indicated resident was cognitive. The MDS further revealed that resident 82 required 1 person extensive assistance with toilet use and personal hygiene. Resident 82 was not on a trial toileting program and was always incontinent of bowel and bladder. The MDS revealed that resident 82 was at risk for developing pressure ulcers. A care plan initiated on 7/18/18 revealed ADL Self Care Performance Deficit r/t (related to) [CONDITION(S)] with obesity hypoventilation syndrome with [CONDITION(S)]/vent and pulmonary [CONDITION(S)] (hypertension) . [CONDITION(S)]. The goal revised on 11/22/2020 by the DON revealed Will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene through the review date. One intervention developed was TOILET USE: Requires one to two person extensive assist to use toilet. [Note: There was no information that resident 82 refused ADL care.] Another care plan dated 7/18/18 and revised on 4/27/20 revealed Has bowel incontinence. The goal was Will remain free from skin breakdown due to incontinence and brief use through the review date. Some of the interventions developed were Ensure there is an unobstructed path to the bathroom. INCONTINENT: Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes Another care plan dated 5/19/19 and updated on 5/12/21 by Corporate Resource Nurse (CRN) 1 revealed Actual behavior problem r/t refusing care and vitals to be taken IE pericares, and repositioning [resident 82] will only allow certain aides to take care of her. She will refuse cares if the ones she doesn't like are working. The goal developed was Will have fewer episodes of by review date. Interventions developed were Document behaviors, and resident response to interventions. An intervention dated 5/23/21 by CRN 3 revealed, Provide a log for refusal of care. A review of resident 82's Bowel and Bladder Evaluation forms revealed on 4/27/21 and 1/27/21 she was an unlikely candidate for retraining. According to CNA documentation in the tasks section of resident 82's medical record. Resident was not changed on 4/27/21,4/30/21, 5/8/21, 5/18/21 and 5/21/21 . Resident 82 was changed once during a 24 hour period on 4/25/21, 4/26/21, 5/3/21, 5/4/21, 5/5/21, 5/7/21, 5/11/21, 5/12/21, 5/15/21, 5/19/21, 5/20/21 and 5/22/21. Resident 82 was documented as being changed twice on 5/23/21 which resident 82 confirmed during her interview. There was a binder at the nurses station for resident 82's refusals. According to the form there was a date, concern/refusal, and able to redirect columns on the form. There was nothing documented on 4/27/21, 5/8/21, 5/18/21, or 5/21/21. There was a note on 4/30/21 which revealed resident 82 . refused to be changed or showered by me. Another note revealed, [Resident 82] refused to be changed/showered [and] told us if we turn her light off she was just going to turn it back on. [Resident 82] said I could not change her because of my attitude [and] 'aura.' There was no documentation regarding which staff members talked with resident 82. A form dated 5/16/21 revealed that resident 82 refused to be changed by staff on floor and was requesting a staff member that was not on the scheduled floor and refused four times. The CNA that signed the form was a male CNA and CNA 7 a female CNA. According to the staffing schedule on 5/16/21 provided by the facility DON the male CNA was not listed to be working that day. There was no signature from the resident on the form. According to the Tasks section of the electronic medical record for resident 82 toilet use was completed twice in a 24 hour period on 5/16/21. Resident 82's progress notes revealed the following entries: a. On 2/21/21 at 10:56 AM, . Res incont of BM (bowel movement), frequently refuses to be changed unless specific staff members are available, Briefs are changed when res allows. Redirection and education attempted without success. b. On 3/14/21 at 10:26 PM, Resident refused to be changed by CNA on PM Shift. CNA offered multiple times and resident continued to refuse. c. On 3/15/21 at 4:48 AM, Resident refused to be changed by CNA on NOC (night) Shift. CNA offered multiple times and resident continued to refuse. Residents room smells strongly of urine. Will continue to educate resident on importance of frequent brief changes to prevent UTI (urinary tract infection and skin breakdown. d. On 4/30/21 at 12:14 AM, Resident refused to be changed by female agency aid at 2300. Resident called asking to have brief change and RN informed resident that girl agency aid on 400 hall could come up and change her, resident refused and stated she would wait for am aid. e. On 4/30/21 at 3:08 PM, Patient refused to be changed from 10 pm on 4/29 because she didn't like the aide from an agency. Patient continued to refused care because she did not like the aide was on the floor. Both aides were female and the nurse offered to assist in changing her and told [resident 82] that it wasn't healthy to be sitting in BM for that amount of time. Patient refused and cried and talked about things not relevant to the aides changing her that she was mad about. (an old boss from [AGE] years ago, ect) RN listened and tried to offer her assistance and come to a resolve but patient was not able to be redirected. Patient refused to be changed and sat in her BM until 1500 (3:00 PM) on 4/30. DON notified. Administrator also came and met with [resident 82] and heard her voiced concerns. Patient still refused cares all day. On 5/24/21 at 10:30 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 82 was only assigned female staff for brief changes and showers per the resident's request. CNA 3 also stated that if you are a new aide or she hasn't seen you before she will refuse all cares. She won't even let you do a brief change. She has only a handful of aides she lets work with her. It's scary because last week she wasn't changed almost all day, but she didn't like the aide that was on that day. The whole hall reeked. On 5/23/21 at 7:33 PM, an interview was conducted with the Administrator. The Administrator stated that resident 82 was particular about who cares for her. The Administrator stated that typically she likes female aides. The Administrator stated that resident 82 wanted to be cared for by specific aides. The Administrator stated that he had talked with resident 82 a lot. The Administrator stated that he was unable to resolve resident 82's concerns. The Administrator stated that he did not file a grievance for resident 82 because he tried to address issues directly. 4. Resident 99 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/26/21 at 10:49 AM, an interview was conducted with resident 99. Resident 99 stated that she had to hold her bowel movements because there were not enough staff. Resident 99 stated that she held her bowel movements during the night shift because there was only one CNA on the 200 hall. Resident 99 stated that CNA 11 was really small and did not know how to operate the sit to stand lift. Resident 99 stated that she did not feel safe with CNA 11 using the sit to stand lift. Resident 99 stated that she skipped meals and did not drink because there were not enough staff to get her up to the bathroom. Resident 99 stated that she was changed at 10:00 PM and then waited till the dayshift CNAs came at 6:00 AM to be changed and put on the toilet. Resident 99 stated that last night she waited for 4 hours to get to the bathroom for a bowel movement. Resident 99 stated that she wanted to use the toilet instead of going in her brief. Resident 99 stated that if she did not have a bowel movement when she was put on the toilet staff will say to her Well, you didn't have to even go. Resident 99's medical record was reviewed 5/25/21 through 5/28/21. A quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which revealed resident was cognitively intact. The MDS revealed that resident 99 did not have a trial toileting program for bowel or bladder. Resident 99 was frequently incontinent of urine. Resident 99 was frequently incontinent of bowel. A care plan dated 12/12/19 revealed Bowel/Bladder: [Resident 99] has requent (sic) bowel/bladder incontinence. The goals developed were Risk for [CONDITION(S)] will be minimized/prevented via prompt recognition and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes and Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. [Note: There was no information regarding a retraining program or assisting resident 99 to the toilet.] Another care plan dated 12/19/21 created by CRN 1 and updated on 5/10/21 revealed resident 99 has Multiple [CONDITION(S)] and is w/c (wheelchair) dependent. The goal developed was Will maintain optimal status and quality of life within limitations imposed by Disease process through review date, as evidenced by: An intervention developed was Bowel/bladder program to improve or maintain continence PRN (as needed). Resident 99 had a Bowel and Bladder Evaluation completed on 3/24/21 that revealed she was a possible candidate for bowel and bladder retraining. An assessment completed on 2/4/21 revealed that resident 99 was Continent or Good Candidate for retraining. According to the CNA documentation in the tasks section, toilet use did not occur during the night shift on 4/29/21, 4/30/21, 5/1/21, 5/2/21, 5/6/215/9/21, 5/14/21, 5/15/21, 5/17/21, 5/22/21, 5/23/21, and 5/24/21. On 5/27/21 at 1:53 PM, an interview was conducted with CNA 12. CNA 12 stated that multiple residents on the 200 hall had complained to her about CNA 11. CNA 12 stated that she told the CNA coordinator that resident 99 did not want CNA 11 to care for her. CNA 12 stated that residents refused to use the restroom because they did not feel safe during transfers with CNA 11. CNA 12 stated that CNA 11 worked as the only CNA on night shift for the 200 hall. CNA 12 stated that the CNA Coordinator told her that other halls have complained about CNA 11, so we have to make due. On 5/27/21 at 3:49 PM, an interview was conducted with CNA 15. CNA 15 stated there were no residents on a bowel and bladder retraining program. CNA 15 stated resident 99 was incontinent with urine but continent with bowel movements. CNA 15 stated that resident 99 knew when she had urinated. CNA 15 stated resident 99 used 1 person with a sit to stand for transfers to the bathroom. CNA 15 stated that resident 99 complained of other CNAs on the hall that were unable to transfer her because the CNA was not big enough to use the lifts. CNA 15 stated that she usually toileted resident 99 before she left at night so that the resident did not have to get up with CNA 11 during the night. CNA 15 stated she told the CNA coordinator that resident 99 was not comfortable with CNA 11 transferring her. CNA 15 stated that she told the CNA coordinator and Administrator that resident 99 wanted a female CNA only and would not let some CNAs help her. CNA 15 stated that she had been told by residents and other staff that CNA 11 had a hard time using lifts. CNA 15 stated that she stayed late a few times to toilet resident 99 before leaving for the night. 5. Resident 102 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/26/21 at 9:11 AM, an interview was conducted with resident 102. Resident 102 stated she would like to use the toilet verses using a brief. Resident 102 stated staff would take her to the restroom, if they answered her call light. Resident 102 stated it took staff up to an hour to answer her call light. Resident 102 stated that she has had accidents in her pants waiting for staff to answer her call light. Resident 102 stated that if she was able to use the bathroom without help she would get herself to the bathroom so she did not have to use a brief. Resident 102 stated it made her feel like she can't do nothing. Resident 102's medical record was reviewed 5/25/21 through 5/28/21. A annual MDS dated [DATE] revealed that resident 102 had not had a trial of a toileting program for bowel or bladder. The MDS revealed that resident 102 was always incontinent of bladder and frequently incontinent of bowel. Resident 102 had a BIMS of 14 which revealed resident was cognitively intact. A care plan dated 5/20/19 revealed, Has bowel/bladder incontinence. One of the goals developed was Will decrease frequency of urinary incontinence through review date. Interventions included, Offer assistance with toileting with rounds, cares and prn and BRIEF USE: uses disposable briefs. Check/Change with rounds, cares and prn. Another care plan dated 5/7/19 and updated on 5/20/20 revealed ADL Self Care Performance Deficit r/t Immobility and weakness secondary to CVA with [CONDITION(S)] affecting left side, Obesity & Incontinence. A goal developed was Will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene; ADL Score through the review date. An intervention developed was TOILET USE: requires Extensive assistance to: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet, to use toilet. A Bowel and Bladder Evaluation dated 10/26/20 revealed that resident 102 was a possible candidate for a bowel and bladder re-training. A Bowel and Bladder Evaluation dated 4/12/21 revealed that resident 102 was an Unlikely Candidate for a re-training program. The form revealed that it was unknown how long resident had been incontinent, always incontinent of bowel and bladder, and was indifferent with behavior/attitude. According to CNA documentation in the tasks section in the last 30 days resident 102 was continent of bowel 4 times and did not have any continent episodes of bladder. On 5/28/21 at 1:29 PM, an interview was conducted with CNA 8. CNA 8 stated that resident 102 really wanted to be continent. CNA 8 stated that a majority of the time she is incontinent. CNA 8 stated that resident 102 was a 2 person pivot transfer. CNA 8 stated resident 102 was not able to transfer herself to use the bathroom. CNA 8 stated that she did not assist resident 102 to the bathroom and had her use her brief. On 5/27/21 at 5:53 PM, an interview was conducted with CNA 13. CNA 13 stated resident 102 did not have any confusion. CNA 13 stated that resident 102 used the toilet for bowel movements. CNA 13 stated resident 102 was able to use the call light and tell staff when she needed to use the bathroom. CNA 13 stated that she assisted resident 102 to the bathroom every 4 hours. CNA 13 stated resident 102 was not on a re-training program for bowel and bladder. On 5/27/21 at 2:41 PM, an interview was conducted with the DON. The DON stated the facility had a new bowel and bladder program. The DON stated that new admissions were monitored for 3 days to determine a bowel and bladder routine. The DON stated if a resident was continent, then the routine would be written on the CNA report sheet. The DON stated that if a resident was more incontinent then maybe they would be put on a re-training program. The DON stated the facility tried to have enough staff to take residents to the bathroom every 1 to 2 hours. On 5/28/21 at 10:52 AM, an interview was conducted with the DON. The DON stated that no residents were on a bowel and bladder re-training program. The DON stated that incontinence care protocol was to change residents every 2 hours. The DON stated that some residents who were continent were able to wait to use the bathroom every 4 hours. The DON stated if a resident was ambulatory then they were taken to the toilet every 2 hours. The DON stated if they were not ambulatory and incontinent then the resident was changed and cleaned every 2 hours. The DON did not know which residents were on a re-training program. 6. Resident 37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 37's medical record was reviewed on 5/23/21. On 11/26/20, an admission MDS assessment was completed by staff for resident 37. The MDS indicated that resident 37 was always incontinent of both bowel and bladder, and that the resident was not on a toileting program. A bowel and bladder evaluation dated 11/22/20 was filled out upon resident 37's admission. The evaluation indicated that the resident was incontinent of bowel, but showed willingness to do a training program. The evaluation indicated that resident 37 was a good candidate for bowel and bladder training. The evaluation did not indicate that resident 37 was incontinent of bladder, as indicated by resident 37's MDS. On 3/29/21, a quarterly MDS assessment was completed by staff for resident 37. The MDS indicated that resident 37 was always incontinent of both bowel and bladder, and that the resident was not on a toileting program. Resident 37's care plan was reviewed. The resident's care plan did not indicate that resident 37 was on a bowel and bladder training program, nor did it address resident 37's needs with regard to his bowel and bladder incontinence. On 5/23/21 at 4:06 PM, an interview was conducted with resident 37. Resident 37 stated that he had been asking staff to be on a bowel and bladder training program, and that he had spoken with Restorative Nurse Aid (RNA) 1 about it, but had not been started on a program yet. On 5/28/21 at 11:30 AM, an interview was conducted with RNA 1. RNA 1 stated that the facility had not initiated a bowel and bladder training program for resident 37, but that resident 37 has been wanting to do it. On 5/28/21 at 10:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility did not currently have any residents on a bowel and bladder training program. The DON stated the the facility did not have a policy about bowel and bladder training.

Based on observation, interview and record review it was determined, for 3 of 51 sample residents, that the facility did not ensure residents received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was assisted with a brief change with only one staff member instead of two, resulting in the resident falling out of bed and sustaining a [CONDITION(S)]. This incident was found to have occurred at a harm level. In addition, a resident sustained a burn after a staff member placed a wet wash cloth from the microwave on the resident. This incident was found to have occurred at a harm level. Another resident was not assessed to determine if he was safe to smoke independently. Resident identifiers: 1, 37, and 103. Findings include: HARM 1. Resident 1 was admitted on [DATE] with diagnoses that included functional [CONDITION(S)], diabetes mellitus, chronic [CONDITION(S)] with [CONDITION(S)], dysphagia, muscle weakness, , hypertension, difficulty walking, [CONDITION(S)], and [CONDITION(S)]. Resident 1's medical record was reviewed on 5/23/21. Resident 1's quarterly Minimum Data Set (MDS) admission assessment dated [DATE] was reviewed. The MDS indicated that resident 1 required extensive assistance with 2 staff members for bed mobility, and was totally dependent on 2 staff members for transferring. Resident 1's care plan dated 2/23/21 was reviewed. The care plan indicated that resident 1 required extensive staff participation to reposition and turn in bed. Nurses notes for resident 1 revealed the following: a. On 5/12/21 at 8:00 PM, CNA found RN (Registered Nurse) and alerted her that patient had fallen out of bed during a brief change and was on the floor. CNA states she was changing the resident when she ran out of wipes. She told the resident to go ahead and roll back while she went and got more wipes. The resident then rolled forward rolling off the bed and onto the floor instead of rolling backwards onto her back. CNA returned to the room to find the resident on the floor. Resident head was resting on the stand holding the ventilator and posterior head was actively bleeding . Res (Resident) c/o (complains of) pain all over body and especially her head. Res was assisted back into Bed and Posterior head was clean and area assessed. 1.5 inch laceration and goose bump noted to posterior head . NP (Nurse Practitioner) notified and gave orders to transport Res to [name of local emergency room ] . b. On 5/13/21 at 1:20 AM, Resident was transferred back to facility via [name of ambulance company] 3 staples noted to laceration on posterior head. Res Noted to have bruised ribs. Staples to be removed 5/19/21. Resident 1's Medication Administration Record (MAR) indicated that resident 1 received a [MEDICATION(S)] for pain on the following dates and times: [Note: Pain scale was 0 to 10 with 0 indicating no pain and 10 indicating excruciating pain.] a. On 5/13/21 at 12:46 PM for pain 10/10 b. On 5/14/21 at 7:57 AM for pain 2/10 c. On 5/14/21 at 7:48 PM for pain 5/10 [Note: Resident 1 did not receive any other [MEDICATION(S)] during the month of May 2021 as of 5/26/21.] The MAR also indicated that resident 1 complained of pain 9/10 during the night shift on 5/12/21. Physical therapy notes dated 5/12/21 documented that resident 1 required maximum assistance for bed mobility training. Physical therapy notes dated 5/14/21 documented that resident 1 was still not feeling like herself after falling out of bed; body aches due to fall. Physical therapy notes dated 5/18/21 documented that resident 1 was extremely anxious and did not want to attempt sitting EOB (end of bed) today either; has taken a big step back since her fall a week ago. On 6/8/21 at 4:00 PM, an interview was conducted with RN 7. RN 7 stated that she was on duty the night that resident 1 fell out of bed. RN 7 stated that there was only one CNA working that night, and it was an agency CNA, who was not familiar with resident 1. RN 7 stated that the CNA working that night had rolled resident 1 on to her side, and then told resident 1 to roll back, but had left the room before making sure that resident 1 was in a safe position. RN 7 stated that she thought resident 1 had somehow rolled forward, resulting in resident 1 hitting her head on the ventilator stand and sustaining an inch-long gash in her head. RN 7 stated that after that incident, resident 1 always insisted on having two people assist her with cares. On 5/23/21, a confidential staff interview was conducted with SM (Staff Member) 2. SM 2 stated that the facility was poorly staffed. SM 2 stated that all the residents on the 500 hall should be 2 person assistance with brief changes. SM 2 stated that it's dangerous how low the staffing was for the 500 hall. SM 2 stated that there was one agency CNA (Certified Nursing Assistant) for the 500 hall one day, and that resident 1 had an accident because there was only one CNA. SM 2 stated that resident 1 was rolled to her side for a brief change. SM 2 stated that the agency CNA left the room to get wipes and resident 1 rolled out of bed. SM 2 stated that when resident 1 rolled out of bed, she hit her head and ended up with staples. SM 2 stated when Agency CNAs worked on the 500 hall there were a lot more accidents. On 5/23/21 at 7:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after the incident on 5/12/21 with resident 1, we took all agency staff off that hall. Now all staff that are up there are our people or are agency who have trained for that hall and know how to reposition those residents. The DON also stated that the CNA left the resident on her side when she left the room and that the CNA should not have left the resident on her side. She should have laid her (the resident) back down on her back and taken all of the supplies in with her. The DON stated that staff can use 1 person to change resident 1. The DON stated that he had not provided education to staff on how to provide 1 person care. On 5/24/21 at 9:16 AM, an interview was conducted with the Administrator. The Administrator stated that he had seen that we were staffing only 1 aide when we should be staffing 2. The Administrator stated that 2 weeks ago, I told them (management) we had to have 2 CNAs up there (500 hall) because of the care. The Administrator stated that after an incident when a resident rolled out of bed a Quality Assurance (QA) plan was created. On 5/24/21 at 10:30 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 1 needs two people to change her. She's a total assist. CNA 3 further stated that when he changed resident 1's briefs, he always used two people because the bed is kind've small so I can pull her over to the side to give me enough space, so in case she falls forward she falls into the bed. On 5/24/21 at 10:55 AM, an interview was conducted with resident 1. Resident 1 stated that she was unable to move herself around in bed. When asked about the incident on 5/12/21, resident 1 stated that there were usually two people that changed her brief, but on 5/12/21 it was only one. Resident 1 stated that the lone staff member had rolled the resident to her right side on the edge of the bed and left the room. Resident 1 stated that she had subsequently fallen out of the bed and hit her head on the equipment next to her bed. Resident 1 stated that it was scary. On 5/26/21 a confidential staff interview was conducted with SM 11. SM 11 stated that all the residents on the 500 hall should be assisted by two staff members with brief changes, transfers etc. SM 11 stated that he/she had worked on the 500 hall alone multiple times. SM 11 stated that if there was not another staff member to assist him/her, then he/she would ask the resident, and if the resident says they are ok with me doing stuff by myself I do it. SM 11 stated that after resident 1's fall on 5/12/21, resident 1 doesn't trust anyone [to work with her] by themselves anymore. 2. Resident 103 was admitted to the facility on [DATE] with diagnoses which included multiple [CONDITION(S)], mild cognitive impairment, [CONDITION(S)], and [CONDITION(S)]. Resident 103's medical record was reviewed on 5/24/2021 through 5/28/2021. A nursing progress notes dated 2/11/21 at 2:48 PM by RN 6, revealed, Has [CONDITION(S)] on the back of her neck. Stated that resident heat up a wet wash rag in the microwave and put it on her neck unsupervised. resident education about hot pack use with supervision was completed and she understood well. abx (antibiotic) ointment for [CONDITION(S)] was applied. she tol (tolerated) well. MD (Medical Doctor) notified. DON notified. Resident 103's Treatment Administration Record (TAR) and Medication Administration Record (MAR) for February 2021 were reviewed. There was no documentation of treatment for the burn. Resident 103's orders were reviewed and there were no orders for a burn treatment. On 5/24/21 at 1:15 PM, an interview was conducted with resident 103. Resident 103 stated she asked staff to put a wash rag on her back because she was unable to get a hot pack from the therapy department. Resident 103 stated a CNA warmed up a wet wash cloth and did not check with the nurse. Resident 103 stated that her skin was red. On 5/27/21 at 5:44 PM, an interview was conducted with RN 6. RN 6 stated that the therapy staff members have hot packs for residents. RN 6 stated CNAs should not provide any heated item for residents to put on their bodies. RN 6 stated that she heard from the night shift nurse that resident 103 had sustained a burn on her shoulders. RN 6 stated she was unable to remember who the night shift nurse was. RN 6 stated that she explained to resident 103 to not let CNAs heat up things to place on her body. RN 6 stated that she applied an ointment to the red skin. RN 6 stated resident 103 stated it was painful and felt better after the ointment was applied. RN 6 stated that resident 103 stated she was not aware of how hot the wash cloth was until the washcloth was removed. RN 6 stated that she reported to MD and they said to apply the ointment until healed. RN 6 stated that she notified the DON and did not hear back from the DON. RN 6 stated she educated CNAs not to heat wash cloths and all hot packs were to be applied by therapy staff. On 5/27/21 6:04 PM, an interview was conducted with the DON. The DON stated there were no incident reports or investigation information regarding resident 103's burn. The DON stated he was not aware of the incident. The DON stated that if it was documented that he was notified then he had been notified. The DON stated that he did not complete any systemic changes after the incident. The DON stated that he would have told nurse to notify the MD. The DON stated that he would have educated staff and resident. POTENTIAL FOR HARM 3. Resident 37 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, functional [CONDITION(S)], chronic pain, gout and neuromuscular dysfunction of bladder. On 5/27/21 at approximately 9:53 AM, an interview was conducted with the DON. The DON stated that the facility's smoking program was that upon admission, the resident read and signed the facility's Smoking Policy to acknowledge that they understood the facility's smoking rules. The DON stated that the resident was given information on the smoking times and location for the care unit they reside in. The DON stated that the resident was then evaluated by facility staff to determine if the resident was safe to smoke independently or if there was a need for supervision when they were smoking. The facility's Smoking Policy (Revised 3/2008) revealed the following: Policy: It is the policy of this facility to provide to its' residents a smoke free environment. It is also policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of other residing in the facility. Procedure: 1. 