Every finding on record at Ridgewood at the Woodlands

Based on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care services for one of two residents (Resident #1) reviewed for PASARR. The facility failed to submit a request through the simple LTC portal for a customized manual wheelchair for Resident #1 within the time frame set by PASARR. This failure could place residents at risk of not having their PASARR specialized service needs met.Findings included:Record review of Resident #1's face sheet dated 11/25/25 revealed an [AGE] year-old female admitted on [DATE]. Her diagnoses included developmental disorder of speech and language, dementia, and rhabdomyolysis (a serious condition characterized by the breakdown of skeletal muscle tissue leading to the release of myoglobin [iron- and oxygen-binding protein] and other harmful substances into the bloodstream).Record review of Resident #1's quarterly MDS assessment, dated 10/29/25, revealed a BIMS score of 0, which indicated severe cognitive impairment. She was dependent on staff for toileting and oral hygiene, and required assistance with showers, dressing, and personal hygiene.Record review of Resident #1's care plan, dated 11/5/25, revealed Resident #1 was PASRR positive and received services with the local authority related to a diagnosis of developmental disorder of speech and language. Interventions were: initial PASSR meeting held on 4/21/25. PASSR services ST, PT, OT, habitation coordinator, and independent living skills with date initiated 7/18/25. 7/18/25, 10/22/25 - quarterly PASSR meeting held. Continue PT/OT/ST, and PASSR services provided, date initiated 7/18/25.Record review of Resident #1's PASRR Level 1 Screening, dated 4/14/25, revealed Resident #1 had intellectual and developmental disability. Record review of Resident #1's PASRR Comprehensive Service Plan Form initial IDT/SPT meeting, dated 4/21/25, revealed the IDT recommended a customized manual wheelchair as a new specialized service for Resident #1. The Nursing Facility Comments read, PASSR meeting held with resident, Tri country (sic) Coordinator, and IDT team members listed above. Resident and case worker agreed to habitation coordination. PT, OT, ST and independent living skills training. Will remain on psych services provided in house. Case worker verbalized understanding and will participate in PASSR provided services. Customized Manual Wheelchair to be provided.Record review of Resident #1's progress note, dated 4/21/25 at 4:18 p.m. written by the previous MDS Coordinator, read in part, OT service and customized wheelchair added to initial PASSR.Record review of Resident #1's undated Form Activity from the Simple LTC portal revealed there was no NFSS submitted for Resident #1's customized manual wheelchair. Record review of Resident #1's PASRR Comprehensive Service Plan Form quarterly meeting, dated 7/18/25, revealed the customized manual wheelchair was ongoing.Record review of Resident #1's PASRR Comprehensive Service Plan Form quarterly meeting dated 10/22/25 revealed the customized manual wheelchair was received.An observation on 11/25/25 at 11:09 a.m., revealed Resident #1 was sitting in the TV room in her customized wheelchair. In an interview on 11/25/25 at 11:28 a.m., the DOR said Resident #1's customized manual wheelchair was ordered when he started working for the facility in June of 2025. He said the company set a delivery date for the wheelchair for 10/16/25. The DOR said the company was unable to send it prior due to the resident's Medicaid not being renewed. He said the customized manual wheelchair was for positioning and pressure relief and he did not see in the portal that a NFSS was submitted for the wheelchair. He said the previous DOR was responsible for submitting the NFSS request within 30 days from the quarterly meeting.In an interview on 11/25/25 at 11:54 a.m., the previous MDS Nurse said Resident #1's initial PASRR IDT meeting was held on 4/21/25 and the previous DOR initiated the NFSS forms for the customized wheelchair but was unsure if she passed the report on to her manager before leaving the facility. She said the NFSS forms were in the process of being signed and were supposed to be uploaded and submitted within 20 days from the meeting date. She said therapy was responsible for submitting the forms but MDS and therapy both had roles in PASRR. She said there was an issue with Resident #1's Medicaid and that would sometimes return the NFSS, but the facility should still submit the NFSS. She said Resident #1 needed the wheelchair for upper trunk adjustment and comfort. In an interview on 11/25/25 at 12:21 p.m., the Administrator said she was not familiar with the PASRR IDT requesting a customized manual wheelchair for Resident #1. She said an NFSS was not sent for the wheelchair. She said the previous DOR probably ordered the wheelchair through the residents Medicaid benefits, instead of through PASRR. She said the difference between ordering through PASRR and insurance benefits would be that PASRR benefits would pay for the wheelchair instead of Medicaid which may be a different approval process. She said Resident #1 did get her wheelchair. She said PASRR training was provided by the MDS nurse, Corporate, and Therapy. She said she believed the previous DOR knew how to submit the PASRR request for the wheelchair because she had submitted PASRR requests in the past. She said the regional DOR would submit PASRR request in the absence of a DOR. In an interview on 11/25/25 at 3:16 p.m. the previous DOR said she ordered Resident #1 a wheelchair when she transitioned off skilled services, which was prior to her being on PASRR. She said she did not recall if the IDT requested a customized manual wheelchair during her initial PASRR IDT meeting in April 2025. She said if a customized wheelchair was requested, she would have to submit the request through the Simple LTC portal, have the therapist complete a packet, and obtain MD and Administrator signatures. She said she did not recall doing that. She said the wheelchair Resident #1 currently had was the same wheelchair she would have if ordered through PASRR. She said she was familiar with the PASRR process and was trained by her regional director. She said no one followed up with her regarding the status of the NFSS request for Resident #1's wheelchair. She said she stopped working for the facility in June 2025.Record review of the facility's Resident Assessment - Coordination with PASARR Program, dated 10/2023, read in part, .Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: . 7. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care.

Based on observation, interview, and record review the facility failed to ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 5 residents (Resident #49 and Resident #77) reviewed for behavioral services. - The facility failed to assess Resident #49 and provide behavioral health services from [DATE] to [DATE] after she reported that she wanted to die. - The facility failed to immediately assess Resident #77 after he reported that he wanted to die. These failures could place residents at risk of mental and psychosocial harm, injury, and suicidal ideation. An Immediate Jeopardy (IJ) that started on [DATE] was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 04:45 PM. While the immediacy was removed on [DATE] at 01:55PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. Findings include: Resident #49 Record review of Resident #49's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: bone cancer, shortness of breath, anal cancer, cognitive communication deficit, difficulty swallowing and pressure ulcer on her sacrum (triangular bone at the base of the spine). Record review of Resident #49's undated Care Plan revealed, focus: pneumonia; intervention: monitor/document/report to MD as needed for the following symptoms of pneumonia: fever, chills, cough, fast breathing, low oxygen. Focus: receiving nebulizer breathing treatments; interventions- monitor O2 saturation (levels) as needed or per orders, administer breathing treatments as ordered by MD. Focus: Hospice services due to terminal illness of anal cancer; intervention- assist with ADLs and provide comfort measures as needed, monitor for signs and symptoms of increased pain, discomfort-give medications/treatments monitor for relief. There was no focus area for oxygen administration. Record