Every finding on record at Richmond Health Care Center

Based on, interviews, and record review, the facility failed to ensure each resident was free from abuse for 5 of 15 residents (Residents #9, #3, #5, #2 and CR #3) reviewed for abuse in that: 1. Resident #5 was physically abusive to Resident #9 on 7/22/26 when Resident $5 pushed Resident #9 to the ground and Resident #9 fell and hit her head, resulting in a 1.2 cm laceration. 2. Resident #5 was physically abusive to CR #3 on 6/24/26, when Resident #5 hit CR #3 causing CR #3 to put Resident #5 in a chokehold and they both fell to the floor. 3.Resident #2 was physically abusive to Resident #1 on 4/4/26 when Resident #2 hit Resident #1 on the left arm. These failures placed residents, who resided in the facility at risk of abuse, injuries, pain and emotional distress. The findings included:1. Record review of Resident #9's admission Record generated on 8/7/26 revealed she was admitted to the facility on [DATE] and resided in the memory care unit. She had diagnoses of dementia, severe with other behavioral disturbance. She was [AGE] years old. Record review of Resident #9's Care Plan Report dated 5/18/26 revealed she was at risk for elopement or wandering related to disease process, stating she wandered aimlessly. Interventions included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. identify pattern of wandering. provide environment with decreased stimuli.resident requires secure unit placement. Record review of Resident #9's admission MDS assessment dated [DATE] revealed she had a BIMS of 8, indicating she had moderate cognitive impairment. She had no indicators of psychosis and no behavioral symptoms. She had no functional limitations in range of motion. She used a walker for mobility. She required substantial/maximal assistance with personal hygiene and required partial/moderate assistance with walking 10 to 150 feet. Record review of Resident #9's Care Plan Report dated 7/2/26 revealed she had impaired cognitive function or impaired thought processes related to dementia. Interventions included, Address needs such as hunger, thirst, hot or cold room temperatures, need for toileting, dignity and privacy, etc. and attempt to anticipate needs.ask yes/no questions in order to determine the resident's needs.' Record review of Resident #5's admission Record generated on 7/23/26 revealed she was admitted to the facility on [DATE] with diagnoses of aphasia, restlessness and agitation, anxiety disorder (a mental health condition involving excessive, ongoing fear or worry that interferes with daily life), major depressive disorder (causes ongoing sadness, loss of interest in activities, low energy, and changes in sleep or weight lasting at least two weeks) and dementia. She was [AGE] years old. Record review of Resident #5's Care Plan Report revealed the following focus areas and interventions: -Care plan dated 9/8/25 stated Resident #5 had impaired cognitive function or impaired thought processes related to neurological symptoms. Interventions included, ask yes/no questions in order to determine the resident's needs. cue, reorient and supervise as needed. -Care plan dated 9/3/25 and revised on 7/21/26 stated Resident #5 had behavior problems like aggression toward others, refusal of care, making loud vocalizations repeatedly for no apparent reason, and refused to wear shoes and socks. Interventions included, allow resident her safe space and/or an alternate space to be able to calm down and 'regroup.'. provide reassurance and redirection when patient starts to be become agitated and before impulsive behaviors begin.monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Record review of Resident #5's nurse progress notes revealed the following:-3/4/26- Resident #5 had a verbal disagreement with her next-door neighbor resulting in Resident #5 moving to a different room. -3/25/26- Resident #5 was agitated and unable to be redirected. She was yelling and attempting to hit staff. -6/9/26- Resident #5 was aggressive toward staff and used her walker to push the nurse, then threw food from the table onto the floor. Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 5, indicating she had severe cognitive impairment. She had no indicators of psychosis and no behavioral symptoms. She had no functional limitations in range of motion and used a walker for mobility. She required substantial/maximal assistance for personal hygiene tasks. She required substantial/maximum assistance with walking 10 feet. The section for Active Diagnoses indicated that she had Huntington's Disease (a fatal inherited genetic disorder that causes progressive breakdown of nerve cells in the brain. It leads to a triad of physical, cognitive, and psychiatric symptoms). Record review of Resident #5's nurse progress notes revealed the following: -6/24/26- Resident #5 was physically aggressive toward another resident and was placed on 1:1 supervision (a designated staff member is assigned to closely monitor one specific patient at all times) and transferred to a psychiatric hospital. -7/3/26- Resident #5 readmitted to the facility from the hospital. -7/21/26- Resident #5 was found in her room with another resident on the floor and bleeding.Record review of Resident #5 and Resident #9's Census Location in their electronic medical records revealed they resided in different rooms on 7/21/26. Record review of Resident #9's Incident Note dated 7/21/26 at 6:01pm written by RN T stated, Around [5:52pm], this writer was at the hallway passing medications when she had (sic) a loud noise in a resident's room. This writer quickly rushed into the resident's room meeting the nursing assistant who also had rushed before this writer. This writer saw this resident bleeding on her head while lying on the floor with her head laying on the bed frames. This writer quickly assessed both residents, and with the assistance of the nursing assistant, first of all picked up this resident who was actively bleeding, and applied pressure dressings on her. Then the nursing assistant assisted the other resident up back to bed. vital signs for this writer BP 158/89, P 88, O2 97, Temp 97.3. 911 was called and resident was sent to the ER. Management was informed, Family was notified and NP was notified as well.Record review of Resident #9's History and Physical Note from the local acute care hospital dated 7/22/26 revealed she was sent to the emergency room after a fall with head trauma. She was found to have a 1.2cm laceration on her scalp near the occipital area. The laceration was stapled using two staples. Record review of a Provider Investigation Report dated 7/25/26 revealed on 7/21/26 at 5:52pm, a CNA heard Resident #5 screaming from insider her room and observed Resident #5 push Resident #9 to the floor. The charge nurse assessed Resident #9 and found a laceration to the posterior aspect of her head with active bleeding. The findings of the investigations read, The investigation determined that this incident was an unanticipated resident-to-resident altercation involving two cognitively impaired residents residing on the secured Memory Care Unit. There was no evidence that facility staff abused, neglected, or failed to appropriately supervise either resident. Staff responded immediately upon hearing resident distress, initiated emergency medical interventions, notified nursing leadership, activated EMS promptly, and followed facility policies throughout the event. In an interview on 7/22/26 at 5:00pm, CNA N stated that Resident #5 had some behaviors such as screaming. She said people could hear her throughout the hall. She said Resident #5 was aggravated and threw a fit and when she did not get something right away. She said she would bump people with her walker or grab someone's arm. She said Resident #5 hit her (CNA N) all the time. When asked about interventions for her behaviors, she said she would let the nurse know, redirect her to room, and try to get her to lay down. She said Resident #9 was quiet and polite. She said Resident #9 tended to forget where her room was and she laid down in other resident's beds. In an interview on 7/22/26 at 5:31pm, CNA D said Resident #5 had behaviors daily such as yelling or screaming and would push people with her walker at times. She said Resident #9 liked to walk around the memory care unit. She said Resident #9 had sundowning behaviors in the evening and asked for her family and tried to leave. She said Resident #9 was unaware of the location of her room. She said on the day of the incident between Resident #9 and Resident #5 she was in the hallway and another aide was in the dining room around 5:50pm. She said she heard Resident #5 yelling from her room. When she walked into Resident #5's room, Resident #5 was sitting on the bed, Resident #9 was standing next to Resident #5, and Resident #5 pushed Resident #9. She said she lifted Resident #9 and noticed a lot of blood. She said Resident #9 was calm and did not complain of pain. In an interview by phone on 7/23/26 at 9:36am, Resident #9's family member stated the ADON informed him of incident that occurred. The family member stated Resident #9 was in the hospital on 7/23/26. The family member stated he was not told who pushed Resident #9, but thought it was the resident who walks around barefoot and she gets in people's faces. The family member said something needed to be done for the resident because she is aggressive all the time. Something needed to be done with the patient, she is aggressive all the time. The family member stated Resident #9 was passive, could not walk without a walker and was hutched over. When asked how Resident #9 would feel about the altercation, the family member stated Resident #9 would feel afraid because she was attacked. In an interview on 7/23/26 at 11:21am, LVN H said residents in the memory care unit could be aggressive. He said Resident #5 had behaviors about once a week. She would become angry, upset, try to hit others with her walker. Said they needed to meet her needs and redirect her to her room. He said between 7/3/26 and 7/21/26, there were no new interventions for Resident #5's behaviors. 2. Record review of CR #3's admission Record generated on 7/23/26 revealed she was admitted to the facility on [DATE] and discharged from the facility on 7/8/26. She had diagnoses of encephalopathy, dementia and bipolar disorder with psychotic features (lifelong mental health conditions defined by severe shifts in mood, energy, and activity levels. These shifts range from highs of extreme energy and euphoria to lows of deep sadness and fatigue). She was [AGE] years old. Record review of CR #3's admission MDS assessment dated [DATE] revealed she had a BIMS of 1, indicating she had severe cognitive impairment. She had no indicators of psychosis or behavioral symptoms. She rejected care on 1 to 3 days out of 7 days. She required partial/moderate assistance with personal hygiene tasks. She required supervision with walking 10 to 150 feet. She had no functional limitations in range of motion. Record review of CR #3's Care Plan dated 4/29/26 revealed she had the potential to be physically aggressive related to anger, dementia, poor impulse control. Interventions included, Administer medications as ordered. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs.When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later. Record review of CR #3's progress note dated 6/24/26 at 8:24am completed by the ADON stated, Resident was physically assaulted by another resident on the memory care unit, heat to toe assessment was completed and no injuries noted, denied pain, call placed to {Family Member} to update on incident, question and concerns answered. NP also updated at this time also. Record review of CR #3's SNF Follow Up Progress Note dated 6/26/26 completed by NP G read, On 06/24/2026, staff reported that the patient was assaulted by another resident in the memory care unit. No visible injury was identified at the time. On today's assessment, there is no physical trauma or injury noted. Per staff, the assaulting resident has been kept away from the patient. The patient appears comfortable and not in any danger. Recommended to continue with memory and supportive care per facility protocol. Record review of a Provider Investigation Report dated 6/28/26 indicated on 6/24/26 at 7:50am, Resident #5 became increasingly agitated in the memory care dining room. She stood up and began striking a CNA and a hospice employee, threw food items, and threw CR #3's meal tray. The report stated Resident #5 grabbed CR #3's shoulders, CR #3 pulled Resident #5's hair, and both residents fell to the floor. An assessment of both residents revealed no injuries or complaints of pain. Investigation Findings read, The investigation determined that [Resident #5] experienced an acute behavioral escalation related to her underlying cognitive impairment and psychiatric condition. Staff responded promptly by attempting verbal redirection and removing the resident from the environment. When resident-to-resident contact occurred, staff immediately intervened and prevented any further physical interaction. There was no evidence of abuse, neglect, or failure to supervise by facility staff. Staff interventions were timely and appropriate under the circumstances.Record review of a statement signed by CNA W stated that on the morning of 6/24/26, Resident #5 was agitated and could not be redirected. Resident #5 knocked a snack out of CNA W's hand, and she paced back and forth from the bathroom to her bed. She attempted to hit me with her walker, by picking it up and throwing at me as she walked by me.I told the oncoming CNA about the night and that [Resident #5] was on 1:1 and 'She is all yours.' In an interview on 7/22/26 at 5:00pm, CNA N said she was working when the incident occurred between CR #3 and Resident #5. She said the incident occurred in the dining room while she was passing breakfast trays on the hallway. She said CNA V was present. She said she walked into the dining room and noticed CR #3 and Resident #5 were lying next to each other by a dining room table. She said CR #3 looked shocked and scared. In an interview by phone on 7/23/26 at 1:39pm, CNA V stated she was working on the day of the incident between Resident #5 and CR #3. She said the CNA who worked overnight was with her providing 1:1 supervision when she arrived to work at 6:00am. She said she asked the nurse and no one told her to continue 1:1 supervision. She said at the beginning of her shift Resident #5 was combative and trying to hit people. She said she was in the dining room passing breakfast trays. She said Resident #5 hit her (CNA V) 3 to 4 times in the chest, then hit a hospice worker. She said Resident #5 hit CR #3, then threw CR #3's tray and drink. She said CR #3 grabbed Resident #5's shoulder then put her in a chokehold, hit her with a closed fist, and pushed her onto the floor, then CR #3 followed her to the floor. She said she could not describe where the residents were hit. She said Resident #5 frequently pushed people with her walker and spit on people. She said interventions never really worked. She said the nurses knew that Resident #5 was combative and hit others. She said there was not a clear plan on how staff were handling Resident #5's behavior. Record review of an undated statement signed by CNA V stated, On the morning of June 24th, when I first arrived on my shift, I received report that [Resident #5] was being agitated and combative during the night.[Resident #5] was calm for the first part of my shift.I asked her if he (sic) wanted to eat in her room or the dining room, and she got up and we went to the dining room to eat breakfast. Once she was in the dining room, she was seated and her food was brought to her. She was calm. She then began to 'fiddle' with her food. She began to make verbal noises and got up and began to pace or move about in a small area. She then walked up to a CNA and struck her. I attempted to intervene and redirect, but was unsuccessful. [Resident #5] then turned and struck a hospice staff member. Then she went into the hall, as the other staff were trying to get other resident's out of the dining room. She went back into the dining room, as I was not able to redirect successfully, and she sat down calmly. It was then that she knocked a cup for a resident's hand, knocking it to the floor, and a breakfast tray to the floor. She then got up and as she passed a resident, she grabbed the other resident by the shoulders, that resident in turn reached around, grabbed [Resident #5] by the hair and pulled her to the floor (or they lost their balance). The two were separated.All this took place in just a very few minutes. In an interview by phone on 7/23/26 at 3:41pm, CR #3's family member stated CR #3 was discharged from the facility in part because she was assaulted. The family member said CR #3 always stands her ground. 3. Record review of Resident #1's admission Record generated on 8/7/26 revealed she was admitted to the facility on [DATE] and resided on the memory care unit. She had diagnoses of dementia, anxiety disorder and adjustment disorder (an emotional or behavioral reaction to a stressful life change, like a divorce, job loss, or move). She was [AGE] years old. Record review of Resident #1's Care Plan Report dated 10/30/25 revealed she had impaired cognitive function or impaired thought processes related to dementia. Interventions included, Administer medications as ordered.keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Memory Care Unit Placement for Safety. Present just one thought, idea, question or command at a time. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had short-term and long-term memory problems. She did not have indicators of psychosis of behavioral symptoms. She was dependent on staff for personal hygiene and required supervision for walking 10 to 150 feet. She had no functional limitations in range of motion.Record review of Resident #2's admission Record generated on 8/7/26 revealed she was admitted to the facility on [DATE] and resided on the memory care unit. She had diagnoses of dementia, anxiety, major depressive disorder and schizophrenia (a severe, chronic brain disorder that affects how a person thinks, feels, and acts. People with this condition may struggle to tell the difference between reality and their imagination). She was [AGE] years old. Record review of Resident #2's Care Plan Report dated 3/10/25 revealed she had a psychosocial well-being problem related to anxiety, cursing at others, disruptive behaviors, verbal aggression and ineffective coping. Interventions included, Allow the resident time to answer questions and to verbalize feelings perceptions, and fears.consult with: Pastoral care, Social Services, Psych Services.increase communication between resident/family/caregivers about care and living environment. when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 7, indicating she had severe cognitive impairment. She did not have indicators of psychosis of behavioral symptoms. She required supervision for personal hygiene tasks and was independent walking 10 to 150 feet. She had no functional limitations in range of motion. Record review of a provider investigation report dated 4/8/26 signed by the Administrator revealed on 4/4/26, Resident #2 was observed yelling and screaming, stating she would harm someone if cigarettes were not provided. While approaching the memory care unit entrance, she struck [Resident #3]. After the incident, it was noted Resident #2 refused to return to her room and continued yelling and threatening others. Emergency services was called and Resident #2 was transferred to a psychiatric hospital. In an interview on 7/23/26 at 12:20pm, CNA U stated she witnessed incident between Resident #2 and Resident #1 that occurred a few months ago. She said Resident #2 was a smoker and got agitated, including verbally attacking the staff when she could not smoke. She said Resident #2 ran out cigarettes the evening of the incident and did not get a smoke break. She said Resident #1 was standing at the entrance of the memory care unit and Resident #2 walked over to her. She said it looked like Resident #1 touched Resident #2's glasses, and Resident #2 reacted and hit Resident #1 on the arm and back then cussed her out. She said the hit appeared intentional. She said at the time of the incident, she (CNA U) was at the end of the hall and the other CNA who was present was not present in the common area. In an interview on 7/23/26 at 4:04pm, the Administrator stated in response to resident-to-resident altercations, they immediately put the aggressor on 1:1 supervision, reach out to physician, ensure there is a psychological evaluation or medication management. She said the psychological NP will evaluate to determine if it was safe for the aggressor to remain in the facility. She said an aggressor had more than 2 incidents, then they would talk to their responsible party about putting them in a different facility as they could not meet their needs. She said Resident #5 went to the hospital after an altercation with a resident, and when she returned she was calm. She said they updated her care plan and in-serviced staff on monitoring and intervening when residents had behaviors. She said when residents showed signs of anger, staff would monitor and let them know if they need to do 1:1 supervision and catch it before altercations happen. She said Resident #5 did not have daily behaviors. She said Resident #5 was not one to put her hands on anyone so the incident with Resident #9 was surprising.In an interview on 8/7/26 at 6:34pm, the DON said Resident #5 was sent to the hospital after the first resident-to-resident altercation. She said it usually took 6 to 8 weeks for medications to be therapeutic and you hope they do what they are supposed to do. Regarding residents with dementia, she said we do not know what was going on in their heads and staff can just watch, intervene and minimize triggers. Record review of the facility's policy regarding Abuse, Neglect and Exploitation dated 2023 read, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms.

Based on observation, interview, and record review the facility failed to ensure each resident received supervision and assistance devices to prevent accidents for 4 of 15 residents (Residents #1, #10, #11 and #12) reviewed for supervision. The facility failed to ensure Residents #1, #10, #11 and #12, who resided on a memory care unit, were provided adequate supervision on 7/22/26 and 7/23/26 when they were wandering into other residents' rooms and staff did not intervene. The facility failed to ensure residents were provided adequate supervision when Resident #12 pushed Resident #10 in her wheelchair on 7/22/26 and facility staff did not intervene. This failure could place residents at risk of injury, harm, and accidents. Findings included:Record review of Resident #1's admission Record generated on 8/7/26 revealed she was admitted to the facility on [DATE] and resided on the memory care unit. She had diagnoses of dementia, anxiety disorder and adjustment disorder. She was [AGE] years old. Record review of Resident #1's Care Plan Report dated 10/7/25 revealed she was at a low risk for elopement and wandering related to dementia. Interventions included, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.Encourage family/resident interaction such as telephone calls, specified visits, event visits, etc.Identify pattern of wandering: Is wandering purposeful, aimless, or escapists? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had short-term and long-term memory problems. She did not have indicators of psychosis of behavioral symptoms. She was dependent on staff for personal hygiene and required supervision for walking 10 to 150 feet. She had no functional limitations in range of motion. Record review of Resident #10's admission Record generated on 8/7/26 revealed she was admitted to the facility on [DATE] and resided on the memory care unit. Resident #10 had diagnoses of dementia with behavioral disturbance, diabetes, major depressive disorder and lack of coordination. She was [AGE] years old. Record review of Resident #10's Care Plan Report revised on 6/19/26 revealed she had limited physical mobility and was at risk for decline with mobility related to being wheelchair bound. Interventions included, .Provide cues, direction and assist as necessary to promote safety awareness with mobility. provide encouragement and reassurance as needed with mobility tasks. Further review of Resident #10's Care Plan Report revealed she was at moderate risk for elopement and wandering related to disease process, disoriented to place and impaired safety awareness. Interventions included, Assess for fall risk. Provide environment with decreased stimuli. Resident prefers to reside on the secured/locked unit . Record review of Resident #10's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 0, indicating she had severe cognitive impairment. She had no behavioral symptoms or presence of wandering. She did not have functional limitations in range of motion and used a wheelchair for mobility. She was dependent on staff for all activities of daily living and mobility tasks. Record review of Resident #10's Care Plan Report revised on 7/28/26 revealed she had actual falls on 5/22/26, 6/25/26 and 7/24/26. Record review of Resident #10's Nurse Progress Note dated 7/24/26 revealed on 11:33am, Resident #10 was found in another room, on her knees, leaning against another resident bed.small thin scratch noted to the right inner thigh. no other marks noted. Record review of Resident #11's admission Record generated on 8/7/26 revealed she admitted to the facility on [DATE] and resided on the memory care unit. She had diagnoses of Alzheimer's disease, macular degeneration an eye disease that damages the macula, the central part of the retina needed for sharp, straight-ahead vision), restlessness and agitation. She was [AGE] years old.Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 1, indicating she had severe cognitive impairment. She had no behavioral symptoms or presence of wandering. She did not have functional limitations in range of motion and did not use a mobility device. She required supervision for mobility tasks such as sit-to-stand, chair/bed-to-chair transfer and walking 10 to 150 feet. Record review of Resident #11's Care Plan Report dated 1/2/26 revealed she had a high risk for elopement and wandering related to dementia. Interventions included, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.Encourage family/resident interaction such as telephone calls, specified visits, event visits, etc.Identify pattern of wandering: Is wandering purposeful, aimless, or escapists? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Resident requires secure unit placement. Record review of Resident #12's admission Record generated on 8/7/26 revealed she was admitted to the facility on [DATE] and resided in the memory care unit. She had diagnoses of dementia, anxiety disorder and major depressive disorder. She was [AGE] years old.Record review of Resident #12's Care Plan Report dated 3/4/25 revealed she had a wandering behavior problem related to going into other resident rooms and picking their belongings. Interventions included, Assist the resident to develop more appropriate methods of coping and interacting. Intervene as necessary to protect the rights and safety of others. Remove from situation and take to alternate location as needed.Provide a program of activities that is of interest and accommodates residents status. Record review of Resident #12's quarterly MDS assessment revealed she had a BIMS of 0, indicating she had severe cognitive impairment. She had no behavioral symptoms or presence of wandering. She did not have functional limitations in range of motion and did not use a mobility device. She required supervision for mobility tasks such as sit-to-stand, chair/bed-to-chair transfer and walking 10 to 150 feet.In an observation and interview on 7/22/26 between 12:34pm and 1:05pm revealed Resident #11 was in the dining room and walked into another resident's room, then left in approximately 15 seconds. At 12:38pm, Resident #12 was in the hallway and walked into another resident's room. CNA D was charting at the kiosk in the hallway. Resident #12 left at 12:39pm and went into her own room at 12:39pm. Resident #11 went into another resident's room at 12:40pm and left at 12:42pm. Resident #12 left her room and went into another resident's room at 12:42pm. When Resident #12 left the room shortly afterwards, Resident #12 and Resident #11 walked down the hallway together. Resident #10 was seated in a wheelchair ambulating toward the exit door at 12:42pm. She pushed the exit bar for about 30 seconds then went into the dining room. Resident #11 and Resident #12 both entered the dining room. Resident #12 began to touch the floor at 12:49pm. At 12:50pm, Resident #10 left the dining room and ambulated in her wheelchair in the hallway. Resident #12 started pushing Resident #10's wheelchair down the hallway. CNA D was at the end of the hall seated at a bedside table and did not intervene. At 12:54pm, Resident #12 pushed Resident #10 into Resident #12's room and left her next to Resident #12's bed facing the window. At 1:00pm, Resident #10 was trying to ambulate backwards out of Resident #12's room. Resident #10 stood up for a moment, sat back down, ambulated backwards then her wheelchair hit the edge of the door. Resident #10 stood up and turned around. When asked about Resident #10, RN T said she wandered around all day. RN T assisted Resident #10 out of the room. At 1:02pm, Resident #11 had her pants down near a chair in the dining room and wiped her bottom with a sock. RN T assisted Resident #11 to help her get dressed. CNA D assisted Resident #11 to her room and closed the door. RN T started cleaning the chair in the dining room. At 1:05pm, Resident #12 was in the hallway and walked into another resident's room past both resident's beds while they were lying down, then walked back into the hallway. She left the room and went into another resident's room.In an interview on 7/22/26 at 5:00pm, CNA N said residents who resided on the memory care unit were in and out of each other's rooms all day. She said Residents #1, #12 and #10 walked/ambulated in her wheelchair from the time they wake up to the time they go to bed. She said interventions for residents who wander in the unit is to redirect them from the room they wander into. She said she knew if a resident could not be found then they would be in one of the resident rooms. In an interview on 7/22/26 at 5:31pm, CNA D said there were 2 aides who worked in the memory care unit and said one was in hallway and one was in the dining room. She said she let the other aide know where she was going if she had to step away. CNA D said she did not always intervene for residents with wandering behaviors. She said at times, she would try to find out what they were looking for, let the residents outside, or take them to the dining room. She said if they were just walking around, it was safe. She said she would monitor to ensure residents were safe and report anything abnormal to the nurse. When asked about residents who pushed other residents down the hall in their wheelchair, she said she did not think that was a problem. In an interview on 7/23/26 at 11:21pm, LVN H said the facility staff kept an eye on residents who wandered in the memory care unit. He said there were some rooms that they could not go into due to residents with aggressive behaviors. When asked how wandering could be unsafe, he said the residents on the memory care unit were older ladies and were not a threat to anyone. Says some rooms that they shouldn't go into, like Resident #2 and Resident #5. He said he intervened when residents wandered by redirecting, bringing them to their room, calm them down, see what they need, and try to give them a snack or hydration. He said he thought there were enough staff on the memory care unit that were effectively supervising residents and he had not had any problems. In an observation on 7/23/26 between 1:11 and 1:17pm revealed at 1:11pm, Resident #1 was in the hallway and walked into another resident's room, and Resident #10 followed her in her wheelchair at 1:12pm. At 1:13pm, Resident #10 was standing up and pushing her wheelchair backwards towards the door of the room. At 1:15pm, Resident #10 was not near her wheelchair, and someone could be heard using the bathroom. At 1:17pm, State Surveyor informed CNA B that Resident #10 and Resident #1 were in the other resident's room, and she said, Oh! and went in the bathroom with Resident #10. In an interview by phone on 7/23/26 at 1:39pm, CNA V said she used to work in the memory care unit. She said there should be 3 staff members in the unit. She said, there is no way they can manage everything. Even with the nurse. There is a lot going on back there. She said the nurse managers were aware that it was difficult because the CNAs were talkative and reported problems to them. In an interview on 7/23/26 at 4:04pm, the Administrator acknowledged there were residents who wandered on the memory care unit. She said there was only one resident room they could not go into. She said Resident #1 could have behaviors and the residents knew they could not go into her room, even when they had dementia. She said the staff kept the residents who wandered out of other residents' belongings and monitored and to make sure there were no unwanted interactions. She said wandering was not necessarily unsafe unless their gait was unstable. She said one CNA should be in the hallway while the other CNA was providing care in a room or helping with activities in the dining room. In an interview on 8/7/26 at 6:34pm, the DON said wandering was a behavior. She said residents resided in the memory care unit due to wandering behaviors. She said they could use interventions such as redirecting out of other resident rooms, use stop signs on doors, black pained lines outside of the entryways but said they only work for a short period of time. She said she would not say it was unsafe to wander. She said it was difficult to keep residents on the memory care unit out of other resident rooms. She said some residents who wandered could be a fall risk. When asked if residents could push other residents in their wheelchairs, she said some residents could push too fast or too hard. She said staff should always intervene in that situation. Record review of the facility's policy regarding Accidents and Supervision dated 2025 read, The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluate and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary.Definitions: 'Risk' refers to any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. 'Supervision/Adequate Supervision' refers to intervention and means of mitigating risk of an accident.The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents.All staff.are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident.

Based on observation, interview, and record review, that facility failed to ensure residents had the right to personal privacy, including personal care, for 1 of 15 residents (Resident #4) reviewed for resident rights. The facility failed to provide privacy to Resident #4 when she was seated in a shower chair with her buttocks exposed and an open, dirty brief placed on the floor beneath her on 7/23/26. This failure placed residents at risk of receiving activities of daily living without privacy, loss of dignity and feelings of embarrassment. Findings included:Record review of Resident #4's admission Record generated on 8/7/26 revealed she was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a general term for brain dysfunction caused by an underlying systemic illness, organ failure, or chemical imbalance in the blood), aphasia (a brain disorder that affects how you use and understand language), chronic ischemic heart disease (progressive heart muscle damage caused by long-term narrowing of the coronary arteries from plaque buildup) and dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, affecting memory, communication, and thinking). She was [AGE] years old. Record review of Resident #4's Care Plan Report dated 3/12/25 revealed she had impaired cognitive function or impaired thought processes related to dementia. Interventions included, Address needs such as hunger, thirst, hot or cold room temperature, need for toileting, dignity and privacy, etc., and attempt to anticipate needs.Memory Care Unit (a specialized residential or distinct wing within an assisted living facility or nursing home that provides 24-hour supervised care and secure environments tailored for individuals with Alzheimer's disease or other forms of dementia) Placement for Safety . Record review of Resident #4's Care Plan Report dated 3/24/25 revealed she had ADL self-care performance deficit and required cutes, setup, and or assistance with ADLs related to dementia. Interventions included providing assistance of 1 staff with showering. Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed she had a BIMS (a short, standard test used in nursing homes and care centers to check a person's memory, attention, and thinking skills) of 5, indicating she had severe cognitive impairment. She required supervision for toileting hygiene and required partial/moderate assistance for bathing, dressing and personal hygiene. She was always incontinent of bowel and bladder. In an observation on 7/23/26 at 1:00pm, Resident #4 was by the front door of her room with the door open seated in a shower chair (a specialized, water-resistant seat placed inside a bathtub or walk-in shower to let a person sit while bathing). She was wearing a hospital gown; her buttocks were exposed as the chair did not have a full seat. There was an open brief under the chair that contained bowel movement. Resident had her eyes closed, the door was open and residents and staff were walking by her room. There were no staff members in her room. In an interview on 7/23/26 at 1:05pm, CNA B said she got Resident #4 ready for a shower and she put a brief on the floor in case she was incontinent. She said she should have closed the door to ensure she had privacy, but the residents on the memory unit liked to open the doors. In an interview on 8/7/26 at 6:02pm, the Administrator said the facility ensured the residents' right to privacy by closing doors when providing care and knocking on the door before entering. When asked about the memory care unit, she said it should be no different. When State surveyor described what was observed regarding Resident #4, she said it was a privacy concern. In an interview on 8/7/26 at 6:24pm, the DON said the expectation for the nursing staff was to still pull residents' curtains and close their doors to ensure residents' right to privacy. When asked about the observation of Resident #4, she said that was a problem and she would not want her own bottom exposed. Record review of the facility policy regarding Resident Rights dated 2024 read, .The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents.The has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility.The resident has a right to personal privacy.personal privacy includes accommodations, medical treatment.personal care.

Based on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, based on the comprehensive assessment for 1 of 15 residents (CR #1) reviewed for quality of care in that: The facility failed to complete and document assessments including neurological assessments when CR #1 had a neurological change of condition on 03/26/26 at 6:08 pm and was sent to the hospital 6.5 hours later at 12:45 am. This deficient practice placed residents at risk of delayed treatment, worsening symptoms and distress. Findings include:Record review of CR #1's admission Record generated on 8/7/26 revealed she was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (. The body's immune system attacks the protective cover of nerve cells, which causes scars. This damage slows or blocks messages between the brain and the body, leading to numbness, weakness, and balance problems), diabetes mellitus (a long-term health condition where the body cannot keep blood sugar at a normal level), epilepsy (a common brain disorder that causes ongoing, repeated seizures), morbid obesity (when a person has a Body Mass Index of 40 or higher), Alzheimer's disease (a progressive brain disorder and the most common cause of dementia, gradually destroying memory, thinking skills, and the ability to carry out simple tasks) and gastrostomy status (the clinical condition of having an artificial opening into the stomach). She was [AGE] years old. Record review of CR #1's care plan report revealed the following focus' and interventions: -A care plan dated 8/24/23 revealed she had an actual communication problem related to expressive aphasia, hearing deficit and weak voice. Interventions included allowing adequate time to respond, repeat as necessary and reduce environmental noise. -A care plan dated 11/23/24 revealed she had multiple sclerosis. Interventions included to monitor for signs and symptoms of damage to motor nerve tracts including weakness, paralysis, spasticity and fatigue and report to physician as needed. -A care plan dated 11/23/24 revealed she had a history of diabetes. Interventions included to monitor for signs and symptoms of hypoglycemia, including sudden onsite of weakness, and hyperglycemia, including increased thirst and urination, fatigue, headache, and intervene as appropriate, document and notify the physician. Record review of CR #1's Order Summary Report for orders that were active on 3/25/26 revealed an order dated 5/14/25 for the following: Observation: Hypoglycemia (happens when blood glucose drops below 70 mg/dL) & Hyperglycemia (occurs when the body has too little insulin or cannot use insulin properly) signs/symptoms: 1. Weakness/dizziness; 2. Restlessness or muscle twitching; 3. Tachycardia; 4. Pale/cool/moist skin; 5. Excessive perspiration; 6. Irritability/bizarre behavior; 7. Blurred vision 8. Headaches; 9. Numbness of tongue & lips/thick speech; 10. (more severe) stupor, unconsciousness and/or convulsions; 11. (More severe) coma; 12. Increased thirst; 13. Frequent urination; 14.Sugar in urine; 15. Fatigue. every shift for Monitoring [diabetes mellitus]. Record review of CR #1's Laboratory Results Report dated 1/14/26 revealed CR #1's HA1C Level (measures your average blood sugar levels over the past two to three months) was 6.1%. The reference range was 0.0% to 6.5%, indicating CR #1's HA1C Level was within normal limits. Record review of CR #1's quarterly MDS assessment dated [DATE] indicated she had moderate difficulty hearing and unclear speech. She had a BIMS of 3, indicating she had severe cognitive impairment. She was dependent on staff for ADL tasks such as toileting hygiene, bathing, dressing and transfers. She was incontinent of bowel and bladder. Record review of CR #1's vital signs in the electronic medical record revealed facility staff last checked CR #1's blood sugar value on 11/10/25. Record review of CR #1's Medication Administration Record dated March 2026 indicated nursing staff completed observations of hypoglycemia and hyperglycemia signs and symptoms on the day and night shifts between 3/1/26 and 3/26/26. Record review of CR #1's Health Status Note dated 3/26/26 at 6:08pm completed by RN Y read, Resident noted with neurological decline this shift and is no longer following commands as previously observed last week. Assessment completed, and vital signs obtained with results within normal limits at this time. No acute distress noted during assessment but change in neurological status remains present. Provider was informed of resident's condition with code status and states family is already aware of decline. ADON informed, and resident's status was communicated to interdisciplinary team during rounds for ongoing awareness and monitoring. Record review of CR #1's assessments in the electronic medical record revealed there were no assessments completed on 3/26/26.Record review of CR #1's Medication Administration Record dated March 2026 revealed RN Y documented CR #1's vital signs on 3/26/26 during the day shift as: BP 94/77; Temp 97.4; Pulse 98; respirations 18; oxygen saturations 98. Record review of CR #1's SBAR Summary for Providers dated 3/27/26 at 12:35am revealed CR #1 had altered mental status, shortness of breath and unresponsiveness. Record review of CR #1's Health Status Note dated 3/27/26 at 12:45am completed by LVN C read, Resident observed with altered mental status. Alert but unresponsive unable (sic) to follow commands, unable to obtained (sic) blood pressure, heart rate very high upon assessment. 911 was called to be send (sic) to Hospital emergency room ER at 12:45 911 took her to [local acute care hospital].the RP notified. on call dr notified with message left. Record review of CR #1's Medication Administration Record dated March 2026 revealed LVN C documented CR #1's vital signs on 3/26/26 during the night shift as: BP 122/65; Temp 97.4; Pulse 135; respirations 18; oxygen saturations 99. Record review of CR #1's Emergency Department Report from the local acute care hospital dated 3/27/26 at 1:05am revealed CR #1 arrived to the emergency room after being found unresponsive at the nursing facility. The note stated CR #1 had significantly elevated glucose. The report indicated she had a blood glucose level of 993mg/dL. The report showed it was high with a reference range of 75-100mg/dL. The report indicated she had a BUN level (measures urea nitrogen in your blood to check how well your kidneys work) of 49. The report showed the BUN was high with a reference range of 9-23. The report indicated she had a creatinine level (a natural waste product from muscle use that healthy kidneys filter out of the blood) of 2.1. The report showed the creatinine level was high with a reference range of 0.6-1. Record review of CR #1's Discharge Summary Note dated 3/27/26 at 10:00pm revealed upon arrival to the emergency department, CR #1 had severe metabolic derangements, severe dehydration, evidence of severe DKA/septic shock (a serious, life-threatening emergency that happens when the body does not have enough insulin) along with markedly elevated lactate. She was admitted to the ICU and resuscitation began. The note indicated CR #1 had a CT scan that showed evidence of gastric outlet obstructions likely due to ampullary/pancreatic head mass and CR #1's family wanted to pursue hospice and comfort care. Record review of CR #1's Certificate of Death dated 4/2/26 revealed the date of death was listed as 3/27/26 at 11:30pm. The chain of events that directly caused the death was listed as septic shock, diabetic ketoacidosis, pancreatic head mass causing gastric outlet obstructions and advanced dementia. The manner of death was listed as natural. In an interview on 8/7/26 at 1:07pm RN M said she remembered caring for CR #1 when she was in orientation with another nurse. She said CR #1 wasn't fully conscious. She said when they spoke to her, she would open her eyes briefly, then close them again. She said she did not notice any type of change of condition or critical illness. In a telephone interview on 8/7/26 at 1:59pm, NP B said she cared for CR #1. She said CR #1 was not receiving medications for diabetes management because her A1C levels were normal for a couple of cycles. She said A1C levels should be checked at least once a year. She said nurses would monitor for signs of hypoglycemia and hyperglycemia. She said she would have ordered labs and requested a blood sugar reading if she had signs of hyperglycemia and monitor for 3-5 days. She said she could not remember when CR #1 had a change of condition before her death. When asked about the progress note written by RN Y on 3/26/26, she said she was unsure if she was notified. In a telephone interview on 8/7/26 at 2:18pm, CR #1's family member stated CR #3 had type II pre-diabetes. The family member stated CR #1 had been diagnosed when she admitted to another nursing facility a few years ago. The family member stated they noticed she was declining and stopped eating. The family member stated they believed the decline was caused by the facility. The family member further stated it was possible she had pancreatic cancer and it was hard to catch. In an interview on 8/7/26 at 2:51pm, the DON stated she filled in at the facility in March 2026 then started working at the facility full time in April 2026. She said staff would monitor for signs and symptoms of high and low blood sugar levels if a resident with diabetes was taken off diabetic medications. She said blood sugar can increase very rapidly. She said if a resident had a change of condition, then the nursing staff should report their findings to the nurse practitioner so they follow their orders. She said she could not remember CR #1's change of condition. An attempt to interview RN Y on 8/7/26 at 4:44pm was unsuccessful. In an interview on 8/7/26 at 6:02pm, the Administrator said the DON was responsible for reviewing incidents when residents had a change of condition. She said the DON started at the facility in March 2026 on an interim basis. She said she had not received any concerns regarding CR #1's change of condition or death.

Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #1) reviewed for infection control, in that: - CNA Z and CNA R failed to wear PPE for EBP, when they provided incontinence care to Resident #1.- The facility failed to have Enhanced Barrier Precaution signage on the door or anywhere visible in Resident #1's room.- The facility failed to have PPE readily available for staff to don before entering Resident #1's room. This deficient practice could place residents at risk for infection, sepsis (infection throughout body), and hospitalization due to cross contamination.Findings included: Record review of Resident #1's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with diagnoses of dementia (decline in mental ability severe enough to interfere with daily life), hemiplegia and hemiparesis (paralysis and weakness) after a stroke, affects from a stroke, history of falling, unspecified psychosis (psychotic disorder where the symptoms are present but don't fully meet the criteria for a more specific diagnosis), acute embolism and thrombosis (blockage/blood clot in a blood vessel) of deep veins in lower extremity, major depression, aphasia (trouble speaking), muscle wasting and atrophy (muscle decreases in size), and muscle weakness. Record review of Resident #1's Quarterly MDS Assessment, dated 7/1/2025, revealed a BIMS could not be performed due to the resident's condition. The resident had moderately impaired cognitive skills for daily decision making. The MDS indicated the resident had impairment on one side of his upper and lower extremities and had a limb prosthesis. The resident was dependent (the helper does all of the effort, or the assistance of 2 or more helpers is required) with all ADL's. The resident was always incontinent of bowel and bladder. The MDS indicated Resident #1 had 1 unstageable (wound has dead tissue and wound bed cannot be seen) pressure ulcer and was receiving wound care. Record review of Resident #1's care plan dated 12/13/23, revealed the care plan did not have the resident's pressure ulcer or the EBP on it. Record review of Resident #1's Progress Notes from 6/26/25 by LVN F, revealed the Wound Care MD recommended an MRI of the L ankle/foot due to an unstageable wound on the L heel. Record review of Resident #1's Progress Note from 6/27/25 by NP M, revealed he was being seen for an unstageable wound on the L heel. The resident had just finished abx for a wound infection and there was concern about the wound not healing over the past couple weeks. Record review of Resident #1's Physician Orders revealed the following orders from MD C:- Wound Treatment to left heel: Cleanse with Dakin's solution (wound cleanser), pat dry, apply Santyl (wound debridement), Bactroban (antibiotic), cover with alginate (promotes wound healing), and secure with dry dressing. Ordered on 6/25/25 at 2:06pm.- MRI of the ankle and foot. DX: LT heel wound. Ordered on 7/1/25 at 9:25am.- Enhanced Barrier Precautions due to wounds. Ordered on 7/2/25 at 12:55pm. In an observation on 7/9/25 at 1:22pm, Resident #1 was lying in bed on his back, sleeping. His L heel had a pressure relieving boot on it and his heels were floated off the bed. There were no isolation signs on the door. An observation on 7/9/25 at 2:31pm, revealed CNA Z and CNA R provided incontinence care to Resident #1. Neither CNA had a gown on during incontinence care. An observation and interview on 7/9/25 at 2:40pm, revealed RN U was about to start wound care on Resident #1 without a gown on, when the ADON had CNA Z come into the room and handed RN U a gown to put on. CNA Z said, The ADON told me to bring these gowns in for y'all. I did not know he had a wound and we messed up when we changed him because we did not have gowns on. In an interview on 7/9/25 at 2:56pm, RN U said she had to wear a gown during wound care, but she was unsure of what residents were supposed to be on EBP. She said she was a brand-new nurse out of school and was brand new with the facility. She said cross contamination could happen if a gown was not worn. In an interview on 7/9/25 at 2:58pm, CNA Z said EBP was for wounds, but she was not sure what else. She said she was supposed to wear a gown and gloves, and it was to prevent cross contamination. She said she was supposed to wear a gown during Resident #1's incontinence care but she did not know he had a wound because that was not her resident, and she was just assisting. In an interview on 7/9/25 at 3:29pm, the ADON said EBP was for resident's who had wounds, Foleys (tube into bladder for draining urine), or dialysis (machine that filters blood instead of kidneys) and gloves, a gown, and a mask should be worn during close contact, like incontinence care or wound care. She said the PPE was to prevent contamination to the resident and to the staff. The ADON said she had she had given in-services on Enhanced Barrier Precautions the week before. Record review of the facility's policy and procedure on Candida auris (C. auris) Screening and Infection Control Recommendations (Revised 9/27/23) read in part: .Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and MDROs. EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO. A policy on Infection Control was requested from the facility on 7/9/25 but was not received.

Based on observation, interview, and record review, the facility failed to ensure a copy of the 30-day discharge notice was sent to a representative of the State Long-Term Care Ombudsman for one (Resident #35) of four residents reviewed for discharge planning. -The Long-Term Care Ombudsman did not receive a copy for Resident #35's discharge notice. -The Ombudsman contact information on the letter was incorrect. The failure could place residents at risk for not being able to have representation to contest the discharge. Findings include: Record review of the Admission Record (copied 08/29/24) revealed Resident #35 was a [AGE] year old female, and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease, bipolar disorder, and dementia. Record review of the MDS dated [DATE] for Resident #35 revealed she scored 0 of 15 on the BIMS, indicative of severely impaired cognition. Record review of the Care Plan (revised 02/28/23) for Resident #35 revealed she required living on a secured unit due to wandering risk. Record review of the 30-Day Discharge Notice for Resident #35, dated 08/01/24 revealed the letter was sent to the resident's family member on that date. The Notice reflected a move-out date of 08/31/24. The Ombudsman contact information (address and telephone number) was not for the county (County A) of where Resident #35 resided. The contact information reflected on the Notice was for County B. In a telephone interview on 08/27/24 at 8:48 a.m. the Ombudsman for County A said Resident #35's family member was given a 30-Day Discharge Notice by the facility. He said the Notice did not have the correct contact information, and a copy had not been received by County A Ombudsman. He said the family did contact him and provided him with a copy of the Notice. At that time, he was able to schedule an appeal meeting. He said he contacted the County B Ombudsman, and was told they had not received a copy of the Notice either. Observations of the secure unit on 08/27/24 revealed the following: *At 09:12 a.m. and 01:05 p.m. revealed Resident #35 was asleep in her room. *At 1:05 p.m. Resident #35 was asleep in her room. In an interview on 08/29/24 at 01:05 p.m. the Administrator said Resident #35 was the only resident issued a 30-day Discharge Notice since she has been the Administrator of this facility. She said a copy was sent to the Responsible Party via Certified Mail. She said the Ombudsman's copy was not sent Certified Mail. In an interview on 08/29/24 at 2:05 p.m. the Administrator said the Ombudsman in County A was sent a copy of the Notice for Resident #35 after the facility realized the contact information on the Notice was incorrect. She did not provide a date. She provided a copy of an email dated 08/09/24 in which the Ombudsman in County A discussed the Notice. In an interview via telephone on 08/29/24 at 2:14 p.m., the Ombudsman in County A said he had an email from the Ombudsman in County B confirming they did not receive a copy of the Notice for Resident #35. Review of the email from the Ombudsman in County B, dated 08/15/24 revealed they had not received a copy of the Notice for Resident #35 as of that date. In an interview via telephone on 08/29/24 at 5:15 p.m., the Ombudsman in County B said they had not received a copy of the Notice for Resident #35. When the Surveyor read him the address on the Notice, the Ombudsman said that was the address to the school of nursing. Record review of the facility policy Transfer and Discharge (2003) read, in part, .4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will contain all of the following at the time it is provided .h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. In addition, the document read, in part, .7. The facility will maintain evidence that the notice was sent to the Ombudsman.

Based on observation, interview, and record review the facility failed to ensure the resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 18 residents (Resident #53) reviewed for ADLs. The facility failed to ensure CNA B provided incontinent care every two hours as required for Resident #53 on 08/28/24, which resulted in a saturated brief, linens, and mattress. This failure could result in pressure injuries, infections, psychosocial harm, and a decreased quality of life. Findings included: Record review of a face sheet dated 08/29/24 indicated Resident #53 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and Benign Prostatic Hyperplasia (noncancerous enlargement of the prostate gland). Record review of Resident #53's MDS quarterly assessment dated [DATE] revealed resident had a BIMS Summary Score of a 09 (moderate impairment). Record review of Resident #53's care plan date initiated 03/22/24 indicated he had bowel and bladder incontinence. Resident #53's care plan indicated he should be checked every 2 hours and as required for incontinence. His perineum should be washed, rinsed, and dried, with change of clothes as needed. The goal was for the resident to remain free from skin breakdown due to incontinence and use of briefs. Observation and interview on 08/28/24 at 3:25 PM, Resident #53 said he had not been changed and felt dirty. He was unable to provide a timeframe but pushed the call light for assistance . CNA A entered the room and said she would assist the resident; however, this was not her assigned room. CNA A removed the covers and observed resident brief, gown, and linen saturated with urine. CNA A provided peri care times 2 wipes with wet towelette. She turned Resident #53 to right side, and soft brown stool was noted on his buttocks. CNA A agreed the linen, gown and brief was saturated. The resident's blue mattress was darker where his buttocks was laying and lighter above and below the buttocks area. Interview on 08/28/24 at 3:45 PM with CNA A, said she was not aware of the CNA who was assigned the room but it was usually located in the assignment book. CNA A said the CNAs was supposed to round on the residents and check them every 2 hours. CNA A said it was important to provide incontinent care to the residents frequently so they did not have skin breakdown, and because they could get an infection. Interview on 08/28/24 at 5:30 PM Resident #53 stated he does not remember being changed after 6:00 AM. He said he enjoyed being change every two hours and having clean and fresh gowns on. He said he deflated when his brief was soiled and he does not get changed regularly. Interview on 08/28/24 at 5:47 PM CNA B, said she did not check her assignment today and was not aware she was assigned to Resident #53's room. CNA B said she had not checked on Resident #53 today. CNA B said she was supposed to check on incontinent residents every two hours. CNA B said it was important to provide incontinent care to prevent skin breakdown. Interview on 08/28/24 at 6:04 PM LVN F, said she was informed by CNA C that CNA B had not been in Resident #53's room today and it appeared Resident #53 had not been changed all day. LVN F said the CNAs should be checking on the residents at least every 2 hours. LVN F said not providing incontinent care could cause pressure ulcers and infections. Interview on 08/28/24 at 6:08 PM with the DON, stated Resident #53 had not received care since change of shift at 6:00 AM. The DON said the CNAs should be checking on the residents at least every 2 hours. The DON said she was unaware of why the assigned CNA (CNA B) did not check her assignment this morning. She said not assessing a resident in 8 hours can contribute to a multitude of issues including pressure injuries and infection. During an interview on 08/28/24 at 7:37 PM, the Administrator said Resident #53 was wet and had not been changed until after 3:30 PM. The Administrator said the CNAs should be checking on the residents every 2 hours and as needed. The Administrator said not changing the residents in adverse effects such as skin breakdown.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 6 residents (Resident #53) reviewed for infection control. The facility failed to ensure CNA A followed proper infection control and hand washing procedure during incontinent care for Resident #53. This failure could lead to cross-contamination and the development of infection. Findings included: Record review of a face sheet dated 08/29/24 indicated Resident #53 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and Benign Prostatic Hyperplasia (noncancerous enlargement of the prostate gland). Record review of Resident #53's Quarterly MDS Assessment on 06/13/24 revealed resident had a BIMS Summary Score of a 09 (moderate impairment). Record review of Resident #53's care plan date initiated 03/22/24 indicated he had an ADL self-care performance deficit and required 1 to 2 persons extensive to total assistance with toileting, bed mobility and transfers. Observation on 08/28/24 at 3:36 PM, revealed CNA A provided Resident #53 with incontinence care. CNA A did not perform hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. CNA A provided peri care 3 times with wet wipes from [NAME]-wipe packet. She turned the resident over to his right side and cleaned moist, brown stool of resident's buttocks, retrieving wipes from the same multi-use packet without changing gloves. CNA A wiped buttocks 6 times until resident wet wipe was clean and free from discoloration. Soiled linen was removed and placed in bag. CNA did not doff gloves and attempted to apply clean lined with same soiled gloves. Surveyor intervened when staff attempted to retrieve new linen, gown, and brief. CNA A doffed soiled gloves without washing or sanitizing her hands and donned clean gloves. CNA A completed incontinent care and with the new gloves she touched the resident's clean gown, brief, and sheets. She completed her incontinent care and did not wash her hands after doffing gloves before leaving the room. Interview on 08/28/24 at 3:35 PM with CNA A who said she started working full time at the facility 4 years ago. She said she did not recall doing CNA competency checks for incontinent care but had an in-service last month regarding hand hygiene. CNA A said not performing hand hygiene while changing gloves could cause infection and cross-contamination. Interview on 08/29/24 at 12:40 PM, with the DON, she said she expected staff to make sure they provided complete and proper incontinent care each time they perform incontinent care. She said staff should wash/sanitize their hands upon entering a resident's room, in between glove changes, and before leaving the resident's room. She said these failures could result in cross-contamination. Interview on 08/28/24 at 3:32 PM the Administrator said she expected staff to wash/sanitize their hands before, during and after providing incontinent care to residents. She said the risk of not washing/sanitizing their hands was spreading infection and contaminating surface areas. Record review of facility's In-Service Program Attendance Record dated 8/22/2024 revealed Topic: Hand Hygiene was signed by CNA A. Record review of facility's Hand Hygiene Policy undated, read in part: .Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6.Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Record review of facility's Standard Precautions Infection Control Policy not dated, read in part: .Policy: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff, and visitors. Explanation and Compliance Guidance: 1. Hand Hygiene: a. During delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. b. Perform hand hygiene in accordance with the facility's Hand Hygiene Policy

Based on interview and record review the facility failed to ensure there was a communication process, which included how the communication would be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for 1 of 2 residents (Resident #36) reviewed for hospice services. -The facility failed to maintain required hospice forms and documentation to ensure Resident #36 received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care. Findings included: Record review of the admission sheet (undated) for Resident #36 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses which included dysphagia (swallowing difficulties) , cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs) and encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). Record review of Resident #36's Quarterly MDS, dated [DATE], revealed the BIMS score was 12 out of 15 indicated intact cognitively. She required supervision from staff for personal hygiene, toilet and transfer. Record review of Resident #36's physician order, dated 07/17/2024 read in part, .Patient is admitted to [hospice company name] under services of hospice Dr. [name] and facility services of Dr [name] . Record review of Resident #36's Care plan, initiated 08/06/2021 and revised on 07/25/2024, revealed the following: Focus: [Resident #36] is under hospice care and requires special attention for comfort and hospice care. Goal: The resident's comfort will be maintained through the review date. Interventions: Consult with physician and Social Services to have Hospice care for resident in the facility. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record Review of Resident #36's medical file revealed there was no documentation of coordination of care or any communication with hospice company after 7/16/24. In an interview and record review with on 8/29/23 at 12: 37 p.m., with RN C she said she was the nurse for Resident #36. She said Resident #36 was receiving hospice services. RN C said hospice staff communicated with the facility by always logging in their binder when they were there. She said they told them verbally what they did, and they also documented in their binders. When asked when did the last time hospice came and what they did when they were there, she said, RN C stated I need to check the binder to see when hospice last came to see the resident. RN C reviewed the hospice binder for Resident #36 with the Surveyor. RN C said she could not find the documentation which stated what Hospice did while they were there. She checked the binder and said, there is RN initial assessment dated [DATE] but no weekly assessment. RN C said she did not know who was responsible for ensuring hospice was documenting in the binder. RN C said it was important for nursing to know the hospice's plan of care for the patient. In an interview and record review on 8/29/23 at 1:23 p.m., the DON reviewed Resident #36's hospice binder and said the hospice nurse came once a week and the hospice aides were supposed to come 3 times a week. The DON said, she would get with hospice company to see what the plan was and to request current notes for the binder. She said it was important to have the current hospice plan of care for the resident if there were any changes to keep the facility informed and for communication purpose. In an interview on 8/29/24 at 2:34p.m., the DON presented Surveyor Resident#36's skilled nursing visit documentations. DON stated medical records had access to hospice documentation. Medical records was responsible for printing hospice documentation and file in resident's hospice binder for nursing staff. In an interview on 8/29/24 at 3:55p.m., the Medical Records/HR, she said hospice company randomly sent documentation either by email or paper and her responsibility was to print the documents and upload them in PCC (electronic medical records) for nursing to review. Medical records/HR said she was not a nurse and did not review the hospice documents when received. Record review of facility's Hospice Services Facility Agreement (February 2023 Revision) read in part: .Policy: It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. Policy Explanation and Compliance Guidelines: 6d. Obtaining the following information from the hospice: i. The most recent hospice plan of care specific to each resident ii. Hospice election form iii. Physician certification and recertification of the terminal illness specific to each resident iv. Names and contact information for hospice personnel involved in hospice care of each resident v. Instructions on how to access the hospice's 24-hour on-call system vi. Hospice medication information specific to each resident vii. Hospice physician and attending physician (if any) orders specific to each resident 7. The facility will, under a written agreement, ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 5 residents (Resident #4) reviewed for pain management. The facility failed to ensure Resident #4's pain control was maintained at a level acceptable to the resident. This failure could place the resident at risk of a decrease in quality of life due to pain. Findings included: Record review of a face sheet dated 08/29/24 indicated Resident #53 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities with behaviors), End Stage Renal Disease (Condition in which the kidneys lose the ability to remove waste and balance fluids), Benign Prostatic Hyperplasia (noncancerous enlargement of the prostate gland), and Type 2 Diabetes Mellitus (Chronic condition when your body cannot use insulin properly). Record review of Resident #4's Quarterly MDS Assessment on 07/24/24 revealed resident had a BIMS Summary Score of a 05 (severe impairment). Record review of Resident #4's care plan date initiated 02/21/24 indicated he had a risk for pain related to ESRD , Vascular wound, PVD, and right Below Knee amputation. The Physicians was to be notified if current complaint was a significant change from residents past experience of pain. Record review of Resident #4's physician orders started on 07/17/24 indicated Tylenol with Codeine #3 300- 30 MG 1 tab every 8 hours for pain and Tylenol 325 mg 2 tabs every 4 hours as needed for pain. Record review of Resident #4's MAR dated 8/28/2024 revealed resident was administered his 8:00 AM Tylenol with Codeine #3 300- 30 MG 1 tab. Observation and interview with Resident #4 and RN A on 08/28/24 at 8:21 AM. revealed the resident awake and alert and complained of pain to penis. RN A was aware and stated the resident had received his scheduled medication. Record review of progress notes indicated that RN A reassessed resident complaint of pain and noted it was a 4 on the pain scale. He was administered Tylenol 325 mg 2 tabs every 4 hours as needed for pain. At 11:08 AM, the pain was listed as a 0 on the pain scale. Interview with the ADON on 08/29/24 at 10:53 AM, who said she was not aware Resident #4 had complaint of pain. She said if the pain medication was not sufficient and the resident was not getting relief from the pain medication, or have a new pain concern the staff should notify the physician. She said if the resident was having penial pain, he should be referred to the Urologist and the pain management doctor. Interview on 08/29/24 at 4:15 p.m. the Administrator, said it was her expectation to see pain levels decrease once pain medication was administered. She said staff should follow the nursing protocol and notify the physician if the resident was not provided relief after administration. She said the risk of constant pain could cause adverse effects and decrease quality of life. Observation and interview Resident #4 and RN B on 08/29/24 at 4:25 PM who said his dick hurt. Nurse pulled brief back and there was a skin tear noted near the urethral opening of the penis. RN B moved penis to assess tear. Facial grimaces were noted from resident during the assessment. Resident verbalized he was in pain. Nurse B stated she was aware of the skin tear that had been there for weeks. RN B said she did not inform the doctor of the resident's penis pain because he was confused and his pain comes and goes. Review of the facility's policy Pain Management, not dated, read in part .The facility must ensure that pain management is provided to residents who require such services . Pain Management and Treatment: 7. i. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen .

Based on observation, interview and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. -The facility failed to post the daily nursing staffing information on 08/27/2024. This failure could affect residents, facility visitors, vendors and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Included: Observation on 08/27/24 at 11:05a.m., during rounds revealed nursing staffing information was posted by the receptionist desk dated 08/20/2024. Observation on 08/28/24 at 9:05a.m., during rounds revealed nursing staffing information was posted by the receptionist desk dated 08/20/2024. Record review and interview on 08/28/24 at 1:12p.m., with the Activities director, she stated the receptionist was responsible for posting the daily nursing staff information. The Activities director stated Receptionist was on leave and the staff were taking turns answering phone. The Activities director stated, need to update. That one is from 8/20. In an interview on 08/28/24 at 3:43 p.m., with the Administrator, she stated the receptionist was responsible for the daily nursing staffing posting and the staffing coordinator helped. Both happen to leave last week. It falls on nursing. It was overlooked. She stated the ADON will update posting daily until further notice. She stated it was important to post the staffing information to know how many residents were in the facility. Staffing information for the potential visitors coming to the facility. In interview on 08/29/24 at 3:33 p.m., the DON stated the receptionist along with the staffing coordinator were responsible for the daily nursing posting. She stated after it was brought to their attention and it was decided nursing DON/ADON will be responsible to post daily nursing staffing. The DON stated the daily nursing staffing was supposed to be posted in the front of the facility each day. Record review of the facility's Nurse Staffing Posting Information policy (February 2023 Revision) read in part: .Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: Facility name The current date Facility's current resident census The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses Licensed Practical Nurses/Licensed Vocational Nurses Certified Nurse Aides The facility will post the Nurse Staffing Sheet at the beginning of each shift. The information posted will be: Presented in a clear and readable format. In a prominent place readily accessible to residents and visitors .

Based on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 1 (Resident #2) of 2 residents reviewed for respiratory care. -Resident #2's Nebulizer mask was not labeled/bagged while not in use on 02/09/2024. This failure could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Record review of Resident#2's Face Sheet (undated) revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: chronic systolic congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypertension (a condition in which the force of the blood against the artery walls is too high), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident#2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. She was independent with bed mobility, dressing, personal hygiene, and toilet use. Resident#2 was continent of bladder and bowel. Record review of Resident#2's Care Plan initiated 08/28/2023 and updated on 01/19/2024 revealed the following: Focus: Resident has COVID-19 infection related to Multiple Co-morbidities. Goal: Resident will have minimal complications associated with the COVID-19 infection through next review date. Interventions: Assist resident with ADL's in room as indicated. Assist resident with application of a face mask when exiting their room. Remind resident to wash hands/perform hand hygiene before and after meals and as needed. Resident will adhere to room restrictions. Resident will don a face mask when staff are in the their room. Record review of Resident #2's physician order dated 08/24/24 revealed an order to administer Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 milliliter inhale orally three times a day for Wheezing at 9:00am, 2:00pm, and 9:00pm. Record review of Resident #2's physician order dated 02/09/24 at 1:14pm by the Regional Nurse for Nebulizer tubing: change nebulizer tubing when visibly soiled or malfunction present every 12 hours as needed AND every night shift every Sun. Observation and interview on 02/09/24 at 10:10 a.m., with Resident#2 revealed her sitting on the side of the bed. Resident's nebulizer mask was sitting on top of the bedside table not labeled orbagged while not in use. Resident#2 said she received routine breathing treatment several times a day. She said she was not sure how often the nebulizer mask set was changed. She said, I had COVID two weeks ago and had to request the nurse to change the neb mask, so I don't get re-infected. Observation and interview on 02/09/24 at 10:39 a.m., with LVN A revealed Resident #2 was resting on her bed. Resident's nebulizer mask was sitting on top of the bedside table. LVN A said Resident #2's nebulizer mask was not dated and not bagged while not in use. LVN A said nebulizer mask and tubing was supposed to be changed weekly by the nurses. She said it was standard practice to change/label tubing. She said MAR/TAR prompted nurses to change the set. She said the risk of not changing the neb mask was infections. She said she administered the routine breathing treatment this morning but did not check for the label/date and forgot to place the mask back in the bag after use. In an interview on 02/09/24 at 12:34 p.m., with the ADON, she said the nurse that entered the treatment order needed to enter the order to change tubing/neb mask every Sunday. She said there was a place on the MAR or TAR for nurses to sign off after the nurse changed the tubing. The ADON said the nurses should be checking prior to administering the treatment. She said the risk of not changing the nebulizer mask was infections. Record review of facility's Department (Respiratory Therapy)-Prevention of Infection policy (Revised November 2011) read in part: .Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents, and staff. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. 9. Discard the administration set-up every seven (7) days .

Based on interviews and records reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (CR#1) out of 3 residents reviewed for base-line care plans. -The facility failed to ensure CR#1 had a baseline care plan developed within 48-hours after admission with goals and interventions. The failure could place newly admitted residents at risks of not receiving the care and continuity of services. Findings included: Record review of CR#1's Face Sheet (undated) revealed, an [AGE] year-old male who admitted to the facility on [DATE] and discharged to acute care hospital on 01/17/2024 with diagnoses which included: fracture of unspecified part of neck or right femur (type of hip fracture of the thigh bone (femur) just below the ball of the ball-and-socket hip joint), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and cognitive communication deficit (those thought processes that allow humans to function successfully and interact meaningfully with each other). Record review of CR#1's Discharge MDS assessment dated [DATE] revealed a BIMS score of blank indicating severely impaired cognitively. He required substantial/maximal assistance with bed mobility, dressing, personal hygiene, and toilet use. CR#1 was occasionally incontinent of bladder and always incontinent of bowel. Record review of CR #1's electronic medical records on 02/09/2024 revealed CR #1 did not have a baseline care plan. In an interview on 02/09/2024 at 12:30 p.m., with the Regional Nurse and the interim Administrator, Regional Nurse said she looked in CR#1's EMR and could not locate a base-line care plan for CR#1. Regional Nurse said the base line care plan was a collaboration of IDT/ and nurse leadership. Regional Nurse said nurses needed to follow the plan of care. In an interview on 02/09/2024 at 12:34 p.m., the ADON said baseline care plans were supposed to be developed within 48-hours after admission by the nurses on the floor/management (DON, ADON) and different departments (dietary, activities). She said she and the DON were responsible for checking for completion. She said she checked UDA every day if not every other day. She said UDA were (assessments that patient was scheduled). She said the importance of the baseline care plan was to provide nursing staff with information and interventions about residents so the staff could provide appropriate care and services. The ADON said CR#1's baseline care plan was missed. Record review of the facility's Care Plans- Baseline policy (Revised December 2016) read in part: .Policy Statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .

Based on interview and record review the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 of 2 residents (CR #1) reviewed for discharge requirement, in that: -The facility failed and refused to readmit CR #1 from the hospital where he was transferred for evaluation and treatment. This failure placed residents at risk of not receiving care and services to meet their needs upon discharge. Findings included: Record review of CR#1's Face Sheet (undated) revealed, a [AGE] year-old male who admitted to the facility on [DATE] and discharged to acute care hospital on 01/17/2024 with diagnoses which included: fracture of unspecified part of neck or right femur (type of hip fracture of the thigh bone (femur) just below the ball of the ball-and-socket hip joint), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and cognitive communication deficit (those thought processes that allow humans to function successfully and interact meaningfully with each other). (Date of Discharge 01/17/2024 at 10:30pm to acute care hospital) Record review of CR#1's Discharge MDS assessment dated [DATE] revealed a BIMS score of blank indicating severely impaired cognitively. He required substantial/maximal assistance with bed mobility, dressing, personal hygiene, and toilet use. CR#1 was occasionally incontinent of bladder and always incontinent of bowel. Section A. Entry/discharge reporting coded: 11. Discharge assessment-return anticipated. Record review of CR #1's electronic medical records on 02/09/2024 revealed CR #1 did not have a Baseline Care Plan. Record review of CR #1's nurses notes dated 01/18/2024 at 1:25am written by LVN B revealed read in part: .around 2230 [EMS company] here to transport resident to [hospital name] ER. Alert and oriented, no distress noted . In a telephone interview on 02/09/24 at 9:03 a.m., with CR#1's family member, she said as per family's request CR#1 was sent to the ER around 10:00-10:30pm on 1/18/24. The doctor at the hospital did a CT of the stomach and it showed the CR#1's bowels were full and ordered an enema. By 3:30-4am CR#1 was cleared to go back to the facility to continue rehabilitation services. She said the ER nurse in charge said policy dictated that he was an outpatient and was required to go back to the facility. EMS workers loaded CR#1 along with her and went back to the facility. Upon arrival at the facility, LVN B said that policy was that if he was out past midnight that Medicare would not pay. LVN B said that the hospital had to call to readmit him and that he forfeited his bed at that facility. The family member said she asked what she needed to do with CR#1 and LVN B did not care. The EMS workers said if the facility denied entry than they had to transport CR#1 back to the hospital. The nurse denied him at the facility and so without any choice EMS loaded CR#1 and her back up and went back to the hospital. The hospital staff were adamant that the facility could not deny him because he was considered outpatient. They proceeded to call several administrators at the facility and by 6am the EMS had to go, so CR#1 was put in an ER bed and they waited. CR#1 was completely exhausted and was in a state of confusion and had anxiety about being transported back and forth. Family member said, CR#1 is 89 and has dementia. This was such a roller coaster for him. She said she ended up taking him home for a few hours while the new facility worked with insurance to expedite his transfer. In an interview on 02/09/24 at 10:46a.m., with the interim Administrator, he said CR#1 was sent to the hospital and the hospital sent the resident back around 2am without calling a report to the facility and without an authorization. He said CR#1 had insurance that required an authorization after midnight. He said the facility needed authorization from his insurance company, without an authorization the resident would be private pay. In an interview on 02/09/24 at 12:34p.m., with the ADON, she said she received a call from LVN B that CR#1 was sent to the hospital as per family's request. The previous administrator said the resident was not allowed to come back to the facility after midnight, it had something to do with the insurance. CR#1 was sent to the facility from the hospital without calling a report. The ADON said it was late at night, but she tried calling the previous Administrator regarding denied entry. The previous Administrator did not answer. She said she called the Marketing Representative and she said that the resident was allowed entry to the facility regardless the type of insurance the resident had. The ADON said she called LVN B to allow CR#1 entry to the facility. LVN B said that EMS ended up taking the resident back to the hospital. The ADON said she called the hospital and notified them that the resident could return to the facility and that the facility was not denying entry. She said the hospital staff said that the resident was back at the ER, and they had to restart the whole process. The ADON said, either way we got to take the resident back. I don't know why the previous Administrator did not allow entry. In a telephone interview on 02/09/24 at 1:09a.m., with LVN B, she said as per the family's request CR#1 was transferred to the hospital. LVN B said the facility's policy was anytime a resident was sent to the hospital the nurse needed to notify the Administrator. She said she called the previous Administrator, and the previous Administrator asked her for the type of insurance that CR#1had. She said she looked at the resident's insurance from the EMR and gave the information to the Administrator. The previous Administrator said that CR#1 would not be able to readmit after midnight due to the type of insurance he had. LVN B said CR #1 showed up at the facility's door with the EMS the same night. She said she told the family member that the resident was not allowed re-entry to the facility as per the administrator. She said that EMS ended up taking CR#1 back to the hospital. In an interview on 2/9/24 at 3:16p.m., with the interim Administrator and the Regional Nurse, the interim Administrator said per (managed care insurance) policy, they can't accept the resident without authorization unless they are private pay. He said managed care insurance that CR #1 had, ran from midnight to midnight. If the resident was to return after midnight an authorization was required for reentry, or the facility would not get paid. He said the resident was not allowed entry because the facility had to call the insurance. It was 1:00am in the morning and the facility had to wait for the insurance company to open in the morning to obtain authorization. Record review of facility's Transfer or Discharge Notice dated (Revised March 2021) read in part: .Policy Statement: Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. Policy Interpretation and Implementation 1. Transfer and discharge includes movement of, a resident from a certified bed in the facility to a non certified bed in another part of the facility, or to a non-certified bed outside the facility. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Specifically: a. transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and b. discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. 2.Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. c. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. (1) Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. 2) For a resident who becomes eligible for Medicaid after admission to a facility, the facility will only charge a resident allowable charges under Medicaid. d. the facility ceases to operate .