2. Upon admission (7-10 days), residents who desire to smoke will be assessed as well as their ability to do so safely. The Interdisciplinary Team will accomplish this using the Smoking Assessment form and a review of the resident's clinical record. At the end of this period it will be determined if the resident will be allowed to smoke with or without protective devices. 3. All resident will be on supervised smoking. 4. The results of the evaluation will be put in the resident's chart. 5. Upon annual review by the IDT (interdisciplinary team), or at any time a significant change of condition occurs, smoking residents will be reassessed as to their ability to smoke safely with or without protective devices and their ability to understand and comply with facility non-smoking policy using the Smoking Assessment form. 7. The frequency of smoking for all residents will be the following times (posted at nurses station) with staff supervision. These times will be no more than twenty (20) minute increments or 2 cigarettes. 8. All smoking materials are to be left at nurses station. [Note: There was no mention in the facility's Smoking Policy about allowing resident to smoke independently if they leave the facility's property or providing smoking materials when a resident wanted to leave the facility's property to smoke.] On 5/27/21, resident 37's medical record was reviewed. Resident 37's Care Plan dated 4/1/21 revealed Potential for injury r/t (related to) Smoking. A goal developed was Will be compliant with smoking protocols and individual smoking plan until next review. Another goal was Will have no injuries related to smoking. Interventions developed were Complete smoking assessment. Explain smoking policy. Maintain smoking materials at nurses' station or other designated area. Monitor to assess compliance with facility smoking policy/individual plan. Observe smoking while in designated area. Report non-compliance or unsafe smoking habits to MD and responsible party. Resident 37's Smoking Agreement that he signed on 4/6/21 revealed .3. I agree to abide by individual restrictions related to smoking safety based on the facilities interdisciplinary team's assessment of my ability to smoke responsibly and safely. [Note: No smoking safety evaluation/assessment was found in resident 37's medical record.] On 5/27/21 at approximately 12:23 PM, an interview was conducted with Certified Nursing Assistant 1. CNA 1 stated that resident's, who smoked could not have their own lighter and they could only have one cigarette, but she give them whatever they want. CNA 1 further stated that residents, who smoked have to be able to wheel themselves out and light the cigarette themselves. CNA 1 stated if residents wanted to smoke on the facility's property, then they would only go during the scheduled times. On 5/27/21 at approximately 6:00 PM, resident 37 was observed near the nurses' station asking CNA 2 for a cigarette. CNA 2 first replied that he could not have a cigarette and stated that smoking is a privilege here. Resident 37 replied back to CNA 2 that she knew he could go smoke anytime he wanted as long as he went off the facility's property. CNA 2 then provided a cigarette and lighter to resident 37. Resident 37 wheeled himself in his wheel chair down the hall and outside. On 5/27/21 at approximately 6:16 PM, an interview was conducted with CNA 2. CNA 2 stated that the smoking times for residents to smoke had recently changed about 3 weeks ago. CNA 2 stated that the facility used to allow smoking 5 times a day, but they did not have enough staff to supervise residents outside smoking so the facility decreased smoking for residents to only 3 times a day. CNA 2 pointed out a sign posted near the nurses' station, which revealed 3 times a day when residents could smoke (10:30 AM, 2:30 PM & 6:30 PM). CNA 2 then stated that resident, who smoked independently, could smoke whenever they want as long as they went off the facility's property. CNA 2 stated that nursing decided if resident were safe to smoke independently. On 5/27/21 at approximately 6:27 PM, resident 37 was observed wheeling himself in his wheel chair coming back toward the nurses' station. An interview was conducted with resident 37. Resident 37 stated that he had become tired of only being able to smoke during the posted times and only out in the courtyard. Resident 37 stated that a couple months ago that the CNA Coordinator told him that he could smoke whenever he wanted as long as he went off of the facility's property. Resident 37 stated he had enjoyed going to smoke when he wanted to and he liked leaving the facility's property to smoke because it gave him some new scenery rather than just going to the facility's courtyard. Resident 37 stated that he usually smoked 2 to 3 times a day and went off property to smoke. On 5/27/21 at approximately 7:18 PM, an interview was conducted with the DON. The DON stated that the facility's smoking times were recently changed because there were too many staff outside supervising smokers rather inside assisting residents. The DON stated that they allowed residents, who smoked safely independently to leave the facility's property to smoke. The DON stated that residents, who smoked were evaluated to determine if they could smoke safely without supervision. The DON stated that resident 37 should have had an evaluation to assess whether he could smoke safely without supervision.

Based on interview, record review and observation it was determined, for 1 of 51 sample residents, that the facility did not provide care to prevent unavoidable pressure ulcers, nor did they provide timely treatment and services for the resident's pressure ulcer. Specifically, a resident developed an unstageable pressure sore and was not provided interventions to prevent the pressure sore. In addition, after the pressure sore was developed treatment and services were not provided in a timely manner to heal the pressure sore. This resulted in a finding of harm. Resident identifier: 108. Findings include: Resident 108 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 108's medical record was reviewed on 5/23/21. On 4/29/21, staff completed an Initial Admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed an Initial Admission Record for resident 108. The admission record indicated that resident 108 had a blister on left heel, old pressure wound on coccyx. There were no measurements or description of either wound. On 4/30/21, staff completed a document entitled Functional Performance Evaluation. The evaluation indicated that resident 108 required substantial/maximal assistance with sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed to chair transfer. On 4/30/21, staff completed a document entitled Braden Scale for Predicting Pressure Sore Risk. The document indicated that resident 108 was slightly limited in her ability to respond to pressure-related discomfort, had skin that was occasionally moist, was chairfast, and was slightly limited in her ability to change and control body position. The document also indicated that resident 108 was at low risk for developing a pressure sore. On 4/30/21 staff developed a care plan for resident 108 that indicated resident had a self care performance deficit related to immobility and weakness. The care plan indicated that resident 108 required Extensive assistance 2 staff participation to reposition and turn in bed. On 5/3/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. On 5/10/21 staff completed a weekly skin evaluation. Staff indicated that there were no wounds, and no new skin issues. Nurses notes for resident 108 indicated the following note: On 5/12/21 wound team note. team notified 5/11 of sores present on admit. [Resident 108] has MASD (moisture associated skin damage) under L (left) breast, center to L [NAME] (sic), and BL (bilateral) buttock, scaring (sic) noted on BL buttocks from old wounds. she has a fluid filled blister on her R (right) heel, 4.7x4.5xUTD (unable to determine). PI (pressure injury) unstageable. dark in color. no drainage. no s/s (signs or symptoms) of infection. [NAME] (Decubitis ulcer) noted on the L pad of foot. old and very stable, 0.5x0.7xUTD. education on offloading. On 5/12/21 staff developed a care plan for resident 108 that stated Has pressure ulcer development to R (right) heel r/t (related to) immobility. The care plan also stated that the pressure ulcer was present on admission, was unstageable, and was 4.7 centimeters by 4.5 centimeters in size. On 5/12/21 staff also developed a care plan for resident 108 that stated resident 108 Has actual impairment to skin integrity r/t MASD. [Note: The initial skin integrity care plan for resident 108 developed on 4/30/21 did not indicate that resident 108 had any impairments to her skin integrity.] Resident 108's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No orders for wound care were written prior to 5/12/21. On 5/18/21 staff completed a weekly skin evaluation. Staff documented that resident 108 had an unstageable pressure ulcer to her R heel that was present on admission. However, no notes could be located in resident 108's medical record to indicate that resident 108 had any skin issues on her R heel prior to 5/11/21. In addition, nurses notes did not indicate that the wound team was notified of any skin issues prior to 5/11/21. On 5/19/21 Wound Assessment Progress Note was completed by a wound specialist. The note indicated that resident 108 had an unstageable pressure ulcer on her right heel that was 4.7x4.5xUTD in size. The note also indicated the that wound was intact, dark discoloration [with] fluid and boggy. The note indicated that resident 108 had a skin issue on her left heel that was resolved. On 5/28/21 at 2:00 PM, an interview was conducted with the facility Wound Nurse (WN). The WN stated that resident 108's heel should not be placed directly on the bed or a pillow. The WN stated that resident 108 doesn't have a lot of mobility in her right leg. The WN stated that resident 108 would try to lift her R leg but doesn't succeed. The WN stated that resident 108 was admitted with a blister to her right heel. When asked why there was no documentation about a wound to her R heel prior to 5/11/21 or treatment implemented prior to 5/12/21, the WN stated he did not know. On 5/24/21 at 2:32 PM, an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated that resident 108 could move her leg a little bit. CNA 6 stated that resident 108's heels were supposed to be floated during the day. CNA 6 stated that she was supposed to do rounds on resident 108 every two to three hours. CNA 6 stated that rounds included repositioning resident 108 because resident 108 required staff assistance to reposition herself in bed. On 5/28/21 at 1:50 PM, an interview was conducted with Registered Nurse (RN) 8. RN 8 stated that he was unsure how resident 108's pressure ulcer started. RN 8 stated that resident 108 could not reposition herself in bed. On 5/24/21 at 11:05 AM, an interview was conducted with resident 108. When asked about her stay, resident 108 stated I'm not getting very good care here. Resident 108 stated that she had pain a lot in my back and two sores on my butt. When asked if she could move herself around in her bed, the resident stated she did not attempt to reposition herself in bed because it hurts too much. The resident also stated that she had a sore on her right heel and it hurts like hell. I think it's because I'm just laying in bed. I can wiggle my toes but I can't move my foot off the pillows. It's damn scary to be worried about my foot . On 5/25/21 at 1:23 PM, a follow up interview was conducted with resident 108. Resident 108 stated that staff repositioned her in bed but they don't do it very often. I'll have to call for someone to help. The resident stated that she also had two painful sores on her bottom, that she was admitted with, but my butt feels like its on fire. It needs to be moved. On 5/24/21 a continuous observation was made of resident 108 as follows: a. At 11:35 AM, resident 108 was observed to be in her room in seated her bed, with the head of the bed elevated, and her legs outstretched toward the end of the bed. b. At 12:33 PM, a staff member entered the room to deliver resident 108's lunch tray. c. At 1:10 PM, the Social Services Worker (SSW) entered the room, seated herself in a chair, and spoke with resident 108 for several minutes. d. At 1:23 PM, a staff member entered resident 108's room and obtained a blood glucose sample. e. At 1:41 PM, a staff member entered resident 108's room and administered resident 108's insulin. f. At 2:22 PM, a staff member entered resident 108's room to assist resident 108 out of bed and into her wheelchair. During the duration of the observation from 11:35 AM to 2:22 PM, no staff members were observed to reposition resident 108, nor did resident 108 make any efforts to reposition her buttocks or her legs. On 5/28/21 at 12:55 PM, two staff members were observed to enter resident 108's room. They slid resident 108 up in bed, but did not reposition her right heel. The right heel was observed to be directly laying on a pillow, instead of being floated. On 5/28/21 at 10:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility did not have a policy regarding pressure sore prevention or treatment.

Based on observation, interview and record the review, for 3 of 51 sample residents, it was determined that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident experienced uncontrolled pain from a [CONDITION(S)] for at least six hours prior to being sent to the hospital. This resulted in a finding of harm. In addition, the nursing staff did not provide oral or topical pain medication to residents who were complaining of pain. Resident identifiers: 17, 53 and 110. Findings include: HARM 1. Resident 110 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 110's medical record was reviewed 5/23/21 through 5/28/21. Nurses notes for resident 110 revealed the following entries: a. On 3/2/21 at 11:33 AM, a large bruise was located on the resident's right thigh. The nurse did not indicate if the resident was in pain. b. On 3/2/21 at 4:24 PM, Symptoms or signs noted of Condition change: Pain (uncontrolled). RLE (right lower extremity) rotated laterally. The note indicated that the physician had been notified at 4:00 PM. The note did not indicate how long resident %% had been in pain, onset of pain, level of pain, or interventions for pain management. On 3/2/21 at 6:51 PM, R (right) leg is turned laterally and pt (patient) cries out upon attempt to rotate medially. Large R bruise noted on inner R thigh than L (left) leg. NP (Nurse Practitioner) assessed pt (patient) and ordered R hip x-ray. Pt denies pain, except upon palpation of site. [Note: No progress notes had been entered prior to this to indicate when the pain first started, or how it progressed.] c. On 3/2/21 at 10:15 PM, the NP entered a note that After detailed skin check and nursing assessment of shortened and internally rotated R LE with new bruising to upper groin/leg area. Pt was sitting in w/c (wheelchair) yesterday, but unable to get out of bed today d/t (due to) pain. Also c/o (complains of) pain with any slight movement to RLE and pain to R hip with palpation. Xray ordered. Follow up note: Findings of Comminuted acute intertrochanteric fracture of the right hip with comminuted components and pt sent to ER . for further management and orthopedic consult. d. On 3/2/21 at 10:28 PM, a radiology note indicated that the resident had Comminuted acute intertrochanteric fracture of the right hip with comminuted components. e. On 3/2/21 at 10:35 PM, the facility contacted the resident's husband and stated that the physician was recommending the resident be sent out to the hospital. f. On 3/6/21 at 3:18 AM, Resident readmitted on [DATE] S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 110's March 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/2/21, facility staff documented that resident 110 did not have any pain for either shift, despite calling the physician for uncontrolled pain at 4:24 PM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An abuse investigation report dated 3/2/21 revealed that Resident reports attempting to transfer self to wheelchair on 3/2/21 and then suffering increased pain leading to being sent to [local] emergency room . Review of an incident report revealed that resident 110 told staff she was transferring from her chair when the injury happened. However, according to a 12/10/20 Admission, Minimum Data Set (MDS) Assessment, resident 110 could not state what the date, month or year was. She was assessed as having long term and short term memory problems, as well as severely impaired cognitive skills for daily decision making. In addition the incident report did not indicate what time the resident allegedly fell . On 5/27/21 at 4:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the information about the resident attempting to transfer to the wheelchair was obtained through an interview with the husband. The DON could not provide an explanation as to why resident 110 was in pain from a fractured hip with no pain medication for at least 6 hours. On 5/27/21 at 5:36 PM, an interview was conducted with resident 110's husband. Resident 110's husband stated that resident 110 had a [CONDITION(S)] with a fall in February and she was complaining of pain in her lower legs. Resident 110's husband stated that resident 110 was sent to the hospital and her lower legs were X-rayed and there were no fractures. Resident 110's husband stated that a couple weeks later, the facility called him and stated that resident 110 had pain in her right hip with some bruising. Resident 110's husband stated that the facility then sent her to the hospital a second time and she had a fractured hip which required surgery. Resident 110's husband stated he did not witness a fall and was not told about a fall. Resident 110's family member stated that he had not witnessed or been told by facility staff that resident 110 had transferred herself to her wheel chair, sustaining an injury to her hip. POTENTIAL FOR HARM 2. Resident 17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/26/21 at 11:51 AM, an interview was conducted with resident 17. Resident 17 stated his knees and shoulders needed to have [MEDICATION(S)] gel twice a day. Resident 17 stated there were not enough staff to apply the gel twice daily to his shoulders and knees. Resident 17 stated that the gel helped but needed to be applied during the busy times of the day in the morning and before bed. Resident 17's medical record was reviewed on 5/28/21. An order dated 11/16/20 revealed [MEDICATION(S)] Gel 1% apply application transdermally every 6 hours as needed for pain. A quarterly MDS dated [DATE] revealed that resident 17 had scheduled pain medications, as needed medications, and non-medication interventions for pain. A pain assessment was completed and revealed resident had almost constant pain. Resident 17's pain made it had for him to sleep at night and limited his day to day activities. A care plan dated 10/9/20 and updated on 3/25/21 revealed Has acute/ chronic pain r/t (related to) surgical repair of LLE (left lower extremity) fx (fracture), muscle spasms, [CONDITION(S)] [MEDICATION(S)] as ordered.Tylenol as ordered, [MEDICATION(S)] gel 0.5% as ordered, [MEDICATION(S)] as ordered, [MEDICATION(S)] as ordered oxycodone 5/325mg (milligrams) as ordered, [MEDICATION(S)] gel 1% as ordered. The goals were Will not have an interruption in normal activities due to pain through the review date. Will voice a level of comfort through the review date. Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The interventions developed were Administer [MEDICATION(S)] medication as per orders. Give 1/2 hour before treatments or care. Anticipate need for pain relief and respond immediately to any complaint of pain. Report occurrences to the physician. Monitor/record pain characteristics: . Pain assessment every shift. According to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. 5/1/21, 6 and the gel was effective. b. 5/12/21, 8 and the gel was effective c. 5/16/21, 6 and the gel was effective. d. 5/19/21, 3 and the get was effective. e. 5/22/21, 7 and the gel was effective. f. 5/26/21, 10 and the gel was effective. On 5/28/21 at 1:33 PM, an interview was conducted with Certified Nursing Assistant (CNA) 8. CNA 8 stated that resident 17 had [MEDICATION(S)] gel in his drawer in his room. CNA 8 stated he applied it to his shoulders and knees. CNA 8 stated that the gel provided pain relief and he seemed to feel better after the gel was applied. CNA 8 stated that resident 17 asked to have her apply it occasionally. On 5/28/21 at 1:45 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated [MEDICATION(S)] gel was a medication to be administered by the nurse. RN 1 stated that resident 17 had the gel in his top drawer and was able to apply it himself to his knees but needed assistance applying it to his shoulders. On 5/28/21 at 1:50 PM, a follow up interview was conducted with resident 17. Resident 17 stated that he wanted a nurse to apply the gel to his shoulders and knees. Resident 17 stated that the gel really helps with the pain. Resident 17 stated that the nurses were too busy to apply it in the morning and at night. Resident 17 stated that he sometimes asked CNAs to apply it but they were very busy. Resident 17 stated he tried to apply the gel to his shoulders but was unable to reach all the way behind his shoulder. Resident 17 stated he did not apply it to his knees because he was unable to reach his knees and almost fell forward trying to reach them. 3. Resident 53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/25/21 at approximately 2:36 PM, resident 53 complained of pain in both shoulders. Resident 53 stated he had taken medication for it but it did not provide relief. Resident 53 stated he told the physician that the [MEDICATION(S)] did not provide relief. On 5/25/21 at approximately 2:45 PM, resident 53 reported pain in his chest area. Resident 53 stated, I think I'm having a [CONDITION(S)]. Registered Nurse (RN) 3 stated that resident 53 always had complaints of pain. The Assistant Director of Nursing (ADON) approached and obtained resident 53's vital signs and they were within normal limits. The ADON stated that resident 53 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 53's medical record was reviewed 5/27/21. Resident 53 had the following MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] a. Acetaminophen 1000 mg (milligrams) by mouth two times a day for pain not to exceed (NTE) 3000 mg in a 24 hour period from all sources. Order Date 3/2/21 b. Acetaminophen 1000 mg by mouth every 24 hours as needed (PRN) for pain prn NTE 3000 mg in a 24 hour period from all sources. Order Date 3/2/21 c. [MEDICATION(S)] Tablet Delayed Release 40 mg by mouth one time a day for GERD. Order Date 12/18/20 Resident 53 was having his pain assessed twice-a-day, morning and evening, using a pain scale of 0 - 10, where a score of 0 was no pain, and a score of 10 was the worst possible pain. Review of resident 53's April 2021 and May 2021 Medication Administration Records (MARs) revealed the following pain score monitoring while receiving Acetaminophen 1000 mg by mouth twice a day [morning and evening]: April 2021 a. 4/4/21 morning pain score was 3, evening pain score was 1. b. 4/5/21 morning pain score was 4, evening pain score was 1. c. 4/6/21 morning pain score was 2, evening pain score was 1. d. 4/8/21 morning pain score was 8, evening pain score was 0. [Note: An additional PRN pain medication (Acetaminophen 1000 mg) by mouth was administered at 12:21 PM and charted as Effective.] e. 4/9/21 morning pain score was 2, evening pain score was 2. f. 4/10/21 morning pain score was 2, evening pain score was 0. g. 4/11/21 morning pain score was 0, evening pain score was 6. h. 4/12/21 morning pain score was 4, evening pain score was 1. i. 4/13/21 morning pain score was 1, evening pain score was 1. j. 4/14/21 morning pain score was 4, evening pain score was 1. k. 4/15/21 morning pain score was 0, evening pain score was 5. l. 4/17/21 morning pain score was 0, evening pain score was 1. m. 4/18/21 morning pain score was 2, evening pain score was 2. n. 4/19, 21 morning pain score was 2, evening pain score was 1. o. 4/20/21 morning pain score was 2, evening pain score was 0. p. 4/22/21 morning pain score was 0, evening pain score was 4. q. 4/24/21 morning pain score was 2, evening pain score was 0. r. 4/26/21 morning pain score was 3, evening pain score was 1. s. 4/27/21 morning pain score was 1, evening pain score was 1. t. 4/28/21 morning pain score was 1, evening pain score was 1. u. 4/29/21 morning pain score was 0, evening pain score was 1. [Note: No additional PRN pain medication was administered except for the dose on 4/8/21.] May 2021 a. 5/2/21 morning pain score was 3, evening pain score was 0. b. 5/3/21 morning pain score was 3, evening pain score was 3. c. 5/5/21 morning pain score was 0, evening pain score was 10. d. 5/9/21 morning pain score was 5, evening pain score was 5. e. 5/10/21 morning pain score was 4, evening pain score was 0. f. 5/11/21 morning pain score was 4, evening pain score was 0. g. 5/12/21 morning pain score was 4, evening pain score was 4. h. 5/17/21 morning pain score was 4, evening pain score was 2. i. 5/24/21 morning pain score was 2, evening pain score was 1. j. 5/26/21 morning pain score was 2, evening pain score was 0. [Note: No additional PRN pain medication was administered.] On 5/27/21 at approximately 5:42 PM, an interview was conducted with resident 53. Resident 53 stated that his left shoulder pain was an 8 out of 10 on the pain scale. Resident 53 was observed to hold his left shoulder. Resident 53 stated that he told the nurses that this shoulder hurt so it must be his chest, so it must be having a [CONDITION(S)]. Resident 53 was observed to rub his left shoulder. [Note: No additional PRN pain medication was administered until 6:43 PM.] On 5/27/21 at approximately 5:50 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she did not know why resident 53 did not receive any additional PRN pain medication after reporting a pain score of 10 out of 10 on 5/5/21. RN 1 stated that if a resident had reported a pain score of 10 to her, that she would have checked to see if the resident had a PRN pain medication ordered and then would administer it and notify the resident's provider. On 5/27/21 at approximately 6:43 PM, resident 53 was observed grimacing, holding and rubbing both shoulders while standing near the nurses' station. Resident 53 complained of pain in his shoulders and requested his pain medication from RN 2. RN 2 asked resident 53 how he rated his pain. Resident 53 responded that it was an 8 out of 10. RN 2 administered resident 53 his scheduled evening dose of Acetaminophen 1000 milligrams (mg) by mouth with water. On 5/27/21 at approximately 6:50 PM, an interview was conducted with RN 2. RN 2 stated she did not know why resident 53 did not receive any additional PRN pain medication after reporting a pain score of 10 on 5/5/21. RN 2 stated if a resident had reported a pain score of 10 that she would have checked to see if the resident had a PRN pain medication ordered and would have administered it. On 5/27/21 at approximately 7:29 PM, an interview was conducted with the DON. The DON stated that he did not know why resident 53 did not receive any additional PRN pain medication after reporting a pain score of 10 on 5/5/21. On 5/27/21 at approximately 7:40 PM, resident 53 was observed at the nurses' station. Resident 53 stated that he had shoulder pain and no one loves me, no one cares about me. On 5/28/21 at 8:25 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process for evaluating a resident's pain was by done by the nurse every shift with a pain assessment utilizing a pain scale and with each pain medication administration. The DON stated that if the pain was reported at a higher level the nurse would assess the resident and report it to the physician. The DON stated that for a report of a pain level of a 10/10 (on a scale of 1 to 10, with 10 being the highest), he would expect the nurse to administer a PRN (as needed) pain medication, and then follow up with the physician. The DON stated that if the physician was informed he would expect that the resident would get something additional for the pain, like with a fracture. The DON stated that this would also be dependent on what was the cause of the pain. What is the reason behind this? If it is something big, yes. If its a one time thing, maybe not. With a fracture they get an x-ray and see what is causing the pain and treat the pain. The DON stated that resident 17 had not reported any pain in the arm and knees. The DON stated that resident 17 had [MEDICATION(S)] gel that helped if applied every night. If they are consistent with it, it would really help. The DON stated that resident 53 reported chest pain. The DON stated that resident 53 was not alert and oriented. The DON stated that resident 53 had left the facility before to seek treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON then stated that resident 53 was alert and oriented enough to come back to the facility. The DON stated that he was not aware that resident 53 was reporting pain at a level of 8/10 last evening. The DON stated the facility did not have a policy and procedure for pain management.