review of Resident #49's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15 and use of O2 was not indicated. The resident reported no symptoms of being down/depressed/hopeless, little interest or pleasure in doing things, and feelings of social isolation. Record review of Resident #49's Change of Condition MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15 and use of O2 was not indicated. The resident was on hospice, Pain was present with rare impact on sleep, rare interference with therapy activity and occasional interference with day-to-day activities. Record review of Resident #49's Hospice RN Comprehensive Visit dated [DATE] revealed, Resident #49 was experiencing pain. was uncomfortable due to her pain and her pain was located on her rectum. Mental status: disoriented, withdrawn, forgetful, unable to report anxiety/depression due to not responding. Resident #77 was co-operative, indifferent, and showed abnormal behavior/mood and effect because she was withdrawn. Record review of Resident #49's Order Summary Report dated [DATE] revealed, Admit to Hospice. Hospice Care effective [DATE]; diagnosis: anal cancer and other conditions of cancer spread to the bone. Oxycodone w/ Acetaminophen 5-325 mg- give 1 tablet every 12 hours for pain management. Oxycodone w/ Acetaminophen 5-325 mg- give 1 tablet every 6 hours as needed for pain level 7-10. Morphine 20 mg/ml- give 0.25 ml by mouth every 6 hours for severe pain. Morphine 20 mg/ml- give 0.25 ml by mouth every 4 hours as needed for pain and shortness of breath. The record indicated that Oxycodone was discontinued when the resident was started her Morphine Sulfate on [DATE]. Record review of Resident #49's [DATE] MAR revealed, all doses of PRN pain medication were documented as effective on follow up pain assessments. Record review of Resident #49's Progress Notes from admission ([DATE] to [DATE]) and saved on [DATE] at 02:23 PM revealed: - [DATE] at 11:07- Resident repositioned multiple times to relieve sacral pain - [DATE] at 04:02 PM- Resident resident in bed, no shortness of breath, no complaints of pain. - [DATE] at 10:27 PM- Resident participated in PT and OT while remaining in pain. Resident denied pain or discomfort - [DATE]: IDT met with family at this time. Family asked about DNR and hospice. Family stated they are ready to move. forward with the process. At this time, we gave Family the DNR form, and they filled out his part and a referral were sent to a hospice company. No other concerns were voiced at this time. - [DATE] at 09:27 PM- Resident refused breathing treatment, she said she was breathing fine. Resident denied pain or discomfort. - [DATE] at 09:23 PM- Resident denies pain or discomfort. Resident observed calm and pleasant in bed with eyes closed. - [DATE]: Resident #49 refused care, treatment, and meal in the morning. She shouted No, let me die, leave me alone! Hospice RN made aware, and RP stated Resident #49 had been making statements of this nature to her guests. There was no other documentation to show Resident #49's MD was notified, Resident #49 received psychiatric evaluation/consultation, Resident #49 was evaluated by social services or any other nursing facility staff about her mental state/psychosocial condition. - [DATE] at 06:53 AM- Resident continues with routine pain medication and comfort measures as needed. All needs met, vitals stable - [DATE] at 02:54 PM- Resident states he wants to die. This started on [DATE]. The following makes this condition WORSE: resident being in pain. - [DATE]: Patient psychosocial goals are to adjust to the facility. Patient social services need to provide home health and DME. No ancillary services. There have not been any changes in the RES's family status over this past quarter. The res does get along with res and staff. The res does have family contact and involvement in help with D/C Record review of Resident #49's Clinical Assessments on [DATE] at 12:36 PM revealed, Resident #49 did not have any clinical assessments, SBARs or social services assessments completed after her statement of wanting to die made on [DATE]. Record review of Resident #49's EMR on [DATE] at 04:12 PM revealed, Resident #49 had no documented psychologist, psychiatry visits after stating she wanted to die on [DATE]. An observation on [DATE] at 09:33 AM revealed, Resident #49 received oxygen via nasal canula between 3.5-4 L/min. The resident was dressed in a hospital gown, appeared well fed and in no immediate distress. Resident #49 woke up and said she had no current issues or concerns, and she would talk to the surveyor at a different time. An observation on [DATE] at 02:45 PM revealed, Resident #49 in bed grimacing from pain. The resident said she could not think because of her pain and the pain was due to an ulcer on her bottom. She said the pain was so severe that she could not sleep, and she pressed the call light, but no one answered. The resident and the surveyor both pressed the call light and the light that indicated a call did not work. At 02:55 PM, the Administrator entered Resident #49's room after the surveyor notified her of the malfunctioning call light. She first pressed the call light to verify it was not working, then she unplugged the call light and plugged it back in, and at that time the call light became functional. The resident did not communicate any other form of distress beyond the pain from her sacral ulcer; she would not elaborate further on her mental state or feelings. An observation and Interview on [DATE] at 03:24 PM revealed, Resident #49 received wound care with the Wound Care Nurse and CNA F. The resident was on her right side with support from CNA F and wound care was completed with good technique. Resident #49 said her pain medication had been working and her pain medications were received regularly. In an interview on [DATE] at 12:15 PM, the DON said when a resident experienced a change of mood the nursing staff must immediately notify the administrator and DON, then the social worker interviews the resident and finally a referral for psych services should be made. She said the assessment must be immediate/ the same day. The DON said if a resident said they want to die; the statements need to be investigated immediately to find out more information like why. She said additional interventions like increased observation of the resident, and every staff member providing care for the resident should be aware of the resident's change of mood. The surveyor notified the DON that Resident #49 stated that she wanted to die on [DATE] and the DON said she was not aware of the president's statement. The DON said the facility should have taken immediate action to address Resident #49's statement that she wanted to die faster, they should have immediately notified the social worker to ensure the resident was safe and not a danger to herself or others. She said the facility had not taken any action to address Resident #49's change of mood. In an interview on [DATE] at 01:00 PM, the DON said Resident #49 was seen by her hospice nurse on [DATE] but they did not notify the facility of any concerns regarding the resident's statements of wanting to die. She said after learning about the resident's statements from the surveyor, she just completed a stat psych referral, and social services would visit the resident. The DON said the facility had not performed a mood or behavioral assessment of Resident #49 or put any interventions in place since she made the statement of wanting to die on [DATE] but she said it's going to be happening. The DON said when a resident made a statement that they want to die, the facility was expected to report and discuss the situation in their 24-hr. report, communicate the incident with all staff and follow up initiated with the resident. She said not having timely response to mood or behavioral changes could place residents in mental distress. In an interview on [DATE] at 02:58 PM, Psychiatric NP A said previously she was not following Resident #49, but she received a psychiatric consultation request today ([DATE]) at 02:18 PM. She said she received a STAT referral from the facility to evaluate the resident, which meant she would see Resident #49 by the next working day. Psychiatric NP A said since Monday was a holiday she would see Resident #49 on Tuesday [DATE], and the interventions in place prior to her visit with the patient was