Based on interview and record review, the facility failed to safeguard, manage, and account for the personal funds of the residents, deposited with the facility, for one (Resident#2) of three residents reviewed for trust funds - The facility failed to provide Resident#2 with the $75 that she was supposed to get. This failure could place residents whose personal funds were managed by the facility at risk of loss of those funds. Finding included: Record review of Resident#2's Face Sheet (undated) revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: chronic systolic congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should ), hypertension (a condition in which the force of the blood against the artery walls is too high) and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. She was independent with bed mobility, dressing, personal hygiene, and toilet use. Resident#2 was continent of bladder and bowel. Record review of Resident#2's Care Plan initiated 08/28/2023 and updated on 01/19/2024 revealed the following: Focus: Resident has COVID-19 infection related to Multiple Co-morbidities. Goal: Resident will have minimal complications associated with the COVID-19 infection through next review date. Interventions: Assist resident with ADL's in room as indicated. Assist resident with application of a face mask when exiting their room. Remind resident to wash hands/perform hand hygiene before and after meals and as needed. Resident will adhere to room restrictions. Resident will donn a face mask when staff are in their room. In a telephone interview on 02/09/2024 at 8:54 a.m., with the Ombudsman, he said his volunteer Ombudsman notified him that some of the residents did not receive the $75 increase of their allowance from Social Security. The increase was on January 1, 2024. In an interview on 02/09/24 at 10:10a.m., with Resident#2, she said there was an increase as of January 1st on the Social security allowance from $60 to $75. She said she received an allowance on the 3rd Wednesday of each month. Resident#2 provided a bank statement to Surveyor A to show the payment of $60 received on Wednesday, January 17, 2024. She said she had a neurologist appointment on Wednesday (02/07/24) which she had to cancel. She said when she got to the appointment, she was asked to pay co-pay of $34. She said, If I had paid $34 co-pay out of $60, I would not have enough money to last me until I get the next allowance. In an interview on 02/09/2024 at 11:01 a.m., the Social Worker said Resident#2 had a neurologist follow up appointment on Wednesday (02/07/24) that she had scheduled. She said when Resident #2 went to the neurologist the front office asked for a $34 copay. She said the facility's scheduling coordinator that accompanied Resident#2 called and informed her that the resident had to pay a copay and the resident refused to pay. She said she went and asked the business office if we cover the co-pay the business office said she was not sure. SW said she asked interim Administrator yesterday (02/08/24) if we ever pay copay and he said yes, we can.'' In an interview on 02/09/2024 at 11:24 a.m., the interim Administrator said after Surveyor A brought it to his attention, the BOM reconciled, and a few residents were short paid $15 last month (January). He said it was an honest error on the Business Office Manager's part. Resident #2 got cash in advance, so it was an error in calculation. He said corporate spot checked BOM and the corporate said it was overlooked on her part. In an interview on 02/09/2024 at 12:04 p.m., with the BOM, she said she started working at this facility towards the end of November of last year. She said she was still in training. She said residents funds went directly into the resident trust fund account. When the resident asked for money, she gave $60, and the rest went towards the care cost of the month. She said it was discussed in training, at that beginning of 2024, there was an increase from $60 to $75. She said, I'm finding out now that I have to deduct $75, and the rest will go to care cost depending on patients' liability. She said sometime this week the social worker came to her and asked her how the copay was taken care of. BOM said Resident#2 had Medicare/Medicaid, but the resident went to an appointment which was out of network. She said interim Administrator told her today that the facility could pay with the company card so the resident would not miss appointments. In an interview on 02/09/2024 at 12:34 p.m., the ADON said, the Social Worker was responsible to set up the appointments and facility transportation for the resident to their appointment. She said Resident#2 had a follow up appointment with the neurologist this week but she was not aware that the resident canceled the appointment because of co-pay. She said when setting up the appointment the Social Worker needed to find out if there was a co-pay. In an interview on 02/09/2024 at 1:33 p.m., the interim Administrator said, I was not aware of any resident missing a doctor's appointment because they were short paid $15 last month. When asked who was responsible to ensure the staff were trained regarding this. He said at corporate level, notices were sent to the facilities Administrators about the increase. He said, I don't know if the previous Administrator notified the BOM. That's the previous administrator's question. Record review of the facility's Surety Bond policy (Revised March 2021) read in part: .Policy Statement: Our facility has a current surety bond to assure the security of all residents' personal fund deposited with the facility. Policy Interpretation and Implementation: 2. This facility holds a surety bond to guarantee the protection of residents funds managed by the facility on behalf of its residents. 4. The purpose of the surety bond is to guarantee that the facility will pay the resident for losses occurring from any failure by the facility to hold, account for, safeguard, and manage the residents funds (i.e., losses occurring as a result of acts or errors of negligence, incompetence or dishonesty) .

Based on observation, interview and record review the facility failed to ensure all alleged violations involving abuse were reported immediately within 2 hours to state agency for 1(Resident #1) of 6 reviewed for reporting in that: Administration failed to report to the state agency when Resident #1, who had dementia was not able to tell them how she got skin tears to both sides of her neck on 1/10/2024. This failure placed current residents at risk for abuse. Findings Included: Observation on 1/12/2024 at 10:00 a.m. of Resident #1's neck revealed a skin tear and bruise on the right side of her neck and a bandage slightly left of her throat. Record review of Resident #1 undated face sheet revealed a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses: Dementia (unspecified), Emphysema (is a chronic lung condition that cause blockage of airflow in the lungs), Traumatic subdural hemorrhage without loss of consciousness(caused by a head injury, such as a blow to the head), heart failure(a chronic condition in which the heart does not pump blood as well as it should), chronic kidney disease and age-related osteoporosis. Record review of Resident #1's MDS dated [DATE] revealed BIMS score was coded at 06 which suggests severe cognitive impairment. Functional Abilities & Goals revealed Roll left and right, sit to lying, lying to sitting, sit to stand, chair to bed transfers, and toileting transfers were all coded as (03)- which meant Partial/moderate assistance with helper did more than half the effort. Record review of the incident reports from 10/12/2023-1/12/2024 did not notate skin tears to Resident #1's neck. Record review of Resident #1 progress nursing note dated 1/11/2024 revealed Nurse A wrote: The outgoing nurse reported Resident #1 had skin tears to both left and right neck. The writer did skin assessment and noted the tears had been covered with bandages. No acute distress, shortness of breath noted. At 12:35 a.m. Resident #1 FM came into the facility to check on her wellbeing. The resident denied pain and no further concerns as of present. Plan of care ongoing and call light within reach . An interview with Resident #1 on 1/12/2024 at 10:03 a.m. revealed she did not know what happened to her neck. She did not recall having a fall. She said she never had visitors to come see her. She could not recall CR#2(roommates' name). She said no one told her about what happened to her. She fell asleep so the interviewed ended. An interview and observation with FM of CR#2 on 1/12/2024 at 10:15 a.m. revealed CR#2 was at a local hospital because of a medical condition. He said she was confused and sometimes combative since she had a stroke in June 2023. He said Resident was a young robust person and really needed to be in another type of facility mostly for her behaviors. He said she does use profanity at times but denied any knowledge of an altercation with Resident #1, CR#2, or her family member. He stated that he visited with her every other week. He said he was not her RP. He began to pack her personal belongings and said she would not be returning to the facility. He said he was not her RP. An interview with Nurse B on 1/12/2023 at 10:30 a.m., revealed she was not at work on 1/10/2024 or 1/11/2024, she returned to work on today (1/12/2024). She said the notes in PCC stated that it was unknown how the skin tears happened . She said that she was not aware of any altercations verbal or physical between Resident #'s 1 and 2. She stated she has been employed at the facility for 3 months and worked on this unit daily. Interviews separately with two CNA's on 1/12/2024 at 10:42 a.m. revealed they were not aware of what happened to Resident #1's neck. They said the Abuse Coordinator was the Administrator. They were able to identify types of abuse. An interview attempted with Resident #1's RP was unsuccessful on 1/12/2024 at 11:17 a.m. An interview with the DON on 1/12/2024 at 1:30 p.m., revealed Resident #1 most likely scratched herself. She said she asked Resident #1 what happened to her, and she said some man tried to kill her . She said in speaking with staff no one saw how Resident #1 got the skin tears. She said she spoke with Resident #1's RP on or about 1/11/2024 and she said she had recently (over previous weekend on or about 1/6/24), had Resident #1's nails cut. So, she did not believe that she could have scratched herself unless a hang nail was left. She stated Resident #1's RP complained that CR#2 was talking crazy recently. She said CR#2 was using profanity towards Resident #1's FM, not Resident #1. She said RP said she turned the television up to tune her out. She said RP had not reported any behavior towards her or Resident #1 prior to that incident. She said RP never implied that she suspected CR#2 of abusing Resident #1. The DON stated Nurse C had discovered the skin tears on 1/10/2024. She said a skin tear could be considered an injury of unknown origin if the resident had dementia or could not verbally tell them what happened. She said this would be considered something reportable to State agency. She said either the Administrator or herself would report an incident to State agency. She said they had no evidence of abuse by CR#2 or staff. So, it was not reported. She said she was not aware of any other incidents with CR#2 other than her wandering at night. An interview with Resident #1's FM on 1/12/2024 at 1:50 p.m., revealed yesthe DON was made aware of the incident concerning CR#2 using profanity towards her, not Resident #1. She said she could not recall the exact date, but this incident occurred between 1/9/2024-1/10/2024. She said, she was visiting Resident #1 when CR#2 attempted to sit down on her bed. The FM stated she told her she could not sit on Resident #1's bed. She said CR#2 was about to sit on Resident #1's leg so she walked towards the bed to stop her from sitting. She said CR#2 began using profanity towards her, so she yelled for a nurse. She said she did not know the CNA's name, but she came in after hearing CR#2 cursing and asked her to reframe from using profanity. She said the CNA pulled the curtain to give FM and Resident #1 privacy, but CR#2 tried to open the curtain and continued to use profanity. She said she had not received a call about a fall, so she told the DON that she felt badly to think that CR#2 might have done this to Resident #1. But it was possible given her behavior the previous day. She denied any other incidents involving Resident #1 and CR#2. An interview with an anonymous FM on 1/12/2024 at 2:18pm, revealed Nurse C reported CR#2 was no longer at the facility because she had attacked Resident #1. An interview attempted with Nurse C on 1/12/2024 at 2:26 p.m., was unsuccessful. Record review of an undated facility responsibilities reporting allegations policy read in part: Injuries of unknown source when it is unobserved/unexplained scratches and bruises found in suspicious locations such as head, neck, upper chest or back is reportable. There was no timeframe indicated to report injuries of unknown source.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 16 of 18 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, and Resident #16) reviewed for pharmacy services. The facility failed to ensure medications that were scheduled three and four times daily were administered at their scheduled times, resulting in medications being administered with only 2-4 hours between doses for Residents #1, #2, #5, #6, #8, and #13. The facility failed to ensure medications were administered timely between 11/03/2023 and 11/10/2023 which resulted in extremely late administration, up to 8 hours, of medications, such as insulin, Benzodiazepines (anxiety and panic disorders), antibiotics, decarboxylase inhibitors (for Parkinson's Disease), SSRI's (for depression and psychiatric disorders), anticonvulsants, antidepressants, antihypertensives, anticoagulants, beta blockers, narcotics, and antipsychotics 16 of 18 residents. The facility failed to notify or receive guidance from the residents' physicians when medications were administered up to eight hours late. The facility failed to ensure Resident #7 received her prescribed medication, Ferrous Gluconate, according to physician's orders for an undetermined length of time. An Immediate Jeopardy (IJ) was identified on 11/11/2023 at 6:11 p.m. The IJ template was provided to the facility on [DATE] at 6:11 p.m. While the IJ was removed on 11/13/2023, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of experiencing exacerbation of pain and other health and psychiatric diagnoses, harmful drug to drug interactions, and other serious health-related complications from taking prescribed medication after the scheduled times. Findings include: Observation of medication pass and interview with Med Tech A on 11/08/2023 at 9:40 a.m. revealed she was passing morning mediations. Med Tech A stated she passed morning, afternoon, and evening medications to the entire building (approximately 40 residents), other than the memory care unit and a few other residents on the other halls. She said her shift was from 7:00 a.m. to 7:00 p.m. and there was only one medication aide on each morning shift. She said the nurses passed their own medications on the night shift (7:00 p.m. - 7:00 a.m.). She said some residents took longer to take their medication, so she passed their medications last on their particular hall. She said she normally passed medications to all the other residents on the hall, then she went back and passed medications to the slow takers. She stated she had already passed medications to half of the 100 hall, but she still had to complete the other half of the 100 hall (ten residents), who were mostly bed bound. She said she completed medication pass on the 200 hall, other than Resident #6 (she was passing Resident #6's medications at that time, 10:11 a.m.). Med Tech A said the facility's management knew it took her a long time to get all residents' medications passed and that she was late daily. She said she did not have a conversation with the DON or Administrator about not completing medication passes timely, but she did voice her concerns to her nurse, LVN E. She was told by LVN E that there were not enough residents to get another med aide on the shift. At 10:13 a.m., Med Tech A stated she still had to pass medications to the residents on the 100 (ten residents) hall and all of the resident's medications turned red on the eMAR at 10:00 a.m., indicating they were all late at that time. Observation of Med Tech A's computer screen at that time revealed the medications on each resident's eMAR were highlighted in red. She said she had only spoken to LVN E about her concerns because she did not want to jump the chain of command. Medications scheduled three and four times daily Resident #1 Record review of Resident #1's face sheet dated 11/3/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included: hypoglycemia (low blood sugar), acute respiratory failure with hypoxia (difficulty breathing), metabolic encephalopathy (problem in brain caused by chemical imbalance in the blood), sepsis (life threatening infection), bacteremia pulmonary candidiasis (fungal infection in the lungs), type 2 diabetes (insulin resistant), muscle weakness (generalized), dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, muscle wasting and atrophy, left and right shoulder, other lack of coordination, retention of urine, anemia, hypothyroidism, hyperlipidemia, anxiety disorder, essential (primary) hypertension, cellulitis of unspecified part of limb (bacterial skin infection) , dorsalgia (back pain) , and altered mental status. Record review of Resident #1's physician's orders for November 2023 revealed the following active orders: * Clonidine HCl Oral Tablet 0.3 MG (Clonidine HCl) Give 1 tablet by mouth three times a day for hypertension. Record review of the facility's Medication Administration Audit Report for 11/03/2023 - 11/10/2023 revealed the following for Resident #1: * Clonidine HCl Oral Tablet 0.3 MG (Clonidine HCl). Give 1 tablet by mouth three times a day for hypertension. Scheduled - 11/06/2023 12:00 p.m.; administered - 11/06/2023 2:12 p.m. Record review of Resident #1's MAR for November 2023 revealed she was administered another dose of Clonidine HCL on 11/06/2023 at 4:00 p.m. as scheduled. * Clonidine HCl Oral Tablet 0.3 MG (Clonidine HCl). Give 1 tablet by mouth three times a day for hypertension. Scheduled - 11/09/2023 9:00 p.m.; administered - 11/10/2023 12:38 a.m. Record review of Resident #1's MAR for November 2023 revealed she was administered another dose of Clonidine HCL on 11/10/2023 at 8:00 a.m. as scheduled. Resident #2 Record review of Resident #2's face sheet dated 11/08/2023 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's diagnoses included: cerebral infarction (disrupted blood flow to the brain), aphasia (a language disorder that affects the ability to communicate), hydrocephalus (build-up of fluid in the cavities deep within the brain), diabetes (chronic condition that affects the way the body processes blood sugar), dementia (condition characterized by progressive or persistent loss of intellectual functioning), Parkinsonism (a motor syndrome that manifests as rigidity, tremors, and bradykinesia [slowness of movement], epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), essential hypertension (abnormally high blood pressure that is not the result of a medical condition), and chronic kidney disease (longstanding disease of the kidney leading to renal failure). Record review of Resident #2's physician's orders for November 2023 revealed the following active orders: * Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa). Give 2 tablet by mouth three times a day for anti-Parkinson. Active 10/20/2023. Record review of the facility's Medication Administration Audit Report for 11/03/2023 - 11/10/2023 revealed the following for Resident #2: * Carbidopa 25-100 MG - scheduled daily at 9:00 a.m. was administered at 12:31 p.m. on 11/04/2023 (Record review of Resident #2's MAR for November 2023 revealed he was administered another dose of Carbidopa on 11/04/2023 at 1:00 p.m. as scheduled); administered at 12:30 p.m. on 11/05/2023 (Record review of Resident #2's MAR for November 2023 revealed he was administered another dose of Carbidopa on 11/05/2023 at 1:00 p.m. as scheduled); administered at 11:08 a.m. on 11/06/2023 (Record review of Resident #2's MAR for November 2023 revealed he was administered another dose of Carbidopa on 11/06/2023 at 1:00 p.m. as scheduled); and administered at 12:37 p.m. on 11/09/2023 (Record review of Resident #2's MAR for November 2023 revealed he was administered another dose of Carbidopa on 11/09/2023 at 1:00 p.m. as scheduled). Resident #5 Record review of Resident #5's face sheet dated 11/13/2023 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5's diagnoses included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), vascular dementia (brain damage caused by multiple strokes), dysphagia (difficulty swallowing), aphasia (a language disorder that affects a person's ability to communicate), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), COPD (Chronic Obstructive Pulmonary Disease - a group of disease that cause airflow blockage and breathing-related problems), joint pain, congestive heart failure (a chronic condition in which the heart does not pump a blood as well as it should), essential hypertension (when you have abnormally high blood pressure that is not the result of a medical condition), and long-term use of anticoagulants (necessary to prevent the high frequency of recurrent venous thrombosis or thromboembolic events). Record review of Resident #5's physician's orders for November 2023 revealed the following active medication orders: * Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol). 1 dose inhale orally four times a day for shortness of breath. Active 10/09/2023. Record review of the facility's Medication Administration Audit Report for 11/03/2023 - 11/10/2023 revealed the following for Resident #5: * Ipratropium-Albuterol Inhalation Solution - scheduled daily for 8:00 a.m. was administered at 9:47 a.m. on 11/04/2023 (Record review of Resident #5's MAR for November 2023 revealed she was administered another dose of Ipratropium-Albuterol on 11/04/2023 at 12:00 p.m. as scheduled); was administered at 11:10 a.m. on 11/06/2023 (Record review of Resident #5's MAR for November 2023 revealed she was administered another dose of Ipratropium-Albuterol on 11/06/2023 at 12:00 p.m. as scheduled); was administered at 10:49 a.m. on 11/07/2023 (Record review of Resident #5's MAR for November 2023 revealed she was administered another dose of Ipratropium-Albuterol on 11/07/2023 at 12:00 p.m. as scheduled). Resident #6 Record review of Resident #6's face sheet dated 11/06/2023 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6's diagnoses included: osteomyelitis of the vertebra (inflammation of bone caused by infection), functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic venous hypertension (abnormalities in the capillaries within the leg tissues that make them more permeable), psoriasis (a condition in which skin cells build up and form scales and itchy, dry patches), and candidiasis (infection with candida) of skin and nail. Record review of Resident #6's physician's orders for November 2023 reveled the following active medication orders: * Sucralfate Oral Tablet 1 GM (Sucralfate). Give 1 tablet by mouth four times a day for GERD. Active 11/01/2023 Record review of the facility's Medication Administration Audit Report for 11/03/2023 - 11/10/2023 revealed the following for Resident #6: * Sucralfate Oral Tablet 1 GM (Sucralfate) Give 1 tablet by mouth four times a day for GERD. Scheduled - 11/06/2023 12:00 p.m.; administered - 11/06/2023 at 2:15 p.m. Record review of Resident #6's MAR for November 2023 revealed he was administered another dose of Sucralfate on 11/06/2023 at 5:00 p.m. as scheduled. Resident #8 Record review of Resident #8's face sheet dated 11/08/2023 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #8's diagnoses included: cerebral infarction (ischemic stroke; disrupted blood flow to the brain), diabetes (too much sugar in the blood), bacteremia (bacteria in the blood), anemia (when the blood does not have enough healthy red blood cells), pain, major depression (disorder which affects how you think and behave), anxiety (intense, excessive, and persistent worry and fear about everyday situations), essential hypertension (abnormally high blood pressure that is not the result of a medical condition), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #8's care plan revised on 10/30/2023 revealed the following care areas: * Resident #8 was prescribed antidepressant medication due to Depression. Goal included: Resident #8 will be free from discomfort or adverse reactions related to antidepressant. Interventions included: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness. * Resident #8 was prescribed antipsychotic medications due to bipolar disorder. Goal included: Resident #8 will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Interventions included: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness. Consult with pharmacy and doctor to consider dosage reduction when clinically appropriate at least quarterly. * Resident #8 was prescribed pain medication therapy due to generalized pain and discomfort with joint pain due to age. Goal included: Resident #8 will achieve a level of comfort that allows participation in activities of choice daily. Interventions included: Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness. Record review of Resident #8's physician's orders for November 2023 reveled the following active medication orders: * Lithium Carbonate Oral Tablet 300 MG (Lithium Carbonate) Give 1 tablet orally every 8 hours for Bipolar. Active 10/17/2023. Record review of the facility's Medication Administration Audit Report for 11/03/2023 - 11/10/2023 revealed the following for Resident #8: * Lithium Carbonate Oral Tablet 300 MG (Lithium Carbonate). Give 1 tablet orally every 8 hours for Bipolar. Scheduled - 11/03/2023 12:00 a.m.; administered - 11/03/2023 2:06 a.m. Record review of Resident #8's MAR for November 2023 revealed he was administered another dose of Lithium Carbonate on 11/03/2023 at 8:00 a.m. as scheduled. * Lithium Carbonate Oral Tablet 300 MG (Lithium Carbonate). Give 1 tablet orally every 8 hours for bipolar. Scheduled - 11/07/2023 12:00 a.m.; administered - 11/07/2023 3:00 a.m. Record review of Resident #8's MAR for November 2023 revealed he was administered another dose of Lithium Carbonate on 11/07/2023 at 8:00 a.m. as scheduled. Resident #13 Record review of Resident #13's face sheet dated 11/06/2023 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13's diagnoses included: congestive heart failure (heart does not pump blood efficiently), Alzheimer's disease (a progressive disease that destroys memory and other mental functions), dysphagia (difficulty swallowing), insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep), schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), Bipolar (, a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), panic disorder (an anxiety disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), constipation (difficulty emptying the bowels), type 2 diabetes (high blood sugar), hypertension (high blood pressure), pain, and peptic ulcer (a lesion in the lining [mucosa] of the digestive tract). Record review of Resident #13's care plan revised on 10/02/2023 revealed the following care areas: * Resident #13 has impaired cognitive function/impaired thought processes due to Alzheimer's, Dementia. Goal included: Resident will maintain current level of cognitive function. Interventions included: Administer medications as ordered. Observe for side effects and effectiveness. * Resident #13 uses anti-anxiety medication due to anxiety. Goal included: Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions included: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness .Review medication for effectiveness, discuss gradual dose reductions when appropriate, and/or discontinue once stabilization has been achieved. * Resident #13 uses antipsychotic medications due to schizoaffective disorder. Goal included: Resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions included: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness .Consult with pharmacy, doctor to consider dosage reduction when clinically appropriate at least quarterly. Record review of Resident #13's physician's orders for November 2023 revealed the following active medication orders: * Buspirone HCl Oral Tablet 10 MG (Buspirone HCl). Give 1 tablet by mouth three times a day for anxiety. Active. Record review of the facility's Medication Administration Audit Report for 11/03/2023 - 11/10/2023 revealed the following for Resident #13: * Buspirone HCl Oral Tablet 10 MG (Buspirone HCl). Give 1 tablet by mouth three times a day for anxiety. Scheduled - 11/04/2023 9:00 a.m.; administered - 11/04/2023 12:35 p.m. Record review of Resident #13's MAR for November 2023 revealed she was administered another dose of Buspirone HCI on 11/04/2023 at 2:00 p.m. as scheduled. * Buspirone HCl Oral Tablet 10 MG (Buspirone HCl). Give 1 tablet by mouth three times a day for anxiety. Scheduled - 11/05/2023 9:00 a.m.; administered - 11/05/2023 12:20 p.m. Record review of Resident #13's MAR for November 2023 revealed she was administered another dose of Buspirone HCI on 11/05/2023 at 2:00 p.m. as scheduled. * Buspirone HCl Oral Tablet 10 MG (Buspirone HCl). Give 1 tablet by mouth three times a day for anxiety. Scheduled - 11/06/2023 9:00 a.m.; administered - 11/06/2023 11:28 a.m. Record review of Resident #13's MAR for November 2023 revealed she was administered another dose of Buspirone HCI on 11/06/2023 at 2:00 p.m. as scheduled. * Buspirone HCl Oral Tablet 10 MG (Buspirone HCl). Give 1 tablet by mouth three times a day for anxiety. Scheduled - 11/09/2023 9:00 a.m.; administered - 11/09/2023 1:16 p.m. Record review of Resident #13's MAR for November 2023 revealed she was administered another dose of Buspirone HCI on 11/09/2023 at 2:00 p.m. as scheduled. Continued record review of Resident #1 Record review of Resident #1's Comprehensive MDS dated [DATE] revealed she understood others and was able to make herself understood; she had a BIMS score of 0 (severe cognitive impairment); she exhibited behaviors related to rejection of care; she as wheelchair bound; she required assistance with oral hygiene, toileting, bathing, dressing, and transfers; she had an indwelling catheter; she was always incontinent of bowel. Record Review of Resident #1's care plan dated 11/06/2023 revealed the following care areas: * Resident #1 was prescribed anti-anxiety medication due to anxiety and attention seeking behaviors. Goal included: Resident #1 will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions included: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness. Monitor/document/report PRN any adverse reactions to anti-anxiety therapy. Review medication for effectiveness, discuss gradual dose reductions when appropriate, and/or discontinue once stabilization has been achieved. * Resident #1 was prescribed insulin or hypoglycemic (drug) due to uncontrolled diabetes mellitus type 2 with bouts of hypoglycemia due to Resident #1 not eating. Goal included: Resident #1 will be free of adverse drug reactions from insulin administration. Interventions included: Administer insulin as ordered. Monitor/document for side effects and effectiveness. Monitor insulin injection site for presence or absence of any bruising, pain, redness, swelling or unusual marks on or near the injection site intervene, notify doctor, and document. * Resident #1 was prescribed antidepressant medication due to depression. Goal included: The resident will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions included: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness. * Resident #1 was prescribed pain medication therapy due to chronic pain. Goal included: Resident #1 will achieve a level of comfort that allows participation in activities. Interventions included: Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness. Record review of Resident #1's physician's orders for November 2023 revealed the following active orders: * Arnuity Ellipta 100 MCG INH Give 1 puff by mouth one time a day related to Acute Respiratory Failure with Hypoxia. * Atorvastatin 20 MG TAB Give 1 tablet by mouth a t bedtime related to Hyperlipidemia, Unspecified. * Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)). 1 dose inhale orally two times a day for SOB. * Clonidine HCl Oral Tablet 0.3 MG (Clonidine HCl) Give 1 tablet by mouth three times a day for hypertension. * Humalog injection Solution 100 UNIT/ML (Insulin Lispro) Inject 4 unit subcutaneously before meals related to Type 2 Diabetes Mellitus with Unspecified Complications. * Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously at bedtime related To Type 2 Diabetes Mellitus with Unspecified Complications. * Lactulose Oral Solution (Lactulose) Give 30 ml by mouth two times a day for Constipation. Record review of the facility's Medication Administration Audit Report for 11/03/2023 - 11/10/2023 revealed the following for Resident #1: * Humalog Injection Solution 100 UNIT/ML (Insulin Lispro). Inject 4 units subcutaneously (under the skin) before meals related to type 2 diabetes mellitus with unspecified complications. Scheduled - 11/06/2023 4:00 p.m.; administered - 11/06/2023 6:22 p.m. * Humalog Injection Solution 100 UNIT/ML (Insulin Lispro). Inject 4 units subcutaneously before meals related to type 2 diabetes mellitus with unspecified complications. Scheduled - 11/08/2023 7:30 a.m.; administered - 11/08/2023 9:38 a.m. * Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 4 units subcutaneously before meals related to type 2 diabetes mellitus with unspecified complications. Scheduled - 11/09/2023 7:30 a.m.; administered - 11/09/2023 8:55 a.m. * Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 4 units subcutaneously before meals related to type 2 diabetes mellitus with unspecified complications. Scheduled - 11/09/2023 11:00 a.m.; administered - 11/09/2023 1:03 p.m. * Lactulose Oral Solution (Lactulose) Give 30 ml by mouth two times a day for constipation. Scheduled -11/09/2023 4:00 p.m.; administered - 11/09/2023 5:50 p.m. * Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)). 1 dose inhale orally two times a day for SOB. Scheduled - 11/03/2023 8:00 p.m.; administered - 11/03/2023 9:48 p.m. * Arnuity Ellipta 100 MCG INH Give 2 puff by mouth two times a day related to acute respiratory failure with hypoxia. Scheduled -11/03/2023 8:00 p.m.; administered - 11/03/2023 9:45 p.m. * Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)). 1 dose inhale orally two times a day for SOB. Scheduled - 11/04/2023 8:00 p.m.; administered - 11:38 p.m. * Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)). 1 dose inhale orally two times a day for SOB. Scheduled - 11/05/2023 8:00 p.m.; administered - 11/05/2023 9:47 p.m. * Arnuity Ellipta 100 MCG INH Give 2 puff by mouth two times a day related to acute respiratory failure with hypoxia. Scheduled - 11/05/2023 8:00 p.m.; administered - 11/05/2023 9:47 p.m. * Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)). 1 dose inhale orally two times a day for SOB. Scheduled - 11/06/2023 8:00 p.m.; administered - 11/07/2023 1:47 a.m. * Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 15 units subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS. Scheduled - 11/06/2023 9:00 p.m.; administered - 11/07/2023 1:48 a.m. * Atorvastatin 20 MG TAB Give 1 tablet by mouth at bedtime related to hyperlipidemia, unspecified. Scheduled - 11/06/2023 9:00 p.m.; administered - 11/07/2023 1:48 a.m. * Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)). 1 dose inhale orally two times a day for SOB. Scheduled - 11/09/2023 8:00 p.m.; administered - 11/09/2023 11:36 p.m. * Atorvastatin 20 MG TAB Give 1 tablet by mouth at bedtime related to HYPERLIPIDEMIA, UNSPECIFIED. Scheduled -11/09/2023 9:00 p.m.; administered - 11/09/2023 11:36 p.m. * Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine). Inject 15 unit subcutaneously at bedtime related to type 2 diabetes mellitus with unspecified complications. Scheduled - 11/09/2023 9:00 p.m.; administered - 11/09/2023 11:38 p.m. Observation and interview with Resident #1 on 11/06/2023 at 1:15 p.m. revealed she was lying in bed. Resident #1 was alert and oriented. She expressed feeling sad and became tearful several times. Continued record review of Resident #2 Record review of Resident #2's admission MDS dated [DATE] revealed he was sometimes able to express ideas and wants and he was sometimes able to understand verbal content; he had a BIMS of 0 (severe cognitive impairment); he used a wheelchair for ambulation; he was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and transfers; he always incontinent of bowel and bladder; and he did not indicate pain or possible pain in the previous five days before the assessment. Record review of Resident #2's care plan, revised 10/23/2023 revealed the following care areas: * Resident #2 had impaired cognitive impairment thought processes due to decreased cognition. Goal included: The resident will be able to communicate basic needs on a daily basis. Interventions included: Administer medications as ordered. Observe for side effects and effectiveness. * Resident #2 is resistive to care, refuses treatment, refuses medication, chooses not to participate in care. Goal included: Resident #2 will cooperate with care. Interventions included: Allow Resident #2 to make decisions about treatment regime, to provide sense of control. Assess for pain and medicate as ordered PRN. Explain all procedures to the resident before starting and allow the resident adequate time to adjust to changes. If Resident #2 resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. * Resident #2 is on an anticonvulsant medication due to epilepsy seizures. Goal included: Resident #2 will be free of adverse drug reactions from anticonvulsant. Interventions included: Administer anticonvulsant medications as prescribed. Monitor/document/report PRN any adverse reactions to anticonvulsant medication. * Resident #2 has Diabetes Mellitus. Goal included: Resident will have no complications related to diabetes. Interventions included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #2's physician's orders for November 2023 revealed the following active orders: * Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate). Give 1 tablet by mouth one time a day for primary hypertension. Active 10/05/2023. * Carvedilol Oral Tablet 25 MG (Carvedilol). Give 25 mg by mouth two times a day for primary hypertension. Active 10/05/2023. * Levetiracetam Oral Solution 100 MG/ML. Give 5 ml by mouth two times a day for anticonvulsants. Active 10/05/2023. * Memantine HCl Oral Tablet 10 MG (Memantine HCl). Give 1 tablet by mouth in the morning for Alzheimer's Disease. Prescriber Active 10/05/2023. * Trazodone HCl Oral Tablet. Give 25 mg by mouth at bedtime for Antidepressant. Prescriber. Active 11/06/2023. Record review of the facility's Medication Administration Audit Report for 11/03/2023 - 11/10/2023 revealed the following for Resident #2: * Carvedilol 25 MG - scheduled daily at 8:00 a.m. was administered at 12:10 p.m. on 11/04/2023; administered at 12:31 p.m. on 11/05/2023; administered at 11:08 a.m. on 11/06/2023; administer at 11:31 a.m. on 11/07/2023; and administered at 12:36 p.m. on 11/09/2023. * Levetiracetam 100 MG/ML - scheduled daily at 8:00 a.m. was administered at 12:10 on 11/04/2023; administered at 12:30 on 11/05/2023; administered at 11:08 a.m. on 11/06/2023; administered at 11:31 a.m. on 11/07/2023; and administered at 12:36 p.m. on 11/09/2023. * Amlodipine 10 MG - scheduled daily at 8:00 a.m. was administered at 12:11 p.m. on 11/04/2023; administered at 12:30 p.m. on 11/05/2023; administered at 11:08 a.m. on 11/06/2023; administered at 11:31 a.m. on 11/07/2023; and administered at 12:36 p.m. on 11/09/2023. * Memantine 10 MG - scheduled daily at 9:00 a.m. was administered at 12:09 p.m. on 11/04/2023; administered at 12:31 p.m. on 11/05/2023; administered at 11:09 a.m. on 11/06/2023; administered at 11:31 a.m. on 11/07/2023; and administered at 12:37 p.m. on 11/09/2023. * Carbidopa 25-100 MG - scheduled daily at 5:00 p.m. was administered at 8:31 p.m. on 11/09/2023. * Carvedilol 25 MG - scheduled daily at 5:00 p.m. was administered at 8:31 p.m. on 11/09/2023. * Levetiracetam 100 MG/ML - scheduled daily at 5:00 p.m. was administered at 8:31 on 11/09/2023. * Levetiracetam 100 MG/ML - scheduled daily at 7:00 p.m. on 11/03/2023 was administered at 4:32 a.m. on 11/04/2023. * Trazodone 25 mg - scheduled daily at 9:00 p.m. on 11/07/2023 was administered at 1:00 a.m. on 11/08/2023. Observation and interview with Resident #2 on 11/08/2023 at 12:30 p.m. revealed he was lying in a low bed. Resident #2 was alert and opened his eyes to verbal stimulus. He responded yes and no to some questions. Resident #2 said, No when asked if his medications were administered on time. Resident #2 began repeating an [NAME] [TRUNCATED]