Based on interview, observation and record review it was determined, for 6 of 56 sample residents, that the facility did not provide appealing options of similar nutritive value to residents who chose not to eat food that was initially served. Specifically, a resident was served food she was allergic to resulting in administration of an Epi-Pen. These findings were cited at a harm level. In addition, residents receiving ground foods were not provided a substitute for dry bread, and residents were not provided a substitute for unwanted vegetables. Resident identifiers: 26, 29, 53, 64, 84, and 151. Findings include: HARM 1. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/24/18 at 11:30 AM, resident 29 was interviewed. Resident 29 stated that she was allergic to shellfish and had been served shellfish while in the facility. Resident 29 stated that a few months prior, she was served some sort of patty and thought they looked fishy so she did not eat them. However, she did eat rice that was touching the patties. Resident 29 stated that her throat then began to itch. Resident 29 stated that she had been sent krabby patties other times at the facility but has not since eaten anything on the tray when they were served to her. Resident 29's most recent Minimum Data Set assessment documented that resident 29 had a Brief Interview Mental Status score of 15, indicating that she was cognitively intact. On 11/3/17, an Initial Dietary Assessment was completed by the Dietary Aide. The assessment revealed that resident 29 reported having an allergy to shellfish. On 11/7/17 at 3:59 PM, an Medication Administration Note documented that resident 29 was given [MEDICATION NAME] tablet 25 milligrams (mg) for itching. On 11/7/17 at 4:58 PM, a Medication Administration Note documented that the [MEDICATION NAME] was effective. On 11/7/17 at 7:00 PM, a Medication Administration Note documented that resident 29 was administered an [MEDICATION NAME] related to difficulty breathing and itchy, per the Nurse Practitioner (NP) order. On 11/7/17 at 11:54 PM, a Medication Administration Note documented that the [MEDICATION NAME] was effective and that resident 29 no longer had complaints of difficulty breathing or SOB. On 11/7/17 at 4:19 PM, resident 29 had a temperature of 99.3 °F. On 11/7/17, the allergen shellfish was added to resident 29's electronic medical record. On 11/8/17 at 1:11AM, facility nursing staff documented the following in a nursing note. Pt (patient) continues on ABX (antibiotics) for UTI (urinary tract infection). No adverse noted, no nausea, vomiting or diarrhea. Pt also started on [MEDICATION NAME]. No adverse side effects at this time. WCTM (will continue to monitor). On PM shift pt had allergic reaction to crab fish that was for dinner, pt was given [MEDICATION NAME] per MD (medical doctor) order. Symptoms continued, MD was notified order given to administer [MEDICATION NAME] injection, oxygen remained above 90 (per cent) on 2 liters. Shortly after injection administered pt felt better, no further difficulty breathing. Pt currently asleep with no s/s (signs or symptoms) of any distress. On 11/8/17 at 11:17 PM, facility nursing staff documented the following in a nursing note. Cont (continue) on oral abx for UTI, tol (tolerates) med well. Fluids enc. (encouraged) VS (vital signs) stable. No problems noted form recent allergic reaction to shellfish. Resting in bed, call light within reach. On 11/9/17 at 9:28 PM, the facility NP documented the following in a progress note for an acute visit related to an allergic reaction. HPI (History of Present Illness): Pt had an anaphylactic reaction to crab. She ate her rice for dinner then noticed it was touching some crab. She first noticed some itchy throat (sic). Nursing gave her [MEDICATION NAME]. then she started having SOB (shortness of breath) and difficulty breath (sic). Epi-pen was administer (sic). Her symptoms resolved. She has not had any further symptoms . .Psychiatric: The patient is oriented and conversant. Mood and affect are appropriate. A/P (Assessment/Plan): Anaphylactic allergic reaction.-pt is stable Cont to avoid crab and monitor pt. f/u (follow up) prn (as needed). On 5/24/18 at 1:51 PM, resident 29's family member was interviewed. The family member stated that resident 29 was allergic to shellfish. The family member stated that she would bring in food for resident 29 but had not brought in crab patties. The family member stated that resident 29 was able to eat clam chowder, so she had brought that in. The family member stated that resident 29 stated that the facility served her crab patties a couple of times. The family member stated that resident 29 was provided [MEDICATION NAME] after eating from the plate with a crab patty. The family member stated that resident 29 did not eat them the second time. On 5/24/18 at 11:00 AM, the Dietary Manager (DM) was interviewed. The DM stated that she was not aware of resident 29 receiving shellfish while in the facility and having an allergic reaction. The DM stated that either herself or her Dietary Aide (DA) will complete the 'Initial Dietary Assessment'; and then input that information into the kitchen's tray card system. The DM stated that she would update the tray card information after receiving it. Resident 29's tray card was reviewed with the DM, and the DM confirmed that the resident's tray card stated she was allergic to shellfish. The DM was unable to determine when that information was entered into the tray card system. On 5/24/18 at 11:45 AM, the Director of Nursing (DON) was interviewed. The DON stated that he was not employed by the facility when the incident occurred and would need to look into it. At 12:02 PM, the DON stated that he discovered that the DA was not able to add allergies [REDACTED]. The DON stated that the DA reported that typically allergens were already entered in the medical record before she would interview residents. The DA however was not certain if she had verified that allergens reported to her were in the electronic medical record. The DON stated that they had identified a potential break down in communication related to allergens. On 5/24/18 at 2:00 PM, the RD was interviewed. The RD stated that she was not aware resident 29 was receiving shellfish at the facility until 5/24/18. On 5/30/18 at 2:46 PM, the Prior Director of Nursing (PDON) was interviewed. The PDON stated that she did not remember much about the event on 11/7/18. The PDON recalled that she believed resident 29 had been served shellfish by the facility. The PDON stated she did not recall if the resident had a reaction at that time. The PDON stated that she remembered doing a Quality Assurance review (QA) of the incident. The PDON stated that the DM was to re-educate her staff on checking tray card and ensuring correct diets and that the Certified Nursing Assistants were to be re-educated on checking tray cards and meals when serving residents. The PDON stated that she thought that resident 29 had been served a crab cake. On 5/30/18, the facility Administrator (Admin) provided the QA that was completed following the event on 11/7/18. The Quality Improvement Team Tracking Form identified the problem that a resident received food she was allergic to. The form identified the causal factors as staff education. The interventions implemented were for the DM to provide education to dietary staff on reviewing allergies [REDACTED]. In-services were completed for all staff by the PDON, prior Assistant DON, and Administrator in November. POTENTIAL FOR HARM 2. On 5/22/18, the posted lunch meal was: Beef Brisket with Gravy Garlic Cheese Mashed Potatoes California Blend Vegetable Garlic Bread Stick Pear Pie Beverage Milk Whole During trayline service at 12:10 PM, an observation was made of resident 26's lunch. Resident 26 was served ground meat, California vegetable blend, mashed potatoes, gravy and pear pie. Resident 26 was not served a bread stick or a substitute. Resident 26's diet card revealed that he was to receive a fortified, large portion at breakfast and dinner diet with dysphagia mechanical soft National Dysphagia Diet (NDD) 2 consistency. An NDD 2 diet consists of foods that are moist, soft-textured and easily formed into a bolus. During trayline service at 12:12 PM, an observation was made of resident 84's lunch. Resident 84 was served ground meat, California vegetable blend, mashed potatoes, gravy and pear pie. Resident 84 was not served a bread stick or a substitute. Resident 84's diet card revealed that he was to receive a controlled carbohydrate diet, with a dysphagia mechanical soft NDD 2. The Dietary Staff Member (DSM) stated that speech therapy worried about the residents with chopped and ground diet orders choking on bread so the facility did not give those residents dry breads. The facility spreadsheet menu was reviewed. The menu revealed that residents on a NDD 2 diet should have received a pureed garlic breadstick with their meal. On 5/24/18 at 11:00 AM, the DM was interviewed. The DM stated that about 3 months ago speech therapy asked for dietary to not send bread to residents with ground or chopped diet orders. The DM stated that the Registered Dietitian (RD) told the kitchen to serve the bread. The DM stated that the kitchen decided not to serve the bread to prevent a choking incident. The DM stated that the facility recently got a new speech therapist and she would discuss the bread with him. On 5/24/18 at 2:00 PM, the RD was interviewed. The RD stated that she told the kitchen there are recipes for all modifications and textures. The RD stated she told the kitchen they need to provide bread at the appropriate texture for residents who could not eat regular bread. 3. On 5/22/18, the posted lunch meal was: Beef Brisket/gravy Garlic Cheese Mashed Potatoes California Blend Vegetable Garlic Bread Stick Pear Pie Beverage Milk Whole During lunch tray service on 5/22/18, the following observations were made. Resident 64's lunch consisted of a scoop of pureed vegetables, a scoop of pureed meat, and a scoop of mashed potatoes all covered with a thin gravy; and a bowl of pureed pie. A garlic bread stick or substitute was not included with the meal. Resident 64's meal card revealed that her diet order was a NDD 1 or pureed diet. Resident 151's lunch consisted of a scoop of pureed vegetables, a scoop of pureed meat, and a scoop of mashed potatoes all covered with a thin gravy; and a bowl of pureed pear pie. A garlic bread stick or substitute was not included with the meal. Resident 152's meal card revealed that her diet order was a fortified NDD 1 or fortified pureed diet. A puree test tray was acquired at that time and consisted of a scoop of pureed vegetables, a scoop of pureed meat, and a scoop of mashed potatoes all covered with a thin gravy; and a bowl of pureed pear pie. There was not a garlic bread stick or substitute included with the meal. On 5/24/18 at 10:30 AM, a Dietary Staff Member (DSM) was interviewed. The DSM stated that she remembered making the pureed bread for lunch on 5/22/18 and did not know why it was not served. On 5/24/18 at 11:00 AM, the DM was interviewed. The DM was unaware that the pureed bread was not served on 5/22/18. The DM stated that the pureed bread should have been served. 4. On 5/22/18, the posted lunch meal was: Beef Brisket/gravy Garlic Cheese Mashed Potatoes California Blend Vegetable Garlic Bread Stick Pear Pie Beverage Milk Whole During lunch tray service on 5/22/18, the following observations were made. Resident 53's lunch meal included brisket and gravy, mashed potatoes, a garlic bread stick and a pear pie. Resident 53 was not served a vegetable. Resident 53's meal card revealed that she received a regular consistent carbohydrate diet and did not like cauliflower. (Note: The California blend vegetable consisted of broccoli, carrots, and cauliflower.) On 5/24/18 at 11:00 AM, the DM was interviewed. The DM stated that residents should be served an alternate vegetable.