facility dependent/specific. In an interview on [DATE] at 03:03 PM, the MD said a resident stating they wanted to die was a mood change and she expected to receive notification within hours and the social worker should be informed. The MD said she was actively having conversations with Resident #49 about end of life and was discussing her choices of comfort care and eventually Resident #49 was placed on hospice. She said she was not notified of Resident #49's statement that she wanted to die on [DATE], but she was told by staff that she was saying that during the week ([DATE] to [DATE]). She said she never heard or discussed it with the resident but she heard rumors from staff. The MD said she expected staff to immediately assess and document a resident's change of mood and immediately notify the MD of MD on call. In an interview on [DATE] at 04:35 PM, the Social Worker said she last saw the resident on [DATE], but the resident did not feel well at the time. She said she was not aware that Resident #49 said she wanted to die on [DATE] and she had not performed a mood or behavioral assessment of Resident #49's. The Social Worker said when a resident reports a change in mood, staff were expected to initiate an assessment, notify the ADON/DON of the resident's change in mood, and document it as a change of condition. She said failure to assess and take immediate action after a resident experienced a change in mood could place residents at risk of psychosocial discomfort, depression, and psychosocial distress. In an interview on [DATE] at 03:45 PM, LVN C said Resident #49 was actively dying when she made the statement that she wanted to die so she took it as the resident verbalizing her feelings. She said in the morning of [DATE] she woke Resident #49 up to have breakfast and she looked at her tray and shouted she wanted to be left alone and wanted to die. LVN C said she reported the incident to ADON A, the residents family member son, the hospice service but she did not remember if she notified the doctor. She said Resident #77 had accepted her condition (terminal illness) and did not want to continue. LVN C said Resident #49 was in pain sometimes, but her pain was well controlled. She said the facility was repositioning the resident every 1-1/2 hours, she had an air mattress, wedges in place and received wound care as ordered. LVN C said she was not sure if Resident #49 received any behavioral interventions or monitoring after she verbalized, she wanted to die. She said she did not know the procedure to handle residents who voiced suicide but if the resident was not on hospice, she would have called for a psych consult and placed the resident on 1on1 observation. LVN C said she did not take Resident #49's statements as suicidal ideation because the resident was actively dying/received hospice. Resident #77 Record review of Resident #77's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: diabetes, colostomy (is a surgical procedure that creates an opening in the abdominal wall to allow stool to exit the body), and anxiety disorder. Record review of Resident #77's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, little interest or pleasure in doing things, resident did not report feeling down, depressed, or hopeless, no social isolation or behavioral symptoms. Record review of Resident #77's Care Plan completed [DATE], focus- risk for altered mood state related to depression; interventions- administer medications per MD order, document staff interventions in the clinical record, listen when resident is upset and try to resolve the issue, psych referral as needed. Focus- uses antidepressant medications; interventions- monitor/report as needed adverse reactions to antidepressant medications: change in behavior/mood/condition . social isolation, suicidal thoughts, and withdrawal. Record review of Resident #77's SBAR with effective [DATE] at 02:54 PM revealed, before calling MD/NP/PA a- evaluate the resident, c- review record: recent progress notes, labs, orders. The change in condition, symptoms, or signs I am calling about is/are resident states he wants to die. This started on [DATE]; things that make the condition/symptoms worse are resident being in pain; this condition, symptom, or sign has occurred before: No. Record review of Resident #77's Psychiatric Subsequent assessment dated [DATE] revealed, medical necessity for visit- per facility request for crisis. Resident reported chronic anxiety, depressive symptoms related to medical issues and endorses recent end of life statement. Assessment (RN) or Appearance (LPN), LPN- the resident appears: upset but safe. Request- other new orders: psych eval, reported to NP. Record review of Resident #77's Progress Notes printed [DATE] revealed, [DATE] at 03:34 PM- per therapy staff resident states he wants to die, maybe upset about room change. Resident in bed at time in safe position call light in reach. The writer asked the resident why he was upset resident states do not talk to me social worker notified NP and [family member] made aware. Record review of Resident #77's Trauma Screening Assessment effective [DATE] at 02:09 PM revealed, the assessment was blank. No assessment was documented. Record review of Resident #77's Order Summary dated [DATE] at 02:31 AM revealed, Hydrocodone w/ Acetaminophen 5-325 mg- Give 1 table by mouth every 6 hours as needed for pain, initiated [DATE]. Hydrocodone w/ Acetaminophen 05-325 mg- Give 2 tablet by mouth every 6 hours as needed for pain, initiated [DATE]. Fentanyl 25 mcg/hr. patch- apply 1 patch one time a day every 3 days, initiated on [DATE]. Record review of Resident #77's [DATE] MAR revealed, all PRN administration of Hydrocodone was effective on follow up pain assessment. An observation and interview on [DATE] at 10:05 AM revealed, Resident #77 in bed, resident appeared to be sleeping and said he was all right when surveyor tried to talk to him. The resident would not further interact with the surveyor. An observation and interview on [DATE] at 11:07 APM revealed, MD and LVN X talking to each other as they came out of a resident's room. When the surveyor entered the room, Resident #77 was observed in a new room in bed. Resident #77 said he was in pain and could not talk. He said the facility moved his room because something was not working in the room. The resident looked away and would not further interact with the surveyor. Record review of Resident #77's MD Progress note dated [DATE] revealed, Patient seen lying down with head of bead elevated. The resident complained of pain to his back and to his stomach with no report of cramps. Breathing was stable with no wheezing noted. The MD discussed adding a fentanyl patch and increasing his hydrocodone to 2 tablets every 6 hours for pain until fentanyl is placed and then it will continue as needed. In an interview on [DATE] at 01:04 PM, LVN X said Resident #77 had cancer and returned from the hospital with a colostomy after colitis. She said she was working with the resident since he was on the other hall. LVN X said the resident received therapy and reported pain for the last 2 weeks since his colostomy and he was being treated with PRN medications. She said she had not observed any changes in Resident #77's behaviors and the resident did what he wanted. LVN X said Resident #77 had not complained about wanting to die and had not heard about any such complaints or complaints about suicide. She said if she was notified that a resident wanted to die, she would expect the social worker to be notified and the DON as well. LVN X said so far, the resident has not had any additional behavioral monitoring, and management had not communicated any interventions such as behavioral monitoring or increased supervision. In an interview on [DATE] at 01:45 PM, ADON A and the Interim DON said the IDT discussed residents daily in their stand-up meeting when they go over progress notes that appeared on the 24-hour report. They said they had only discussed his room change in the standup meeting because he was changed from the 100 to 500 hall. The Interim DON said they had not heard about the resident wanting to die, or anything like that. ADON A said she may have heard that the resident said he wanted to die because she did a psych consult for him on [DATE]. ADON A and Interim DON said when a resident made a statement like they wanted to die, they should be immediately