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permitted only authorized personnel to have access in accordance with State and Federal laws for 3 of 3 storage rooms, (Medication room [ROOM NUMBER], Medication room [ROOM NUMBER], and Oxygen Storage room [ROOM NUMBER]) reviewed for storage of drugs and biologicals. The facility failed to ensure all drugs, including antipsychotics, anticonvulsants, antidepressants, anti-hypertensives, blood thinners, antibiotics, and antihistamines, were properly secured when staff conspicuously wrote the code to the keypad lock on the door/door frame for two of two medication rooms and an oxygen tank storage room. This failure placed residents at risk of drug overdose, drug interactions, and other health complications from possible misuse of medications and supplies. Findings include: Observation of Medication room [ROOM NUMBER], on 11/10/2023 at 1:15 p.m. which was located across from Nurse's Station 1, near the corner of the 100 Hall and 200 Hall, and interview with Resident #17 revealed there was a sequence of numbers written on left side of the doorframe attached to the medication room's door. The numbers were written in dark black marker at eye level. There was a sign on the door which indicated it was a medication room. Interview at that time with Resident #17 who was sitting in her wheelchair, facing Medication room [ROOM NUMBER] stated, I know what you are looking at, and it is not good. Resident #17 stated the code to the medication room had been written on the doorframe for several months. Resident #17 said the code to the medication room was previously written on the light switch panel, which was next to the medication room door. Resident #17 said after the code was removed from the light switch, someone wrote it on the doorframe. Resident #17 stated other residents were aware the code to the medication room was written on the doorframe. Observation reflected when the sequence of numbers was entered on the keypad to the mediation room, the door opened. Observation of Medication room [ROOM NUMBER] and interview with RN D inside Medication room [ROOM NUMBER] on 11/10/2023 at 1:25 p.m., revealed RN D stated most of the residents' medications were stored in the medication carts. The refrigerator inside the medication room was stocked with various bags of insulin pens and an emergency drug kit with three different types of insulin pens and the pen needles used to administer the insulin. There were two E-kits (emergency drug kits) with various drugs for emergency use. The E-kits were large plastic containers with handles and were secured with zip-ties. One E-kit contained Methylprednisone (steroid), Glucagon (for low blood sugar), Insta-Glucose (for low blood sugar), Lokelma (for high potassium), Catapress (Clonidine - sedative and antihypertensive), Coumadin (blood thinner), Decadron (steroid), Dilantin (anticonvulsant), Lasix (a diuretic for fluid retention), Mephyton (for vitamin K deficiency), Nitrostat (a vasodilator for chest pain), Lopressor (for high blood pressure), Amoxil (antibiotic), Ampicillin (antibiotic), Augmentin (antibiotic), Ceftin (antibiotic), Cipro (antibiotic), Clindamycin (antibiotic), Diflucan (antifungal), Doxycycline (antibiotic), Zithromax (antibiotic), Atropine (involuntary nervous system blocker), Adrenalin (blood pressure support), Aquamephyton (used to help blood clot), filter needle, Benadryl (antihistamine), Decadron (steroid), Garamycin (antibiotic), Haldol (antipsychotic), Heparin )anticoagulant), Kenalog (used to treat inflammation), Lasix (diuretic), Lovenox (anticoagulant), Narcan (opioid overdose treatment), Rocephin (antibiotic), Solumedrol (steroid), Tobramycin (antibiotic), Zofran (for nausea), Lidocaine (pain reliever), Albuterol (used to treat bronchospasms), and Toradol (pain relief). The second E-kit contained solutions, including Dextrose (sugar substitute), Sodium Chloride (salt water), Heparin (anticoagulant), various antibiotics, catheter supplies, and other supplies. The room contained a large box with a red bag inside that contained the facility's discontinued medications. The box was full and contained various prescription drugs, including Farxiga (used to treat diabetes), Buspirone HCL (for anxiety), Digoxin (antiarrhythmic), Losartan (antihypertensive), Glimepiride (for diabetes), Benzonate (cough suppressant), Levetiracetam (anticonvulsant), Trazodone (antidepressant and sedative), Quetiapine (antipsychotic), Gabapentin (anticonvulsant and nerve pain), and Midodrine (blood pressure support). There were additional drugs inside the room, including over-the-counter heartburn medication, aspirin, vitamin D, magnesium, sodium chloride, and cough syrup. RN D stated she worked at the facility for five months and the code to the medication room was written on the doorframe since she was hired. RN D said she knew the code, so she did not have to look at it. RN D said residents did not know the code was written there, so they would not know to check it. RN D said CNAs did not go into the room, so they did not know the code was written on the doorframe. Observation of the Oxygen Storage room [ROOM NUMBER] on 11/10/2023 at 1:45 p.m. revealed it was located on the same hall as Medication room [ROOM NUMBER]. There was a sequence of numbers written at eye level on the right side of the doorframe. The sequence of numbers unlocked the door. There were multiple oxygen tanks around the room. There were also other supplies related to oxygen use, including masks and tubing. Observation of Medication room [ROOM NUMBER], which was located behind Nurse's Station 2 on 11/10/2023 at 2:00 p.m. revealed a sequence of numbers written on the door in pen directly above the keypad. The sequence of numbers opened the door to the medication room. There was a refrigerator inside which contained insulin pens, IV antibiotics, and dextrose sodium chloride. There were also other supplies in the room including a box of pen needles (for use on insulin pens), syringes, colostomy bags (a bag attached to the intestines for the collection of feces), IV needles, lancet needles, and feeding kits. In an interview with the Regional Director, Regional Nurse, Administrator, and DON on 11/10/2023 at 2:30 p.m., the Regional Nurse stated they were alerted by staff regarding the medication room codes on the doors. The Administrator said the codes were no longer written on the doors and the codes were changed. The Administrator said they previously changed the codes to the medication rooms back in September 2023. The Regional Director stated he never previously noticed the codes written on the doors. The Regional Nurse said she never saw the codes. The DON said she previously knew the code to the linen room was written on the door, but they changed the code there as well. The Administrator stated having an unsecured medication room made the drugs/medications easily accessible to anybody, including residents, family members, aides, and nurses. The Administrator stated nobody had ever brought the codes to their attention. The DON stated she entered the medication rooms weekly and she never noticed the codes. In an interview with Med Tech A on 11/11/2023 at 5:50 p.m., she stated she was hired in February 2023 and the codes to the medication rooms were written on the doors since she arrived. She said she asked someone for the codes She asked for the code when she started working and the Receptionist, who was a CNA at that time, showed her where it was written on the door frame. She said she did not know if management knew the codes were written on the doors. In an interview with CNA F on 11/11/2023 at 5:55 p.m., she stated the codes to the medication room were written on the door frames since she was hired in April 2023. She stated another CNA told her about the codes. She said everyone knew the codes were written there because they were so visible. She said based on conversations, even the residents knew about the codes. She said she never knew of any resident or visitor who attempted to get into the rooms. In an interview with LVN E on 11/11/2023 at 6:00 p.m., he stated the codes to the medication rooms were written there by other staff, although he did not know who wrote them. He said he could not say management knew about the codes. In a telephone interview with LVN A on 11/12/2023 at 9:22 p.m., she stated management recently changed the codes to the medication rooms. She said she did not know who wrote the codes on the doors. She said she and LVN E previously erased the codes from the doors with alcohol. She said they were off two to three days, and the codes were written on the doors again when they came back. She said she had no knowledge that any resident or visitor attempted to enter the rooms. In an interview with LVN E on 11/13/2023 at 10:39 a.m., he stated he and other staff were in-serviced on 11/12/2023 regarding the medication room codes. He said management told them where they could find the codes and informed them not to give anybody the codes. He said he and LVN A previously removed the codes from the doors once. He said LVN A showed him where the codes were written and that was not appropriate. He said that day (he could not recall when this happened), they wiped the codes off. He said the following day, the codes were written again. In an interview with the Administrator on 11/13/2023 at 12:32 p.m., she stated she was not aware staff wrote the codes to the medication rooms on the doors. She said she never would have allowed the codes to remain on the doors. She said after administration was made aware of the situation, they tried to ask around to see who wrote the codes, but they were unsuccessful. She said they in-serviced and educated staff on the importance of securing the medication rooms. She said management would continue to check the doors to ensure the situation does not occur again. She said they planned to remove the keypad and replace them with locks and keys. She said there was no negative outcome. Observation of Medication room [ROOM NUMBER], Medication room [ROOM NUMBER], and Oxygen Storage room [ROOM NUMBER] on 11/13/2023 at 1:00 p.m. - 1:15 p.m. revealed the codes were removed from the doors/doorframe and the previous codes were changed. Record review of facility policy, Storage of Medications revised 11/2020 revealed, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe. And sanitary manner

Based on observation, interview and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 12 of 30 days reviewed for sufficient staffing. The facility failed to ensure there were enough staff to administer medications timely from 11/3/23 through 11/10/23. The facility failed to ensure the night and weekend staff had an appropriate amount of nurses and CNAs to meet the needs of the residents. This failure could place residents at risk of their needs not being met, injury, skin breakdown, low self-esteem, depression, embarrassment, and psychological harm. Findings included: Record review of the Facility Assessment Tool updated 9/20/23 revealed the average daily census was 54-59 residents. The facility averaged 24-28 residents with behavioral needs, and 18 -22 residents required injections. The facility residents break down of ADL care was dependent dressing, 6 dependent on bathing, 5 dependent on transfer, 4 dependent on eating, 1 dependent on toileting, and 40 residents in the chair most of the time and required an assistive device used to ambulate. The facility had 52 residents that required 1 to 2 person assist in dressing, 45 for bathing, 50 for transfers, 25 for eating and 53 for toileting. The average number suggested for licensed nurses providing direct care was 2 to 5, and nurse aides was 4 to 7. The Facility Assessment tool revealed the staffing may be increased to meet the needs of the residents. Record review of the facility CMS 672 dated 11/3/23 revealed a census of 61 residents with the following: *24 residents required assist of one or two staff for bathing. *29 residents were dependent for bathing. *59 residents required assist of one or two staff for dressing. *2 residents were dependent for dressing. *48 residents required assist of one or two staff for transfers. *13 residents were dependent for transfers. *53 residents required assist of one or two staff for toilet use. *8 residents dependent on toilet use *58 residents required one or two staff for eating *3 residents dependent on staff for eating Record review of a list provided by Administrator revealed in rooms 109-116 there were 7 residents that were two person assist, in rooms 117-208 there were 8 residents that were 2 person assist, and in rooms 101-108 there were 7 residents that were 2 person assist. Record review of facility map revealed Station 1 was room [ROOM NUMBER] through 116; Station 2 was 117 through 124 and rooms 201 through 208; Station 2 had the skilled hall which was rooms 117 through 124. The memory care unit included rooms 215 through 226. Record review of the facility resident roster dated 11/3/23 revealed Station 1, rooms 101-116, included 14 residents; Station 2, rooms 117-208 (including the skilled hall) revealed 16 residents; and the memory care, rooms 215 through 226, included 15 residents. Record review of the Master Schedule for 4 weeks printed on 11/3/23 revealed staff scheduled to work for the following days: *10/23/23: Night shift, 1 LVN, and 1 RN, with 4 CNAs *10/28/23: Night Shift, 2 LVNs, 1 RN, and 2 CNAs *11/2/23: Night shift, 2 LVNs, 1 RN, and 3 CNAs *11/3/23: Night Shift, 2 LVNs, 1 RN, and 3 CNAs *11/4/23 weekend day shift included 5 CNAs, 1 LVN and 1 RN; night shift was 1 LVN and 4 CNAs *11/6/23 Night shift, 1 LVN and 4 CNAs *11/7/23 : Night shift, 2 LVNs, 2 RNs, and 3 CNAs *11/8/23: Night shift, 3 CNAs, 2 LVNs, and 2 RNs Record review of Daily Staffing Report revealed the following: *10/23/23: Census of 60 residents. Night shift: 1 RN and 1 LVN and 4 CNAs *10/28/23: Census of 60 residents. Night Shift: 1 RN, 2 LVNs and 4 CNA *10/29/23: Census of 60 residents. Night shift: 1RN, 2 LVN, 3 CNA *11/1/23: Census of 61: Night shift: 2 LVNs, 4 CNA *11/2/23: Census of 61: Night shift : 1RN, 2 LVNs, and 4 CNAs *11/3/23: census 62: Night shift : 1RN, 2 LVN, 4 CNAs *11/4/23: Census 61: Day Shift: 1 RN, 2 LVNs, 5 CNAs and 1 MA; Night shift: 1 RN, 2LVNs, 4 CNA *11/6/23 Census of 61: Night shift: 2 LVNs, 4 CNA *11/7/23 census of 61 Night Shift: 1 RN, 2 LVN, 4 CNA *11/8/23 census of 61 Night shift: 1 RN, 1 LVN, and 4 CNA *11/9/23 census of 61: Night shift: 2 LVN and 4 CNA *11/10/23 census of 62: Night shift: 2 LVN and 4 CNAs Record review of the Medication Administration Audit Report for 11/03/2023 through 11/10/2023 revealed 46 of 61 residents received morning, afternoon, and evening medications up to eight hours late. The medications included insulin, Benzodiazepines (anxiety and panic disorders), antibiotics, decarboxylase inhibitors (for Parkinson's Disease), SSRI's (for depression and psychiatric disorders), anticonvulsants, antidepressants, antihypertensives, anticoagulants, beta blockers, narcotics, and antipsychotics. In an interview on 11/3/23 at 10:45 a.m. with CNA V she stated her shift is 6am to 6pm. She said she works room numbers 109-116, and 101- 108. She said she sometimes had to work by herself. She said many residents are total care that she is assigned to. She said some residents requires more assistance. She said they do not have a lot of staff. She said suddenly they do not have enough staff to care for the residents. She said she believes some families have complained as well. She said 101-108 is being worked by someone else today, and today she only has 109-116. She said she is providing care for 16 residents today. She said only one resident is continent. She said the number of residents that require two people assist for ADLs is 7. She said when she needs to assist them, the other CNA on the other hall will help her. She said there was only one nurse, but she didn't know how many halls the nurse had. She said there are two nurses for the entire building. She said the two nurses includes the memory care nurse. When she started they used to have more staff, but now it's smaller. She said that the Administrator has only been here about a month and half. She said she heard that the night staff have a hard time and they do not even know their assignments. In an interview on 11/3/23 at 11:00 a.m. with Med Tech A, she said she worked a 12-hour shift from 7am to 7pm shift. She only passed meds. She said she was the only med tech on duty. She said she did not pass medications to memory care residents. She said that she passed meds to 38 residents. She said she had to be patient with quite a few of them, because they are slow takers or fight and refuse. She said she was sometimes overwhelmed. She said it's always been that way. She said sometimes she passed meds late, but it was only considered late for certain people because they are slow takers so she did those residents last. She said the 9 AM meds are sometimes passed at 11 AM for the slow taker residents. In an interview on 11/3/23 at 11:08 a.m. with LVN E, he stated that he worked 6a to 6pm today. He said he worked unit 1, which had about 22 residents. He worked 101- 116. There was another station, station 2 which has another nurse. He said he was working with 2 aides for about the 22 residents. If an aide called out they would have to share, sometimes they will pull from memory care, because there are 2 aides on memory care. He said there are a few behaviors of screaming and crying for no reason. He said there are people with falls as well and sometimes they roll out of bed. He said there was enough staff, but sometimes they aren't scheduled enough or when someone doesn't show up it's a big issue. He said if a staff called in the staff would just call whoever is on call and let that person know. If there is not a replacement provided, then the staff are shared. He said that the problem that is going on with management is the way they talk to staff, and that makes staff get angry and mad, especially when they are short of the floor, they will call management and they are slow and not proactive. He said communication was not good. He said 2 to 3 days ago they were short on nurses, and because of that they were using 2 nurses for 3 units. When they pull nurses to the floor it puts too much pressure on the staff. He said it affected the residents because they do not get proper care. For example, call lights were left unanswered and took some time to answer. He said there haven't been any incidents, and no one has been harmed from insulin or other meds being administered late that he was aware of. Interview on 11/3/23 at 11:40 a.m. with CNA C, she stated there were 15 residents in memory care. The schedule changed from 3 nurses to 2 nurses at night. One nurse quit so she could protect her license in case something happened. On Saturday, 10/28/23, the Administrator sent a text message to her, because she was very upset because there were only 2 aides on 10/28/23 and there were supposed to be 4 aides for the entire building. She told the Administrator there were only 2 aides in the building and that was unsafe due to the number of fall risk residents in the building. The Administrator just told her that one other aide may come. CNA C told the Administrator there should be 4 aides, but the Administrator said that wasn't what was agreed on and there should only be 3 aides. She said she told the Administrator she had been at the facility since April 2023 and there is always supposed to be 4 aides. The Administrator then stopped speaking to her. She said she was working the memory care and skilled care which is 22 to 23 residents, CNA M had station 1 and CNA R had all of station 2 and a part of station 1 and she had a nurse on memory. In an interview on 11/3/23 at 1:00 p.m. with LVN B, she said she worked 6am to 6pm today. She said she was on station 2. She said she worked with 23 residents; Rooms 110-118, and also rooms all 200 numbers except memory care numbers which was also 200. She said she had only 2 aides. She said there were currently 3 nurses at the facility today. She said that is the normal staffing pattern; two nurses for the floor and 1 nurse for memory care unit. In an interview on 11/3/23 at 1:07 p.m. with Resident #18, she stated that the staffing can depend on the day. She said she didn't' want to be a pain. She said the last few days had been rough to get up out of bed and changed due to staffing. She said she understood there was an issue with staffing, she tried to be patient, and she didn't have a lot of needs. She said she realized staffing was an issue and voiced her concerns to aides, DON, and nurses. They tell her we are doing the best we can. In an interview on 11/3/23 at 1:18 p.m. with Resident #17, she said the facility had some staffing issues. She said residents needs weren't being met. She said that no one knows what they are doing at the facility. She said they took the list down that tells staff the schedule, and it should have dates. On Friday they had no idea who was working or what halls. She said she had observed 2 to 3 nurses at night. At night it's a joke; they don't know who was where or even who was working. The management is not managing. There was no communication. She said the issues have come up in resident council and it has been reported to management and they just say they will change and make things better, but it does not get better. In an interview on 11/3/23 at 1:40 p.m. with the Administrator, she stated she had one specific nurse reaching out about wanting more staff. The nurse reached out to her and she talked to her last night. The situation was resolved last night. She was looking for the staffing assignment sheet, but a nurse moved it to another location. She said for the day time she staffed 6a to 6p with 4 to 5 nurses and 5 to 7 CNAs; depending on acuity and the census. At night, staffing should be 3 nurses and 4 to 5 CNAs. She said memory care is 1 to 2 aides depending on how many residents and outside the unit should be 3 CNAs. The CNAs assignments are 2 CNAs for memory care and 1 aide for each side of the 100 hall and 1 aide on the skilled hall. She said the DON and staffing coordinator/Receptionist completed the schedule daily. In an interview on 11/4/23 at 6:32 p.m. with RN D she stated that she worked the morning shift on this day, 6 am to 6pm. She completed her progress notes and then would leave at 7 p.m., late and after her shift was over. She said she worked station 1 rooms 101 to 108 and then rooms 109, 111, 113, and 115. She said she had one aide on each side of the 100 hall, so she had two aides for her halls. She said the total number of aides in the building today was 4 aides. There were 3 nurses, her, LVN G and LVN D who was in memory care. She said the census today was 62. She said there were not enough aides. She said 1 nurse was for memory care and then 2 other nurses for the rest of the building. She said LVN F is relieving her. She said there will be LVN C (memory care) and then an RN on station 2 and LVN F for station 1. In an interview on 11/4/23 at 6:33 p.m. with Med Tech B, she said she wasn't late on meds yet for the evening. In the morning she had to pass meds late due to her being the only med aide for 30 residents, but she has not seen any negative effects on residents. In an interview on 11/4/23 at 6:37 p.m. with LVN C she stated that she was working the memory care unit which has 13 residents. She was working the 6pm to 6am shift. She is working with one aide. She stated that if someone didn't come to work then there isn't anyone to work. In an interview on 11/4/23 at 6:40 p.m. with CNA D, she stated that she was worked the 6pm to 6am shift and she was the only aide on the memory care unit. She said when she takes her lunch only the nurse on the memory care unit will be there and she will be by herself. Residents should be asleep. In an interview on 11/4/23 at 6:51 p.m. with LVN G, she stated that she worked 6a to 6p. She couldn't tell surveyor what room numbers she worked, she didn't know the numbers of the rooms, she had station 2 and part of station 1. She had the whole hall. She had about 27 residents total. She believes she had 3 aides but can only remember two aides. She stated this was her first day on the floor. In an interview on 11/4/23 at 7:03 p.m. LVN F, she stated that she worked the 6pm to 6am shift. She said there had been issues with staffing overnight and not had enough staff. She said two nurses worked the floor. She said scheduling is confusing. Facility online schedule is different than the hand the written schedule. In an interview on 11/07/2023 at 6:15 P.M with RN F, she stated that she quit over week ago. She usually worked the MC. There would be an aide and RN on the unit. Usually, 3 nurses on duty and one aide on each hall. The reason she quit was because administration wanted to change to only staffing two nurses at night time. RN F did not agree with that, for residents safety. There was no med aide at night, anything can happen at night. Nurses and aides needed more staffing support. The DON wanted three nurses at night, it was the Administrator who wanted two nurses at night. She would have stayed if there were three nurses, and not being rushed. One night, someone called in, so there were only two nurses. After that, the administrator stated the facility was changing to two nurses, staring Nov. 1, 2023. Observation of medication pass and interview with Med Tech A on 11/08/2023 at 9:40 a.m. revealed she was passing morning mediations. Med Tech A stated she passed morning, afternoon, and evening medications to the entire building, other than the memory care unit and a few other residents on the other halls. She said her shift was from 7:00 a.m. to 7:00 p.m. and there was only one medication aide on each morning shift. She said the nurses passed their own medications on the night shift (7:00 p.m. - 7:00 a.m.). She said some residents took longer to take their medication, so she passed their medications last on their particular hall. She said she normally passed medications to all the other residents on the hall, then she went back and passed medications to the slow takers. She stated she had already passed medications to half of the 100 hall, but she still had to complete the other half of the 100 hall (ten residents), who were mostly bed bound. She said she completed medication pass on the 200 hall, other than Resident #6 (she was passing Resident #6's medications at that time- 10:11 a.m.) Med Tech A said the facility's management all knew it took her a long time to get all residents' medications passed and that she was late daily. She said she did not have a conversation with the DON or Administrator about not completing medication passes timely, but she did voice her concerns to her nurse, LVN E. She was told by LVN E that there were not enough residents to get another med aide on the shift. At 10:13 a.m., Med Tech A stated she still had to pass medications to the residents on the 100 hall and all of the resident's medications turned red on the eMAR at 10:00 a.m., indicating they were all late at that time. Observation of Med Tech A's computer screen at that time revealed the medications on each resident's eMAR were highlighted in red. She said she had only spoken to LVN E about her concerns because she did not want to jump the chain of command. In an interview on 11/8/23 at 10:15 a.m. with the DON, she stated that the staffing seems to be an issue everywhere ever since COVID-19. She said that the person that had been doing the schedule was the Receptionist and she did the schedule independently. She stated that if a nurse didn't show up, they would try to call staff and provide incentives to pick up the shift. If no one picked up shift, then the facility will post on the agency staff website. She said it could take a few minutes to an hour to get staff from the agency, depending on the shift. She stated that there was one med tech to pass medications on station 1 and station 2 and that is 45 residents. The nurse passed medications to peg tube residents which is 3, and then to 3 additional residents. Med techs passed meds to 39 residents. She said meds are given on time, and the med techs haven't complained at all. She said she reviewed medication administration when she needs to which is only if someone says medications are late or missing medications. She said meds can be given one hour before and one hour after its due. The medication aide arrives at facility at 7am and then the medications start at 8 a.m. on the 200 hall. Medications for rooms 117 to 123 are at 9 a.m. and then the long-term hallway which is rooms 101 to 116 are at 10 a.m She stated that she didn't observe medications being passed late because she was doing wound care. She said medication administration time is documented on the MAR. She said she had not looked at the MAR recently. She should review the MAR every day, but she did not because her hands are full; she is the ADON, the DON, the wound care nurse, and has been an aide before on the floor because there were only 2 aides. She said they did reach out to staffing agency to get an aide. She was an aide for a few hours which last Thursday (11/2/23) during the day shift. She said she did not remember a staffing issue Thursday evening. She stated that 2 aides ended up showing up for that day, one of their own and one from staffing agency. She had raised these concerns with the staffing coordinator, the Receptionist, and she just says people call out and that the facility tried to offer bonus or gift. The Receptionist is scheduling coordinator, maintains the front desk as a receptionist, and is accounts payable which means she is over billing, bills, and invoices. She was also a CNA but she did not get pulled to the floor to assist with care because she was told she cannot because she is Accounts Payable. She asked the Administrator if she could use the Receptionist as an aid and she was told no because she was Accounts Payable. A nurse quit last week, and a few staff members are leaving because of the issues. In an interview with LVN E on 11/08/2023 at 10:20 a.m., he stated morning medication pass times were between 9:00 a.m. and 10:00 a.m. He said they could pass medications for an hour before and an hour after the scheduled medication pass times and still be considered on-time. He said the medication aides could not administer every resident's medication exactly at their scheduled times because the time it took each resident to take their medication was different. He said some residents took their medications right away and some took longer, which would slow the medication aide down. LVN E said Med Tech A kept telling him she could not pass all medications on time, but there was nothing he could do about it. He said sometimes, the workload was different based on the fluctuating census. LVN E said he did not have any conversations with the DON, or the Administrator regarding Med Tech A's late medication passes or her concerns because he did not think they would do anything about it. He said talking to management would have been a waste of time because they would have said it was not too much work. He said administering residents' medications late meant a medication could be given too close to the time they were scheduled for the next dose and would not be able to take that next dose. He said Med Tech A always complained about not completing medication pass on time. He stated there were no negative outcomes due to late medication administration. In an interview on 11/10/23 at 9:54 a.m. with CNA G, he stated he typically works with 3 CNAs for the outside of the memory care unit. It depends on the census. But on average there were 3 to 4 CNAs, and 1 med tech and the nurses pass meds too. There is a charge nurse on each station, one in memory care, and one on each station, 1 and 2. In an interview on 11/10/23 at 10:30 a.m. with CNA H, she stated that she has worked both shifts but is now on day shift. Recently, they had staffed three aides on the floor, one per hall and had one nurse and one aide in MC. Currently, there was2 aides and one nurse in MC. CNA was a shower tech and restorative aide for a month. She then received a text and stating she was going back to floor because of budget. CNA was told the facility had too many aides staffed and they needed to save money and had to cut back on aides. She stated that with only one aide on a hall, it was very hard and stressful. She didn't get a break sometimes. There was one hall that was difficult to work and get everyone bathed because there were 7 to 8 hoyer transfers required to get the residents out of bed. The rooms numbers were 108-116. The room [ROOM NUMBER]-116 required two people at all times on the hall to provide proper care to the residents. When the facility staffed one aide per hall, the aides had to go look for another aide for help. The nurses were busy and didn't come help. Med aides cannot assist with resident care because they pass medications. She believed there was an increase of skin break down of skilled hall due to not being changed and turned properly and timely. She believed that because there are certain aides, mostly at night who are don't change the residents as often as needed. The Receptionist was a CNA, but the Administrator told her not to work the floor. Its hard to get additional aides because nobody wanted to come in and work another 12 hours while they were off. The facility did not have PRN staff (aides) and did not use agency staff (aides) for aides. Staffing trended down to one nurse at night, one aide in MC and MC nurse had to split with station one. She stated that the nurses who also had to pass meds at night sometimes felt overwhelmed. She talked to the Administrator and she said the nurses needed to get up and help the med aide. CNA talked to nurses and med aide, but they have their own job to do; nobody wanted to work two jobs. The facility cut out OT. She had to leave things for the next shift to do; she ran out of time on a regular shift. The facility had a meeting about not having time to complete everything and the administration said just to leave it to the next shift. She stated all the staff are all tired. Receptionist made it seem like residents were just a number, not like they cared about residents. In an interview on 11/10/23 at 11:05 am. with the Receptionist, she said she just does a little bit of everything wherever she can help. She said her job duties consist of the staffing coordinator; she has put the schedule in through January. She is the receptionist, and has been a CNA. She stated to determine how many staff she needed she went by PPD, she did not know what it meant but to her knowledge, it was based on money and people. She stated that 60 residents would be 5 to 6 aids during the day and 3 nurses during the day. For 60 residents there should be 3 nurses at night and 4 aids at night. Currently the census was 60 and there were only 2 full time nurses on shift at night. She stated that they can run 3 at night but have 2 on each rotation. They use 2 full time nurses at night and will ask a nurse from the other rotation to work and pick up a shift. The facility will staff 2 nurses and if an agency nurse is available to pick up then they have a third nurse. She said it's been a few weeks that she can think of that an agency has picked up. The nurses help each other and are really good with working as a team. She said currently nothing is going on other than one nurse RN F who complained. She said it was unsafe and too much. She stated that if people call out there was still enough people to work. On the floor they always work 4 to 6 aides. She said there are two CNAs in memory and 4 on the outside. They staff one med aide. She stated that there had not been any increase of staffing issues lately that she is aware of. One of the aides had to leave and go home early and they used an agency staff then for an aide. She stated that they used an agency CNA when one of the aides had to go home, she couldn't remember the date, but it was recently. She said she had not worked the floor but if needed she will and would not mind. She said no one has had to work the floor that shouldn't and they haven't been short enough for her to have had to come in. She said she doesn't know why anyone would say that they have been short and asked her to work the floor. She said there's normal work issues like aides bickering because someone wont help. It took nurses extra time to pass meds, so they needed help and got a med aide, but only one. The one med aide passed meds to everyone except the memory care. She said she isn't a med aide so she doesn't know how they do their pass; she only makes sure there is a med aide in the building. She said she doesn't believe nurses have had to take on the med aid job. It's too much for nurses to do both. She hasn't been told they are not able to pass meds on time. When asked how does she know if she is scheduling enough, she said no one has come to report anything about staffing to her or bring it up in the meeting. She said if its reported there are staffing issues, she has to go through chain of command, and it would be up to Administrator and corporate to adjust staffing. She said staffing is based on the census and corporate. She said she had made adjustments they had a shower aide, and not the shower aid is a CNA and CNAs do showers. In an interview on 11/10/23 at 11:40 a.m. LVN D said the receptionist does schedule. Days are ok with number of staff they have now that state is here. LVN D stated that on her rotation, they staff one aide in MC. She was on MC. Now, she has two aides since state is here for residents to get proper ADLs. They said the budget was cut so cut back on staffing. Shen never worked at night, but has talked to night staff. Two weeks ago, there was a nurse and 2 aides for whole building. If no one is available, the scheduler (Receptionist) should work; she is a CNA. The Receptionist said they did not want her to work extra. They called staff to come in and work. Two staff came in. If someone called in, it's the Receptionist's responsibility to provide. Residents are up, especially in the MC. When facility had two nurses at night, MC nurse has to come out. In an interview on 11/10/23 at 12:39 p.m. LVN A stated that she worked nights. There are 3 nurses, and the facility is going down to 2 nurses. On Tuesday there was only 2 nurses, and that was to cover the memory care and the other halls . The date was 11/7/23. Prior to that, there were 3 nurses, and if one didn't show up there were just 2 nurses. They were told the facility was cutting down to 2 CNAs as well. She said she is supposed to work with 4 aides. Sometimes there was a call in, and management would tell her that they were calling and no one wanted to work. She found staff herself to work and called management and staffing and asked for approval for the CNA to work, and no one called back. She said she did medication administration as soon as she started her shift at 7 p.m She did assist CNAs with lifting, and does dressing changes when dressings fell off, she had to do incontinent care and emptied urinals. She said she had expressed her concerns and was met with rudeness from the staffing coordinator. The Receptionist would give excuses of working two to three jobs. She said the med aid left around 6 p.m. to 7 p.m. and she started the 8 p.m. med pass on station 1 which is 22 residents, and sometimes she will divide the hall between her and another nurse when only 2 nurses and then it's 30 residents. She said many medications are administered late because sometimes her administration is interrupted. She said many times she is pulled to other tasks and meds get passed late. She stated that she has asked if a med tech could stay until 8 to get it done and she has asked to have that concern addressed with the staffing coordinator. But it had not been addressed. In an interview on 11/12/23 at 9:45 p.m. RN E stated that she always worked nights. He stated he has given late meds because too many residents. Recently down to two nurses at night. One on station one and he gets middle section, skilled and MC. About 30 residents at one time. To give all at one night is difficult. MC get agitated and don't stay still. Hard to get them to take meds and they are late by the time he gets out of there. Just started last week with 2 nurses. Prior to that was 3. Only concern is working with two nurses at night. Workload has increased heavily. It's late because workload been heavier with two nurses. Residents don't sleep in MC. Sometimes, go to bed at 1 a.m., mixed half go by 9:30 then other half up sitting watching TV. By 2 a.m. all asleep. Last night, they were told there were going to be two on staff. Corporate said they were over budget, so switched to two nurses. In an interview on 11/13/23 at 9:21 a.m. with CNA O, she said the staffing is so short. She said CNAs can't reposition and turn residents nor change them timely. In an interview on 11/13/23 at 9:24 a.m. with CNA V- she said she is still by herself on the hall with residents that are two-person assist for everything. The facility had not made any adjustments to staffing. In an interview on 11/13/23 at 10:29 a.m. CNA L, she stated she worked day shift 6a to 6p all the time. She said she had 18 residents today. She had 117 through 208. She was working by herself. She said she 5 aides today. 2 aides are in memory care and outside is just 3. They have told staffing coordinator and the DON that the work is too much. She said her residents were total care and many are two person assist and incontinent. She said she was overwhelmed and tired. Rooms 109 to 116 were also total care many two person assist and that is the hall that another CNA V was working. Rooms 101 to 108 is the third aides hall. Interview on 11/13/23 at 12:18 p.m. with the Administrator and Regional Director revealed they confirmed that they had not used agency staff fro [TRUNCATED]

Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 2 (Resident #1 and Resident #12) of 3 residents reviewed for dignity in that: The facility failed to provide dignity and respect for Resident #1 and Resident #12 by leaving the resident's privacy bag off their foley bag exposing the full urinary bag to open doorway. This failure placed resident with an indwelling catheter at risk for embarrassment and low self- esteem. Findings included: Resident #1 Record review of Resident #1's face sheet dated 11/3/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included: hypoglycemia (low blood sugar), acute respiratory failure with hypoxia (difficulty breathing), metabolic encephalopathy (problem in brain caused by chemical imbalance in the blood), sepsis (life threatening infection), bacteremia pulmonary candidiasis (fungal infection in the lungs), type 2 diabetes (insulin resistant) muscle weakness (generalized), dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, muscle wasting and atrophy, left and right shoulder, other lack of coordination, retention of urine, anemia, hypothyroidism, hyperlipidemia, anxiety disorder, essential (primary) hypertension, cellulitis (skin infection) of unspecified part of limb, dorsalgia (back pain), altered mental status, elevation of levels of liver transaminase levels. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed all cognitive test revealed a 0. Resident #1 had a BIMS of 00 which indicated severe cognitive deficit. Section H noted the resident had an indwelling catheter. Record Review of Resident #1's undated care plan revealed Resident #1 had an Indwelling Catheter: Interventions included were to perform catheter care every shift and as needed. The resident has a 16F Foley catheter, position catheter bag and maintain tubing below the level of the bladder, make sure tubing is secured. Change catheter PRN based on clinical indications such as infection, obstruction, or when the closed system is compromised OR per physician's order. Document and notify physician for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. Obtain and record output as per facility policy and/or physician order. Observation on 11/4/23 at 6:45 p.m. revealed Resident #1 was lying in bed. She was in her room alone, her spouse was not present. Resident #1's Foley bag was on the floor, and without a privacy bag, and half full of dark urine. The foley bag was visible at the doorway. In an interview on 11/4/23 at 6:51 p.m. with LVN G, she stated that the catheter bag should be covered. She said Resident #1 was her resident to provide care for. She stated she was unaware the bag was uncovered. She said she had not looked at the catheter bag all day. In an interview on 11/10/23 at 9:54 a.m. with CNA G, he stated that he was aware the Foley bags should be covered. He stated Resident #1's family member liked to take the privacy cover off. CNA G stated that he did try to keep them covered. Resident #12 Record review of Resident #12's face sheet dated 11/1323 revealed Resident #12 was a [AGE] year old[AGE] year-old female admitted to the facility on [DATE]. Resident #12's diagnoses included: chronic obstructive pulmonary disease, unspecified, type 2 diabetes mellitus with diabetic chronic kidney disease, type 2 diabetes mellitus with hyperglycemia, major depressive disorder, hyperlipidemia, chronic kidney disease, stage 3 unspecified, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or chronic kidney disease, need for assistance with personal care, malignant neoplasm of unspecified ovary (malignant tumor in the ovary), malignant neoplasm of endometrium (cancer in the uterus), nausea with vomiting, dehydration, pressure ulcer of sacral (bottom of the spine) (region, stage 3, flaccid neuropathic bladder (overactive bladder), and essential (primary) hypertension. Record review of Resident #12's Quarterly MDS dated [DATE] revealed Resident #12 had a BIMS of 15, which indicated the resident's cognition was intact. Section H noted the resident had an indwelling catheter. Record review of Resident #12's Care plan revealed resident had a catheter to promote wound healing of sacrum per MD orders. Interventions included: Catheter care every shift and as needed. Document and notify physician for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Skilled Nurse to Change catheter every 30 days and PRN based on clinical indications such as infection, obstruction, or when the closed system is compromised OR per physician's order. Observation and interview with Resident #12 on 11/13/2023 at 1:53 p.m. revealed she was laying in her bed. Resident #12 was alert and oriented. She said staff to emptied her catheter bag and changed it when needed. Observation of Resident #12's catheter bag revealed it was hanging at the bottom of her bed. There was no privacy bag covering the catheter bag. Resident #12's urine was very dark. Resident #12's bed and catheter bag could be seen from the hall. In an interview on 11/8/23 at 10:15 a.m. with the DON, she stated Resident #1 had a catheter. She said the catheter should be covered with a privacy bag. She stated the bag should be covered for privacy and dignity. Resident #1's family member likes to take it off. The Investigator informed the DON that during observation of the uncovered foley bag, Resident #1's family member was not in the building. The DON stated every shift should be monitoring the foley bags to ensure they are covered and not on the floor. In an interview on 11/13/23 at 12:36 p.m. with the Administrator, she stated that the family member to Resident #1 will remove the privacy bag. She stated the expectation is that staff should ensure the urine is always covered when the family member is not in the building. She stated the nurses and CNA's were responsible to ensure the bag is covered to protect the resident's dignity. In an interview on 11/13/23 at 2:20 p.m. with the Administrator, she stated that she saw Resident #12's catheter bag was missing the privacy bag. She stated that all catheter bags should be covered for privacy. Record review of facilities policy titled Quality of Life-Dignity revised February 2020 revealed in part, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example: helping the resident to keep urinary catheter bags covered