Based on observation, interview and record review, it was determined the facility did not ensure that a resident who entered the facility without a pressure sore did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable; and that the resident received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically, the facility did not monitor the resident's right foot for pressure sores resulting in the resident's right foot being amputated. Resident identifier: CL 2. Findings include: Resident CL 2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident CL 2's medical record was reviewed on 11/15/12. On 5/9/12, the facility staff completed an annual Minimal Data Set (MDS) Assessment. The facility staff assessed resident CL 2 as requiring extensive assistance with a two person physical assist for bed mobility, transfers and dressing. The facility staff assessed resident CL 2 as requiring extensive assist with a one person physical assist for eating. Resident CL 2 was not steady with surface-to-surface transfers and had impairments on her upper and lower extremities. The facility staff assessed resident CL 2 as having one pressure sore that was assessed as being a Stage 3 (defined in the MDS as "Full thickness tissue loss. Subcutaneous fat may be visible but one, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.") A Care Area Assessment triggered for activities of daily living (ADL's), Nutritional Status, Dehydration, and Pressure Ulcers. The facility staff documented that the care areas would be addressed in a care plan. On 8/9/12, a quarterly MDS Assessment was completed by the facility staff. The facility staff assessed resident CL 2 as requiring the following assistance: Extensive assist with a two person physical assist for bed mobility and dressing, extensive assistance with a one person physical assist for eating, and that resident CL 2 was totally dependent with a two person physical assist for transfers. The facility staff also assessed resident CL 2 has having impairment on both the upper and lower extremities. Review of the care plans developed for resident CL 2 revealed: 1. "Mobility, Impaired Physical" - The facility staff documented "Impaired physical mobility related to [MEDICAL CONDITION] manifested by the inability to purposefully move within the environment including: bed mobility, transfer, and ambulation". The goals that were developed included "...Resident will show no evidence of complications such as: contractures, venous stasis, and skin breakdown". The approaches developed to achieve that goal included: "a. Pressure reducing mattress; b. turn and reposition q (every) 2 hrs (hours); c. ROM (Range of Motion), unless contraindicated; d. Encourage independence; e. Assist resident with ADL's they are unable to complete; f. Assist resident with transfer and ambulation; g. Remind resident to use call light; and h. Monitor skin for redness every shift. ..." The care plan was documented as being developed on 3/10/12 and revised on 5/21/12. 2. "ADL Self-Care Deficit..." - The facility staff documented "At risk of developing complications assisted with decreased ADL self-performance manifested by [MEDICAL CONDITION], weakness and depression. ..." The goals developed included: "a. Not develop any complications related to decreased mobility and b. ADL needs will be met daily. ..." The approaches developed to achieve those goals included: "a. Report significant changes in ADL status to physician; b. Encourage daily care (dressing, bathing, etc); c. Provide assistance in areas resident unable to complete independently; and d. Turn and reposition, shifting weight to enhance circulation every hour while in bed/chair and with cares, round, and PRN (as needed). ..." The facility staff documented additional approaches which included: "R (right) foot splint @ (at) all times r/t (related to) fx (fracture)". (Note: The facility staff did not date when the right foot splint was applied.) 3. "Skin Integrity Care Plan" - The facility staff developed "Actual Skin Breakdown and Potential for skin breakdown r/t: immobility and incontinence" with an "Alteration in Skin Integrity: "...a. 9/12/12 R heel unstagable (sic), and R foot unstagable (sic); and d. 9/25/12 R inner foot (with an) intact blister". The goals that were developed were "Will not have any skin breakdown" and "Pressure ulcer will show no s/s (signs or symptoms) of infx. (infection)". The approaches developed by the facility staff included: a. "Encourage to turn/reposition/shift position frequently; b. Weekly skin check; c. Report any skin problems to the charge nurse; d. Pressure reducing mattress; e. Provide skin care frequently (daily bath, shower 2X (twice) a week; f. Clean the resident's skin after each episode of incontinence; g. Apply protective lotion after shower/pericare; h. Elevate legs as tol (tolerated); i. Float heels as tolerated; j. Dietary Consult per protocol; k. Wound care as ordered; l. Monitor site for s/s of infection, notify MD (medical doctor) PRN; m. MVI (Multi-Vitamin with Iron) per orders; n. Supplements as ordered; o. Labs as ordered; p. Discuss risks/benefits PRN if with non-compliant behavior; q. Get resident involved with plan of care; and r. 9/12/12 Ehob boot (an air splint that relieves pressure on the heel). Review of the orders received from the primary care physician included the following: 1. 7/27/12: Continuous right foot pain from pt. (patient) running over foot with her electric wheelchair." 2 7/30/12: "Follow up with Ortho (orthopedic) for second and third metatarsal non displaced fracture". 3. 7/30/12: "Keep splint to right foot on at all times, nurse to do circulation checks q shift". 4. 8/1/12: "Keep boot applied to right foot. Weight bearing as tolerated". 5. 8/7/12: "place non bordered foam to right heel, secure with med pore tape change q tuesday, thursday, saturday. DX: Prevention". 6. 9/12/12: "Discontinue: place non bordered foam to right heel, secure with med pore tape change q tuesday, thursday, saturday. DX: Prevention". 7. 9/12/12: "paint wound to rt heel and rt dorsal foot with [MEDICATION NAME] cover with oil [MEDICATION NAME] wrap with kerlix q day. DX: PU (pressure ulcer)". 8. 9/12/12: "pt. to wear EHOB boot to rt heel at all times may remove from (sic) shower and skin checks and PRN if heel is floated. DX: PU". 9. 9/12/12: "CMP (complete metabolic profile), [MEDICATION NAME], CBC (complete blood count) with diff (differential)". 10. 9/12/12: "Liquacell 30 cc (cubic centimeters) PO (orally) TID (three times a day). DX: Promote wound healing". 11. 9/19/12: "clean wounds to rt heel and rt dorsal foot with wound cleanser paint with [MEDICATION NAME] q day leave open to air. DX: PU". 12. 9/22/12: "Zinc Sulfate 220 mg (milligrams) PO QD (daily) for 14 days for DX: Deficiency". 13. 9/23/12: "Keflex 500 mg PO q 6 hrs (hours) for 7 days for DX: Redness to right foot, Redness to Right thigh wound". 14. 9/23/12: "Cleanse right heel with wound cleanser or normal saline pat dry apply silver gel to wound edges place foam dressing secure with Kerlix". 15. 9/23/12: "Cleanse wounds to right dorsal foot with wound cleanser or normal saline pat dry paint with [MEDICATION NAME] wrap with kerlix". 16. 9/27/12: "Cleanse right heel with wound cleanser or normal saline pat dry apply ABX (antibiotic) oint (ointment) to wound edges place foam dressing secure with kerlix". 17. 9/27/12: "Cleanse wounds to right dorsal foot with wound cleanser or normal saline pat dry, apply ABX ointment around wound edges, secure with kerlix". 18. 9/28/12: "[MEDICATION NAME] 750 mg IV (intravenously) BID (twice a day) X 3 days for DX: Redness to right foot and redness to right thigh wound". Review of the facility "physician progress notes [REDACTED]. 1. 7/26/12 at 11:17 AM: "Patient hyperextended Right foot under foot rest while driving electric wheel chair to therapy. She continued on to therapy where she spent her session time before reporting her incident with nurse. Upon assessment her foot has no redness or inflammation. Her pain is minimal and refuses any pain relief medication. Cap refill is less than 3 seconds. No decrease in sensation from original condition. Skin is cool to touch, color is pink as usual. MD notified, no order given but will watch for any signs of inflammation or increase in pain. Family and Unit manager notified. Incident report filled out". 2. 7/26/12 at 11:31 PM: "Resident hyperextended her right foot while driving her wheelchair. She did not have any c/o pain at this time. Her foot has minimal bruising. her cap (capillary) refill is less than 3 and her pedal pulses are palpable". 3. 7/27/12 at 7:34 PM: "Pt. complained of constant pain in right foot where she hyperextended her right foot while driving her wheelchair. Food (sic) assessed and didn't show signs of bruising. Able to palpate petal (sic) pulses and capillary refill times is less than three seconds. Pt. stated she didn't feel good today. She asked if she could have an Xray (electromagnetic [MEDICAL CONDITION]) done to rule out a possible break. Doctor notified and doctor ordered an xray to be performed. Will continue to monitor". 4. 7/28/12 at 3:43 AM: "X-ray completed. Impression: Second and third metatarsal nondisplaced fractures. Pt. c/o px. Administered px medications as per physician's orders [REDACTED]. Will continue to monitor". 5. 7/28/12 at 6:48 PM: "physician notified about xray results. N/O (new order) to send pt. to ER (emergency room ) for eval (evaluation) and treatment. pt. went to (local hospital via ambulance service) at 1015 (10:15 AM). pt. came back at 1210 (12:10 PM). 90 degree splint placed on Right foot. N/O to f/u (follow up) with (orthopedist). Note left for (name removed) to make appt. no other concerns.". 6. 7/29/12 at 3:58 AM: "Pt splint in place. Capillary refill -3 seconds on LLE (left lower extremity). Pt c/o px. Administered prn px medication as per physician's orders [REDACTED]. 7. 7/29/12 at 6:47 PM: "Pt. cont (continues) wearing splint to right foot. No c/o pain or discomfort this shift. will cont to monitor". 8. 7/30/12 at 3:11 AM: "...R foot in splint. Pt. c/o px. Administered prn px medications. Pt. reports this effectively treats px at this time. ..." 9. 7/30/12 at 1:03 PM: "IDT - Resident ran over her foot on 7/26/12 and c/o minor discomfort, x-ray completed on 7/27/12 and showed second and third metatarsal nondisplaced fractures. Resident was seen in emergency department and splint placed, resident to be scheduled with ortho for follow up. Resident states pain controlled. ..." 10. 7/30/12 at 3:07 PM: "Patient has broken bones in foot. Requires checks to ensure proper circulation to Right foot. Patient has complaints of pain and requires regular use of pain meds (medications). No signs of inflammation or loss of circulation". 11. 7/30/12 at 3:18 PM: "Patient is alert and oriented X 3. Requires extensive assistance with bed mobility, transfers, hygiene, feeding, toileting, dressing. ..." 12. 8/1/12 at 7:27 AM: "Pt. sustained a left foot fracture. Pedal puses (sic) present bilaterally. Left foot warm to the touch and pink. No s/s of circulation loss. Moderate pain and discomfort controlled with PRN [MEDICATION NAME] and tylenol. will continue to monitor". (Note: Previous documentation revealed a right foot fracture). 13. 8/1/12 at 11:08 AM: "Patient is alert and oriented X3. Pt has left foot fracture, foot remains in 90 degree splint. pain meds given prn. Requires extensive assistance with bed mobility, transfers, hygiene, feeding, toileting, dressing. ..." (Note: Previous documentation revealed a right foot fracture). 14. 8/1/12 at 6:52 PM: "pt. had ortho appt this am. N/O for boot to fractured foot and f/u in 5 weeks". 15. 8/1/12: Resident CL 2 was seen by an orthopedic physician. The orthopedic physician ordered a "boot (walking boot) with WBAT (weight bearing as tolerated) related to a [DIAGNOSES REDACTED]. 16. 8/3/12 at 12:58 PM: "...Pt. has left foot fracture. Performing circulatory checks on right foot. Foot remains in 90 degree splint. ..." (Note: Previous documentation revealed a right foot fracture). 17. 8/7/12: The facility WN documented "Pt. (with) blancable (sic) redness to R heel (with) bruising from fall (with) fx foot that requires a brace boot to be worn @ (at) all times which is causing a pressure point on the hell (sic) putting pt. @ high risk for PU (pressure ulcer). MD notified. ..." 18. 8/17/12: The facility WN documented "Pt. R heel is improving still intact, still blancable (sic). ..." 19. 9/12/12 at 1:39 PM: "Resident returned from ortho appt, wounds to right foot (dorsal) and right heel. Treatment orders received from (primary care physician). Resident has follow up wound clinic appt. daughter notified". 20. 9/12/12: Resident CL 2 was seen by an orthopedic physician. The orothpedic physician ordered a "Wound consult. Float heel. No pressure on heel. DCC (discontinue current) boot". 21. 9/12/12 at 2:22 PM: "N.O. (new order) for 1) CMP, [MEDICATION NAME], CBC with diff; 2) foot straps to left foot r/t spasms to inability to position foot on footrest; 3) f/u (name removed) in 4 weeks. ..." 22. 9/13/12 at 9:09 AM: "IDT Note: Resident went to follow up ortho appt, pressure ulcers noted to Right heel, and Right top of foot. New orders given for treatments reviewed with (primary care physician). Resident to follow up with wound clinic. Daughter notified of plan of care and reviewed with resident. ...RD (registered dietitian) notified new orders for labs received and carried out. Will continue to monitor and provide treatment as ordered". 23. 9/13/12 at 4:33 PM: "Skin/lab Note: CMP PAB ([MEDICATION NAME]) collected 9/12. all nutrition related labs WNL (within normal limits), except low ALB ([MEDICATION NAME]). PAB indicates inadequate serum protein status. Resident will stage III pressure ulcer L sacrum, unstagable (sic) to R heel, R dorsal. ..." 24. 9/13/12 at 5:29 PM: "Right foot has open area approximately 7 cm (centimeters) wide. Patient has no complaints of pain or discomfort. Upon assessment of lower extremety (sic) darker skin noted and cool skin temperature present. Patient complains of some tingling sensations near the tips of each toe. Pedal pulses are palpable and no s/s of [MEDICAL CONDITION] found. Boot was removed for inspection and returned with adaquate (sic) circulation and skin integrity environment provided". 25. 9/14/12 at 12:37 AM: "...right foot assessed. slight feeling in toes. cap refill < (less than) 3 seconds. foot re-wrapped because gauze was slightly saturated. wound nurse has been notified previously and is also assessing condition". 26. 9/.14/12 at 4:06 PM: "Pts right foot was assessed. Blow up boot was on pt when assessment started. Capillary refill time was less than three seconds. Pt able to wiggle toes. Blow up boot was taken off to assess skin under it. Dressing was in place. wound nurse changed dressing this morning. There is no drainage of any kind present at this time coming through dressing. Pt. denies pain or discomfort at this time. Denies numbness or tingling. Pedal and post tibial pulses are palpable 2+ and no s/s of [MEDICAL CONDITION] found. blow up boot was returned after assessment. Capillary refill time less than 3 seconds. Pt. requires extensive assist X 2 (two people) with bed mobility, transfers, hygiene. Pt. uses electrical (sic) wheelchair to get around facility. Able to make needs known. ..." 27. 9/15/12 at 1:00 AM: "...Pt has dressing in place to right foot, and boot is in place. boot taken off and replaced this shift by RN (Registered Nurse) to assess circulation and skin on leg. Cap refill is less than 3 seconds. No redness noted. ..." 28. 9/15/12 at 2:56 PM: "Removal of Right boot revealed the extent of patient pressure ulcer. It is 7 cm wide and 5 cm long, colored black and red. Some serousanganous (sic) drainage noted in dressing change on dorsal and heel of Right foot. Patient tolerated with no pain verbalized. Use of [MEDICATION NAME] and covered both with oil [MEDICATION NAME] wrap with [MEDICATION NAME]. circulation check showed warmth in lower extremities and cap refill time < than 3 seconds. Breast cleaned to the right and covered w/algante (sic) and covered with spot [MEDICATION NAME]. skin redened (sic) and no drainage noted. Right hip wound is old and followed by wound nurse, cleaned and covered with algiante (sic) [MEDICATION NAME]. Sacrum is reddened and use of [MEDICATION NAME] applied every brief change". 29. 9./15/12 at 11:45 PM: "...Right foot and heel assessed. slight tingling in right foot. cap refill <3 seconds. dressing clean dry and intact. ..." 30. 9/16/12 at 11:33 PM: "...Right foot assessed. dressing clean dry and intact. wound nurse aware of skin integrity issue. cap refill <3 seconds". 31. 9/19/12 at 6:37 PM: "Patient recorded temp of 100.5 at midday today. After further assessment patient was absent of pain or discomfort and a temperature of 98.3 was noted. patient is of regular LOC (level of consciousness). Inspection of right foot with boot removed shows more redness and swelling at sore. Some drainage which is serousanguanous (sic) noted. Patient visited with Wound Clinic and returned with sock covering for facility wound nurse to continue care. Patient denies any pain to foot or change in sensation. All circulation is good, with < 3 seconds cap refill time". 32. 9/19/12: Resident CL 2 was seen at a local wound clinic. The wound clinic ordered for the facility staff to "apply [MEDICATION NAME] once a day, cover dressing". 33. 9/20/12 at 7:48 AM: "Skin/Wound Note - rt dorsal foot, unstagable (sic). 3.2 cm X 1.3 cm X 0.0 with 100% stable eschar black at the wound base. Note: pt was seen at wound clinic yesterday the (sic) want to cont with painting with [MEDICATION NAME] but d/c [MEDICATION NAME] and leave open to air return to wound clinic if eschar starts to become unstable". 34. 9/20/12 at 7:52 AM: "Skin/Wound Note - rt heel unstagable (sic). 7.5 cm X 6.5 cm X 0.0 with 100% stable eschar to the wound base. Note: pt. seen at wound clinic yesterday the original outer cover of eschar had pelled (sic) away and md trimmed the edges there is still 100% black but softer eschar to site which is stable and intact at this time th (sic) are going to cont with [MEDICATION NAME] q day but d/c [MEDICATION NAME] and return if eschar becomes unstable". 35. 9/20/12 at 12:17 PM: "IDT - Resident will unstageable pressure ulcers to right heel and right dorsal foot with 100% stable eschar, continue current treatment. Resident had wound clinic appt 09/19/2012. Resident does not need to return to clinic at this time, wound nurse to continue to follow at facility. ...Reviewed and revised care plan". 36. 9/23/12 at 4:32 PM: "Resident with increased redness and warmth to right foot, intact blister to right inner foot, blanchable purple discoloration to right great toe, purple discoloration to right dorsal foot near eschar area. Serosanguineous drainage from right heel wound eschar intact. ...Notified MD new treatment orders received and abt (antibiotic) orders. ..." 37. 9/14/12 at 3:18 AM: "Pt resting in bed got all pm (evening) medications pt had a high Temp last night of 103.7 Physician and DON (Director of Nursing) notified. Dr. ordered a time dose of [MEDICATION NAME] 1 mg IM (intramuscularly) then to continue on Keflex 500 mg. She still have (sic) an open sore in cocxys (sic) will continue to monitor". 38. 9/24/12 at 1:33 PM: "Late Entry: physician progress notes [REDACTED]. She has some new blisters on the foot. She has been running a low grade fever. o (objective): right foot eschar on heel with some yellow drainage around the edges, see wound nurse report for full report on wound. A (assessment)/P (plan): right foot wound - She is running a fever. this could just be a uti (urinary tract infection) but will order a foot xray to rule out osteo[DIAGNOSES REDACTED]. Will start vanco ([MEDICATION NAME]) and imipenem empirically". 39. 9/24/12 at 7:13 PM: "Patient is receiving Keflex ABX for R foot, R thigh wound, and increased redness and drainage. Patient tolerated last dose of Keflex with no s/s of adverse effects. Redness on foot has decreased and patient has no complaints of pain r/t wounds". 40. 9/24/12 at 11:58 PM: "...right foot examined. cap refill <3 seconds, some sensation noted in both feet. trace [MEDICAL CONDITION] in right foot. PICC (peripherally inserted central catheter) was inserted by PICC line nurse. Nurse verified placement. IV ABX [MEDICATION NAME] started. no s/s of adverse reaction. will continue to monitor". 41. 9/26/12 at 3:52 AM: "...Pt. on IV ABX for r foot infection no S&S (signs and symptoms) of AE (adverse effect) from ABX therapy will continue to monitor". 42. 9/26/12 at 6:40 PM: "Pt. continues on IV ABX for foot infection with no adverse effects noted. No c/o pain or discomfort voiced throughout shift. Pt alert, able to make needs known. Afebrile. Pt states, 'I'm starting to feel better'. Will continue to observe". 43. 9/27/12 at 4:56 AM: "...Pt. continues on IV ABX for foot infection no S&S of adverse effects from ABX therapy. Will continue to monitor". 44. 9/27/12 at 6:42 PM: "...Pt continues on IV ABX for foot infection no S&S of adverse effects from ABX therapy. Wound nurse treated pt today". 45. 9/28/12 at 12:17 AM: "Pt is receiving [MEDICATION NAME] and Imipenem through Left PICC line. Pt is tolerating well with no s/s of adverse reaction. PICC is patent with no s/s of infection present. coban was removed from around PICC insertion. slight redness noted on arm. Pt. stated some pain at the area. wound nurse notified. will continue to monitor. Pt. right leg has trace [MEDICAL CONDITION]. Wound is being treated by wound nurse. cap refill in bilateral lower extremities (sic) is <3 seconds. no s/s of further infection noted at this time. Pt thigh is slightly red with no s/s of further infection or redness. no c/o of pain with foot or thigh". 46. 9/29/12 at 12:43 AM: "pt A/o (alert and oriented) X 3. cont on abx for infection of right foot. no ase (adverse side effects) noted. foot remains wrapped. cap refil (sic) wnl (within normal limits). +1-2 [MEDICAL CONDITION] noted in right lower extremity. both abx given this evening. picc line dressing changed this am and remains c/d/i (clean, dry and intact). ..." 47. 9/29/12 at 2:40 PM: "Assessment of thigh and foot redness shows no increase in redness. No s/s of further infection. Patient tolerated shower and had dressing changed over sites. Patient tolerates medication and has no complaints of pain". 48. 9/30/12 at 1:34 AM: "...right foot wound dressing is clean dry and intact. no c/o pain. no numbness or tingling. cap refill <3 seconds. no redness around wound. right thigh wound dressing is clean dry and intact. no redness noted around wound. no c/o pain. right breast wound dressing is clean dry and intact. no c/o pain. no redness noted. ..." 