assessed and placed on observation. The Interim DON would not state what the facility's expectation of staff or interventions required when a resident stated they wanted to die, she said it depended on the assessment. The Interim DON said at the moment she did not see any form of documentation that an assessment was completed for Resident #77 after he said he wanted to die. In an interview on [DATE] at 01:55 PM, the Social Worker said the first time she talked to Resident #77 about his statement that he wanted to die was today, [DATE] at approximately 12:00 PM but she had not had the opportunity to document her visit. She said when she met with the resident, he said he was fine, but she did not ask the resident specifically if he wanted to die but asked all the questions in the PH-Q9 (depression assessment). The social worker said she asked Resident #77 what was going on and he said there were a lot of people going in and out of his room and would not further elaborate. She said her coworker told her Resident #77 said he wanted to die at around 09:00 AM and she saw him at 12:00 PM. The Social Worker said she had seen Resident #77 once and will see him again because she was new to her position and the first time a resident saw a resident they may not open up. The social worker said she had not gone back after the visit at 12:00 PM to see Resident #77 and she did not read the resident's progress notes that showed the resident was reporting pain and a room change being exacerbating factors for the resident feeling like he wanted to die. The Social Worker said the physical therapist her coworker said the resident was safe, and she asked the resident how he was feeling and did not ask about his pain, or room changes and how they made him feel. She said normally if a resident made a statement that they wanted to die, the nursing team would normally review the resident, make medication changes, and have an impromptu IDT meeting to discuss the statement, but the facility had not had a meeting regarding Resident #77's statements. The surveyor asked the Social Worker to read the time she was notified of Resident #77's statement of wanting to die by her coworker; she checked her phone and said 12:00 PM on Monday ([DATE]). After reading the text and confirming the date, the Social Worker changed her narrative and said she first talked to Resident #77 on Monday [DATE]. In an interview on [DATE] at 02:10 PM, the DON said Resident #77 was seen today, [DATE] and his MD gave an order for Fentanyl because the resident's pain was not well controlled on his medications on [DATE]. She said Resident #77 recently got a colostomy, and that was the cause of his self-esteem issues, and possibly why he was depressed. The DON said she talked to the resident, and he did not verbalize any suicidal ideation. In an interview on [DATE] at 02:15 PM, PT A said as she worked with Resident #77 on [DATE] the resident said, I want to die, I want to die, don't tell anyone I said that. She said she immediately put the resident back in bed and immediately notified the charge nurse, who was not a regular full-time nurse she knew, and the DOR. PT A did not report Resident #77 was in pain during the therapy session. Record review of Resident #77's PT Therapy Progress Report dated [DATE] signed by PT A revealed, there was no documentation of Resident #77 being in pain during the therapy session. In an interview on [DATE] at 04:19 AM, the Psychiatric NP B said she had just interviewed Resident #77, but the interview was short because the resident was not feeling well since he experienced nausea and vomiting. She said Resident #77 reported feeling safe and was already receiving Buspar for his old diagnosis of depression. Psychiatric NP B said Resident #77's Paxil, an antidepressant, was increased recently in response to his behaviors, she said Resident #77 had no intention to harm himself. Psychiatric NP B said she had limited availability to talk to the surveyor because she had emergent issues with other residents, she had to take care of. In an interview on [DATE] at 03:03 PM, the MD said she was not aware when she saw Resident #77 on [DATE] that he wanted to die, she said she talked to him about pain that required an increased in the use of his PRN pain occurred [DATE]. The MD said in response to the reported pain and increased used of PRN medications on [DATE] she changed his medications [DATE]. She said she was not told when she arrived the facility, but it was possible the on-call physician was notified. After reviewing the on-call physician's notes the MD said, the on-call physician was notified of Resident #77's statement and an order for a psych consult was given . The MD said when a resident state they want to die, the facility staff were expected to ensure the resident got a psychological consult and the resident should be interviewed to figure out what happened. The MD said most of Resident #77's issues were regarding pain, and his medication was increased. She said the resident says his pain was better so in her mind his is improving and in a better mood. The MD said Resident #77 said he wanted to die because of the pain, and the facility had put interventions in place since they changed his pain medication/treatment. Record review of the facility policy Behavioral Assessment, Intervention and Monitoring revised 04/2023 revealed, 1.The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using facility-approved behavioral screening tools and comprehensive assessment. continues on next page. Management 1.The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress. b. If the behavior is atypical but not problematic or dangerous and the resident does not appear to be in distress, then the IDT will monitor for changes but not necessarily intervene to normalize the behavior. 7. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. An IJ that started on [DATE] was Identified on [DATE]. The Administrator was notified of the IJ, and the template was provided to the facility on [DATE] at 04:45 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 04:37 PM. Plan of Removal Name of facility: [Ridgewood At the Woodlands Rehabilitation and Healthcare Center Date: [DATE] F-740. Problem: The facility failed to take action for resident #49 and resident #77 when they expressed to staff that they wanted to die. 1.Resident #49 and resident # 77, no longer a resident in the facility. a. Resident #49 Expired on Hospice Services b. Resident #77 Currently hospitalized , Dx: Sepsis, with intent to return 2. The Administrator and DON received 1:1 in-service on the facility Behavioral Health Policy and procedures along with the company expectation to adhere to it by the Vice-President of Clinical Services. Completion date [DATE] 3. [DATE] the facility corporate nurse/DON/SW/designee conducted resident interviews who were able to participate and answer questions regarding their current mood status, pain needs, and identify any passive and active suicidal thoughts. No residents voiced current suicidal thoughts, intent for self-harm passive suicidal thoughts and/ or uncontrolled pain. Completion date [DATE] 4. The Facility Corporate nurse reviewed the Behavioral Health Services policy and procedure no changes were needed. Staff in-serviced on policy and procedure. Completion [DATE] Interventions 5. [DATE] The facility DON/Designee conducted an in-service with all facility License nurses and the social worker on adhering to the facility Behavioral Health Policy focusing on addressing resident behavioral needs. Completed [DATE] 6. [DATE] the DON/Designee initiated an in-service with the facility nursing staff (C.N.A, LVN's and RN) on Communicating Changes in Condition via the STOP and WATCH tool, including but not limited to changes in resident moods, expressing thoughts of suicide, increased pain, etc. Completed [DATE]. 7. [DATE] the DON/Designee initiated an in-service with the licensed nurses regarding communicating changes in condition including but not limited to changes in mood, suicidal thoughts, uncontrolled pain .etc. via SBAR to the physician to initiate and or change resident treatment, orders, recommendation for psych referral, transfers out to the hospital. Completed [DATE] 8. Staff will not be allowed to work until after completion of in-service. Completed [DATE]. 