Every finding on record at Red Cliffs Health and Rehab

Based on interview and record review, it was determined that for 2 of 10 sampled residents, that the facility did not ensure that the resident was given the appropriate treatment and services to maintain or improve their ability to carry our the activities of daily living. Specifically, residents were not provided bathing/shower assistance. Resident identifier: 1 and 5. Findings Included: On March 24, 2025, the surveyor interviewed Resident 1. Resident 1 stated that she was not receiving her scheduled showers from the facility and had occasionally gone a week without a shower. On March 25, 2025 the surveyor reviewed Resident 1's medical record, and the following entries were observed: A care plan dated August 8, 2024, revealed that Resident 1 had an ADL (Activities of Daily Living) self-care performance deficit and required substantial/maximal assistance with bathing/showering. Resident 1 ' s showers were scheduled twice a week. Shower documentation revealed the following: a. In February 2025, she received 2 showers and was missing 6 or 8 scheduled showers. [It should be noted that the resident's husband gave both showers.] b. In March 2025, she was offered/received 4 showers and was missing 3 of 8 scheduled showers. [It should be noted the resident's husband gave one of the showers documented.] On March 26, 2025, the surveyor interviewed Admin 3. Admin 3 stated that Resident 1's showers are twice a week, and staff should offer her a shower on the days she is scheduled to receive them; staff should document all showers and refusals. Admin 3 stated that Resident 1's husband would shower her on Saturday because Resident 1 felt like she was not getting her showers on her scheduled Sunday day. On March 25, 2025, the surveyor interviewed Admin 2. Admin 2 stated that if cares were not documented, then they were not completed. 2. On March 24, 2025, the surveyor reviewed Resident 5's medical records. Resident 5's medical records revealed that the only documented showers in January 2025 were on January 20 and 25th. The surveyor interviewed Admin 4 and Admin 5. Both staff members stated that resident showers were often missed. The facility was unable to locate documentation showing that showers were offered and/or completed on the missing dates for Residents 1 and 5.

Based on interview and record review, it was determined that for 1 of 10 sampled residents, that the facility failed to provided the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents who were unable to carry out activities of daily living. Specifically, a resident was not provided showers or oral care as scheduled. Resident identifier: 4. Findings Included: On March 24, 2025 the surveyor reviewed resident 4 ' s medical record, and revealed the following. Resident 4 had an ADL (activities of daily living) self care performance deficit related to paralysis of the left side and aphasia following a CVA (cerebrovascular accident) and requires substantial/maximal assistance with bathing/showering, and is DEPENDENT on staff for personal hygiene. Resident 4's showers were scheduled for twice a week, shower documentation revealed the following: a. February 2025, she received 2 showers, missing 6 out of 8 showers. b. March 2025 she received 3 with one documented as a refusal with the reason of no soap, missing 4 out of 7 showers. Resident 4's medical record revealed she required oral care to be complete daily morning and night, documentation revealed the following: a. March 2025 POC (Point of Care) Response History of the Tasks: ADL- Bathing section revealed she missed at least one or both of her twice daily oral care for 22 out of 25 days reviewed. On March 25, 2025 the surveyor interviewed Admin 6. Admin 6 stated that resident 4 required assistance with all cares. On March 25, 2025 the surveyor interviewed Admin 7. Admin 7 stated that each resident has a scheduled shower that should be completed, time a resident is showered, a shower sheet was filled out and placed in a binder as well as documented in the residents POC. If this was not documented in either place it probably was not completed. On March 25, 2025 the surveyor interviewed Admin 2. Admin 2 stated that if cares were not documented then it was not completed. The Admin 2 was unable to locate documentation showing showers and oral care was offered and/or completed on the missing dates for resident 4.

Based on interview and record review it was determined, for 4 of 53 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident sustained multiple falls with one resulting in a fracture, a resident transported in the facility vehicle was not properly secured and sustained a fall with injury. These findings were cited at a harm. In addition, a resident with wandering behaviors, eloped from the facility and a resident was not secured in their wheelchair and sustained a fall. Resident identifiers: 5, 18, 367, and 374. Findings Included: 1. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. Resident 5's medical record was reviewed on 6/3/24 thru 6/6/24. On 5/2/24, a State Optional Minimum Data Set (MDS) documented resident 5 was a two-person extensive assist with transfers, toileting and bed mobility. On 4/4/24, a Quarterly MDS documented resident 5 had a Brief Interview for Mental Status [BIMS] score of 1 which indicated severe cognitive impairment. There was no information located under the mobility section for functional abilities. A care plan focus area initiated on 8/11/23 documented resident 5 was at risk for falls related to impaired mobility and confusion secondary to Dementia/Alzheimer's. The listed interventions included: 1. Fall mattress in place. This was initiated on 8/25/23. 2. Bed in the lowest position and locked in place whenever resident 5 was in bed. This was initiated on 12/27/23. A care plan focus area initiated on 8/28/23 and resolved on 10/19/23 documented resident 5 had an unwitnessed fall on 8/25/23 resulting in bruising/swelling to right lower leg. Resolved interventions included: 1. Educated CNA's (certified nursing assistant) about safety protocols related to falls. 2. Fall mattress in place. On 10/15/23, a post fall Morse Fall Scale documented resident 5 had scored 75 which indicated they were a high fall risk. The document stated resident 5 had an impaired gait and overestimated/forgot limitations. Resident 5's progress notes and facility incident reports were reviewed and documented the following falls: a. On 8/25/23 at 12:25 PM, a late entry fall note documented, Per floor nurse: Resident found by CNA [certified nursing assistant] on floor. Bruising noted to right lower leg, under her shin. Resident unable to explain what happened. Fall assessment completed. Hospice notified regarding fall, waiting for further orders. b. On 8/25/23 at 3:50 PM, a facility incident report documented resident 5 had an unwitnessed fall in their room. The nursing description of the incident report documented, Pt [patient] was found by the CNA's on the floor next to the bed with her right leg tucked under her left leg. She was not crying out in pain. Pt reported no injury. CNA placed pt back in bed with assessment completed after movement to bed: she has a large bruise to the right lower leg under her shin. The Immediate actions taken included education on fall safety protocol and hospice had been notified of the fall. It documented the facility was waiting for an update from hospice on how to proceed post fall. A Pain Assessment in Advance Dementia (PAINAD) was done and documented resident 5's pain post fall was a 2 which indicated mild pain. The predisposing physiological factors listed included impaired memory, opioid therapy, antianxiety therapy and hospice patient. Confusion. The Predisposing situation factors listed included inadequate communication and side rails up. Resident 5's mental status was documented as oriented to person. c. On 12/26/23 at 8:53 AM, a nurse note documented, Pt [patient] was found on the floor next to her bed sitting on her bottom. Pt was in bed being combative hitting out at staff 15 minutes prior to this incident when staff was trying to change pt brief. EMT [emergency medical technician] was contacted and pt was transported to the ER [emergency room ] where it wasdetermined [sic] pt has a fractured femur and tibia. Hospital is going to monitor pt overnight to determine surgery needs. Dr [doctor] notified at 12pm. Voice mail left for POA [power of attorney]. POA was determined to be deployed in saudi [NAME] and wife [name removed] POA at the moment. [name removed] spoke with hospital and the Dr will be in touch with her tomorrow. d. On 12/26/23 at 11:35 AM, a facility incident report documented resident 5 had an un-witnessed fall in their room. The incident report description stated resident 5 had been unable to give a description of their fall. The nursing description documented resident 5 had been found on the floor next to their bed on their bottom. It documented resident 5 had been combative with staff during a brief change, 15 minutes before the fall. Resident 5 was taken to the hospital and was required to stay overnight due to having a fractured femur and tibia and needing possible surgery. Resident 5's power of attorney was notified of the fall. The incident report documented no injuries had been observed post incident. The predisposing physiological factors listed included confusion and impaired memory. The predisposing situational factors listed included physical aggression and refusing 1 on 1 help. Resident 5 was documented to be a total assist with transfer. A Pain Assessment in Advance Dementia (PAINAD) was done and documented resident 5's pain post fall was a 10 which indicated severe pain. e. On 12/28/24 at 5:33 PM, a nurse note documented, Resident is admitted from [local hospital] around 1424pm [2:24 PM] via [name removed] ambulance on gurney. She is alert but weak and pale looking .Has R [right] lateral thigh surgical site with steri strips and covered with clear dressing. She has 2 little site with dressing. No bleeding noted. She is going to be on [name removed] hospice care and confirmed by daughter in law on the phone . On 12/26/23 at 11:35 AM, a facility incident report documented resident 5 had an un-witnessed fall in their room. The incident report description stated resident 5 had been unable to give a description of their fall. The nursing description documented resident 5 had been found on the floor next to their bed on their bottom. It documented resident 5 had been combative with staff during a brief change, 15 minutes before the fall. Resident 5 was taken to the hospital and was required to stay overnight due to having a fractured femur and tibia and needing possible surgery. Resident 5's power of attorney was notified of the fall. The incident report documented no injuries had been observed post incident. The predisposing physiological factors listed included confusion and impaired memory. The predisposing situational factors listed included physical aggression and refusing 1 on 1 help. Resident 5 was documented to be a total assist with transfer. A Pain Assessment in Advance Dementia (PAINAD) was done and documented resident 5's pain post fall was a 10 which indicated severe pain. An exhibit form 358 was submitted to the State Survey Agency (SSA) on 12/26/23 at 11:30 AM. The exhibit documented resident 5 had a fall with injury and staff had become aware of the incident on 12/26/23 at 11 AM. The exhibit documented resident 5 had fallen in their room and the suspected injury had either been a hip fracture or dislocation. Resident 5 was sent to the emergency for evaluation and treatment due to the injury obtained. On 12/26/23 at 1:51 PM, a hospital history and physical report documented resident 5 had arrived to the emergency room with right hip pain after being found down bedside their bed. It documented, Upon arrival, EMS [emergency medical services] reported an obvious deformity of her right hip/pelvis and possible deformity of her right knee. An exhibit form 359 was submitted to the SSA on 1/2/24 at 1:15 PM. The additional information section of the exhibit form documented a hip fracture had been confirmed. The X-ray report showed that resident 5 had sustained a closed fracture proximal end of femur. The witness interview summary documented the fall had not been witnessed. It documented the certified nursing assistant (CNA) had gone in to change resident 5's brief minutes earlier and resident 5 was being combative. The CNA stopped the brief change and went to find additional help. When the CNA returned with a nurse, resident 5 was found sitting on the floor. A staff interview documented resident 5 had been very confused and restless and must have either rolled off the bed or tried to stand up. Resident 5's CNA for the shift stated the bed was in the low position and the fall mat had been in place when they arrived on shift. It documented when the CNA returned to resident 5's room at 11 AM, the fall mat was not in place, but the bed was still in the low position. The CNA raised the bed to change resident 5's brief but resident 5 became combative. The interview documented the CNA had lowered resident 5's bed to close to the lowest position and stepped into the hall to get assistance. It documented the CNA heard resident 5 fall and entered the room to find resident 5 on the floor. The investigation documented there was no perpetrator identified for the incident. The investigation concluded the allegation of a fall with an injury had been verified and documented, resident 5's care plan stated that here should be a floor mat. Even through (sic) the CNA only left the room quickly to get assistance and did lower the bed, the floor mat was not in place. Corrective actions implemented after the investigation included a point of care task for CNAs to ensure the floor mat was in place and one on one CNA education/training regarding fall mats and other interventions. On 6/5/24 at 9:41 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated resident 5 was dependent on all cares. CNA 5 stated resident 5 was bedbound and was unable to walk. CNA 5 stated resident 5 was a fall risk but they were unsure if resident 5 had any falls. CNA 5 stated resident 5's bed was put in the lowest position and they had a fall mat next to their bed. On 6/5/24 at 11:09 PM, an interview was conducted with CNA 7. CNA 7 stated resident 5 was a total care resident. CNA 7 stated resident 5 was able to make their needs known occasionally. CNA 7 stated resident 5 had a fall mat because they climbed out of bed. CNA 7 stated resident 5 was a fall risk and they had interventions in place such as a fall mat, bed in the lowest position, frequent checks and having resident 5 in the day room with staff. CNA 7 stated they were sure resident 5 had been injured due to previous falls. On 6/6/24 at 7:57 AM, an interview was conducted with CNA 17. CNA 17 stated resident 5 was mentally out of it. CNA 17 stated resident 5 frequently rolled themselves out of bed. CNA 17 stated the resident was placed in the day room during the day so staff was able to observe them often. On 6/6/24 at 7:49 AM, an interview was conducted with CNA 12. CNA 12 stated resident 5 was confused. CNA 12 stated depending on how resident 5 was feeling during the day, they needed to have a second staff member with them during resident cares. CNA 12 stated they usually rounded on resident's every two hours. CNA 12 stated resident 5 was a fall risk and needed a hoyer lift for transfers. CNA 12 stated resident 5 was a fall risk and had interventions in place such as a fall mat, bed in the lowest position, and frequent checks. CNA 12 stated they were aware resident 5 had falls in the past but they were unsure of the severity of the falls. On 6/6/24 at 8:12 AM, an interview was conducted with CNA 18. CNA 18 stated resident 5 was a total assist and was a two-person hoyer lift with transfers. CNA 18 stated resident 5's dementia was so severe they were unable to recall the date. CNA 18 stated resident 5 was unable to express their needs. CNA 18 stated resident 5 was a fall risk because they forgot they were unable to bear weight and tried to stand. CNA 18 stated if resident 5 was in bed, staff made sure resident 5's bed was in the lowest position with the fall mat in place. CNA 18 stated resident 5 was put in high traffic areas near staff so staff always had eyes on resident 5. CNA 18 stated resident 5 had a fall about 5 months ago where they messed their leg up. CNA 18 stated they had heard details about the fall and stated whoever resident 5's aid was at the time, left the resident's room to find help. CNA 18 stated resident 5 fell and landed on her hip in the short time the aid had left to find help. On 6/6/24 at 8:32 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated they looked in the care plan to see what interventions were put in place to prevent a resident from falling. LPN 3 stated resident 5 had a fall where something was fractured. LPN 3 stated interventions for resident 5 were frequent two-hour checks, bed in the low position and the floor mat. LPN 3 stated resident 5 was confused and when resident 5 was in the day room they needed to monitor them. On 6/6/24 at 9:38 AM, an interview was conducted with the Resident Advocate (RA). The RA stated resident 5 required a bit of help from staff and was dependent for most of their cares. The RA stated resident 5 was wheelchair bound. The RA stated they believed resident 5 was a high fall risk. The RA stated fall interventions included the bed in the lowest position and fall mats if the residents crawled out of bed. The RA stated they were unsure if resident 5 had any falls with injury. On 6/6/24 at 10:31 AM, an interview was conducted with the Assistant Director of Nursing (ADON) 1. The ADON 1 stated resident 5 was able to reposition themselves while in bed and they were able to roll out of bed. The ADON 1 stated resident 5 was unable to get out of bed safely. The ADON 1 stated resident 5 had fall interventions that included the bed in the lowest position and the fall mat on the floor when resident 5 was in bed. The ADON 1 stated resident 5 had rolled out of bed and broken their hip. The ADON 1 stated they were unsure of the specific details of the fall. The ADON 1 stated they assisted resident 5's nurse after the resident had fallen. The ADON 1 stated they remembered seeing resident 5 on the floor and the fall mat was stood up against the wall. The ADON 1 stated they were unsure if the emergency medical technicians had moved it out of the way to assist resident 5. 38031 2. Resident 374 was admitted to the facility on [DATE] with a diagnosis of vascular dementia. On 6/3/24, resident 374's medical records were reviewed. On 11/6/23, resident 374's Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 5/15, which would indicate a severe cognitive impairment. On 11/16/23, resident 374's Montreal Cognitive Assessment (MOCA) score was 8/30. A score of less than 10 indicated a severe cognitive impairment. Resident 374's progress notes documented the following: a. On 11/1/23 at 3:17 PM, the admission note documented that resident 374 wandered at times and required redirection. The mental status documented that the resident was alert and confused at baseline. b. On 11/8/23 at 11:57 AM, the social service note documented that resident 374 .BIMS score shows he is severely impaired with a score of 5. PTs [patients] goal is to maintain his quality of life while being care for in a safe environment. c. On 2/21/24 at 4:30 AM, the nurse note documented, PT [patient] assisted another resident in an elopement attempt (1900) last night. PT was redirected and instructed to ask us for help when a resident wants to know the location of the exits. PT was monitored by staff, no further incidents noted. d. On 2/25/24 at 10:30 AM, the nurse note documented, Resident became aggressive with staff when staff attempted to guide him out of other residents's (sic) rooms. e. On 2/28/24 at 7:04 AM, the nurse note documented, Resident appears to be more confused, wandering into other Residents rooms. f. On 3/16/24 at 7:24 PM, the alert note documented, Elopement: Resident remains on elopement precautions. He has been in the hallway, in his room, at the nurse station and in the activity room. Resident has not demonstrated seeking to leave. Doorbell checks on going all day continue for safety and elopement prevention. g. On 3/22/24 at 5:59 AM, the nurse note documented, Resident is with ongoing monitoring for elopement. He is wandering around the facility. He is alert but with episodes of confusion. He is forgetful and always loose (sic) his cellphone. He is able to ambulate. Will continue monitor resident. h. On 3/23/24 at 6:40 AM, the nurse note documented, Resident is on continues (sic) 15 minutes monitoring due to elopement. He is ambulatory and with confusion. Resident eats in the dining area with supervision, is continent of bowel and bladder. Will continue monitor resident. i. On 4/3/24 at 3:50 AM, the nurse note documented, resident remains on elopement precautions per facility protocol. resident currently resting in bed with eyes closed. re orientation provided regarding residents (sic) room and facility. frequent reminders provided by staff. will continue to monitor closely. j. On 4/3/24 at 2:48 PM, the nurse note documented, Pt [patient] did exit the facility and got out to the parking lot area. He was followed out to the parking lot by multiple staff members, to which he was verbally aggressive towards. He then proceeded to go across the street when this nurse went inside to get pt sisters' number. The nurse he was with was shoved by pt as she was attempting to redirect him back into the building. Pt was not being cautious of traffic as he was crossing the street and was ignoring the nurse he was with as she was trying to keep him safe from traffic. Pt was attempting to go into the building across the street and the other nurse was blocking the door to the building to which he was forcefully trying to open and move nurse. A male staff member came over and was able to redirect pt back into the building. Sister aware as well as dr [doctor]. k. On 4/4/24 at 11:06 AM, the nurse note documented, Upon being notified of resident exiting facility, staff immediately went to ensure safety and found him a short distance off of property, and across the street. Resident redirected and calming communication initiated, and safe escort back into facility. Frequent checks and monitors initiated, per protocol. Family notified. Cause of resident being able to exit was sought after and identified that he was able to get out of door with no alert system due to the door being propped open. This was fixed and staff was educated on not propping door open, and re-edcuated (sic) on the door alarm system function. Future placement for resident in another facility with designated memory care unit has been initiated. l. On 4/13/24 at 5:28 PM, the alert note documented, Resident attempted to exit out of the front of the building before being stopped by the CNA's [Certified Nurse Assistant]. He then snuck out the back and made it out to the road. We wee (sic) able to redirect him back to the building. m. On 4/19/24 at 3:44 PM, the alert note documented, New behavior observed. Resident is forgetful and confused. Leaving valuable belongings such as wallet and cellphone and will approach staff to help him. He roams around the facility Monitors his whereabouts and redirect resident if needed. n. On 4/24/24 at 11:02 AM, the nurse note documented, PT had an episode of elopement. PT walked out of facility to the main road and up to the stores. An aide asked for assistance so I left the facility and ran towards the road where I met her. I saw the resident up the road about 1/4 mile. I continued to run where I was in earshot so I could try and get his attention. I asked him where we were going and he said to go away, go back, and don't touch me. I continued to keep my distance as we walked into the store where he wandered and looked for a restroom. At this time I contacted the ADON's [Assistant Director of Nursing] to let them know where I was. I showed him the bathroom; he went in and used the bathroom. After he used the bathroom he started to walk out of the facility, again I followed at a distance when the ADON showed up. She told me to head back to the facility. o. On 4/25/24 at 1:17 AM, the alert note documented, Due to recent elopement and physical attack on a CNA, resident is on a 1 to 1. Resident wondered [sic] around the facility with a 1 to 1 then went to bed where he has been asleep without any issues. p. On 4/25/24 at 8:41 PM, the alert note documented, Elopement: Resident was on a 1 to 1 observation for several hours today where he wondered [sic] around the facility with a 1 to 1. However, there were short periods of time when he disappeared into other pt rooms. I found him inside the door of 414 sitting in a chair eating a small chocolate bar she gave him. She was not alarmed. He went into rm [room] 403 and scared resident A there, as she reported this to me, and that no contact was made. [Resident 374] was compliant with his med [medication] regimen today. He ate adequate amounts at meals. He remained calm and pleasant. He did not leave the building. On 10/30/23, the Additional Admission Assessment documented under Wander Risk Scale that the resident was a low risk for wandering. On 11/16/24, resident 374's care conference documented, nursing stated that PT has had no recent falls but that he does wander so the concern would be if he got out. On 11/30/23, the physician communication form documented a concern was Pt has exited the facility multiple times while exit seeking. Exit seeking is daily occurrence now. New order documented, tell family he needs lock down memory care. On 3/12/24, the wander risk scale documented a score of 19, which indicated a high risk to wander. The assessment documented the resident was ambulatory, could not follow instructions, had a history of wandering, had a medical diagnosis of dementia, had wandered within the home without leaving the grounds, and had wandered in the past month. The community risk assessment documented that resident 374 did not know the address or phone number, was not aware of basic traffic/pedestrian laws, was not aware of surroundings and safety, was not able to make his own medical decisions, and was not able to remember to sign out. The elopement assessment documented that resident 374 was not safe independently in the community, but the care plan was not updated. On 4/3/24, resident 374's incident report documented that the Staff was notified by separate resident of another resident who exited building and was seen heading away from the facility. Staff immediately left to locate resident and found him of premise a short distance from facility. Resident began aggressive verbal behavior and staff called from [sic] additional staff assistance. Multiple staff then escorted resident back into facility to ensure safety. The incident report documented that resident 374 was confused, had an impaired memory, and was an active exit seeker. On 11/6/23, resident 374 had a care plan initiated for at risk for impaired safety related to wandering, vascular dementia, and confusion. Interventions identified included to anticipate the needs of the resident as much as possible; resident 374 enjoyed walking up and down the halls, sitting in the lobby looking out the window and working out in the therapy room; calmly redirect and cue as needed related to wandering; and monitor for significant changes in behavior. On 3/8/24, resident 374 had a care plan initiated for elopement risk/wanderer related to dementia. Interventions identified included assess for a fall risk; distract from wandering by offering pleasant diversions, structured activities, food, conversation, television and books; door bell/sensor installed on main doors to alert staff when opened; and monitor for fatigue and weight loss. On 3/6/24, the 24 hour every 15 minute safety checks were initiated for resident 374. The safety sheet revealed incomplete documentation for the 15 minute checks from midnight through 11:45 AM, from 4:45 PM through 5:15 PM, and at 6:45 PM. On 3/7/24, the 24 hour every 15 minute safety check sheet for resident 374 revealed incomplete documentation from midnight through 5:45 AM. On 3/13/24, the 24 hour every 15 minute safety check sheet for resident 374 revealed incomplete documentation from 6:15 AM through 5:45 PM. On 3/14/24, the 24 hour every 15 minute safety check sheet for resident 374 revealed incomplete documentation from midnight through 5:45 AM, and from 2:00 PM through 11:45 PM. On 3/16/24 and 3/17/24, the 24 hour every 15 minute safety check sheet had both dates documented on the form. The safety sheet had incomplete documentation from 6:15 AM through 5:30 PM. On 3/21/24, the 24 hour every 15 minute safety check sheet for resident 374 revealed incomplete documentation from midnight through 5:45 AM, and from 5:00 PM through 11:45 PM. On 3/25/24, the 24 hour every 15 minute safety check sheet for resident 374 revealed incomplete documentation from 10:00 AM through 11:45 PM. It should be noted that no documentation could be found of the 24 hour every 15 minute safety checks for 3/9/24, 3/10/24, 3/11/24, 3/15/24, 3/18/24, 3/19/24, 3/20/24, 3/22/24, 3/23/24, and 3/24/24. Additionally, no documentation could be found of the 24 hour safety checks for resident 374 after 3/25/24 until his discharge on 4/26/24. On 6/04/24 at 9:46 AM, an interview was conducted with CNA 11. CNA 11 stated that resident 374 was confused and had dementia. CNA 11 stated he would hear resident 374 ramble and say stuff that would not make sense. CNA 11 stated that resident 374 had sudden outbursts of aggression with staff. CNA 11 stated that resident 374 had exit seeking behaviors and some of the nurses would report that he exited the building. CNA 11 stated that resident 374 was found outside the building a few times. CNA 11 stated that when they would try to bring resident 374 inside he would become aggressive. CNA 11 stated that if a resident was high risk for elopement they checked their location every 15 minutes and charted it to make sure they were in a safe area. CNA 11 stated that the facility did not have a wander guard system. CNA 11 stated that the side door chimed when opened they were supposed to check it. On 6/04/24 at 9:58 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that an elopement was when a resident had left the facility grounds or when they go outside intending to leave. LPN 1 stated that a resident was determined to be high risk for elopement based on assessing multiple incidents of exit seeking behavior or actual elopements from the facility. LPN 1 stated that staff precautions for exit seeking behaviors were to move the resident closer to the nurse's station, conduct hourly rounding by the Certified Nurse Assistant (CNA) and nurses, training on re-direction or activities to distract, de-escalation techniques, and administering ordered medications to help with agitation and anxiety. If you see them walking around with their bag it's a good indication that they are trying to exit seek. LPN 1 stated that if a resident was placed on 1:1 monitoring the staff would need to have eyes on the resident at all times, and they would have a dedicated and assigned staff. LPN 1 stated that if the resident was on every 15 minute safety checks the staff would frequently check on the resident's location. LPN 1 stated that they had pictures of the residents that had exit seeking behaviors posted in the staff break room to alert the staff of who needed monitoring. LPN 1 stated that they also relayed this information during shift report and it was located in the resident's chart. LPN 1 stated that they had received training on de-escalating techniques upon hire and during all staff meetings. On 6/04/24 at 10:07 AM, an interview was conducted with CNA 12. CNA 12 stated that resident 374 was exit seeking and usually was trying to find a bathroom or to find his way home. CNA 12 stated that they would re-direct resident 374 or offer a snack or drink. CNA 12 stated they would walk with resident 374 and take him outside for fresh air. CNA 12 stated that resident 374 would respond to having a cup of coffee, but did not like to be told what to do. CNA 12 stated that resident 374 could get aggressive and responded better to male staff. CNA 12 stated that resident 374 had exited the building 2-3 times. CNA 12 stated that safety monitoring included having a staff member with resident 374 at all times. CNA 12 stated that they mostly checked on resident 374 every 15 minutes and would ask over the radio if anyone had eyes on him. CNA 12 stated that the nurse documented resident 374's wandering, but the CNAs did not document for the 15 minute checks. CNA 12 stated that resident 374 was alert and confused with short-term and long-term memory deficits. On 6/04/24 at 12:35 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that an elopement was when a resident was off the property without a staff member or someone having eyes on them. The RA stated that those residents who were at risk for elopement were posted in the room behind the nurse's station, and they had visual checks completed hourly. The RA stated that resident 374 was a known elopement risk and would try to exit the facility. The RA stated that she was not sure when resident 374's exit seeking behaviors started, but he had been a known risk for awhile before he was discharged . The RA stated that she spoke to resident 374's family member and was informed that he was not safe at home and had previously gone to the grocery store and could not find his way home. The RA stated that resident 374 had cognitive deficits that made him not safe in the community without supervision. The RA stated that she was aware of resident 374 exiting the facility off property only once. The RA stated that staff found him and by the time they got to him he was across the road. On 6/04/24 at 2:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that an elopement was when a resident left the facility unsupervised and they did not have the capacity to do that. The DON stated that a wander risk assessment should be completed upon admission and quarterly for every resident, and based upon the assessment they would care plan it and put alerts in place. The DON stated that they had photos on the elopement risk wall in the medication room, and the nurse or aide had to round on that patient every hour or more frequently if needed. The DON stated that the room was accessible by all staff. The DON stated that if a resident was on a 1:1 safety check they had a dedicated staff with eyes on the resident at all times. The DON stated that if a resident was on every 15 minutes safety checks staff had to see where the resident was located every 15 minutes, and the check needed to be signed by the staff on the form. The DON stated that the purpose of the form was to have accountability to ensure the resident was safe. The DON stated that the facility did not have a wander guard system. The DON stated they had a doorbell that chimed when the door was opened. The DON stated that they had set the chime to alert during the evening hours after the day shift staff had left the building. The DON stated when the door was opened it would chime at the nurse's station. The DON stated that the door bell was implemented as an intervention around the first part of March 2024 and this was a [TRUNCATED]