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for medications. Resident #1 experienced exacerbated symptoms of her illness with involuntary movements of her tongue and legs after she missed six doses of [MEDICATION(S)] medication because the facility failed to order it before it ran out. This failure placed all residents whose medications were supervised by the facility at risk of experiencing serious side effects from possible interruptions to their medication regimen. Findings included: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with end-stage kidney disease (a medical condition in which a person's kidneys cease functioning), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), [CONDITION(S)] (a disorder that affects a person's ability to think, feel, and behave clearly), [CONDITION(S)] (a condition in which the blood does not have enough healthy red blood cells), [CONDITION(S)] (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and [CONDITION(S)] (a condition in which bones become weak and brittle). Record review of Resident #1's MDS (Minimum Data Set), dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) of 15 (cognitively intact); she did not exhibit any symptoms of [CONDITION(S)] or behaviors; she required supervision and set-up assistance from staff for bed mobility, transfers, walking, dressing, eating, toilet use, and personal hygiene; she was independent with bathing; and she was always continent of bowel and bladder. Record review of Resident #1's care plan updated [DATE] revealed she was on sedative/hypnotic therapy; she used anti-anxiety medications; she used antidepressant medication; and she used antipsychotic medications (Goal: resident will be/remain free of [CONDITION(S)] drug related complications, including movement disorder .), (Interventions: Administer [MEDICATION(S)] for Tardive Dyskinesia [a condition affecting the nervous system, often caused by long-term use of some psychiatric drugs. Symptoms include repetitive, involuntary movements, such as grimacing, rapid blinking, tongue thrusting, lip smacking/puckering] .) Observation and interview with Resident #1 on [DATE] at 12:40 p.m. revealed she was alert, oriented, and ambulated via wheelchair. Resident #1 stated she had not received her medication, [MEDICATION(S)], since the previous Monday, [DATE]. She stated she asked the nurses about the medication daily, but they always said it was coming tomorrow. She said the [MEDICATION(S)] was for her Tardive Dyskinesia and since she had not received the medication, she noticed her tongue hung out of her mouth more, her legs went up and down involuntarily more and she did not sleep. She said these symptoms were very frustrating and she was upset because it would take some time for her body to adjust to the medication again. She said she had been up since 3:00 a.m. that day ([DATE]). She said nobody tried to order the medication until Sunday ([DATE]) and Monday ([DATE]) when they told her the pharmacy did not answer the phone. She said the medication came from a specialty pharmacy and nobody knew how to order it. Further observation of Resident #1 at that time revealed her tongue projected from her mouth at times while she talked and while at rest. Record review of Resident #1's, Medication Review Report (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia, Notify SW when supply runs low at 8 doses left. Order Status: Discontinued (no date was listed), Order Date: [DATE], Start Date: [DATE]. Record review of Resident #1's, Medication Review Report (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia, Call pharmacy for refills (pharmacy name and phone number). Order Status: Active, Order Date: [DATE], Start Date: [DATE]. Record review of Resident #1's MAR for [DATE] revealed: [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia, Notify SW when supply runs low at 8 doses left. Start Date: [DATE], D/C Date: [DATE]. Further review of the record revealed [MEDICATION(S)] was administered daily in [DATE] until [DATE]. Doses were not administered [DATE] - [DATE]. Record review of Resident #1's MAR for [DATE] revealed: [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia, Notify SW when supply runs low at 8 doses left. Start Date: [DATE], D/C Date: [DATE]. [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia, Call pharmacy for refills (pharmacy name and phone number). Start Date: [DATE]. Further review of the record revealed the medication was not administered on [DATE]. Record review of Resident #1's Nursing Progress Notes for [DATE] revealed: On [DATE] at 8:38 p.m., LVN A wrote, [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia Notify SW when supply runs low at 8 doses left. Medication not available. On [DATE] at 6:27 p.m., LVN B wrote, MAR indicates Social Worker needs to be informed Eight (8) doses before the medication runs out to order it. Today is Saturday Weekend [DATE] (resident informed me she has missed 4 Evening doses - no orders noted to date). I will inform Social Worker at earliest convenience so medication could be ordered ASAP (Note: I was informed by Night Shift Nurse [night shift nurse was not named] that 1. Information for Specialty Pharmacy is on the order, but it is not, it shows old pharmacy information and 2. Social Worker needs to order it). On [DATE] at 6:46 a.m., LVN C wrote, Reported to DON about [MEDICATION(S)] order needed via Social Worker thru a Specialty Pharmacy. DON will follow up. Day Shift Nurse informed/will monitor situation. On [DATE] at 10:24 a.m., the DON wrote, Spoke with specialty pharmacy and the order for the [MEDICATION(S)] Capsule 40 MG was called in and the medication will be sent out today and will be delivered tomorrow. In an interview with the DON on [DATE] at 10:30 a.m., she said the facility had trouble getting Resident #1's [MEDICATION(S)], which had to be ordered through a specialty pharmacy. She said communication between the facility and the pharmacy was not effective. The DON said once she found out over the weekend ([DATE]) that the medication was not available in the facility, she contacted the specialty pharmacy who said they were trying to get the refill order from a doctor who no longer saw residents at the facility. The DON said she had to wait until Tuesday, [DATE], to call the specialty pharmacy because Monday, [DATE] was a holiday and the pharmacy was closed. She said she contacted the current doctor to refill the medication. She said medication refills should be requested within seven days before they ran out, but none of the nurses ever reported any problems with getting the medication within the seven days. She said regular medications were refilled through their computer system, but since the [MEDICATION(S)] had to be ordered from a specialty pharmacy, the nurses may not have known how to order it. She said most of the nurses on the 2:00 p.m. - 10:00 p.m. shift (Resident #1 received the [MEDICATION(S)] during this shift) were agency staff. In an interview with the Social Worker on [DATE] at 11:00 a.m., she stated she was not sure why there was a note to contact her about Resident #1's medication refill. She said she was the one who figured out which pharmacy to order the medication from back in [DATE] (when Resident #1 started taking the medication), so maybe the nurses thought she was the one who had to order the medication. She said in [DATE], she called their regular pharmacy because they did not provide the [MEDICATION(S)] and they told her the name of the specialty pharmacy who could provide the medication. She said nobody ever notified her when Resident #1 had eight doses of the [MEDICATION(S)] left, or when it ran out. She said she was not made aware when the nurses had issues with the medication refill. In an interview with the Administrator on [DATE] at 1:00 p.m., he said he was aware of Resident #1's medication situation. He said one of agency nurses must have put the note in Resident #1's MAR to contact the Social Worker about ordering the medication, but that was not correct. He said the facility's policy was to re-order medications within three days of last dose, but if the medication was hard to get, the nurses should have written a special note on the MAR to try and re-order more than three days ahead. He said he was not aware of any side effects Resident #1 had experienced due to not having her medication. He said even when Resident #1 received the medication daily, she still had some signs of it the Tardive Dyskinesia. He stated he observed and talked to Resident #1 while passing through the hallways and he did not notice anything unusual. In an interview with the DON on [DATE] at 1:15 p.m., she said Resident #1's doctor never stopped seeing residents at the facility, but his NP stopped seeing residents in [DATE]. She said when she found out about the issue on Saturday ([DATE]), she told LVN C to look for any notes from the Social Worker to find the specialty pharmacy's phone number, but LVN C said she could not find it. The DON said she found the name and phone number for the specialty pharmacy, but there was no answer after hours on a Saturday ([DATE]). She said she tried again on Sunday ([DATE]) and Monday ([DATE]) but there was no answer. She said when she called the specialty pharmacy on Tuesday ([DATE]), the representative said Resident #1's prescription was expired and a new order had to be submitted. She said the representative said the pharmacy had been trying to reach the old NP, but they could not reach her. The DON said she called Resident #1's doctor and he wrote a new order. She said she tried to get an order from Resident #1's primary doctor, but they could not write the order because the medication was referred by the psychiatrist. The DON stated the [MEDICATION(S)] was delivered by the specialty pharmacy 20 minutes ago (on [DATE] 20 minutes prior to the interview) and would be administered to Resident #1 that evening. The DON said she deleted the note on Resident #1's MAR to contact the Social Worker (that was why the initial order for [MEDICATION(S)] was discontinued on [DATE] and a new order was created on the same day) and instead, wrote the name and phone number of the specialty pharmacy on the MAR. She said she did not know why the nurses did not contact the Social Worker eight days ahead, as the note instructed. She said the nurses did call her, but not eight days before the medication ran out. She said if Resident #1 was out of her medication since last Monday ([DATE]), she (Resident #1) would have found her (the DON) and hounded (harassed) her until the medication was in because that is what she normally did whenever she felt her medications were low. She said most of the 2:00 p.m. - 10:00 p.m. shift were agency nurses, but the facility tried to staff the same nurses who were familiar with their processes. She said they provided an orientation for all agency nurses and gave them her phone number to call with any questions. The DON said her expectation was for the agency nurses to call the Social Worker because that was what the order said. She said the next thing for them to do would have been to follow the chain of command and call her (the DON) or the ADON and bring the issue to their attention sooner. The DON said Resident #1 told her she needed the medication because her tongue and legs were moving more, but she (the DON) did not observe anything unusual about Resident #1. She said although she could not see anything different, maybe Resident #1 could see and feel the difference. In a telephone interview with LVN B on [DATE] at 1:35 p.m., she said she worked on Saturday ([DATE]) and Resident #1 said she had not received the [MEDICATION(S)] for the last four nights. She said she looked at Resident #1's MAR and noted the last time the medication was ordered was sometime in [DATE]. She said she saw the note to inform the Social Worker eight doses ahead on Saturday ([DATE]), but she did not see the note before then. She said she called the regular pharmacy because they were the last to fill the order, but they said it had to be filled by a specialty pharmacy because they no longer supplied it. She said he called the DON, who said she would follow up. LVN B said she was familiar with Resident #1 because she had previously cared for her. She said she observed that Resident #1's tongue was doing something a little unusual. She said Resident #1 asked her if she saw anything unusual about her tongue, but she did not want to alarm her, so she said she did not see anything different. She said she told LVN C about the issue because she was the on-coming nurse. She said the standard policy had always been to refill medications five days ahead of the last dose. In a telephone interview with LVN A on [DATE] at 1:50 p.m., she stated when she worked at the facility on [DATE], she spoke with Resident #1 and she could tell she had Tardive Dyskinesia because of her leg movements and tongue smacking. She said that was the first time she worked with Resident #1. She said Resident #1 said she had not received her medication in ,d+[DATE] days. She said she looked in the computer system to order it, but she could not find information on the specialty pharmacy. She said she called the DON to inform her about the issue. LVN A said she did not see any note on Resident #1's MAR to call the Social Worker about the medication, but on [DATE], the medication was already out. In a telephone interview with Resident #1's doctor on [DATE] at 2:15 p.m., he stated he was informed about the problem with Resident #1's [MEDICATION(S)] on Tuesday ([DATE]). He said the medication was used to control Resident #1's involuntary movements. He said he immediately called the specialty pharmacy and spoke with the pharmacist, who assured him the medication would be shipped the same day. He said the pharmacist was aware they (the pharmacy) were awaiting a call from him (the doctor). He said he was not informed the pharmacy was trying to reach another doctor. An unsuccessful attempt was made to contact LVN C by phone on [DATE] at 2:45 p.m. LVN C returned the phone call on [DATE] at 12:17 p.m. and stated she worked with Resident #1 on Sunday ([DATE]) and Monday ([DATE]) on the 2:00 p.m. - 10:00 p.m. shift. She said the nurse from the previous shift (she could not recall the nurse's name) told her about the situation with Resident #1's medication. She said when she looked in the computer system, it showed the medication was ordered from the regular pharmacy, but Resident #1 said the medication had to be ordered from a specialty pharmacy. She said she did not see a note on Resident #1's MAR to contact the Social Worker, but she did see that note on the 24-hour report (the nurse on a previous shift documented to call the Social Worker on the 24-hour report). Record review of, Medication and Treatment Orders, revised [DATE] revealed, Policy Statement, Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation . 11. Drugs and biologicals that are required to be refilled must be ordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure that Resident #1's [MEDICATION(S)] medication was ordered from the pharmacy and received timely, as a result Resident #1's Tardive Dyskinesia worsened. This failure could place residents whose medications were supervised by the facility at risk of experiencing serious side effects from possible interruptions to their medication regimen. Findings included: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with end-stage kidney disease (a medical condition in which a person's kidneys cease functioning), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), [CONDITION(S)] (a disorder that affects a person's ability to think, feel, and behave clearly), [CONDITION(S)] (a condition in which the blood does not have enough healthy red blood cells), [CONDITION(S)] (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and [CONDITION(S)] (a condition in which bones become weak and brittle). Record review of Resident #1's MDS (Minimum Data Set), dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) of 15 (cognitively intact); she did not exhibit any symptoms of [CONDITION(S)] or behaviors; she required supervision and set-up assistance from staff for bed mobility, transfers, walking, dressing, eating, toilet use, and personal hygiene; she was independent with bathing; and she was always continent of bowel and bladder. Record review of Resident #1's care plan updated [DATE] revealed she was on sedative/hypnotic therapy; she used anti-anxiety medications; she used antidepressant medication; and she used antipsychotic medications (Goal: resident will be/remain free of [CONDITION(S)] drug related complications, including movement disorder .), (Interventions: Administer [MEDICATION(S)] for Tardive Dyskinesia [a condition affecting the nervous system, often caused by long-term use of some psychiatric drugs. Symptoms include repetitive, involuntary movements, such as grimacing, rapid blinking, tongue thrusting, lip smacking/puckering] .) Observation and interview with Resident #1 on [DATE] at 12:40 p.m. revealed she was alert, oriented, and ambulated via wheelchair. Resident #1 stated she had not received her medication, [MEDICATION(S)], since the previous Monday, [DATE]. She stated she asked the nurses about the medication daily, but they always said it was coming tomorrow. She said the [MEDICATION(S)] was for her Tardive Dyskinesia and since she had not received the medication, she noticed her tongue hung out of her mouth more, her legs went up and down involuntarily more and she did not sleep. She said these symptoms were very frustrating and she was upset because it would take some time for her body to adjust to the medication again. She said she had been up since 3:00 a.m. that day ([DATE]). She said nobody tried to order the medication until Sunday ([DATE]) and Monday ([DATE]) when they told her the pharmacy did not answer the phone. She said the medication came from a specialty pharmacy and nobody knew how to order it. Further observation of Resident #1 at that time revealed her tongue projected from her mouth at times while she talked and while at rest. Record review of Resident #1's, Medication Review Report (Physician's Orders) for [DATE] revealed: [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia, Notify SW when supply runs low at 8 doses left. Order Status: Discontinued (no date was listed), Order Date: [DATE], Start Date: [DATE]. Record review of Resident #1's, Medication Review Report (Physician's Orders) for [DATE] revealed: [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia, Call pharmacy for refills (pharmacy name and phone number). Order Status: Active, Order Date: [DATE], Start Date: [DATE]. Record review of Resident #1's MAR for [DATE] revealed: [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia, Notify SW when supply runs low at 8 doses left. Start Date: [DATE], D/C Date: [DATE]. Further review of the record revealed [MEDICATION(S)] was administered daily in [DATE] until [DATE]. Doses were not administered [DATE] - [DATE]. Record review of Resident #1's MAR for [DATE] revealed: [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia, Notify SW when supply runs low at 8 doses left. Start Date: [DATE], D/C Date: [DATE]. [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia, Call pharmacy for refills (pharmacy name and phone number). Start Date: [DATE]. Further review of the record revealed the medication was not administered on [DATE]. Record review of Resident #1's Nursing Progress Notes for [DATE] revealed: On [DATE] at 8:38 p.m., LVN A wrote, [MEDICATION(S)] Capsule 40 MG, Give 1 capsule by mouth at bedtime for Tardive Dyskinesia Notify SW when supply runs low at 8 doses left. Medication not available. On [DATE] at 6:27 p.m., LVN B wrote, MAR indicates Social Worker needs to be informed Eight (8) doses before the medication runs out to order it. Today is Saturday Weekend [DATE] (resident informed me she has missed 4 Evening doses - no orders noted to date). I will inform Social Worker at earliest convenience so medication could be ordered ASAP (Note: I was informed by Night Shift Nurse [night shift nurse was not named] that 1. Information for Specialty Pharmacy is on the order, but it is not, it shows old pharmacy information and 2. Social Worker needs to order it). On [DATE] at 6:46 a.m., LVN C wrote, Reported to DON about [MEDICATION(S)] order needed via Social Worker thru a Specialty Pharmacy. DON will follow up. Day Shift Nurse informed/will monitor situation. On [DATE] at 10:24 a.m., the DON wrote, Spoke with specialty pharmacy and the order for the [MEDICATION(S)] Capsule 40 MG was called in and the medication will be sent out today and will be delivered tomorrow. In an interview with the DON on [DATE] at 10:30 a.m., she said the facility had trouble getting Resident #1's [MEDICATION(S)], which had to be ordered through a specialty pharmacy. She said communication between the facility and the pharmacy was not effective. The DON said once she found out over the weekend ([DATE]) that the medication was not available in the facility, she contacted the specialty pharmacy who said they were trying to get the refill order from a doctor who no longer saw residents at the facility. The DON said she had to wait until Tuesday, [DATE], to call the specialty pharmacy because Monday, [DATE] was a holiday and the pharmacy was closed. She said she contacted the current doctor to refill the medication. She said medication refills should be requested within seven days before they ran out, but none of the nurses ever reported any problems with getting the medication within the seven days. She said regular medications were refilled through their computer system, but since the [MEDICATION(S)] had to be ordered from a specialty pharmacy, the nurses may not have known how to order it. She said most of the nurses on the 2:00 p.m. - 10:00 p.m. shift (Resident #1 received the [MEDICATION(S)] during this shift) were agency staff. In an interview with the Social Worker on [DATE] at 11:00 a.m., she stated she was not sure why there was a note to contact her about Resident #1's medication refill. She said she was the one who figured out which pharmacy to order the medication from back in [DATE] (when Resident #1 started taking the medication), so maybe the nurses thought she was the one who had to order the medication. She said in [DATE], she called their regular pharmacy because they did not provide the [MEDICATION(S)] and they told her the name of the specialty pharmacy who could provide the medication. She said nobody ever notified her when Resident #1 had eight doses of the [MEDICATION(S)] left, or when it ran out. She said she was not made aware when the nurses had issues with the medication refill. In an interview with the Administrator on [DATE] at 1:00 p.m., he said he was aware of Resident #1's medication situation. He said one of agency nurses must have put the note in Resident #1's MAR to contact the Social Worker about ordering the medication, but that was not correct. He said the facility's policy was to re-order medications within three days of last dose, but if the medication was hard to get, the nurses should have written a special note on the MAR to try and re-order more than three days ahead. He said he was not aware of any side effects Resident #1 had experienced due to not having her medication. He said even when Resident #1 received the medication daily, she still had some signs of it the Tardive Dyskinesia. He stated he observed and talked to Resident #1 while passing through the hallways and he did not notice anything unusual. In an interview with the DON on [DATE] at 1:15 p.m., she said Resident #1's doctor never stopped seeing residents at the facility, but his NP stopped seeing residents in [DATE]. She said when she found out about the issue on Saturday ([DATE]), she told LVN C to look for any notes from the Social Worker to find the specialty pharmacy's phone number, but LVN C said she could not find it. The DON said she found the name and phone number for the specialty pharmacy, but there was no answer after hours on a Saturday ([DATE]). She said she tried again on Sunday ([DATE]) and Monday ([DATE]) but there was no answer. She said when she called the specialty pharmacy on Tuesday ([DATE]), the representative said Resident #1's prescription was expired and a new order had to be submitted. She said the representative said the pharmacy had been trying to reach the old NP, but they could not reach her. The DON said she called Resident #1's doctor and he wrote a new order. She said she tried to get an order from Resident #1's primary doctor, but they could not write the order because the medication was referred by the psychiatrist. The DON stated the [MEDICATION(S)] was delivered by the specialty pharmacy 20 minutes ago (on [DATE] 20 minutes prior to the interview) and would be administered to Resident #1 that evening. The DON said she deleted the note on Resident #1's MAR to contact the Social Worker (that was why the initial order for [MEDICATION(S)] was discontinued on [DATE] and a new order was created on the same day) and instead, wrote the name and phone number of the specialty pharmacy on the MAR. She said she did not know why the nurses did not contact the Social Worker eight days ahead, as the note instructed. She said the nurses did call her, but not eight days before the medication ran out. She said if Resident #1 was out of her medication since last Monday ([DATE]), she (Resident #1) would have found her (the DON) and hounded (harassed) her until the medication was in because that is what she normally did whenever she felt her medications were low. She said most of the 2:00 p.m. - 10:00 p.m. shift were agency nurses, but the facility tried to staff the same nurses who were familiar with their processes. She said they provided an orientation for all agency nurses and gave them her phone number to call with any questions. The DON said her expectation was for the agency nurses to call the Social Worker because that was what the order said. She said the next thing for them to do would have been to follow the chain of command and call her (the DON) or the ADON and bring the issue to their attention sooner. The DON said Resident #1 told her she needed the medication because her tongue and legs were moving more, but she (the DON) did not observe anything unusual about Resident #1. She said although she could not see anything different, maybe Resident #1 could see and feel the difference. In a telephone interview with LVN B on [DATE] at 1:35 p.m., she said she worked on Saturday ([DATE]) and Resident #1 said she had not received the [MEDICATION(S)] for the last four nights. She said she looked at Resident #1's MAR and noted the last time the medication was ordered was sometime in [DATE]. She said she saw the note to inform the Social Worker eight doses ahead on Saturday ([DATE]), but she did not see the note before then. She said she called the regular pharmacy because they were the last to fill the order, but they said it had to be filled by a specialty pharmacy because they no longer supplied it. She said he called the DON, who said she would follow up. LVN B said she was familiar with Resident #1 because she had previously cared for her. She said she observed that Resident #1's tongue was doing something a little unusual. She said Resident #1 asked her if she saw anything unusual about her tongue, but she did not want to alarm her, so she said she did not see anything different. She said she told LVN C about the issue because she was the on-coming nurse. She said the standard policy had always been to refill medications five days ahead of the last dose. In a telephone interview with LVN A on [DATE] at 1:50 p.m., she stated when she worked at the facility on [DATE], she spoke with Resident #1 and she could tell she had Tardive Dyskinesia because of her leg movements and tongue smacking. She said that was the first time she worked with Resident #1. She said Resident #1 said she had not received her medication in ,d+[DATE] days. She said she looked in the computer system to order it, but she could not find information on the specialty pharmacy. She said she called the DON to inform her about the issue. LVN A said she did not see any note on Resident #1's MAR to call the Social Worker about the medication, but on [DATE], the medication was already out. In a telephone interview with Resident #1's doctor on [DATE] at 2:15 p.m., he stated he was informed about the problem with Resident #1's [MEDICATION(S)] on Tuesday ([DATE]). He said the medication was used to control Resident #1's involuntary movements. He said he immediately called the specialty pharmacy and spoke with the pharmacist, who assured him the medication would be shipped the same day. He said the pharmacist was aware they (the pharmacy) were awaiting a call from him (the doctor). He said he was not informed the pharmacy was trying to reach another doctor. An unsuccessful attempt was made to contact LVN C by phone on [DATE] at 2:45 p.m. LVN C returned the phone call on [DATE] at 12:17 p.m. and stated she worked with Resident #1 on Sunday ([DATE]) and Monday ([DATE]) on the 2:00 p.m. - 10:00 p.m. shift. She said the nurse from the previous shift (she could not recall the nurse's name) told her about the situation with Resident #1's medication. She said when she looked in the computer system, it showed the medication was ordered from the regular pharmacy, but Resident #1 said the medication had to be ordered from a specialty pharmacy. She said she did not see a note on Resident #1's MAR to contact the Social Worker, but she did see that note on the 24-hour report (the nurse on a previous shift documented to call the Social Worker on the 24-hour report). Record review of, Medication and Treatment Orders, revised [DATE] revealed, Policy Statement, Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation . 11. Drugs and biologicals that are required to be refilled must be ordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available . Record review of, Abuse, Neglect, Exploitation, and Misappropriation of Property Prevention, Protection and Response Policy and Procedures, revised [DATE] revealed, . Neglect: The failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure that care is provided as needed by the patient .

Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 6 residents (CR #1) reviewed for quality of care. 1. The facility failed to timely identify CR #1's change in condition of lethargy, impaired communication and motor functions. 2. The facility failed to timely assess, notify CR #1's physician, and provide interventions to CR #1 who began to have an increased altered mental state, lethargy and physical impairments. 3. The facility failed to timely address CR #1's increase in [CONDITION(S)] activity. An Immediate Jeopardy (IJ) situation was identified on 11/3/21. While the IJ was removed on 11/06/2021 at 4:30PM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving timely care, health complications, serious illness or death. Findings include: Record review of CR #1's facesheet revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged to the hospital on 9/26/21. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's quarterly MDS, dated [DATE], revealed a BIMS score of 3 out of 15, which indicated severe impaired cognition. The MDS indicated CR #1 had unclear speech and usually made herself understood and usually understood others. She required one-person limited assist with eating and had no impairment of upper extremities. The MDS revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated antianxiety medication was received 2 days with the last 7 days of the MDS. Record review of CR #1's, undated, care plan revealed she required assistance with all of her ADL's due to cognitive deficits and limited mobility. Her intervention included in part, .eating CR #1 is able to eat her meals once setup by staff. Cut foods, open packages, etc. Provide cueing when CR #1 gets off task. Provide a divided plate with meals. 9/16/21 [CR #1] was limited assist of one staff in the lookback 9/4/21 - 9/10/21 . Further review of the care plan revealed CR #1 had the potential to be verbally aggressive (curses at staff, and at other residents) related to poor impulse control. Per CR #1's mother, verbal outburst generally precedes [CONDITION(S)] activity. At times, CR #1 will hallucinate or yell out. Her interventions included: Administer medications as ordered. Monito/document for side effects and effectiveness, Monitor behaviors (every shift). Document observed behavior and attempted interventions, provide positive feedback for good behavior. Emphasize the positive aspects of compliance, when CR #1 becomes agitated, attempt to intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk away, and approach later. Record review of CR #1's, undated, care plan revealed CR #1 used anti-anxiety medication ([MEDICATION(S)]) PRN related to anxiety disorder, seizures. She's at risk for adverse effects. Her interventions included: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness. As needed, Educate family/caregivers about risks, benefits and the side effects. Observe for any adverse reactions to anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: [CONDITION(S)], hostility, rage, aggressive or impulsive behavior, hallucinations. Observe for target behavior symptoms (inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Reassure resident. Record review of CR #1's physician orders, dated 10/3/17, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician orders, dated 8/1/18, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician orders, dated 11/20/18, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician orders, dated 3/25/20, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician orders, dated 4/27/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician orders, dated 4/30/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Administration was noted to be effective. Record review of CR #1's progress notes, dated 5/18/21, at 1:42 PM revealed [MEDICATION(S)] was administered prior to ambulance transport. Record review of CR #1's Neurology consult, dated 5/18/21, revealed in part, .history of [CONDITION(S)] status post [MEDICAL RECORD OR PHYSICIAN ORDER] . For her acute headache she has been taking [MEDICATION(S)] 10 mg. She has been experiencing about one [CONDITION(S)] a month . Mental status: today she is awake and smiling. She is able to follow simple commands . She moves upper extremities against gravity Further review of the consult progress note revealed in part, .Her seizures have been relatively well - controlled. I have asked that she continue with her current regimen of medications including [MEDICATION(S)] 200 mg twice a day, [MEDICATION(S)] 800 mg a day, [MEDICATION(S)] 8 mg a day, and [MEDICATION(S)] 300 mg a day. She may also use [MEDICATION(S)]; however, I will switch her to the intranasal 10 mg/0.1 mL for her acute headaches Record review of CR #1's progress notes, dated 5/21/21 at 12:28 PM, revealed [MEDICATION(S)] was given, resident noted jerking, loud outburst of yelling and screaming. Record review of CR #1's progress notes, dated 5/31/21 at 9:31 PM, revealed resident was given [MEDICATION(S)] for [CONDITION(S)] at exactly 9:18 PM by mouth. Vital signs were taken (temp 98.6, BP 142/66, pulse 74, O2 96). Will continue to monitor. Record review of CR #1's progress notes, dated 5/31/21 at 10:14 PM, revealed Resident RP notified of the mild [CONDITION(S)] episode. Resident is stable and resting now. Record review of CR #1's June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's progress notes, dated 6/11/21 - 6/24/21, revealed no documentation regarding [CONDITION(S)] activity despite [MEDICATION(S)] being administered. Record review of CR #1's July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's progress notes, dated 7/5/21- 7/14/21, revealed no documentation regarding seizures despite [MEDICATION(S)] being administered. Record review of CR #1's progress notes, dated 7/18/21 at 6:03 PM, revealed the [MEDICATION(S)] was administered as needed for seizures and noted, patient having a little [CONDITION(S)] activity Record review of CR #1's progress notes, dated 7/18/21 at 9:56 PM, revealed Patient had a little [CONDITION(S)] activity today, [CONDITION(S)] pill [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] was administered. Within 10 minutes patient was calm, vital signs are within limit. Patient was monitored closely. Patient was sleeping as the shift ended, next nurse will continue to monitor. Record review of CR #1's progress notes, dated 7/20/21 at 10:25 AM, revealed resident was alert and able to verbalize needs to staff and resident had not exhibited any shouting, yelling, cursing or jerking movements. Record review of CR #1's progress notes, dated 7/27/21 at 9:21 PM, revealed, patients mother stated patient had a short episode of seizing, but none was witnessed by nurse. Will continue to monitor. Record review of CR #1's progress notes, dated 7/29/21 - 7/31/21, revealed no documentation regarding [CONDITION(S)] activity despite [MEDICATION(S)] being administered. Record review of CR #1's progress notes, dated 7/29/21 at 1:21 PM, revealed CR #1 was diagnosed with a [CONDITION(S)] with ESBL and MDR. CR #1 was started on [MEDICATION(S)] 875/125 twice daily for 14 days. Record review of CR #1's August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrations were listed as effective. Record review of CR #1's progress notes, dated 8/2/21, revealed no documentation of [CONDITION(S)] activity despite [MEDICATION(S)] being administered. Record review of CR #1's NP A progress notes, dated 8/3/21, revealed in part, .No [CONDITION(S)] episode . congenital [CONDITION(S)]/[CONDITION(S)] disorder - supportive care, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], Neuro Follow-up as recommended, [CONDITION(S)] precautions, [MEDICATION(S)] PRN . Record review of CR #1's progress note, dated 8/4/21 at 2:07 PM, revealed PRN [MEDICATION(S)] was given for [CONDITION(S)] and noted, given for behaviors, cursing and screaming. Record review of CR #1's progress notes, dated 8/5/21 - 8/6/21, revealed no documentation of [CONDITION(S)] activity despite [MEDICATION(S)] being administered. Record review of CR #1's progress note, dated 8/9/21 at 10:24 AM, revealed in part, .Resident exhibiting pre-[CONDITION(S)] behavior yelling and cursing. Resident given PRN [MEDICATION(S)] Record review of CR #1's August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . He noted in part, .No seizures lately/no pain issues, up and feeling herself, complained of body aches no fever, mild cough Record review of CR #1's progress notes, dated 8/10/21 - 8/17/21, revealed no documentation of [CONDITION(S)] activity despite [MEDICATION(S)] being administered. Record review of CR #1's NP A progress notes, dated 8/13/21 at 9:30 AM, revealed she was seen for generalized pain and experienced chronic back pain which was discussed with mother over the phone. Further review of note revealed in part, .[CONDITION(S)] controlled on medications Record review of CR #1's progress notes, dated 8/18/21 at 11:45 AM, revealed PRN [MEDICATION(S)] for seizures was given and noted, Resident having verbal outburst screaming shut up. Record review of CR #1's progress notes, dated 8/28/21 at 5:20 PM, revealed PRN [MEDICATION(S)] was given for seizures and notes, resident observed twitching during care, [MEDICATION(S)] tablet 10 mg PO PRN given, resident tolerated well. Record review of CR #1's progress notes, dated 8/30/21 - 8/31/21, revealed no documentation of [CONDITION(S)] activity despite [MEDICATION(S)] being administered. Record review of CR #1's September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrations were listed as effective. Record review of CR #1's progress notes, dated 9/1/21 - 9/6/21, revealed no documentation of [CONDITION(S)] activity despite [MEDICATION(S)] being administered for seizures. Record review of CR #1's 24-hour report, dated 9/1/21 - 9/7/21, revealed she had 0 [CONDITION(S)] activity despite [MEDICATION(S)] being administered for seizures. Record review of CR #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .[CONDITION(S)] in control [MEDICATION(S)] ([CONDITION(S)] medication) level 11.5 Record review of CR #1's progress notes, dated 9/8/21 at 5:42 AM, revealed in part, .up through the shift . No [CONDITION(S)] activity noted this shift . Record review of CR #1's 24-hour report, dated 9/8/21, revealed she was awake and talkative until 3 AM during night shift. Record review of CR #1's progress notes, dated 9/9/21 at 5:55 AM revealed in part, .remained awake through shift. at intervals. No [CONDITION(S)] activity noted . Record review of CR #1's 24-hour report, dated 9/10/21, revealed she was up all-night .No distress. Vital signs were stable. Record review of CR #1's 24-hour report, dated 9/11/21 - 9/15/21, revealed she had 0 [CONDITION(S)] activity despite [MEDICATION(S)] being administered for seizures. 9/12/21 during night shift it was noted she was up all night. Record review of CR #1's progress notes, dated 9/11/21 - 9/15/21, revealed no documentation regarding [CONDITION(S)] activity or change in condition. Record review of CR #1's Medication Regimen Review, dated 9/16/21, revealed in part, Patient has order for [MEDICATION(S)] 10 mg q6hr for seizures. Please ensure this medication in only being administered when the patient is having a [CONDITION(S)], not for anxiety or other indication. Record review of CR #1's 24-hour report, dated 9/16/21, revealed CR #1 was given PRN [MEDICATION(S)] during the day shift otherwise no further documentation regarding seizures. Record review of CR #1's 24-hour report, dated 9/18/21, evening shift noted, monitor patient for drowsiness, mother asked that NP be notified. ADON notified, patient is to go to dining room for all 3 meals. Record review of CR #1's 24-hour report, dated 9/19/21, night shift noted, stable, monitor patient for drowsiness, patient is to go to dining room for all 3 meals. No documentation of [CONDITION(S)] activity despite [MEDICATION(S)] being administered twice for [CONDITION(S)] activity. Record review of CR #1's 24-hour report, dated 9/20/21, revealed she was stable with no [CONDITION(S)] activity documented despite [MEDICATION(S)] being administered for [CONDITION(S)] activity. Record review of CR #1's 24-hour report, dated 9/22/21, revealed she was given [MEDICATION(S)] at 8 AM but did not eat lunch, ate less than 25%. No further documentation regarding [CONDITION(S)] activity. Record review of CR #1's progress notes, dated 9/23/2021 at 12:28 PM, written by Social Worker revealed, Data: IDT has observed a change/decline in her cognition and communication and upper extremity range of motion. Action: ST/OT to screen for evaluation and treatment. continues to visit with resident twice weekly. Record review of CR #1's progress notes, dated 9/23/2021 at 1:42 PM written by LVN B, revealed, Resident constantly yelling .take me shopping. Record review of CR #1's 24-hour report, dated 9/23/21, revealed she was up talking to herself throughout the night. Record review of CR #1's physician orders, dated 9/24/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's 24-hour report, dated 9/24/21, revealed labs were ordered, and UA was collected. Record review of CR #1's progress notes, dated 9/24/21, revealed no documentation of change in condition or why STAT lab were ordered. Record review of CR #1's CBC (Complete Blood Cell Count) with Differential/Platelet, CMP and UA was a routine order and the CBC, CMP was collected on 9/25/21 at 12:00 AM, received on 9/26/21 and reported on 9/27/21. The Urinalysis was not performed due specimen not at refrigerated temperature. Record review of CR #1's progress notes, dated 9/25/21, at 1:38 PM revealed CR #1 was resting in bed with eyes opened, her respirations were even and unlabored and she required total care with ADL's. Her lung sounds were clear, no SOB/distress noted. Her vital signs were stable. 10 PM - 6 AM shift had collected a urine sample and stored it in refrigerator. The writer (LVN A) noted she contacted the lab company to check on pick up time but current closed. Oncoming nurse to follow - up. Record review of CR #1's 24-hour report, dated 9/25/21, revealed in part, .facial [CONDITION(S)] to left side, lab results pending . abscess to left face. Record review of CR #1's 24 hours reports for the month of September 2021 revealed report from 9/26/21 was not provided. Record review of CR #1's progress notes, dated 9/26/21 at 12:08 PM written by LVN A, revealed CR #1 had a change in condition of altered mental status. An Evaluation was completed which revealed her blood pressure was 118/68, pulse was 74, respiration was 18, temperature (tympanic - ear) was 98.2, and O2 was 96%. Physical assessment revealed she had altered level of consciousness and needed more assistance with ADLs, general weakness, and decreased mobility. Further review of the assessment revealed in part, Writer was in the dining room assisting residents with lunch meals, Writer informed by a staff member resident was assisted with meals, and unable to eat her lunch, resident holds food in her mouth. Writer observed resting on bed with eyes opened, respiration even and unlabored. Resident skin to bilateral hands cold, resident unable to respond by name calling or touch. Lung sounds increased bilateral breath sounds to anterior right upper lobe abdomen soft, non-tender, bowel sound active in 4 quadrants . NP on-call (NP B) was informed of resident condition, new order received to transfer resident to hospital. Record review of CR #1's progress notes, dated 9/26/21 at 1:58 PM, revealed NP on call (NP B) ordered to transfer CR #1 to the hospital for altered mental state. Record review of CR #1's hospital records, dated 9/26/21, revealed she entered the emergency room at 1:14 PM and her triage started at 1:20 PM for altered mental status and nursing home reported she was last seen at her baseline last night. She ate 50% of her breakfast and none of her lunch which is not normal for her. History of [CONDITION(S)] and normally alert and oriented x1. Records noted she had an altered mental status since 10 AM and her baseline was usually conversive, but staff told EMS she had been less responsive than usual and altered. She was noted to not be eating or drinking as much as she usually did, nor is she talking. EMS measured her blood glucose to be in 150s. Resident temperature during triage was noted to be 87.3 degrees and pulse of 44 bpm. CR #1 reasons for admission were: Hypothermia, lethargy, altered mental status, and abnormal LFTS (Liver Function Test), she started warming blankets and was admitted to the IMU (intermediate care unit). Record review of the hospital history and physical, dated 9/26/21, revealed in part, .Majority of history is obtained from the mother who is sitting at bedside. At baseline, the patient is alert, very talkative, friendly to everyone in the facility, likes to listen to music, wheelchair bound, requires assistance with ADL's apart from feeding. Mother and Father both visit daily. Mother reports that for the last two weeks she has been having frequent 'staring spells' that she believes are seizures and says they are occurring 'back to back' in the of their conversations . For the last 24 to 48 hours, her mental status became progressively worse to where she became completely unresponsive except to pain Interview on 9/29/21 at 4:35 PM, CR #1's visitor said she hadn't seen CR #1 since July 2021 prior to her visit on 9/26/21. The visitor said she arrived at the facility on 9/26/21 and found CR #1 in her room and she looked completely different than the last time she saw her. The visitor said CR #1 laid in bed and her eyes were blood shot red and fixated. The visitor said CR #1 was unable to communicate on 9/26/21 and said CR #1 was usually very talkative and friendly. The visitor described her condition as being unresponsive. The visitor said she found LVN A in the hallway and asked her how long CR #1 had been in her current condition. The visitor said LVN A told her it was only her second day back to work and she was told by the previous nurse (name unknown), CR #1's change in condition happened a week ago. The visitor said she told LVN A to call the physician and send CR #1 out to the hospital. CR #1 said LVN A then called the physician and got orders to transfer CR #1 out. The visitor said she immediately called CR #1's RP and told her about CR #1's condition and she agreed she wanted her transferred to the hospital and reported she was on her way there. The visitor said she was very upset and felt it was neglectful the facility let CR #1 sit in the facility all week with the changes CR #1 experienced. The visitor said she was close with CR #1's RP and was also upset because the RP had been telling the facility CR #1's seizures had increased, and she had silent seizures. The visitor said the RP had visited CR #1 the last week she was in the facility and noticed she was different as well and was told by the facility to make CR #1 a neurologist appointment. Interview on 9/29/21 at 5:07 PM, CR #1's RP said CR #1 had passed away in the hospital on 9/27/21 and she was in the process of making her funeral arrangement. The RP said she told the facility CR #1's seizures had increased, and she had them more frequently but at the care plan meeting they told her they had not observed CR #1 having any seizures. The RP said she would walk into the facility and ask the nurses if CR #1 had any seizures and they would tell her no, then she would walk into the CR #1's room and find her in the middle of having a [CONDITION(S)]. The RP said the [CONDITION(S)] activity she reported wasn't like a grand mal [CONDITION(S)] and said it was more of a, silent [CONDITION(S)]. She said she would walk in and CR #1 would not be talking, her eyes would be locked in, and she would be gritting her teeth. The RP said CR #1 would typically yell out and say bad words before she would seize but the silent seizures were different, and she was not doing her usual [CONDITION(S)] behavior. The RP said she was told to make CR #1 a Neurologist appointment for the seizures she observed. The RP said she did make the appointment for 9/28/21 but CR #1 was transferred to the hospital and passed away before the appointment. The RP said she would visit CR #1 every day and had noticed physical changes in her the last week she was in the facility and said when she asked the staff about it they said they did not know what was causing it. The RP said she noticed CR #1's color was darker, and her gums were darker as well the last few days she was in the facility. The RP said CR #1 stopped eating as much of her food at first, then CR #1 transitioned to not being able to feed herself the week prior to her passing away. The RP said she visited CR #1 on 9/25/21 and CR #1 was unable to hold her head up or eat at all, the RP said she was only able to get CR #1 to drink a small can of coke. The RP said on 9/25/21 CR #1 could not communicate clearly or move her arms like she previously could. The RP said she did not feel the facility addressed CR #1's increased [CONDITION(S)] activity like they should have. The RP said when CR #1 got to the hospital on 9/26/21, they did an EEG (a test that detects abnormalities in your brain waves, or in the electrical activity of your brain) and it showed CR #1 had seizures repeatedly throughout the night. Phone interview on 10/6/21 at 5:00 PM, LVN A said she remembered transferring CR #1 out to the hospital on 9/26/21 because she became unstable. LVN A said she could not recall how she was unstable without her notes in front of her but said she thought CR #1 was unable to eat her lunch which was what prompted her to call the NP. LVN A said she had just returned to work on 9/25/21 and the CNA's and nurses reported to her CR #1 needed more assistance than usual. LVN A said, previously CR #1 was able to feed herself and communicate well. LVN A said she remembered CR #1 had a visitor on 9/26/21 and she told the visitor CR #1 was transferred to the hospital but could not recall anything else that was said. Interview on 11/1/21 at 2:30 PM, the Social Worker said on 9/23/21 they had their weekly IDT meeting and CR #1 was recognized to have experienced a change. The Social Worker said CR #1 was noticed to be more tired than usual, required more assistance, and had a change in her communication. The Social Worker said she thought the physician was notified and said the previous DON would have been the person to notify the physician. The Social Worker said the previous DON no longer worked at the facility and she would be the person to know what the physician said in response to the reported change on 9/23/21. Interview on 11/1/21 at 2:40 PM, the Administrator said the previous DON no longer worked at the facility and she was unable to assist the facility with any questions they had. The Administrator said he knew the DON had notified the physician but was not sure of the date. The Administrator said he saw in the records STAT labs were ordered for CR #1 on 9/24/21 and agreed he saw no further documentation as to why the labs were ordered but said it must have been from the nurses notifying the physician of CR #1's change in condition. The Administrator said there should be documentation from the nurses. Phone interview on 11/1/21 at 2:50 PM, CR #1's Community Support Trainer said she visited with CR #1 twice a week on Tuesday's and Wednesday's. The Community Support Trainer said she had in her records she last saw CR #1 on Wednesday (9/22/21) and she recalled CR #1's health had gone down quite a bit. The Community Support Trainer said CR #1 had slurred speech and was not able to communicate clearly like she usually could. She said CR #1's appearance looked like she was sick and said her eyes and nose were running. She said CR #1's was very lethargic, and her coordination was off. The Community Support Trainer described activity CR #1 would complete using alphabets and letters and said on 9/22/21 CR #1 was unable to complete the activity because she was unable to properly use her hands to pick up the letters and numbers. The Community Support Trainer said she did not recall talking about the changes she observed with facility staff. Interview on 11/1/21 at 2:58 PM, CNA B said CR #1 started sleeping a lot before she transferred to the hospital on 9/26/21. CNA B said she could not recall when CR #1's change started, but said it was within the last week she was at the facility and said maybe guessed it was the last 3 or 4 days she worked with her. CNA B said CR #1 was previously not like that and was more alert and talkative and did not require assistance with eating. CNA B said the last few days she worked with CR #1 she did not communicate well, needed assistance with eating, and did not eat as much. CNA B said CR #1 started yelling out people's names as well and she did not do that before. CNA B said when she first observed the changes, she told the nurses but was not sure what the nurses did after she told them. CNA B said she recalled she tried to feed CR #1 and she was unable to eat and said the food was just falling out of her mouth when she tried to feed her. CNA B said she told the nurse about CR #1 not being able to eat and was not sure what happened after. CNA B was not sure of the date when CR #1 was unable to eat. Phone interview on 11/1/21 at 3:35 PM, LVN B said she recalled CR #1 was sleeping a lot, more than usual and she would be up all night. LVN B said CR #1 would usually sleep through the night and not be so sleepy and tired during the day. LVN B said she recalled CR #1's left side of her face was swollen and thought she could have had an abscess. LVN B said she notified the NP of CR #1's change and the NP ordered STAT labs to see if she had a [CONDITION(S)]. LVN B said she recalled CR #1's RP reported CR #1 had silent seizures. LVN B said CR #1 would typically yell out and start cursing and that was how they knew she was about to have a [CONDITION(S)]. LVN B said she had not observed the silent seizures but CR #1's RP said CR #1 had a Neurologist appointment on 9/28/21 to get her checked for her seizures but CR #1 transferred to the hospital before the appointment date. LVN B said the changes happened with CR #1 over the last few days she was at the facility, but she could not recall specific dates when it started or when she notified the NP. LVN B said when she last worked CR #1's lab results had not resulted yet

Based on observation, interview, and record review, the facility failed to provide adequate supervision to two residents (Resident #1 and Resident #2) of four residents reviewed for supervision in that -The facility staff failed to properly supervise Resident #1 and #2. -Resident #1 had a history of [REDACTED]. -Resident #2 had a history of [REDACTED]. -The nurse on duty observed Resident #2 enter Resident #1's room and did not intervene until there was an altercation between the two residents. Resident #1 sustained injuries due to the altercation. Findings included: Resident #1 Record review of the Admission Record for Resident #1, dated 02/06/19, revealed he was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed he exhibited moderately impaired cognitive skills for daily decision making. He did not exhibit any behavioral symptoms during the seven day look-back period prior to the assessment. Resident #1 required supervision with bed mobility, transfers, and locomotion. Record review of the Care Plan (no date) for Resident #1 revealed The resident is at times resistive to care, refuses medications, labs, showers, etc. The Care Plan also revealed Resident #1 had the potential to be physically aggressive and had a history of [REDACTED]. The Care Plan revealed in part .often becomes agitated when other residents, even roommate (sic) enters his room. Interventions included to monitor, document and report as needed any signs of resident posing danger to self and others. Observation on 01/23/19 at 11:05 a.m. revealed Resident #1 was in the secured unit of the facility. He was propelling himself in his wheelchair. He did not respond to a verbal greeting. There was one nurse and two Certified Nurse Aides (CNA) in the unit. Interview on 01/23/19 at 11:35 a.m. with a family member of Resident #1 he said he was told in a Care Plan meeting on 01/22/19 that LVN A had separated the two residents. The family member said he was not contacted on the night of the occurrence. He said the Administrator called him the next morning and said there was a black eye and bruising. The family member said he would have taken Resident #1 to the hospital on the night of the occurrence had he been told. Resident #2 Record review of the Admission Record for Resident #2, dated 02/06/19, revealed he was [AGE] years of age, and admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #2's MDS, dated [DATE], revealed he exhibited severely impaired cognitive skills for daily living. He did not exhibit any behavioral symptoms during the seven day look-back period prior to the assessment. Resident #2 required supervision for bed mobility, transfers, and ambulation. Record review of the Care Plan ( no date) for Resident #2 revealed the resident was at risk for wandering. The Care Plan revealed Assist and provide resource for safe placement for resident, anticipate residents needs . Record review of the Progress Note dated 01/10/19 revealed Resident #2 went into another resident's room and a fight occurred. Resident #2 was redirected to his room. The progress note was signed by Licensed Vocational Nurse (LVN) A. Record review of the progress note dated 01/11/19 at 10:49 p.m. revealed Resident #2 was sent to a behavioral hospital.The resident was not admited back to the facility as of 2/6/19. Record review of the Incident Report dated 01/10/19 (revised 02/06/19) revealed The call light was on and I answered the call light. Another resident was in this resident's room and laid on bed A. As a result, this resident became upset with the resident and was trying to communicate that he wanted the other resident to leave. I removed the resident out of the room and took him back to his room. The Report revealed there were no injuries, and there were no witnesses. The Report was signed by LVN A. Record review of the Provider Investigation Report dated 01/23/19 revealed the occurrence happened at 5:30 p.m. on 01/10/19. The Investigation Summary revealed Resident #1 and Resident #2 were assessed immediately by LVN A and Registered Nurse (RN) B. Resident #1 sustained a bruise on the left eye. The report also documente that a nurse noted the bruise on Resident #1's face on 01/11/19 in the morning. At that time, the MD and family were infrmed, X rays ordered and Resident #2 was sent to the hospital. Interview on 02/06/19 at 1:53 p.m. with RN B revealed an hour had passed between the occurrence and when she saw Resident #1. The facility did not document Resident #1's history of physical aggression. The Investigation revealed there were no witnesses to the occurrence. Interview on 01/23/19 at 3:00 p.m. with RA C revealed she said she was working that evening but was off of the unit when the altercation occurred. She said when she returned to the unit, she saw Resident #1, and he had a bloody nose. She said only LVN A and CNA D were the other staff on the unit at that time. She said the only time she observed Resident #2 become aggressive was when he was hit by another resident. She said Resident #1 had exhibited aggressive behaviors. Interview on 01/23/19 at 3:10 p.m. with CNA D revealed he said he was working that evening, but he was in a room assisting a resident when the altercation occurred. He said when he came out of the room, LVN A was telling Resident #2 to go to his room. CNA D said Resident #1 had bleeding on his nose. He said Resident #2 was pretty new and would walk around a lot and would go into other resident rooms. He said Resident #2 had a lot of energy but he had not seen him hit anyone. CNA D said he had seen Resident #1 be aggressive, but not hit any other residents. He said Resident #1 did not like other residents going into his room. Interview on 01/23/19 at 3:20 p.m. with LVN A revealed he was asked if he had observed Resident #2 enter Resident #1's room. He replied, Yes. He went into every room. He said he did not redirect Resident #2 at that time. LVN A said he was passing out medications when he heard yelling. He said he heard Resident #1 yell Get out of my room. LVN A said there was banging on the door. He said he went in and told Resident #2 to leave. He said he did not see a bloody nose or injuries, but he saw a bruise the next day. Interview on 2/06/19 at 1:45 p.m. with the Administrator revealed that when he was informed of the inconsistency between LVN A's verbal statement and the facility investigation report, the Administrator said he had also received different accounts of the incident from LVN A. He said he was unaware that LVN A had observed Resident #2 enter Resident #1's room.

Based on interview and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of six residents (CR#1) reviewed for quality of care. The facility failed to ensure CR#1 with significant change in condition was timely transferred to the hospital for proper evaluation and treatment. CR#1 was transferred 4 hours later following change in condition to the hospital where he was diagnosed with [REDACTED]. CR#1 passed away at the local hospital. This failure affected one closed record and could affect 54 residents in the facility placing them at risk of health decline and diminished quality of life. Findings include: Record review of CR#1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of CR#1's admission MDS [DATE], revealed the resident had clear speech, he was understood by others and usually understood others. His Brief Interview for Mental Status (BIMS), score was 3 indicating severe cognitive impairment for daily living decision making. He had no behavioral symptoms or mood problems. He needed extensive assistance of two staff for bed mobility, transfer, dressing, toilet use and personal hygiene. He needed extensive assistance of one staff for locomotion and limited assistance of one staff for eating. The resident was non-ambulatory and used a wheelchair for locomotion. CR#1 was always incontinent of bowel and bladder, received scheduled and as needed pain medication. The resident received physical and occupational therapy. Further review of CR#1's admission MDS dated [DATE], revealed discharge plan was in active for the resident to return to the community and had no prognosis, condition or chronic disease that may result in a life expectancy of less than 6 months. Record review of CR#1's care plan not dated revealed the resident was a full code. The care plan goal was to respond with treatment to resident's preferences through the next review period. The care plan interventions included, begin CPR, call 911 (EMS) as needed. Record review of CR#1's Nurses Notes dated [DATE] at 9:37 a.m., revealed CR#1 was alert, had dry mouth, dry tongue, dry lips and was yelling and stated water, water , ooh God I need to go, give me DNR, assessment was done, lower abdomen tender to touch with muscle guarding, unable to get BP (blood pressure) , resident constantly pulling off the BP machine, respirations 22, temperature 98.1 degrees (F) Fahrenheit, (P) pulse 88, O2 sats (Oxygen saturation), 97% on room air. The physician's office was contacted. Received orders for (STAT) immediate laboratory study for (UA) urinalysis with culture and sensitivity and draw blood for CBC (complete blood count) and BMP (blood metabolic panel). The note further revealed the writer (LVN#1) was told by the on-call provider the resident's physician would be in the facility on that day. Note was written by LVN#1. Record review of CR#1's Nurses Notes dated [DATE] at 10:25 a.m., revealed STAT, CBC, BMP orders were noted, and the lab (laboratory agency) informed of the orders. CR#1's Nurses Notes revealed the resident's RP was with the resident at that time, a Foley catheter was inserted into CR#1's bladder and it drained dark colored blood into the catheter tubing and catheter bag and the physician on call service was called. The writer was again informed the physician would be in the facility that morning to see the resident. Note was written by LVN#1. Record review of CR#1's Nurses Notes dated [DATE] at 10:55 a.m., revealed crackles on auscultation. Note was written by LVN#1. Record review of CR#1's Nurses Notes dated [DATE] at 10:58 a.m., revealed DON updated on resident and she was in room to see resident. Note was written by LVN#1. Record review of CR#1's Nurses Notes dated [DATE] at 11:08 a.m. revealed 100 ml (milliliters) blood noted in Foley bag, on call physician services called, the on-call Physician/Nurse Practitioner (NP) will call back, writer waiting for orders from the on-call Physician /NP. Note was written by LVN#1. Record review of CR#1's Nurses Notes dated [DATE] at 11:09 a.m., revealed the resident had congestion and had low BP of ,[DATE]. Further review of nurses' notes revealed no documentation the physician was notified of the low blood pressure and no documentation indicated STAT blood work or UA had been done and communicated the physician. Note was written by LVN#1. Record review of CR#1's Nurses Notes dated [DATE] at 11:30 a.m., revealed Clarification: noted 100 ml in Foley bag of urine dark red in appearance. Note was written by LVN#1. Record review of CR#1's Nurses Notes [DATE] at 11:44 a.m. Resident assessed and noted to have difficulty breathing, noted congested lung sounds and wet cough non-productive, resident lethargic in and out of alertness, able to verbally respond but confused, oriented to name only. Skin is cool and clammy. Foley draining, bag noted to have moderate amount of dark blood in urine. VS (vital signs) P (pulse) 160, BP ,[DATE] R (respirations) 22 even and labored O2 (oxygen) sats (saturation) 78%. O2 was placed per non-re-breather (device used to deliver high levels of oxygen). Head of bed elevated. The Physician was notified via telephone and ordered the resident to be transferred to the Hospital. At 11:55 a.m., 911 (Emergency Medical Services) EMS was called. 12:00 p.m., EMS arrived. Note was written by DON. Record review of CR#1's Nurses Notes dated [DATE] at 12:12 p.m., revealed note written by LVN #1 911 (EMS) was called and arrived at the facility within 4 minutes. P/R (patient representative) was present. Resident transported to ER (emergency room ) for evaluation via stretcher, VS P 160, BP ,[DATE], R 22, T (temperature) 98.2 degrees Fahrenheit, O2 sats 88% on oxygen 2/L (liters) per minute via nasal cannular (non- re-breather mask in place). Family member present upon resident leaving the facility. Note was written by LVN#1. Record review of CR#1's Nurses Notes dated [DATE] at 12:55 p.m., revealed note written by MDS Coordinator While paramedics on scene, resident family member was present and speaking with another family member via telephone. She asked that I speak to this family member and provide update regarding resident's condition and reason for 911 call. This family member was updated due to the resident's current condition, the resident would be transported to the nearest emergency room . The notes further revealed If anything happens to CR#1 I will be coming after all of you with everything I've got. The notes documented resident's family member was very upset, tearful, anxious. I advised family member that I did not feel comfortable allowing resident's family member to drive to the hospital due to her level of distress and that she would either be riding in the ambulance or a staff member would transport her. Resident's family member arrived at facility prior to ambulance departure, this writer met family member at ambulance and offered support. Interview on [DATE] at 12:45 p.m., LVN #1 stated on [DATE], she first saw the resident about 8:00 a.m., the resident had a breakfast tray, but he had just drank the milk. LVN#1 stated she was passing medications at the time and CR#1 asked for water. LVN#1 stated the resident's mouth was dry and he kept on saying give me water, give me water and he was rubbing his stomach. LVN#1 assessed the resident with abdominal pain, she notified the on-call Physician/NP (Nurse Practitioner) and labs for a UA and blood work were ordered stat (to be drawn immediately). LVN#1 stated the on-call provider told her the physician was coming to the facility later that day to assess the resident. LVN#1 stated the labs were not drawn as there was 1 to 4-hour window for STAT labs to be drawn and stated, before labs were drawn he was discharged to the hospital. LVN#1 stated he kept on calling and complaining of shortness of breath and complained of stomach pain and his mouth was dry. I called the on-call physician and notified him of the resident's complaints. LVN#1 stated the resident's family member arrived at about 10:00 a.m., by 11:00 a.m., the residents developed crackles in his lungs, I put a Foley Catheter in place and it drained a mixture of urine with red blood in it. LVN#1 stated the resident's medical condition was getting worse. LVN#1 stated she notified the on-call provider who told LVN#1 the physician would be in the facility later that day. LVN#1 said she notified the DON who was in a meeting about 10:58am, the DON assessed the resident at 11:44 a.m., and sent the resident to the hospital by ambulance. LVN#1 stated the resident continued to get worse from the time she saw him at 8:00 a.m., she did not send the resident to the hospital earlier as the on-call provider said the physician was coming to the facility. LVN#1 confirmed no labs were drawn and the physician had not come to the facility by 12:00 p.m., when the resident was sent out via ambulance for evaluation and treatment. Interview on [DATE] at 3:30 p.m., the DON stated, when LVN#1 noticed CR#1 had a change in condition, she notified the on-call service covering for the physician right away and gave the assessment to the provider. The DON stated the on-call physician/NP gave LVN #1 orders and told the LVN CR#1's physician will be in the facility that day. The DON stated, other than straight catheter (for urine specimen), a UA, CBC and BMP, the on-call provide gave no other orders. The DON stated when a straight catheter was applied, CR#1's urine was not clear, blood was noted in the urine, so the Foley catheter was left in place for monitoring. The DON stated LVN #1 notified the on-call provider of blood in the urine and leaving the Foley catheter in place. The DON stated the resident's family member who was one of the Medical Power of Attorney (MPOA) was at the bedside when all this was going on. The DON stated another family member was also listed as MPOA. The DON stated, the biggest thing was that LVN #1 was communicating with the on-call provider. The DON stated, I don't know what the nurse was thinking, if she had notified me soon I would have told her to go ahead and send the resident out (to ER). The DON stated at about 11:45 a.m., she went over to check on the resident. The DON said she assessed the resident in distress and called EMS right away. The DON stated, when I assessed the resident I recognized the critical change in condition and made a decision to get him to a higher level of care right away. The DON stated LVN #1 should have notified the DON of the resident's critical change in condition right away. The DON stated, LVN#1 should have come get me sooner. The DON stated the LVN #1 had not been in serviced about critical change in condition following that incident. Record Review of CR#1's emergency room (ER) Report dated [DATE] at 12:35 p.m., revealed the following: CR#1 arrived at the ER via ambulance, for complaint of dyspnea and a history of [MEDICAL CONDITIONS]. His symptoms started today he was sent via EMS from the facility for complaints of difficulty breathing and chest pain and is still present (persistent present). Nursing notes from the facility reviewed with agreement regarding the chief complaint. Vital Signs have been reviewed- Appearance: Lethargic. Patient in moderate distress, dry mucous membranes present, moderate respiratory distress with accessory muscle use, tachypnea and decreased mental status, decreased air movement, wheezing present, rales present, lower extremity [MEDICAL CONDITION], altered mental status, he has weakness and sensory deficient present. Disposition: admitted to Intensive Care Unit (ICU) on [DATE] at 1:17 p.m. condition: serious and critical. clinical impression: Acute [MEDICAL CONDITIONS] with altered mental status and acute urinary tract infection. Patient (CR#1), intubated. Record review of the facility policy on Policy titled Change in a Resident's Condition or Status dated ,[DATE] revealed a significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting). Impacts more than one area of the resident's status. Except in medical emergencies, notification (physician and MPOA) will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. Record review of the facility policy on Policy titled Transfer or Discharge, Emergency dated ,[DATE] revealed emergency transfer or discharge may be necessary to protect the health and/or well-being of the resident(s). Residents will not be transferred unless, the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. Review of facility CMS 672 dated [DATE] revealed 54 residents.

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (Resident #35) reviewed for pain management. Resident #35, who had an unstageable pressure ulcer to her sacral area, was not provided effective pain management. The resident verbalized being in pain rated as a 10 on a scale of 1 to 10, with 10 being the worst pain, during wound care. This failure affected one resident and placed 17 residents on pain management and 3 with pressure ulcers receiving wound care, at risk for pain which could cause nausea, loss of appetite, suffering, depression and a decline in their medical, psychological and social condition. Findings include: Resident #35 Record Review of Resident #35's face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #35's admission MDS dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. Further review of this MDS revealed the resident was on a pain medication regimen and was ssessed for pain presence which indicated occasional pain with intensity of 5 on a scale of 10. Further review of this MDS revealed the resident was at risk for pressure ulcers, and was admitted with two unstageable-deep tissue injuries with Eschar. Record review of Resident #35's care plan, not dated, revealed the resident had acute pain related to a sacral wound and [MEDICAL CONDITION]. The goal was for the resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included: the resident's pain is alleviated/relieved by pain medications and repositioning. Monitor/record pain characteristic every shift and as need: quality (e.g. Sharp, burning); severity (1 to 10 scale); anatomical location; Onset; duration (e.g. continuous, intermittent); Aggravating factors; relieving factors. Monitor and document side effects of pain medication, monitor / record / report to nurse any signs of non-verbal pain. Record review of Resident #35's MAR indicated [REDACTED] [MEDICATION NAME] HCL 50 mg tablet, given by mouth one hour before wound care. Ordered 3/11/17 and ordered time was 9am. Apply Biofreeze cream topically to left hip and thigh three times a day for pain on left hip and thigh. Monitor pain and document quantity every shift. Order date was 2/4/17. Recorded pain intensity scores included: Pain intensity of 2 on 4/1/17 for evening shift and no pain intensity recorded on night shift. Pain intensity of 3 on 4/3/17 and 6 on 4/4/17 for day shift with no pain intensity recorded on night shift. [MEDICATION NAME] HCL gel 2%, apply to sacrum topically every day shift for unstageable, ordered dated 2/8/17. Pain levels recorded were 3 on 4/1/17, 2 on 4/2/17, 0 on 4/3/17, 1 on 4/4/17 and 10 on 4/5/17. Santyl Ointment 250 unit /GM, apply to sacrum topically every day for unstagable pressure ulcer. Cleanse sacrum with Daskin solution, pat dry, apply santyl, apply calcium alginate, and cover with foam dressing. Ordered 3/27/17. Observation on 4/5/17 at 9:20 a.m. during incontinent care, revealed Resident #35's wound had a foul odor and was covered by dark slough. Resident #35 verbalized pain to the sacral area and cringed whenever the area was wiped. Observation and interview on 4/5/17 at 9:55am, Resident #35 verbalized her pain score was 10 on a scale of 1 to 10, with 10 being the worst pain. Resident #35 said . it hurts all the time now. I wish the pain would go away. Observation on 4/5/17 at 10:03 a.m., the Wound Care Nurse applied [MEDICATION NAME] gel to Resident #35's unstageable sacral wound. Observation and interview on 4/5/17 at 10:44 am, the Wound Care Nurse completed wound care on Resident #35's unstageable sacral wound. The wound had a foul odor and was very sensitive. The Resident clinched when the area was wiped. The Resident asked the DON to stay in the room during the wound care to make the pain better. Interview on 4/6/17 at 11:00 a.m., the Wound Care Nurse said Resident #35's wound was cultured last week and the result indicated infection. She said she tried to reach the resident's physician on Friday (3/31/2017) prior to the end of her shift but was not successful. She said she left a message for a call back but did not received a call back. She said [MEDICATION NAME] gel was applied to the wound 30 minutes before wound care. She also administered [MEDICATION NAME] 50 mg an hour ago to the resident to help control her pain. She expressed the resident's pain did not seem to be controlled. She said the areas appeared to be more sensitive. Interview on 4/6/17 at 12:08 p.m., the DON agreed Resident #35 was in pain. When the resident rated her pain 10 on a scale of 1 to 10, the DON said it meant the resident's interventions were not working. The DON said he was not aware the resident's wound was infected. He agreed the resident could have more pain and sensitivity due to infection to the wound. The DON agreed the pain assessment should reflect the intervention like pain medications administered by staff. Record review of facility protocol revised June 2013 revealed the physician and staff will identify individuals who have pain and who are at risk of having pain. The nursing staff will assess each individual for pain whenever there is significant change in condition and when there is onset of new pain or worsening of existing pain. Staff and physician will continue to evaluate how pain is affecting mood, activities of daily living, sleep and the resident's quality of life. The staff will discuss significant changes in level of comfort with the attending physician who will consider adjusting interventions accordingly. CMS form 672 dated 4/4/17 revealed 17 residents on pain management and 4 residents with pressure ulcers.

Based on observation, interview and record review the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical health for one of two residents (Resident #35) reviewed for pressure ulcers. Resident #35, developed an infection to her unstageable pressure ulcer that was cultured as Staphylococcus Aureus on 3/30/2017 and her physician was not notified of these lab results until 6 days later. This failure affected one resident and placed three other residents with pressure sores at risk of infections, neglect, and decline in health status. Findings include: Resident #35 Record Review of Resident #35's face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #35's admission MDS dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. Further review of this MDS revealed the resident was at risk for pressure ulcers, and was admitted with two unstageable-deep tissue injuries with Eschar. Record review of Resident #35's care plan, not dated, revealed the resident had acute pain related to a sacral wound and [MEDICAL CONDITION]. The goal was for the resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included: the resident's pain is alleviated/ relieved by pain medications and repositioning. Monitor /record pain characteristic every shift and as need: quality (e.g. Sharp, burning); severity (1 to 10 scale); anatomical location; Onset; duration (e.g. continuous, intermittent); aggravating factors; relieving factors. Monitor and document side effects of pain medication, monitor/record /report to nurse any signs of non-verbal pain. Further review of this care plan revealed no care plan addressing pressure ulcer treatments. Record review of Resident #35's physician's order dated 3/27/17 revealed an order for [REDACTED]. Apply calcium alginate. Cover with foam dressing. Record review of Resident #35's physician's order dated 3/28/17 revealed on order which read wound culture of the sacral wound one time only for unstageable ulcer until 3/29/17. Record review of Resident #35's sacral wound culture result dated 3/30/17 revealed Staphylococcus Aureus of moderate growth. This result had a written note on it which read MD notified 3/31/17. Record review of Resident #35's clinical records revealed no intervention or change in treatment following the above culture result from 03/30/17 until 4/05/17. Record review of Resident #35's physician's orders dated April 2017 revealed an order which read Refer to (local) wound care center for sacral wound debridement DX: unstageable sacral wound. Record review of Resident #35's TAR for April 2017 revealed the following orders: Santyl ointment 250 unit/gm ([MEDICATION NAME]) Apply to sacrum topically every day shift for unstageable pressure ulcer cleanse sacrum with DWC/NS. Pat dry. Apply santyl. Apply calcium alginate. Cover with foam dressing. Start date 2/4/17. DC date 3/27/17. Santyl Oiontment 250 unit/gm ([MEDICATION NAME]) Apply to sacrum topically every day shift for unstageable pressure ulcer cleanse sacrum with Dakin s. Pat dry. Apply Santyl. Apply calcium alginate. Cover with foam dressing. Start date 3/27/17. Record review of Resident #35's wound consult report dated 4/3/17 revealed wound #1 to sacrum, pain score of 2 on assessment, moderate serous and fragile peri wound tissue. No odor, 85% slough and 15% granulation tissue. Assessment and plan revealed; cleanse with saline, protect Peri-wound, apply to wound bed; [MEDICATION NAME] 250 mg crushed, [MEDICATION NAME], santyl, Alginate, cover with polymem or dry dressing daily. Plan discussed with staff. Record review of Resident #35's TAR dated April 2017 revealed the wound consult report was not addressed with the Resident's physician and not documented on the TAR as being implemented by staff. Record review of Resident #35's physician's order dated 4/4/17 revealed [MEDICATION NAME] tablet 500 mg, give one tablet by mouth one time a day for wound infection -Staphylococcus Aureus for 10 days. Record review of Resident #35's MAR indicated [REDACTED]. Observation on 4/5/17 at 9:20 am, during incontinent care, Resident #35's unstageable sacral wound had a foul odor and was covered by a dark slough. Resident #35 verbalized pain to the sacral area and cringed whenever the area was wiped. Observation and interview on 4/5/17 at 9:55 am, Resident #35 verbalized her pain score was 10 on a scale of 1 to 10, with 10 being the worst pain. Resident #35 said it hurts all the time now. I wish the pain would go away. Observation on 4/5/17 at 10:03 a.m., the Wound Care Nurse applied [MEDICATION NAME] gel to the sacral wound. Observation and interview on 4/5/17 at 10:44 am, revealed slough to the wound bed, with dark coloration to the inner edges of the wound. Resident #35's peri-wound appeared macerated and tender. The Wound Care Nurse completed wound cleansing, then applied on oversized Calcium Alginate with Santyl to the wound with some of the applied Calcium Alginate with Santyl on the peri-wound area. The wound had foul odor and was very sensitive. Resident #35 clinched when the area was wiped. The Resident asked the DON to stay in the room during wound care to make the pain better. Interview on 4/6/17 at 11:00 a.m., the Wound Care Nurse said the resident's wound was cultured last week and the result indicated infection. She said she tried to reach the resident's physician on Friday (3/31/2017) prior to the end of her shift but was not successful. She said she left a message for a call back but did not received a call back. She said she shared the report with the other nurses but nobody followed up or tried to reach the doctor throughout the weekend. The Wound Care Nurse said the wound care specialist saw the resident on Monday 4/3/17 and had recommendations and asked the facility to consult with the resident's physician and discuss treatment. The Wound Care Nurse stated she tried to reach the attending physician without success. The Wound Care Nurse said the Resident's attending physician came to the facility on [DATE] and ordered [MEDICATION NAME] 500 mg daily for 10 days instead of the treatments recommended by the wound care specialist. The Wound Care Nurse further said the [MEDICATION NAME] was initiated on 4/5/17. The Wound Care Nurse said she did not document her attempts to reach Resident #35's physician and did not document that she informed other staff of the lab result on Friday when she could not reach the physician. Interview on 4/6/17 at 11.10 a.m., when the Wound Care Nurse was asked about the size of the calcium alginate and santyl applied to the wound and how it could affect the healthy surrounding skin, said she did not think of that and should have measured to ensure excess was not on the healthy skin. Interview on 4/6/17 at 12:08 p.m., the DON agreed staff failed to coordinate Resident #35's care. He agreed there was a delay in getting interventions for the resident when the wound culture results indicated infection to the sacral wound. He agreed calcium alginate and santyl applied to the healthy skin could affect the healthy surrounding skin. He further said the Wound Care Nurse had been doing wound care for about a year and received training prior to assuming her duties. Record review of the facility policy on pressure ulcer/skin breakdown - clinical protocol revised March 2014 revealed the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; the physician will help identify medical interventions related to wound management for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, managing pain related to wound or to wound treatment. Monitoring - the physician will help staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated. Facility CMS form 672 dated 4/4/17 revealed 4 residents with pressure ulcers.