9. [DATE] the Administrator/ Designee initiated an in-service on Maintaining the Mental and Psychosocial Wellbeing of Hospice Residents with staff. The in-service includes approaches staff can take to address and improve resident's psychosocial wellbeing. Monitoring 10. [DATE] The DON and administrator are immediately notified of residents expressing passive or active suicidal ideation, uncontrolled pain to provide guidance and ensure proper assessment, and interventions are done completed. Issues identified will be immediately addressed through further education, disciplinary action and or termination of employment. Administrator and DON are on call 24/7. 11. [DATE] The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with all employees. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Completed [DATE]. 12. [DATE] The Nursing management team reviews Stop and Watch Tools and SBAR for changes in residents' behaviors/mood/ pain needs .etc . daily. Any issues identified will be addressed at this time. 13. [DATE] An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved [DATE] Monitoring of the POR In an interview on [DATE] 11:35 AM with RN A , she said she was trained on resident behavior changes on [DATE]. She said if a resident experienced a mood change of condition you immediately stop what you are doing, RN A said that the resident will be watched constantly, and any issues and information will be reported to DON or Admin so the individual can receive whatever next step help that is needed. All information should be documented in PCC as change of condition and in the progress notes. The RN stated that staff were expected to treat hospice residents the same way they would treat a regular resident in all areas of care. In an interview on [DATE] at 11:43 AM, the Activity Director said she received an inservice on resident behaviors on [DATE]. She said that any mental health or changes in condition, would be reported to the Admin. The Activity Director said that she if a resident experienced a mood change or verbalized thoughts of suicide, she would call for assistance for someone to monitor the resident and then proceed to report to DON and Admin. She said all staff were responsible for ensuring all issues were reported and that residents received treatment and or assistance. The Activity Director said that hospice residents were are treated in the same manner, when dealing with suicidal ideations or changes in behavior. In an interview on [DATE] at 11:50 AM, the Social Worker said she received an in-service on behavior changes and or suicidal ideations. She said staff were trained on how to report in PCC and to report to the [NAME] and Admin. The Social Worker said hospice residents will go through the same process as all other residents in the

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #17) reviewed for accidents and supervision. The facility failed to ensure the locking mechanism on Resident #17's bed was operating properly, which caused her to fall and hit her head and resulted in a head injury, laceration over her right eye, and need for emergency medical attention. An IJ was identified on 6/12/2025. The IJ template was provided to the facility on 6/12/2025 at 2:33 pm. While the IJ was removed on 6/13/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility ' s need to evaluate the effectiveness of the corrective systems. This failure placed all residents who have wheel locks on their beds at risk for falls, decline in health, serious injury, and hospitalization from poor maintenance of the bed rails. Findings include: Resident #17 Record review of Resident #17 ' s face sheet dated June 11, 2025 revealed an [AGE] year old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnoses of cerebral infarction (stroke-blood flow to the brain is blocked), dysphagia (difficulty swallowing), hypertension (high blood pressure), osteoarthritis, rheumatoid arthritis, chronic kidney disease, atrial fibrillation (irregular heart rate), anticoagulants (medication that prevents blood clots), repeated falls, symbolic dysfunction, and pain. Record review of Resident #17 ' s Quarterly MDS (Minimum Data Set) dated 3/29/2025 revealed memory problems with moderate impaired cognitive skills for decision making. Resident #17 had upper and lower impairments of extremities and was ambulated with a wheelchair. Resident #17 required partial/moderate assistance where the helper does less than half the effort for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. She required set up or clean-up assistance for rolling left and right, and partial/moderate assistance where the helper does less than half the effort for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfers. Walking 10 feet was not attempted due to medical conditions or safety concerns. Record review of Resident #17 ' s Care Plan last reviewed on 04/17/2025 revealed Resident #17 required assistance to perform functional abilities in self-care and mobility AEB poor quality in functional range of motion r/t stroke with intervention to provide self-care assistance: .toilet hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene, chair/bed-to-chair transfer, and toilet transfer were all partial assistance. Resident #17 was at risk for falls and increased falls and injury r/t psychoactive drug use with interventions to anticipate needs, provide prompt assistance with ADLs and other special needs, assess for psych services, be sure the resident ' s call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, call MD of any falls, ensure that resident is wearing appropriate footwear or nonskid socks when ambulating or when up in wheelchair for mobility, fall risk assessments per facility protocol and rehab screen/evaluate and treat as indicated for therapeutic exercises and safety measures. Record Review of Provider Investigation Report dated 9/10/2024 written by former Administrator revealed Resident #17 Fell out of the bed and hit her head receiving a hematoma and laceration to the right eye, and skin tear on forearm 911 was contacted and the patient was transferred to the hospital for further evaluation and treatment. Patient was returned to the facility few hours later with four sutures and laceration above her right eye. Resident is prescribed Eloquis 2x daily. Record review of Resident #17 ' s Order Summary Report revealed acetaminophen tablet 325 mg for pain, apixaban tablet 2.5 mg for anticoagulants, and Lexapro oral tablet 5 mg for generalized anxiety disorder. In an observation and attempted Interview on 05/20/25 at 1:30 Pm Resident #17, was observed to be nonverbal and was non interview able. At the time of the attempted interview and observation, Resident #17 had no marks or bruises. Resident #17 ' s bed was observed, and locks were not working at the time of the observation of her room. Interview on 05/20/2025 at 2:40 PM with CNA E she stated she was no longer employed by the facility. CNA E stated that on 9/10/24 at 9PM she was helping Resident #17 get out of the bed due to resident having bowel movement in the bed. The resident has to be physically lifted out of bed. While CNA E was assisting with lifting the resident, she somewhat swung her arms out, falling off the bed and hitting her head. She stated that the wheel on the bed was not working and therefore not secured on the floor, causing the bed to move at the time the accident occurred. Interview on 05/20/2025 at 2:40 PM with the Former Interim DON, she stated that she was very familiar with Resident #17. She stated that because Resident #17 was non-verbal, she may at times swing her arms and or jerk away when being bathed or moved or aided in getting dressed. She stated that she has never witnessed her being abused. Observation on 05/21/2025 at 2:00 PM of the bed for Resident#43 and Resident # 17 revealed both beds to not have slip resistant pads to avoid movement that would lead to injury to the residents. Both beds had movement with locks on at the time of observation. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 6/12/2025. The Administrator was informed and provided the IJ template on 6/12/2025 at 2:33 PM. The Plan of Removal (POR) was requested. The following Plan of Removal was submitted by the facility and was accepted on 6/12/2025 at 8:37 PM: PLAN OF REMOVAL F689- Accidents/supervision Problem: - The facility failed to act after Resident #17, #43 and #44 injuries and possible injury occurred. -The facility failed to take prompt action after Resident #17 fell and hit her head on a cabinet after bed wheels would not lock in place to hold bed movement. Immediate action: 6/12/25 Residents #17, #43 and #44 remain in the facility in stable condition. Their beds wheels have been assessed for safety, and all wheels are working properly and have working bed locks and/or stoppers that secure the bed. Completed 6/12/25 All beds wheels observed are in working order. 