Based on interview and record review, the facility did not ensure, for 3 of 53 sampled residents, were free of significant medication errors. Specifically, a resident was given linezolid for more days than what was ordered by the hospital, narcotics were given outside of physician ordered parameters, and lorazepam was given more often than what was ordered. Resident identifiers: 41, 50, and 372. Findings Included: 1. Resident 41 was admitted to the facility on [DATE] and again on 4/9/24 with diagnoses which include chronic respiratory failure with hypoxia, functional quadriplegia, obstructive pulmonary disease, neuromuscular dysfunction of bladder, protein-calorie malnutrition, protein-calorie malnutrition, contracture of muscle, rheumatoid arthritis, bed confinement status, urinary tract infection, pyelonephritis, resistance to multiple antibiotics, dependence of supplemental oxygen, acute respiratory failure, anemia in chronic kidney disease, heart failure, major depressive disorder, obstructive sleep apnea, anxiety disorder, insomnia, muscle weakness, and presence of automatic cardiac defibrillator. On 6/2/24 at 3:45 PM, an interview with resident 41 was conducted. Resident 41 stated that she had to go to the hospital on 4/1/24 because she had acute blood loss. Resident 41 stated that prior to her hospitalization while taking Linezolid, she had felt fatigued, confused, and had dark stools. Resident 41 stated that her hair had fallen out due to the acute blood loss. Resident 41's electronic medical record was reviewed. Hospital records dated 3/1/24 documented that resident 41 was admitted to the hospital on 3/1/24 with a primary diagnosis of sepsis secondary to a urinary tract infection (UTI). The hospital records revealed that resident 41 was discharged from the hospital on 3/9/24. Hospital discharge orders from 3/9/24 were reviewed. Linezolid 600 milligrams (mg) oral tablet was ordered with instructions that stated, 1 tabs (600 mg) Oral BID [twice a day] for 14 days. A review of resident 41's Medication Administration Records (MAR) revealed that resident 41 was given Linezolid Oral Tablet 600 MG twice a day from 3/9/24 to 4/1/24. It should be noted that the hospital orders for linezolid had instructions that stated, Oral BID for 14 days and the resident 41 received the medication for 23 days. Resident 41 received 17 extra doses of linezolid that were not ordered from the hospital discharge orders. A Nurses Note from 4/1/24 at 8:40 PM documented, resident co [complains of] feeling dehydrated. bp [blood pressure] 95/57 hr [heart rate] 97 o2 [oxygen] sat [saturation] 94%. Temp [temperature] wnl [within normal limits]. Primary care physician notified 500ml [milliliter] bolus of normal saline given over one hour as per md [medical director] order instructions. resident tolerated well. will continue to monitor closely. A Nurses Note from 4/1/24 at 10:35 PM documented, resident continues to c/o upset stomach and generalized malaise. bp no 85/45 hr 117 md notified and resident request to go to ER [emergency room ]. MD notified. EMT [emergency medical technician] transferred resident to ER at this time. will continue to monitor closely for updates on condition. family is on phone and aware of transfer. Hospital records from 4/2/24 documented, .In the emergency room : [NAME] blood cell count was 2.9 with ANC [absolute neutrophil count] at 1200. Platelet count was 18. Hemoglobin was 4.7 . In the emergency room , 2 units of packed red blood cells were ordered and 1 unit of platelets .She was admitted to the hospitalist service for medical management .She presents with 2 days of dark stool in conjunction with low hemoglobin, platelets, and neutrophils. She recently completed a 2-week course of treatment with linezolid. I suspect she has myelosuppression from linezolid leading to thrombocytopenia/anemia and subsequent gastrointestinal bleeding .She will be admitted to the intermediate care unit for careful evaluation . On 6/5/24 at 12:11 PM, an interview with the Regional Nurse Consultant (RNC) was conducted. The RNC stated that it looked like whoever entered the order for the medication did not put an end date, and the medication was given until 4/1/23. 30563 2. Resident 372 was admitted to the facility on [DATE] and readmitted on [DATE] and discharged on [DATE] with diagnoses which included palliative care, chronic respiratory failure, diastolic heart failure, obesity, and respiratory failure. Resident 372's medical record was reviewed 6/2/24 through 6/6/24. A Physician's Visit for follow up after a hospitalization dated 5/5/23 revealed no orders for Lorazepam. A hospice History and Physical dated 6/7/23 revealed no orders for Lorazepam. A hospice physician's order dated 6/12/23 revealed emergency kit as directed Lorazepam 2 mg/milliliters (ml) 0.5 ml by mouth (PO)/sublingual (SL) every 4 hours for anxiety as needed (PRN). A nursing progress note dated 9/20/23 at 9:09 AM revealed, Pt [patient] is requesting Lorazepam be scheduled. Called an (sic) notified hospice about patient's request. They stated to go ahead and have it scheduled. Scheduled for 6 times a day 4hrs [hours] apart and PRN q [every] 4 if needed during hours of sleep. Pt has been notified of change and state that she was happy cause she doesn't have to remember to ask the nurse to bring it in. A physician's order dated 9/21/23 and discontinued on 9/26/23 revealed Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 4 hours for anxiety, nausea, hold for sedition Do not wake up to give medication. A nursing progress note dated 9/26/23 at 12:31 PM revealed, Hospice nurse [name removed] came in to see patient today, gave verbal orders to update medication. Lorazepam TID [three times a day] and Bisacodyl 5mg BID [twice daily]. A Hospice physician's order dated 9/20/23 and signed by a facility nurse on 9/26/23 revealed Lorazepam 2 MG/ml give 0.5ml TID for anxiety. Hold for excessive sedation. A physician's order dated 9/26/23 and discontinued on 10/4/23 revealed, Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth three times a day for anxiety, nausea, hold for sedition Do not wake up to give medication. A hospice order dated 10/4/23 revealed resident was to have Lorazepam scheduled TID discontinued and schedule Lorazepam 2MG/ml concentrate take 0.5 ml by mouth at bedtime. A physician's order dated 10/4/23 and discontinued 10/17/23 revealed Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 4 hours as needed for anxiety, nausea, hold for sedation. On 6/5/24 at 9:21 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated staff coordinated with a hospice nurse and team by contacting the hospice agency or nurse directly. LPN 1 stated the hospice nurse evaluated residents weekly and brought signed orders by the hospice physician. LPN 1 stated hospice provided all the supplies, medications, and refills if needed. LPN 1 stated if there was a narcotic, the order was sent to the pharmacy directly. LPN 1 stated the hospice nurse provided a paper copy of the physician's order to the nurse or was faxed to the facility. On 6/5/24 at 9:40 AM, an interview was conducted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC). The RNC stated the hospice nurse faxed physician's orders or provided a verbal physician's orders to nurses. The RNC stated the physician orders were faxed to the pharmacy to get the medication filled. The RNC stated Lorazepam medication would require a written physician order. On 6/6/24 at 9:11 AM, a follow-up interview was conducted with the RNC. The RNC stated the orders were entered into the electronic medical record wrong. The RNC stated physician's orders should have been for three times a day from 9/20/23 through 9/26/23. The RNC stated the Lorazepam order should not have been scheduled for every 4 hours. 38031 3. Resident 50 was admitted to the facility on [DATE] with diagnoses which included palliative care, chronic obstructive pulmonary disease, anxiety disorder, viral hepatitis, epilepsy, low back pain, hypertensive heart disease, neuromuscular dysfunction of the bladder, hemiplegia, insomnia, chronic pulmonary embolism, and osteoarthritis. On 6/02/24 at 2:41 PM, an interview was conducted with resident 50. Resident 50 stated that he had pain in his back and he had to wait for his pain medication. Resident 50 stated that when it was given on time the pain was managed and controlled. Resident 50 stated that he had an order for Oxycodone 10 milligrams (mg) that was scheduled every 4 hours and as needed. Resident 50 stated that sometimes the 4:00 AM dose was delayed to 6:00 AM or 7:00 AM. On 6/3/24, resident 50's medical records were reviewed. On 11/1/22, resident 50 had Oxycodone 10 mg every 4 hours for chronic pain ordered. Resident 50's administration time for the Oxycodone 10 mg in May 2024 revealed the following: a. On 5/5/25, the medication was documented as administered at 3:01 AM, 5:04 AM, 8:04 AM, and 11:21 AM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. b. On 5/6/24, the medication was documented as administered at 5:06 AM and 7:06 AM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. c. On 5/7/24, the medication was documented as administered at 4:16 AM, 7:15 AM, 2:25 PM, 4:53 PM, and 7:18 PM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. d. On 5/8/24, the medication was documented as administered at 4:50 AM, 7:37 AM, 4:58 PM and 7:43 PM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. e. On 5/9/24, the medication was documented as administered at 5:34 AM, 7:57 AM, 11:44 AM, 4:16 PM, and 7:23 PM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. d. On 5/10/24, the medication was documented as administered at 6:04 AM and 8:26 AM. It should be noted that the medication was administered early and not at the every four hour interval as ordered by the physician. Resident 50's May 2024 Medication Administration Record (MAR) documented that the Oxycodone 10 mg was scheduled to be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Review of the facility policy on Administering Pain Medications defined pain management as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. The policy documented Administer pain medications as ordered. If there are signs or symptoms of serious adverse consequences related to narcotic (opioid) analgesics (including somnolence, delirium, respiratory depression), notify the practitioner prior to administering. The policy was last revised in March 2024. On 6/06/24 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 50 had Oxycodone scheduled for administration every 4 hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. LPN 3 stated that the resident should receive 6 doses of Oxycodone a day. LPN 3 stated that narcotic pain medication should not be administered early and a complication of early administration was overdose. LPN 3 stated that resident 50 also received morphine scheduled and as needed for pain. LPN 3 stated that they monitored the resident for orientation, pain, effectiveness and how alert they were. On 6/06/24 at 8:29 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that for medications that were ordered to be administered every 4 hours the resident should be receiving 6 doses a day. The RNC stated that for narcotic pain medication a potential complication of administering doses too close together was overdose. The RNC stated that PRN narcotics should be administered at least 2 hours apart. [Cross-refer F697]

Based on interview and record review it was determined, for 1 out of 53 sampled residents, 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 care plan, and the residents' goals and preferences. Specifically, the resident's pain medication was not administered per the physician orders and the resident had complaints of uncontrolled pain. Resident identifier: 50. Findings included: Resident 50 was admitted to the facility on [DATE] with diagnoses which included palliative care, chronic obstructive pulmonary disease, anxiety disorder, viral hepatitis, epilepsy, low back pain, hypertensive heart disease, neuromuscular dysfunction of the bladder, hemiplegia, insomnia, chronic pulmonary embolism, and osteoarthritis. On 6/02/24 at 2:41 PM, an interview was conducted with resident 50. Resident 50 stated that he had pain in his back and he had to wait for his pain medication. Resident 50 stated that when it was given on time the pain was managed and controlled. Resident 50 stated that he had an order for Oxycodone 10 milligrams (mg) that was scheduled every 4 hours and as needed. Resident 50 stated that sometimes the 4:00 AM dose was delayed to 6:00 AM or 7:00 AM. On 6/3/24, resident 50's medical records were reviewed. On 11/1/22, resident 50 had Oxycodone 10 mg every 4 hours for chronic pain ordered. Resident 50's administration time for the Oxycodone 10 mg in May 2024 revealed the following: a. On 5/1/24, the medication was documented as administered at 4:19 AM and 7:26 PM. b. On 5/2/24, the medication was documented as administered at 1:45 AM, 5:06 AM, and 8:01 PM. c. On 5/3/24, the medication was documented as administered at 12:06 AM, 5:07 AM, and 7:27 PM. d. On 5/4/24, the medication was documented as administered at 12:12 AM, 3:52 AM, and 7:39 PM. e. On 5/5/25, the medication was documented as administered at 3:01 AM, 5:04 AM, 8:04 AM, 11:21 AM, 4:01 PM, 7:49 PM, and 11:16 PM. f. On 5/6/24, the medication was documented as administered at 5:06 AM, 7:06 AM, 11:42 AM, 3:23 PM, 7:51 PM and 11:16 PM. g. On 5/7/24, the medication was documented as administered at 4:16 AM, 7:15 AM, 2:25 PM, 4:53 PM, and 7:18 PM. h. On 5/8/24, the medication was documented as administered at 12:08 AM, 4:50 AM, 7:37 AM, 11:37 AM, 4:58 PM and 7:43 PM. i. On 5/9/24, the medication was documented as administered at 12:16 AM, 5:34 AM, 7:57 AM, 11:44 AM, 4:16 PM, and 7:23 PM. j. On 5/10/24, the medication was documented as administered at 1:50 AM, 6:04 AM, 8:26 AM, 12:27 PM, and 5:20 PM. Resident 50's May 2024 Medication Administration Record (MAR) documented that the Oxycodone 10 mg was scheduled to be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Resident 50's pain scores on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain possible, were documented as follows: a. On 5/1/24, the pain score was a 6/10 at 10:01 AM, a 4/10 at 11:29 AM, a 5/10 at 7:25 PM, and a 0/10 at 11:44 PM. b. On 5/2/24, the pain score was a 4 at 5:06 AM, a 2/10 at 7:15 AM, and a 4/10 at 7:58 PM. c. On 5/3/24, the pain score was a 4/10 at 5:07 AM, a 1/10 at 4:38 PM, and a 4/10 at 7:26 PM. d. On 5/4/24, the pain score was a 6/10 at 12:11 AM, a 1/10 at 1:45 AM, a 4/10 at 5:49 AM, a 7/10 at 5:45 PM, and a 4/10 at 7:42 PM. e. On 5/5/24, the pain score was a 5/10 at 5:04 AM, a 3/10 at 11:02 AM, and a 3/10 at 7:49 PM. f. On 5/6/24, the pain score was a 8/10 at 9:31 AM, a 4/10 at 11:45 AM, a 3/10 at 7:51 PM, and a 1/10 at 11:54 PM. g. On 5/7/24, the pain score was a 7/10 at 1:53 PM and a 4/10 at 7:19 PM. h. On 5/8/24, the pain score was a 6/10 at 12:11 AM, a 1/10 at 12:51 AM, a 2/10 at 11:20 AM, a 5/10 at 7:41 PM, and a 0/10 at 11:09 PM. i. On 5/9/24, the pain score was a 4/10 at 5:34 AM, a 8/10 at 11:45 AM, a 0/10 at 12:39 PM, a 7/10 at 1:49 PM, a 0/10 at 2:16 PM, and a 4/10 at 7:25 PM. j. On 5/10/24, the pain score was a 4/10 at 6:04 AM, a 3/10 at 7:05 AM, and a 5/10 at 11:38 PM. Resident 50 had a care plan for at risk for pain related to chronic immobility secondary to hemiplegia, back pain, osteoarthritis, and end of life initiated on 11/8/22. The care plan documented an intervention of Anticipate the resident's need for pain relief and respond immediately to any complaints of pain. This intervention was last revised on 11/15/23. Review of the facility policy on Administering Pain Medications defined pain management as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. The policy documented Administer pain medications as ordered. If there are signs or symptoms of serious adverse consequences related to narcotic (opioid) analgesics (including somnolence, delirium, respiratory depression), notify the practitioner prior to administering. The policy was last revised in March 2024. On 6/06/24 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 50 had Oxycodone scheduled for administration every 4 hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. LPN 3 stated that the resident should receive 6 doses of Oxycodone a day. LPN 3 stated that narcotic pain medication should not be administered early and a complication of early administration was overdose. LPN 3 stated that resident 50 also received morphine scheduled and as needed for pain. LPN 3 stated that they monitored the resident for orientation, pain, effectiveness and how alert they were. LPN 3 stated that if the pain medication was scheduled they should be waking the resident to administer it if he was sleeping unless he refused. LPN 3 stated that if the resident refused they would document it in the Medication Administration Record and in a progress notes. On 6/06/24 at 8:29 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that licensed nurses should monitor adverse side effects, and non-pharmacological interventions to pain relief for any as needed (PRN) pain medications. The RNC stated that the licensed nurse should monitor pain scores and side effects of any scheduled pain medications. The RNC stated that for medications that were ordered to be administered every 4 hours the resident should be receiving 6 doses a day. The RNC stated that for narcotic pain medication a potential complication of administering doses too close together was overdose. The RNC stated that PRN narcotics should be administered at least 2 hours apart.

Based on interview and record review, the facility did not ensure that 3 of 53 sample residents received treatment and care in accordance with professional standards of practice. Specifically, one resident experienced a change in condition, and the facility did not act in a timely manner to treat the condition. This resulted in a finding of harm for this resident. In addition, one resident was not monitored for a change in condition after a dental procedure, and a resident who was incontinent developed Moisture Associated Skin Damage (MASD). Resident identifiers: 5, 7, and 365. Findings include: 1. Resident 365 was admitted to the facility on [DATE] with diagnoses that included spontaneous right patellar tendon rupture, encounter for other orthopedic aftercare, history of falling, and hypertension. Resident 365's entry Minimum Data Set (MDS) assessment indicated that facility staff assessed resident 365 as having a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Resident 365's medical record was reviewed from 6/2/24 through 6/6/24 and revealed the following: a. On 9/24/22 a nurses note documented: Pt (patient) arrived to facility via wheelchair from [name of local hospital]. Pt had a right knee repair surgery 9/23. Pt is alert and oriented x4, moves upper extremities equally, is non weightbearing [sic] on RLE (right lower extremity), able to move LLE (left lower extremity), sensation intact. Bowel sounds audible all lobes, abdomen soft and nontender, Pt reports that LBM (last bowel movement) was 9/23 in the morning. Pt is incontinent of bowel and bladder, Pt has briefs, wipes, and cream in room for bowel care. Pt is alert, able to verbalize needs . b. On 9/26/22 a nurses note documented: Pt was c/o (complaining of) excruciating bladder spasms. The pt was not seen by his primary, [name of physician], this shift to express his concerns or symptoms. Pt asked RN (Registered Nurse) to ask house MD [medical doctor] to do something to give him relief. RN messaged [name of physician] and received orders for a one time dose of 200mg [milligrams] of pyridium. RN administered medication and assessed pt 45 min after and he stated that he feels better and the spasms stopped. pt is alert and able to verbalize needs to staff, tolerated medications whole without complications . c. An MD Communication form dated 9/26/22, two days after resident 365 was admitted , revealed the following: . Concern: pt (patient) admitted Sat (Saturday) - is concerned he is developing infection, wants to see MD and discuss concerns. NEW ORDER 1 - Notify his ortho (orthopedic) Dr (doctor) who operated on him ASAP [As Soon As Possible]! 2 - I will see him after clinic today. [Note: No documentation could be located to indicate that the physician saw resident 365 that day, or that facility staff had contacted the orthopedic surgeon during resident 365's stay. ] d. On 9/28/22 at 12:26 AM a nurses note documented: . pt had an episode of forgetfulness and confusion this shift. Pt was found sitting on the side of his bed. Staff asked what he was doing, pt stated that he was going to the bathroom. Staff reminded him that he is NWB (non weight bearing) on his R (right) knee and could not walk to the bathroom. Staff got him into bed safely, his R knee is bleeding through the bandage . e. On 9/28/22 at 9:41 AM a nurses note documented: . Pt is alert, able to verbalize needs, takes medications whole, . Night nurse reported that Pt had an episode of confusion last night, Nurse went in this AM (morning) to assess Pt. Pt has diminished lung sounds in the bases, SOBLF (?) and SOBOE (shortness of breath on exertion). Pt's neuro (neurological) assessment showed minimal left sided facial weakness, moves all extremities equally, denies any numbness or tingling, no changes in sensation, or H/A (headache). MD has been notified of situation. f. On 9/28/22 at 10:46 AM a nurses note documented: . As ordered by MD, nurse tried to contact surgeon about duration of Bactrim. Unable to reach them, Nurse left a message for the surgeon's office . [Note: This is two days after the physician wrote a note to contact the orthopedic physician for resident 365 as soon as possible regarding the resident's possible infection.] g. On 9/29/22, a nurses note documented: . Resident is alert and verbally responsive, able to make needs known. Resident c/o bladder spasms and not being able to void. Bladder scanned and 85 cc (cubic centimeters) residual noted. MD notified. h. On 9/29/22, the facility physician documented the following in a physician's note: . [Resident 365] .reported pain to his abdomen that started during physical therapy, pain us located to RLQ (right lower quadrant), upon examination no hernia or any other abnormalities were noted. Claims that is able to control bladder and bowels. However, he is experiencing bladder spasms with little urine output post spasms. Denies prior or similar problems prior to this surgery. Reported last PSA (Prostate Specific Antigen) levels were done back in January with normal results. Physician will place patent (sic) on Flomax . i. On 9/29/22 resident 365's blood pressure was 144/81. j. On 9/30/22 at 4:51 PM, resident 365's blood pressure was 143/76. k. On 9/30/22 at 4:52 PM, resident 365's blood pressure was 177/85. l. On 10/1/22 at 12:05 AM, a nurses progress note documented: Resident found on floor next to recliner and walker . When asked resident what happened he said he was not sure.No c/o pain. Resident already has baseline hx (history) of confusion and falls upon admission. Resident has no s/s (signs and symptoms) of injury at this time. No complaints of pain or distress. Resident educated on importance of call light and demonstrated its use. RLE (knee) dressing changed and inspection of surgical site completed. surgical scar well approximated, all staples intact and in place and trace drops of drainage. No swelling, redness, and surgical site is cool to the touch. Clean dressing re applied, wrapped, and ble [bilateral lower extremity] knee brace secured . Will notify, PCP (primary care physician), family and on call administrator of incident and continue to monitor closely. m. On 10/1/22 at 8:30 PM a nurses progress note documented: resident POA (power of attorney) contacted staff and communicated concern regarding residents increased confusion. Family very concerned and request to send to ER (emergency room ). PCP contacted . transfer was completed. Will continue to monitor closely. n. On 10/2/22 at 10:16 AM a nurses progress note documented that the resident had been admitted to the hospital, and was in the intensive care unit. On 6/6/24 at 8:43 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that with regard to the physician note written about resident 365 on 9/26/22, STAT would have been a better word to use than asap. The RNC also stated that the facility nurses should have reached out after the doctor said to get in contact with the orthopedic surgeon. The RNC stated that best practice was to reach out and get a urinalysis (UA) with the bladder spasms and excruciating pain. The RNC stated that the facility could still get a culture and sensitivity on a urinalysis even if the resident was on an antibiotic already. The RNC stated that the doctor should have ordered a UA and culture and sensitivity. The RNC did not have any other information regarding the facility's lack of response to the change of condition in resident 365. The facility's policy for Change in a Resident's Condition or Status was reviewed. The policy indicated the following: Our facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . g. need to transfer the resident to a hospital/treatment center; . i. specific instruction to notify the physician of changes in the resident's condition. 2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . 30563 2. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paroxysmal atrial fibrillation, fibromyalgia, type 2 diabetes mellitus, obesity and major depressive disorder. On 6/3/24 at 9:56 AM, an interview was conducted with resident 7. Resident 7 stated she had her teeth were extracted. Resident 7 stated she was wondering when she was getting dentures. Resident 7 stated she had not been to a follow-up appointment after having her teeth extracted. Resident 7's medical record was reviewed on 6/2/24 through 6/6/24. A nursing progress note dated 3/26/24 at 3:50 PM, Spoke with [name removed] surgical regarding PT [patient] surgery in the morning. PT to be NPO [nothing by mouth] after 0045 [12:45 PM]; may take BP [blood pressure] medication in morning if necessary. Faxed over health history. The next progress note was 4/1/24 at 2:02 PM from the Nutrition/Dietary note. The note revealed .RDN [Registered Dietitian Nutritionist] spoke with resident about mouth pain. Resident had all teeth pulled and needs altered texure (sic). There were no notes regarding monitoring of resident 7 after having dental surgery. On 6/6/24 at 8:30 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated she was aware that resident 7 had a dental procedure. ADON 1 stated when a resident returned to the facility after a surgical procedure, the physicians sent guidance and orders to care for the resident. ADON 1 stated the nurse needed to complete a progress note regarding the surgical procedure, what the physician ordered, what to monitor and when there was a follow-up appointment. ADON 1 stated after a dental procedure, nursing staff should monitor for pain and bleeding. ADON 1 confirmed there was no monitoring of resident 7 after the dental procedure. ADON 1 was unable to find orders from the dentist or information regarding the dental procedure. On 6/6/24 at 8:58 AM, a follow-up interview was conducted with resident 7. Resident 7 stated she had not heard anything about getting dentures. Resident 7 stated she had asked staff about her follow-up appointment for dentures but staff did not know anything. On 6/5/24 at 9:13 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated they were not aware that resident 7 had teeth extracted and needed dentures. LPN 1 stated there was a transport director that scheduled appointments. LPN 1 was observed to review nursing progress notes. LPN 1 stated there was a note from resident 7's physician on 6/4/24 that resident 7 needed to be fitted for dentures. On 6/5/24 at 3:48 PM, an interview was conducted with the Transport Driver. The Transport Driver stated she scheduled appointments. The Transportation Driver stated resident 7 did not have a follow up dental appointment scheduled. The Transport Driver stated she transported resident 7 to a dental appointment a couple of months ago. On 6/6/24 at 9:01 AM, an interview was conducted with the RNC. The RNC stated after a resident had teeth extracted, nurses should monitor for bleeding, fever, and sign and symptoms of infection. The RNC stated usually a resident received prophylactic antibiotics after having teeth extracted and there would be alert charting by nurses. The RNC stated resident 7 was provided a follow-up dental appointment on 5/6/24 but there was no information regarding dentures on the form. The RNC stated there was no follow-up or monitoring of resident 7 after having her teeth extracted. 3. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. Resident 5's medical record was reviewed on 6/3/24 through 6/6/24. On 4/4/24, a Quarterly Minimum Data Set [MDS] documented resident 5 had a Brief Interview for Mental Status [BIMS] score of 1 which indicated severe cognitive impairment. There was no information located under the mobility section for functional abilities. The skin section of the MDS documented resident 5 was at risk from developing pressure ulcers/injuries and it documented at the time of the assessment resident 5's only skin problem were skin tears. Resident 5 was not noted to have MASD (Moisture Associated Skin Damage). On 5/2/24, a stated optional MDS documented resident 5 was a two-person extensive assist with transfers, toileting and bed mobility. On 12/19/23, a weekly skin review/assessment documented, Blanchable redness to buttocks rest of skin is dry and intact. On 1/3/24, a professional wound specialist note documented resident 5 had dermatitis associated with moisture. The examination section documented the age of the coccyx wound to be 1 week and it noted the wound type to be MASD. The stage of the wound documented it was limited to breakdown of skin and the wound bed had erythema and was blanchable. It noted the coccyx wound was shallow and stated the wound was likely to heal well but may be slowed down due to resident 5's inability to reposition herself and lying in bed all the time. On 1/6/24 at 7:34 AM, a skin/wound note documented, MASD TO COCCYX Wound bed is 100% [percent] pink, red, healthy, erythema, blanchable. Wound edges are attached to base. Periwound tissues are macerated. No drainage, no odor. A physician order with a start date of 1/7/24 documented as followed: BUTTOCKS EXCORIATION: Cleanse with NS [normal saline] and apply chamosyn with brief changes. every shift for buttocks excoriation. On 1/10/24 at 12:11 PM, a nutrition/dietary note documented, Moisture Associated Skin Damage [MASD] to coccyx noted to be new .will continue to monitor. On 1/10/24, a professional wound specialist note documented resident 5's MASD to coccyx was progressing well and had nice improvement. On 1/12/24 at 1:10 AM, an orders administration note documented, .She has 2 stage II [two] sacral area which were cleansed, skin prepped, covered with a pink silicone bordered bandage. She tolerated the care well. She verbalized being in pain, hydrocodone was effective. On 1/13/24 at 6:29 AM, a skin/wound note documented, MASD to coccyx: PROXIMAL: . Wound bed is 100% pink, red, healthy, erythema, blanchable. Wound edges are attached to base. Periwound tissues are macerated. No drainage, no odor. On 1/17/24, a professional wound specialist note documented resident 5's MASD to coccyx had resolved within 4 weeks and it documented a treatment order of chamosyn to coccyx area every day for 14 days. On 1/17/24 at 5:46 PM, a skin/wound note documented, Wound care to coccyx: Remove old dressing, cleanse with NS. Apply skin prep to periwound. Apply Medihoney wound gel to wound bed. Secure with bordered absorbent dressing. To be completed three times a week. one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday]. wound resolved, no dressing required On 1/20/24 at 1:15 PM, a skin/wound note documented, MASD TO COCCYX: Resolved. On 2/13/24 at 5:22 PM, an orders administration note documented, Weekly skin checks every Tues [Tuesday] Day shift. Please complete the WEEKLY SKIN ASSESSMENT after you do skin check. These are to be completed by the end of your shift. one time a day every Tue On 3/3/24 and 3/11/24, a weekly skin review/assessment documented, .redness noted to coccyx. On 3/13/24, a nurse note documented, Resident with blanchable redness to sacrum. Silicone dressing placed. On 3/17/24, a weekly skin review/assessment documented, redness noted to coccyx. On 3/25/24 and 3/31/24, a weekly skin review/assessment documented, redness noted to coccyx. ointment applied. reposition every 2 hours or PRN [as needed]. no other skin issues noted. On 3/28/24 at 8:17 PM, a physician progress note documented, Nursing report no skin lesions to sacrum or coccyx. She is not ambulatory and is confined to wheeled recliner. On 4/14/24, a weekly skin review/assessment documented, excoriation on the buttocks. On 4/30/24, a hospice visit note documented the hospice nurse had assisted a facility certified nursing assistant (CNA) in providing a brief change for resident 5 and noted resident 5's skin to be intact at the time. On 5/1/24, a hospice visit note documented resident 5 had healing skin tears to bilateral arms and there was no other evidence of skin break down. On 5/12/24, a weekly skin review/assessment documented, Excoriation on the buttocks . On 5/13/24, a hospice visit note documented an integumentary assessment was conducted and assessed resident 5's skin was pale and had poor turgor. A Braden risk assessment scale was done and revealed resident 5's skin was occasionally moist and required an extra linen change once a day. The assessment documented resident 5 had a potential problem with friction and shear due to their skin probably sliding down sheets and chairs. On 5/23/24, a weekly skin review/assessment documented, Excoriation on the buttocks. Hospice nurse is bringing skin barrier for this. On 5/23/24 at 3:54 PM, an alert note documented, Skin Check: 1. Moisture Associated Skin Damage [MASD] Excoriation on the buttocks. Hospice nurses is bringing skin barrier for this. Bowel prep meds [medication] are changed from scheduled to prn [as needed]. On 5/23/24, a hospice visit note documented, Redness present to coccyx area, no open sores, Advised staff to apply barrier cream with all brief changes and reposition frequently. An integumentary assessment was conducted and documented a Braden risk assessment scale. It stated resident 5's skin is often but not always moist and linens needed to be changed as often as 3 times in 24 hours. It stated resident 5 was completely immobile and did not make even slight changes in body without assistance. It stated resident 5 had a problem with friction and shear due constant friction from sliding down in bed, sliding against the sheet with transfers, and frequent repositioning. On 5/28/24, a weekly skin review/assessment documented, Multiple small skin tears noted during brief change in sacral area. Red, no odor. It documented there was a new skin integrity problem on resident 5's sacrum and documented the new skin problem as a skin tear. On 5/29/24 at 9:47 AM, a nurse note documented, New pressure sores found on resident's R [right] buttocks and coccyx. Other areas on L [left] buttocks becoming red. Hospice notified; no new orders at this time. Silicone dressings and zinc cream placed where appropriate. Pillows placed for pressure relief. On 5/29/24, a weekly skin review/assessment documented, New pressure sores to R buttock and coccyx, other areas on L buttocks becoming red. Hospice notified. The skin review documented resident 5 had altered skin integrity to their right buttocks and coccyx and documented the skin problem as a pressure. On 6/2/24, a weekly skin review/assessment documented, Current pressure sores to R buttock and coccyx, other areas on L buttocks becoming red. Hospice notified. On 6/2/24 at 6:35 PM an alert note documented, New Skin Issue found on Weekly Skin Check. Skin treatment in progress. On 6/3/24 at 2:20 PM, a nutrition/dietary note documented, Continues hospice cares. Recent notes of pressure sores. Will await upcoming wound note to complete full assessment. Resident 5's Medication Administration Records (MAR) and Treatment Administration Records (TAR) were reviewed for the past 5 months for the buttocks excoriation treatment which was scheduled for twice a day. The following documentation revealed: a. January: Resident 5 had 10 missed treatments out of 49 total treatments. b. February: Resident 5 had 13 missed treatments out 58 total treatments. [Note: There were 3 days where resident 5 had not receive treatments twice a day.] c. March: Resident 5 had 12 missed treatments out of 62 total treatments. [Note: There was 1 day where resident 5 had not received treatments twice a day.] d. April: Resident 5 had 11 missed treatments out of 60 total treatments. [Note: There were 2 days where resident 5 had not received treatments twice a day.] e. May: Resident 5 had 10 missed treatments out of 62 total treatments. [Note: There was 1 day where resident 5 had not received treatments twice a day.] On 6/5/24 at 10:37 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated resident 5 needed assistance with rolling in bed and was incontinent of bowel and bladder. LPN 4 stated incontinence care was provided to resident 5 and they checked on them frequently to see if they needed to be clean and if they needed barrier cream. LPN 4 stated if a resident's brief was not changed often enough, then it caused skin break. LPN 4 stated a type of skin break down that was developed was excoriation which was redness and inflammation of the skin. LPN 4 stated the wound nurse was notified as soon as they noticed any kind of skin breakdown on a resident. LPN 4 stated resident 5 had some pressure ulcer on their coccyx and sacrum area. LPN 5 stated resident 5 was on an air mattress which helped prevent ulcers by distributing the pressure to different areas and helped with circulation. LPN 5 stated they just barely received new orders for repositioning resident 5 every two hours. On 6/6/24 at 10:01 AM, an interview was conducted with the Assistant Director of Nursing (ADON) 2. ADON 2 they were the wound care nurse. ADON 2 stated if a resident had a new wound or skin injury, staff filled out a form and turned it in to them and they notified the house doctor if needed. ADON 2 stated they put the orders in for wounds which informed the nurses of the specific wound care instructions. ADON 2 stated they monitored the skin breakdown and treatments ordered for all the residents. ADON 2 stated a pressure sore was a cause of Moisture Associated Skin Damage (MASD). ADON 2 stated the skin irritation occurred when a resident was in a wet brief. ADON 2 stated MASD had many stages and it started with an abrasion. ADON 2 stated MASD created friction on the skin and caused the skin to break down. ADON 2 stated the skin breakdown led to an abrasion from the brief pulling on the skin. ADON 2 stated if MASD was not cared for or taken care of regularly, then it became a pressure sore. On 6/6/24 at 10:15 AM, an interview was conducted with the Assistant Director of Nursing (ADON) 1. ADON 1 stated they had previously been the wound care nurse at the facility. ADON 1 stated any time they had been notified of a wound, they examined and determined if the wound needed to be seen by the wound care provider. ADON 1 stated if a resident had MASD, the facility doctor followed up with the resident and wound care did not see them. ADON 1 stated MASD was moisture associated skin dermatitis and it was found under the breast and groin. ADON 1 stated MASD was an avoidable rash. ADON 1 stated a resident could have had moisture associated skin problems if they were in a wet brief for prolonged periods of time. ADON 1 stated frequent rounding and brief changes were done to prevent skin problems. ADON 1 stated resident 5 had MASD to their bottoms in January. ADON 1 stated the moisture weakened the skin and if not taken care of, turned into a greater issue. ADON 1 stated they were notified that resident 5 had pressure sores by the hospice nurse. ADON 1 stated resident 5's bottom had been blanchable last week but now it had opened and was no longer blanchable.