Based on observation, interview and record review the facility failed to provide the necessary treatment and services to promote healing and prevent infection for one of two residents (Resident #35) reviewed for pressure ulcer. Resident #35, developed an infection to her unstageable pressure ulcer that was cultured as Staphylococcus Aureus on 3/30/2017 and she was not provided an antibiotic intervention or treatment until 6 days later. This failure affected one resident and placed three other residents with pressure sores at risk of infections, neglect, and decline in health status. Findings include: Resident #35 Record Review of Resident #35's face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #35's admission MDS dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. Further review of this MDS revealed the resident was at risk for pressure ulcers, and was admitted with two unstageable-deep tissue injuries with Eschar. Record review of Resident #35's care plan, not dated, revealed the resident had acute pain related to a sacral wound and [MEDICAL CONDITION]. The goal was for the resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included: the resident's pain is alleviated/ relieved by pain medications and repositioning. Monitor /record pain characteristic every shift and as need: quality (e.g. Sharp, burning); severity (1 to 10 scale); anatomical location; Onset; duration (e.g. continuous, intermittent); aggravating factors; relieving factors. Monitor and document side effects of pain medication, monitor/record /report to nurse any signs of non-verbal pain. Further review of this care plan revealed no care plan addressing pressure ulcer treatments. Record review of Resident #35's physician's order dated 3/27/17 revealed an order for [REDACTED]. Apply calcium alginate. Cover with foam dressing. Record review of Resident #35's physician's order dated 3/28/17 revealed on order which read wound culture of the sacral wound one time only for unstageable ulcer until 3/29/17. Record review of Resident #35's sacral wound culture result dated 3/30/17 revealed Staphylococcus Aureus of moderate growth. This result had a written note on it which read MD notified 3/31/17. Record review of Resident #35's clinical records revealed no intervention or change in treatment following the above culture result from 03/30/17 until 4/05/17. Record review of Resident #35's physician's orders dated April 2017 revealed an order which read Refer to (local) wound care center for sacral wound debridement DX: unstageable sacral wound. Record review of Resident #35's TAR for April 2017 revealed the following orders: Santyl ointment 250 unit/gm ([MEDICATION NAME]) Apply to sacrum topically every day shift for unstageable pressure ulcer cleanse sacrum with DWC/NS. Pat dry. Apply santyl. Apply calcium alginate. Cover with foam dressing. Start date 2/4/17. DC date 3/27/17. Santyl Oiontment 250 unit/gm ([MEDICATION NAME]) Apply to sacrum topically every day shift for unstageable pressure ulcer cleanse sacrum with Dakin s. Pat dry. Apply Santyl. Apply calcium alginate. Cover with foam dressing. Start date 3/27/17. Record review of Resident #35's wound consult report dated 4/3/17 revealed wound #1 to sacrum, pain score of 2 on assessment, moderate serous and fragile peri wound tissue. No odor, 85% slough and 15% granulation tissue. Assessment and plan revealed; cleanse with saline, protect Peri-wound, apply to wound bed; [MEDICATION NAME] 250 mg crushed, [MEDICATION NAME], santyl, Alginate, cover with polymem or dry dressing daily. Plan discussed with staff. Record review of Resident #35's TAR dated April 2017 revealed the wound consult report was not addressed with the Resident's physician and not documented on the TAR as being implemented by staff. Record review of Resident #35's physician's order dated 4/4/17 revealed [MEDICATION NAME] tablet 500 mg, give one tablet by mouth one time a day for wound infection -Staphylococcus Aureus for 10 days. Record review of Resident #35's MAR indicated [REDACTED]. Observation on 4/5/17 at 9:20 am, during incontinent care, Resident #35's unstageable sacral wound had a foul odor and was covered by a dark slough. Resident #35 verbalized pain to the sacral area and cringed whenever the area was wiped. Observation and interview on 4/5/17 at 9:55 am, Resident #35 verbalized her pain score was 10 on a scale of 1 to 10, with 10 being the worst pain. Resident #35 said it hurts all the time now. I wish the pain would go away. Observation on 4/5/17 at 10:03 a.m., the Wound Care Nurse applied [MEDICATION NAME] gel to the sacral wound. Observation and interview on 4/5/17 at 10:44 am, revealed slough to the wound bed, with dark coloration to the inner edges of the wound. Resident #35's peri-wound appeared macerated and tender. The Wound Care Nurse completed wound cleansing, then applied on oversized Calcium Alginate with Santyl to the wound with some of the applied Calcium Alginate with Santyl on the peri-wound area. The wound had foul odor and was very sensitive. Resident #35 clinched when the area was wiped. The Resident asked the DON to stay in the room during wound care to make the pain better. Interview on 4/6/17 at 11:00 a.m., the Wound Care Nurse said the resident's wound was cultured last week and the result indicated infection. She said she tried to reach the resident's physician on Friday (3/31/2017) prior to the end of her shift but was not successful. She said she left a message for a call back but did not received a call back. She said she shared the report with the other nurses but nobody followed up or tried to reach the doctor throughout the weekend. The Wound Care Nurse said the wound care specialist saw the resident on Monday 4/3/17 and had recommendations and asked the facility to consult with the resident's physician and discuss treatment. The Wound Care Nurse stated she tried to reach the attending physician without success. The Wound Care Nurse said the Resident's attending physician came to the facility on [DATE] and ordered [MEDICATION NAME] 500 mg daily for 10 days instead of the treatments recommended by the wound care specialist. The Wound Care Nurse further said the [MEDICATION NAME] was initiated on 4/5/17. The Wound Care Nurse said she did not document her attempts to reach Resident #35's physician and did not document that she informed other staff of the lab result on Friday when she could not reach the physician. Interview on 4/6/17 at 11.10 a.m., when the Wound Care Nurse was asked about the size of the calcium alginate and santyl applied to the wound and how it could affect the healthy surrounding skin, said she did not think of that and should have measured to ensure excess was not on the healthy skin. Interview on 4/6/17 at 12:08 p.m., the DON agreed staff failed to coordinate Resident #35's care. He agreed there was a delay in getting interventions for the resident when the wound culture results indicated infection to the sacral wound. He agreed calcium alginate and santyl applied to the healthy skin could affect the healthy surrounding skin. He further said the Wound Care Nurse had been doing wound care for about a year and received training prior to assuming her duties. Record review of the facility policy on pressure ulcer/skin breakdown - clinical protocol revised March 2014 revealed the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; the physician will help identify medical interventions related to wound management for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, managing pain related to wound or to wound treatment. Monitoring - the physician will help staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated. Facility CMS form 672 dated 4/4/17 revealed 4 residents with pressure ulcers.

Based on interview and record review the facility Administration failed to administer the facility in a manner that enabled it to use its resources effectively maintain the highest practicable physical well-being for 1 of 10 residents (CR#2) reviewed for their highest practicable well-being. The Administrator failed to: --to report an incident involving CR #2's narcotic overdose and did not conduct an a thorough investigation in a timely manner; --identify possible circumstances sorrounding CR #2's overdose in order to implement appropriate interventions and safety measures, especially in the facility Memory Unit; --failed to identify training needs for staff after an emergency incident involving a resident occurred; --CR #2 was found unresponsive in the facility on 07/18/15 and rushed to the emergency room . The resident tested positive for opiates and was diagnosed with [REDACTED].#2 had no physician orders for opiates. --CNA B said that on 07/17/15 LVN B ask her to hold CR #2 ' s arm while the nurse administered an unknown injection. An immediate jeopardy (IJ) was identified on 7/22/15; however the IJ started on 07/18/15. While the IJ was removed on 7/27/15, the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not an Immediate Jeopardy as the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected one discharged resident and placed 56 current residents at risk of experiencing a decline in their physical, mental or psycho-social well-being. Complaint # 5 and # 6 Findings include: In an interview with the Administrator on 07/19/15 at 1:10 pm she stated that the facility had received a call from the hospital and the attending physician on 07/18/15 to inform them of the narcotic overdose for CR #2. She said that the nurse checked the orders for the resident over the phone with the hospital and the resident has no orders for opiates. In an interview with the Administrator on 7/21/15, at 11:10 a.m., she stated that CR #2 was given [MEDICATION NAME] by EMS and this is a drug used to reverse opiate overdose. The Administrator stated she was still trying to get records from EMS from that night to figure out what happened to the resident. The Administrator stated she did not know why the resident's respiration rate was 16 or if that was normal. The Administrator stated she was not aware of CR #2's blood pressure the day of the incident. She said that CR #2 had an order for [REDACTED]. The Administrator stated that she got the statement from the last Nurse (LVN B) who gave CR#2 medication. The Administrator stated that since the incident was reported to them by the hospital on Saturday 07/18/15 no changes have been made in the facility or with the staff and she was working on receiving the EMS report to take further actions. In an interview on 7/22/15 at 12:30 p.m. with the Administrator she stated that in regards to the incident with CR#2 that she had not completed an investigation, no in-services had been done and no changes have been made in the facility or with the staff. The Administrator stated that she would be discussing the incident with the Medical Director in the Quality Assurance meeting tomorrow. In a phone interview with the Administrator on 07/22/15 at 3:04 PM she said that she did not understand why she had to report the incident with the narcotic overdose to DADS because the hospital told her they were going to report the situation to DADS. She said she believed she did not have to report it to DADS too as an incident. In an interview on 07/23/15 at 8:30 am the Administrator said that a CNA had come forward to say that LVN B had administer CR #2 a shot the day of the incident and that she was saying that LVN B had confronted her on 07/22/15 asking why she had to tell about the medication given that night. She said that LVN B was then suspended on 07/22/15 in the afternoon. Further interview at the time, the Administrator said she had not interviewed any of CNAs that worked in the unit on 07/17/15 until yesterday, 07/22/15. In a follow up interview on 7/23/15 at 10:22 a.m. LVN B said that the last day she worked with CR #2 was on 7/17/15 when she worked from 2 to 10 p.m. LVN B stated that CR #2 was not able to walk, she used a wheel chair to ambulate, she had an unsteady gait, she had a G tube and she received pleasure meals. LVN B stated that CR #2 received her medication by G tube and she did not take any pills by mouth. LVN B stated that on Friday, 7/17/15 CR #2 was not her normal self, was agitated and she became verbally abusive. CR #2 was observed sitting on side the bed, and she had pushed the G tube pole and the resident was rubbing her hands and chewing on something at around 6:15 to 6:20 p.m. LVN B stated she ran into CR #2's room and unplugged her G tube and she crushed the resident's medication, put them in a cup with water, she flushed the G tube and gave CR #2 her medication, then she flushed it again because the resident stated she felt like throwing up. LVN B stated she then gave CR #2 a basin, just in case she needed to throw up and the resident was still chewing on something. In further interview at the same time when asked why she did not call the MD to report the change in condition and why there were no documentation in the chart she said she had no time to do the notes and that she believed it was not something she needed to call the MD for because the resident did not threw up and she was showing normal behavior that night. When ask why she did not administer [MEDICATION NAME] to the resident if she was agitated, she said she looked in the med cart, but it was not available. She then said that she did not leave the facility until about midnight that night. LVN B stated the last time she talked to CR #2 was around 10:40 p.m. When asked LVN B denied giving any injections and she stated that CR #2 did not have an order for [REDACTED]. In an interview on 7/24/15 at 11:50 a.m. with the Administrator she stated that the facility had been conducting in-services this morning and they have another in-service at 2 p.m. The Administrator stated that the facility had an IJ because she should have called in the investigation because it was a form of abuse and chemical restraint. The Administrator went on to state that she understands that if she would have called in the investigation and started and investigation immediately; she would have been given 5 days to investigate. The Administrator stated that now that she is doing in-services and writing the Plan of Removal for the IJ, she understands why it was called. In an interview on 7/23/15 at 11:41 a.m. with the Regional Director he said that due to the received about possible injection administration, the facility was contacting law enforcement. He said the facility looked at all the opiate and no resident in the Memory Unit had opiates ordered. The Regional Director stated that LVN B had been suspended and CNA B also just reported that LVN B also gave an injection to Resident #9. Resident #9 does have an order for [REDACTED]. Record Review of a Daily Skilled Nurse's Note, dated 7/18/15, revealed that at 2:45 a.m., CR #2 was found by staff to be lethargic and her respiration was 16, pulse 84, o2 stats were at 97% and temperature was 98. 911 was called due to the change in condition. Taken to ER. Message left for responsible party, MD and Administrator. Record Review of local fire department EMS records dated 7/18/15, revealed that EMS arrived at the facility at 2:07 a.m. Further review of the narrative revealed that the resident was not responsive to painful stimuli and had decreased efforts in respiration. Patient had pinpoint pupils .she does not have any medication records of narcotic medications to be administered. Patient does have signs of a narcotic overdose .assessed CR #2 at 2:10 a.m. as unconscious. At 2:25 a.m. EMS gave CR #2 [MEDICATION NAME] 1 mg for narcotic overdose due to her having signs of narcotic overdose. CR #2 then became responsive and attempted to sit up. The resident was observed to look around after being unresponsive. CR #2 had one episode of emesis in the ambulance and her head was turned and suctioned. CR #2 remained alert until hospital arrival. Record Review of a local hospital records dated 7/18/15 revealed a urine drug screen collected on 7/18/15 at 2:40 a.m. for CR #2 tested positive for Opiates. Record Review of the residents' records revealed that CR #2 was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. CR #2 received all her medications via feeding tube. The facility Administrator and Compliance Nurse from Corporate were notified on 7/22/15 at 2:35 p.m. that an Immediate Jeopardy situation had been identified due to the above failures; however the IJ started on 07/18/15. A Plan of Removal (POR) was requested. A POR for the IJ was submitted on 07/22/15 at 9:54 pm. After several revisions, the plan was accepted on 7/24/15 at 3:10 p.m. The POR included in part: Plan of Removal for Immediate Jeopardy EMS records were obtained to review the events that night. Completed by Administrator on 7/22/15 · 100% audit on narcotic medications with their count sheets. Started and complete by Compliance Nurse on 7/22/15 · Room search was done of secure unit looking specifically for any medications or anything harmful to ingest- started and completed on 7/22/15 · Interviewed and obtained statements from CNAs,. · Suspended Nurse on 7/22/15 and CNA on 7/23/15 pending investigation · Called in a reportable to DADS Completed by Administrator on 7/23/15 · Police was called and a report filed Completed by Administrator on 7/23/15 · Nurse terminated for failure to comply with investigation. Completed by Administrator on 7/23/15 · Administrator will report any reportable incidents to DADS even if known to have been called in by someone else and review policy so all staff is aware of what is a reportable. Specifically: Abuse & Neglect- including over medicating or under medicating, exploitation, un usual circumstances of death, missing resident, misappropriation of funds, drug diversion, injuries of unknown sources, fires, conditions that pose a threat to resident health and safety. To be completed by Administrator on 7/24/15 · In-service all staff on Abuse and Neglect, specifically: Physical abuse-including physical force, improperly and illegally restraining, and chemical restraints-over medicating, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect. Signs and symptoms of abuse (including those present in the dementia residents) and what to do if you suspect abuse . · In-service All staff on the implementation of a sign in/out book for all visitors in the memory unit. · In-service all staff on recognizing, reporting and documenting resident ' s change of condition (including signs and symptoms of a narcotic overdose specifically for nurses). · In-service all staff on understanding and caring for the Dementia resident. Including appropriate communication and expectations for residents with dementia. Also included recognizing aggression and appropriate interventions and documentation of behaviors for dementia residents. · In-service nurses on medication administration of narcotics. · In-service nurses on definition and types and prevention of medication errors and appropriate response, specifically the process. No one is allowed to return to work until they have been in-serviced on the appropriate in-service . The plan was monitored from 07/24/15 until 07/27/15 by the surveyor with the following results: Facility protocols concerning notifying physician of changes of condition, and when to call 911 were reviewed. In-services on caring for dementia residents, appropriate care, communications, how to care for agitated/aggressive residents using appropriate interventions, when to give medications, how to document behaviors, medication error and prevention, procedures to follow if medication error is recognized, implementation of a sign in and out book for memory care unit, abuse/neglect and recognizing a reportable incident. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff and other facility employees covering three shifts were interviewed on 7/24-7/27/15, all expressed up to date knowledge on abuse/neglect, restraints, dementia care, medication administration and narcotic sheets. Observations of residents in the facility revealed fewer use of Geri chairs and residents were being attended and cared for. The Administrator was informed on 7/27/15 at 11:05 a.m. that the IJ was removed. While the IJ was removed on 7/27/15, the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not an Immediate Jeopardy because the facility was continuing to monitor and evaluate the effectiveness of their plan. Refer to F225 and 225 for additional information. According to the facility's roster, the census was 57.

Based on observation, interview and record review and interview, the facility failed to implement their written policues and procedures that prohibit neglcet and about for 1 of 10 residents (CR#2) reviewed for abuse and neglect. -The facility did not immediately report to DADS and did not immediately investigate when CR#2 was found unresponsive in the facility on 07/18/15 at 2:30 am, 911 was called and she was rushed to the emergency room . The resident tested positive for opiates and was diagnosed with [REDACTED].#2 had no physician orders for opiates. - The facility did not initiate a thorough investigation to find out the circumstances around CR #2's narcotic overdose. - CNA B reported that LVN B administer and unknown injection to CR #2 on 07/17/15. CR #2 had no physician orders for injections. An immediate jeopardy (IJ) was identified on 7/22/15; however the IJ started on 07/18/15. While the IJ was removed on 7/27/15, the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not an Immediate Jeopardy as the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected one discharged resident and placed 56 current residents at risk of experiencing a decline in their health. This failure affected one discharged resident and placed 56 current residents at risk of experiencing a decline in their physical health. Complaint # 5 and # 6 Findings include: Record Review of the facility Policy on Abuse and Neglect Prohibition Policy dated 12/26/14 revealed in part: .Suspected actions or allegations of abuse including physical, mental, verbal, sexual, involuntary seclusion, neglect or misappropriation of property by any individual including resident to resident altercations with injury will be reported to local authorities, state and federal agencies, and other appropriate agencies as required by law. The policy further states, Any employee that witnessed, suspected, alleged statements of abuse including injuries of an unknown source, or unusual deaths must report to the Administrator or Designated Representative and the Nurse on call immediately. Administrator or Designee Representative must call local law enforcement and DADS within 24 hours of being notified.the facility will act immediately upon notification when an individual has been witnessed, suspected or alleged to have cause abuse. Record Review of the residents' records revealed that CR #2 was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of CR #2's MDS assessment dated as signed complete on 6/01/15 revealed a BIMS score of 03 that indicates she had severely impaired cognitive skills. Resident ' s behaviors were marked as 0, not exhibited. CR#2's ADL needs revealed she required limited to extensive assistance for bed mobility, transfers one person to assist her with all of her needs. CR #2 was no able to walk. CR#2 was revealed to score a 4 for eating; which indicates that she needs total assistance for eating 24 hours a day. In CR#2's active [DIAGNOSES REDACTED]. Record Review of CR#2's Care Plan initiated on 7/23/14 revealed an ADL self-performance deficit/fatigue, history of aggressive behavior, limited mobility, chronic disease process, confusion and potential for pain . Further review of CR#2 care plans revealed she also had cognitive impairment function due to dementia and dysphagia causing her to have a communication problem and required tube feeding and this was revised on 3/19/15. Record review of the CR #2's physician orders for the month of July 2015 revealed that the following medications were to be administered via [DEVICE]: [MEDICATION NAME] tablet, sodium [MEDICATION NAME] tablet, [MEDICATION NAME] tablet, [MEDICATION NAME] tablet, [MEDICATION NAME] tablet, Losartan potassium tablet, Aspirin, Calcium + D3 tablet, [MEDICATION NAME] sulfate, [MEDICATION NAME] Powder, [MEDICATION NAME] capsule, quetiapine tablet, [MEDICATION NAME]. PRN medications included: [MEDICATION NAME] tablet, [MEDICATION NAME] tablet. Record Review of a Daily Skilled Nurse's Note, dated 7/18/15, revealed that at 2:45 a.m., CR #2 was found by staff to be lethargic and her respiration was 16, pulse 84, o2 stats were at 97% and temperature was 98. 911 was called due to the change in condition. Taken to ER. Message left for responsible party, MD and Administrator. Record Review of local fire department EMS records dated 7/18/15, revealed that EMS arrived at the facility at 2:07 a.m. Further review of the narrative revealed that the resident was not responsive to painful stimuli and had decreased efforts in respiration. Patient had pinpoint pupils .she does not have any medication records of narcotic medications to be administered. Patient does have signs of a narcotic overdose .assessed CR #2 at 2:10 a.m. as unconscious. At 2:25 a.m. EMS gave CR #2 [MEDICATION NAME] 1 mg for narcotic overdose due to her having signs of narcotic overdose. CR #2 then became responsive and attempted to sit up. The resident was observed to look around after being unresponsive. CR #2 had one episode of emesis in the ambulance and her head was turned and suctioned. CR #2 remained alert until hospital arrival. Record Review of a local hospital records dated 7/18/15 revealed a urine drug screen collected on 7/18/15 at 2:40 a.m. for CR #2 tested positive for Opiates. Record Review of a local hospital records date of admission 7/18/15 revealed that EMS gave CR #2 one dose of [MEDICATION NAME] and the resident responded and woke up. CR #2's drug screen was positive for opioids. The record revealed that according to the nursing home medication records, the resident was not taking any narcotic pain medications so there was a discrepancy. The local hospital called the nursing facility and the medication list was checked and CR #2 was not on any narcotic pain medications that would explain her urine drug screen positive for opioids. Further review revealed that the local hospital would have to do an investigation around that issue. In an interview with the Administrator on 07/19/15 at 1:10 pm she stated that the facility had received a call from the hospital and the attending physician on 07/18/15 to inform them of the narcotic overdose for CR #2. She said that the nurse checked the orders for the resident over the phone with the hospital and the resident has no orders for opiates. In an interview with the Administrator on 7/21/15, at 11:10 a.m., she stated that CR #2 was given [MEDICATION NAME] by EMS and this is a drug used to reverse opiate overdose. The Administrator stated she was still trying to get records from EMS from that night to figure out what happened to the resident. The Administrator stated she did not know why the resident's respiration rate was 16 or if that was normal. The Administrator stated she was not aware of CR #2's blood pressure the day of the incident. She said that CR #2 had an order for [REDACTED]. The Administrator stated that she got the statement from the last Nurse (LVN B) who gave CR#2 medication. The Administrator stated that since the incident was reported to them by the hospital on Saturday 07/18/15 no changes have been made in the facility or with the staff and she was working on receiving the EMS report to take further actions. In an interview with LVN A on 7/21/15 at 2:00 p.m., she stated that the incident regarding CR #2 happened on the weekend and she did not work on the weekend, but CR #2 was not prescribed opiates. LVN A stated that there was no one on CR #2's hall that was prescribed opiates that she was aware of. In a further interview with LVN A on 07/21/15 at 3:20 p.m. she stated that according to CR #2's Medication Administration Record [REDACTED]. LVN A conducted a search for CR #2's prescription for [MEDICATION NAME] and she could not locate the medication in the facility. In an interview with Regional Nurse B on 7/21/15 at 3:44 p.m. she stated she contacted the local pharmacy and found the last time [MEDICATION NAME] was prescribed was on 8/9/14. Regional Nurse B stated that CR #2 still has an order for [REDACTED]. In an interview with LVN B on 7/21/15 at 3:51 p.m. she stated she worked on Friday 07/17/15 on the 2 to 10 pm shift. She said that CR #2 was observed to be sitting on the edge of the bed agitated. She said that CR #2 was chewing something, but CR #2 would not let her see what it was. LVN B stated she changed CR #2's G tube and CR #2 stated she felt like throwing up. LVN B stated she gave the resident a basin and put her in bed. LVN B stated she left for the day that night and the medications that she remembers giving CR #2 was for blood pressure, [MEDICATION NAME] and [MEDICATION NAME]. LVN B stated she did not know why CR #2 had opiates in her system. In an interview on 7/22/15 at 10 a.m. at a local hospital with RN B, she stated CR #2 was doing a lot better today, but she was agitated this morning. She said that all of CR #2 ' s medication where administer via G tube. She said CR #2 ' s was in the hospital because she overdosed on opiates. In an interview on 7/22/15 at 10:18 a.m. with CR #2 at a local hospital she stated she could not remember anything about what happened on the day of the incident. CR #2 stated she did not remember chewing on anything. CR #2 appeared to be calm with her hands lying on her chest. CR #2 was able to speak and make herself understood but was confused. In an interview on 7/22/15 at 12:30 p.m. with the Administrator she stated that in regards to the incident with CR#2 that she had not completed an investigation, no in-services had been done and no changes have been made in the facility or with the staff. The Administrator stated that she would be discussing the incident with the Medical Director in the Quality Assurance meeting tomorrow. In a follow up interview on 7/22/15 at 12:59 p.m. with LVN B she said that she did ask CR #2 what she was chewing, but CR #2 got aggressive and CR #2 did not answer her when she asked. LVN B stated that it did concern her that CR #2 was chewing on something, but she knew that the resident did receive pleasure meals sometimes. LVN B said that CR #2 stated she felt like throwing up and she was really agitated. LVN B stated she flushed the G tube but she did not give her any medication to keep her from being agitated. LVN B said she did not call the doctor that night to tell her about CR #2 being agitated or nauseous, because the resident did not vomited. In an interview on 7/22/15 at 1:07 p.m. with LVN C he said that he worked the 10 pm to 6 am shift on 07/17-07/18/15. He stated that he did attend to CR #2 on the day of the incident (07/17/15 to 07/18/15) and he said she was asleep. He said that CR #2 was alert and breathing calm, but she did not look as normal so he checked her vitals and then she became very lethargic. LVN C stated he called 911. LVN C stated that EMS did not ask him any questions or tell him anything about narcotics. LVN C stated he gave EMS CR #2 ' s MAR, history and Physical and labs and they just took her. LVN C said that he did not administer medications to CR #2 that night. In an interview on 7/22/15 at 2:01 p.m. with CNA B she worked with CR #2 on 07/17/15 from 2-10 p.m. She said that CR #2 was in an out of the bed that day and appeared agitated, trying to get out of the bed. CNA B stated that LVN B gave CR #2 her medication and she changed her adult briefs every 2 hours. CNA B stated that around 6-6:30 pm LVN B called her into CR #2 ' room and asked her to hold CR #2 ' s hand so she could get a shot in her arm. CNA B stated that after CR #2 received her medication, she noticed that the medication really calmed CR #2 down. She said that after that CR #2 she completely calmed down stayed in bed until she left at 10 pm. She said that she does not recall the resident being nauseous that night. CNA B said that the only medication she saw LVN B give was the shot. In an interview on 7/22/15 at 2:09 p.m. with CNA C she stated that she worked on 7/17/15 from 2-10 p.m. She said that and after supper that night CR #2 was really agitated and hyper . CR #2 was put back in bed and she began to state that she needed to get on a bus to Houston. CNA C explained that CR #2 was not her resident that night, but due to CR #2 being a two person assist, she helped CNA B to change her. CNA C stated that she did notice that CR #2 calmed down and was not fussing anymore. CNA C stated she did not observe any medication being given to the resident. The facility Administrator and Compliance Nurse from Corporate were notified on 7/22/15 at 2:35 p.m. that an Immediate Jeopardy situation had been identified due to the above failures; however the IJ started on 07/18/15. A Plan of Removal (POR) was requested. In a phone interview with the Administrator on 07/22/15 at 3:04 PM she said that she did not understand why she had to report the incident with the narcotic overdose to DADS because the hospital told her they were going to report the situation to DADS. She said she believed she did not have to report it to DADS too as an incident. In an interview on 07/23/15 at 8:30 am the Administrator said that CNA B had come forward on 07/22/15 to say that LVN B had administer CR #2 a shot the day of the incident and that she was saying that LVN B had confronted her on 07/22/15 asking why she had to tell about the medication given that night. She said that LVN B was then suspended on 07/22/15 in the afternoon. Further interview at the time, the Administrator said she had not interviewed any of CNAs that worked in the unit on 07/17/15 until yesterday, 07/22/15. In a follow up interview on 7/23/15 at 9:20 a.m. with CNA B she stated that she was newly hired at the facility and she worked on Friday 07/17/15 with CR #2. CR #2 was stated to be agitated at around 3:30 to 4 p.m. She said that she changed CR #2's adult brief with CNA C and CR #2 wanted to sit on side the bed and was agitated. LVN B asked CNA B to come after dinner around 6 to 6:30 p.m. to give CR #2 her medication. LVN B had CNA B to hold CR #2's hand and LVN B gave CR #2 a shot. CR #2 was really calm after the medication and CNA B left the facility between 10:05 p.m. or 10:10 p.m. CNA B said that yesterday after she spoke with the surveyor, she told a coworker what she reported about that night and LVN B. She said that later on 07/22/15 LVN B came to her and asked her why she reported that about CR #2's medication. In a follow up interview on 7/23/15 at 10:22 a.m. LVN B said that the last day she worked with CR #2 was on 7/17/15 when she worked from 2 to 10 p.m. LVN B stated that CR #2 was not able to walk, she used a wheel chair to ambulate, she had an unsteady gait, she had a G tube and she received pleasure meals. LVN B stated that CR #2 received her medication by G tube and she did not take any pills by mouth. LVN B stated that on Friday, 7/17/15 CR #2 was not her normal self, was agitated and she became verbally abusive. CR #2 was observed sitting on side the bed, and she had pushed the G tube pole and the resident was rubbing her hands and chewing on something at around 6:15 to 6:20 p.m. LVN B stated she ran into CR #2's room and unplugged her G tube and she crushed the resident's medication, put them in a cup with water, she flushed the G tube and gave CR #2 her medication, then she flushed it again because the resident stated she felt like throwing up. LVN B stated she then gave CR #2 a basin, just in case she needed to throw up and the resident was still chewing on something. In further interview at the same time when asked why she did not call the MD to report the change in condition and why there were no documentation in the chart she said she had no time to do the notes and that she believed it was not something she needed to call the MD for because the resident did not threw up and she was showing normal behavior that night. When ask why she did not administer [MEDICATION NAME] to the resident if she was agitated, she said she looked in the med cart, but it was not available. She then said that she did not leave the facility until about midnight that night. LVN B stated the last time she talked to CR #2 was around 10:40 p.m. When asked LVN B denied giving any injections and she stated that CR #2 did not have an order for [REDACTED]. In an interview on 7/23/15 at 11:41 a.m. with the Regional Director he said that because now they had receive information about a possible injection administration, the facility was contacting law enforcement and reporting the incident to DADS. He said the facility looked at all the opiate and no resident in the Memory Unit had opiates ordered. The Regional Director stated that LVN B had been suspended and CNA B also just reported that LVN B also gave an injection to Resident #9. Resident #9 does have an order for [REDACTED]. Record review of Resident #9 ' s clinical file revealed that he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9 ' s physician orders revealed an order for [REDACTED].#9 ' s MAR indicated [REDACTED]. In an interview on 7/24/15 at 11:50 a.m. with the Administrator she stated that the facility had been conducting in-services this morning and they have another in-service at 2 p.m. The Administrator stated that the facility had an IJ because she should have called in the investigation because it was a form of abuse and chemical restraint. The Administrator went on to state that she understands that if she would have called in the investigation and started and investigation immediately; she would have been given 5 days to investigate. The Administrator stated that now that she is doing in-services and writing the Plan of Removal for the IJ, she understands why it was called. A POR for the IJ was submitted on 07/22/15 at 9:54 pm. After several revisions, the plan was accepted on 7/24/15 at 3:10 p.m. The POR included in part: Plan of Removal for Immediate Jeopardy EMS records were obtained to review the events that night. Completed by Administrator on 7/22/15 · 100% audit on narcotic medications with their count sheets. Started and complete by Compliance Nurse on 7/22/15 · Room search was done of secure unit looking specifically for any medications or anything harmful to ingest- started and completed on 7/22/15 · Interviewed and obtained statements from CNAs,. · Suspended Nurse on 7/22/15 and CNA on 7/23/15 pending investigation · Called in a reportable to DADS Completed by Administrator on 7/23/15 · Police was called and a report filed Completed by Administrator on 7/23/15 · Nurse terminated for failure to comply with investigation. Completed by Administrator on 7/23/15 · Administrator will report any reportable incidents to DADS even if known to have been called in by someone else and review policy so all staff is aware of what is a reportable. Specifically: Abuse & Neglect- including over medicating or under medicating, exploitation, un usual circumstances of death, missing resident, misappropriation of funds, drug diversion, injuries of unknown sources, fires, conditions that pose a threat to resident health and safety. To be completed by Administrator on 7/24/15 · In-service all staff on Abuse and Neglect, specifically: Physical abuse-including physical force, improperly and illegally restraining, and chemical restraints-over medicating, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect. Signs and symptoms of abuse (including those present in the dementia residents) and what to do if you suspect abuse . · In-service All staff on the implementation of a sign in/out book for all visitors in the memory unit. · In-service all staff on recognizing, reporting and documenting resident ' s change of condition (including signs and symptoms of a narcotic overdose specifically for nurses). · In-service all staff on understanding and caring for the Dementia resident. Including appropriate communication and expectations for residents with dementia. Also included recognizing aggression and appropriate interventions and documentation of behaviors for dementia residents. · In-service nurses on medication administration of narcotics. · In-service nurses on definition and types and prevention of medication errors and appropriate response, specifically the process. No one is allowed to return to work until they have been in-serviced on the appropriate in-service . The plan was monitored from 07/24/15 until 07/27/15 by the surveyor with the following results: Facility protocols concerning notifying physician of changes of condition, and when to call 911 were reviewed. In-services on caring for dementia residents, appropriate care, communications, how to care for agitated/aggressive residents using appropriate interventions, when to give medications, how to document behaviors, medication error and prevention, procedures to follow if medication error is recognized, implementation of a sign in and out book for memory care unit, abuse/neglect and recognizing a reportable incident. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff and other facility employees covering three shifts were interviewed on 7/24-7/27/15, all expressed up to date knowledge on abuse/neglect, restraints, dementia care, medication administration and narcotic sheets. Observations of residents in the facility revealed fewer use of Geri chairs and residents were being attended and cared for. The Administrator was informed on 7/27/15 at 11:05 a.m. that the IJ was removed. While the IJ was removed on 7/27/15, the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not an Immediate Jeopardy because the facility was continuing to monitor and evaluate the effectiveness of their plan. According to the facility's roster, the census was 57.