6/12/25 The facility maintenance director/Designee initiated bed safety screenings on all the beds to ensure their wheels break/stoppers are working and that beds are not moving unnecessarily during resident ADL care. Wheels stopper pads have been placed on all bed wheels noted moving during ADL care. Patient beds not in use have working breaks or bed stoppers in place, unless designated as out of order with a posted sign and flagged for no use by admissions. Completed 6/12/25 Interventions: On 6/12/25 the Administrator and DON along with the corporate nurse re-review the facility Accidents and Supervision Policy and the Incident and Accidents Policy to ensure understanding of policies and expectations to always sustain compliance. No modifications or changes needed to either policy. Completed 6/12/25 On 6/12/25 the facility Adm/DON/corporate nurse initiated an in-service with all staff on the facility Accidents and Supervision Policy and the Incident and Accidents Policy to ensure understanding. Completed 6/12/25 On 6/12/25 The Corporate Maintenance Director conducted an in-service with the facility Administrator and Maintenance Director on the TELS System and how to run reports to ensure all work orders are promptly addressed. Completed 6/12/25 On 6/12/25 the facility DON/Designee initiated an in-service with all facilities in regard to the TELS system focusing on immediately reporting beds that are not secure or noted moving. A work order is entered into the EMR. Staff members are to apply wheel stoppers with spare stoppers provided to them in order to secure the beds. In the event the staff are unable to secure the wheels, the bed will be taken out of service until the Maintenance Director is able to correct. The Maintenance Director receives TELS work order and corrects the bed reported issues as soon as possible with a goal of the same business day. Defective equipment will not be in use. Completion on 6/12/25 On 6/12/25 The Adm/designee conducted an in-service with all nursing staff and all therapy staff on incident and accident prevention focusing on bed safety, interventions they are to initiate if resident bed wheel/breaks are noted moving during ADL care. This includes reporting it to TELS and immediately placing stopper pads onto the unsecure beds. Failure to comply will result in disciplinary action and up to termination of employment. Completed 6/12/25. Ongoing Projected Completion 6/13/25 Any staff member who is not present in the service will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff complete. Monitoring On 6/13/25 The DON/designee began administering a quiz to validate the effectiveness of the training for each member of the staff. Immediate re-education will be completed by the DNS/designee if any staff are unable to answer appropriately the questions on the quiz. Staff will not be allowed to work until after completion of the quiz. Projected completion 6/13/25 Starting on 6/12/25, the facility Administrator/Designee will review TELS work order report daily to ensure completion. Administrator/ Designee will also review the incidents and accidents to promptly identify possible accidents caused by unsafe beds. Any issues identified will be addressed at that time. An impromptu QAPI meeting was conducted with the facility's Medical Director, on 6/12/25, to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 6/12/25 Monitoring of the Plan of Removal included the following: Observation on 6/13/25 at 11:00 AM of four beds in the facility showed that slip pads had been put in place and beds were currently stable without added movement. Record Review of Skilled services in-service dated 6/12/2025 revealed an in-service in which staff are to report if the wheel locks on the bed move, they should report to the maintenance man and have TEL stoppers placed on the bed. Record review on 06/13/2025 of in-service signature sheet, revealed in service completed with staff to ensure that they know when and how to report issues with residents' beds. Record Review on 06/13/2025 QAPI minutes and recommendation reviewed, and ad-hoc minutes and documentation reviewed. Facility and staff are aware of issues with bed locks. All locks have been secured with slip pads. Interview with the Administrator on 06/13/2025 at 9:45 AM, the Administrator presented signature sheet for staff in-service addressing resident beds and how to recognize issues with beds and how to report it. Interview with Staff A on 06/13/2025 at 11:02 AM revealed that the facility since 6/12/25 has completed training and in-service for all staff about bed safety and methods to ensure they are safe and how to report. The staff member was able to describe all steps of reporting and items to use for a bed with any function issues. Interview with Staff B on 06/13/2025 at 10:30 AM revealed that staff member was in service today prior to clocking in and start of shift. Staff B was able to discuss the procedure of reporting and how to determine if the bed needed adaptive hardware for the resident's safety. Interview with the maintenance director on 06/13/2025 at 12:34 PM revealed that the maintenance staff has checked every bed in the facility, along with tagging all non-occupied beds for future use. The maintenance director stated that he participated and will continue to participate in the in-service for new and future employees. Interview with Staff C on 06/13/2025 at 12:52 PM revealed that the staff member was in service on the beds and wheels. Staff stated that she was in service on how to report on maintenance and record work order in the system. Face to Face Staffing with Administrator on 06/13/2025 1:55 PM The Investigator currently has lowered the IJ. The facility has completed the necessary training and completed the necessary maintenance to all beds in the facility to ensure the safety and well-being of each resident. The facility was informed that the immediacy was removed on 06/13/2025 at 1:55 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure that residents had the right to self-administer medication, if the interdisciplinary team, has determined this practice as clinically appropriate for 1 out of 8 residents (Resident #45) reviewed for self-administration of medication. The failed to assess Resident #45, who suffered from tremors associated with a diagnosis of Parkinson's Disease, for the ability to self-administer lubricant eye drops in that Resident #45 self-administered eye drops to herself from admission [DATE]) to 05/21/25. This failure could place residents at risk of inappropriate medication doses, medication errors, drug interactions, and side effects. Findings include: Record review of Resident #45's Face Sheet dated 05/22/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: Parkinsonism (a group of disorders that have tremors like those identified in Parkinson's Disease), anxiety disorder, voice and resonance disorders, mild dementia without behavioral disturbance. Record review of Resident #45's Undated Care plan revealed, focus- resident has Parkinson's disease and is at risk for injury from increased tremors and involuntary muscle movements; interventions- assist with ADL's as needed and give meds per order. There was no focus area that addressed self-administration of eye drops. Record review of Resident #45's Quarterly MDS dated [DATE] revealed, the use of corrective lenses and intact cognition as indicated by a BIMS score of 14 out of 15. Resident #45 needed partial/moderate assistance with toileting, showering, lower body dressing, the resident did not have Parkinson's disease but instead had unspecified Parkinsonism. Record review of Resident #45's EMR on 05/21/25revealed, no documentation of a completed assessment for the self-administration of Medication. Record review of Resident #45's Order Summary Report dated 05/22/25 revealed, Resident #45 did not have an order for eye drops prior to 05/21/25. Record review of Resident #45's Self