Based on interview and record review it was determined, for 5 out of 53 sampled residents, that the facility did not ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a staff member recorded a video in the shower room while a resident was in the bathtub naked, a cognitively impaired resident kissed two different cognitively impaired residents on two different occasions and another resident who was cognitively impaired was involved in a sexual relationship. Resident Identifiers: 5, 12, 17, 36, 42, and 374. Findings Included: 1. Resident 42 was admitted to the facility on [DATE] with the following diagnoses of delirium, unspecified dementia with psychotic disturbance, anxiety disorders, cognitive communication deficit, and major depressive disorder. Resident 42's medical records were reviewed on 6/5/24 through 6/6/24. A facility admission agreement signed and dated 9/2/20, section G subsection f documented the following authorization to pictures, Authorization to Photograph. Resident authorizes Facility and its affiliates to photograph client and/or portions of client's body for documentation of physical conditions, and/or to follow medical progress. Photos will be protected and the Client's right to privacy will be observed. On 3/1/24, a Quarterly and Annual Review documented resident 42 was confused at baseline line, struggled to answer questions and was a poor historian. It also documented resident 42 had not reported any history of trauma. On 5/23/24, a Montreal Cognitive Assessment (MoCA) assessment documented resident 42 had scored a 3 out of 30 which indicated severe cognitive impairment. On 5/31/24, a Quarterly Brief Interview for Mental Status (BIMS) assessment was done and documented resident 42 had severe cognitive impairment. On 5/31/24, a Quarterly and Annual Review documented resident 42 was confused at baseline and had not reported any history of trauma. On 2/2/24 at 4:07 PM, a facility incident report documented that an incident had occurred with resident 42 in the shower room. The incident description stated, it had been discovered due to a video clip that had been sent and resident 42 was unaware of what had occurred. It stated that resident 42 was in the bath tub being bathed by staff who took a recording of themselves with the resident 42 clearly visible in the background. The incident report documented the video had been sent via social media application to unknown sources and once the video had been discovered by the Certified Nursing Assistant (CNA) coordinator, it was reported to the abuse coordinator. No other information was located in the incident report. A form titled exhibit 358 was submitted to the State Survey Agency (SSA) on 2/3/24 at 11:15 AM. The form revealed that an allegation of mental/verbal abuse had occurred. The incident documented that a CNA had posted a video on a social media application of themselves dancing while showering a resident. Resident 42 was seen in the background of the video without their consent. This had been anonymously reported to human resources. It documented the incident had occurred on 2/2/24 at 11:30 PM and staff had become aware the following day at 10:00 AM. The form documented there had been no change to resident 42's mental status and no physical injury had occurred to them. The measure taken to protect residents' safety by the facility stated, the CNA no longer worked at the facility. Adult Protective Services and the Ombudsman had been notified of the incident. The form documented the incident had not been reported to a law enforcement agency. A form titled exhibit 359 was submitted to the SSA on 2/9/24 at 12:40 PM. The form 359 documented resident 42 had severe dementia and did not have any recollection of the incident. A summary of the interviews with witnesses confirmed resident 42 was exposed in a social media application video without their consent. The perpetrator no longer worked at the facility during the time of the investigation, and it documented the NA (Nursing Assistant] shortly sent in their resignation after the incident via text message. It documented the picture disappeared on the social media application. The investigation verified that the allegation had occurred and documented that several witnesses had confirmed that resident 42's back was seen while in the bathtub. The form documented that resident 42 was unable to understand the situation or recall the incident. It concluded that abuse had occurred because the NA had sent the video to a social media application where resident 42 was exposed and without their consent. Corrective actions taken by the facility included in-service education to staff regarding the facility's digital images policy and the relation to abuse. On 6/5/24 at 9:54 AM, an interview was conducted with CNA 6. CNA 6 stated resident 42 was a one person assist with showers and needed to have staff in the shower room with them. CNA 6 stated resident 42 was able to follow showering instructions and was able to help bathe themselves. CNA 6 stated staff were not allowed to have personal cellphones in resident areas because they need to respect residents personal home. On 6/5/24 at 3:51 PM, an interview was conducted with CNA 13. CNA 13 stated they had a shower schedule which notified the CNA's what rooms they were assigned to shower for the shift. CNA 13 stated resident 42 had showers scheduled for the evening shift. CNA 13 stated resident 42 was able to help with their showers if they were talked through it. CNA 13 stated there was a video taken of the shower room with resident 42 in it. CNA 13 stated resident 42 was tilted forward in the bathtub and their stomach and whole chest were visible in the video. CNA 13 stated they were not supposed to have their own person phones near resident care areas. CNA 13 stated resident 42 was unaware of the video taken of them. On 6/5/24 at 4:11 PM, a telephone interview was conducted with CNA 14. CNA 14 stated them and a few other CNA's were together outside of work hours when they viewed a video that showed a resident in the background. CNA 14 stated CNA 16 had filed a report stating they were injured and had been put on light duty. CNA 14 stated for safety purposes CNA 16 should not have been allowed to shower resident 42. CNA 14 stated CNA 16 had been taking pictures of themselves and resident 42 and then CNA 16 posted a video about being on light duty. CNA 14 stated resident 42 was in the background of the video. CNA 14 stated resident 42 was naked in the bathtub and they were seen playing with the water. CNA 14 stated resident 42's exposed chest made it visible they did not have breasts. CNA 14 stated resident 42's privacy was violated. CNA 14 stated staff were not allowed to have phones while they provided resident care and they were not allowed to take picture or videos of residents due to privacy violations. On 6/5/24 at 4:44 PM, an interview was conducted with the Administrator (ADMIN). The Admin stated the CNA coordinator had been notified by another CNA of a social media video where a resident was visible in the background. The Admin stated the CNA coordinator had informed them the video was taken around midnight the night before or around when the shower was done. The Admin stated the platform the video was taken on was temporary and the video disappeared a short time later. The Admin stated CNA 16 had taken a short video in the shower room where resident 42 appeared to be in the bathtub. The Admin stated they viewed the video and resident 42's bare back, shoulders and face were seen in the video. The Admin stated the video consisted of CNA 16 doing a dance and stating they loved light duty and then phone was turn and resident 42 was seen in the video. The Admin stated they notified Adult Protective Services (APS) and APS had not referred them to law enforcement. The Admin stated they had not notified the police. The Admin stated the police should have been notified so they could make the determination if the incident was considered a crime. The Admin stated CNA 16 resigned shortly after the incident and they had been unable to interview resident 42 since they were unable to recall what happened. The Admin stated they notified resident 42's son about the video and the son became upset. The Admin stated the investigation included asking anyone that viewed the video to delete it. The Admin stated they were unsure if they had individually asked all the CNAs about deleting the video. The Admin stated they wanted it deleted so it would not be viewed anymore. The Admin stated the staff should already know the digital media policy which was staff did not take pictures or video of a resident without their consent and they were not allowed to be distributed. On 6/5/24 at 5:05 PM, an interview was conducted with CNA 15. CNA 15 stated resident 42's CNA was supposed to be on light duty. CNA 15 stated CNA 16 posted a video to their private story on a social media application which showed CNA saying they were on light duty and could not wait to get off. CNA 15 stated CNA 16 was seen dancing and resident 42 was seen in the background of the video naked in the bathtub. CNA 15 stated resident 42 was observed to be naked from their head down to the their stomach due to the camera's angle. On 6/5/24 at 5:15 PM, an interview was conducted with the Resident Advocate (RA). The RA stated they were made aware of resident 42's incident after the Admin had submitted the 358 and notified APS. The RA stated the CNA coordinator had shown the Admin the social media video. The RA stated they were notified what had occurred in the video by the Admin. The RA stated it had been described that resident 42 was in a bathtub naked and they could be seen from the belly up while a CNA had been doing a dance. The RA stated they were the main contact for APS. The RA stated the APS investigator had asked for the CNA's contact information to let them know the incident had been reported. The RA stated the APS investigator had spoken to resident 42. The RA stated the APS investigator stated resident 42 did not remember what had happened and they had been talking gibberish during the interview. The RA stated the APS investigator notified them the case was going to be referred to the Attorney General's Office. The RA stated the APS investigator later told them, the attorney general was going to talk to resident 42. The RA stated they were unsure if the attorney general had come in and talked to resident 42. On 6/5/24 at 12:30 PM, an attempt was made to contact CNA 16 by phone. On 6/7/24 at 6:06 PM, CNA 16 responded by text message and stated the following, if you have any further questions can contact my attorney [name removed] at [phone number removed]. please do not contact me any further thank you. 2. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. Resident 5's medical record was reviewed on 6/3/24 through 6/6/24. On 4/4/24, a Quarterly Minimum Data Set (MDS) documented resident 5 had a BIMS score of 1 which indicated severe cognitive impairment. A care plan focus area initiated on 3/7/23 documented resident 5 had a potential communication problem related to difficulty understanding secondary to Dementia. Documented interventions included to ensure/provide a safe environment. On 3/29/24 at 10:24 AM, a facility incident report documented a resident-to-resident interaction had occurred in the activity room. The nursing description documented, Victim was in activity room with perpetrator. Victim lifted up her chin when she saw and then he kissed her on or near the lips. Victims did not appear disturbed, though has cognitive impairment. Resident 5 was unable to give a description of the incident. Immediate actions taken included the immediate separation of both resident. It documented the perpetrator was monitored and the victim was under the supervision of staff since they had been assisted to the day room. The incident report documented resident 5 to be wheelchair bound. The mental status section documented both the perpetrator and the victim had severe dementia. The incident report revealed the APS, the Ombudsman, the responsible party and the state had been notified of the incident. On 4/4/24 at 10:37 AM, a nurse note documented, Staff witnessed incident and immediately separated residents and began directly monitoring and supervising. Victim was then placed in day room. Staff immediately administrator [sic] who began process of investigation with staff and RA. Proper authorities and responsible parties were notified and safety of residents ensured by verifying supervision, monitoring, and placement of victim in separate location. Care plan updated. Victim assessed for any signs and symptoms of distress. None identified to this point. Care plan and medications reviewed for both residents. Psychotropics medication to be reviewed with physician and pharmacy. A physician order with a start date of 4/12/24 documented as followed: [Resident 5] to be monitored in the dayroom as able and as she tolerates for safety. every shift A form titled exhibit 358 was submitted to the State Survey Agency (SSA) on 3/29/24 at 3:30 PM. The form noted that the incident was an allegation of sexual abuse. The victim identified was resident 5 and the alleged perpetrator was resident 374 who was noted as a resident with dementia. Staff had become aware of the incident on 3/29/24 at 2:45 PM. A detailed account of the incident stated, Victim was in the activity room with perpetrator. Victim was kissed, on or close to the lips by the perpetrator. It is unknown if this was welcome because the victim was dementia. The immediate steps taken to ensure the resident's safety included the separation of the resident 5 from the perpetrator and kept safe from resident 374. The resident's family had been notified of the incident. The Agencies notified included the Ombudsman and APS. The exhibit 358 documented that the incident had not been reported to a law enforcement agency. A form titled 359 was submitted to the SSA on 4/5/24. The facility's investigation included 3 staff interviews and 5 resident interviews. The perpetrator statement documented resident 374 had dementia and was unable to be interviewed but he stated that resident 5 was his women. A staff interview documented resident 374 was observed to kiss resident 5 during an activity. Resident 5 put her hand out and he held it and went in and kissed her. No additional outcomes were documented to had occurred to either resident post incident. A summary of the witnesses interview documented, Residents were in the activity room, [resident 374] walked over to [resident 5]. She looked up at him and he leaned down and kissed her. Staff redirected [resident 374]. [Resident 5] did not react or respond in a manner to suggest that it was unwelcome; however, she doesn't have the cognitive capacity to consent. An interview summary with resident 374 documented he had dementia and stated resident 5 was his lady. An interview summary with other resident revealed other resident noted resident 374 was very friendly and had seen resident 374 attempt to kiss other women before. The relevant summary information provided documented, Perpetrator is a pleasant [AGE] year old male with vascular dementia. He is independently mobile, and takes a medication that has a potential side affect of increased libido (asking Dr. to review) His BIMS score is a 4. Victims is a [AGE] year old female with Alzheimer's dementia and multiple comorbitites. Her BIMS score is 1. The investigation verified the allegation type had occurred and stated, Multiple witnesses saw [resident 374] kiss [resident 5] near the mouth. Although it did not appear unwelcome, the victim does not have decision making capacity. The corrective actions taken from the investigation of the allegation included separating both residents and resident 374 was put on frequent checks. The systemic action documented was, Perpetrator's medication that has a side effect of increased libido was discontinued by his physician. No counseling needs or other interventions were documented to assist resident 5 with the sexual abuse that had been verified. The form documented, Victim has a BIMS score of 1 and cannot recall the incident. On 6/5/24 at 9:41 AM, an interview was conducted with CNA 5. CNA 5 stated resident 5 was not mentally with it. CNA 5 stated resident 5 was not able to consent kissing other residents. CNA 5 stated they were not aware of any incident that involved resident 5 being kissed. On 6/6/24 at 7:49 AM, an interview was conducted with CNA 12. CNA 12 stated resident 5 was confused. CNA 12 stated depending on how resident 5 was feeling during the day, they needed to have a second staff member with them during resident cares. CNA 12 stated they usually rounded on resident's every two hours. CNA 12 stated resident 5 was unable to consent to anything due to them being confused and being unable to recall events. CNA 12 stated resident 374 had a history of behaviors such as wandering and exit seeking. CNA 12 stated resident 374 attempted to link up with other residents and one time they had grabbed on to resident 374. CNA 12 stated resident 5 was unable to give consent for a kiss. On 6/6/24 at 8:12 AM, an interview was conducted with CNA 18. CNA 18 stated resident 5 required two-person physical assistance with a Hoyer lift with transfers. CNA 18 stated resident 5's dementia was so severe they were unable to recall the date. CNA 18 stated resident 5 was unable to express their needs. CNA 18 stated they were unaware of any interactions between resident 374 and resident 5. CNA 18 stated resident 374 believed they were a ladies man and they liked to show affection in the form of kisses. On 6/6/24 at 8:32 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated resident 5 was confused and when resident 5 was in the day room they needed to monitor them. LPN 3 stated they were aware a resident had kissed another resident and stated maybe resident 374 had kissed resident 5. LPN 3 stated resident 5 was not able to consent to being kissed. On 6/6/24 at 10:31 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated resident 5 was kind of able to make their needs known. ADON 1 stated resident 5 did not like being left on their own and liked human interaction. ADON 1 stated they did not believe resident 5 was able to consent to being kissed by another resident. ADON 1 stated there had been a resident that had been making advances towards other residents. ADON 1 stated they were unsure who those residents had been. On 6/6/24 at 10:50 AM, an interview was conducted with the Admin. The Admin stated they tried to interview both residents involved. The Admin stated they had been notified by the nurse, that two CNA's who stated they saw resident 374 kiss resident 5. The Admin stated they interviewed the CNAs and they stated resident 374 brought their face close to resident 5 and resident 5 was kissed when they looked and saw resident 374. The Admin stated they had been informed by staff that an activity at the time this happened. The Admin stated resident 374 had a prior history but they were unsure of what had occurred the first time. The Admin stated the doctor changed some of resident 374's medications due to the incident. The Admin stated resident 5 had a diagnosis of dementia with a BIMS score of 1 and it was unlikely that resident 5 remembered the incident. 22992 3. Resident 17 was admitted to the facility on [DATE] with diagnoses that included amnesia, pulmonary heart disease, generalized osteoarthritis, pulmonary hypertension, severe protein-calorie malnutrition, anxiety disorder, and chronic pain syndrome. Resident 17's medical record was reviewed from 6/2/24 through 6/6/24. On 9/8/23, a Saint [NAME] University Mental Status (SLUMS) examination was completed for resident 17. The resident was assessed as having a score of 13 out of 30, indicating that the resident's cognitive status was in the dementia category. On 12/23/23, a care conference was held with resident 17. Staff documented that the resident . had increasing behaviors and has been more confused than normal. Care concerns PT [patient] increased confusion. On 2/1/24, a MOCA was completed for resident 17. The resident was assessed as having a score of 13 out of 30, indicating moderate cognitive impairment. Progress notes for resident 17 revealed the following: a. On 1/25/24, Resident has appeared to be very confused, she is reporting that her room mate is threatening to kill her, punch her, find her and kill her. Resident states that her roommate is calling her uglyface. Resident is very upset, crying and scared, she doesn't feel safe. It is noted very clearly that Resident's roommate was not in room when Resident states these threats where (sic) made. b. On 4/12/24 . PTs BIMS score showed that she is Moderately impaired with a score of 11. PTs cognition has declined recently and she is having a harder time remembering where her friends rooms are located. c. On 5/23/24, . pt started a shared companionship with a male resident. BIMS ranges from 11-15 historically. Reviewed resident mental status. IDT [Interdisciplinary Team] spoke with resident and discussed her relationship and if resident is capable of communicating her thoughts of the relationship. She does enjoy the relationship with male resident and is having sexual relations. Interviewed staff concerning this residents relationship with male resident. Staff agree it is consensual and conducted in privacy. IDT created and implemented a care plan. Contacted PCP [primary care physician] for capacity to consent to the relationship. The progress note did not indicate how the resident's capacity to consent was assessed or determined, nor did it address her BIMS, SLUMS, or MOCA evaluations. On 6/5/24 at 4:30 PM, an interview was conducted with the RA. When asked about resident 17 being involved in a sexual relationship with another resident, the RA stated she was unaware of the issue, and did not know who the other resident involved in the relationship was. On 6/6/24 at 7:40 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that he was unsure about how long resident 17 had been in a sexual relationship with another resident. The ADM stated that it had come to his attention approximately 4 to 6 weeks prior when a corporate team member identified it. When asked how he had determined if the residents were capable of giving consent for a sexual relationship, the ADM stated that he had reviewed it with the IDT team, and they (the residents) seemed ok. The ADM stated that the residents had been interviewed and were able to state that they understood what a relationship means and about sexual contact. The ADM stated that he was aware resident 17 had a diagnosis of amnesia but that he had looked it up and it meant that the resident was forgetful . so I didn't feel like that related to the determination of consent. The ADM further stated that I didn't see that as a diagnosis that would impair her. The ADM stated that he was unaware of resident 17's MOCA and SLUMS scores, or her increased confusion in previous assessments. The ADM also stated that they had reached out to the physicians for both residents to also help determine if the residents were able to give consent, but the physician had not yet responded. On 6/6/24 at 8:43 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that there was a corporate pathway of determining if residents had the capacity to consent to a sexual relationship, and that the physician was supposed to be contacted. The RNC confirmed that neither resident had been evaluated by their physician to determine capacity to consent, even though multiple attempts have been made . The doctor needs to be first and until the doctor clears it, we should have stopped it. After the survey team completed the recertification survey, The facility provided a letter dated 6/7/24 that had been written and signed by resident 17's physician. The letter stated, . I have been asked to provide a letter or note regarding her (resident 17) capacity to consent. Patient does not have any history of dementia. She is not on any dementia medication at this time as well. She is free of any communicable diseases that I know of. The patient manages her own checkbook and other affairs. The patient does have osteoarthritis and does not drive a vehicle. However she is able to leave the facility whenever she desires. If she would like to be in any intimate relationship I do not see any reason to stop her at this point legally. I would caution her to only become romantically involved in relationship (sic) and not financially at this stage in life. 38031 4. A. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of encounter for palliative care, rheumatoid arthritis, type II diabetes mellitus, vascular dementia, polyneuropathy, pulmonary hypertension, hypertension, hyperlipidemia, aphasia, cerebral infarction, thrombophilia, hemiplegia and hemiparesis, anxiety disorder, and major depressive disorder. On 6/2/24, resident 12's medical records were reviewed. On 9/8/23, resident 12's MDS assessment documented a BIMS score of 4/15, which would indicate that the resident was severely cognitively impaired. Resident 12's progress notes revealed the following: a. On 11/8/23 at 4:51 PM, the nurse note documented, Pt has been increaslingly (sic) tearful this shift. She is unable to verbalize why she is upset. POA [Power of Attorney] was called and visited. POA is concerned the behaviors may be caused by a UTI [urinary tract infection] or that the pt may need an increase in her antidepressant medication. PCC [sic] notified. b. On 11/9/23 at 10:34 PM, the nurse note documented, Pt had resident [374] who was in her room. She felt uncomfortable and asked me to get him out of her room. Pt's roommate claimed he had been in there earlier that day as well. c. On 1/18/24 at 4:45 PM, the nurse note documented, Resident has an episode of sadness and crying and requested for her daughter to call her up. Had Tylenol for headache and requested to put her to bed. She is on antibiotic for UTI without adverse reaction noted. Resident has runny nose and cough and informed [provider name removed]. Will continue to monitor resident. On 4/28/21, a care plan for impaired cognitive function/dementia or impaired thought process was initiated. Interventions included: use the resident preferred name; identify yourself at each interaction; face the resident when speaking and make eye contact; reduce any distractions; provide necessary cues; reorient and supervise as needed; and monitor for any changes in cognitive function. Resident 12's Kardex documented, DO NOT ALLOW PT TO BE IN PRESENCE OF [RESIDENT 374] UNATTENDED. PT IS NOT TO BE LEFT ALONE WITH [RESIDENT 374] D/T [due to] INAPPROPRIATE BEHAVIOR. The facility abuse investigation, form 358, documented that on 11/13/23 at 3:30 PM, resident 12's Power of Attorney (POA) informed the ADM that resident 374 took resident 12 back to her room and the roommate [resident 36] heard kissing noises. The form documented that the date of the alleged incident was 7/13/23. The report documented that the residents were separated. On 11/13/23, the ADM interview with resident 374 documented Resident has BIMS of 4-5. Could not describe situation but denies kissing. On 11/13/23, the interview with resident 12 documented, Asked if she's been kissing perpetrator, she says 'yes'. Asked why she's kissing him, replied 'because it feels good'. Resident has BIMS of 4-5. Roommate says 'She wants to but she doesn't want to.' The facility final investigation, form 359, documented the steps to investigate the allegation was, Asked the victim if [resident 374] has been kissing her; replied 'Yes'. Asked why, she responded, 'because it feels good' and 'it tasted good'. The summary of interviews documented, Resident's roommate says that perpetrator has been coming back into the room with her after dinner. Then they go on the other side of the room and she hears kissing sounds. Says victim wants to do it, but also doesn't want to do it. The report documented that the perpetrator was mobile which made it difficult to monitor his location and staff observed resident 374 wheeling resident 12 around. The conclusion of the facility investigation documented, Evidence does not verify that abuse occurred. Victim says they've been kissing because it feels good. Both residents have dementia. The corrective action taken documented that the residents were separated and staff were notified to intervene if resident 374 tried to wheel resident 12 around or enter her room. The investigation included a form for Tips on Assessing Consent to Sexual Intimacy in Older Adults and documented questions to ask residents with impaired cognition to determine capacity to consent to physical/sexual intimacy. The form documented that the IDT should meet and review the residents most recent BIMS scores, any documentation of behaviors, change in condition, responsible party input when applicable, responses to questions and any input from a therapist regarding decision making abilities. The form stated that a summary note of findings that included a determination of whether residents could knowingly consent to physical/sexual intimacy should be documented and care planned. The form documented that after the assessment was completed and determined that one or both residents were unable to consent that the staff should ensure that residents were protected from sexual abuse or exploitation. It should be noted that no documentation could be found to demonstrate that the facility evaluated resident 12 or resident 374 for the capacity to consent to sexual activity. On 6/3/24 at 2:26 PM, an interview was conducted with resident 36 who was resident 12's roommate. Resident 36 stated that there was a male resident that kissed resident 12 and would not let go. Resident 36 stated that she could hear the kissing, but did not see it because resident 12 and resident 374 were behind the privacy curtain. Resident 36 stated that she could hear resident 12 whining like a whimper during this time. Resident 36 stated that resident 12 did not say anything during the kissing noises. Resident 36 stated that she only witnessed the one incident and she informed resident 12's POA about it. Resident 36 stated that the male resident [resident 374] tried to enter resident 12's room afterwards but the facility put a sign up that kept him out. Resident 36 stated that after the incident resident 12 was more quiet than usual. On 6/3/24 at 2:38 PM, an interview was conducted with resident 12. Resident 12 replied yes when asked if she had a relationship with a male resident at the facility in the past. Resident 12 was unable to say who the individual was, to recall their name, or to describe what the relationship was like. On 6/3/24 at 3:21 PM, an interview was conducted with CNA 10. CNA 10 stated that resident 12 was a two-person assist for transfers utilizing the sit to stand lift. CNA 10 stated that resident 12 could propel herself in a manual wheelchair. CNA 10 stated that resident 12 had occasional confusion and sometimes could not answer questions properly. CNA 10 stated that sometimes resident 12 could not identify the people in the pictures in her room. CNA 10 stated that a few months ago resident 374 wanted to talk to resident 12 and be close to he [TRUNCATED]