49. 9/30/12 at 9:56 AM: "Skin redness assessed on patient thigh and R foot. No drainage noted on top of R foot, although there is some drainage noted on heel of R foot. Redness has not spreaded (sic) over sites and monitoring every shift is in effect for noting any changes. Patient has no c/o pain due to skin integrity". 50. 10/1/12 at 2:34 PM: "Pt. continue son IV [MEDICATION NAME] & Imepenem (sic) for tx of right foot infection with no adverse effects noted at this time. ...". 51. 10/1/12: Resident CL 2 returned to the local wound clinic. The following findings were documented: "R foot: wounds are improved but still a large amount of eschar appreciated. The eschar is well connected and stable. I feel that leaving the eschar intact for now is in the patients best interest. ..." 52. 10/2/12 at 1:15 AM: "Pt. on [MEDICATION NAME] no S&S of AE from ABX therapy we are monitoring red foot redeness (sic). ..." 53. 10/2/12 at 2:52 PM: "Pt alert, able to make needs known, SPO2 (oxygen saturation) @ 93% on RA (room air) at this time. continues on IV [MEDICATION NAME] for right foot infection with no adverse effects noted. Afebrile. ..." 54. 10/3/12 at 2:27 AM: "Pt. still on [MEDICATION NAME] no S&S of AE from ABX therapy we are monitoring red foot redeness (sic) dressing was changed before pt. had appointment with wound clinic. ..." 55. 10/3/12 at 6:50 PM: "Skin redness assessed on patient thigh and R foot. No drainage noted on top of R foot, although there is some drainage noted on heel of R foot. Redness has not spreaded (sic) over sites and monitoring every shift is in effect for noting any changes. Patient has no complaints of pain". 56. 10/4/12 at 12:08 AM: "Pt right foot was assessed with [REDACTED]. redness still noted but not increasing. small drainage on heel. no drainage on top of foot. right thigh wound has slight redness. has not increased. no c/o pain with foot or thigh. Pt. is receiving ABX [MEDICATION NAME] through PICC line in left antecubital space. ..." 57. 10/4/12 at 10:17 AM: "Patient has good circulation through foot and leg where wound are situated. Pedal pulses are present and no s/s of [MEDICAL CONDITION]. No s/s of fever or discomfort reported. Wounds site has no red streaking or spread of discoloration. ..." 58. 10/5/12 at 12:23 AM: "Pt. had some c/o pain this evening, pain of 6/10. [MEDICATION NAME] administered with noted relief. Pt right foot wound dressing is clean dry and intact. wound nurse treatment. cap refill in bilateral extremities <3 seconds. Pt states some tingling in toes of right foot. no numbness or tingling in left foot. Pt. right thigh wound no redness noted. dressing is clean dry and intact.. being treated by wound nurse. Pt. receiving ABX [MEDICATION NAME] through PICC line. PICC line is clear and patent with no s/s of infiltration or phlebitis. Pt. is tolerating medication well with no s/s of adverse reaction". 59. 10/5/12 at 6:29 PM: "Pt. finished abx therapy today through PICC line and tolerated well. PICC line patent. Denies pain at site and denies generalized pain throughout body throughout the shift. PICC line site showing no s/s of infection. Pt. has right foot wound dressing on. Dressing is clean dry and intact. Treatment is being done by wound nurse. Capillary refill time less than 3 seconds bilateral extremities. Denies numbness or tingling in both feet. Pt. right thigh wound no redness noted. Dressing dry, clean and intact. Treatment done by wound nurse. ..." 60. 10/12/12 at 5:53 AM: The facility staff completed a "Pressure Ulcer Review" for resident CL 2's right heel. The facility staff documented that the wound had an "80% necrotic area with 20% granulation tissue around necrotic area. Redness to peri wound". The facility staff documented that the wound measured 3.6 cm X 4.8 cm. The facility staff further documented that the measurements were obtained on 10/8/12. 61. 10/12/12 at 5:56 AM: The facility staff completed a "Pressure Ulcer Review". The facility staff did not document a site of the wound but documented "...wound bed is DTI (deep tissue injury), eschar healing, foot [MEDICAL CONDITION], petachiae (sic), has lack of circulation to foot noted". The facility staff documented that the wound measured 0.5 cm X 0.5 cm. The facility staff documented that the measurements were obtained on 10/8/12. 62. 10/15/12 at 4:51 PM: "Pt. re-admitted on [DATE], noted during daily dressing change on Friday 10/12/12 to rt heel, black eschar now soft and mushy. F/U wound clinic appt set up. Upon discharge black eschar to center wound stable". 63. On 10/17/12 at 10:47 AM, the facility staff completed a "Pressure Ulcer Review". The facility staff documented "Right heel 80% eschar, 10% granulation tissue around eschar, 10% slough. Redness to peri wound". The facility staff documented that the wound measured 4.8 cm X 5.5 cm. The facility staff further documented that the wound measurements were obtained on 10/15/12. 64. 10/23/12 at 1:50 PM: "Pt had wound clinic appt this am, MD debrided unstable, soft/mushy black eschar to rt heel, which exposed pt's heel bone and also debrided pt's dorsal of rt foot, exposing tendon shealth (sic). No s/s of infection present, no odor noted as well. Received new orders for wound vac to be applied 3 x's (times) a week, starting tomorrow, pt to keep dry dressing to all wounds site till tomorrow. MD explained to pt of needing vascular consult appt. Vascular appt set up for 11/2/12 @ 9:30 AM and weekly wound clinic appts. ..." 65. 10/23/12: Resident CL 2 was seen at the wound clinic. The wound clinic documented: "Necrotic injury to R foot/ankle. Debrided necrotic nonviable tissue today. Achilles tendon removed. Calcaneous prominent in wound. discussed amputation of R leg to expedite healing. Place wound vac when possible to wounds R foot/ankle. [MEDICATION NAME] with border lateral R leg. Appt (appointment) (with) vascular for evaluation for possible AKA (above the knee amputation). ..." 66. 10/25/12 at 9:50 AM: The facility completed a Pressure Ulcer Review. The facility staff documented "rt dorsal of foot, wound debrided by wound clinic MD at appt, exposed tendon shealth (sic) noted with granulating tissue surrounding wound, redness to peri wound". The facility staff documented that the wound measured 5.8 cm X 3.8 cm X 0.5 cm. The facility staff further documented that the wound measurements were obtained on 10/23/12. 67. 10/25/12 at 10:12 AM: The facility completed a Pressure Ulcer Review. The facility staff documented "rt lateral aspect of foot, debrided at wound clinic, now with 100% granulating tissue present, redness to peri-wound". The facility staff documented that the pressure ulcer measured 1.7 cm X 1.5 cm X 0.5 cm. The facility staff further documented that the measurements were obtained on 10/23/12. 68. 10/29/12 at 3:01 PM: "Left message for (MD) @ the wound clinic, regarding appearance of pt's wound to dorsal of rt foot and rt heel, wound edges with masceration (sic) and dark purple discoloration to ankle, size significantly larger in size. Pt. does have f/u wound clinic appointments on 10/31/12 and vascular consult appt on 11/2/12. Awaiting return call from (MD's) office". 69. 10/31/12 at 1:23 PM: "Pt went to wound clinic appt, from appt pt admitted to hospital..." 70. 10/31/12 at 1:55 PM: A pressure Ulcer review was completed by the facility. The facility staff documented "rt lateral aspect of foot with granulating tissue to center of wound with DTI (deep tissue injury) to surrounding peri wound, mascerated (sic) wound edges. Continues with wound vac as ordered. Has f/u wound clinic appt on 10/31/12". The facility staff further documented that the wound was measured 2.2 cm X 2.1 cm X 0.5 cm. The facility staff documented that the measurements were obtained on 10/29/12. 71. 10/31/12 at 1:47 PM: A Pressure Ulcer Review was completed by the facility. the facility staff documented "Right heel - exposed bone with granulating tissue surrounding bone, dark non-blanchable purple tissue to peri wound. Continues with wound vac as ordered. Has f/u wound clinic appt on 10/31/12". The facility staff documented the right heel pressure ulcer to be a stage 4 that measured 5.2 cm X 7.5 cm. The facility staff documented that the measurements were obtained on 10/29/12. 72. 11/7/12 at 5:42 PM: "Pt. readmitted post R LE (lower extremity) amputation. Pt. a/o X 4. Pt. s

Based on record review and interview, it was determined the facility did not ensure that each resident received necessary care and services to attain or maintain the highest practicable physical health for 3 of 10 sampled residents. Specifically, (1) The facility nurses did not notify the primary care physician of radiology results for five (5) days for two (2) residents and (2) The facility licensed nurses did not initiate physician orders [REDACTED]. Resident identifiers: CL 1, CL 2, and CL 3. Findings Include: 1. CL 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident CL 1's medical record was reviewed on [DATE]. On [DATE], an order was received by resident CL 1's physician to start " O2 (oxygen) nasal cannula 5L (fiver liters) PRN (as needed) " and to obtain a "Chest x-ray ". Review of chest x-ray results obtained on [DATE] revealed the following: "EXAM REASON: Diminished lung sounds, SOB (Shortness of breath), Poss (possible) PNA (pneumonia). ...FINDINGS: ...There is mild [MEDICAL CONDITION] venous congestion. There is modest right lower lobe and large left lower lobe infiltrate. ...IMPRESSION: ...Modest right lower lobe and large left lower lobe infiltrate". The final x-ray report was documented as being dictated by the radiologist on [DATE] at 10:56 PM. The final x-ray report was dated [DATE] at 5:42 PM as being faxed to the facility. Review of the "Progress Notes" revealed the following: a. [DATE] at 3:46 AM: "VS (vital signs) (blood pressure) ,[DATE], (pulse 84), (respirations 18), (temperature) 97.1, (oxygen saturation) 90% @ (at) RA (Room Air). Pt. (patient) attempted to get up from chair, chair alarmed. aided pt in quickly sitting down again in chair. Pt. being turned q2h (every two hours), bed alarm and blue pad in place. No s/s (signs or symptoms) of pain r/t (related to) fall on Monday. WCTM (Will Continue To Monitor)". b. [DATE] at 2:48 PM: " vs - ,[DATE], p-90, resp (respirations)-20, t (temperature)97.5, O,[DATE] ra (room air). Pt. was an extensive assist X 2 (two people) for ambulation. assistance X 1 (one person) for adls (activities of daily living) and meals. Pt is incontinent, and self propels in w/c (wheel chair). Pt ate all meals in dining room and was compliance w/ (with) all medications. No complaints or s/s (sign or symptoms) of pain or prn (as needed) meds (medications) requested after fall. vs stable for patient, will continue to monitor". c. [DATE] at 6:47 PM: "new orders received for pt- O2-nasal cannula 5L prn, and a chest x-ray". d. [DATE] at 5:26 PM: "Pt is somewhat lethargic and oriented to person. Pt. continues to attempt to transfer without assistance, though no falls occurred today. Slept for a few hours during shift; oxygen worn while in bed. Ext (extensive assistance) X 2 with transfers and toileting, ext X 1 (one person assist) with bed mobility today. Cueing required with meals. Pt less ready to respond to questions today than normal. Meds taken without difficulty. Pt. stated did not need anything when asked; no c/o (complaints of pain)". (Note: The facility nurse did not document an attempt to contact the x-ray company to obtain the x-ray results that were completed on [DATE].) e. [DATE] at 1:45 AM: "VS (blood pressure) ,[DATE], (pulse) 60, (respirations) 18, (temperature) 99.1, (and oxygen saturation) 92%. Pt. able to make needs known however pt is confused weak and dilousional (sic). ..." (Note: The facility nurse did not document an attempt to contact the x-ray company to obtain the x-ray results that were completed on [DATE] despite the increase in his temperature.) f. [DATE] at 2:25 PM: "...Pt. slept excessively this shift X (for) 6 hours. No attempts to stand up in wheelchair. Currently resting in bed. ..." g. [DATE] at 2:55 PM: "VS-bp-,[DATE], O2 91 p-81 resp-22. ...Pt. slept excessively this shift x6 hours. No attempts to stand up in wheelchair. Currently resting in bed. Eating and drinking poor, compliant w/ all meds. ...pt. O2 dropped to 87 on 5L nasal cannula, called respiratory, basic mask applied and O2 stabilized, will continue to monitor". (Note: The facility nurse did not document an attempt to contact the x-ray company to obtain the x-ray results that were completed on [DATE].) h. [DATE] at 12:09 AM: "Pt. found in room deceased this pm (evening). CNA (Certified Nurse Assistant) had done rounds on pt prior to death approximately 30 min (minutes) prior to being found passed away. Pt had no vitals. Pt had a positive x-ray for infiltrate in the lungs. Upon arriving on shift the doctor was being notified of pt's (patient's) condition. At approximately 1930 (7:30 PM) doctor called nurse and the nurse was informed to call the family to see how they wanted to treat. Son called shortly after with no answer. Message left on voicemail. Waited approximately 30 min for return phone call. Pt was then found in room by CNA. Dr. (doctor) notified of death and family called to inform them of passing. ..." Review of the "Death Summary" revealed that resident CL 1 was deceased on [DATE] at 8:15 PM. On [DATE] at 11:54 PM, resident CL 1's primary care physician (PCP) was interviewed. The PCP stated that she was not notified of resident CL 1's chest x-ray results until [DATE]. She stated that when she received a call from the facility licensed nurse on [DATE], she gave an order for [REDACTED]. She further stated that she had a meeting with the facility administration to discuss why the facility had not notified her of the x-ray results that were obtained on [DATE] until [DATE]. 2. Resident CL 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident CL 3's medical record was reviewed on [DATE]. Review of the physician orders [REDACTED]. a. [DATE]: "Chest 2 view x-ray ". b. [DATE]: "[MEDICATION NAME] 500 mg (milligrams) QD (daily)". c. [DATE]: "[MEDICATION NAME] Nebulizer Q (every) 4 hrs (hours) PRN". d. [DATE]: "[MEDICATION NAME] 40 mg QD X 3 days, then 20 mg QD X 3 days, then 10 mg QD X 3 days". Review of chest x-ray results obtained on [DATE] revealed the following: "EXAM REASON: Crackles, Decreased O2 Sats. ...FINDINGS: ...There is right basilar consolidation, likely pneumonia. ...IMPRESSION: Right basilar consolidation, likely pneumonia " . The final x-ray report was documented as being dictated by the radiologist on [DATE] at 11:05 PM: The final x-ray report was dated [DATE] at 7:27 AM as being faxed to the facility Review of the "Progress Notes" revealed the following: a. [DATE] at 12:28 AM: "Pt. was wheezing after smoke break tonight. pt. 02 sat was at 86 and pulse at 140. pt. had decreased lower lobe sounds with rales and rhonchi bilat. (bilaterally). stat chest xray showed no active disease in chest. pt. was placed on 2L 02 from RT (Respiratory Therapy) and 02 sats last checked were 93. will continue to monitor pt". (Note: The chest x-ray report revealed right basilar consolidation with "likely pneumonia".) b. [DATE] at 10:22 AM: The PCP documented "...had a drop in oxygen sats last night. XCR (chest x-ray) was unremarkable. He says he doesn't feel well. ..." The PCP further documented "[MEDICAL CONDITION] - cxr was negative. This may just be related to smoking but will order [MEDICATION NAME] to cover for [MEDICAL CONDITION]". (Note: The chest x-ray report revealed right basilar consolidation with "likely pneumonia".) c. [DATE] at 1:43 AM: "Pt continues charting for a chest xray. Pt given [MEDICATION NAME] via nebulizer and condition improved. will continue to monitor for any changes in condition". d. [DATE] at 11:38 AM: "Pt on charting for a chest x-ray. Pt now has PRN order for [MEDICATION NAME] nebulizer. One treatment given this AM (morning) shift, condition slightly improved. Pt also now on ABX (antibiotic)". (Note: [MEDICATION NAME] was ordered to be administered on [DATE].) e. [DATE] at 11:40 AM: "Pt now on ABX per MD (physician) order after chest x-ray. Pt. will continue on ABX for 10 days". f. [DATE] at 5:54 AM: "Pt. continues on abx. Pt HR (heart rate) 140, O2 sat at 82% on RA. RT (Respiratory Therapy) was called, put pt. on 4L O2. Reported hearing wheeze during pt respirations. Pt. kept pulling NC (nasal cannula) off. Sats 97% on 4L while on. 2 [MEDICATION NAME] given at 0400. Assessed 1 hour later, HR at 150. MD notified. DON (Director of Nursing) notified. Will continue to monitor". g. [DATE] at 1:11 AM: "Pt. continues abx therapy. No s/s of any adverse reaction to therapy noted during this shift. Pt tolerated all meds as ordered. will continue to monitor for any changes in condition". h. [DATE] at 1:11 AM: "Pt continues abx therapy. No s/s of any adverse reaction to therapy noted during this shift. Pt tolerated all meds as ordered. will continue to monitor for any changes in condition". i. [DATE] at 7:00 PM: "Pt continues on abx, no s/sx (signs or symptoms) of adverse reactions noted. Pt is quiet and sleeps in chair. Pt refused to be put in bed". j. [DATE] at 3:16 AM: "pt. continues on ABX for pneumonia. pt. is on 3L 02 at this time and sats are ,[DATE]. pt continues to have labored breathing and is at a 30 degree angle for sleeping. pt given a pain pill and [MEDICATION NAME] to help sleep better at 0300. Pt is sleeping in bed at this time and nurse continues to monitor". (Note: The facility nurse did not administer an [MEDICATION NAME] nebulizer for the "labored breathing".) k. [DATE] at 4:17 PM: "pt c/o pain in right side of chest and difficulty breathing. Pt on 5L O2 and sats at 92%. Pt sent to (local hospital) ER (emergency room ) for evaluation". The Medication Administration Records (MARs) for October and [DATE] were reviewed. The facility licensed nursing staff documented administering the following medications: [REDACTED] a. [MEDICATION NAME] 500 mg was not initiated until [DATE]. (Note: The PCP ordered for the [MEDICATION NAME] to be initiated on [DATE].) b. [MEDICATION NAME] 40 mg daily for 3 days was not initiated until [DATE]. (Note: The PCP ordered for the [MEDICATION NAME] to be initiated on [DATE].) The History and Physical from resident CL 3's admission to the hospital revealed that resident CL 3 had "...possible recent right lower lobe infiltrate". On [DATE] at 2:30 PM, the facility DON was interviewed. The DON stated that she "Pulls all orders" from the previous day every morning when she gets to work. The DON stated that she gives the copy of all new orders to the unit managers to "follow up with" to ensure that the labs (laboratory results)/x-rays were obtained and that the results had been received. The DON stated that she was out of the facility during the time the x-ray was ordered for resident CL 3, so she did not "pull the orders". On [DATE] at 3:00 PM, Unit Manager (UM) 1 was interviewed. UM 1 stated that she was "out sick" for a couple of days around [DATE], so she did not follow up on the x-ray results that were obtained on [DATE]. On [DATE] at 11:30 PM, the facility DON was re-interviewed. The DON was unable to provide additional information as to why the facility licensed nurses did not initiate the [MEDICATION NAME] and [MEDICATION NAME] as ordered. The DON was further unable to provide additional information as to why the facility nurses did not follow up on the chest x-ray results that were obtained on [DATE] until [DATE], when resident CL 3 was discharged to the hospital. On [DATE] at 11:54 PM, resident CL 3's PCP was interviewed. The PCP stated that she expected the facility licenses nurses to initiate new orders the day the orders were received. The PCP further stated that she expected antibiotics to be administered to the resident(s) within four (4) hours of the order being given. 3. Resident CL 2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident CL 2's medical record was reviewed on [DATE]. Review of the physician's orders [REDACTED]. a. [DATE]: "KCL 20 mEq (Milliequivalents) every day for 5 days" for a low potassium level of 3.2 (normal value 3XXX,[DATE].50). b. [DATE]: "[MEDICATION NAME] QID (four times a day) 500 mg X 14 days" for a [DIAGNOSES REDACTED]. The [DATE] MAR indicated [REDACTED]. On [DATE] at 11:54 PM, resident CL 2's PCP was interviewed. The PCP stated that she expected the facility licenses nurses to initiate new orders the day the orders were received. On [DATE] at 12:18 PM, the facility DON was interviewed. The DON stated that she did not know why the KCL or the [MEDICATION NAME] was not administered as ordered. Cross refer to F511.