Based on observation, interview and record review, the facility failed to report to the Department of Aging and Disability Services (DADS) and injury of unknown source and failed to thoroughly investigate allegations of abuse/neglect for 1 of 10 (CR#2) residents reviewed for neglect. -The facility did not immediately report to DADS and did not immediately investigate when CR#2 was found unresponsive in the facility on 07/18/15 at 2:30 am, 911 was called and she was rushed to the emergency room . The resident tested positive for opiates and was diagnosed with [REDACTED].#2 had no physician orders for opiates. - The facility did not initiate a thorough investigation to find out the circumstances around CR #2's narcotic overdose. - CNA B reported that LVN B administer and unknown injection to CR #2 on 07/17/15. CR #2 had no physician orders for injections. An immediate jeopardy (IJ) was identified on 7/22/15; however the IJ started on 07/18/15. While the IJ was removed on 7/27/15, the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not an Immediate Jeopardy as the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected one discharged resident and placed 56 current residents at risk of experiencing a decline in their health. Complaint # 5 and # 6 Findings include: Record Review of the residents' records revealed that CR #2 was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of CR #2's MDS assessment dated as signed complete on 6/01/15 revealed a BIMS score of 03 that indicates she had severely impaired cognitive skills. Resident ' s behaviors were marked as 0, not exhibited. CR#2's ADL needs revealed she required limited to extensive assistance for bed mobility, transfers one person to assist her with all of her needs. CR #2 was no able to walk. CR#2 was revealed to score a 4 for eating; which indicates that she needs total assistance for eating 24 hours a day. In CR#2's active [DIAGNOSES REDACTED]. Record Review of CR#2's Care Plan initiated on 7/23/14 revealed an ADL self-performance deficit/fatigue, history of aggressive behavior, limited mobility, chronic disease process, confusion and potential for pain . Further review of CR#2 care plans revealed she also had cognitive impairment function due to dementia and dysphagia causing her to have a communication problem and required tube feeding and this was revised on 3/19/15. Record review of the CR #2's physician orders for the month of July 2015 revealed that the following medications were to be administered via [DEVICE]: [MEDICATION NAME] tablet, sodium [MEDICATION NAME] tablet, [MEDICATION NAME] tablet, [MEDICATION NAME] tablet, [MEDICATION NAME] tablet, Losartan potassium tablet, Aspirin, Calcium + D3 tablet, [MEDICATION NAME] sulfate, [MEDICATION NAME] Powder, [MEDICATION NAME] capsule, quetiapine tablet, [MEDICATION NAME]. PRN medications included: [MEDICATION NAME] tablet, [MEDICATION NAME] tablet. Record Review of a Daily Skilled Nurse's Note, dated 7/18/15, revealed that at 2:45 a.m., CR #2 was found by staff to be lethargic and her respiration was 16, pulse 84, o2 stats were at 97% and temperature was 98. 911 was called due to the change in condition. Taken to ER. Message left for responsible party, MD and Administrator. Record Review of local fire department EMS records dated 7/18/15, revealed that EMS arrived at the facility at 2:07 a.m. Further review of the narrative revealed that the resident was not responsive to painful stimuli and had decreased efforts in respiration. Patient had pinpoint pupils .she does not have any medication records of narcotic medications to be administered. Patient does have signs of a narcotic overdose .assessed CR #2 at 2:10 a.m. as unconscious. At 2:25 a.m. EMS gave CR #2 [MEDICATION NAME] 1 mg for narcotic overdose due to her having signs of narcotic overdose. CR #2 then became responsive and attempted to sit up. The resident was observed to look around after being unresponsive. CR #2 had one episode of emesis in the ambulance and her head was turned and suctioned. CR #2 remained alert until hospital arrival. Record Review of a local hospital records dated 7/18/15 revealed a urine drug screen collected on 7/18/15 at 2:40 a.m. for CR #2 tested positive for Opiates. Record Review of a local hospital records date of admission 7/18/15 revealed that EMS gave CR #2 one dose of [MEDICATION NAME] and the resident responded and woke up. CR #2's drug screen was positive for opioids. The record revealed that according to the nursing home medication records, the resident was not taking any narcotic pain medications so there was a discrepancy. The local hospital called the nursing facility and the medication list was checked and CR #2 was not on any narcotic pain medications that would explain her urine drug screen positive for opioids. Further review revealed that the local hospital would have to do an investigation around that issue. In an interview with the Administrator on 07/19/15 at 1:10 pm she stated that the facility had received a call from the hospital and the attending physician on 07/18/15 to inform them of the narcotic overdose for CR #2. She said that the nurse checked the orders for the resident over the phone with the hospital and the resident has no orders for opiates. In an interview with the Administrator on 7/21/15, at 11:10 a.m., she stated that CR #2 was given [MEDICATION NAME] by EMS and this is a drug used to reverse opiate overdose. The Administrator stated she was still trying to get records from EMS from that night to figure out what happened to the resident. The Administrator stated she did not know why the resident's respiration rate was 16 or if that was normal. The Administrator stated she was not aware of CR #2's blood pressure the day of the incident. She said that CR #2 had an order for [REDACTED]. The Administrator stated that she got the statement from the last Nurse (LVN B) who gave CR#2 medication. The Administrator stated that since the incident was reported to them by the hospital on Saturday 07/18/15 no changes have been made in the facility or with the staff and she was working on receiving the EMS report to take further actions. In an interview with LVN A on 7/21/15 at 2:00 p.m., she stated that the incident regarding CR #2 happened on the weekend and she did not work on the weekend, but CR #2 was not prescribed opiates. LVN A stated that there was no one on CR #2's hall that was prescribed opiates that she was aware of. In a further interview with LVN A on 07/21/15 at 3:20 p.m. she stated that according to CR #2's Medication Administration Record [REDACTED]. LVN A conducted a search for CR #2's prescription for [MEDICATION NAME] and she could not locate the medication in the facility. In an interview with Regional Nurse B on 7/21/15 at 3:44 p.m. she stated she contacted the local pharmacy and found the last time [MEDICATION NAME] was prescribed was on 8/9/14. Regional Nurse B stated that CR #2 still has an order for [REDACTED]. In an interview with LVN B on 7/21/15 at 3:51 p.m. she stated she worked on Friday 07/17/15 on the 2 to 10 pm shift. She said that CR #2 was observed to be sitting on the edge of the bed agitated. She said that CR #2 was chewing something, but CR #2 would not let her see what it was. LVN B stated she changed CR #2's G tube and CR #2 stated she felt like throwing up. LVN B stated she gave the resident a basin and put her in bed. LVN B stated she left for the day that night and the medications that she remembers giving CR #2 was for blood pressure, [MEDICATION NAME] and [MEDICATION NAME]. LVN B stated she did not know why CR #2 had opiates in her system. In an interview on 7/22/15 at 10 a.m. at a local hospital with RN B, she stated CR #2 was doing a lot better today, but she was agitated this morning. She said that all of CR #2 ' s medication where administer via G tube. She said CR #2 ' s was in the hospital because she overdosed on opiates. In an interview on 7/22/15 at 10:18 a.m. with CR #2 at a local hospital she stated she could not remember anything about what happened on the day of the incident. CR #2 stated she did not remember chewing on anything. CR #2 appeared to be calm with her hands lying on her chest. CR #2 was able to speak and make herself understood but was confused. In an interview on 7/22/15 at 12:30 p.m. with the Administrator she stated that in regards to the incident with CR#2 that she had not completed an investigation, no in-services had been done and no changes have been made in the facility or with the staff. The Administrator stated that she would be discussing the incident with the Medical Director in the Quality Assurance meeting tomorrow. In a follow up interview on 7/22/15 at 12:59 p.m. with LVN B she said that she did ask CR #2 what she was chewing, but CR #2 got aggressive and CR #2 did not answer her when she asked. LVN B stated that it did concern her that CR #2 was chewing on something, but she knew that the resident did receive pleasure meals sometimes. LVN B said that CR #2 stated she felt like throwing up and she was really agitated. LVN B stated she flushed the G tube but she did not give her any medication to keep her from being agitated. LVN B said she did not call the doctor that night to tell her about CR #2 being agitated or nauseous, because the resident did not vomited. In an interview on 7/22/15 at 1:07 p.m. with LVN C he said that he worked the 10 pm to 6 am shift on 07/17-07/18/15. He stated that he did attend to CR #2 on the day of the incident (07/17/15 to 07/18/15) and he said she was asleep. He said that CR #2 was alert and breathing calm, but she did not look as normal so he checked her vitals and then she became very lethargic. LVN C stated he called 911. LVN C stated that EMS did not ask him any questions or tell him anything about narcotics. LVN C stated he gave EMS CR #2 ' s MAR, history and Physical and labs and they just took her. LVN C said that he did not administer medications to CR #2 that night. In an interview on 7/22/15 at 2:01 p.m. with CNA B she worked with CR #2 on 07/17/15 from 2-10 p.m. She said that CR #2 was in an out of the bed that day and appeared agitated, trying to get out of the bed. CNA B stated that LVN B gave CR #2 her medication and she changed her adult briefs every 2 hours. CNA B stated that around 6-6:30 pm LVN B called her into CR #2 ' room and asked her to hold CR #2 ' s hand so she could get a shot in her arm. CNA B stated that after CR #2 received her medication, she noticed that the medication really calmed CR #2 down. She said that after that CR #2 she completely calmed down stayed in bed until she left at 10 pm. She said that she does not recall the resident being nauseous that night. CNA B said that the only medication she saw LVN B give was the shot. In an interview on 7/22/15 at 2:09 p.m. with CNA C she stated that she worked on 7/17/15 from 2-10 p.m. She said that and after supper that night CR #2 was really agitated and hyper . CR #2 was put back in bed and she began to state that she needed to get on a bus to Houston. CNA C explained that CR #2 was not her resident that night, but due to CR #2 being a two person assist, she helped CNA B to change her. CNA C stated that she did notice that CR #2 calmed down and was not fussing anymore. CNA C stated she did not observe any medication being given to the resident. The facility Administrator and Compliance Nurse from Corporate were notified on 7/22/15 at 2:35 p.m. that an Immediate Jeopardy situation had been identified due to the above failures; however the IJ started on 07/18/15. A Plan of Removal (POR) was requested. In a phone interview with the Administrator on 07/22/15 at 3:04 PM she said that she did not understand why she had to report the incident with the narcotic overdose to DADS because the hospital told her they were going to report the situation to DADS. She said she believed she did not have to report it to DADS too as an incident. In an interview on 07/23/15 at 8:30 am the Administrator said that CNA B had come forward on 07/22/15 to say that LVN B had administer CR #2 a shot the day of the incident and that she was saying that LVN B had confronted her on 07/22/15 asking why she had to tell about the medication given that night. She said that LVN B was then suspended on 07/22/15 in the afternoon. Further interview at the time, the Administrator said she had not interviewed any of CNAs that worked in the unit on 07/17/15 until yesterday, 07/22/15. In a follow up interview on 7/23/15 at 9:20 a.m. with CNA B she stated that she was newly hired at the facility and she worked on Friday 07/17/15 with CR #2. CR #2 was stated to be agitated at around 3:30 to 4 p.m. She said that she changed CR #2's adult brief with CNA C and CR #2 wanted to sit on side the bed and was agitated. LVN B asked CNA B to come after dinner around 6 to 6:30 p.m. to give CR #2 her medication. LVN B had CNA B to hold CR #2's hand and LVN B gave CR #2 a shot. CR #2 was really calm after the medication and CNA B left the facility between 10:05 p.m. or 10:10 p.m. CNA B said that yesterday after she spoke with the surveyor, she told a coworker what she reported about that night and LVN B. She said that later on 07/22/15 LVN B came to her and asked her why she reported that about CR #2's medication. In a follow up interview on 7/23/15 at 10:22 a.m. LVN B said that the last day she worked with CR #2 was on 7/17/15 when she worked from 2 to 10 p.m. LVN B stated that CR #2 was not able to walk, she used a wheel chair to ambulate, she had an unsteady gait, she had a G tube and she received pleasure meals. LVN B stated that CR #2 received her medication by G tube and she did not take any pills by mouth. LVN B stated that on Friday, 7/17/15 CR #2 was not her normal self, was agitated and she became verbally abusive. CR #2 was observed sitting on side the bed, and she had pushed the G tube pole and the resident was rubbing her hands and chewing on something at around 6:15 to 6:20 p.m. LVN B stated she ran into CR #2's room and unplugged her G tube and she crushed the resident's medication, put them in a cup with water, she flushed the G tube and gave CR #2 her medication, then she flushed it again because the resident stated she felt like throwing up. LVN B stated she then gave CR #2 a basin, just in case she needed to throw up and the resident was still chewing on something. In further interview at the same time when asked why she did not call the MD to report the change in condition and why there were no documentation in the chart she said she had no time to do the notes and that she believed it was not something she needed to call the MD for because the resident did not threw up and she was showing normal behavior that night. When ask why she did not administer [MEDICATION NAME] to the resident if she was agitated, she said she looked in the med cart, but it was not available. She then said that she did not leave the facility until about midnight that night. LVN B stated the last time she talked to CR #2 was around 10:40 p.m. When asked LVN B denied giving any injections and she stated that CR #2 did not have an order for [REDACTED]. In an interview on 7/23/15 at 11:41 a.m. with the Regional Director he said that because now they had receive information about a possible injection administration, the facility was contacting law enforcement and reporting the incident to DADS. He said the facility looked at all the opiate and no resident in the Memory Unit had opiates ordered. The Regional Director stated that LVN B had been suspended and CNA B also just reported that LVN B also gave an injection to Resident #9. Resident #9 does have an order for [REDACTED]. Record review of Resident #9 ' s clinical file revealed that he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9 ' s physician orders revealed an order for [REDACTED].#9 ' s MAR indicated [REDACTED]. In an interview on 7/24/15 at 11:50 a.m. with the Administrator she stated that the facility had been conducting in-services this morning and they have another in-service at 2 p.m. The Administrator stated that the facility had an IJ because she should have called in the investigation because it was a form of abuse and chemical restraint. The Administrator went on to state that she understands that if she would have called in the investigation and started and investigation immediately; she would have been given 5 days to investigate. The Administrator stated that now that she is doing in-services and writing the Plan of Removal for the IJ, she understands why it was called. A POR for the IJ was submitted on 07/22/15 at 9:54 pm. After several revisions, the plan was accepted on 7/24/15 at 3:10 p.m. The POR included in part: Plan of Removal for Immediate Jeopardy EMS records were obtained to review the events that night. Completed by Administrator on 7/22/15 · 100% audit on narcotic medications with their count sheets. Started and complete by Compliance Nurse on 7/22/15 · Room search was done of secure unit looking specifically for any medications or anything harmful to ingest- started and completed on 7/22/15 · Interviewed and obtained statements from CNAs,. · Suspended Nurse on 7/22/15 and CNA on 7/23/15 pending investigation · Called in a reportable to DADS Completed by Administrator on 7/23/15 · Police was called and a report filed Completed by Administrator on 7/23/15 · Nurse terminated for failure to comply with investigation. Completed by Administrator on 7/23/15 · Administrator will report any reportable incidents to DADS even if known to have been called in by someone else and review policy so all staff is aware of what is a reportable. Specifically: Abuse & Neglect- including over medicating or under medicating, exploitation, un usual circumstances of death, missing resident, misappropriation of funds, drug diversion, injuries of unknown sources, fires, conditions that pose a threat to resident health and safety. To be completed by Administrator on 7/24/15 · In-service all staff on Abuse and Neglect, specifically: Physical abuse-including physical force, improperly and illegally restraining, and chemical restraints-over medicating, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect. Signs and symptoms of abuse (including those present in the dementia residents) and what to do if you suspect abuse . · In-service All staff on the implementation of a sign in/out book for all visitors in the memory unit. · In-service all staff on recognizing, reporting and documenting resident ' s change of condition (including signs and symptoms of a narcotic overdose specifically for nurses). · In-service all staff on understanding and caring for the Dementia resident. Including appropriate communication and expectations for residents with dementia. Also included recognizing aggression and appropriate interventions and documentation of behaviors for dementia residents. · In-service nurses on medication administration of narcotics. · In-service nurses on definition and types and prevention of medication errors and appropriate response, specifically the process. No one is allowed to return to work until they have been in-serviced on the appropriate in-service . The plan was monitored from 07/24/15 until 07/27/15 by the surveyor with the following results: Facility protocols concerning notifying physician of changes of condition, and when to call 911 were reviewed. In-services on caring for dementia residents, appropriate care, communications, how to care for agitated/aggressive residents using appropriate interventions, when to give medications, how to document behaviors, medication error and prevention, procedures to follow if medication error is recognized, implementation of a sign in and out book for memory care unit, abuse/neglect and recognizing a reportable incident. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff and other facility employees covering three shifts were interviewed on 7/24-7/27/15, all expressed up to date knowledge on abuse/neglect, restraints, dementia care, medication administration and narcotic sheets. Observations of residents in the facility revealed fewer use of Geri chairs and residents were being attended and cared for. The Administrator was informed on 7/27/15 at 11:05 a.m. that the IJ was removed. While the IJ was removed on 7/27/15, the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not an Immediate Jeopardy because the facility was continuing to monitor and evaluate the effectiveness of their plan. Record Review of the facility Policy on Abuse and Neglect Prohibition Policy dated 12/26/14 revealed in part: .Suspected actions or allegations of abuse including physical, mental, verbal, sexual, involuntary seclusion, neglect or misappropriation of property by any individual including resident to resident altercations with injury will be reported to local authorities, state and federal agencies, and other appropriate agencies as required by law. The policy further states, Any employee that witnessed, suspected, alleged statements of abuse including injuries of an unknown source, or unusual deaths must report to the Administrator or Designated Representative and the Nurse on call immediately. Administrator or Designee Representative must call local law enforcement and DADS within 24 hours of being notified.the facility will act immediately upon notification when an individual has been witnessed, suspected or alleged to have cause abuse. According to the facility's roster, the census was 57.

Based on observation, interview and record review and interview, the facility failed to implement their written policues and procedures that prohibit neglcet and about for 1 of 10 residents (CR#2) reviewed for abuse and neglect. -The facility did not immediately report to DADS and did not immediately investigate when CR#2 was found unresponsive in the facility on 07/18/15 at 2:30 am, 911 was called and she was rushed to the emergency room . The resident tested positive for opiates and was diagnosed with [REDACTED].#2 had no physician orders for opiates. - The facility did not initiate a thorough investigation to find out the circumstances around CR #2's narcotic overdose. - CNA B reported that LVN B administer and unknown injection to CR #2 on 07/17/15. CR #2 had no physician orders for injections. An immediate jeopardy (IJ) was identified on 7/22/15; however the IJ started on 07/18/15. While the IJ was removed on 7/27/15, the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not an Immediate Jeopardy as the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected one discharged resident and placed 56 current residents at risk of experiencing a decline in their health. This failure affected one discharged resident and placed 56 current residents at risk of experiencing a decline in their physical health. Complaint # 5 and # 6 Findings include: Record Review of the residents' records revealed that CR #2 was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of CR #2's MDS assessment dated as signed complete on 6/01/15 revealed a BIMS score of 03 that indicates she had severely impaired cognitive skills. Resident ' s behaviors were marked as 0, not exhibited. CR#2's ADL needs revealed she required limited to extensive assistance for bed mobility, transfers one person to assist her with all of her needs. CR #2 was no able to walk. CR#2 was revealed to score a 4 for eating; which indicates that she needs total assistance for eating 24 hours a day. In CR#2's active [DIAGNOSES REDACTED]. Record Review of CR#2's Care Plan initiated on 7/23/14 revealed an ADL self-performance deficit/fatigue, history of aggressive behavior, limited mobility, chronic disease process, confusion and potential for pain . Further review of CR#2 care plans revealed she also had cognitive impairment function due to dementia and dysphagia causing her to have a communication problem and required tube feeding and this was revised on 3/19/15. Record review of the CR #2's physician orders for the month of July 2015 revealed that the following medications were to be administered via [DEVICE]: [MEDICATION NAME] tablet, sodium [MEDICATION NAME] tablet, [MEDICATION NAME] tablet, [MEDICATION NAME] tablet, [MEDICATION NAME] tablet, Losartan potassium tablet, Aspirin, Calcium + D3 tablet, [MEDICATION NAME] sulfate, [MEDICATION NAME] Powder, [MEDICATION NAME] capsule, quetiapine tablet, [MEDICATION NAME]. PRN medications included: [MEDICATION NAME] tablet, [MEDICATION NAME] tablet. Record Review of a Daily Skilled Nurse's Note, dated 7/18/15, revealed that at 2:45 a.m., CR #2 was found by staff to be lethargic and her respiration was 16, pulse 84, o2 stats were at 97% and temperature was 98. 911 was called due to the change in condition. Taken to ER. Message left for responsible party, MD and Administrator. Record Review of local fire department EMS records dated 7/18/15, revealed that EMS arrived at the facility at 2:07 a.m. Further review of the narrative revealed that the resident was not responsive to painful stimuli and had decreased efforts in respiration. Patient had pinpoint pupils .she does not have any medication records of narcotic medications to be administered. Patient does have signs of a narcotic overdose .assessed CR #2 at 2:10 a.m. as unconscious. At 2:25 a.m. EMS gave CR #2 [MEDICATION NAME] 1 mg for narcotic overdose due to her having signs of narcotic overdose. CR #2 then became responsive and attempted to sit up. The resident was observed to look around after being unresponsive. CR #2 had one episode of emesis in the ambulance and her head was turned and suctioned. CR #2 remained alert until hospital arrival. Record Review of a local hospital records dated 7/18/15 revealed a urine drug screen collected on 7/18/15 at 2:40 a.m. for CR #2 tested positive for Opiates. Record Review of a local hospital records date of admission 7/18/15 revealed that EMS gave CR #2 one dose of [MEDICATION NAME] and the resident responded and woke up. CR #2's drug screen was positive for opioids. The record revealed that according to the nursing home medication records, the resident was not taking any narcotic pain medications so there was a discrepancy. The local hospital called the nursing facility and the medication list was checked and CR #2 was not on any narcotic pain medications that would explain her urine drug screen positive for opioids. Further review revealed that the local hospital would have to do an investigation around that issue. In an interview with the Administrator on 07/19/15 at 1:10 pm she stated that the facility had received a call from the hospital and the attending physician on 07/18/15 to inform them of the narcotic overdose for CR #2. She said that the nurse checked the orders for the resident over the phone with the hospital and the resident has no orders for opiates. In an interview with the Administrator on 7/21/15, at 11:10 a.m., she stated that CR #2 was given [MEDICATION NAME] by EMS and this is a drug used to reverse opiate overdose. The Administrator stated she was still trying to get records from EMS from that night to figure out what happened to the resident. The Administrator stated she did not know why the resident's respiration rate was 16 or if that was normal. The Administrator stated she was not aware of CR #2's blood pressure the day of the incident. She said that CR #2 had an order for [REDACTED]. The Administrator stated that she got the statement from the last Nurse (LVN B) who gave CR#2 medication. The Administrator stated that since the incident was reported to them by the hospital on Saturday 07/18/15 no changes have been made in the facility or with the staff and she was working on receiving the EMS report to take further actions. In an interview with LVN A on 7/21/15 at 2:00 p.m., she stated that the incident regarding CR #2 happened on the weekend and she did not work on the weekend, but CR #2 was not prescribed opiates. LVN A stated that there was no one on CR #2's hall that was prescribed opiates that she was aware of. In a further interview with LVN A on 07/21/15 at 3:20 p.m. she stated that according to CR #2's Medication Administration Record [REDACTED]. LVN A conducted a search for CR #2's prescription for [MEDICATION NAME] and she could not locate the medication in the facility. In an interview with Regional Nurse B on 7/21/15 at 3:44 p.m. she stated she contacted the local pharmacy and found the last time [MEDICATION NAME] was prescribed was on 8/9/14. Regional Nurse B stated that CR #2 still has an order for [REDACTED]. In an interview with LVN B on 7/21/15 at 3:51 p.m. she stated she worked on Friday 07/17/15 on the 2 to 10 pm shift. She said that CR #2 was observed to be sitting on the edge of the bed agitated. She said that CR #2 was chewing something, but CR #2 would not let her see what it was. LVN B stated she changed CR #2's G tube and CR #2 stated she felt like throwing up. LVN B stated she gave the resident a basin and put her in bed. LVN B stated she left for the day that night and the medications that she remembers giving CR #2 was for blood pressure, [MEDICATION NAME] and [MEDICATION NAME]. LVN B stated she did not know why CR #2 had opiates in her system. In an interview on 7/22/15 at 10 a.m. at a local hospital with RN B, she stated CR #2 was doing a lot better today, but she was agitated this morning. She said that all of CR #2 ' s medication where administer via G tube. She said CR #2 ' s was in the hospital because she overdosed on opiates. In an interview on 7/22/15 at 10:18 a.m. with CR #2 at a local hospital she stated she could not remember anything about what happened on the day of the incident. CR #2 stated she did not remember chewing on anything. CR #2 appeared to be calm with her hands lying on her chest. CR #2 was able to speak and make herself understood but was confused. In an interview on 7/22/15 at 12:30 p.m. with the Administrator she stated that in regards to the incident with CR#2 that she had not completed an investigation, no in-services had been done and no changes have been made in the facility or with the staff. The Administrator stated that she would be discussing the incident with the Medical Director in the Quality Assurance meeting tomorrow. In a follow up interview on 7/22/15 at 12:59 p.m. with LVN B she said that she did ask CR #2 what she was chewing, but CR #2 got aggressive and CR #2 did not answer her when she asked. LVN B stated that it did concern her that CR #2 was chewing on something, but she knew that the resident did receive pleasure meals sometimes. LVN B said that CR #2 stated she felt like throwing up and she was really agitated. LVN B stated she flushed the G tube but she did not give her any medication to keep her from being agitated. LVN B said she did not call the doctor that night to tell her about CR #2 being agitated or nauseous, because the resident did not vomited. In an interview on 7/22/15 at 1:07 p.m. with LVN C he said that he worked the 10 pm to 6 am shift on 07/17-07/18/15. He stated that he did attend to CR #2 on the day of the incident (07/17/15 to 07/18/15) and he said she was asleep. He said that CR #2 was alert and breathing calm, but she did not look as normal so he checked her vitals and then she became very lethargic. LVN C stated he called 911. LVN C stated that EMS did not ask him any questions or tell him anything about narcotics. LVN C stated he gave EMS CR #2 ' s MAR, history and Physical and labs and they just took her. LVN C said that he did not administer medications to CR #2 that night. In an interview on 7/22/15 at 2:01 p.m. with CNA B she worked with CR #2 on 07/17/15 from 2-10 p.m. She said that CR #2 was in an out of the bed that day and appeared agitated, trying to get out of the bed. CNA B stated that LVN B gave CR #2 her medication and she changed her adult briefs every 2 hours. CNA B stated that around 6-6:30 pm LVN B called her into CR #2 ' room and asked her to hold CR #2 ' s hand so she could get a shot in her arm. CNA B stated that after CR #2 received her medication, she noticed that the medication really calmed CR #2 down. She said that after that CR #2 she completely calmed down stayed in bed until she left at 10 pm. She said that she does not recall the resident being nauseous that night. CNA B said that the only medication she saw LVN B give was the shot. In an interview on 7/22/15 at 2:09 p.m. with CNA C she stated that she worked on 7/17/15 from 2-10 p.m. She said that and after supper that night CR #2 was really agitated and hyper . CR #2 was put back in bed and she began to state that she needed to get on a bus to Houston. CNA C explained that CR #2 was not her resident that night, but due to CR #2 being a two person assist, she helped CNA B to change her. CNA C stated that she did notice that CR #2 calmed down and was not fussing anymore. CNA C stated she did not observe any medication being given to the resident. The facility Administrator and Compliance Nurse from Corporate were notified on 7/22/15 at 2:35 p.m. that an Immediate Jeopardy situation had been identified due to the above failures; however the IJ started on 07/18/15. A Plan of Removal (POR) was requested. In a phone interview with the Administrator on 07/22/15 at 3:04 PM she said that she did not understand why she had to report the incident with the narcotic overdose to DADS because the hospital told her they were going to report the situation to DADS. She said she believed she did not have to report it to DADS too as an incident. In an interview on 07/23/15 at 8:30 am the Administrator said that CNA B had come forward on 07/22/15 to say that LVN B had administer CR #2 a shot the day of the incident and that she was saying that LVN B had confronted her on 07/22/15 asking why she had to tell about the medication given that night. She said that LVN B was then suspended on 07/22/15 in the afternoon. Further interview at the time, the Administrator said she had not interviewed any of CNAs that worked in the unit on 07/17/15 until yesterday, 07/22/15. In a follow up interview on 7/23/15 at 9:20 a.m. with CNA B she stated that she was newly hired at the facility and she worked on Friday 07/17/15 with CR #2. CR #2 was stated to be agitated at around 3:30 to 4 p.m. She said that she changed CR #2's adult brief with CNA C and CR #2 wanted to sit on side the bed and was agitated. LVN B asked CNA B to come after dinner around 6 to 6:30 p.m. to give CR #2 her medication. LVN B had CNA B to hold CR #2's hand and LVN B gave CR #2 a shot. CR #2 was really calm after the medication and CNA B left the facility between 10:05 p.m. or 10:10 p.m. CNA B said that yesterday after she spoke with the surveyor, she told a coworker what she reported about that night and LVN B. She said that later on 07/22/15 LVN B came to her and asked her why she reported that about CR #2's medication. In a follow up interview on 7/23/15 at 10:22 a.m. LVN B said that the last day she worked with CR #2 was on 7/17/15 when she worked from 2 to 10 p.m. LVN B stated that CR #2 was not able to walk, she used a wheel chair to ambulate, she had an unsteady gait, she had a G tube and she received pleasure meals. LVN B stated that CR #2 received her medication by G tube and she did not take any pills by mouth. LVN B stated that on Friday, 7/17/15 CR #2 was not her normal self, was agitated and she became verbally abusive. CR #2 was observed sitting on side the bed, and she had pushed the G tube pole and the resident was rubbing her hands and chewing on something at around 6:15 to 6:20 p.m. LVN B stated she ran into CR #2's room and unplugged her G tube and she crushed the resident's medication, put them in a cup with water, she flushed the G tube and gave CR #2 her medication, then she flushed it again because the resident stated she felt like throwing up. LVN B stated she then gave CR #2 a basin, just in case she needed to throw up and the resident was still chewing on something. In further interview at the same time when asked why she did not call the MD to report the change in condition and why there were no documentation in the chart she said she had no time to do the notes and that she believed it was not something she needed to call the MD for because the resident did not threw up and she was showing normal behavior that night. When ask why she did not administer [MEDICATION NAME] to the resident if she was agitated, she said she looked in the med cart, but it was not available. She then said that she did not leave the facility until about midnight that night. LVN B stated the last time she talked to CR #2 was around 10:40 p.m. When asked LVN B denied giving any injections and she stated that CR #2 did not have an order for [REDACTED]. In an interview on 7/23/15 at 11:41 a.m. with the Regional Director he said that because now they had receive information about a possible injection administration, the facility was contacting law enforcement and reporting the incident to DADS. He said the facility looked at all the opiate and no resident in the Memory Unit had opiates ordered. The Regional Director stated that LVN B had been suspended and CNA B also just reported that LVN B also gave an injection to Resident #9. Resident #9 does have an order for [REDACTED]. Record review of Resident #9 ' s clinical file revealed that he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9 ' s physician orders revealed an order for [REDACTED].#9 ' s MAR indicated [REDACTED]. In an interview on 7/24/15 at 11:50 a.m. with the Administrator she stated that the facility had been conducting in-services this morning and they have another in-service at 2 p.m. The Administrator stated that the facility had an IJ because she should have called in the investigation because it was a form of abuse and chemical restraint. The Administrator went on to state that she understands that if she would have called in the investigation and started and investigation immediately; she would have been given 5 days to investigate. The Administrator stated that now that she is doing in-services and writing the Plan of Removal for the IJ, she understands why it was called. A POR for the IJ was submitted on 07/22/15 at 9:54 pm. After several revisions, the plan was accepted on 7/24/15 at 3:10 p.m. The POR included in part: Plan of Removal for Immediate Jeopardy EMS records were obtained to review the events that night. Completed by Administrator on 7/22/15 · 100% audit on narcotic medications with their count sheets. Started and complete by Compliance Nurse on 7/22/15 · Room search was done of secure unit looking specifically for any medications or anything harmful to ingest- started and completed on 7/22/15 · Interviewed and obtained statements from CNAs,. · Suspended Nurse on 7/22/15 and CNA on 7/23/15 pending investigation · Called in a reportable to DADS Completed by Administrator on 7/23/15 · Police was called and a report filed Completed by Administrator on 7/23/15 · Nurse terminated for failure to comply with investigation. Completed by Administrator on 7/23/15 · Administrator will report any reportable incidents to DADS even if known to have been called in by someone else and review policy so all staff is aware of what is a reportable. Specifically: Abuse & Neglect- including over medicating or under medicating, exploitation, un usual circumstances of death, missing resident, misappropriation of funds, drug diversion, injuries of unknown sources, fires, conditions that pose a threat to resident health and safety. To be completed by Administrator on 7/24/15 · In-service all staff on Abuse and Neglect, specifically: Physical abuse-including physical force, improperly and illegally restraining, and chemical restraints-over medicating, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect. Signs and symptoms of abuse (including those present in the dementia residents) and what to do if you suspect abuse . · In-service All staff on the implementation of a sign in/out book for all visitors in the memory unit. · In-service all staff on recognizing, reporting and documenting resident ' s change of condition (including signs and symptoms of a narcotic overdose specifically for nurses). · In-service all staff on understanding and caring for the Dementia resident. Including appropriate communication and expectations for residents with dementia. Also included recognizing aggression and appropriate interventions and documentation of behaviors for dementia residents. · In-service nurses on medication administration of narcotics. · In-service nurses on definition and types and prevention of medication errors and appropriate response, specifically the process. No one is allowed to return to work until they have been in-serviced on the appropriate in-service . The plan was monitored from 07/24/15 until 07/27/15 by the surveyor with the following results: Facility protocols concerning notifying physician of changes of condition, and when to call 911 were reviewed. In-services on caring for dementia residents, appropriate care, communications, how to care for agitated/aggressive residents using appropriate interventions, when to give medications, how to document behaviors, medication error and prevention, procedures to follow if medication error is recognized, implementation of a sign in and out book for memory care unit, abuse/neglect and recognizing a reportable incident. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff and other facility employees covering three shifts were interviewed on 7/24-7/27/15, all expressed up to date knowledge on abuse/neglect, restraints, dementia care, medication administration and narcotic sheets. Observations of residents in the facility revealed fewer use of Geri chairs and residents were being attended and cared for. The Administrator was informed on 7/27/15 at 11:05 a.m. that the IJ was removed. While the IJ was removed on 7/27/15, the facility remained out of compliance at a scope of isolated and a severity level of Actual Harm that is not an Immediate Jeopardy because the facility was continuing to monitor and evaluate the effectiveness of their plan. Record Review of the facility Policy on Abuse and Neglect Prohibition Policy dated 12/26/14 revealed in part: .Suspected actions or allegations of abuse including physical, mental, verbal, sexual, involuntary seclusion, neglect or misappropriation of property by any individual including resident to resident altercations with injury will be reported to local authorities, state and federal agencies, and other appropriate agencies as required by law. The policy further states, Any employee that witnessed, suspected, alleged statements of abuse including injuries of an unknown source, or unusual deaths must report to the Administrator or Designated Representative and the Nurse on call immediately. Administrator or Designee Representative must call local law enforcement and DADS within 24 hours of being notified.the facility will act immediately upon notification when an individual has been witnessed, suspected or alleged to have cause abuse. According to the facility's roster, the census was 57.