Administration of Meds assessment dated [DATE] at 04:11 PM completed by ADON A revealed, Resident #45 was not a candidate for the self-administration of medications because of her diagnosis of dementia. An observation and interview on 05/20/25 at 09:10 AM revealed Resident #45 in bed, well dressed, well-groomed in no immediate distress. The resident had her glasses on as she cleaned her eyes with wipes. Resident #45 experienced tremors, as both her legs and hands jerked as she cleaned her eyes. There was a cart at the resident's bedsides that contained boxes of Refresh Celluvisc and Systane lubricant eye drops. Resident #45 said she had her eyedrops at her bedside and administered the eyedrops herself. She said she had not been trained or assessed to self-administer her eyedrops and did not elaborate on how often she administered the eyedrops daily. An observation and interview on 05/22/25 at 04:01 PM revealed Resident #45 sitting in a wheelchair beside her bed. The cart beside her bed no longer contained eyedrops. The resident said facility staff had removed her eyedrops yesterday, and she did not know she was not supposed to have them. Resident #45 said she had the eyedrops in her room and self-administered them since she was admitted in January of 2025. She said the eye drops were originally stored on her bedside table, but the facility staff said she could not place them there, so she moved them to the cart on the side of her bed. Resident #45 said since the eyedrops were an OTC, she did not think it was an issue for her to keep them in her room or administer them herself. In an interview on 05/22/25 at 03:55 PM, the DON said she was not aware that Resident #45 had eyedrops at her bedside and self-administered the eyedrops until it was identified by the survey team and physician's order was entered. She said Resident #45 did not have an order for the eye drops so her physician entered in an order for lubricant eyedrops in the evening of 05/21/25. The DON said prior to a resident's self-administration of medication they must be assessed for their ability to do so safely, and no assessment for self-administration of medication was completed for Resident #45 yet, so she should not be instilling her own eyedrops or have them at her bedside. The DON said failure to assess a resident's ability to self-administer medication prior to the resident administering the medication could place the resident at risk for drug interactions and side effects. In an interview on 05/23/25 at 09:26 AM, the DON said Resident #45 should not have administered her own eyedrops because she had tremors which would impact her ability to instill the drops. She said the resident was assessed for her ability to self-administer her eyedrops on 05/22/25 but the resident did not pass. A request was made for a policy for self-administration of medication was made on 05/23/25 at 03:52 PM. The policy was not provided prior to exit. Record review of the facility policy titled Medication Administration revised 01/2025 revealed: Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 3 of 4 residents (Resident #1, Resident #22 and Resident #43) reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse when CNA S yelled at her using a cuss word and asking what was wrong with her. The facility failed to ensure Resident #22 was free from verbal abuse when Medication Aide B used a racial slur towards her. The faciity failed to ensure Resident #43 was free from physical abuse when CNA A assisted with changing Resident #43's adult brief. These failures could place residents at risk of feelings of indignity, irritability, and sadness. The findings included: Resident #1 Record review of Resident #1's admission Record dated 5/22/25 revealed she was admitted to the facility on [DATE] with diagnoses of cerebral palsy (a condition that is caused by brain damage or abnormal development of the brain that affects movement and coordination), epilepsy (a neurological condition that causes recurrent seizures), anxiety disorder, dementia (a decline in memory or other thinking abilities that can interfere with daily life), aphasia (a communication disorder that impairs a person's ability to process and understand language), major depressive disorder and adjustment disorder (a mental health condition triggered by a stressful life event or change causing difficulty in coping and adapting). She was [AGE] years of age. Record review of Resident #1's Care Plan Report, undated, revealed the following focus areas, goals, and interventions: - Focus: (Resident #1) was at risk of impaired communication. Goal: Resident would be able to effectively communicate basic needs. Target date: 4/17/25. Interventions: allow adequate time for resident's responses, educate staff on anticipation of resident's needs until an alternate communication method can be established, incorporate alternate means of communication such as music, song or visual demonstration, incorporate visual prompting, cues or gestures, and provide clear, simple instructions. - Focus: (Resident #1) had impaired communication including speech problems and tended to yell out related to expressive aphasia. Goal: Resident will be assisted with communication abilities. Target date: 4/17/25. Interventions: anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense , or responds to the feeling resident is trying to express, validate resident's message by repeating aloud. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed her speech clarity was described as no speech- absence of spoken words. She was rarely/never understood and rarely/never understood others. She had severe cognitive impairment. She was dependent on others for all self-care tasks. Record review of a Provider Investigation Report dated 4/23/25 signed by the Administrator revealed on 4/21/25 at 2:30pm there was an allegation that CNA S, who was a contract worker, verbally abused Resident #1. Witnesses included Medication Aide E and a PASRR Provider. The section for Investigation Summary stated the following: Staff reports that a contract employee was speaking disrespectfully about (Resident #1) and overheard asking her 'What the F*** is wrong with you' while resident was hollering out. Staff immediately intervened and redirected the situation by escorting the staff member from the hallway into the administrator's office and assessing (Resident #1). CNA S was immediately terminated from the facility and the contracted staffing agency was notified. The facility confirmed the incident occurred. The resident was immediately assessed on 4/21/25 at 2:45pm with no signs of distress. Record review of a statement provided by CNA S dated 4/21/25 revealed she asked the Medication Aide why (Resident #1) was yelling. I wanted to know how she was communicating with me and what she was needing . I made a joke and said, is she just being an asshole? I was not in her room, I was down the hall. I did not say it to the resident or in front of the resident. In an observation on 5/20/25 at 1:32pm, Resident #1 was in her room sitting in her wheelchair. When surveyor spoke to her, she said the word fine multiple times loudly and shook her head up and down. In a telephone interview on 5/22/25 at 2:17pm, CNA S said on the day of the incident, she was scheduled to work the 2pm-10pm shift at the facility. She said she worked first at the facility a few months ago, then again in April 2025. She said she walked through the hall with the Medication Aide. She said she heard a patient yelling, and she had a hard time communicating. She said the resident was 3 doors down from where the medication aide was located on the hall. She said she did not yell at the resident. She said she asked the resident, What do you need? Do you need to change your brief? Do you need water? She said she approached the medication aide and wanted to know how she could communicate with her. She said she asked him if Resident #1 needed anything, or was she being an asshole? She said the comment she made was reported to the Administrator. When asked about abuse or neglect training, she said she was not trained beforehand. She said she had to acknowledge something on the agency's website when she selected the shift, but she tapped through it and did not properly read it. Record review of a statement provided by Medication Aide E dated 4/21/25 revealed CNA S asked him what to do and what