Based on interview and record review, it was determined the facility did not ensure that a resident environment remained as fre of accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 10 sampled residents. Specifically, resident CL 2 received eight (8) second degree burns from spilling a hot beverage on four (4) occasions during a six (6) month period of time. Findings include: Resident CL 2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident CL 2's medical record was reviewed on 11/15/12. On 5/9/12, the facility staff completed an annual Minimal Data Set (MDS) Assessment. The facility staff assessed resident CL 2 as requiring extensive assistance with a two person physical assist for bed mobility, transfers and dressing. The facility staff assessed resident CL 2 as requiring extensive assist with a one person physical assist for eating. A Care Area Assessment triggered for activities of daily living (ADL's), Nutritional Status, and Dehydration. The facility staff documented that the care areas would be addressed in a care plan. On 8/9/12, a quarterly MDS Assessment was completed by the facility staff. The facility staff assessed resident CL 2 as requiring the following assistance: Extensive assist with a two person physical assist for bed mobility and dressing, extensive assistance with a one person physical assist for eating. The facility staff documented that resident CL 2 had a burn that was "second or third degree". Review of the care plans developed for resident CL 2 revealed: 1. "Mobility, Impaired Physical" - The facility staff documented "Impaired physical mobility related to [DIAGNOSES REDACTED] manifested by the inability to purposefully move within the environment including: bed mobility, transfer, and ambulation". The goals that were developed included "...Resident will show no evidence of complications such as: contractures, venous stasis, and skin breakdown". The approaches developed to achieve that goal included: "a. Encourage independence; b. Assist resident with ADL's they are unable to complete; and c. Remind resident to use call light. 2. "Adaptive Equipment" - The facility staff documented "Needs adaptive equipment to eat, call light - air call light used by res. (resident) mouth related to a [DIAGNOSES REDACTED]. The goal developed was "Resident will be able to feed self during the next 90 days". The approaches developed to achieve that goal included: "a. Assess resident's ability to feed self routinely; b. Provide adaptive equipment as ordered; c. Provide resident teaching on proper use of adaptive equipment as needed; d. Provide positive reinforcement as needed to encourage and/or maintain resident's independence; e. Assist resident with meals as necessary (e.g., cutting food up, providing a straw for drinking); and f. Allow ample time for resident to eat. ..." 3. "ADL Self-Care Deficit..." - The facility staff documented "At risk of developing complications assisted with decreased ADL self-performance manifested by quadriplegia, weakness and depression. ..." The goals developed included: "a. Not develop any complications related to decreased mobility and b. ADL needs will be met daily. ..." The approaches developed to achieve those goals included: "a. Report significant changes in ADL status to physician; b. Encourage daily care (dressing, bathing, etc); and c. Provide assistance in areas resident unable to complete independently. ..." The facility staff documented an additional approach which included: "8/28/12 - supervised while drinking coffee. ..." 4. "Skin Integrity Care Plan" - The facility staff developed "Actual Skin Breakdown and Potential for skin breakdown r/t: immobility and incontinence" with an "Alteration in Skin Integrity: a. 7/31/12: R breast re-opened and b. 8/14/12: R hip burn and lower back. ..." The goals that were developed were "Will not have any skin breakdown" and "Pressure ulcer will show no s/s (signs or symptoms) of infx. (infection)". The approaches developed by the facility staff included: a. "Encourage to turn/reposition/shift position frequently; b. Weekly skin check; c. Report any skin problems to the charge nurse; d. Pressure reducing mattress; e. Provide skin care frequently (daily bath, shower 2X (twice) a week; f. Clean the resident's skin after each episode of incontinence; g. Apply protective lotion after shower/pericare; h. Elevate legs as tol (tolerated); i. Float heels as tolerated; j. Dietary Consult per protocol; k. Wound care as ordered; l. Monitor site for s/s of infection, notify MD (medical doctor) PRN; m. MVI (Multi-Vitamin with Iron) per orders; n. Supplements as ordered; o. Labs as ordered; p. Discuss risks/benefits PRN if with non-compliant behavior; q. Get resident involved with plan of care; and r. "Supervised (with) coffee. ... (Note: Unable to determine when the facility initiated the approach)". Review of the orders received from the primary care physician included the following: 1. 4/24/12: "apply silverdine (sic) to rt (right) breast wound cover with exuderm change (every) tue (Tuesday) & (and) thurs. (Thursday). DX (diagnosis) burn". 2. 5/11/12: "silverdine (sic) alagnte (sic) tielle (sic) plus to lower back change q m (Monday), w (Wednesday), f (Friday). DX 2nd (second) degree". 3. 6/21/12: "clean wound to rt (right) breast with wound cleanser, cover with spot duoderm change q tue, thu (Thursday), sat (Saturday). DX: burn". 4. 6/21/12: "clean wound to left hip with wound cleanser, cover with hydrocollied (sic) change q tue, thur, sat. DX: burn". 5. 7/11/12: "clean wound to rt hip with wound cleanser, apply silverdine (sic) cover with bordered foam change q tue, thur, sat. DX: Burn". 6. 7/12/12: "clean wound to rt hip with wound cleanser, apply silverdine to base cover with alginate then duoderm cgf (controlled gel formula) with borders change q m, w, f. DX: Burn". 7. 7/31/12: "clean wound to rt breast with wound cleanser, cover with algiante (sic), spot duoderm change q tu, thur, sat. DX: burn". 8. 8/27/12: "clean wound to rt inner thigh with wound cleanser, apply silverdine (sic), cover with algiante (sic) duoderm cgf with borders change q tu, thur, sat. DX: Burn". 9. 9/23/12: "Keflex 500 mg PO q 6 hrs (hours) for 7 days for DX: Redness to right foot, Redness to Right thigh wound". 10. 9/28/12: "Vancomycin 750 mg IV (intravenously) BID (twice a day) X 3 days for DX: Redness to right foot and redness to right thigh wound". Review of the facility "physician progress notes [REDACTED]. 1. 4/9/12: The facility wound nurse (WN) documented "Pt. spilled coffee on ABD (abdomen) resulting in a (second degree) burn with intact clear filled blister. MD notified. Observation of blister only". 2. 4/15/12 at 2:01 AM: "AOX3 (alert and oriented X 3 (person, place and time)). VSS (vital signs stable). Pt. has burns and blisters over chest. Administered px (pain) medication as per physician's orders [REDACTED]. WCTM (will continue to monitor)". 3. 4/16/12 at 2:35 AM: "AOX3. Pt. has burns and blisters over her chest. One blister popped today. Pt. is being monitored by wound care specialist. WCTM". 4. 4/16/12 at 10:03 AM: "Resident alert and cooperative with nurse. Understands the nurse and is able to make needs known. Pt. has burns and blisters over her chest. Pt. is being monitored by wound care specialist. ..." 5. 4/17/12 at 5:48 AM: "...Resident a/o (alert and oriented), able to make needs known, cooperative with nurse. Understands the nurse and is able to make needs known. Pt. has burns and blisters over her chest. Pt. is being monitored by wound care specialist. ..." 6. 4/18/12 at 6:46 AM: "...resident has burns/blisters on her chest r/t a coffee spill that occurred on 4/14/12. Blisters have popped, burn appears to be healing. Wound nurse monitoring/treating wound. wctm. pt. complained of pain 6/10, prn pain pill admin (administered), reduced pain to 1/10. wctm". 7. 4/18/12 at 9:21 PM: "...Burns are bandaged as per orders. Redness is present and is warm to the touch. will notify wound nurse. Call light is within reach. ..." 8. 4/19/12 at 10:25 AM: "Pt. was treated by wound nurse for burns on abdomen today. WCTM". 9. 4/19/12 at 9:30 PM: "...Pt. has tx in place for burns on abdomen and chest. Redness has decreased. Drsgs (dressings) are clean, dry and intact. ...Pt. is able to make needs known". 10. 4/29/12 at 8:45 AM: "Pt. alert; up in electric w/c (wheelchair) at this time. Pt. burns from coffee spill on herself are being treated and dressed by wound nurse. Dressings are clean, dry, and intact. ..." 11. 4/21/12 at 3:03 AM: "...Dressings on burns CDI (clean, dry and intact). Pt. denies px. No s/s of infection. ..." 12. 4/21/12 at 5:41 PM: "Pt burns from coffee spill (sic) on herself are being treated and dressed by wound nurse. Dressings are clean, dry, and intact. Pt. has no c/o (complaints of) pain or discomfort. ..." 13. 4/22/12 at 3:03 AM: "Pt. has burns on chest, and is being treated by wound care specialist. Dressings CDI. ..." 14. 4/22/12 at 11:08 PM: "...Pt. has burns on the chest and abd. she is being treated by wound care specialist. Dressings CDI. ..." 15. 4/24/12: The facility WN documented "Burn to ABD has split into 2 separate wounds, R ABD & R Breast. MD notified. ..." 16. 4/26/12 at 2:37 PM: The primary care physician documented - "...She spilled hot coffee and has a burn on her right breast and chest. ...first degree burns on right breast and chest wall. ..." 17. 5/11/12 at 5:30 AM: "Alert charting: Pt. was found having spilt her coffee. Pt. received blisters to left hip. Will notify wound nurse of situation. Will cont to assess". (Note: This was the second burn resident CL 2 sustained from drinking hot beverages since 4/15/12.) 18. 5/11/12 at 6:55 PM: "Pt. did suffer burn d/t spilt coffee on skin, burns addressed by wound nurse. no c/o of pain, and no s/s of distress related". 19. 5/11/12: The facility WN documented "Pt. again (with) spilt coffee and (second degree) burn with clear fluid filled blister to L (left) lower back, L hip. MD notified. ..." 20. 5/12/12 at 2:27 AM: "...Pt. has burns on L hip. Pt. being monitored by wound care specialist. ..." 21. 5/12/12 at 1:07 PM: "Skin check performed on patient today. Wound nurse is following wound due to coffee burn". 22. 5/13/12 at 4:16 AM: "...Pt. has blisters on L hip from coffee spill. Pt. is being tx by wound care specialist. WCTM". 23. 5/13/12 at 8:11 AM: "Pt. has burns on L hip. Pt. being monitored by wound care specialist. ...". 24. 5/13/12 at 8:11 PM: "Pt. has burns on L hip. Pt. being monitored by wound care specialist. ..." 25. 5/14/12 at 2:07 AM: "...Pt. has burn wound on L hip. Pt is recieving (sic) tx from wound care specialist. WCTM". 26. 5/15/12 at 2:36 PM: "New coffee cups purchased for pt in attempt to prevent future burns. Will monitor for effectiveness". 27. 5/15/12 at 4:37 PM: IDT (Interdisciplinary Team) - "On 5/10/12 pt was in room, in bed and the head of her bed was lower than a 20 degree angle and she was drinking coffee in bed. she was drinking it out of one of the mugs from the kitchen with the plastic lid on it. she told me that because she wasn't siting (sic) straight up in bed the coffee started to coe (sic) out of the hole on the top and then the lid itself fell off. pt was educated about not drinking coffe (sic) while laying in bed to be siting (sic) straight up. coffee mugs with a lid that snaps on were purchased for the pt. the coffe (sic) temp was 170 degrees and regulationms (sic) show that the coffe (sic) shouldn't be above 140. we are having someone from (company name removed) come out and look at the coffe (sic) machine. wound nurse assessed wounds and treatments are in place". 28. 6/5/12: The facility WN documented "Pt. wound to L hip has resolved. MD notified. will D/C (discontinue) tx". 29. 6/12/12: Resident CL 2 was seen by her PCP. The PCP documented "Recent (second) degree burns to bust, L (left) hip. Discussed with treatment nurse. Discussed circulation, positioning, and dependent positions". 30. 6/21/12: The facility WN documented "Pt. wound to R breast, L hip have (decreased) in size. Now (without) exudate. MD notified. ..." 31. 7/3/12: The facility WN documented: "Pt. wound to R breast is intact with heavey (sic) raised scar tissue noted. MD notified. D/C TX". 32. 7/11/12: The facility WN documented "Pt. has again received a burn from coffee spill to R hip (with) intact clear fluid filled blister to site. ..." 33. 7/12/12 at 10:21 AM: "Burn on patient has treatment by wound nurse. No complaints of pain today. Will continue to monitor". 34. 7/12/12 at 11:24 PM: "Dsg (dressing) to R hip burn clean and dry, put in place by wound nurse. pt c/o pain r/t burn, pain meds given per md order. relief noted". (Note: This was the third burn resident CL 12 sustained from hot beverages since 4/15/12.) 35. 7/12/12: The facility WN documented "Blisters to burn on R hip have opened and some of the redness area started to blister last night. MD notified. ..." 36. 7/13/12 at 11:14 PM: "On 7/10/12 Pt. burned her self with coffee on her right hip, she didn't want me to tell (name removed) but I explained that that was something that I had to do so she could receive adequate treatment. ..." 37. 7/13/12 at 8:04 PM: "Pt's right hip burn shows no s/s of infection. Slightly red. Pt. denies pain when asked. will continue to monitor". 38. 7/14/12 at 4:43 AM: "...Burn on R hip drsg CDI". 39. 7/17/12 at 8:03 AM: "IDT - Spoke with resident regarding coffee, resident verbalizes she is only to use a cup with a lid and handle. Tx currently in place to burn resident states that she did not want the teqatment (sic) nurse to know at the time of the burn because she did not want her coffee taken away. Explained to resident that her coffee would not be taken away she needed to use a cup with a lid and handle again resident verbalizes understanding". 40. 7/24/12: The facility WN documented "Pt. wound to L hip has resolved. MD notified. Will D/C TX". 41. 7/30/12 at 3:18 PM: "Patient is alert and oriented X 3. Requires extensive assistance with bed mobility, transfers, hygiene, feeding, toileting, dressing. ..." 42. 8/14/12: The facility WN documented "Pt. wound to R back resolved. ..." 43. 8/22/12 at 9:00 AM: The facility WN documented "Pt. R hip burn has resolved leaving only the R lower hip burn remaining. MD notified". 44. 8/26/12 at 2:17 PM: "Pt. spilled coffee in her right inner thigh while in her wheelchair in her room. Staff found area on right inner thigh upon changing pt's clothes. Area is red with intact blister. cool compress applied for 15 minutes. No c/o pain or discomfort at this time. ..." (Note: This was the fourth burn resident CL 2 sustained from hot beverages since 4/15/12.) 45. 8/27/12 at 1:36 AM: "...Pt has fluid filled blister on R upper leg from coffee burn. No s/s of infection at this time. will continue to monitor". 46. 8/27/12 at 8:31 PM: "Blister on R inner thigh from coffee spill is swollen and waiting to leak. Wound nurse advised to report if blister ruptured or became infected. No s/s of discomfort to patient". 47. 8/27/12 at 9:00 AM: The WN documented "Pt. (with) new burn to R inner thigh over the weekend. Currently site (with) intact clear fluid blister. Peri-wound (with) [DIAGNOSES REDACTED]. MD notified. ..." 48. 8/28/12 at 3:54 AM: "...Dressing change this am. prn medications given RN aware of new blister on right tight (sic) will continue to monitor". 49. 8/28/12 at 6:29 PM: "IDT - Spoke with resident regarding recent coffee spill resident was drinking coffee alone and spilt on her right inner thigh, blister is intact. Area has been assessed by in-house wound nurse and treatment in place. Reviewed risk of her drinking coffee on her own resident verbalized understanding and has agreed to only drink coffee while supervised with staff. Spoke with Dtr (daughter) via telephone and stated 'I know how my mother can be with coffee she has to have it' explained current treatment and that (resident CL 2) had agreed to only drink coffee with supervision". 50. 8/29/12 at 2:26 AM: "...Blister on R inner thigh from coffee spill is swollen and started to leak a little but when the leg was cleansed no more fluid was noticed. will continue to monitor. Pt aware no coffee to be given unless there is supervision". 51. 8/29/12 at 4:32 PM: "Site is clean with with (sic) scant amount of blood that is dried. Fluids encouraged. ..." 52. 9/15/12 at 2:56 PM: "...Right hip wound is old and followed by wound nurse, cleaned and covered with algiante (sic) duoderm. ..." 53. 9/18/12 at 7:49 AM: "pt wound to rt lower hip (burn) has resolved md notified will d/c tx ". 54. 9/18/12 at 7:51 AM: "Skin/Wound Note - ...rt inner thigh burn. Full thickness. 1.4 cm X 1.0 cm X 0.2 cm with small serosangious (sic) exudate. 15% yellow slough, 85% beefy red granulation tissue. Note: wound is improving with a decrease in slough to 15% decrease in size will cont with current tx". 55. 9/18/12 at 7:59 AM: "Skin/Wound Note - rt breast burn with full thickness. 0.2 cm X 0.2 cm X 0.1 cm with scan serosangious (sic) exudate. Note: contiones (sic) to slowly improve with slight decrease in size decrease in exudate will cont with current tx". 56. 9/20/12 at 12:17 PM: "IDT - ...Right breast and R inner thigh burns improving continue current treatment, resident continues to be supervised with coffee and is compliant. Reviewed and revised care plan". 57. 9/23/12 at 4:32 PM: "...wound to right inner thigh with increased brown drainage small pus like area noted in wound base. Notified MD new treatment orders received and abt (antibiotic) orders. ..." 58. 9/14/12 at 3:18 AM: "Pt resting in bed got all pm (evening) medications pt had a high Temp last night of 103.7 Physician and DON (Director of Nursing) notified. Dr. ordered a time dose of rocephin 1 mg IM (intramuscularly) then to continue on Keflex 500 mg. She still have (sic) an open sore in cocxys (sic) will continue to monitor". 59. 9/24/12 at 7:13 PM: "Patient is receiving Keflex ABX for R foot, R thigh wound, and increased redness and drainage. Patient tolerated last dose of Keflex with no s/s of adverse effects. Redness on foot has decreased and patient has no complaints of pain r/t wounds". 60. 9/28/12 at 12:17 AM: "...Pt thigh is slightly red with no s/s of further infection or redness. no c/o of pain with foot or thigh". 61. 9/29/12 at 2:40 PM: "Assessment of thigh and foot redness shows no increase in redness. No s/s of further infection. Patient tolerated shower and had dressing changed over sites. Patient tolerates medication and has no complaints of pain". 62. 9/30/12 at 1:34 AM: "...right thigh wound dressing is clean dry and intact. no redness noted around wound. no c/o pain. right breast wound dressing is clean dry and intact. no c/o pain. no redness noted. ..." 63. 9/30/12 at 9:56 AM: "Skin redness assessed on patient thigh and R foot. ..." 64. 10/3/12 at 6:50 PM: "Skin redness assessed on patient thigh and R foot. ...Redness has not spreaded (sic) over sites and monitoring every shift is in effect for noting any changes. Patient has no complaints of pain". 65. 10/4/12 at 12:08 AM: "...right thigh wound has slight redness. has not increased. no c/o pain with foot or thigh. Pt. is receiving ABX vancomycin through PICC line in left antecubital space. ..." 66. 10/4/12 at 10:17 AM: "Patient has good circulation through foot and leg where wound are situated. ...Wounds site has no red streaking or spread of discoloration. ..." 67. 10/5/12 at 12:23 AM: "Pt. had some c/o pain this evening, pain of 6/10. Percocet administered with noted relief. ...Pt. right thigh wound no redness noted. dressing is clean dry and intact.. being treated by wound nurse. Pt. receiving ABX vancomycin through PICC line. PICC line is clear and patent with no s/s of infiltration or phlebitis. Pt. is tolerating medication well with no s/s of adverse reaction". 68. 10/5/12 at 6:29 PM: "Pt. finished abx therapy today through PICC line and tolerated well. PICC line patent. Denies pain at site and denies generalized pain throughout body throughout the shift. PICC line site showing no s/s of infection. ...Pt. right thigh wound no redness noted. Dressing dry, clean and intact. Treatment done by wound nurse. ..." 69. 10/12/12 at 6:23 AM: The facility staff completed a "Non-Pressure Skin Review" for resident CL 2's right thigh. The facility staff documented "burn to rt thigh improving, 100% granulation tissue. Bleeds easily. no redness to peri-wound". The facility staff documented that the wound measured 1.4 cm X 3.6 cm. The facility staff further documented that the measurements were obtained on 10/8/12. 70. 10/31/12 at 2:06 PM: A non-pressure skin review was completed. The facility staff documented the rt thigh burn, to be resolving with 100% epithelial tissue that "bleeds easily". No redness to the peri wound was documented. The facility staff documented that the wound was 1.6 cm X 1.6 cm that was obtained on 10/29/12. Review of the "Pressure Ulcer Site Sheet" and the "Weekly Wound Assessment" forms revealed that the facility WN documented the following: 1. Right Breast: a. 4/24/12: "Burn - 3.1 cm X 1.8 cm X 0.2 cm with scant amount of serous drainage. 25% beefy red wound bed with 25% granulation tissue, 50% slough. [DIAGNOSES REDACTED] to the surrounding tissue. b. 5/1/12: "Burn - 2.4 cm X 2.1 cm X 0.2 cm with small amount of serosanguineous drainage. 100% granulation tissue. Wound improving now (with) 100% granulation tissue. (Decrease) in size. Cont (with) current tx". c. 5/8/12: "Burn - 2.1 cm X 1.6 cm X 0.2 cm with a scant amount of serosanguineous drainage. 100% granulation tissue. Wound improving (with decrease) in size. 100% granulation tissue. Will continue (with) current tx". d. 5/15/12: "Burn - 1.9 cm X 0.9 cm X 0.2 cm with small amount of serosanguineous drainage. 100% granulation tissue. Wound continues to improve (with decrease) in size. Base (with) 100% granulation tissue. Will continue (with) current tx". e. 5/22/12: "Burn - 1.2 cm X 0.7 cm X 0.1 cm with small amount of bloody drainage. 100% granulation tissue. Wound has (decreased) in size, but base is very fragile. 100% granulation. MD notified. ..." f. 5/30/12: "Burn - 1.0 cm X 0.5 cm X 0.2 cm with scant amount of serosanguineous drainage. 100% granulation tissue. Wound improving (with decrease) in size. (Decrease) in exudate. 100% granulation tissue. Will continue (with) current tx". g. 6/5/12: "Burn - 0.9 cm X 0.5 cm X 0.2 cm with small amount of serosanguineous drainage. 100% granulation tissue. Wound continues to (decrease) in size. Improving base (with) 100% granulation tissue. will continue (with) current tx". h. 6/12/12: "Burn - 0.5 cm X 0.3 cm X 0.2 cm with a scant amount of serosanguineous drainage. 100% granulation tissue. Wound continues to improve (with decrease) in size. 100% granulation tissue. (Decrease) in exudate to scant... Will continue (with) current tx". i. 6/19/12: "Burn - 0.3 cm X 0.2 cm X 0.1 cm with 100% granulation tissue. Wound improving. (Decrease) in size. (No) Exudate. 100% granulation tissue. Will continue (with) current tx". j. 6/26/12: "Burn. 0.2 cm X 0.2 cm X 0.1 cm with scant amount of serosanguineous drainage. 100% granulation tissue. Wound (with) slight (decrease) in size, base (with) 100% granulation issue in middle of larger intact red scar tissue. will continue(with) current tx". k. 7/31/12: "Burn. 1.0 cm X 0.5 cm X 0.1 cm with serosanguineous drainage. 100% granulation tissue. this site has reopened. Site previously (with) the scar tissue covering site. Now (with) 100% granulation. MD notified. ..." l. 8/7/12: "Burn. 0.5 cm X 0.3 cm X 0.1 cm with bloody drainage. Wound (with) some improved (sic). (Decrease) in size. (Decrease) Exudate. Will cont (with) current tx". m. 8/14/12: "Burn - 0.4 cm X 0.2 cm X 0.1 cm with serosanguineous drainage. 100% Granulation tissue. Wound slowly improving (with) slight (increase) in size. will cont (with) current tx". n. 8/22/12: "Burn - 0.3 cm X 0.2 cm with serosanguineous drainage. 100% hypergranulation tissue. Wound (with) slight (decrease) in size. Base (with) 100% hypergranulation. MD notified TX (with) 1 application of silver nitrate then cont (with) current tx. This was done. will cont to monitor". o. 8/29/12: "Burn - 0.5 cm X 0.5 cm with serosanguineous drainage. Hypergranulation. Wound (with increase) size with hypergranulation. MD notified. TX (with) 1 application of Silver Nitrate and cont (with) current tx". p. 9/5/12: "Burn. 0.4 cm X 0.4 cm X 0.1 cm with serosanguineous drainage. 10% granulation tissue. Wound (with) slight (decrease) in size. Hypergranulation tissue from last week resolved. Base now (with) 100% beefy red granulation peri-wound (with) scar tissue. Cont (with) current tx". q. 9/11/12: "Burn. 0.3 cm X 0.2 cm X 0.1 cm with serosanguineous drainage. 10% Granulation Tissue. Wound slowly improving (with decrease) in size. Will cont (with) current tx". 