Based on interview and record review, it was determined the facility did not immediately consult with the 2 of 53 sample residents' physicians after there was a need to alter treatment significantly. Specifically, one resident had symptoms of a change in condition and the facility physician instructed the facility nurses to contact the surgeon, but no evidence could be located that this occurred. This resulted in the finding of a harm for this resident. In addition, a resident experienced elevated blood glucose levels without timely notification of the physician. Resident identifiers: 53 and 365. Findings included: Resident 365 was admitted to the facility on [DATE] with diagnoses that included spontaneous right patellar tendon rupture, encounter for other orthopedic aftercare, history of falling, and hypertension. Resident 365's entry Minimum Data Set (MDS) assessment indicated that facility staff assessed resident 365 as having a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident was cognitively in tact. Resident 365's medical record was reviewed from 6/2/24 through 6/6/24 and revealed the following: a. On 9/24/22 a nurses note documented: Pt [patient] arrived to facility via wheelchair from [name of local hospital]. Pt had a right knee repair surgery 9/23. Pt is alert and oriented x4, moves upper extremities equally, is non weightbearing on RLE [right lower extremity], able to move LLE [left lower extremity], sensation intact. Bowel sounds audible all lobes, abdomen soft and nontender, Pt reports that LBM [last bowel movement] was 9/23 in the morning. Pt is incontinent of bowel and bladder, Pt has briefs, wipes, and cream in room for bowel care. Pt is alert, able to verbalize needs . b. On 9/26/22 a nurses note documented: Pt was c/o [complaining of] excruciating bladder spasms. The pt was not seen by his primary, [name of physician], this shift to express his concerns or symptoms. Pt asked RN [Registered Nurse] to ask house MD to do something to give him relief. RN messaged [name of physician] and received orders for a one time dose of 200mg of pyridium. RN administered medication and assessed pt 45 min after and he stated that he feels better and the spasms stopped. pt is alert and able to verbalize needs to staff, tolerated medications whole without complications . : c. An MD [Medical Doctor] Communication form dated 9/26/22, two days after resident 365 was admitted , revealed the following: . Concern: pt admitted Sat [Saturday] - is concerned he is developing infection, wants to see MD and discuss concerns. NEW ORDER 1 - Notify his ortho [orthopedic] Dr [doctor] who operated on him ASAP [as soon as possible] ! 2 - I will see him after clinic today. [Note: No documentation could be located to indicate that the physician saw resident 365 that day, or that facility staff had contacted the orthopedic surgeon during resident 365's stay. ] d. On 9/28/22 at 12:26 AM a nurses note documented: . pt had an episode of forgetfulness and confusion this shift. Pt was found sitting on the side of his bed. Staff asked what he was doing, pt stated that he was going to the bathroom. Staff reminded him that he is NWB [non weight bearing] on his R [right] knee and could not walk to the bathroom. Staff got him into bed safely, his R knee is bleeding through the bandage . e. On 9/28/22 at 9:41 AM a nurses note documented: . Pt is alert, able to verbalize needs, takes medications whole, . Night nurse reported that Pt had an episode of confusion last night, Nurse went in this AM [morning] to assess Pt. Pt has diminished lung sounds in the bases, SOBLF (?) and SOBOE [shortness of breath on exertion]. Pt's neuro [neurological] assessment showed minimal left sided facial weakness, moves all extremities equally, denies any numbness or tingling, no changes in sensation, or H/A [headache]. MD has been notified of situation. f. On 9/28/22 at 10:46 AM a nurses note documented: . As ordered by MD, nurse tried to contact surgeon about duration of Bactrim. Unable to reach them, Nurse left a message for the surgeon's office . [Note: This is two days after the physician wrote a note to contact the orthopedic physician for resident 365 as soon as possible regarding the resident's possible infection.] g. On 9/29/22, a nurses note documented: . Resident is alert and verbally responsive, able to make needs known. Resident c/o bladder spasms and not being able to void. Bladder scanned and 85 cc [cubic centimeters] residual noted. MD notified. h. On 9/29/22, the facility physician documented the following in a physician's note: . [Resident 365] .reported pain to his abdomen that started during physical therapy, pain us located to RLQ [right lower quadrant], upon examination no hernia or any other abnormalities were noted. Claims that is able to control bladder and bowels. However, he is experiencing bladder spasms with little urine output post spasms. Denies prior or similar problems prior to this surgery. Reported last PSA [Prostate Specific Antigen] levels were done back in January with normal results. Physician will place patent [sic] on Flomax . i. On 9/29/22 resident 365's blood pressure was 144/81. j. On 9/30/22 at 4:51 PM, resident 365's blood pressure was 143/76. k. On 9/30/22 at 4:52 PM, resident 365's blood pressure was 177/85. l. On 10/1/22 at 12:05 AM, a nurses progress note documented: Resident found on floor next to recliner and walker . When asked resident what happened he said he was not sure.No c/o pain. Resident already has baseline hx [history] of confusion and falls upon admission. Resident has no s/s [signs and symptoms] of injury at this time. No complaints of pain or distress. Resident educated on importance of call light and demonstrated its use. RLE [knee] dressing changed and inspection of surgical site completed. surgical scar well approximated, all staples intact and in place and trace drops of drainage. No swelling, redness, and surgical site is cool to the touch. Clean dressing re applied, wrapped, and ble knee brace secured . Will notify, PCP [primary care physician], family and on call administrator of incident and continue to monitor closely. m. On 10/1/22 at 8:30 PM a nurses progress note documented: resident POA [power of attorney] contacted staff and communicated concern regarding residents increased confusion . Family very concerned and request to send to ER [emergency room ]. PCP contacted . transfer was completed. Will continue to monitor closely. n. On 10/2/22 at 10:16 AM a nurses progress note documented that the resident had been admitted to the hospital, and was in the intensive care unit. On 6/6/24 at 8:43 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that with regard to the physician note written about resident 365 on 9/26/22, STAT would have been a better word to use than asap. The RNC also stated that the facility nurses should have reached out after the doctor said to get in contact with the orthopedic surgeon. The RNC stated that best practice is to reach out and get a UA with the bladder spasms and excruciating pain. The RNC stated that the facility could still get a culture and sensitivity on a urinalysis even if the resident was on an antibiotic already. The RNC stated that the doctor should have ordered a UA and culture and sensitivity. The RNC did not have any other information regarding the facility's lack of response to the change of condition in resident 365. 30563 2. Resident 53 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, anxiety disorder, adult failure to thrive and diabetic foot ulcer. Resident 53's medical record was reviewed 6/2/24 through 6/6/24. A Other payment assessment MDS dated [DATE] revealed resident 53 had diabetes mellitus. A care plan dated 12/18/23 and updated on 1/2/24 revealed [Resident 53] has Diabetes Mellitus type II. The goal was [Resident 53] will have no complications related to diabetes through the review date. The interventions were Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness; Monitor PRN [as needed] any s/sx [signs and symptoms] of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd [abdominal] pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma; Monitor PRN any s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Physician's orders revealed the following: a. Start date of 2/27/24, Insulin Lispro Injection Solution 100 UNIT/ML [milliliter] (Insulin Lispro) Inject as per sliding scale: if 60 - 80 = 0; 81 - 150 = 2 units (u); 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 14 units, subcutaneously with meals for DM2 Notify Md if pt BS [blood sugar] >60 or <400. b. A start date of 2/27/24 revealed, Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 61 - 200 = 0 u; 201 - 250 = 2 u; 251 - 300 = 4 u; 301 - 350 = 5 u; 351 - 400 = 7 u, subcutaneously at bedtime for blood sugars. c. A start date of 12/13/23 and an discontinue date of 3/29/24 revealed, AC [before meals]/HS[at bed time] Blood Sugars before meals and at bedtime for DM Notify MD if pt's BS <60 or >400. d. On 4/24/24 at 7:00 AM, **DO NOT CHANGE THE TIMES** Blood sugar checks prior to meals before meals and at bedtime for DM2 monitoring. The March 2024, April 2024 and May 2024 MARs revealed the following blood sugars: a. On 3/9/24 at 8:00 AM, BS was 404. b. On 3/22/24 at 9:00 PM, BS was 400. c. On 3/28/24 at 9:00 PM, BS was 407. d. On 4/2/24 at 9:00 PM, BS was 400. e. On 4/5/24 at 9:00 PM, BS was 546. f. On 4/7/24 at 5:00 PM, BS was 414. g. On 4/11/24 at 9:00 PM, BS was 400 h. On 4/12/24 at 5:00 PM, BS was 517. i. On 4/12/24 at 9:00 PM, BS was 500. j. On 4/16/24 at 9:00 PM, BS was 464. k. On 4/18/24 at 8:00 AM, BS was 1211. l. On 4/26/24 at 8:00 AM, BS was 437. m. On 5/2/24 at 9:00 PM, BS was 404. n. On 5/3/24 at 8:00 AM and 5:00 PM, BS was 404. o. On 5/4/24 at 9:00 PM, BS was 461. p. On 5/6/24 at 9:00 PM, BS was 466. q. On 5/11/24 at 9:00 PM, BS was 404. r. On 5/15/24 at 5:00 PM, BS was 12. s. On 6/3/24 at 7:00 AM, BS was 430. There was no documentation located in resident 53's medical record that the physician was notified of the blood sugars less than 60 and over 400. On 6/6/24 at 7:54 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated when a resident needed a blood sugar obtained a notification came up to alert the nurses in the electronic medical record. LPN 3 stated after obtaining the sample she looked at the physicians order to determine how much insulin needed to be administered. LPN 3 stated if a BS was below 60 or over 400 she would contact the physician to see what the physician wanted her to do. LPN 3 stated high and low blood sugars could cause harm to the resident, so that was why the physician needed to be notified. On 6/6/24 at 8:00 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated if a resident was ordered to have sliding scale insulin, then she would administer the insulin according to the residents blood sugar. ADON 1 stated there was a standing physician's order to contact the physician if the BS is below 60 or above 400. ADON 1 stated she would think the nurse documented the physician notification in the residents progress notes. ADON 1 stated sometimes if the resident refused the insulin, then a progress note popped up in the electronic medical record for the staff to document. ADON 1 stated if a resident's BS was high, the resident could go to Ketoacidosis, and it could be life threatening. ADON 1 stated she was unable to find the physician was notified in resident 53's medical record. On 6/6/24 at 9:16 AM, an interview was conducted with the RNC. The RNC stated residents with sliding scale insulin should have BS parameters and when to notify the physician. The RNC stated generally BS under 60 and BS over 400, the physician should be notified. The facility's policy for Change in a Resident's Condition or Status was reviewed. The policy indicated the following: Our facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . g. need to transfer the resident to a hospital/treatment center; . i. specific instruction to notify the physician of changes in the resident's condition. 2. A 'significant change' of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. impacts more than one area of the resident ' s health status; c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider .

Based on observation, interview and record review it was determined, for 1 of 53 sampled residents, that the facility must assist a resident in making appointments and arranging for transpiration to and from the dental services location. Specifically, a resident had teeth extracted and there was no follow-up appointment for dentures scheduled. Resident identifier: 53. Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paroxysmal atrial fibrillation, fibromyalgia, type 2 diabetes mellitus, obesity and major depressive disorder. On 6/3/24 at 9:56 AM, an interview was conducted with resident 7. Resident 7 stated she had her teeth extracted. Resident 7 stated she was wondering when she was getting dentures. Resident 7 stated she had not been to a follow-up appointment after having her teeth extracted. Resident 7's medical record was reviewed on 6/2/24 through 6/6/24. A nursing progress note dated 3/26/24 at 3:50 PM, Spoke with [name removed] surgical regarding PT [patient] surgery in the morning. PT to be NPO [nothing by mouth] after 0045 [12:45 PM]; may take BP [blood pressure] medication in morning if necessary. Faxed over health history. The next progress note was 4/1/24 at 2:02 PM from the Nutrition/Dietary note. The note revealed .RDN [Registered Dietitian Nutritionist] spoke with resident about mouth pain. Resident had all teeth pulled and needs altered texture. There were no notes regarding monitoring of resident 7 after having dental surgery. On 6/4/24 at 1:16 PM, an interview was conducted with the Resident Advocate (RA). The RA stated there was a dental service that came to the facility and saw residents. The RA stated she put together a list of residents to be seen. The RA stated if the resident was not able to see the dental service company that came to the facility, then the transportation driver scheduled the appointments. The RA stated resident 7 had dental work done outside the facility. The RA stated she did not know about dental appointments outside of the facility and the Transportation Driver knew about it. On 6/6/24 at 8:30 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated she was aware that resident 7 had a dental procedure. ADON 1 stated when a resident returned to the facility after a surgical procedure, the physicians sent guidance and orders to care for the resident. ADON 1 stated the nurse needed to complete a progress note regarding the surgical procedure, what the physician ordered, what to monitor and when there was a follow-up appointment. ADON 1 stated after a dental procedure, nursing staff should monitor for pain and bleeding. ADON 1 confirmed there was no monitoring of resident 7 after the dental procedure. ADON 1 was unable to find orders from the dentist or information regarding the dental procedure. The ADON stated she did not know about dentures or an appointment for resident 7. On 6/6/24 at 8:58 AM, a follow-up interview was conducted with resident 7. Resident 7 stated she had not heard anything about getting dentures. Resident 7 stated she had asked staff about her follow-up appointment for dentures but staff did not know anything. On 6/5/24 at 9:13 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated they were not aware that resident 7 had teeth extracted and needed dentures. LPN 1 stated there was a transport director that scheduled appointments. LPN 1 was observed to review nursing progress notes. LPN 1 stated there was a note from resident 7's physician on 6/4/24 that resident 7 needed to be fitted for dentures. On 6/5/24 at 3:48 PM, an interview was conducted with the Transport Driver. The Transport Driver stated she scheduled appointments. The Transportation Driver stated resident 7 did not have a follow-up dental appointment scheduled. The Transport Driver stated she transported resident 7 to a dental appointment a couple of months ago. On 6/6/24 at 9:01 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated after a resident had teeth extracted, nurses should monitor for bleeding, fever, and sign and symptoms of infection. The RNC stated usually a resident received prophylactic antibiotics after having teeth extracted and there would be alert charting by nurses. The RNC stated resident 7 was provided a follow-up dental appointment on 5/6/24 but there was no information regarding dentures on the form. The RNC stated there was no follow-up or monitoring of resident 7 after having her teeth extracted. The RNC stated she did not know about dentures for resident 7. Additional information provided by the facility on 6/10/24 revealed an email from an outside dental service dated 6/6/24 at 12:26 PM. The email revealed [Name of company] referred [resident 7] to [name removed] Oral surgery for 28 teeth to be extracted on March 27th. This was a near full mouth extraction which can cause lots of swelling. We try to allow 6-8 weeks for the mouth to heal before we do an impression. We have [name of doctor removed] scheduled at another facility Saturday and asked if he could swing by [name of facility] after to get impressions for dentures. If [resident 7] isn't seen Saturday 6/8, she will be seen the following week. I will contact you with the date if needed. It should be noted that it was 10 weeks since resident 7's extractions.

Based on interview and record review it was determined that for 2 out 53 sampled residents, that the facility did not ensure that the resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to extent possible. Specifically, a resident developed a UTI after facility staff were not instructed and trained on the proper changing, frequency, and monitoring of the resident's PureWick urinary system device and a resident had a delay in starting antibiotic therapy for a UTI. Resident identifiers: 36, 54. Findings Included: 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included cervical disc disorder, primary osteoarthritis, type 2 diabetes with neuropathy, hypothyroidism, morbid obesity, weakness, muscle weakness, anxiety, obstructive sleep apnea, hypertension, and a history of falling. Resident 54's medical record was reviewed 6/2/24-6/6/24. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 54 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 would suggest intact cognition. A care plan Focus addressing toileting cares initiated on 2/8/24, documented [Resident 54] has a risk for bladder incontinence and requires assistance with toileting cares r/t [related to] activity intolerance. The interventions included: a. Clean peri-area after each incontinent episode b. [Resident 54] uses a PureWick system for her incontinence c. Monitor and document intake and output per facility policy d. Monitor/document for s/sx [signs and symptoms] UTI [urinary tract infection]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp [temperature], urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns Review of Resident 54's physician orders revealed the following: a. Urinalysis (UA) for dysuria one time only. This order was initiated on 3/1/24. b. Macrobid Oral Capsule 100 milligrams (mg) (Nitrofurantoin Monohyd Macro), Give 1 capsule by mouth two times a day for UTI for 7 days. The order was initiated on 3/6/24 and discontinued on 3/14/24. The medication was documented as administered on 3/6/24 through 3/13/24. Review of resident 54's progress notes revealed the following: a. On 3/1/24 at 1:34 PM, the note documented, .ordered UA for dysuria. b. On 3/1/24 at 3:33 PM, the noted documented, obtained UA. c. On 3/2/24 at 3:35 PM, the note documented, Received UA results, no Bacteria noted. Sent copy to PCP [primary care physician]. d. On 3/6/24 at 10:49 AM, the note documented, UA sensitivity results received from lab. <100,000 CFU/ml E. Coli. [Escherichia coli] MD [medical doctor] notified. New orders from Macrobid 100mg BID [twice a day] x 7 days. Ordered from .Pharmacy, NP [nurse practitioner] gave ok to start first dose HS [hour of sleep]. On 6/2/24 at 2:38 PM, an interview was conducted with resident 54. Resident 54 stated she personally purchased the PureWicks that were used. Resident 54 stated she had a urinary tract infection a few months ago and was given an antibiotic. On 6/4/24 at 9:27 AM, a follow-up interview was conducted with resident 54. Resident 54 stated that CNAs changed the PureWick once daily. Resident 54 stated she trained the CNA's on how to change the PureWick. Resident 54 stated 32 PureWicks come in a box and she purchased them monthly as she used one box a month. Resident 54 stated she informed staff when to change the PureWick. On 6/4/24 at 9:33 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated resident 54's orders are to monitor PureWick while she is in bed. LPN 2 stated she did not know when the PureWick got changed or how often. On 6/4/24 at 9:44 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated there was not a directive order for the PureWick and he was unaware how often it got changed. On 6/4/24 at 9:56 AM, an interview was conducted with Certified Nurse Assistant (CNA) 4. CNA 4 stated there was not a place to chart that the PureWick was changed. CNA 4 stated she was not sure that changing the PureWick was a CNA task. On 6/4/24 at 1:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was unaware that any residents in the facility used a PureWick. On 6/4/24 at 1:35 PM, an interview was conducted with the DON and Minimum Data Set (MDS) Coordinator. The DON stated that CNAs did not document in the medical record with regards to the PureWick. The MDS Coordinator stated that CNAs were to change the PureWick at 4:00 AM and 4:00 PM. On 6/6/24 at 9:20 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that facility staff had not received training on the PureWick urinary device. 38031 2. Resident 36 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, polyosteoarthritis, malignant neoplasm of the ovary, chronic fatigue, morbid obesity, anxiety disorder, bipolar disorder, peripheral neuropathy, presence of left and right artificial knee joint, insomnia, and restless leg syndrome. On 6/02/24 at 2:18 PM, an interview was conducted with resident 36. Resident 36 stated she had frequent urinary tract infections (UTI) and may have a one now. Resident 36 stated that she had pain in her pelvis/abdomen area and burning with urination. Resident 36 stated that she gave a urine sample but she does not know the results of the urinalysis. On 6/05/24, resident 36's medical records were reviewed. On 3/1/24, resident 36's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status score of 14/15, which indicated the resident was cognitively intact. The assessment documented that resident 36 required a one-person physical assistance with supervision for bed mobility, transfers, and toilet use. On 1/9/24, the provider progress note documented that the resident had a history of UTI. UTI: Patient still feels that she has a bladder infection. She is generally not feeling well and has dysuria. She stopped her antibiotics about 4 days ago. The physician's assessment and plan documented, Patient with a UTI, will continue to monitor for now and follow up. We will check a UA and follow up with results. On 1/9/24, resident 36's provider ordered a UA with a culture and sensitivity (C & S). On 1/12/24, resident 36's urinalysis results documented the appearance of the specimen as slightly cloudy, with 1+ bacteria and 1+ mucus in the sample. On 1/12/24, resident 36's urine culture revealed Klebsiella pneumoniae as the infectious organism and it was susceptible to Nitrofurantoin or Macrobid. On 1/15/24 at 8:00 PM, a physician order for Macrobid Oral Capsule 100 milligrams (mg) two times a day for UTI for 5 days was entered for resident 36. Resident 36's Medication Administration Record (MAR) documented the Macrobid 100 mg by mouth two times a day was administered on 1/16/24 through 1/21/24 for a total of 9 doses administered. It should be noted that the medication order was for a total of 10 doses to be administered. On 1/15/24, the evening dose documented to see the progress note. On 1/16/24 at 11:19 PM, the MAR documented that Ceftriaxone Reconstituted 1 gram intramuscular injection, one time only for UTI was administered. Resident 36's progress notes revealed the following: a. On 1/1/24 at 8:06 PM, the note documented, Resident finished last dose of Macrobid for UTI, no ADR [adverse drug reaction] observed or reported. b. On 1/9/24 at 2:24 PM, the note documented, Received orders from [name of provider omitted] to do a repeat UA on this pt. [patient] received UA via straight cath per pt request. c. On 1/15/24 at 5:09 PM, the note documented, received orders from [name of provider omitted] to start this pt on macrbid (sic) 100 mg tab [tablet] BID [two times a day] for 5 days. d. On 1/15/24 at 7:43 PM, the progress note documented that the Macrobid had not arrived from the pharmacy. e. On 1/17/24 at 4:43 PM, the note documented, Pt on abx [antibiotic] for UTI. No adverse reactions noted. Pt is more unsteady on feet than at baseline. [NAME] in reach. Pt encouraged to wait for assistance before toileting or ambulating. f. On 1/21/24 at 3:08 PM, the note documented, Resident finished course of Macrobid for UTI. No ADR observed or reported. Fluids encouraged. On 6/04/24 at 2:39 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4. The LPN stated they could get lab results back within a day or two, depending on if it was ordered immediately. The LPN stated that they documented a progress note to show that the lab order was completed, and it could be passed on in report for the next shift to follow up with the results. The LPN stated that the results were faxed to them. The LPN stated that once they reviewed the results they placed the results in the medical records basket to be scanned into the resident chart and notified the provider by the communication app or by telephone. The LPN stated that they would then document that the provider was notified in a progress note. On 6/04/24 at 2:46 PM, an interview was conducted with LPN 1. LPN 1 stated that it usually took 1-2 days to get lab results back. LPN 1 stated that they obtained the lab specimens and entered a progress note that it was completed. LPN 1 stated that it was passed off in report to the next shift. LPN 1 stated that if there were questions about labs they had documentation of when it was sent in the progress notes. LPN 1 stated that they could also call the lab and follow-up on the results. On 6/05/24 at 8:02 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that the nurses should manage all of their patient's lab orders. The RNC stated that when the nurse sent a specimen they should follow-up with the lab for results by the end of the day and if it was ordered stat they should follow-up within a couple of hours. The RNC stated that the nurse should notify the provider immediately if the results were critical, otherwise the result was placed in the provider binder for review. The RNC stated that resident 36 had a lot of UTIs that were escherichia-coli associated. The RNC stated that they provided education with the aides on proper wiping from front to back. The RNC stated that resident 36's UA with C & S was ordered on 1/9/24 and results were obtained on 1/12/24. The RNC stated that the culture showed the organism as Klebsiella. The RNC stated that resident 36 was treated with Macrobid on 1/15/24 and Ceftriaxone on 1/16/24, and that the culture showed it was susceptible to both antibiotics. The RNC stated that it was not an appropriate timeframe for the treatment of the UTI. The RNC stated that treatment was dependent on the results of the culture and sensitivity report. The RNC stated that they had a difficult time getting this provider to respond. The RNC stated that if the nurses were not able to reach resident 36's provider they should call the facility medical director within 24 hours and then notify the Director of Nursing. 46232