2. Right abdomen: a. 4/9/12 - "Second Degree Burn" - 3.1 cm X 0.8 cm with no drainage. "Intact clear fluid filled blister. ..." b. 4/16/12 - 3.4 cm X 1.5 cm X 0.2 cm with serosanguineous drainage. "Blister deflated exposing a full thickeness (sic) (with) 25% granulation, 75% slough. MD notified". c. 4/24/12: "Burn - 2.1 cm X 1.2 cm X 0.2 cm with scant amount of serosanguineous drainage. 50% granulation tissue, 50% slough. All blisters to site open. Portions of wound resolved leaving 2 separate wounds. This wound (with) some improvement (with decrease) in slough. Peri-wound (with) [DIAGNOSES REDACTED]. MD notified. ..." d. 5/1/12: "Burn - 2.0 cm X 1.0 cm X 0.2 cm with brown flacky (sic) scab. Wound improving only slightly (decrease) in size. However there some areas that are now intact. rest covered (with) brown scab. cont (with) current tx". e. 5/8/12: "Burn - 1.2 cm X 0.4 cm X 0.1 cm with 100% granulation tissue. Scab removed (with) drsg (change). Base (with) 100% granulation. Large (decrease) in size. Improving. Continue (with) current tx". f. 5/15/12: "burn - 0.7 cm X 0.3 cm X 0.2 cm with scant amount of serosanguineous drainage. 100% granulation tissue. Wound continues to improve (with decrease) in size. will continue (with) current tx". g. 5/22/12: "Burn - 0.5 cm X 0.3 cm X 0.1 cm with scant amount of serosanguineous drainage. 100% granulation tissue. wound improving (with decrease) in size. Will continue (with) current tx". h. 5/30/12: "Burn - 0.4 cm X 0.3 cm X 0.2 cm with small amount of bloody drainage. Wound (with) slight (decrease) in size. 100% granulation tissue. Site is fragile (with) start of hypergranulation tissue noted. MD notified. Continue (with) current tx. Apply silver nitrate application if needed PRN". i. 6/5/12: "Burn - 0.3 cm X 0.1 cm X 0.1 cm with 100% granulation tissue. Wound continues to improve. Now (with no) exudate. 100% granulation tissue to base. Peri-wound clear. (Decrease) in size. Cont (with) current tx". 3. Right Lower Back: a. 7/17/12: "Burn. 6.9 cm X 2.7 cm X 0.2 cm with a small amount of serosanguineous drainage. 100% slough. Wound to R hip separated into two separate wounds. this wound started as intact blister. Now covered (with) 100% slough. Will continue (with) current tx". b. 7/24/12: "Burn. 3.7 cm X 1.4 cm X 0.2 cm with serosanguineous drainage. Scant drainage. 75% granulation tissue with 25% slough. This wound has vastly improved (with decrease) in size. (Decrease) in 100% slough to 25% (with) new 75% granulation. Will cont (with) current tx". c. 7/31/12: "Burn - 2.3 cm X 1.2 cm X 0.2 cm with serosanguineous drainage. Slight odor with scant amount of drainage. 100% granulation tissue. Wound improving (with decrease) in size. Now (with) 10% granulation. Cont (with) current tx". d. 8/7/12: "Burn - 0.7 cm X 0.5 cm X 0.2 cm with a scant amount of bloody drainage. Wound (with) large (decrease) in size. 100% granulation. will cont (with) current tx". 4. Left Lower Back: a. 5/11/12: "Burn (Second Degree) - 7.4 cm X 1.2 cm with a clear fluid filled blister. Red surround (sic) skin". b. 5/15/12: "(Second Degree) Burn - 5.4 cm X 1.0 cm X 0.2 cm with scant amount of serosanguineous drainage. Pink wound bed. Blister deflated. Loose skin removed (with) wound cleansing exposing partial thickenss (sic) wound. Cont (with) current tx. improving (with decrease) in size. c. 5/22/12: "Burn - 2.3 cm X 0.5 cm X 0.2 cm with 100% granulation tissue. Wound improving (with) large (decrease) in size. (No) exudate. 100% granulation tissue. Cont (with) current tx". d. 5/30/12: "Burn - 5.1 cm X 3.7 cm X 0.3 cm with small amount of serosanguineous drainage. 60% granulation tissue with 40% slough. Wound improving (with decrease) in size. (Decrease) in slough from 80% to 40% (with) 60% beefy red granulation. will continue (with) current tx". 5. Right Hip: a. 7/11/12: "Burn (Second Degree) - 18.9 cm X 5.6 cm with clear fluid filled blister intact. b. 7/17/12: "Burn - 10.4 cm X 5.4 cm X 0.2 cm with small amount of serosanguineous drainage. 100% slough with red surround skin. Blisters to site open. Base covered (with) 100% yellow fibour's (sic) slough. Middle of original wound closed. Separating wound into 2 separate parts. See R lower back note. Will continue (with) current tx". c. 7/24/12: "Burn. - 3.8 cm X 2.1 cm X 0.2 cm with serosanguineous drainage. 25% granulation tissue with 75% slough. This is now its own separate wound as center of wound resolved. Base (with) new 25% granulation mixed (with) 75% slough. Current drsg covers both sites so will continue (with) current tx". d. 7/31/12: "Burn - 3.2 cm X 1.8 cm X 0.2 cm with serosanguineous drainage. Slight odor or scant amount of drainage. 75% granulation tissue with 25% slough. Wound now (with) 75% granulation and 25% slough. (Decrease) in size. cont (with) current tx". e. 8/7/12: "Burn - 2.9 cm X 1.7 cm X 0.2 cm. Bloody with a slight odor. 80% granulation tissue, 20% slough. Wound improving (with decrease) in size. slight (decrease) in slough to 20% with 80% granulation. cont (with) current tx". f. 8/14/12: "Burn - 0.9 cm X 0.5 cm X 0.1 cm. 100% granulation tissue. Wound has vastly improved (with) large (decrease) in size now (without) exudate. 100% granulation tissue. Will cont (with) current tx". 6. Left Hip: a. 5/11/12: "Burn - 12.4 cm X 6.45 cm with small amount of serous drainage. Clear fluid filled blister with [DIAGNOSES REDACTED] to the surrounding skin". b. 5/15/12: "(Second Degree) Burn - 10.4 cm X 5.2 cm X 0.2 cm with scant amount of serosanguineous drainage. Pink/beefy red wound base. Pt. wound improving (with decrease) in size. All blisters have deflated and loose skin removed (with) wound care. Most distal portion of wound intact (with

Based on interview and record review, it was determined that the facility did not ensure that residents were free of significant medication errors. Specifically, 1 of 10 residents was given an incorrect dosage of [MEDICATION NAME] which resulted in a low blood pressure and required an injection of [MEDICATION NAME] ([MEDICATION NAME]). Resident identifier: CL6. Findings include: Resident CL6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident CL6 was admitted with medication orders which included a [MEDICATION NAME] Patch 100 micrograms (mcg) every 3 days and [MEDICATION NAME] 2 milligrams (mg) every four hours as needed. A physician order [REDACTED]. On 11/19/12 a review of resident CL6's closed medical record was conducted. The Minimum Data Set assessment dated [DATE] identified that resident CL6 had vocal complaints of pain three (3) to four (4) days in the last five (5) days. A nursing assessment note dated 10/11/12, revealed that resident CL6 had a pain level of "4-6 or moderate pain" and that "[MEDICATION NAME] 2 mg Q (every) 4 hrs (hours)" was given. No documentation could be found as to whether or not the [MEDICATION NAME] was effective for the resident CL6's pain. The documented blood pressure (BP) was within normal limits (WNL) for resident CL6 at 137/82. A nursing assessment note dated 10/12/12, revealed that resident CL6 had a pain level of "4-6" and that "Pt (patient) c/o (complains of) pain, treated with PRN (as needed) pain meds (medications) with noted relief ". The documented BP was WNL for resident CL6 at 128/74. A nursing assessment note dated 10/16/12, revealed that resident CL6 had a pain level of "4-6" and that "Pt c/o pain, treated with PRN pain meds with noted relief ". The documented BP was WNL for resident CL6 at 135/62. A nursing assessment note dated 10/17/12, revealed that resident CL6 had a pain level of "4-6" and that "Pt c/o pain, treated with PRN pain meds with noted relief ". The documented BP was WNL for resident CL6 at 112/76. A nursing assessment note dated 10/18/12, revealed that resident CL6 had a pain level of "7-10 or severe pain" and that "Pt rotated and PRN medications administered with positive results". The documented BP was WNL for resident CL6 at 120/71. A nursing assessment note dated 10/20/12, revealed that resident CL6 had a pain level of "7-10" and that "PRN medication administered with positive results". The documented BP was WNL for resident CL6 at 122/69. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "4-6" and that" PRN medication administered with positive results". Documented BP was WNL at 131/71. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "4-6" and that "PRN pain medication" had been given. No documentation could be found as to whether or not the pain medication was effective. The documented BP was WNL for resident CL6 at 137/74. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "4-6" and that "PRN pain meds are administered as ordered. Pt is repositioned to decrease pain." The documented BP was slightly high at 145/76. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "4-6" and that "pain meds prn". No documentation could be found as to whether or not the pain medication was effective. The documented BP was WNL for resident CL6 at 122/76. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "4-6" and that "Pain meds administered as ordered. Pt repositioned q (every) 2 hrs (hours) and PRN". No documentation could be found as to whether or not the pain medication was effective. The documented BP was slightly high at 144/85. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "7-10" and that "prn meds given with noted releif (sic)". The documented BP was WNL for resident CL6 at 131/79. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "7-10" and that "prn meds given with noted releif (sic)". A physician order [REDACTED]. The documented BP was WNL for resident CL6 at 139/78. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "4-6" and that "Pt has chronic pain. PRN pain meds are administered as ordered with verbalized decrease in pain". The documented BP was slightly high at 156/81. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "4-6" and that "Pt has generalized chornic (sic) pain. Pt is repositioned to help with pain. Pt is administered PRN and scheduled pain meds as ordered". The documented BP was high at 161/92. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "4-6" and that "[MEDICATION NAME] for pain" was administered. The documented BP was high at 158/102. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "7-10" and that "PRN pain meds given with noted releif (sic)". The documented BP was slightly high at 145/86. A nursing assessment dated [DATE], revealed that resident CL6 had a pain level of "7-10" and that "Pt has been repositioned and given his PRN dose of [MEDICATION NAME]. He seems to get some relief ". The documented BP was WNL for resident CL6 at 113/74. A physician order [REDACTED]. The pharmacy label for the [MEDICATION NAME] for resident CL6 revealed that the correct dosage was 20 mg/1 ml, not the 5 ml that had been transcribed. The pharmacy label further revealed to give "1 ml three times daily (TID) as directed". A controlled drug record for resident CL6 [MEDICATION NAME] revealed that 5 ml or 100 mg of [MEDICATION NAME] had been given to resident CL6 on 11/8/12 at 7:30 AM and again at 1:30 PM. A nurses note for resident CL6 dated 11/8/12 at 20:17 (8:17 PM) revealed that resident CL6 was "found to have BP of 76/56 and 1430 (2:30 PM) MD (physician) notified [MEDICATION NAME] (a medication that is used as an injection to prevent or reverse the effects of opiate (narcotic) overdose, including difficulty breathing, sleepiness, low blood pressure, and death.)was given, patient BP increased to 126/76..." No documentation could be found of resident CL6's respirations during this period. (NOTE: Resident CL6's BP was found to be low one hour after the second dose of [MEDICATION NAME] had been administered.) On 11/6/12 at 4:22 PM, a physician order [REDACTED]. On 11/19/12 an interview was conducted with the Director of Nursing (DON). The DON stated that the order had been transcribed wrong and that the nurse who had transcribed the [MEDICATION NAME] was a new nurse. The DON stated that she (the DON) contacted the physician. The DON stated that the physician told her that she (the physician) was "OK" with the BP, but, that if she (the DON) was not ok with it, she could give the resident an injection of [MEDICATION NAME] ([MEDICATION NAME]). The DON stated that she was not "OK" with the low BP and chose to give resident CL6 a dose of [MEDICATION NAME], "which was very helpful". The DON stated that the new nurse had been in-serviced on the computer program and how to correctly transcribe all medications. The DON further stated that the nurse that had administered the [MEDICATION NAME] had not followed the 5 rights of passing medications.

Based on observation, interview and record review, the facility did not ensure that residents were free of any significant medication errors. Specifically, (1) one resident did not have physician admission orders [REDACTED]. This failure created a situation of immediate jeopardy which had a potential for causing serious injury, impairment or death to residents in the facility. In addition, the following significant medication errors occurred that did not rise to the level of immediate jeopardy: (1) facility licensed nursing staff did not administer significant medications at the ordered time for three residents (resident identifiers: 49, 108, and 115), (2) facility licensed nursing staff did not administer the ordered dose of insulin to eleven residents (resident identifiers: 2, 14, 30, 57, 60, 65, 112, 130, 145, 217, and 220), and one resident did not receive intravenous [MEDICATION NAME] as scheduled (resident identifier: 104). NOTICE: Notice of immediate jeopardy was given verbally to the Administrator Designee/Operations Manager on 2/1/11 at 10:30 AM, as the Administrator was not available at the facility for the duration of the survey. The Administrator Designee/Operations Manager was asked to develop an immediate plan to ensure resident safety related to insulin administration with appropriate clarification of physician's orders and administration of insulin as ordered by the physician. PLAN: On 2/1/12 at 5:00 PM, the Administrator Designee/Operations Manager provided the surveyors with a written plan of action to remove the immediate jeopardy to residents in the facility. The written plan dated 2/1/12 at 5:00 PM revealed the following: "Provo Rehabilitation and Nursing, 1001 North 500 West, Provo, Utah Please accept this letter as our immediate actions to abate the immediacy of the issues identified on the complaint survey which was conducted at my facility on 2/1/12. F Tag 333: 1. All 13 residents identified by the survey team have had their insulin and sliding scale insulin orders clarified. 2. All facility residents receiving insulin and/or sliding scale insulin will be assessed by a nurse on the Milestone Clinical Support Team, to ensure their insulin and/or sliding scale insulin orders are accurate. a. All insulin and/or sliding scale insulin will be drawn up by a nurse and verified by a second nurse prior to administration for the next 72 hours. b. The Nurse Resource will audit seven diabetic resident's insulin administration records for seven days to ensure insulin and/or sliding scale insulin has been administered as ordered by the attending physician. c. Thereafter, the Director of Nursing or designee will audit five diabetic resident's insulin administration records every week times four weeks to ensure insulin and/or sliding scale insulin is being administered as ordered by the attending physician. 3. All Licensed Staff will receive in-service training on the following: a. Diabetic protocol. b. Insulin administration. c. [MEDICAL CONDITION]/[DIAGNOSES REDACTED] d. Medication administration e. 6 Rights of administration. 4. The policy and procedures regarding the Diabetic Protocol and Insulin Administration have been evaluated. 5. The identified concerns will be discussed by the facility Quality Assurance Committee weekly. The QA committee will adjust the frequency of the meetings and the monitoring as it deems appropriate. 6. These immediate interventions will be achieved by 2/1/12 to abate the immediacy of the issue." Prior to leaving the facility on 2/1/12, the surveyors confirmed the components outlined above in the written plan of action had been implemented. During the survey on 2/1/12, the surveyors confirmed removal of the immediate jeopardy situation as of 2/1/12. Deficient practice with potential for more than minimal harm remained for the risk of injury. Findings included: Immediate Jeopardy: 1. Resident 108 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 108's medical record was reviewed on 1/31/11. Review of resident 108's hospitalization paperwork (date of admission 12/8/11 with discharge from the hospital on [DATE]), revealed discharge paperwork for another patient at the hospital, not resident 108. Review of the January, 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the medications administered to resident 108 during his hospital stay was reviewed. The following medication discrepancies was identified: a) The hospital Licensed Nursing Staff (LNS) administered [MEDICATION NAME] 20 units SQ BID. (Note: The January, 2012 MAR indicated [REDACTED].) b) The Hospital LNS administered [MEDICATION NAME] Insulin 2-18 units SQ AC & HS. (Note: The January, 2012 MAR indicated [REDACTED] 1) AC: 81-50 = 2 units; 151-200 = 4 units; 201-250 = 6 units; 251-300 = 8 units; 301-350 = 10 units; 351-400 = 14 units; 401-450 = 18 units. 2) HS: 81-150 = 0 units; 151- 200 = 0 units; 201-250 = 2 units; 251 - 300 = 4 units; 301-350 = 5 units; 351-400 = 7 units; 401-450 = 10 units.) On 2/1/12 at 9:00 AM, the facility Director of Nursing (DON) was interviewed. The DON was unable to provide documentation that indicated resident 108's physician had ordered the insulins to be administered as above. 2. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 13's medical record was reviewed on 1/30/12. Review of resident 13's physician orders revealed an order on 10/3/11 to administer the following "[MEDICATION NAME] R 100 units/ml (milliliters) SQ AC & HS with a low sliding scale" for blood sugars as follows: a) AC: < 60-200 = 0 units, 251-300 = 4 units, 301-350 = 6 units, 351-400 = 8 units, 401-450 = 12 units, (Note: There was no order to administer insulin for a blood sugar from 201 - 250) and b) HS: <60-200 = 0 units, 201-250 = 0 units, 251-300 = 3 units, 301-350 = 4 units, 351-400 = 5 units, and 401-450 = 6 units. Review of the blood sugar monitoring and insulin injection record revealed the following: a) The facility LNS were administering insulin with the following sliding scales: 1) AC: 201-250 = 2 units, 251-300 = 4 units, 301-350 = 6 units, 351-400 = 8 units, 401-450 = 12 units. (Note: The AC sliding scale was different from what was ordered by the physician); and 2) HS: 201-250 = 2 units, 251-300 = 3 units, 301-350 = 4 units, 351-400 = 5 units, and 401-450 units. (Note: The HS sliding scale was different from what was ordered by the physician). b) The facility LNS documented the following blood sugars and insulin administration without notifying the physician for blood sugars above 400. 1) 1/1/12 at 2:00 AM: BS 434. 6 units of insulin administered. 2) 1/2/12 at 5:00 PM: BS = 454. 12 units of insulin administered. (NOTE: There was no physician's order to administer insulin for blood sugars greater than 450.) 3) 1/6/12 at 2:00 AM: BS 432. 5 units administered. 4) 1/12/12 at 5:00 PM: BS 567. 14 units administered. 5) 1/16/12 at 10:00 PM: BS 431. 12 units administered. 6) 1/17/12 at 10:00 PM: BS 441. 3 units administered. 7) 1/18/12 at 10:00 PM: BS 405. 6 units administered. 8) 1/21/12 at 10:00 PM: BS 432. 6 units administered. 9) 1/25/12 at 10:00 PM: BS 409. 3 units administered. 10) 1/26/12 at 2:00 AM: BS 451. 6 units administered. 11) 1/26/12 at 10:00 PM: BS 477. 6 units administered. c) The facility LNS documented the following blood sugars and insulin administration: 1) 1/1/12 at 2:00 AM: BS 434. 6 units administered. (Note: There was no physician's order to administer insulin at 2:00 AM.) 2) 1/2/12 at 5:00 PM: BS 454. 12 units administered. (Note: There was no physician's order to administer insulin for blood sugars greater than 450.) 3) 1/4/12 at 2:00 AM: BS 308. 4 units administered. 4) 1/5/12 at 7:00 AM: BS 224. 2 units administered. (Note: There was no physician's order to administer insulin for blood sugars between 200 - 250.) 5) 1/5/12 at 1100 AM: BS 473. 12 units administered. 6) 1/5/12 at 2:00 AM: BS 221. 2 units administered. 7) 1/6/12 at 2:00 AM: BS 432. 5 units administered. 8) 1/7/12 at 2:00 AM: BS 284. 3 units administered. 9) 1/8/12 at 2:00 AM: BS 210. 2 units administered. 10) 1/9/12 at 5:00 PM: BS 214. 2 units administered. 11) 1/9/12 at 2:00 AM: BS 244. 2 units administered. 12) 1/11/12 at 5:00 PM: BS 220. 2 units administered. 13) 1/12/12 at 7:00 AM: BS 223. 2 units administered. 14) 1/12/12 at 5:00 PM: BS 567. 14 units administered. 15) 1/12/12 at 2:00 AM: BS 236. 2 units administered. 16) 1/13/12 at 1100 AM: BS 224. 2 units administered. 17) 1/13/12 at 5:00 PM: BS 280. 2 units administered instead of 4 units as ordered. 18) 1/13/12 at 10:00 PM: BS 315. 2 units administered instead of 4 units as ordered. 19) 1/16/12 at 11:00 AM: BS 226. 2 units administered. 20) 1/16/12 at 10:00 PM: BS 421. 12 units administered instead of 6 units as ordered. 21) 1/16/12 at 2:00 AM: BS 259. 3 units administered. 22) 1/17/12 at 5:00 PM: BS 210 . 2 units administered. 23) 1/17/12 at 10:00 PM: BS 44. 3 units administered instead of 6 units as ordered. 24) 1/18/12 at 7:00 AM: BS 232. 2 units administered. 25) 1/21/12 at 7:00 AM: BS 200. 2 units administered. 26) 1/22/12 at 2:00 AM: BS 202. 2 units administered. 27) 1/23/12 at 2:00 AM: BS 231. 2 units administered. 28) 1/24/12 at 5:00 PM: BS 232. 2 units administered. 29) 1/24/12 at 10:00 PM: BS 337. 2 units administered instead of 4 units as ordered. 30) 1/24/12 at 2:00 AM: BS 45. 6 units administered. 31) 1/25/12 at 10:00 PM: BS 409. 3 units administered instead of 6 units as ordered. 32) 1/25/12 at 2:00 AM: BS 263. 3 units administered. 33) 1/26/12 at 7:00 AM: BS 225. 2 units administered. 34) 1/26/12 at 7:00 AM: BS 200. 2 units administered. 35) 1/27/12 at 2:00 AM: BS 201. 1 unit administered. 36) 1/28/12 at 7:00 AM: BS 220. 4 units administered. 37) 1/28/12 at 2:00 AM: BS 325. 4 units administered. 38) 1/29/12 at 2:00 AM: BS 251. 3 units administered. 39) 1/30/12 at 5:00 PM: BS 271. 6 units administered instead of 4 units as ordered. 40) 1/30/12 at 10:00 PM: BS 347. 8 units administered instead of 4 units as ordered. d) The facility "Nurse's Notes" were reviewed. There was no documentation that resident 13's physician was notified when the blood sugars were 400 or greater. Review of the "Consultant Pharmacist's Medication Regimen Review" revealed that the pharmacist did not complete a medication review during January, 2012. 3. Resident 60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 60's medical record was reviewed on 1/31/11. Review of resident 60's physician orders revealed insulin orders as follows: a) 2/8/11: [MEDICATION NAME] R 100 units/ml (milliliters) SQ AC with a high sliding scale for blood sugars as follows: 1) AC: 81-150 = 5 units, 151-200 = 9 units, 201-250 = 13 units, 251-300 = 17 units, 301-350 = 21 units, 351-400 = 25 units, 401-450 = 30 units. 2) HS: <200 = 0 units, 201-250 = 5 units, 251-300 = 8 units, 301-350 = 10 units, 351-400 = 12 units, and 401-450 = 15 units. Review of the blood sugar monitoring and insulin injection record revealed the following: a) The facility LNS administered insulin according to the following "Custom Sliding Scale": 1) AC: 81-150 = 5 units, 151-200 = 9 units, 201-250 = 13 units, 251-300 = 17 units, 301-350 = 21 units, 351-400 = 25 units, 401-450 = 30 units. 2) HS: 81-150 = 5 units, 151-200 = 9 units, 201-250 = 13 units, 251-300 = 17 units, 301-350 = 21 units, 351-400 = 25 units, 401-450 = 30 units. . (Note: The HS sliding scale was different from what was ordered by the physician). b) The facility LNS documented the following blood sugars that were greater than 400 according to the "Diabetic Protocol (see below for definition)": 1) 1/1/12 at 5:00 PM: BS 475 2) 1/6/12 at 10:00 PM: BS 410 3) 1/9/12 at 10:00 PM: BS 500 4) 1/11/12 at 5:00 PM: BS 442 5) 1/12/12 at 7:00 AM: BS 447 6) 1/12/12 at 11:00 AM: BS 442 7) 1/12/12 at 10:00 PM: BS 420 8) 1/14/12 at 10:00 PM: BS 449 9) 1/16/12 at 5:00 PM: BS 441 10) 1/17/12 at 5:00 PM: BS 414 11) 1/19/12 at 5:00 PM: BS 425 12) 1/19/12 at 10:00 PM: BS 404 13) 1/20/12 at 5:00 PM: BS 415 14) 1/23/12 at 11:00 AM: BS 435 15) 1/30/12 at 5:00 PM: BS 512 16) 1/30/12 at 11:00 AM: BS 437 17) 1/30/12 at 10:00 PM: BS 507 c) Facility LNS documented administering insulin at 10:00 PM as follows: 1) 1/1/12: BS 311 - 21 units administered instead of 10 units as ordered. 2) 1/2/12: BS 316 - 21 units administered instead of 10 units as ordered. 3) 1/3/12: BS 168 - 9 units administered instead of no insulin as ordered. 4) 1/4/12: BS 265 - 17 units administered instead of 8 units as ordered. 5) 1/5/12: BS 385 - 25 units administered instead of 12 units as ordered. 6) 1/6/12: BS 410 - 30 units administered instead of 15 units as ordered. 7) 1/7/12: BS 294 - 12 units administered instead of 8 units as ordered. 8) 1/8/12: BS 282 - 17 units administered instead of 8 units as ordered. 9) 1/9/12: BS 500 - 30 units administered. The LNS did not notify the primary physician for orders to administer insulin that was greater than 450. 10) 1/10/12: BS 396 - 25 units administered instead of 12 units as ordered. 11) 1/11/12: BS 275 - 17 units administered instead of 8 units as ordered. 12) 1/12/12: BS 420 - 30 units administered instead of 15 units as ordered. 13) 1/13/12: BS 353 - 25 units administered instead of 12 units as ordered. 14) 1/14/12: BS 449 - 30 units administered instead of 15 units as ordered. 15) 1/15/12: BS 223 - 13 units administered instead of 5 units as ordered. 16) 1/16/12: BS 187 - 9 units administered instead of no insulin as ordered. 17) 1/17/12: BS 210 - 13 units administered instead of 5 units as ordered. 18) 1/18/12: BS 225 - 13 units administered instead of 5 units as ordered. 19) 1/19/12: BS 404 - 30 units administered instead of 15 as ordered. 20) 1/20/12: BS 212 - 13 units administered instead of 5 units as ordered. 21) 1/21/12: BS 169 - 9 units administered instead of no insulin as ordered. 22) 1/22/12: BS 352 - 25 units administered instead of 12 units as ordered. 23) 1/23/12: BS 315 - 21 units administered instead of 10 units as ordered. 24) 1/24/12: BS 291 - 17 units administered instead of 8 units as ordered. 25) 1/25/12: BS 254 - 17 units administered instead of 8 units as ordered. 26) 1/26/12: BS 382 - 25 units administered instead of 12 units as ordered. 27) 1/27/12: BS 324 - 21 units administered instead of 10 units as ordered. 28) 1/28/12: BS 280 - 17 units administered instead of 8 units as ordered. 29) 1/29/12: BS 218 - 21 units administered instead of 5 units as ordered. 30) 1/30/12: BS 507 - 30 units administered. The LNS did not notify the primary physician for orders to administer insulin that was greater than 450. c) Review of the facility "Nurse's Notes" revealed a note on 1/10/12 at 2:30 AM "...Pt. (Patient) slightly agitated, possibly r/t (related to) (high) BS (at) 500, [MEDICATION NAME] 30 units given per sliding scale." (Note: the physician was not notified for orders to administer insulin when the BS was 500.) 4. Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 176's medical record was reviewed on 1/31/2. Review of the monthly January, 2012 Physician's Orders (printed 1/23/12) revealed an order to administer "[MEDICATION NAME] R (Insulin Regular (Human)) 100 UNIT/ML Subcutaneous (SQ) - complex,: AC and HS PER high S/S. AC: 81-120: OU (no insulin), 121-150: 2U, 151-200: 4U, 201-250: 6U, 251-300: 8U, 301-350: 10U, 351-400: 12U, >400: 15U. HS: 81-120: OU, 121-150: 1U, 151-200: 2U, 201-250: 3U, 251-300: 4U, 301-350: 5U, 351-400 6U, >400: 8U. Review of the blood sugar monitoring and insulin administration form revealed the facility LNS administered insulin according to the following sliding scale instead of the ordered sliding scale as above: a) AC: 81-150; 5 units, 151-200; 9 units, 201-250; 13 units, 251-300; 7 units, 301-350; 21 units, 351-400; 25 units, 401-450; 30 units. b) HS: 81-150; 0 units, 151-200; 0 units, 201-250; 5 units, 251-300; 8 units, 301-350; 10 units, 351-400; 12 units, 401-450; 15 units. c) The facility LNS documented the following: 1) 1/18/12 to 1/19/12 at 7:00 AM - No BS or insulin documented as being administered. 2) 1/19/12 at 11:00 AM: BS 139. 5 units administered instead of 2 units as ordered; 1/19/12 at 5:00 PM: BS 142. 5 units administered instead of 2 units as ordered; 1/19/12 at 10:00 PM: BS 123. No insulin was administered instead of the 1 unit as ordered. 3) 1/20/12 at 7:00 AM: BS 124. 5 units administered instead of 2 units as ordered; 1/20/12 at 5:00 PM: BS 145. 5 units administered instead of 2 units as ordered; 1/20/12 at 10:00 PM: BS 154. No insulin was administered instead of the 1 unit as ordered. 4) 1/21/12 at 7:00 AM: BS 152. 5 units administered instead of 4 units as ordered; 1/21/12 at 11:00 AM: BS 161. 9 units administered instead of 4 units as ordered; 1/21/12 at 5:00 PM: BS 97. 5 units administered instead of no insulin as ordered; 1/21/12 at 10:00 PM: BS 255. 8 units administered instead of 4 units as ordered. 5) 1/22/12 at 7:00 AM: BS 201. 13 units administered instead 6 units as ordered; 1/22/12 at 5:00 PM: BS 150. No insulin was administered instead of 6 units as ordered; 1/22/12 at 10:00 PM - BS 165. No insulin was administered instead of 2 units as ordered. 6) 1/23/12 at 7:00 AM: BS 113. 5 units administered instead of no insulin as ordered; 1/23/12 at 11:00 AM - BS 112. 5 units administered instead of no insulin as ordered; 1/23/12 at 5:00 PM - BS 189. 9 units administered instead of 4 units as ordered; 1/23/12 at 10:00 PM - BS 157. No insulin administered instead of 2 units as ordered. 7) 1/24/12 at 7:00 AM: BS 122. 5 units administered instead of 2 units as ordered; 1/24/12 at 11:00 AM - BS 112. 5 units administered instead of no insulin as ordered; 1/24/12 at 5:00 PM - BS 137. 5 units administered instead of 2 units as ordered. 8) 1/25/12 at 7:00 AM: BS 135. 5 units administered instead of 2 units as ordered; 1/25/12 at 11:00 AM - BS 108. 5 units administered instead of no insulin as ordered. 9) 1/26/12 at 7:00 AM: BS 122. 5 units administered instead of 2 units as ordered. 1/26/12 at 11:00 AM - BS 108. 5 units administered instead of no insulin as ordered. 1/26/12 at 5:00 PM - BS 115. 5 units administered instead of no insulin as ordered. 10) 1/27/12 at 7:00 AM: BS 154. 9 units administered instead of 4 units as ordered. 1/27/12 at 5:00 PM - BS 151. 9 units administered instead of 4 units as ordered. 11) 1/28/12 at 7:00 AM: BS 138. 5 units administered instead of 2 units as ordered. 1/28/12 at 11:00 PM - BS 128. 5 units administered instead of 4 units as ordered. 1/28/12 at 5:00 PM - BS 103. 5 units administered instead of no insulin as ordered. 1/28/12 at 10:00 PM - BS 132. No insulin administered instead of 1 unit as ordered. 12) 1/29/12 at 7:00 AM: BS 117. 5 units administered instead of O insulin as ordered. 1/29/12 at 11:00 AM - BS 92. 5 units administered instead of no insulin as ordered. 1/29/12 at 5:00 PM - BS 118. 5 units administered instead of no insulin as ordered. 13) 1/30/12 at 7:00 AM: BS 118. 5 units administered instead of no insulin as ordered. 1/30/12 at 11:00 AM - BS 88. 5 units administered instead of no insulin as ordered. 1/30/12 at 5:00 PM - BS 136. 5 units administered instead of 2 units as ordered. 14) 1/31/12 at 7:00 AM: BS 123. 5 units administered instead of 2 units as ordered. On 1/31/12 at 10:45 AM, Registered Nurse (RN) 4 was interviewed related to insulin orders above. RN 4 was unable to provide documentation that the physician was contacted to clarify the difference in the sliding scale orders. 5. Resident 77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 77's medical record was reviewed on 1/31/12. Review of the physician orders revealed an order received on 11/13/12 to administer "[MEDICATION NAME] R per medium sliding scale 1-50 units Subcutaneous (SQ) - Complex,: per medium sliding scale." Review of the blood sugar monitoring and insulin administration form revealed the facility LNS administered insulin according to the following medium sliding scale: a) AC: 81-150: 2 units; 151-200: 4 units; 201-250: 6 units; 251-300: 8 units; 301-350: 10 units; 351-400: 14 units; 401-450: 18 units. b) HS: 81-200: No insulin; 201-250: 2 units, 251-300: 4 units; 301-350: 5 units; 351-400: 7 units; 401-450: 10 units. c) The facility LNS documented the following BS, insulin administration without orders and did not notify the primary care physician: 1) 1/7/12 at 10:00 PM: BS 491. 10 units administered. 2) 1/12/12 at 11:00 AM: BS 589. 18 units administered. 3) 1/17/12 at 11:00 AM: BS 480. 18 units administered. 4) 1/21/12 at 11:00 AM: BS 471. 18 units administered. 5) 1/25/12 at 11:00 AM: BS 512. 18 units administered. 6) 1/20/12 at 5:00 PM: BS 488. 18 units administered. 7) 1/23/12 at 5:00 PM: BS 508. 18 units administered. 8) 1/24/12 at 5:00 PM: BS 465. 18 units administered. 9) 1/25/12 at 11:00 AM: BS 512. 18 units administered. 10) 1/26/12 at 10:00 PM: BS 501. 18 units administered. Review of the facility "Nurse's Notes" revealed an order received on 1/13/12 at 5:00 PM to increase [MEDICATION NAME] to 75 units SQ in the AM. On 1/30/12 at 3:20 PM, (Licensed Practical Nurse)LPN 1 was interviewed. LPN 1 stated she did not administer insulin as ordered to resident 77 as he had "already eaten." Review of the "Consultant Pharmacist's Medication Regimen Review" revealed that the pharmacist did not identify insulin irregularities during January, 2012. 6. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 10's medical record was reviewed on 1/31/12. Review of the physician's orders revealed an order to administer "[MEDICATION NAME] MEDIUM S/S Subcutaneous (SQ) - BETWEEN MEAL X3 (three times a day) Everyday, 0700 (7:00 AM) 1100 (11:00 AM) 1700 (5:00 PM): AC&HAS BS LEVELS MEDIUM S/S: 81-150: 2 units; 151-200: 4 units; 201-250: 6 units; 251-300: 8 units; 301-350: 10 units; 351-400: 14 units; 401-450: 18 units. IF BS ABOVE 251 CALL PHYSICIAN." Review of the blood sugar monitoring and insulin administration form revealed the facility LNS administered insulin according to the following medium sliding scale: a) AC: 81-150: 2 units; 151-200: 4 units; 201-250: 6 units; 251-300: 8 units; 301-350: 10 units; 351-400: 14 units; 401-450: 18 units. b) HS: 81-200: No insulin; 201-250: 2 units, 251-300: 4 units; 301-350: 5 units; 351-400: 7 units; 401-450: 10 units. (Note: The primary care physician did not order a separate sliding scale to be used at HS.) c) The facility LNS documented the following BS that were greater than 251 and did not document physician notification: 1) 1/5/12 at 11:00 AM: BS 427 2) 1/6/12 at 7:00 AM: BS 264 3) 1/7/12 at 11:00 AM: BS 253 4) 1/9/12 at 5:00 PM: BS 322 5) 1/12/12 at 7:00 AM: BS 464; 1/12/12 at 11:00 AM: BS 405; and 1/12/12 at 10:00 PM: BS 256. 6) 1/17/12 at 11:00 AM: BS 302 7) 1/18/12 at 5:00 PM: BS 389 8) 1/19/12 at 11:00 AM: BS 269 9) 1/24/12 at 10:00 PM: BS 410 10) 1/27/12 at 11:00 AM: BS 342 d) The facility LNS documented administering insulin on 1/12/12 at 7:00 AM for a BS of 464. 18 units of insulin was administered without a physician's order. e) The facility LNS documented the following blood sugar and insulin administration that was not according to physician orders: 1) 1/1/12 at 11:00 AM: BS 152. 2 units administered instead of 4 units as ordered. 2) 1/2/12 at 10:00 PM: BS 226. 2 units administered instead of 6 units as ordered. 3) 1/3/12 at 5:00 PM: BS 170. 2 units administered instead of 4 units as ordered. 1/3/12 at 10:00 PM: BS 191. No insulin administered instead of 4 units as ordered. 4) 1/4/12 at 10:00 PM: BS 158. No insulin administered instead of 4 units as ordered. 5) 1/5/12 at 10:00 PM: BS 173. No insulin administered instead of 4 units as ordered. 6) 1/6/12 at 10:00 PM: BS 170. No insulin administered instead of 4 units as ordered. 7) 1/7/12 at 10:00 PM: BS 111. No insulin administered instead of 2 units as ordered. 8) 1/8/12 at 10:00 PM: BS 207. 2 units administered instead of 6 units as ordered. 9) 1/9/12 at 10:00 PM: BS 242. 2 units administered instead of 6 units as ordered. 10) 1/10/12 at 10:00 PM: BS 226. 2 units administered instead of 6 units as ordered. 11) 1/11/12 at 10:00 PM: BS 180. No insulin administered instead of 4 units as ordered. 12) 1/12/12 at 7:00 AM: BS 464. 18 units was administered. (Note: the sliding scale ordered did not indicate how much insulin to administer for blood sugars that were greater than 450.) 1/12/12 at 10:00 PM: BS 256. 4 units administered instead of 8 units as ordered. 13) 1/13/12 at 10:00 PM: BS 141. No insulin was administered instead of 2 units as ordered. 14) 1/14/12 at 10:00 PM: BS 173. No insulin was administered instead 4 units as ordered. 15) 1/15/12 at 10:00 PM: BS 122. No insulin administered instead of 2 units as ordered. 16) 1/16/12 at 10:00 PM: BS 146. No insulin administered instead of 2 units as ordered. 17) 1/17/12 at 10:00 PM: BS 148. No insulin administered instead of 2 units as ordered. 18) 1/18/12 at 10:00 PM: BS 164. No insulin administered instead of 4 units as ordered. 19) 1/19/12 at 10:00 PM: BS 172. No insulin administered instead of 4 units as ordered. 20) 1/20/12 at 10:00 PM: BS 167. No insulin administered instead of 4 units as ordered. 21) 1/21/12 at 10:00 PM: BS 190. No insulin administered instead of 4 units as ordered. 22) 1/22/12 at 10:00 PM: BS 119. No insulin administered instead of 2 units as ordered. 23) 1/23/12 at 10:00 PM: BS 106. No insulin administered instead of 2 units as ordered. 24) 1/24/12 at 10:00 PM: BS 410. 10 units administered instead of 18 units as ordered. 25) 1/25/12 at 10:00 PM: BS 121. No insulin administered instead of 2 units as ordered. 26) 1/26/12 at 10:00 PM: BS 130. No insulin administered instead of 2 units as ordered. 27) 1/27/12 at 10:00 PM: BS 157. No insulin administered instead of 4 units as ordered. 28) 1/28/12 at 10:00 PM: BS 88. No insulin administered instead of 2 units as ordered. 29) 1/29/12 at 10:00 PM: BS 148. No insulin administered instead of 2 units as ordered. Review of the pharmacy consultant report completed by the facility pharmacist on 1/19/12, revealed "No irregularities". 7. Resident 145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 145's medical record was reviewed on 1/31/12. Review of the physician's orders revealed an order to administer "HUMALIN (sic) R MEDIUM S/S Subcutaneous (SQ) - BETWEEN MEAL X3 (three times a day) Everyday, 0700 (7:00 AM) 1100 (11:00 AM) 1700 (5:00 PM) BS SLIDING SCALE AS FOLLOWS: 81-150: 2 units; 151-200: 4 units; 201-250: 6 units; 251-300: 8 units; 301-350: 10 units; 351-400: 14 units; 401-450: 18 units. IF BS ABOVE 251 CALL PHYSICIAN." Review of the blood sugar monitoring and insulin administration form revealed the facility LNS administered insulin according to the following medium sliding scales: a) AC: 81-150: 2 units; 151-200: 4 units; 201-250: 6 units; 251-300: 8 units; 301-350: 10 units; 351-400: 14 units; 401-450: 18 units. b) HS: 81-200: No insulin; 201-250: 2 units, 251-300: 4 units; 301-350: 5 units; 351-400: 7 units; 401-450: 10 units. (Note: The primary care physician did not order insulin to be administered at HS) c) The facility LNS documented administering the following insulin at HS without an order: 1) 1/2/12: BS 282. 4 units was administered; 2) 1/15/12: BS 209. 2 units was administered; and 3) 1/18/12: BS 342. 5 units was administered. Review of the monthly "Consultant's Pharmacists Medication Regimen Review" revealed "No irregularities" identified during the month of January, 2012. 8. Resident 112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders revealed an order to administer "[MEDICATION NAME] R SLIDING SCALE Subcutaneous (SQ) - HS Everyday, 2000 (8:00 PM): LOW BETWEEN MEAL X3 (three times a day) Everyday, 0700 (7:00 AM) 1100 (11:00 AM) 1700 (5:00 PM) BS SLIDING DING SCALE: AC AS FOLLOWS: <200 = 0 UNITS, 201-250 = 2 UNITS, 251-300 = 4 UNITS, 301 - 350 = 6 UNITS, 351 - 400 = 8 UNITS, 401 - 450 = 12 UNITS. HS AS FOLLOWS: <60 = 0 UNITS/ 61-80 = 0 UNITS/ 81 - 150 = 0 UNITS/ 151 - 200 = 0 UNITS; 201 - 250 = 2 UNITS/ 251 - 300 = 3 UNITS; 301 - 350 = 4 UNITS/ 351 - 400 = 5 UNITS/ 401 - 450 = 6 UNITS/ > 450 CALL MD FOR ORDERS." Review of the blood sugar monitoring and insulin administration form revealed that the LNS did not check the blood sugar at 11:00 AM or 5:00 PM or administer insulin according to the AC sliding scale above. Review of the monthly "Consultant's Pharmacists Medication Regimen Review" completed on 1/26/12, revealed "No irregularities." 9. Resident 227 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 227's medical record was reviewed on 1/31/12. Review of the discharge orders from the hospital, documented an order to administer "Insulin [MEDICATION NAME] ([MEDICATION NAME]) 1 units subcutaneous 5 times per day". Review of the orders transcribed into the facility computer system revealed insulin to be given as "[MEDICATION NAME] R (Insulin Regular (Human)) 100 UNIT/ML Subcutaneous (SQ) - complex,: BS check q AC & HS; low S/S." (Note: There was no documentation available for review to indicate that the physician had ordered the S/S above.) Review of the blood sugar monitoring and insulin administration form revealed the facility LNS administered insulin according to the following low sliding scale: a) AC: 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; and 401 - 450 = 12 units. b) HS: 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units;

Based on record review and interview the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one sample resident. Specifically, a resident waited for nearly eight hours after a fall to be treated for [REDACTED]. Findings include: Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 21's medical record was reviewed on 1/26/11. On 10/7/11 a physician's orders [REDACTED]. Nurses' notes for resident 21 documented the following (Note: All entries were made by Registered Nurse 6): a) 10/16/11 at 11:30 PM " . . . able to make needs known. pt (patient) found by RN (Registered Nurse) on floor of bedroom at 2200 (10:00 PM). pt was below window in room and stated that she was going to get something from that side of the room. States that she didn't hit head and pt shows no s/s (signs/symptoms) of neuro (neurological) injury but neuro/vital sign checks are in place. pt had no socks or footwear on at time of incident and bed alarm was in place but not turned on. pt c/o (complained of) pain located on L (left) hip and given PRN (as needed) pain meds per MD (medical doctor) orders. Stat (immediate) x ray ordered to L hip r/t (related to) recent fall/pain and to r/o (rule out) fractures. . . pt has no visible injury r/t fall but c/o pain to L hip. . ." b) 10/17/11 at 3:45 AM "Pt xray report received-- 'Impression: 1) Acute, displaced and angulated left intertrochanteric [MEDICAL CONDITION]. . .' MD notified of results via text message. Will await instructions from MD." c) 10/17/11 at 5:45 AM "Message received from DON (Director of Nursing) to send (resident 21) to (local acute care hospital) ER (emergency room ) r/t hip fx (fracture). (Ambulance) called and pt sent to ER. . . Pt given PRN pain meds at 0420 (4:20 AM) and before transfer to ER stated that pain was 10/10 still." Resident 21's Controlled Drug Record and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 2/2/12 at 12:50 PM an interview was conducted with RN 6 regarding the incident that occurred with resident 21 on 10/16/11. RN 6 stated that as she entered resident 21's room, resident 21 was on the floor by the window. RN 6 stated that resident 21 reported she fell while trying to reach something and now was in extreme pain. RN 6 stated that she had been instructed by the DON to obtain an x-ray whenever a resident was in pain after a fall. RN 6 stated that she ordered the x-ray stat but that the x-ray technicians did not arrive at the facility for approximately four hours, which was "frustrating". RN 6 stated that she provided pain medication and an ice pack to resident 21 while they waited for the x-ray technicians to arrive. When asked about the delay in sending the resident to the emergency room , RN 6 stated that it was due to a delay in a response from the physician. RN 6 stated that she had attempted to text the physician but that he did not respond. RN 6 stated that resident 21 was "uncomfortable" and she could not give more pain medication than what was ordered or send the resident to the emergency room without the doctors approval. RN 6 stated that the physician usually responded "pretty well" before midnight, but that after midnight "it's a lot harder to get a response." RN 6 stated that she was finally able to contact the Director of Nursing (DON), who instructed her to send resident 21 to the local emergency room at 5:45 AM, nearly eight hours after resident 21 fell . On 2/2/12 at 9:00 AM an interview was conducted with the facility DON. The DON stated that if a resident has a known fracture, the nurse on duty should send the resident to the local emergency room immediately. The DON also stated that the nurse caring for resident 21 on 10/16/11 should not have waited for the physician to give permission to send the resident to the hospital.