Based on interview and record review it was determined, 7 of 53 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to thoroughly investigate and report the results of all investigations to the State Survey Agency (SSA) within 5 days of the incident. Specifically, medication was left in a resident room and the resident had not been evaluated for safe self-administration, missing fentanyl patches for multiple residents, hot coffee was thrown on a resident and resulted in skin redness, an allegation of sexual abuse in which a resident had been kissed and a resident eloped from the facility. Resident identifiers: 5, 12, 31, 42, 43, 368, and 374. Findings Included: 1. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. On 6/5/24 at 11:44 AM, an observation was made of resident 5 in their room. Resident 5 was brought back to their room by the licensed practical nurse (LPN) 4 and regional nurse consultant (RNC). The RNC and LPN 4 informed resident 5 they needed to look at their back. The RNC and LPN 4 helped lean resident 5 in the chair and pulled their shirt up. Resident 5's back was observed, and no fentanyl patch was located on their back. Resident 5's medical record was reviewed on 6/3/24 to 6/6/24. On 4/4/24, a Quarterly Minimum Data Set (MDS) documented resident 5 had a Brief Interview for Mental Status (BIMS) score of 1 which indicated severe cognitive impairment. Resident 5's physician orders were reviewed and documented the following fentanyl patch orders: a. An order with a start date of 4/22/24 documented, Fentanyl- Remove Fentanyl Patch - Co-signature With Another Nurse Upon Narcotic Destruction (q [every] 3days). every 72 hours. b. An order with a start date of 4/23/24 documented, Check fentanyl patch placement. every shift for pain. c. A physician order with a start date of 5/16/24 documented, FentaNYL Patch 72 Hour 75 micrograms (MCG)/hour (HR.) Apply 1 patch transdermally every 72 hours for pain and remove per schedule. Resident 5's progress notes were reviewed from April 2024 to June of 2024 and documented the following notes for resident 5's fentanyl patch: a. On 4/21/24 at 10:57 PM, a nurse note documented, [name and hospice name removed] will be coming 04/22/24 at the facility to give a written order from MD [medical doctor] per RN [registered nurse] [name removed]. She reported having a new order for Fentanyl Will clarify the orders resident had before before [sic] giving a new orders. b. On 4/22/24 at 2:58 PM, an orders administration note documented, Fentanyl- Remove Fentanyl Patch - Co-signature With Another Nurse Upon Narcotic Destruction (q3days). every 72 hours. first patch placed today 4/22. c. On 5/1/24 at 5:44 PM, an orders administration note documented, fentaNYL Transdermal Patch 72 Hour 50 MCG [micrograms]/HR [hour]. Apply 1 patch transdermally every 72 hours for pain and remove per schedule. unable to find; confirmed with second nurse. d. On 5/4/24 at 5:46 PM, an orders administration note documented, Check fentanyl patch placement every shift for pain. old patch not located. e. On 5/5/24 at 12:24 PM, an orders administration note documented, Check fentanyl patch placement every shift for pain. no patch on resident. f. On 5/7/24 at 2:51 PM, an orders administration note documented, fentaNYL Transdermal Patch 72 Hour 50 MCG/HR. Apply 1 patch transdermally every 72 hours for pain and remove per schedule. Old patch not present. g. On 5/7/24 at 3:56 PM, an orders administration note documented, Fentanyl- Remove Fentanyl Patch - Co-signature With Another Nurse Upon Narcotic Destruction (q3days). every 72 hours. No patch present. h. On 5/18/24 at 3:04 PM, an orders administration note documented, Check fentanyl patch placement. every shift for pain. no patch noted. i. On 5/19/24 at 2:12 PM, an orders administration note documented, Fentanyl- Remove Fentanyl Patch - Co-signature With Another Nurse Upon Narcotic Destruction (q3days). every 72 hours. not on resident. j. On 5/19/24 at 4:13 PM, an orders administration note documented, FentaNYL Patch 72 Hour 75 MCG/HR. Apply 1 patch transdermally every 72 hours for pain and remove per schedule. not on resident. k. On 5/25/24 at 1:16 PM, an orders administration note documented, Fentanyl- Remove Fentanyl Patch - Co-signature With Another Nurse Upon Narcotic Destruction (q3days). every 72 hours. old patch was not found. l. On 5/29/24 at 6:05 PM, an orders administration note documented, Check fentanyl patch placement every shift for pain. fentanyl patch not found. m. On 6/1/24 at 2:59 PM, an order administration note documented, Check fentanyl patch placement every shift for pain. not on resident. It should be noted there was no documentation located to indicate an investigation had been done on resident 5's fentanyl patches. On 6/5/24 at 11:09 AM, an interview was conducted with certified nursing assistant (CNA) 7. CNA 7 stated resident 5's patch came off when they had cleaned her. CNA 7 stated they had it aside and put it in the trash can. CNA 7 stated they had informed the nurse, but they didn't have a chance to notify other staff. CNA 7 stated the trash had just been thrown away. CNA 7 stated they were unsure how medications were disposed of since they did not deal with medications. On 6/5/24 at 11:32 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated the Minimum Data Set Coordinator (MDSC) had just thrown resident 5's trash away and they were not aware a medication patch had been discard of in there. The RNC stated they were going to inform the MDSC to look for the trash bag in the dumpster and to have them locate the patch. 2. Resident 42 was admitted to the facility on [DATE] with the following diagnoses of Delirium, unspecified dementia, moderate, with psychotic disturbance, anxiety disorders, cognitive communication deficit, and major depressive disorder. Resident 42's medical records were reviewed on 6/5/24 to 6/6/24. On 5/31/24, a Quarterly BIMS assessment was done and documented resident 42 had severe cognitive impairment. Resident 5's physician orders were reviewed and documented the following fentanyl patch orders: a. An order with a start date of 4/8/24 and end date of 6/3/24 documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift. every shift. b. An order with a start date of 4/10/24 and end date of 5/1/24 documented the following, Fentanyl- Remove Fentanyl Patch & Provide To DON [Director of Nursing] /RN [Registered Nurse] Designee For Narcotic Destruction (q3days) one time a day every 3 day(s). c. An order with a start date of 4/22/24 and end date of 5/1/24 documented, fentanyl Transdermal Patch 72 Hour 12 MCG/HR. **DAW [Dispense as written]** Apply 1 patch transdermally in the evening every 3 day(s) for Pain. d. An order with a start date of 5/1/24 and end date of 5/5/24 documented, fentanyl Transdermal Patch 72 Hour 12 MCG/HR. **DAW** Apply 2 patch transdermally in the evening every 3 day(s) for Pain. e. An order with a start date of 5/1/24 and end date of 6/3/24 documented, Fentanyl- Remove Fentanyl Patch & Provide To DON/RN Designee For Narcotic Destruction (q3days) one time a day every 3 day(s). f. An order with a start date of 5/5/24 and end date of 6/4/24, documented, fentanyl Transdermal Patch 72 Hour 12 MCG/HR. **DAW** Apply 2 patch transdermally in the evening every 3 day(s) for Pain. Resident 42's progress notes were reviewed from March 2024 to June 2024 and documented the following notes for resident 42's fentanyl patch: a. On 3/22/24 at 8:42 PM, a late entry nurse note stated, SN [skilled/staff nurse] had been looking through out the day to see if a Fentanyl patch had been placed, could not find one, and placed a new one. It may be that behaviors could be from pain as we do not know how long she has been with out this pain medication. b. On 4/21/24 at 10:54 AM, an orders- administration note documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift.every shift. unable to find; verified by 2 nurses. c. On 4/24/24 at 6:31 PM, an orders- administration note documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift. every shift. fentanyl patch not noted on patient since 04/20. No new one placed. d. On 5/1/24 at 1:24 PM, an orders-administration note documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift. every shift. not on pt [patient]. e. On 5/1/24 at 2:53 PM, an orders- administration note documented, Fentanyl- Remove Fentanyl Patch & Provide To DON/RN Designee For Narcotic Destruction (q3days) one time a day every 3 day(s). no fentanyl patch present; placing new one f. On 5/19/24 at 2:11 PM, an orders- administration note documented, Fentanyl- Remove Fentanyl Patch & Provide To DON/RN Designee For Narcotic Destruction (q3days) one time a day every 3 day(s). not on resident. g. On 5/19/24 at 2:11 PM, an orders- administration note documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift every shift. not on resident. h. On 5/28/24 at 4:06 PM, an orders- administration note documented, Fentanyl- Remove Fentanyl Patch & Provide To DON/RN Designee For Narcotic Destruction (q3days). one time a day every 3 day(s). Fentanyl patch not found. i. On 6/3/24 at 4:47 PM, a Nurse Practitioner note documented, .She has been having a hard time getting pain relief. She tears of her pain patches, so they are not working. We went back to pill for to try and help her . j. On 6/4/24 at 1:47 PM, an orders- administration note documented, fentaNYL Transdermal Patch 72 Hour 12MCG/HR**DAW** Apply 2 patch transdermally in the eveningevery 3 day(s) for Pain. Dr. [doctor] discontinued these patches due to resident continually removing them. It should be noted there was no documentation located to indicate an investigation had been done on resident 42's fentanyl patches. 3. Resident 43 was admitted to the facility on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, hypothyroidism, muscle wasting, adult failure to thrive, nicotine dependence, and osteoarthritis. Resident 43's medical records were reviewed. On 4/11/24, a Quarterly BIMS assessment documented resident 43 had a score of 0 which indicated severe cognitive impairment. Resident 43's physician orders were reviewed and documented the following fentanyl patch orders: a. An order with a start date of 8/25/23 and end date of 6/6/24 documented, FentaNYL Patch 72 Hour 75 MCG/HR. Apply 1 patch transdermally every 72 hours for pain and remove per schedule. b. An order with a start date of 9/13/23 and end date of 6/6/24 documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift. c. An order with a start date of 9/15/23 and end date of 6/6/24 documented, Fentanyl- Remove Fentanyl Patch - Co-signature With Another Nurse Upon Narcotic Destruction (q3days) one time a day every 3 day(s). Resident 43's progress notes were reviewed from April 2024 to June 2024 and documented the following notes for resident 42's fentanyl patch: a. On 4/27/24 at 6:04 PM, an Administration Note documented, Fentanyl- Remove Fentanyl Patch - Co-signature With Another Nurse Upon Narcotic Destruction (q3days). one time a day every 3 day(s). CNA and I both searched her back and found no prior fentanyl patch. b. On 4/29/24 at 7:49 PM, an Administration Note documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift. every shift. Patch is not on Resident. c. On 4/30/24 at 12:07 PM, an Administration Note documented, FentaNYL Patch 72 Hour 12 MCG/HR. Apply 1 patch transdermally every 72 hours for pain and remove per schedule. fentanyl patch not found on pt. another one was placed. d. On 5/2/24 at 7:53 PM, an Administration Note documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift. every shift. Patch is not in place. e. On 5/5/24 at 1:56 PM, an Administration Note documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift. every shift. unable to find patch. f. On 5/6/24 at 8:56 AM, an Administration Note documented, Fentanyl- Remove Fentanyl Patch - Co-signature With Another Nurse Upon Narcotic Destruction (q3days). one time a day every 3 day(s). No patch located on patient. g. On 5/11/24 at 7:12 PM, an Administration Note documented, FentaNYL Patch 72 Hour 12 MCG/HR Apply 1 patch transdermally every 72 hours for pain and remove per schedule .could not find patch anywhere on residents body. h. On 5/12/24 at 9:14 AM, an Administration Note documented, Fentanyl- Remove Fentanyl Patch & Provide To DON/RN Designee For Narcotic Destruction (q3days) one time a day every 3 day(s). Patch was not on resident and was not found. i. On 5/1/7/24 at 9:20 PM, an Administration Note documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift .Fentanyl patch is missing. j. On 5/18/24 at 4:08 PM, an Administration Note documented, Fentanyl- Remove Fentanyl Patch & Provide To DON/RN Designee For Narcotic Destruction (q3days). one time a day every 3 day(s). no patch noted. Verified by 2 nurses. k. On 5/21/24 at 3:58 PM, an Administration Note documented, Fentanyl- Remove Fentanyl Patch & Provide To DON/RN Designee For Narcotic Destruction (q3days) one time a day every 3 day(s). Fentanyl patch was not found on Resident or anywhere in her room. l. On 5/23/24 at 6:53 PM, an Administration Note documented, .We were not able to find if her Fentanyl patch was still in place. The oncoming evening nurse acknowledged this and will attempt to check for it. m. On 5/27/24 at 12:04 PM, an Administration Note documented, FentaNYL Patch 72 Hour 12 MCG/HR. Apply 1 patch transdermally every 72 hours for pain and remove per schedule. no patch on pt. n. On 6/1/24 at 10:48 PM, an Administration Note documented, Fentanyl- Check Placement Of Fentanyl Patch Every Shift. every shift. not present on resident. o. On 6/2/24 at 2:26 PM, an Administration Note documented, FentaNYL Patch 72 Hour 12 MCG/HR. Apply 1 patch transdermally every 72 hours for pain and remove per schedule. not on resident. p. On 6/5/24 at 2:01 PM, an Administration Note documented, FentaNYL Patch 72 Hour 12 MCG/HR Apply 1 patch transdermally every 72 hours for pain and remove per schedule. No patch found. Nurse manager notified. It should be noted there was no documentation located to indicate an investigation had been done on resident 43's fentanyl patches. On 6/5/24 at 10:24 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated they had three different types of narcotics which included pills, patches, and liquid medications. RN 2 stated they followed the physician orders with all medications. RN 2 stated with narcotics, nurses needed to sign them out to make sure they had been given correctly and following the protocol. RN 2 stated a fentanyl patch was considered a narcotic and it needed to be monitored daily if it was placed. RN 2 stated the fentanyl patch needed to be replaced every 3 days. RN 2 stated two nurses were needed to waste the old fentanyl patch. RN 2 stated the other nurse needed to co-sign and served as a witness that the old patch had been removed. RN 2 stated they notified the physician if it was noticed the fentanyl patch had been missing. RN 2 stated they asked the physician if they needed to replace the patch and adjust the timing of the order. RN 2 stated fentanyl patches were placed on a residents upper body if they were alert and oriented. RN 2 stated if a resident was confused, the fentanyl patch was placed in an area where they were unable to reach such as their back. RN 2 stated they documented where the fentanyl patch was placed so other nurses knew where it was located. RN 2 stated when they were unable to find the fentanyl patch, a progress note was written. RN 2 stated the DON became aware of the missing fentanyl patch by reading the progress note. RN 2 stated resident 43 was known to remove their own fentanyl patch since staff were unable to the previous patch. On 6/5/24 at 10:49 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated nursed documented where the fentanyl patch had been placed. LPN 4 stated when the fentanyl patch was removed, two nurses were needed to sign off and waste it to ensure it had been disposed of properly and it had not been stolen. LPN 4 stated the fentanyl patches were placed on a spot the resident was not able to reach super well but there were some residents that took their patches off. LPN 4 stated resident 42 fentanyl patches had been discontinued due to them taking their patches off frequently. On 6/5/24 at 11:32 AM an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated fentanyl patches were signed out before they were applied on the resident. The RNC stated nurses handled narcotics. The RNC stated two nurse signatures were required when the fentanyl patches were wasted. The RNC stated the two signatures served as a verification purpose to ensure the patches were not used inappropriately. On 6/5/24 at 11:47 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2. The ADON 2 stated once a fentanyl patch had been administered, two nurses needed to sign off on it. The ADON 2 stated two nurses were needed to verify placement of the new fentanyl patch and the removal of the old fentanyl patch. The ADON 2 stated they needed to have two sets of eyes since it was a controlled substance and they needed to make sure the patch was recovered and placed correctly. The ADON 2 stated the old fentanyl patches needed to be discarded in the lock to assure they were not able to be used again. The ADON 2 stated the fentanyl patches needed to be placed out of reach on confused residents and a tegaderm needed to placed as well. The ADON 2 stated that it was unacceptable for nurses to documented they were unable to locate the patch. The ADON 2 stated if a fentanyl patch was not located, the nurse should notify nursing management immediately, so they were able to follow up on it. The ADON 2 stated if a fentanyl patch was missing, they conducted their own investigation in tracking the patch. The ADON 2 stated they were unaware of any fentanyl patch investigations for the month of may. On 6/5/24 at 12:58 PM, a phone interview was conducted with Registered Nurse (RN) 5. RN 5 described the process for fentanyl patches. RN 5 stated they first pulled the fentanyl patch out, then it was marked out in the medication administration record and lastly it was placed on the resident. RN 5 stated they looked for the old patch and removed it. RN 5 stated the old patch needed to be wasted with another nurse since the patch was a narcotic. RN 5 stated sometimes it was previously noted in the progress notes the fentanyl patch was not located. RN 5 stated when that occurred they found another RN to confirm it was not located and then they sign off the fentanyl had been wasted without it being located. RN 5 stated they had issues with the fentanyl patch not being placed. RN 5 stated they tried to notify the nurse administration when this happened and would try to do a note but it was forgotten when it got busy. RN 5 stated for resident ([NAME]) and resident 5, a tegaderm patch was placed on top of the fentanyl patch to secure it to the skin. RN 5 stated the fentanyl patch was placed on their back and out of reach. RN 5 stated they recently had an issue locating a resident's fentanyl patch and assumed the previous fentanyl patch had been removed but an new one had not been applied. 38031 4. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of encounter for palliative care, rheumatoid arthritis, type II diabetes mellitus, vascular dementia, polyneuropathy, pulmonary hypertension, hypertension, hyperlipidemia, aphasia, cerebral infarction, thrombophilia, hemiplegia and hemiparesis, anxiety disorder, and major depressive disorder. On 6/02/24, resident 12's medical records were reviewed. The facility abuse investigation, form 358, documented that on 11/13/23 at 3:30 PM, resident 12's Power of Attorney (POA) informed the Administrator (ADM) that resident 374 took resident 12 back to her room and the roommate [resident 36] heard kissing noises. The form documented that the date of the alleged incident was 7/13/23. The report documented that the residents were separated. On 11/13/23, the ADM interview with resident 374 documented Resident has BIMS of 4-5. Could not describe situation but denies kissing. On 11/13/23, the interview with resident 12 documented, Asked if she's been kissing perpetrator, she says 'yes'. Asked why she's kissing him, replied 'because it feels good'. Resident has BIMS of 4-5. Roommate says 'She wants to but she doesn't want to.' The facility final investigation, form 359, documented the steps to investigate the allegation was, Asked the victim if [resident 374] has been kissing her; replied 'Yes'. Asked why, she responded, 'because it feels good' and 'it tasted good'. The summary of interviews documented, Resident's roommate says that perpetrator has been coming back into the room with her after dinner. Then they go on the other side of the room, and she hears kissing sounds. Says victim wants to do it, but also doesn't want to do it. The report documented that the perpetrator was mobile which made it difficult to monitor his location and staff observed resident 374 wheeling resident 12 around. The conclusion of the facility investigation documented, Evidence does not verify that abuse occurred. Victim says they've been kissing because it feels good. Both residents have dementia. The corrective action taken documented that the residents were separated, and staff were notified to intervene if resident 374 tried to wheel resident 12 around or enter her room. The investigation included a form for Tips on Assessing Consent to Sexual Intimacy in Older Adults and documented questions to ask residents with impaired cognition to determine capacity to consent to physical/sexual intimacy. The form documented that the Interdisciplinary Team (IDT) should meet and review the residents most recent BIMS scores, any documentation of behaviors, change in condition, responsible party input when applicable, responses to questions and any input from a therapist regarding decision making abilities. The form stated that a summary note of findings that included a determination of whether residents could knowingly consent to physical/sexual intimacy should be documented and care planned. The form documented that after the assessment was completed and determined that one or both residents were unable to consent that the staff should ensure that residents were protected from sexual abuse or exploitation. It should be noted that no documentation could be found to demonstrate that the facility evaluated resident 12 or resident 374 for the capacity to consent to sexual activity. On 6/03/24 at 2:26 PM, an interview was conducted with resident 36 who was resident 12's roommate. Resident 36 stated that there was a male resident that kissed resident 12 and would not let go. Resident 36 stated that she could hear the kissing, but did not see it because resident 12 and resident 374 were behind the privacy curtain. Resident 36 stated that she could hear resident 12 whining like a whimper during this time. Resident 36 stated that resident 12 did not say anything during the kissing noises. Resident 36 stated that she only witnessed the one incident and she informed resident 12's POA about it. Resident 36 stated that the male resident [resident 374] tried to enter resident 12's room afterwards but the facility put a sign up that kept him out. Resident 36 stated that after the incident resident 12 was more quiet than usual. On 6/04/24 at 11:51 AM, a telephone interview was conducted with resident 12's POA. The POA stated that another male resident was kissing resident 12. The POA stated that the male resident was going into resident 12's room and pushed her to dinner and lunch. The POA stated that as far as she knew everyone put a stop to it. The POA stated that her mother did not tell her about the incident, but she was crying hysterically when she arrived. The POA stated that resident 12's roommate told her about the incident with another male resident. The POA stated that resident 12 had short term memory deficits. The POA stated that the family would come to visit and by the next day resident 12 had no recollection of it. The POA stated that she did not want resident 12 to have the relationship with the other male resident. The POA stated that the facility placed a sign on resident 12's door that stated not to allow any other resident to enter the room. The POA stated that she made everyone aware to keep resident 12 and the other male resident separated. On 6/04/24 at 12:35 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that resident 12's roommate, resident 36, said she heard kissing noises. The RA stated that if a resident could consent to the sexual contact the physician would evaluate for that capacity to consent. The RA stated that she recalled that resident 12 said she liked resident 374, she was not traumatized and did not need a counselor. The RA stated that she did not speak with resident 12's roommate about the incident. The RA stated that resident 12 was confused, she could answer yes/no questions, and had memory deficits. The RA stated that she did not recall if she referred resident 12 to a social worker for an evaluation. The RA stated that normally she would discuss any incidents with the ADM and nurse management, and they would refer to the corporate team before submitting it to the State Survey Agency (SSA). The RA stated that she could not determine if resident 12 was capable to consent. The RA stated that she knew the incident was discussed in an IDT meeting, but she did not recall what was determined. The RA stated that the incident was discussed with the corporate team but does not recall what was determined or what guidance was provided. The RA stated that they were to make sure that the residents had no sexual contact. It should be noted that no documentation could be found to demonstrate that an IDT meeting was conducted to evaluate the incident between resident 12 and resident 374. On 6/04/24 at 3:47 PM, a follow-up interview was conducted with resident 12's POA. The POA stated that she was informed of the incident between resident 12 and the male resident a couple of days later. The POA stated that when she came to visit resident 12 she was wearing a bra. The POA stated that this was unusual because resident 12 never wore a bra, and she speculated on who had put it on the resident. The POA stated that she never found out who had placed the bra on resident 12 and she wondered if it was resident 374. The POA stated that there were issues with resident 374 being in resident 12's room, he would come and get her for breakfast, lunch and dinner. The POA stated that she was aware of it for approximately 4 days before she put a stop to it. The POA stated that when she found out about the kissing incident, she talked to resident 12. The POA stated that resident 12 started crying and said she did not know what to do. The POA stated she asked resident 12 how the kissing made her feel and she said good. The POA stated that she did not want resident 374 touching resident 12 and she told the facility staff to keep them separated. The POA stated that the facility put a sign on resident 12's door that said staff only. The POA stated that she spoke with the RA and made it very clear to keep the residents separated. On 6/05/24 at 1:29 PM, an interview was conducted with the facility Administrator (ADM) and the RA. The ADM stated that the RA informed him of the incident between resident 12 and resident 374. The ADM stated he was rounding and resident 36, the roommate, said she heard kissing noises. The ADM stated that he interviewed resident 36 and she was somewhat reliable. The ADM stated that he reported the incident to the State Survey Agency (SSA) and then started an investigation. The ADM then stated that resident 12's POA notified him of the incident. The ADM stated that resident 12's POA initially obtained resident 12's statement regarding the incident. The ADM verified that the facility interview documentation had the POA listed as the interviewer for resident 12's statement. The ADM then stated that resident 36 reported hearing kissing noises to resident 12's POA and initially the POA obtained resident 36's statement. The ADM stated that the facility final investigation report did not document who interviewed resident 12 and obtained the statement that she liked kissing resident 374. The ADM stated that it was possible that they interviewed resident 12 but that it was not documented. The RA stated that the ADM was the individual who interviewed resident 12 and resident 36. The ADM stated that resident 36 had reported hearing kissing sounds but did not see anything. The ADM stated that he did not have the interview documented but likely would have asked how resident 12 had responded to the touch. The RA stated that resident 12 had said that she liked resident 374 and that he was nice to her. The RA stated that she did not dig into it to get the basic information. The RA stated that she asked resident 12 was he inappropriate to you? The RA stated that resident 12 responded no and she liked resident 374 that he was nice to her. The RA stated that she started the investigation and then the ADM went and spoke to resident 12. The ADM stated, that must have been when she said it tasted good. The ADM stated that resident 12 had difficulty with her memory and gets confused. The ADM stated that the physician had to determine if the resident had the capacity to consent to sexual activity. The RA stated that resident 12 did not have the capacity to consent. The ADM stated that they did not have the physician assess resident 12 for capacity to consent. The ADM stated that based on resident 12's statement that she like to be with resident 374, they determined that the allegation of sexual abuse was unsubstantiated. The ADM stated that resident 12's POA requested that the residents were separated. The ADM stated that he did not have any documentation of resident 36's reports of resident 12's responses to the kissing, and he does not recall the roommates reports of whimpering and whining during the incident. The RA stated that she determined that resident 12 was at her normal baseline after the kissing incident but does not recall if the resident was assessed. The RA stated that she made the determination that resident 12 was at baseline based on asking the floor nurse how the resident was doing. At this point in the interview the Corporate Social Service Worker (CSSW) joined the conversation. The CSSW stated that usually they would put monitoring for any sexual behaviors and would document in the progress notes. The CSSW stated that with allegations of sexual abuse with residents with diminished capacity there should be a physician assessment to determine the resident's capacity to consent. The CSSW stated that it would then be reviewed by the IDT, care planned, and staff education should be provided. [Cross-refer F600] 5. Resident 374 was admitted to the facility on [DATE] with a diagnosis of vascular dementia. On 6/3/24, resident 374's [NAME] [TRUNCATED]

Based on interview and record review it was determined, for 1 of 53 sampled residents, that the facility did not develop and implement a baseline care plan for the resident within 48 hours of the resident's admission and must include at a minimum the initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and any pre-admission screening and resident review PASARR recommendations if applicable. Specifically, the resident did not have a baseline care plan initiated within 48 hours of admission. Resident identifier 36. Findings included: Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, polyosteoarthritis, malignant neoplasm of ovary, hyperlipidemia, chronic fatigue, morbid obesity, anxiety disorder, bipolar disorder, idiopathic peripheral autonomic neuropathy, presence of left and right artificial knee joint, insomnia, opioid dependence, and restless leg syndrome. On 6/2/24, resident 36's medical records were reviewed. On 9/5/23, resident 36 had a baseline care plan initiated and nursing services selected were for oxygen therapy, pain management, activities of daily living (ADL) assistance, skilled nursing assessment, and fall prevention. The care plan also included a Level I PASARR, dietary orders, and preferences. It should be noted that the baseline care plan was initiated 4 days after resident 36 was readmitted to the facility. Resident 36's comprehensive care plan was reviewed. The following care areas were identified as initiated after resident 36's initial admission to the facility on [DATE]: at risk for falls was initiated on 2/1/22; uses psychotropic medication was initiated on 2/4/22; has nutritional problems was initiated on 1/28/22; at risk for pain was initiated on 2/1/22; has malignant neoplasm was initiated on 2/9/22; altered respiratory status was initiated on 2/9/22; at risk for constipation was initiated on 2/1/22; impaired activity was initiated on 2/1/22; and ADL self performance deficit was initiated on 2/1/22. It should be noted that none of the care areas were initiated within 48 hours of resident 36's initial admission. On 6/04/24 at 10:52 AM, an interview was conducted with the Minimum Data Set (MDS) Coordinator (MDSC). The MDSC stated that on the day of admission they care planned all the basics and put the information into the Kardex. The MDSC stated that the baseline care plan was completed on the day of admission or within the first 48 hours and she was responsible for completing it. The MDSC stated that all residents were care planned for falls.

Based on interview, observation and record review it was determined, for 10 out of 53 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, residents voiced concerns with call light wait times and not receiving assistance with bathing and pain management. In addition, concerns with regard to staffing issues were raised during resident council on repeated occasions. Resident identifiers: 7, 10, 15, 36, 41, 50, 54, 55, 116 and 376. Findings included: 1. Resident council notes were reviewed and revealed the following: a. 1/30/24: . The group said they were frustrated with the CNA's (Certified Nursing Assistants) turning off the call lights. I explained that they can put the call light back on if no one comes in 10 minutes. [Names of two residents] were frustrated that they are being woken up at 5:00 AM and dressed. [Names of two residents] said that night shift and early morning they don't answer call lights. [Name of one resident] said they stop answering call lights at 5:00 AM. A Department Response was provided that Education regarding urgency of lights for all shifts .Discuss [with] res (resident) time get up. b. 2/28/24: The Administrator (ADM) . went over that call lights have been an ongoing issue. He shared with the group that the budget has increased so there will be more staff which should help with call light times. [ADM] went over how residents can help by giving positive feedback and encouragement to staff.[Name of resident] brought up that she things (sic) its wrong that CNA's turn off the call light. [Name of one resident] - call lights have been bad 20 minutes or more. There was no department response listed for the above mentioned issues. c. March 2024 there were no issues documented regarding staffing or call light response times. d. 4/29/24: One resident stated that they (staff) never come. Two residents stated that call lights have been the same. A Department Response was provided and indicated that staff education was again given regarding call light response times. It should be noted that the facility did not provide this education until 5/22/24, approximately 3 weeks later. e. May 2024 was not provided. On 6/6/24 at 7:40 AM, an interview was conducted with the facility Administrator (ADM). When asked about the resident council concerns, the ADM stated that after the resident council meeting, he would review the meeting minutes. The ADM stated that its usually food. call lights seem to be the popular thing to talk about. The ADM stated that the minutes were reviewed in the facility Quality Assurance Performance Improvement (QAPI) meetings. The ADM stated that staff have also brainstormed to see if staff were scheduled at the appropriate time. The ADM could not provide any additional information as to what steps had been taken to correct the call light response times. 2. On 6/3/24 at 7:35 AM, an interview was conducted with resident 15. Resident 15 stated that he typically waited for 40 minutes for his call light to be answered. Resident 15 stated that even when staff answered his call light, they would come in and ask what he needed, leave, and not return. 30563 3. On 6/3/24 at 9:42 AM, an interview was conducted with resident 7. Resident 7 stated there was not enough CNAs. Resident 7 stated that the facility hired 2 CNAs and then 2 CNAs would would quit. Resident 7 stated it seamed like it was hard for the facility to get enough staff. 4. On 6/2/24 at 3:14 PM, an interview was conducted with resident 376. Resident 376 stated the CNAs were Swamped. Resident 376 stated she would like to move around her room more often but CNAs were too busy to have time to be with her. Resident 376 stated when she pushed her call light it took 20 to 25 minutes for a staff member to answer it and if she was having a heart attack, she would not be able to get anyone into her room. The form titled Facility Assessment Tool dated 12/13/22 revealed the following: Requirement Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their resident (S483.70(e)). Purpose The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The form titled Facility Assessment Tool revealed it was reviewed by the Administrator, Director of Nursing (DON), Governing Body Representative, Medical Director, and Assistant Director of Nursing and was updated on 6/26/23. The form revealed the facility was licensed to provide care for 124 residents and the average daily census was 70-80. The Admission process including common diagnoses the facility was able to care for was documented. The acuity section revealed the average number of residents with special treatments included 30 for oxygen, 3 for bilevel positive airway pressure (BIPAP)/continuous positive airway pressure (CPAP), 1 for behavioral health needs, 1 for Intravenous (IV) medications, 1 for injections, 1 for dialysis, 1 for ostomy care, 12 for hospice care, and 1 for respite care. The Staffing plan revealed the facility needed 4 licensed nurses to provide direct care, 6-7 Nurses Aides, 1 other nursing personnel, 1 Speech therapist, 1 Activity Manager, 1 Resident Advocate, 1 Registered Dietitian, 1 Dietary Manager, 1 Cook, 2 Dietary Aides, 1 Physical Therapist, 1 Occupational Therapist, and 1 Speech Therapist. The Individual staff assignment section revealed 3.3 Describe how you determine and review individual staff assignments for coordination and continuity of care for residents within and across these staff assignments. Input from direct caregivers, residents, families, IDT [Interdisciplinary Team] and others (surveys, resident council meetings, satisfaction surveys, physicians, and other clinician input). Adverse events (incident reports, medication error reports, laboratory and radiology reports, and consultant reports) performance indicators (QAPI [Quality Assessment and Performance Improvement], Star rating, clinical dashboard) survey findings (2567 and FYI's [for your information]). Complaints/Grievances. (Input by PCP [Primary Care Physician], surveys, council meetings, written comments, feedback from staff and residents.) Staff training was listed on the form. 38031 5. Resident 50 was admitted to the facility on [DATE] with diagnoses which included palliative care, chronic obstructive pulmonary disease, anxiety disorder, viral hepatitis, epilepsy, low back pain, hypertensive heart disease, neuromuscular dysfunction of the bladder, hemiplegia, insomnia, chronic pulmonary embolism, and osteoarthritis. On 6/02/24 at 2:41 PM, an interview was conducted with resident 50. Resident 50 stated that he had pain in his back and he had to wait for his pain medication. Resident 50 stated that when it was given on time the pain was managed and controlled. Resident 50 stated that he had an order for Oxycodone 10 milligrams (mg) that was scheduled every 4 hours and as needed. Resident 50 stated that sometimes the 4:00 AM dose was delayed to 6:00 AM or 7:00 AM. [Cross-refer F697] 6. Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, polyosteoarthritis, malignant neoplasm of ovary, hyperlipidemia, chronic fatigue, morbid obesity, anxiety disorder, bipolar disorder, idiopathic peripheral autonomic neuropathy, presence of left and right artificial knee joint, insomnia, opioid dependence, and restless leg syndrome. On 6/2/24 at 2:09 PM, an interview was conducted with resident 36. Resident 36 stated that her shower schedule was supposed to be Tuesdays and Fridays, but the facility was short staffed. Resident 36 stated that she received a shower yesterday, but she had to insist on the shower yesterday. [Cross-refer F676] 43212 7. On 6/3/24 at 8:31 AM, an interview was conducted with resident 55 who stated she has had to wait 30 minutes for staff to answer her call light. Resident 55 stated the daytime hours were when additional staff were needed. 8. On 6/3/24 at 9:08 AM, an interview was conducted with resident 10 who stated the day shift did not have enough staff. Resident 10 stated she had to wait 20 minutes or longer to receive help. 45470 9. On 6/5/24 at 10:17 AM an interview with Certified Nursing Assistant (CNA) 9 was conducted. CNA 9 stated that he was aware of residents who had multiple missed shower days in a row. CNA 9 stated that the facility did not have enough staff to complete all the showers on top of the other daily tasks. CNA 9 stated that resident 41's showers were often missed because she required two CNAs, and resident 41's showers took longer than the average time to complete. CNA 9 stated that when a resident's shower was missed, the task was passed off to the next shift. 10. On 6/5/24 at 4:07 PM an interview with CNA 8 was conducted. CNA 8 stated that each time a resident required a shower, a shower sheet was filled out and turned into the nurse. CNA 8 stated that resident showers were recorded on the resident electronic medical record. CNA 8 stated that if the resident refused a shower, the resident was required to sign the shower sheet. CNA 8 stated that there was not enough time for staff to complete all of the required resident showers. CNA 8 stated that it would be helpful if the facility staffed one or two extra aides who helped with completing resident showers. CNA 8 stated that if the staff did not have enough time to get to a resident's shower or bed bath, the task would be handed over to the next shift. 50200 11. Resident 54 was admitted to the facility on [DATE] with diagnoses which included cervical disc disorder, primary osteoarthritis, type 2 diabetes with neuropathy, hypothyroidism, morbid obesity, weakness, muscle weakness, anxiety, obstructive sleep apnea, hypertension, and a history of falling. On 6/2/24 at 2:33 PM, an interview was conducted with resident 54. Resident 54 stated she did not feel there was enough staff in the facility to care for her. Resident 54 stated that she was incontinent and used a PureWick urinary device because it was easier than waiting for staff to respond to the call light to change her brief. Resident 54 stated it could take over 20 minutes for staff to respond. On 6/4/24 at 3:10 PM, an observation was made with resident 54. Resident 54's call light was on and the green light flashing. It was observed that no staff were in the room with resident 54. On 6/4/24 at 3:16 PM, an observation was made of resident 54 who pushed the call light again. No staff responded to the call light and it was shut off. On 6/4/24 at 3:38 PM, an observation was made of resident 54 who pushed the call light again. Staff responded to the resident's call light at 3:40 PM. Resident 54 had been waiting for staff assistance from 3:10 PM until 3:40 PM. 12. Resident 116 was admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement therapy, hypertensive chronic kidney disease, type 2 diabetes mellitus, post-polio syndrome, atrial fibrillation, major depressive disorder, obstructive sleep apnea, and cognitive communication deficit. On 6/2/24 at 2:08 PM, an interview was conducted with resident 116. Resident 116 stated that she was often in pain and when she pressed her call light the response time could be in excess of 15 minutes. Resident 116 stated that most of the time she would go out in the hallway to get staff attention because the call light was never answered.

Based on interview, observation and record review, the facility did not ensure that 3 of 53 sampled residents received services in the facility with reasonable accommodation of resident needs and preferences. Specifically, residents were not provided with transportation for personal needs, and one resident was not provided with incontinence briefs despite developing a rash from the ones that the facility offered. Resident identifiers: 7, 15, and 114. Findings included: 1. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure, diabetes mellitus, apraxia following cerebral infarction, hemiplegia, post traumatic stress disorder, irritable bowel syndrome, sacrolitis, pneumonia, and urinary retention. Resident 15 stated that facility staff won't take you to the bank or anything. The van driver . said she will but I have to keep it quiet. I would like to go to the park or the store if I want a treat. I want to see [my kids] at the park but [facility staff] won't take me. On 6/5/24 at 4:30 PM, an interview was conducted with the Resident Advocate (RA). When asked about resident 15 wanting to go to the bank or the park with his children, the RA stated that the resident was able to take himself to the bank because he had a motorized wheelchair. The RA also stated that resident 15 was able to use the bus. The RA then stated, As far as I know, I was always told our facility van is only for medical appointments but I don't know what the guidance is here. If someone can't take themselves I would ask if the family can take them. On 6/6/24 at 9:55 AM, an interview was conducted with the Transportation Driver (TD) and the Administrator (ADM). The TD stated that the van was only supposed to be used for medical appointments, and nothing else. The TD stated that if she took anyone on an errand beside a medical appointment, she would have to obtain approval from the ADM first. The ADM stated that resident 15 had requested to go to the bank, but that the ADM had questioned why the resident needed to go to the bank. When asked if anyone had been denied transportation services, the TD stated that there was a resident who had requested to get cigarettes, but I told her that our policy is that if friends and family are available, then she needed to go through them. On 6/6/24 at approximately 9:45 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that if staff were not busy taking residents to medical appointments, then absolutely staff could take residents to the bank etc. The RNC stated she would just want to make sure the van driver knew about the errands the residents wanted to run, and would not want the driver to have access to resident bank cards. 50200 2. Resident 114 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, anxiety disorder, paroxysmal atrial fibrillation, severe sepsis with septic shock, cognitive communication deficit, dysphagia, and respiratory syncytial virus. An admission Brief Interview for Mental Status (BIMS) dated 5/16/24 documented that resident 114 had a score of 14. A BIMS score of 13-15 suggested resident 113 was cognitively intact. On 6/2/24 at 3:26 PM, an interview was conducted with resident 114. Resident 114 stated that he had not been able to get money from the ATM since he had been in the facility. Resident 114 stated he had asked staff repeatedly to be taken to an ATM because he would like some cash to buy stuff. Resident 114 stated that he stopped asking because he was told that he could not get a ride. On 6/4/24 at 10:49 AM, an interview was conducted with the RA. The RA stated that if a resident had an outside bank account they could sign themselves out and go with family and/or friends to get the money. The RA stated that the facility policy was to only transport residents for medical appointments. On 6/5/24 at 7:42 AM, an interview was conducted with the [NAME] Office Manager (BOM).The BOM stated residents could choose to open a personal funds account or transport would take the resident to the bank or post office to get what they need. On 6/5/24 at 7:50 AM, an interview was conducted with the Transport Driver (TD). The TD stated residents were transported to and from appointments. The TD stated if there were no friends or family that could take a resident to the bank, then in very rare circumstances they could be taken to the bank, but this must be approved by the administrator first. On 6/5/24 at 8:06 AM, an interview was conducted with the Administrator (ADM). The ADM stated transportation was available to all residents regardless of where they were going. On 6/6/24 at 9:00 AM, an interview was conducted with the TD. The TD stated that resident 114 had mentioned to the hall nurse that he wanted to go to the ATM and the nurse reached out to the TD. The TD stated that when she spoke to resident 114, he wanted to get money for the vending machine from the ATM. The TD stated that resident 114 changed his mind about needing a ride on this particular day and requested an oximeter instead. 30563 3. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paroxysmal atrial fibrillation, fibromyalgia, type 2 diabetes mellitus, obesity and major depressive disorder. On 6/3/24 at 9:48 AM, an interview was conducted with resident 7. Resident 7 stated the facility was providing her with briefs that absorbed more, deodorized, and were more comfortable for her extremely sensitive skin. Resident 7 stated she was unable to get those briefs for the last 4 months and had to buy them herself. Resident 7 stated the Administrator came into her room and stated the facility was unable to purchase her briefs because Where does it stop?. Resident 7 stated the Administrator stated to her that other residents would ask for stuff also. Resident 7 stated the briefs cost her about $150 per month. Resident 7 stated when she had to wear the facility provided briefs she got a rash around her waist. Resident 7's medical record was reviewed 6/2/24 through 6/6/24. There were no grievance forms in the grievance binder for resident 7 regarding her briefs. An MDS dated [DATE] revealed a BIMS score of 14 out of 15 which indicated resident 7 was cognitively intact. The MDS further revealed resident 7 was always incontinent of bowel and bladder. A care plan dated 4/15/2020 and updated on 12/19/23 revealed [Resident 7] is at risk for altered skin integrity r/t [related to] Obesity, DM2 [type 2 diabetes mellitus], bed confinement status, incontinence, lymphedema and decreased mobility. The goal was [Resident 7] will maintain clean and intact skin by the review date. The interventions were Apply Barrier Cream after each incontinent episode; Encourage good nutrition and hydration in order to promote healthier skin and; Identify potential causative factors and eliminate/resolve where possible. A care plan dated 11/14/21 revealed [Resident 7] desires to only be changed twice per shift and PRN [as needed]. The goal Chooses to have chucks placed underneath her, which she chooses to provide. The intervention was [Resident 7] choices will be honored; Staff to change [resident 7] twice per shift and PRN, Staff to respect and honor resident choices. Chucks to be placed under resident as she desires. A care plan dated 3/14/23 revealed [Resident 7] is at risk for chronic/recurring MASD [moisture associated skin damage] secondary to incontinence, limited mobility, morbid obesity. The goal was [Resident 7] will have no untreated skin impairment TNR [through next review]. The interventions included Encourage and assist with frequent position changes as able and Medications, treatments, supplements as ordered. On 6/3/24 at 3:58 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 7 used a certain type of brief that had a longer pad. CNA 1 stated resident 7 had to order and pay for the briefs. CNA 1 stated the briefs the facility provided were not very comfortable because of the residents size. CNA 1 stated there was a specific way to put resident 7's brief on. CNA 1 stated the briefs provided by the facility had 2 tabs and the briefs resident 7 bought had 1 large tab. On 6/4/24 at 9:41 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the facility had stock briefs available for residents who were incontinent. LPN 1 stated pull up briefs and tab briefs were available in different sizes. LPN 1 stated he was not aware that resident 7 had different briefs than the ones provided by the facility. On 6/4/24 at 9:48 AM, an interview was conducted with CNA 2. CNA 2 stated each resident had a package in their room of briefs so the CNA's knew what size and kind the resident used. CNA 2 stated pull ups and briefs were offered in all sizes. CNA 2 stated he was not aware of anyone not being able to use briefs the facility provided. On 6/4/24 at 10:00 AM, an interview was conducted with Nursing Aide (NA) 1. NA 1 stated the facility had different brands, types and sizes of briefs available. NA 1 stated all the residents were able to use the facility briefs. NA 1 stated resident 7 used a brief with the tabs. NA 1 stated resident 7 was very sensitive when she was being changed and needed the briefs put on looser. NA 1 stated she was not sure if resident 7 had different briefs or supplied her own. NA 1 stated she used the briefs stored in resident 7's room. On 6/4/24 at 10:06 AM, an interview as conducted with CNA 3. CNA 3 stated the facility had different sizes of briefs. CNA 3 stated resident 7 liked to buy her own briefs because they were more stretchy and absorbed more. On 6/4/24 at 1:11 PM, an interview was conducted with the RA. The RA stated the facility provided briefs or pull ups for the residents. The RA stated she was not aware of any resident that was buying their own briefs. The RA stated if a resident desired different briefs, she would have to get special authorization from the Administrator. The RA stated she thought resident 7 used the facility provided briefs. The RA stated if resident 7 was unable to use the briefs provided then the Administrator would have to provide approval to order the briefs. On 6/4/24 at 1:53 PM, an interview was conducted with the Administrator. The Administrator stated the facility provide everything residents needed. The Administrator stated he talked to resident 7 a while ago regarding her briefs. The Administrator stated the facility had entered a contract with a medical supply company to provide a daily rate for all supplies. The Administrator stated the facility provided briefs for resident 7 but not the kind she liked. The Administrator stated resident 7 bought her own because the facility did not supply the brand she liked. The Administrator stated the briefs provided by the medical supply were on their formulary, so it was easier to manager costs. The Administrator stated resident 7's pull ups were not included in the formulary and was unable to provide the briefs because it was a Cost issue. The Administrator stated he talked to resident 7 about using the facility brief and she stated I understand. The Administrator stated the RA was in the room with him when he talked to resident 7 about using the facility briefs. The Administrator stated it was about 9 months ago and there was no documentation of the conversation. On 6/4/24 at 3:05 PM, a follow up interview was conducted with the Administrator. The Administrator stated that he follow-up with resident 7 about her briefs and resident 7 stated to him she was buying her own briefs because they absorbed better. The Administrator stated that he was unable to remember the other reasons why resident 7 was unable to use the briefs the facility provided because he had walked around the facility and forgot. The Administrator stated that the MDS Coordinator was with him when he talked to resident 7. The Administrator stated the MDS Coordinator was going to do a clinical assessment to determine if the briefs were a want or need. On 6/4/24 at 3:15 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated resident 7 preferred the feel and the absorption of the briefs she purchased. The MDS Coordinator stated resident 7 mentioned that she was buying her own briefs a couple months ago during Angel Rounds. The MDS Coordinator stated she was not aware of any follow-up after the Angel rounds. The MDS Coordinator stated she had not been asked to complete a clinical assessment on resident 7. The MDS Coordinator stated a clinical assessment would consist of contacting the Wound Nurse, look at the brief to see if it was rubbing and ask the aide so see if there was a difference with the leakage. On 6/4/24 at 3:25 PM, the MDS Coordinator provided a form dated 1/4/24 titled Guardian Angel Rounds: Special Survey Edition revealed Bed A: .Doesn't like paying for her briefs and feels like they are lower quality than the ones she used to get. The MDS Coordinator stated there was no documented follow-up on the form. On 6/6/24 at 8:37 AM, an interview was conducted with the Assistant Director of Nursing (ADON) 1. ADON 1 stated she did not know that resident 7 was buying her own briefs. On 6/6/24 at 8:44 AM, a follow-up interview was conducted with resident 7. Resident 7 stated the Administrator walked in and asked why she liked her briefs. Resident 7 stated she used the facility provided briefs for 30 days to try them out and did not like them. Resident 7 stated she was told by the Administrator that she needed to find another more comparable brand to the facility provided ones. Resident 7 stated she used those briefs for [AGE] years and did not want to try different briefs because the ones she ordered worked for her. On 6/6/24 at 9:04 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated if a resident requested different kind of briefs than on the formulary, it would depend on the cost. The RNC stated if there was a reason like for skin or absorption, then the facility should be providing them.

Based on interview and record review, the facility did not consider the views of a resident group, nor did they act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. In addition, the facility was not able to demonstrate their response and rationale for such response. Specifically, residents voiced similar concerns over time in the resident council, and the facility did not follow up in a manner that significantly resolved the concerns. Findings included: Resident council notes were reviewed and revealed the following: a. 1/30/24: . The group said they were frustrated with the CNA's (Certified Nursing Assistants) turning off the call lights. I explained that they can put the call light back on if no one comes in 10 minutes. [Names of two residents] were frustrated that they are being woken up at 5:00 AM and dressed. [Names of two residents] said that night shift and early morning they don't answer call lights. [Name of one resident] said they stop answering call lights at 5:00 AM. A Department Response was provided that Education regarding urgency of lights for all shifts .Discuss [with] res (resident) time get up. b. 2/28/24: The Administrator (ADM) . went over that call lights have been an ongoing issue. He shared with the group that the budget has increased so there will be more staff which should help with call light times. [ADM] went over how residents can help by giving positive feedback and encouragement to staff.[Name of resident] brought up that she things its wrong that CNA's turn off the call light. [Name of one resident] - call lights have been bad 20 minutes or more. There was not department response listed for the above mentioned issues. c. March 2024 there were no issues documented regarding staffing or call light response times. d. 4/29/24: One resident stated that they (staff) never come. Two residents stated that call lights have been the same. A Department Response was provided and indicated that staff education was again given regarding call light response times. It should be noted that the facility did not provide this education until 5/22/24, approximately 3 weeks later. e. May 2024 was not provided. On 6/6/24 at 7:40 AM, an interview was conducted with the facility Administrator (ADM). When asked about the resident council concerns, the ADM stated that after the resident council meeting, he would review the meeting minutes. The ADM stated that its usually food. call lights seem to be the popular thing to talk about. The ADM stated that the minutes were reviewed in the facility Quality Assurance Performance Improvement (QAPI) meetings. The ADM stated that staff have also brainstormed to see if staff were scheduled at the appropriate time. The ADM could not provide any additional information as to what steps had been taken to correct the call light response times.

Based on record review and interview, it was determined, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). In addition, report the results of all investigations to the SSA within 5 working days of the incident. Specifically, for 4 out of 53 sampled residents, exhibit 358 entity reports of neglect and abuse allegations were not submitted to the SSA in a timely manner. In addition, exhibit 359 follow-up investigation report of one resident was submitted to the SSA seven working days after the neglect incident was reported. Resident identifiers: 364, 367, 370 and 374. Findings included: 1. Resident 367 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, dependence on renal dialysis, type 2 diabetes, hypertensive chronic kidney disease stage 5, chronic atrial fibrillation, and cognitive communication deficit. Resident 367's medical record was reviewed 6/2/24 through 6/6/24. On 9/20/23 at 11:04 AM, the facility exhibit 358 entity report documented on 9/19/23 at 8:00 PM, it was reported the resident was transported to the hospital ER [emergency room ] and when returning to the facility he had tipped his wheelchair back and fell . This fall resulted in the resident hitting his head. Per the Administrator, the resident told the transporter he felt fine. However, the transporter returned the resident to the ER where the resident was found to have a non-displaced cervical fracture. Per the Administrator, the course of treatment is a soft collar for about four weeks. As for the manner in which the resident was secured in the vehicle and what, if any, precautions were taken relative to his potential neck injury. APS [Adult Protective Services] and Ombudsman were notified. Review of the exhibit 358 entity report documented the incident occurred on 9/19/23 at 8:00 PM, and it was reported to the SSA on 9/20/23 at 11:04 AM. 2. Resident 370 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included palliative care, paroxysmal atrial fibrillation, moderate protein-calorie deficiency, unspecified dementia, heart failure, chronic kidney disease stage 3, peripheral vascular disease, and pulmonary hypertension. Resident 370's medical record was reviewed 6/2/24 through 6/6/24. On 11/15/23 at 5:19 PM, the facility exhibit 358 entity report was documented on 11/14/23 at 11:30 PM, resident's roommate reported to floor Nurse that the resident had fallen in their room. Resident was assessed and sent to the ER for further evaluation, it was found that the resident sustained a left femur fracture. Review of the exhibit 358 entity report documented the incident occurred 11/14/23 at 11:30 PM, and it was reported to the SSA on 11/15/23 at 5:19 PM. On 6/5/24 at 11:55 AM, an interview was conducted with the Administrator (ADM). The ADM stated a major injury was a fracture, loss of limb, something that would cause permanent damage, a major head injury, and probably sutures. The ADM stated the timeline for reporting major injuries to the ADM was immediately from staff, and then he would report to the state within two hours. 38031 3. Resident 374 was admitted to the facility on [DATE] with a diagnosis of vascular dementia. On 6/3/24, resident 374's medical records were reviewed. Resident 374's progress notes and facility reported incidents revealed the following: a. On 4/3/24 at 2:48 PM, the nurse note documented, Pt did exit the facility and got out to the parking lot area. He was followed out to the parking lot by multiple staff members, to which he was verbally aggressive towards. The facility initial notification to the State Survey Agency (SSA), form 358, documented that the staff were first informed of resident 374's elopement on 4/3/24 at 10:00 AM. No documentation could be found to demonstrate that APS was informed of the elopement. b. On 4/4/24 at 11:06 AM, the nurse note documented, Upon being notified of resident exiting facility, staff immediately went to ensure safety and found him a short distance off of property, and across the street. Resident redirected and calming communication initiated, and safe escort back into facility. Frequent checks and monitors initiated, per protocol. Family notified. Cause of resident being able to exit was sought after and identified that he was able to get out of door with no alert system due to the door being propped open. This was fixed and staff was educated on not propping door open, and re-edcuated [sic] on the door alarm system function. Future placement for resident in another facility with designated memory care unit has been initiated. No documentation could be located to demonstrate that the facility notified the SSA or APS of resident 374's elopement. c. On 4/13/24 at 5:28 PM, the alert note documented, Resident attempted to exit out of the front of the building before being stopped by the CNA's [Certified Nurse Assistant]. He then snuck out the back and made it out to the road. We wee (sic) able to redirect him back to the building. No documentation could be found to demonstrate that the facility notified the SSA or APS of resident 374's elopement. On 6/5/24 at 2:10 PM, an interview was conducted with the facility Administrator (ADM). The ADM stated resident 374 eloped several times. The ADM stated that an actual elopement should be reported to him by staff and should be relayed in the morning stand up meeting. The ADM stated that elopements should then be reported to the SSA. [Cross-refer F689] 30563 4. Resident 364 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encounter for change or removal of surgical wound dressing, major depressive disorder, Alzheimer's disease, and Fall of superior rim of left pubis, subsequent encounter for fracture with routine healing (6/2/23). Resident 364's medical record was reviewed 6/2/24 through 6/6/24. A nursing progress note dated 5/29/23 9:40 PM revealed, Resident was in bathroom and fell to floor and hit head and had goose egg, and L [left] hip edema, pain and not able to put pressure on it. [Physician's name removed] and patient dtr [daughter] [name removed] notified. Dtr came to facility and stated she wants mom seen at ER to rule out hip fx [fracture]. [Physician's name removed] agreed, and patient sent out via [local ambulance company]. A nursing progress note dated 5/29/23 at 11:59 PM, Spoke with [local hospital] nurse and resident was admitted to [NAME] 4, in room [ROOM NUMBER] for left femur fracture. An incident report dated 5/29/23 at 7:40 PM revealed Resident was in bathroom and fell to floor and hit head and had red slightly raised area, and L hip redness, pain, and not able to put pressure on it. [Physician's name removed] and patient dtr [name removed] notified. Dtr came to facility and stated she wants mom seen at ER to rule out hip fx. [Physician's name removed] agreed, and patient sent out via [local ambulance service] . The exhibit 358 that the facility submitted to the SSA revealed that the staff became aware of the incident on 5/29/23 at 7:40 PM. The form further revealed the Administration became aware on 5/30/23 at 9:30 AM during morning meeting. An email dated 6/1/23 at 6:17 PM revealed the SSA was notified that resident 364 sustained a hip fracture. On 6/5/24 at 5:23 PM, an interview was conducted with the Administrator. The Administrator stated after there was an allegation of abuse or neglect, the incident needed to be reported to the SSA within 2 hours. The Administrator stated if a resident sustained a fracture, that would need to be reported within 2 hours because that was a significant injury. The Administrator stated he did not know why the allegation was reported on 6/1/23 when the facility was aware of the fracture on 5/29/24 at 11:59 PM. The Administrator stated he did not recall the allegation and investigation. On 6/6/24 at 7:38 AM, an interview was conducted with the Administrator. The Administrator stated when he looked back on the investigation the previous DON reported the allegation. The Administrator stated the DON failed to meet the reporting within 2 hours.

Based on interview, record review, and observation, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. In addition, the facility did not develop and implement appropriate plans of action to correct identified quality deficiencies. Resident identifiers: 5, 7, 12, 17, 18, 31, 36, 41, 42, 43, 50, 53, 54, 365, 367, 372, and 374. Findings included: 1. Based on interview and record review it was determined, for 5 out of 53 sampled residents, that the facility did not ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a staff member recorded a video in the shower room while a resident was in the bathtub naked, a cognitively impaired resident kissed two different cognitively impaired residents on two different occasions and another resident who was cognitively impaired was involved in a sexual relationship. Resident Identifiers: 5, 12, 17, 36, 42, and 374. [Cross refer to F600] 2. Based on interview and record review, the facility did not ensure that 4 of 53 sample residents received treatment and care in accordance with professional standards of practice. Specifically, one resident experienced a change in condition, and the facility did not act in a timely manner to treat the condition. This resulted in a finding of harm for this resident. In addition, one resident was not monitored for a change in condition after experiencing chest pain, another resident was not monitored for a change in condition after a dental procedure, and a resident who was incontinent developed Moisture Associated Skin Damage (MASD). Resident identifiers: 5, 7, 53, and 365. [Cross refer to F684] 3. Based on interview and record review it was determined, for 6 of 53 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident sustained multiple falls with one resulting in a fracture, a resident transported in the facility vehicle was not properly secured and sustained a fall with injury, and a resident had hot coffee thrown on them by another resident. These findings were cited at harm. In addition, a resident with wandering behaviors, eloped from the facility and a resident was not secured in their wheelchair and sustained a fall. Resident identifiers: 5,18, 31, 43, 367, and 374. [Cross refer to F689] 4. Based on interview and record review it was determined that for 2 out 53 sampled residents, that the facility did not ensure that the resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to extent possible. Specifically, a resident developed a UTI after facility staff were not instructed and trained on the proper changing, frequency, and monitoring of the resident's PureWick urinary system device and a resident had a delay in starting antibiotic therapy for a UTI. Resident identifiers: 36, 54. [Cross refer to F690] 5. Based on interview and record review it was determined, for 1 out of 53 sampled residents, 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 care plan, and the residents' goals and preferences. Specifically, the resident's pain medication was not administered per the physician orders and the resident had complaints of uncontrolled pain. Resident identifier: 50. [Cross refer to F 697] 6. Based on interview and record review it was determined, for 1 out of 53 sampled residents, that the facility did not ensure each resident's drug regimen remained 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 would indicate the dose should be reduced or discontinued. Specifically, a resident's medication was not being monitored and this resulted in the resident being hospitalized . Resident identifier: 41. [Cross refer to F757] 7. Based on interview and record review, the facility did not ensure, for 3 of 53 sampled residents, were free of significant medication errors. Specifically, a resident was given linezolid for more days than what was ordered by the hospital, narcotics were given outside of physician ordered parameters, and lorazepam was given more often than what was ordered. Resident identifiers: 41, 50, and 372. [Cross refer to F 760] 8. On 7/22/22, an annual recertification survey was completed at the facility. The deficiencies cited during the survey included 580, 600, 610, 684 (at a harm level), 757, 758, 761, and 842. All of these deficiencies were re-cited during the June 2024 recertification survey. 9. On 3/2/23, an abbreviated complaint survey was completed at the facility. The deficiencies cited during the survey included 600, 609, 676, 677, and 690. All of these deficiencies were re-cited during the June 2024 recertification survey. On 6/6/24 at 7:40 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that the Quality Assurance and Performance Improvement (QAPI) committee met every month. The ADM stated that part of their QAPI process was to review prior deficiencies that were cited. The ADM stated that the facility had been working on correcting previous deficiencies, and had done a lot with abuse. The ADM stated I don't know why showers is still an issue. I give the shower issue over to the DON (Director of Nursing) and she can delegate that out. I don't know what to implement in that, because its more clinical. It's outside of what I've had my hands on. I try to give ideas in QAPI but other people have better ideas than I do.

Based on interview and record review, it was determined for 1 of 53 sampled resident, that the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, a residents, a resident was not assessed prior to having liquid medication all over her body after the resident sustained an unwitnessed fall. Resident identifier: 368 Findings included: Resident 368 was admitted to the facility on [DATE] with diagnoses which included palliative care, cirrhosis of the liver, hepatic failure, type 2 diabetes with chronic kidney disease, altered mental status, depression, insomnia, and hypothyroidism. Resident 368's medical record was reviewed 6/2/24-6/6/24. Resident 368's incident report dated 10/2/23 was reviewed on 6/4/24. The incident report documented that resident 368 .must have reached for her meds [medications] because she has the lactulose all over her. No documentation could be located in the medical record indicating that resident 368 had been evaluated to safely self administer medications. An admission Brief Interview for Mental Status (BIMS) dated 9/25/23 documented that resident 368 had a score of 9. A BIMS score of 8-12 suggested moderately impaired cognition. On 6/5/24 at 9:55 AM, an interview was completed with the Regional Nurse Consultant (RNC). The RNC stated residents were able to self administer medications after they had the appropriate assessment done by the nursing staff. On 6/5/24 at 12:36 PM, an interview was conducted with the Administrator (ADM). The ADM stated that for this particular investigation it was completed by himself and the former Director of Nursing. The ADM stated the investigation was done on neglect and the resulting fall, but the medication left in the resident's room was not investigated. On 6/6/24 at 7:39 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that residents required a physician's order and an assessment by a floor nurse before being allowed to self administer medications. The MDS Coordinator stated there was not an order for Lactulose to be self administered. The MDS Coordinator stated there was not an assessment done that allowed resident 368 to self-administer medications.

Based on observation, interview and record review it was determined, for 1 of 53 sampled residents, that the facility did not ensure that the resident had the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. Specifically, a resident's bathroom toilet was not secured to the ground and wobbled and the toilet seat was not secured to the base and moved from side to side. Resident identifier: 36. Findings included: Resident 36 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, polyosteoarthritis, malignant neoplasm of the ovary, chronic fatigue, morbid obesity, anxiety disorder, bipolar disorder, peripheral neuropathy, presence of left and right artificial knee joint, insomnia, and restless leg syndrome. On 6/06/24 at 9:21 AM, an interview was conducted with resident 36. Resident 36 stated that they had put in multiple work orders for the toilet seat to be repaired and it had been replaced and secured multiple times in the past. Resident 36 stated that the seat would break again and again and it was not secure or safe. An observation was made of resident 36's toilet. The base was not secured and the seat was askew and moved from side to side. On 6/06/24 at 9:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that there was a maintenance log at the nurse's station for staff to report any maintenance issues that needed to be looked at. Review of the maintenance log from January 2024 to May 2024 revealed no requests for repair of resident 36's toilet seat. On 6/6/24 at 9:30 AM, an interview was conducted with the Director of Maintenance (DOM). The DOM stated that the flooring in resident 36's bathroom was replaced approximately two months ago and at that time the toilet was completely removed. The DOM stated that since then he had tightened resident 36's toilet seat and the base a few times. The DOM stated that he went into the room regularly to check on the toilet. The DOM stated that he did not have any documentation of the repairs that he made on resident 36's toilet. An observation was made of the DOM moving the base of the toilet from side to side. The DOM stated that he needed to remove the toilet again and replace the metal ring. The DOM stated the staff should inform him verbally or write in the maintenance binder that the toilet needed to be repaired.

Based on observation, interview and record review it was determined, for 2 out of 53 sampled residents, that the facility did not ensure that the resident had the right to self-determination through support of the resident choice. Specifically, residents were not offered showers according to their preferences. Resident identifiers: 15 and 27. Findings included: 1. Resident 27 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, cervical root disorders, neuromuscular dysfunction of bladder and major depressive disorder. On 6/33/24 at 9:27 AM, an interview was conducted with resident 27. Resident 27 stated they would like showers every other day but only received showers Mondays and Thursdays. Resident 27 stated it was just how it is. Resident 27 stated they would like more showers but had not been asked. Resident 27 stated he was able to shower independently but there needed to be more staff. Resident 27 was observed to have greasy hair and was observed to be dry shaving his face with a razor. A Minimum Data Set (MDS) dated [DATE] revealed resident had a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated resident 27 was cognitively intact. A care plan dated 10/20/21 and updated 10/19/23 revealed [Resident 27] has an ADL [activities of daily living] self care performance deficit r/t [related to] Cerebral Palsy. The goal was Will be able to participate in part of ADL activity. Will have needs met. Some interventions included Adjust and meet residents needs with ADL assistance per level of need at time of care. Level of assistance may vary depending on time of day and current health conditions and Bathing/Showering: The resident requires up to DEPENDENT assist as needed. Certified Nursing Assistant (CNA) documentation in the tasks section of resident 27's medical record revealed resident 27 required 1 person physical assistance with bathing. Resident 27 was provided showers on 5/13/24, 5/16/24, 5/20/24, 5/23/24, 5/27/24, 5/30/24 and 6/3/24. No documentation could be located to indicate that resident 27 had been asked about how often they would like a shower. 22992 2. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure, diabetes mellitus, apraxia following cerebral infarction, hemiplegia, post traumatic stress disorder, irritable bowel syndrome, sacrolitis, and urinary retention. On 6/3/24 at 7:35 AM, an interview was conducted with resident 15. Resident 15 stated that the facility used to provide him with 3 showers a week, but now they only provided 2. Resident 15 stated he used to be the resident council president, and that this issue had not been discussed at resident council prior to being implemented. Resident 15 stated that he often did not receive the 2 scheduled showers. Resident 15 further stated, and if you said you'd like it (a shower) at a different time, good luck. Resident 15's medical record was reviewed from 6/2/24 through 6/6/24. Resident 15's care plan dated 10/20/21 was reviewed. The care plan indicated that resident 15 has an ADL self care performance deficit r/t Hemiplegia/hemiparesis of Right side, Apraxia. The care plan also indicated that resident 15 required up to substantial or maximal assistance from staff with bathing. Resident 15's shower records were reviewed. Between 5/9/24 and 6/2/24, the records confirmed that resident 15 had only received 2 showers a week. Facility staff completed a document entitled Guardian Angel Rounds: Special Survey Edition. The document was dated October 4, but did not list a year. The document included a question of Are showers given per resident's preference? Staff indicated that they were, however did not document what the resident's preference was. No documentation could be located to indicate that resident 15 had been asked about how often he would like a shower. On 6/5/24 at 9:53 AM, an interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (CRN). The DON stated the CNA Coordinator was in charge of scheduling showers. The DON stated she did not know how showers were scheduled. On 6/5/24 at 10:12 AM, an interview was conducted with the CNA Coordinator. The CNA coordinator stated when she started 3 to 4 months ago showers were not spread out equally among the CNAs. The CNA coordinator stated they went around and asked residents if they had a preferences on the day and the time residents had hours. The CNA Coordinator stated they then created a shower schedule which was located at each nurses station. The CNA Coordinator stated each CNA was to shower no more than 4 resident per shift. The CNA Coordinator stated residents were scheduled at a minimum of 2 showers per week. The CNA Coordinator stated there were only two residents that were provided showers three times per week. The CNA Coordinator stated resident 27 was scheduled twice per week. The CNA Coordinator stated they had not asked resident 27 if they wanted more showers per week. The CNA Coordinator stated if a resident asked for more showers, then staff provided more but the resident needed to ask. On 6/5/24 at 5:28 PM, an interview was conducted with the Administrator. The Administrator stated he was not aware of the shower process. The Administrator stated residents were showered at least twice per week. The Administrator stated in the last year and a half, there were different methods for shower scheduling implemented. The Administrator stated he did not know if staff asked residents how many showers they wanted per week. The Administrator stated from what he knew, the CNA coordinator scheduled showers. The Administrator stated he delegated shower scheduling to the clinical team. The Administrator stated he was not aware of who determined residents were to be showered twice per week. The Administrator stated as an Administrator, would be most concerns about meeting the regulation. The Administrator stated he did not remember if showers had been discussed in the Quality Assurance meetings.

Based on interview and record review it was determined that for 1 of 31 sample residents that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice and comprehensive person-centered care plan. Specifically, a resident experienced a change of condition (wound worsened) without the appropriate interventions and failed to notify the appropriate physician, as well as the facility did not monitor and reassess resident's vitals signs when they had changed. Resident Identifier: 57. Finding include: Resident 57 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/30/22, resident 57 was readmitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/20/22, a review of resident 57's electronic medical record was completed. A hospital discharge summary dated 6/13/22 revealed that resident 57 was admitted to the hospital for a urinary tract infection ([CONDITION(S)]) and multiple pressure ulcers. Resident 57 was started on antibiotics during her hospital admission for her [CONDITION(S)] and was discharged to the facility with a prescription for the antibiotic [MEDICATION(S)] to be administered until 6/14/22. Progress notes revealed: a. Resident 57 was under the care of a primary care physician (PCP) and wound care physician while she resided at the facility and also had access to the facility in house provider. b. Nursing note on 6/14/22 at 1:12 AM, revealed resident 57 arrived to the facility after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation stated Discoloration and [CONDITION(S)] on bilateral lower legs is present. Skin breakdown is present in groin area, bilateral posterior calves, mid lower back, and right hip. Padded pups and silver cloth were placed where the skin breakdown is present. c. Nursing note dated 6/15/22 at 12:40 AM, stated, patient continues to be in pain despite her PRN (as needed) pain medication; I will reach out to [the facility's physician]. Mid back wound is leaking large amounts of purulent drainage. Pressure was placed on the wound for 20+ minutes and it was ineffective in stopping it from draining. The nurse manager on call was notified and I was told to keep the area CDI (clean, dry and intact). Frequent dressing changes throughout the shift took place; each time the dressing would be saturated. The area around the wound appears to be red. Patient remains afebrile. Wound doctor will be notified as well . Nineteen hours later, nursing progress notes revealed, [The wound doctor] gave a verbal order to have [MEDICATION(S)] {[MEDICATION(S)]} to continue for one week. [Note: order for the antibiotic with a start date of 6/15/22 read as followed: [MEDICATION(S)] Tablet 750 MG, Give 1 tablet by mouth at bedtime for Prophylaxis related to NON PRESSURE CHRONIC ULCER OF SKIN OF OTHER SITES LIMITED TO BREAKDOWN OF SKIN]. No documentation was found where resident 57's primary care physician was notified, only the in-house provider was notified. d. Nursing note on 6/16/22 at 1:40 AM stated, Resident is on [MEDICATION(S)] for abscess. Received written order from [the pcp] for CMP, Lipid panel with 8 hour fast, CBC (complete blood count) with auto diff, Hgb (hemoglobin) A1c, Vitamin D25OH, PTH ([MEDICATION(S)]) level. Mid back wound is leaking large amounts of Serosanguineous drainage. No CO (complaints) of N (nausea) V (vomiting) D (diarrhea), No SOB (shortness of breath), wound nurse treated wounds today. Pt (patient) has co of pain, which is treated with [MEDICATION(S)] and has not been as effective as pt would like. Messaging [the facility's physician] because pt is requesting pain meds multiple times before it is due. Will continue to monitor. [Note: No documentation was found where resident 57's primary care physician was notified, only the in house provider was notified.] e. Nursing note on 6/17/22 at 11:43 AM, stated, Pt on abx (antibiotic) treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . No s/s of worsening infection. No adverse effects to the abx treatment. PA into see pt, no order changes at this time. Dressings to wounds changed, moderate amount of bloody drainage noted, pt to have labs drawn today. Pt continues on ABX for wound infection. f. A PCP note on 6/17 at 1:25 PM, revealed resident 57 was seen by the provider for her back abscess, malnutrition, depression and chronic pain. PCP stated in their note that resident 57 has a severe abscess with spontaneous drainage on mid back. 750 cc (cubic centimeters) pus and is being treated by the wound care team. In regards to pain, PA reveals, that resident 57 had requested more pain meds even after doing much better following drainage of abscess. [Note: no wound culture order was located for resident 57's back abscess to determine the appropriate antibiotic to treat the abscess.] g. Skin/Wound note on 6/17/22 at 3:48 PM, stated, Resident admitted with multiple wounds. Resident seen by facility wound specialist P.A. (physician assistant) for assessment and new treatment orders on 6/15/22. Resident has abscess to back with two holes measuring 0.5cmx0.5cm. Large amounts of serosang and purulent drainage has been draining out of holes with each position change. Resident has had chux underneath her to help control wound drainage. Wound specialist P.A. drainage about 500CC of this fluid from abscess. Resident continues to have drainage from abscess and requires frequent dressing changes. h. On 6/18/22 and 6/19/22, nursing notes revealed that resident 57 continued to be on antibiotic due to her wound infection/abscess. i. Nursing note on 6/20/22 4:32 PM, stated, [pcp] notified of Results of [resident 57's] labs. Six hours later a new nursing note stated, Dressing changes were performed on her back wound due to the dressing being saturated with sanguineous drainage. The wound was cleaned with NS and an island dressing was placed. Will continue to monitor wounds. j. Registered Dietitian note on 6/21/22 at 2:19 PM, stated that wound RN reported that wounds had improved. k. PCP note on 6/21/22 11:21 PM, revealed resident 57's low back abscess had been treated by wound care aggressively but wound started to have more heavy bleeding from exit sites and remarkable significant blood on the chuks but appears to be getting better. No significant pus noted and defer to wound care team. Provider noted that resident 57 did not complain of dizziness or lightheadedness and did not present with a fever but was concerned with resident 57 low blood pressures and [CONDITION(S)]. Stated to watch blood pressures and considered blood cultures. [Note: No vitals were documented for 6/21/22.] l. Nursing note on 6/21/22 at 4:54 PM, stated, Assisted wound nurse in wound dressing changes on patients back. There is blood coming out in clots saturating her pads and streams of blood coming out of her back. Pt was compliant but often exclaimed in pain. Pt was given pain medications and [MEDICATION(S)] prior to change. Two hours later, the nurse sent the first MD communication to wound PA. [Note: No documentation was found where resident 57's pcp was notified.] m. Nursing note on 6/22/22 at 12:00 PM, stated, [wound PA] ordered resident to go to ER (emergency room ) for emergency MRI (magnetic resonance imaging) of mid back abscess for excessive and constant bloody drainage over the last week. After resident 57 was sent to the ER, new orders written by PCP were received for senna twice a day and [MEDICATION(S)] as needed. Orders revealed that resident 57 was ordered have vitals taken twice a day with a start date of 6/13/22. Vitals signs were documented as followed: a. On 6/13, 6/14, and 6/16, resident 57's vitals were within normal limits and documented to be the exact same readings for all three days. Blood pressure was documented as 109/57 and heart rate as 87. Vitals signs were only obtained once throughout the day on 6/14 and 6/16 instead of twice as ordered. b. On 6/18 and 6/19, vitals signs were taken twice a day as ordered. Blood pressure readings ranged from 104/57 to 94/45. Resident 57's heart rate remained within normal limits, ranging from 82 to 86. c. On 6/20/22, vitals signs were only taken once throughout the day. Resident 57's blood pressure remained low at 96/54 and heart rate increased to 105. [Note: no documentation was found where any provider was notified of vital signs.] d. On 6/15/22 and 6/21/22, no vitals signs were documented. [Note: resident's PCP stated they were concerned about [CONDITION(S)] and [CONDITION(S)] on 6/21/22 and would continue to monitor vitals.] e. On 6/22/22 vitals signs were taken during the morning shift and revealed a blood pressure of 78/42 and heart rate of 107. All other vitals remained within normal limits. Resident 57 was taken to the ER (emergency room ) on this day. Resident 57's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. Pain medication was increased on 6/17 from [MEDICATION(S)] 5 mg (milligrams) every 6 hours as needed for pain to [MEDICATION(S)] 7.5 mg every 6 hours as needed for pain. b. From 6/13/22 to 6/17/22 resident received pain meds 12 times out of 20 possible opportunities. Pain scores ranged from 2 to 7. c. From 6/18/22 through 6/22/22 resident received pain medication 13 times out of 17 possible opportunities. Pain scores ranged from 5 to 7 out of 10. On 6/22/22, the hospital H&P (history and physical) revealed Resident 57 was taken to the ER due to excessive drainage from her back wound and feeling ill. Resident 57 stated they reported symptoms of diaphoresis, fever and moderate back pain at the facility. An MRI (magnetic resonance imaging) was done in the ER and the results indicated Resident 57 had infectious myositis and [CONDITION(S)]. Resident 57 was admitted to the ICU for septic shock. On 7/21/22 at 10:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated that vitals were done at least twice a day unless there was a requirement to get them more often. If a resident were to have a change in condition, repeat vitals were obtained. CNA 4 stated some resident's vitals ran high while other ran low and every resident had their own set of normal vital signs. CNA 4 stated that a normal blood pressure was 120/80 and normal blood pressures fall either 10 points below that or 10 points above. On 7/21/22 at 10:26 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that vitals were taken every morning before meds pass. RN 3 stated that if vitals signs were outside of parameters, first they rechecked the vitals and then if they were still outside parameters, they held blood pressure medication or notified the MD. RN 3 stated that the blood pressure parameters were 100/60 and the Medical Doctor was notified if a blood pressure was below that parameter. RN 3 stated that they documented in their progress notes when they contacted the MD and if any new orders were received. RN 3 stated that signs and symptoms of an infection were redness, fever, confusion and pain. RN 3 stated that in regards to wounds, other signs of infections were purulent and excess drainage. RN 3 stated that any time they did a wound change, they always looked for any signs and symptoms of infection and would notify the doctor and wound nurse. On 7/21/22 at 10:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that if vitals were abnormal, they would notify the doctor and document in their process notes about the notification. LPN 1 stated that there are times they forget to document the MD notification in their progress notes. Abnormal vitals were considered any blood pressures lower than their given parameters of 100/60 or pulse rate lower than 60 or higher than 100. LPN 1 stated the physician was notified in two ways. Depending on how urgent the matter was, the physician was to be called/messaged immediately or staff wrote down their concerns in a book that was checked daily by the doctor. It was up to the nurse's discretion on how they wanted to notify the doctor. LPN 1 stated vitals were obtained once per shift by either the aid or the nurse and wouldn't get missed. LPN 1 stated that some signs of infection were redness, swelling, warmth/heat, green or pus drainage and foul smell. LPN 1 stated if they identified any of those signs on a resident's wound, they notified the wound nurse who would then notify the doctor. On 7/21/22 at 11:09 AM, an interview was conducted with RN 2. RN 2 stated that all resident's vitals were checked every shift and followed up as necessary. RN 2 stated the abnormal vitals signs were respirations of less than 10 or higher than 20, heart rate less than 60 or greater than 100 and any blood pressure less than 100/60. RN 2 stated that abnormal vitals depended on the resident and their circumstances. RN 2 stated if a resident had abnormal vitals with an unknown circumstance, they notified the doctor since it was a new finding. RN 2 stated that signs and symptoms of a generalized infection were an elevated heart rate and temperature, and respiratory difficulty. Signs and symptoms of a localized infection included redness, inflammation and unusual discharge to the area. RN 2 stated that if they discovered any of those signs or symptoms on a resident, they notified the provider. On 7/21/22 at 12:27 an interview was conducted with the Director of Nursing (DON). The DON stated that resident 57 was sent to the facility after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that resident was admitted to the facility with a bunch of wounds and there was one in particular on her back that drained. The DON stated that the resident was under the care of Physician Assistant (PA) and if needed the in house facility doctor. DON stated they had the wound doctor look at it. The DON stated that they thought the drainage eased up after her abscess had been drained and had purulent drainage come out at first which then turned to bloody drainage. The DON stated they weren't concerned about an infection at that time since her abscess had just been drained and all the icky drainage came out. The DON stated that the wound physician assistant was aware of the drainage coming from her abscess. The DON stated that because of the amount of drainage present, the wound PA ordered an MRI to get done on 6/16 but they were unable to get it done since outpatient MRI's were booked 2 weeks out. DON stated resident 57 was sent to theER on [DATE] due to her back abscess increasing in size and the amount of drainage coming from it and needing a back MRI done promptly. The DON stated that before resident 57 went to the hospital, she was on antibiotics for her abscess. The DON identified signs and symptoms of infection such as malaise, redness, swelling, heat around wound, confusion, fever, increased pain, low blood pressure and a high heart rate. When asked about prescribing the correct antibiotic, the DON stated that normally a culture and sensitivity test was done and proceed to say that is how resident 57 was put on her [MEDICATION(S)] while in the hospital. The DON stated they did not do a culture and sensitivity test on resident 57's wound since the doctor did not order it. The DON stated that resident 57's blood pressure ran on the lower side so they were not concerned about it since it was close to her normal. When this surveyor questioned the DON about resident 57 blood pressure on 6/22, DON replied that resident 57 was sent to the ER that day. On 7/21/22 at 2:18 PM, an interview was conducted with the wound physician assistant (pa). The PA stated that he was the wound specialist for the facility and had been taking care of resident 57 prior to her arrival at the facility on 6/13. The PA stated that resident 57 had a 2 cm by 1/2cm hole in her back that was draining due to an internal abscess she developed at her prior facility. The PA stated that he had drained resident 57 back abscess and wasn't sure how her body would react so he decided to keep resident 57 on the antibiotic she was prescribed from the hospital for a [CONDITION(S)]. The PA stated that at the time he drained the abscess, resident 57 did not have any signs or symptoms of [CONDITION(S)] or a systemic infection. The PA stated there was a cautious wait and see about how her body reacted in terms of did her abscess improved or did resident 57 worsen due to an infection. The PA stated that after he had drained her abscess, he wanted to be notified if resident 57 experienced any signs and symptoms of an infection such as fevers, negative changes to the wound including an increase in size or weeping. The PA stated if he saw the wound hadn't improved, he would have acted on it. The PA stated what concerned him the most was when resident 57 had clots draining from her abscess and at that point decided something needed to be done since her abscess had not improved. The PA stated that he had ordered an MRI to give him an idea of what was going on but had trouble getting it done quickly and was unsure why. The PA stated that at the time he had not seen anything internal going on and the goal was to get her skin to heal. When asked about resident 57 decreased blood pressure, the PA responded that he was only concerned if it was causing resident 57 symptoms such as passing out or being unable to stand. If no symptoms were present, he referred to the physician to take care of it, especially if the residents presented with a high heart rate and low blood pressure due to the fact there may be something else going on within the body other than a wound. The PA stated that the scope of what resident 57 had was a surprise and that it was a fully unanticipated situation.

Based on interview and record review it was determined, for 1 of 25 sample residents that the facility did not ensure the residents were free of significant medication errors. Specifically, a resident's anticoagulant medication was not started on admission resulting in an outcome of an extensive iliofemoral [MEDICAL CONDITION] to the right lower extremity. This occurred at a harm level. Resident identifier 21. Findings include: Resident 21 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 1/6/20 at 3:57 PM an interview was conducted with resident 21. Resident 21 stated that he had been hospitalized for [REDACTED]. A review of resident 21's medical record was conducted on 1/7/20 and revealed that resident 21 was readmitted to the facility on [DATE] following a hospitalization . A review of resident 21's discharge [DIAGNOSES REDACTED]. a. [MEDICAL CONDITION] Fibrillations with RVR b. History of [MEDICAL CONDITION] c. And history of ischemic vetebrobasilar artery thalamic stroke A review of resident 21's discharge medication orders from the hospital to the facility on [DATE] revealed the following orders. a. Rivaroxaban (Xarelto 20mg tablet) 1 tab orally every evening. A review of resident 21's admission orders [REDACTED]. (Note: Resident 21 was receiving Xarelto 20 mg I tablet orally in the evening for preventions of [MEDICAL CONDITION] embolism and [MEDICAL CONDITION] prior to discharge on 11/2/19 to the hospital.) A review of resident 21's medical record conducted on 1/7/20 revealed the following progress notes. a. A progress note dated 12/26/19 at 10:27 AM documented Patient has been complaining of pain in his right inner thigh, there is warmth to the touch and some swelling, previous nurse reported some redness in that area . I contacted doctor (name removed) assistant and her and the doctor will be coming by today to see the patient. b. A progress note dated 12/26/19 at 4:41 PM, documented Note Text: Doctor (name removed)'s Physician Assistant (PA) came in to see patient. Ordered Doppler ultrasound (US) of right upper thigh/groin/popliteal to rule out blood clot. Order faxed to (name of imaging company). c. A progress note dated 12/28/19 at 10:21 AM, documented Note Text: reviewed results for venous Doppler done to right lower extremity on 12/26/19. Called office of doctor (name removed) and was able to leave a message on his medical assistant's phone. Awaiting call back. Patient had no change in loc. No nausea, vomiting or diarrhea. No complains of feeling unusual. No complaints of feeling short of breath. Call light within reach. Continuing to monitor resident. (Note: this was 41 hours after the order for the Doppler ultrasound was ordered.) d. A progress note dated 12/28/19 at 12:01 PM, documented Note text: called pager on doctor (name removed) profile but not answer, unable to leave voice message. Continuing to monitor resident. No change in level of consciousness. Afebrile. No nausea, vomiting, and diarrhea. No complaints feeling shortness of breath. Call light within reach. e. A progress note dated 12/28/19 at 5:00 PM, documented Note Text: spoke to doctor (name removed) medical assistant and reported the [MEDICAL CONDITION]. Awaiting call back. f. A progress note dated 12/28/19 6:27 PM, documented Note text: spoke to nurse practitioner (name removed), gave new order for: Xarelto 20mg once a day, will follow up with further interventions. (Note: Xarelto for resident 21 was documented for initial administration on 12/29/19 at 8:00 PM. This is 25.5 hours after the order was received from the medical doctor.) A review of the Venous Doppler Ultrasound of the Right Lower Extremity revealed the following results on 12/26/19. a. Findings: There is extensive occlusive clot within all the visible deep veins of the right lower extremity through upper visible portion of the right common femoral vein. b. Impression: Extensive iliofemoral [MEDICAL CONDITION] right lower extremity. Occlusive illiofemoral clot with significant symptoms is often best treated with catheter directed [MEDICAL CONDITION] therapy. Consider [MEDICATION NAME] radiology consultation. A review of documentation received from the third party diagnostic company revealed that the ultrasound results were faxed to the facility on [DATE] at 7:26 PM. There is a delay of the initial contact to a medical doctor of 39 hours. A review of resident 21 care plan revealed the following care plan. a. Focus: Mr. (name removed) is on anticoagulant therapy Xarelto related to [MEDICAL CONDITION]. b.Goal: Mr. (name removed) will be free from discomfort or adverse reactions related to anticoagulant use through the review date. c. Interventions/tasks: a. Administer anticoagulant as ordered by physician. Monitor for side effects and effectiveness every shift. b. Monitor for adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. A follow up interview was conducted with resident 21 on 1/8/20 at 9:10 AM. Resident stated that when his [MEDICAL CONDITION] was discovered it was because it was painful, very painful that he left the staff know and they did an ultrasound. Resident 21 stated that it was still painful but not as much as it was. An interview was conducted with Registered Nurse (RN) 1 on 1/8/20 at approximately 10:00 AM. RN 1 stated that on admission the medical records department or the administrative nurses put in the admit medication orders. RN 1 stated they are just there for us. RN 1 stated that the diagnostic company send the results by fax to the facility and the doctor, and when facility receives the results they fax it to the doctor. RN 1 stated that if results are abnormal a call would be made to the physician to ensure the results were received. RN 1 stated that if the abnormal results were received after normal business hours they would call the on call physician. RN 1 stated that if the results do not come by the end of a shift, it would be passed onto the next shift by verbal report and or in the progress notes. An interview was conducted with Licensed practical nurse (LPN) 2 on 1/8/20 at 10:59 AM. LPN 2 stated that she thought the diagnostic company faxed results to the physicians. LPN 2 stated that she did not know how quickly results would come back and that they sometimes go directly to the doctor and then we wait for the doctor orders. LPN 2 stated she did not know how physician would be notified of abnormal results after hours. LPN 2 stated that she thinks medical records puts in new orders for medications on admission. LPN 2 stated then the nurse has to click to confirm them all. LPN 2 stated she thinks they get a list of papers that include the hospital medication orders. An interview was conducted with Nurse Practitioner (NP) 1 on 1/8/20 at 11:16 AM. NP 1 stated that the resident 21 was put on Xarelto in the hospital and that in the transition from the hospital it got lost in translation. NP 1 sated that when the ultrasound results were reported to her she reviewed resident 21's record and noted that it had been ordered on discharge from the hospital to the facility but had not been started. NP 1 stated that the [MEDICAL CONDITION] for resident 21 occurred as a direct correlation of not being on the Xarelto medication. NP 1 stated that for someone with [MEDICAL CONDITION] she would recommend heat to the affected area, that resident does not sit up in a flex position, and some light movement to the area for general circulation health. NP 1 stated that she believes she told the nurse that when she ordered the Xarelto. (Note: nothing could be found in patient medical record progress notes, care plan, ect to reflect these instructions.) NP 1 stated that she did not receive a copy of the ultrasound report, and it was not reported to her that the impression included occlusive iliofemoral clot with significant symptoms is often best treated with catheter directed [MEDICAL CONDITION] therapy. Consider [MEDICATION NAME] radiology consultation. NP 1 stated that those results were super shocking and really important, and that she might still consider the recommendations to get the rest of the clot taken care of. On 1/8/20 at 1:59 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that diagnostic results typically get faxed to us and the physician, usually within 24 hours. The DON stated that sometimes there is an issue and I have to call and and say that we have not gotten the results. The DON stated that the results should be received within 24 hours, and abnormal results should be called into the physician. The DON stated that if it's an urgency abnormal result and after hours the staff can call she and she will call the facility medical director. The DON stated that either a nurse or the medical records department will initiate orders into the system. The DON stated that the floor nurse is responsible to verify the final orders that come with the patient to what's in point click care. The DON had no additional information to provide concerning resident 21's significant medication error, or delay in reporting of the ultrasound results to the physician.

Based on interview and record review, the facility did not ensure that 3 of 25 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was not seen by a physician for approximately 9 days after falling and experiencing a change in condition, a resident with a cough had not been assessed by the physician, and a wound had not been treated timely. The findings for resident 118 were cited at a harm level. Resident identifiers: 24, 52 and 118. Findings include: 1.Resident 118 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 118's medical record was reviewed on 1/6/20. Progress notes and skilled daily notes for resident 118 revealed the following: a. On 9/26/19, a progress note indicated that at 4:30 AM patient fell out of his bed. It was unseen, therefore cause is unknown. Language barrier prevented understanding of how he fell . Nurse found him laying supine on the floor with his head by the foot of the bed, holding on to the bottom of the bed frame. Patient was alert and vitals were within normal range, BP (blood pressure) =136/80, HR (heart rate) =91, O2 (oxygen saturations) =90, Temp (temperature) 98.0, and Resp (respirations) =20. Skin check=negative for bruises, skin tears, nor any new wounds. Patient had no pain with passive range of motion. Slight difficult standing up, but was assisted with two male staff with transferring (sic). Pupils are equal billateraly (sic), brisk, and both dilated at 3 mm. Called daughter from patients (sic) phone two times, and from the facilities (sic) phone once, but she did not answer. Left a message on her phone. Will continue to monitor patient throughout the shift. (Note: The nurse did not indicate in his/her note that resident 118's physician had been contacted regarding the fall.) b. On 9/26/19 a progress note indicated that the Interdisciplinary Team (IDT) review of resident 118 ' s fall had been conducted. Resident had an unwitnessed fall in his room around 0430 am. Resident was not able to state exactly how or why he fell . Resident was found lying in supine position on the floor, his head was by the foot of his bed and he was holding onto the bottom of the bed frame. Resident was assessed by nurse, no apparent injuries were noted. Able to range extremities without pain. MD and daughter notified of fall. Will continue to monitor resident for changes and have CNA's (Certified Nursing Assistants) offer toileting during last rounds. c. On 9/26/19 at 2:46 PM a progress note was entered that the resident . seemed disoriented this morning, difficult for him to follow simple instructions. With patience he was cooperative . d. On 9/26/19 a skilled nursing assessment indicated that resident 118 . had a fall at 4:30am, He seemed more confused this morning and unable to follow simple commands. Pt (patient) seemed disoriented this morning, difficult for him to follow simple instructions. With patience he was cooperative . e. On 9/28/19 a progress note indicated that Resident is sleepy looking but able to follow instructions . f. On 9/28/19 at 5:31 PM, a progress note indicated that the resident had a blood glucose (BG) . reading of 469 at check before dinner. (Name of physician) ' s office is contacted and voicemail left for request to review BG history and address possible changes to sliding scale. BG history is faxed to the office. g. On 9/28/19 at 10:41 PM, a progress note indicated that the resident was complaining of . pain on rt (right)side from former fall. No bruising noted. Strength and mobility lessened. h. On 9/28/19, a skilled nursing assessment indicated that the resident was having a change in level of consciousness as evidenced by him being sleepy. i. On 9/29/19 at 11:18 AM, a progress note indicated that resident 118 was .alert and verbally responsive, with confusion. j. On 9/29/19 at 10:12 PM, a progress note indicated that the resident had . difficulty comprehending instructions even with translation. Communication problems. B.S. (blood sugar) 369 this noc (evening). k. On 9/30/19 a weekly nursing summary indicated that resident 118 had been experiencing Increased sleepiness that week. l. On 9/30/19 at 3:50 PM, a progress note indicated that .Resident has had an overall decline, has been sleeping most of the day, is easy to arouse, but falls right back to sleep. Resident has required extensive assistance with eating during both breakfast and lunch. Resident was up in activity room after breakfast and lunch for activities, but was seen sleeping. Resident did not want to be removed from the activity room, so he stayed in the activity per his request. Resident lungs were clear upon auscultation, heart rate was regular, bowel sounds active, last BM (bowel movement) was 9/29/19. Resident able to follow simple commands, able to take medications without difficulty. Contacted MD to notify him of resident condition, requested UA (urinalysis) and xrays of right ribs and right hip/pelvis per daughter's request. Awaiting for MD response. (Note: A review of resident 118 ' s lab and radiology results was completed. No documentation could be located to indicate resident 118 had the UA or the xrays ordered or completed per the family request. In addition, no documentation could be located to indicate that resident 118 ' s physician returned the nurse ' s phone call regarding the resident ' s apparent change in condition, until 10/4/19.) m. On 10/1/19 a progress note indicated that Resident is alert to verbal stimuli, sleepy but rousable. Resident is able to make some needs known but struggles because of language barrier. Resident was sitting with other residents at the television then resting in bed. Daughter in to help with cares and all medication and treatments given with no ASE (adverse side effects) and no refusals. Resident is resting in bed with call light within reach. n. On 10/2/19 a progress note indicated that Resident is alert to verbal stimuli. Resident is very tired. Rousing only enough to take pills and get eye drops. o. On 10/3/19 at 5:46 PM, a progress note indicated that Resident has been very lethargic today. Difficult to arouse in a.m . p. On 10/3/19 at 10:26 PM, a progress note indicated that Resident resting in chair and in bed. Able to take meds without difficulty. Blood sugar 303. Insulin given as ordered. VSS (vital signs stable). Resident sleepy tonight. q. On 10/3/19 a skilled nursing assessment indicated that the resident was experiencing notable changes in L[NAME] (level of consciousness). as evidenced by Does not respond when spoke (sic) to. r. On 10/4/19 a skilled nursing assessment indicated that The past few days resident has been lethargic, hard to arouse. Primary physician notified. s. On 10/4/19 a progress note indicated that the resident was discharged to the hospital for further evaluation and treatment. (Note: After falling on 9/26/19, the resident ' s physician was not in contact with the facility staff until 10/4/19, approximately 8 days later, when the resident was sent to the emergency room and subsequently admitted .) On 10/30/19, the resident was readmitted to the facility from the hospital, where he had stayed approximately 26 days. The hospital History and Physical dated 10/4/19 indicated that resident 118 was diagnosed with [REDACTED]. On 1/8/20 at 3:00 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that resident 118 fell on [DATE] when he was trying to get out of bed. The DON stated that there were no apparent injuries right away. The DON then stated that a few days later the resident ' s daughter was concerned about the resident ' s decline and asked the DON to do an assessment. The DON stated that she completed the assessment and resident 118 was okay, but that then there was a decline. The DON stated that they had contacted the physician on 9/30/19 due to the level of pain that the resident was in, and confirmed that the physician had not responded to the notification of the resident ' s change in condition. The DON stated that the physicians were difficult to get a hold of sometimes. 2. Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/7/20 from approximately 8:35 AM to 8:45 AM, resident 24 was observed as she ate her breakfast. Resident 24 was in her room in her bed in a seated position and legs extended in front of her in the bed. During the approximate 10 minute observation, resident 24 was observed to cough several times. Her cough was observed to be wet, and she was clearing her throat extensively. On 1/9/20 at 7:45 AM it was observed that resident 24 was resting in bed and was coughing. The resident's cough was notably wet. Resident 24 was noted to be on room air. On 1/9/20 at 9:26 AM, a phone interview was conducted with resident 24's family member. Resident 24's family member not aware that resident 24 had a cough. On 1/9/20 at 10:13 AM an interview with the Assistant Director of Nursing (ADON) stated that the resident had always had a dry cough but that she has never heard resident 24 have a wet cough. The ADON stated that the dry cough happened mostly in the morning and she hasn't noticed any increase in coughing with food or fluids. On 1/9/20 at 10:19 AM, Certified Nurse Assistant (CNA) 1 stated that resident 24 had a cough on and off throughout the day. CNA 1 stated that she didn't know if it sounded wet or dry or if it get worse with food or fluids. On 1/9/20 at 10:21 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 2 has had a dry cough since admit, that the cough is random and didn't know if it was wet or dry. On 1/9/20 at 10:42 AM, an interview was conducted with the dietary aid. The dietary aid stated that she hasn't seen resident 24 coughing during meal time. On 1/9/20 at 10:57 AM, a record review revealed that no doctor had been contacted regarding resident 24's wet or dry cough. 3. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review for resident 52 was conducted on 1/7/2020 and revealed the following progress notes. a. A progress note dated 12/22/19 at 2:50 PM, documented Patient has abrasion/skin tear on the back of her left leg. Injury occurred during transfer treated and will follow up for wound care orders. b. A progress note dated 12/22/19 at 7:35 PM, documented Resident's left leg abrasion is approximately 5 inch half circle. Do to continues oozing and checking injury site with the 2 other nurses, it was agreed the injury needed sutures. Family notified and resident was sent to the emergency room via Gold Cross ambulance. Vital signs within normal. Afebrile. No complaint of pain except at wound site. c. A progress note dated 12/22/19 at 9:51 PM, documented Resident returned from emergency room . Wound dressed, clean and dry with 3 sutures. Afebrile 98.2, blood pressure 113/80, pulse 72, respirations 16. No complaint of pain or signs and symptoms distress. Is a 2 person in activities of daily living. Presently sleeping. (Note: The facility did not have an incident report or investigation of the incident.) d. A progress note dated 12/24/19 at 12:34 PM, documented alert to self only. Eats meals in assisted dining room. Incontinent of bowel and bladder. Wheelchair used for ambulation with assistance. 1 person extensive with late loss activities of daily living. NO signs and symptoms of nausea, vomiting, diarrhea, shortness of breath or pain. Wound care to left lower leg applied. Vital signs within normal limit, afebrile. Attends activity. Safety precautions in place. Will continue to monitor. e. A progress note dated 12/31/19 at 5:36 PM, documented alert to self only. Wound care applied to left lower leg skin tear .Safety precautions in place. f. A progress note dated 1/2/2020 at 10:32 PM, documented This writer was called to replace the dressing on her lower left extremity. The wound is moist and macerated draining a moderate amount of serosanguinous exudate. The skin is sloughing. The sutures remain intact but the areas between the sutures are open. The wound looks like hamburger with a red swollen area surrounding the wound which is warm to the touch. Will contact wound nurse and wound clinic for follow up. Will continue to monitor. (Note: there is a 100 hour delay in physician notification from the initial assessment that the wound has deteriorated.) g. A progress note dated 1/6/2020 at 2:56 PM, documented Doctor (name removed) office called and ordered for the resident to see a wound clinic, noted and transport informed. h. A progress note dated 1/6/2020 at 9:46 PM, documented Resident's dressing dry and intact on left lower leg will continue to monitor for bruises for healing and monitor for skin for any further bruises or breakdown. A review of resident 52 care plan was reviewed and revealed the following. a. Focus: Ms. (name removed) has potential impairment to skin integrity related to fragile, skin, incontinence, decreased mobility, and dementia. Date initiated 12/13/2018. Revision on 6/17/2019 b. Goal: Ms. (name removed) will maintain or develop clean and intact skin by the review date. Date initiated 12/6/2018. Revision date 6/17/2019. c. Tasks: a. Encourage good nutrition and hydration in order to promote healthier skin. Date initiated 12/13/2018 b. Identify/document potential causative factors and eliminate/resolve where possible. Date initiated 12/13/2018. (Note: The facility did not identify or investigate the causative factor of the skin tear on 12/26/19 to eliminate/resolve where possible.) c. Keep skin clean and dry. Use lotion on dry skin. Date initiated 12/12/2018. d. Use draw sheet or lifting device to move resident. Date initiated 12/13/2018. (Note: No care plan update was completed after the skin tear occurred on 12/26/19.) e. Use caution during transfers and bed mobility to prevent striking arms, legs and hands against sharp or hard surface. Date initiated 12/13/2018. On 1/7/19 at 2:52 PM and observation was made of resident 52. Resident 52 was sitting in her wheelchair in the TV room. Resident 52 had a dressing on her left lower extremity. Resident 52's wheelchair had long brake handles sticking up on wheelchair, the ends of the brakes were round, and metal with a hollow inside. Nothing was covering the hard metal ends. An interview was conducted with Certified Nursing Assistant (CNA) 3 on 1/8/20 at 9:25 AM. CNA 3 stated that resident 52 would be considered an extensive assist. CNA 3 stated that when they transfer her they raise the bed, put the wheelchair next to the bed, then assist patient to her feet, and assist her with weight bearing and balance. CNA 3 states resident 52 is a one person transfer unless she is combative then they will use 2. An interview was conducted on 1/8/20 at 9:32 AM with CNA 9. CNA 9 stated that the facility is a no lift facility. CNA 9 stated that meant that they don't really lift anyone that they can do stand by assistance but not do weight bearing transfers, and if a resident needed weight bearing assistance they would use the sit to stand or Hoyer for transfer. CNA 9 stated that resident 52 would help stand up when being transferred. CNA 9 stated she is a kind of pivot, stand and pivot transfer. An interview was conducted with Registered Nurse (RN) 1 on 1/8/20 at approximately 10:00 AM. RN 1 stated that physicians should be notified of falls, refusal of medications, injuries and skin issues. RN 1 stated that physicians can be notified by fax or a phone call. RN 1 stated that she did not know if an incident report would be done on a skin tear. An interview was conducted with Licensed Practical Nurse (LPN) 2 on 1/8/20 at 10:59 AM. LPN 2 stated that resident 52 had a skin tear on her leg that required stitches. LPN 2 stated that the wound looked fine and the dressing was being changed daily, and then it just started falling apart. LPN 2 stated that last time she saw the wound it looked tough and that the stitches were removed per the wound nurse, and she signed the treatment record for her. LPN 2 stated that the wound was the like a half dollar, round with a pink and brownish wound bed, LPN 2 stated that some areas look like hamburger meat. LPN 2 stated that the facility did incident reports for falls, but she did not know if they did incident reports for skin tears. An interview was conducted on 1/8/20 at 1:59 PM, with the director of nursing (DON). The DON stated that the wound nurse round on the wound weekly and will do measurements and document on the wounds. The DON stated that if a physician needs called after hours the staff can call her and she will call the medical director. The Director of nursing had no additional information regarding resident 52 wounds or physician notification delay of the wounds. The DON stated they did not have an incident report for resident 52's skin tear and had no further information about the cause of the skin tear. An interview was conducted with the wound nurse on 1/9/20 at 8:58 AM. The wound nurse stated that she assessed wounds one time a week, and she measures, and documents on the wounds. The wound nurse stated that she communicated with the wound clinic and the physicians if needed. The wound nurse stated that her assessments are documented in the progress notes but that she is behind because it's been crazy. The wound nurse said she assesses pressure ulcers, surgical wounds and bad skin tears like resident 52'. The wound nurse stated that when she notified the physician of wound changes she will fax them, and she notifies the physician of new wounds, if there is a drastic change in the wound, if the wound orders needs to change, if they need to be seen in the wound clinic, if the wound has a smell, is warm, or needs and antibiotic. The wound nurse stated that she removed the stitches for resident 52 on 1/4/20. The wound nurse stated that she had assessed the wound on 12/28/19 and the wound was fine, and that on 1/4/20 she was notified that it had gotten bad. The wound nurse stated that when she assessed the wound there was black and green tissue, the stitches almost fell out when taken out, it was very moist, it's beyond what they could do there. The wound nurse stated that the peri wound was macerated, and was warm. The wound nurse stated that she left a voicemail on the medical assistant's phone on 1/4/20 that the wound has worsened. The wound nurse stated that sometimes an on call physician can be called for a change of condition but they don't really call back. The wound nurse stated that she had received notification that resident 52 missed he wound clinic appointment. On 1/9/20 at 9:58 AM CNA 1 was observed transferring resident 52 into bed with the assistance of another CNA, patient required 50% or more of weight bearing assistance with a pivot transfer. CNA 1 stated that resident 52 sheets had to be changed this morning due to weeping from her lower extremity wound and also weeping from her elbow wound. On 1/9/20 at 10:08 AM an observation was made of the wound nurse changing a dressing to resident 52 left lower extremity. It was observed that the resident's wound was a round, full thickness wound. Resident 52 had 2 wounds to her right elbow. One of the wounds on the right elbow was scabbed and the other was open. The Wound nurse stated that she did not know about the wounds on resident 52's right elbow, but after assessing it she thought it was a skin tear. On 1/9/20 at 11:03 AM, an interview was conducted with resident 52's family member. The family member stated that she was not notified of the incident when resident 52 received the skin tear to her lower extremity. The family member stated she was notified when she was visiting the resident when she noticed a dressing to her leg and asked what had happened. The family member stated she was not notified that resident 52's wound had worsened and that was the reason for the wound clinic appointment. The family member stated when the facility staff member called her about the appointment they did not know the reason for the appointment. 4. Resident 118 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A record review was conducted for resident 118 on 1/8/20 and revealed the following. a. A progress note dated 11/8/19 at 12:47 PM, documented .Gave resident [MEDICATION NAME] for blood sugar of 65. Continue on IV antibiotics as noted. Will continue to monitor. b. A physician order [REDACTED]. c. A physician order [REDACTED].<70 dl and responsive give 4 ounces of clear glucose containing liquid, 40-70 mg/dl and unresponsive or NPO give 50% [MEDICATION NAME] 25 ml IV over 3 minutes STAT. <40 and unresponsive or NPO give 50% [MEDICATION NAME] 50ml IV over 3 minutes after treatment & notify provider for glucose 70mg/dl or less after 2 treatments. d. A progress note dated 11/11/19 at 1:05 AM, documented PM nurse reported patients NG tube was clogged. At about midnight patient was diaphoretic and blood glucose was 27. Called 911, paramedics administered IV meds to raise blood glucose and were unable to unclog NG tube. Feeding running at 80ml/hr. Pt tolerating well. Placement checked, residual 10 cubic centimeters (CC). Blood glucose rechecked periodically and within normal limits. An interview was conducted with Registered Nurse (RN) RN 1 on 1/9/19 at 8:42 AM. RN 1 stated that she worked and documented the progress note on 11/11/19 at 1:05 AM. RN 1 stated that she had received report at 10:00 or 10:30 PM on 11/11/19, but she did not know how long resident 118 NG tube had been clogged prior to that. RN 1 stated she remembered the nurse who gave her report telling her she had given resident 118 insulin. RN 1 stated that she had entered resident 118 room to administer and IV antibiotic when she noticed that he was diaphoretic. RN 1 stated that because resident 118 was diaphoretic she checked his blood sugar, and it was 27 so she called 911. RN 1 stated that resident 118 was NPO. RN 1 stated that after the event she reviewed orders and noted that resident 119 had order for IV [MEDICATION NAME] for [DIAGNOSES REDACTED]. RN 1 stated that prior to the event she had only ever had residents that could take stuff by mouth for [DIAGNOSES REDACTED]. An interview was conducted with the Director of Nursing (DON) on 1/9/19 at approximately 12:00 PM. The DON stated if a resident had orders related to [DIAGNOSES REDACTED] she would expect those orders to be followed.

Based on observation, interview, and medical record review it was determined, for 1 of 25 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the residents. Specifically, a hospice resident who had complaints of leg pain, did not receive the medication available until 1 hour and 50 minutes after the first complaint of leg pain. Resident identifiers: 17. Findings include: 1. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/25/17 at 7:16 AM, an observation was made of resident 17 in the dining room for breakfast. Resident 17 was observed to have some moaning and facial grimacing. On 10/25/17 at 7:26 AM, an observation was made of resident 17 as she stated, leg hurts. Resident 17 was observed to continue to have moaning, shortness of breath (SOB) and facial grimacing. On 10/25/17 at 7:53 AM, an observation was made of resident 17 as she stated, Oh my leg! Resident 17 was observed to continue to have moaning, shortness of breath and facial grimacing. On 10/25/17 at 7:53 AM, an observation was made of RNA 1 as she stated to resident 17, what's wrong with your leg? Is it tender? Do you need a pain pill? Resident 17 was observed to continue to have moaning, shortness of breath and facial grimacing. (Note: No observation was made of RNA 1 placing a call on the radio to resident 17's nurse.) On 10/25/17 at 7:55 AM, an observation was made of resident 17 as she stated, Oh that leg! Resident 17 was observed to continue to have moaning, shortness of breath and facial grimacing. On 10/25/17 at 7:55 AM, an observation was made of RNA 1 as she repositioned resident 17 in her wheelchair. An observation was made of RNA 1 as she stated that didn't work did it! An observation was made of RNA 1 as she looked at resident 17's leg. Resident 17 was observed to continue to have moaning, shortness of breath and facial grimacing. On 10/25/17 at 7:57 AM, an observation was made of RNA 1 as she called on the radio for a pain pill for resident 17. On 10/25/17 at 8:05 AM, an observation was made of resident 17 as she continued to have moaning, shortness of breath, facial grimacing and now shaking her head. On 10/25/17, resident 17's medical record was reviewed. physician's orders [REDACTED]. a. [MEDICATION NAME] ER (extended release) 15 mg (milligrams) 2 tablets twice daily for chronic pain. b. [MEDICATION NAME] concentrate 100 mg/5 ml (milliliters) 0.25 ml every hour for mild breakthrough pain, 0.50 ml every hour for moderate breakthrough pain, 0.75 ml every hour for severe breakthrough pain and 1 ml every hour for worst breakthrough pain. The Medication Administration Record [REDACTED]. On 10/25/17 at 8:25 AM, an observation was made as resident 17 was taken back to her room by her hospice Certified Nursing Assistant (CNA). On 10/25/17 at 8:32 AM, an interview was conducted with RNA 1. RNA 1 stated that she had notified the nurse by calling on the radio but did not recall the time. RNA 1 stated that after she took another resident back to their room, she also stopped at the nurse's station and talked with Registered Nurse (RN) 1. RNA 1 stated that she asked RN 1 if resident 17 had received her pain medication. RNA 1 stated that RN 1 confirmed that resident 17 had received her pain medication earlier. On 10/25/17 at 9:09 AM, an interview was conducted with RN 1. RN 1 stated that the facility protocol for pain was to assess the resident's pain level, ask where the pain was and then monitor the resident for effectiveness of the pain medication. RN 1 stated that she had not received word from RNA 1 that resident 17 had pain and could not have received the call regarding the pain because I have an ear infection and I can't wear the radio today. RN 1 stated that she would assess resident 17 for pain now. On 10/25/17 at 9:23 AM, an observation was made as RN 1 administered [MEDICATION NAME] 0.50 ml to resident 17 in the activity room. On 10/25/17 at 9:23 AM, an interview was conducted with RN 1. RN 1 stated that resident 17 was unable to give a pain score but she observed that resident 17 needed pain medication. RN 1 stated that resident 17 had facial grimacing, grunting, and moaning and she felt like resident 17 needed pain medication. RN 1 explained that the hospice CNA was unable to give resident 17 a shower as resident 17 told the hospice CNA pain, pain. The MAR for October 2017 for resident 17 revealed that [MEDICATION NAME] concentrate 0.50 ml had been signed out at 9:16 AM. On 10/25/17 at 10:25 AM, an interview was conducted with RN 1. RN 1 stated that resident's pain has subsided and according to the Wong-Baker (Faces Pain Assessment), resident 17's pain level is about a 2. On 10/25/17 at 10:27 AM, an observation was made of resident 17 in the activity room. Resident 17 was observed to no longer have moaning, grunting (SOB), or facial grimacing. On 10/25/17 at 12:45 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON confirmed that with any report of complaints of pain, that her expectation of the nurse would be to assess for pain, get the pain level, administer pain medication, and to call the physician and inform if the pain medications were not effective. On 10/25/17 at 1:40 PM, an interview was again conducted with RNA 1. RNA 1 stated that resident 17 has Alzheimer's and that resident 17 told her that she had pain. RNA 1 stated that resident 17 doesn't say that unless she is in pain. RNA 1 stated that I called on the radio to ask for a pain pill and someone answered the call on the radio, but we don't use names so I don't know who it was. RNA 1 stated that after she took another resident back to their room, she stopped at the nurse's station and talked with RN 1 and asked if resident 17 had gotten her pain pill. RNA 1 stated that RN 1 confirmed that resident 17 had received her pain pill. On 10/25/17 at 1:51 PM, an interview was again conducted with RN 1. RN 1 stated that she did not recall RNA 1 stopping at the nurse's station and asking about resident 17's pain pill. RN 1 stated that had RNA 1 stopped by to ask about the pain pill, that she (RN 1) would have said yes because resident 17 received 2 [MEDICATION NAME] ER tablets just after 7:00 AM. RN 1 confirmed that she had not been wearing a radio and was still not wearing a radio because of an ear infection. RN 1 stated that normally the CNA's and RNA's would inform the nurses if a resident was having pain and that she would assess the resident's pain level and then administer the resident's pain medications if needed. RN 1 confirmed that she had not been contacted regarding resident 17's pain. Resident 17 received her as needed pain medication approximately one hour and 50 minutes after she first complained of pain.

Based on interview and record review, it was determined for 1 of 34 sample residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for than excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicates the dose should be reduced or discontinued; or any combination of the above reasons. Specifically, the facility did not adequately monitor the laboratory values of a resident who was receiving [MEDICATION NAME] (an anticoagulant) that resulted in the resident having multiple nose bleeds and a high laboratory value. Resident identifier 111. Findings include: Resident 111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 111's medical record was reviewed on 11/18/15. Review of the initial admission orders [REDACTED] 1. [MEDICATION NAME] ([MEDICATION NAME]) 6 mg (milligrams) orally every day; 2. [MEDICATION NAME] ([MEDICATION NAME]) 2 g (grams) intravenously every day; 3. Fluconazole 400 mg every day; and 4. To have the [MEDICATION NAME] ([MEDICATION NAME]) dosing and PT ([MEDICATION NAME] time)/INR (international normalization ratio) per the (local) anticoagulation clinic . 5. The INR goal was documented as 2.5. (Note: The [MEDICATION NAME] sodium had a drug to drug interaction with anticoagulants which increased bleeding effects with oral anticoagulants, and Fluconazole increased serum levels and therefore therapeutic and toxic effects of [MEDICATION NAME] anticoagulants (2015 Lippincott's Nursing Drug Guide, pages 253 and 518). The electronic progress notes were reviewed. A licensed facility nurse documented, 06/27/2015 14:21 (2:21 PM) Pt (patient) has had nose bleed today, put cold pack behind neck and pressure on bridge of nose, nose bleed stopped for a few hours then started to bleed again. Checked INR and was (greater than) 8.0, contacted (resident 111's primary care physician) to let him know we were sending pt to ER (emergency room ), waiting for response. Pt's wife was contacted and pt was sent via w/c (wheelchair) to (local hospital) per (facility) transportation. Pt's vitals were Temp (temperature) 97.5 pulse was 79 resp (respirations) 20 B/P (blood pressure) was 140/78 and 02 (oxygen) sats (saturation) were (sic) 94% on RA (room air). Pt left in stable condition. Review of the laboratory values obtained for resident 111 revealed that the facility had not obtained laboratory values to monitor the effectiveness of the [MEDICATION NAME] prior to 6/27/15. On 6/27/15 at 7:10 PM, a facility licensed nurse documented, Pt returned back from ER via w/c per (facility) transportation with new orders to hold [MEDICATION NAME] until pt see's (primary care physician) . On 11/18/15 at 2:30 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that the facility did not have a policy on obtaining laboratory values upon admission to the facility. The DON further stated that if the admission orders [REDACTED]. On 11/18/15 at 3:45 PM, the DON was re-interviewed. The DON stated that resident 111 was not an orthopedic patient and would not have had his labs to monitor the effectiveness of the [MEDICATION NAME] through the local [MEDICATION NAME] clinic. The DON further stated that resident 111's primary care physician should have been notified to obtain laboratory orders. Review of the emergency room documentation revealed, .HISTORY OF PRESENT ILLNESS: (Resident 111) comes in with a nosebleed of about 1 day's duration, blood appears to be coming from his right naris (nares).He does have some mild to moderate active bleeding from his right naris (sic). PHYSICAL EXAM: .I could appreciate no contusions, no bruising, no petechia about his skin. His INR, however, is greater than 11. EMERGENCY DEPARTMENT COURSE: Right naris (sic) was suctioned, anesthetized with doxy solution and effectively cauterized with silver [MEDICATION NAME]. Findings were discussed with patient's cardiology, (name redacted), who suggested to give the patient 5 mg of oral vitamin K to begin bringing his INR down to safe limits. Findings and danger of his high INR were discussed with both the patient and his wife.He will hold off on his [MEDICATION NAME] until he sees (the cardiologist) and have his INR rechecked.

Based on observation, interview and record review it was determined the facility did not provide adequate supervision to prevent 1 of 15 sample residents from wandering/eloping from the building which resulted in a fall with injuries. Resident identifier: 13 Findings include: Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 5/16/11 at 12:40 PM, resident 13 was observed in a low bed with a fall mat beside it. Resident 13 was sitting up in bed. The left side of resident 13's face had multiple bruises and abrasions, her lips were swollen and sutures were on her forehead. Her left arm was in a sling. On 5/17/11 at 9:15 AM, resident 13 was observed in her wheelchair in her room. The Home Free System alarm or watch was not on resident 13 or her wheelchair. At 2:30 PM, resident 13 was observed in the hallway with the watch on her wheelchair. On 5/16/11 and 5/17/11, the exit doors of the facility were observed. The west exit door near room 212 went to a patio that was connected to the assisted living facility. This door had a sign that indicated: "Attention Visitors Red Cliffs Regional offers a special program for residents with memory loss. Our doors have been equipped to lock down and alarm if a resident with a monitoring watch attempts to exit. When exiting the building please be aware of our special program and do not assist residents out of the building. If the door is locking down or alarming, please contact staff for assistance. The safety of our residents is our highest priority and we appreciate you support with this program." The three other exit doors in the facility did not have the sign. Resident 13's medical record was reviewed on 5/16/11. A quarterly Minimum Data Set (MDS), dated [DATE], indicated resident 13 had wandering behavior one to three days. A quarterly MDS, dated [DATE], indicated resident 13's cognition was moderately impaired and made poor decisions. A fall risk assessment, dated 2/14/11, indicated resident 13 had a high risk score of 17. Care Plans for resident 13 were reviewed. Resident 13 did not have a care plan for wandering. The care plan dated 2/28/11, for falls included the goal no environmental hazards for 90 days. One action was to modify all environmental or situational hazards. A Wandering/Elopement Risk care plan was provided by the facility on 5/17/11 that was dated 5/16/11. Another was provided by the facility on 5/18/11 by fax. A Care Plan for wandering/elopement was not completed after resident 13's wandering/elopement that happened on 11/20/10. A physicians Communication form, dated 11/20/10, indicated as a concern: "Your patient was found outside the facility in the parking lot. Nursing assessment found no new injuries or abnormalities. Will continue to monitor. . . " An Investigation Follow-UP form dated 11/22/10 indicated the incident happened on 11/22/10. The form indicated: "Found outside in parking lot. Pt (patient) is unable to open doors by self. Staff states someone must have assisted her out. Pt has had increased confusion with room change will continue to monitor. No new changes at this time." Nurses Notes for resident 13 were reviewed. 5/10/11 "Up in wheelchair as per usual routine, remains confused and disoriented at times. . ." 5/15/11 "pt was found outside in the driveway face down about (7:45 PM) by two visitors. pt was assessed by 2 nurses and noted to be able to move all extremities with no complaints of pain to her face. Pt brought into facility assessed and wound lacerations to face cleaned. Noted to have bruises and a laceration to forehead. Bruises to L (left) eye and abrasion under L eye. L side of mouth was swollen. Abrasion to chin . . . 911 called to pick up and transport . . . L hand was noted to be swollen somewhat. Knees had abrasions. . . " 5/16/11 "Pt returned to facility via facility van. . . Pt also has a wrist fracture . . . facial lacerations, sutures should be removed in 7 days. . . " An Interdisciplinary Post Fall Review, dated 5/16/11, was provided by the facility on 5/17/11. The review indicated: "L wrist fracture, laceration x 2 to forehead and abrasions and bruising to face.. . . Pt tipped over wheelchair in parking lot face forward. . . wandering in parking lot in wheelchair. . . Pt was able to exit building during arrival of a singing group who possibly assisted her out the door. Pt is unable to tolerate a watch on her wrist. We will attach to the wheelchair. Staff notified. . . " On 5/16/11 at 2:15 PM, the Director of Nursing (DON) was interviewed. The DON reported that the long term hall was the west hall and the doors had a code to get in and out to keep long term residents from wandering into the short term hall. The DON stated that if a resident had wandering behaviors the facility used the Home Free System and the resident wore a watch that would then alarm when the resident tried to exit the building. The DON mentioned three residents that were on the Home Free System. Resident 13 was not mentioned. The DON stated that resident 13 went out the front door of the facility, but that he did not know how she did it. The DON stated that resident 13 had never left the facility before. The DON stated it looked like resident 13 lost control of her wheelchair. The DON was informed of the exit of resident 13 in November. The DON stated: "If it did happen in November it would be a concern that she would get out again." On 5/17/11 at 11:05 AM, the DON stated that resident 13 had not had a watch for a really long time because she doesn't wander. On 5/16/11 at 2:25 PM, Licensed Practical Nurse (LPN) 1 was interviewed concerning resident 13. LPN 1 stated resident 13 wandered through all the halls with a slow steady pace in her wheelchair. LPN 1 was not aware of any other time resident 13 had exited the facility. LPN 1 stated that now the facility would probably implement the home free system for resident 13. On 5/16/11 at 2:40 PM, Registered Nurse (RN) 1 was interviewed concerning resident 13. RN 1 stated she was not aware of any other time resident 13 had exited the facility. RN 1 stated that if a resident was exit seeking they would wear the watch and facility staff would redirect them. RN 1 stated resident 13 did not have the strength to open a door. RN 1 stated resident 13 did not wear a watch. On 5/17/11 at 8:45 AM, LPN 2 was interviewed. LPN 2 stated that if there was a change of care for a resident they wrote it in the chart and the next shift would read it. LPN 2 stated facility staff would not initiate the Home Free System on their own, they would consult with the DON. LPN 2 stated resident 13 was wheelchair bound and moved about the facility on her own. LPN 2 stated that resident 13 would always ask, "Where am I going?" Resident 13 would knock and push on the doors but was redirected by staff. LPN 2 was not aware of any other time resident 13 had exited the facility. On 5/17/11 at 9:00 AM, Certified Nurse Assistant (CNA) 1 was interviewed. CNA 1 reported that information concerning resident care was communicated by morning report or a nurse or another CNA would mention a change in care. CNA 1 stated that resident 13 roamed the halls to the doors pushing on them. CNA 1 was not aware of any other time resident 13 had exited the facility. On 5/17/11 at 9:15 AM, CNA 3 was interviewed. CNA 3 stated a change in resident care was communicated in report and was verified with the nurse. Information was also put into the communication log. CNA 3 stated that resident 13 was mellow in the mornings, but was agitated and confused in the afternoons and wanted to go home and asked when the bus was leaving. CNA 3 stated that resident 13 pulled herself with her feet with her wheelchair "really well and fast." CNA 3 stated resident 13 tried to exit all the time, but had the watch on so staff stopped her at the doors. CNA 3 reported that resident 13 had tried to exit last October or November, but had not succeeded. On 5/17/11 at 9:25 AM, CNA 4 was interviewed. CNA 4 reported resident 13 was confused and wanted to go home, especially at meal times. CNA 4 reported that resident 13 always asked "to get out of here." CNA 4 stated that resident 13 did not wear a watch because "she had not been that kind of risk". On 5/17/11 at 9:30 AM, CNA 5 was interviewed. CNA 5 stated a change of resident care was communicated when report was given or in the communication log. CNA 5 reported that resident 13 wandered in her wheelchair and always tried to get out. CNA 5 reported that visitors often let the residents out and facility staff had to watch the doors. CNA 5 stated that resident 13 had a watch before when she was on the 100 hall. CNA 5 stated that resident 13 was always trying to take it off. CNA 5 stated that residents who wandered needed to have a watch. On 5/17/11 at 10:42 AM, CNA 6 was interviewed by phone. CNA 6 stated he worked on the long term wing from 4:00 PM to 6:30 PM on 5/15/11 when resident 13 exited the facility and fell . CNA 6 stated that resident 13 was "a major wanderer." Resident 13 always said: "the doors are locked and I can't get out." CNA 6 stated resident 13 did wear a watch and had been since January 2011. CNA 6 stated that he last saw resident 13 in the dining room eating at 6:30 PM, after that he went to the East hall. On 5/17/11 at 1:30 PM, CNA 2 was interviewed by phone. CNA 2 stated she worked the evening shift on 5/15/11 in the long term care hall when resident 13 fell . CNA 2 stated resident 13 always "cruised around". CNA 2 stated that resident 13 was confused. CNA 2 reported that before resident 13's fall she had last seen her outside room 216 between 7:00 PM and 7:30 PM. CNA 2 stated resident 13 had almost run over her and a nurse while they were picking up dinner trays. CNA 2 stated she just "turned her (resident 13) a little bit then finished picking up trays." CNA 2 stated she had heard stories that resident 13 had tried to get out of the facility by room 212 before, so she knew resident 13 would try to elope. CNA 2 stated that resident 13 did not have a watch on May 15. CNA 2 stated that resident 13 was supposed to have a watch and had one less than 2 months ago and a nurse had loosened it up. CNA 2 stated that she usually checked to see if the resident had their watches, "but it was really busy at that time." The long term care communication log was reviewed on 5/17/11. The log did not have information on resident 13. An undated Risk Assessment Elopement Decision Tree form was provided by the facility on 5/17/11 for resident 13. The DON indicated the form had just been implemented. It included that resident 13 had a"change in condition". Several areas were checked on the form. "Resident is cognitively impaired, with poor decision-making skills, and/or pertinent [DIAGNOSES REDACTED]., dementia, Alzheimer's, delusions, hallucinations, anxiety disorder, depression, manic depression, schizophrenia or Resident is alert but non-compliant with facility protocols regarding leaving the unit." "Resident has a history of wandering (either in the facility or elsewhere) or Opening doors to the outside and/or elopement or Requires assist with doors Is making statements that they are leaving or seeking to find someone/something. . . " Care plan for high risk for elopement residents differentiating strategies for the cognitively intact vs. cognitively impaired individuals." "Educate staff and enter notation on White Board." "Utilize Home Free system per manufacturers instructions as warranted" "Add the name of the resident with the Home Free system on the 24 hour report" "Re-evaluate all interventions at least quarterly and verify the watch on the Home Free system." On 5/17/11 at 11:00 AM, the facility ADON (Assistant Director of Nurses) was interviewed. The ADON stated that resident 13 had previously had a watch in place before the November 2010 elopement. She stated that the watch was removed at the families request related to the watch " irritating " the resident. The ADON stated that the facility felt resident 13 was safe as the resident required assistance to get through the facility doors. She stated that a watch was just applied to resident 13 ' s wheelchair. The ADON stated that the facility did not have a formal process to assess or identify resident(s) that were at risk for elopement or wandering until after a mock survey (by an independent agency) was conducted. She stated that hindsight was 20/20 and that the facility should have put the watch on resident 13 ' s wheelchair.