residents she is taking care of. His statement noted, A little while later, she said 'what the F*** is she yelling about. Why is she being an asshole. In an interview on 5/20/25 at 2:47pm, Medication Aide E said on the day of the incident, he was working on Resident #1's hall. He said when he arrived, he showed CNA S what to do, gave her a tour, and briefly described her assigned residents. He said a little while later when he was on the medication cart, he heard CNA S use very unprofessional language down the hall near Resident #1's room. He said the PASRR Provider was nearby, but he was not sure exactly what was said. He said she started talking to him using unprofessional language. He said the incident was immediately reported to the administrator. Record review of a statement provided by the PASRR Provider dated 4/22/25 revealed she overheard the CNA talking to Resident #1 stating, What the F*** is wrong with you, then states she overheard the CNA tell Medication Aide E, what is wrong with (Resident #1) or is she just being an a******. In a telephone interview on 5/22/25 at 10:35am, the PASRR Provider said on the day of the incident, she was two rooms down from Resident #1's room with another resident. She said Resident #1 was usually very loud, and on this day she was being herself. She said she heard a staff member say, What the hell is wrong with you. Shut the F*** up. She said she got up and walked down to Resident #1's room and saw CNA S with Resident #1. She said she asked Resident #1 if she was okay, and she started laughing. She said CNA S looked her up and down. She said they left the room, and Medication Aide E was on a cart nearby. She said she heard CNA S tell the medication aide, Can I ask you a question? What is wrong with her, is she just being an asshole? She said when CNA S left, she told Medication Aide E that Resident #1 could not communicate, and it was reported to the administrator right away. When asked if the interaction between CNA S and Resident #1 was considered verbal abuse, she said yes. Record review of Resident #1's Behavioral Health Diagnostic assessment dated [DATE] revealed she was referred to psychology services due to a recent staff incident. The assessment described using a patient language flip chart to assess mood and clinical concerns. Patient indicated being 'happy' several times . When asked how she was doing she reported being 'fine' and frequently smiled at the clinician . it appears with prompting and assistance (or by yelling out) (patient) is able to make needs known. The assessment was signed by the Licensed Psychologist. In an interview and record review on 5/22/25 at 11:30am, the Administrator said when an agency CNA scheduled a shift at the facility, they had to complete abuse and neglect training and review facility expectations before they scheduled a shift. The Administrator reviewed the agency's website and found CNA S' acknowledgement. Record review of the acknowledge revealed it was dated 4/21/25 at 7:39am. Resident #22 Record review of Resident #22's admission Record dated 5/21/25 revealed she was admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (a group of conditions that affect the blood vessels and blood supply to the brain), morbid obesity, dementia with agitation, contractures of the left and right hand and left and right lower legs (a condition of shortening and hardening of the muscles, often leading to deformity and rigidity of joints), bipolar disorder (a mental health condition characterized by extreme mood swings), anxiety disorder, major depressive disorder and history of transient ischemic attack (a temporary disruption of blood flow to the brain). She was [AGE] years of age. Record review of Resident #22's Care Plan Report, undated, revealed the following focus areas, goals and interventions: - Focus: Resident #22 had periods of inattention and delirium related to disorganized thinking. Goal: Resident would be free of symptoms of delirium including changes in behavior, mood, cognitive function and communication. Target Date: 12/23/24. Interventions: Educate the caregivers to observe for and report any signs and symptoms of delirium, encourage the resident's caregivers to be at bedside during acute episodes in order to provide familiarity and support and engage the resident in simples, structured activities that avoid overly demanding tasks. - Focus: Resident #22 had impaired cognitive function and impaired thought processes related to dementia. Goal: Resident's needs would be met and dignity would be maintained, and the resident would be able to communicate basic needs on a daily basis. Target Date: 12/23/24. Interventions: Ask yes/no questions in order to determine the resident's needs, cue, reorient and supervise as needed, identify yourself at each interaction, keep the resident's routine consistent, try to provide consistent caregivers as much as possible in order to decrease confusion, monitor and report any changes in cognitive function, and present just one thought, idea, question or command at a time. - Focus: Resident #22 had unwanted behaviors related to cursing at staff, made false accusations at staff, and could be racist and called staff names at times. Goal: The resident would have fewer episodes of racial slurs one time a week. Target date: 12/23/24. Interventions: Anticipate and meet the resident's needs, caregivers to provide opportunity for positive interaction and attention, explain all procedures to the resident before starting and allow the resident time to adjust to changes, give 1:1 assistance to try and calm resident down as needed, discuss the resident's behavior and explain why behavior is inappropriate, monitor behavior episode and attempt to determine underlying cause and praise any indication of the resident's progress/improvement in behavior. Record review of Resident #22's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 12, indicating she had moderate cognitive impairment. She had a PHQ-9 score of 7, indicating mild depression. She was dependent on others for all self-care tasks except for eating, when she required partial/moderate assistance of others. Record review of a Provider Investigation Report dated 10/31/24 signed by the Former Administrator revealed Resident #22 told an employee of psychology services that a facility staff member, Medication Aide B, called her white trash. The Former Administrator interviewed the resident, and she said the staff was in the hallway and said white trash. She could not recall the date it occurred. Resident #1 was assessed by psychology services on 10/30/24. The section for Provider Response stated, Staff was removed from 10/30/24 shift pending investigation. Abuse/neglect in-service was initiated. Witness agency CNA for hospice says that the staff of facility (Medication Aide B) did not state what patient said. Witness states resident is not giving a truthful encounter. Agency staff states she would have reported staff if the staff abused resident, but staff did not. The investigation findings were unfounded. Record review of the Former Administrator's attached Investigation Summary dated 10/31/24 revealed she was notified on 10/30/24 at 2pm by a contract psychology services staff member that Resident #22 made an allegation of abuse. She interviewed Resident #22 and she said the staff called her white trash yesterday (the administrator's statement did not indicate who the staff member was), and stated she apologized for calling staff names. At 10/30/24 at 2:30pm, the Former Administrator interviewed the staff that the resident made the allegation about, Medication Aide B. Medication Aide B reported on the evening of 10/29/24, she noticed the hospice aide was assisting Resident #22 with the door open, and she closed the door. The Former Administrator interviewed the hospice aide and the nurse who worked the evening shift with no significant findings. The facility staff interviewed random staff who worked on Resident #22's hallway and found they were not aware of abuse or neglect and could state the abuse/neglect policy and procedures. The Former Administrator concluded, no abuse or neglect occurred. The resident has history of calling staff racial slurs/names (the N-word). The staff in question is African American and has admitted this resident has called her (the N-word) on several occasions. She stated she doesn't enter the resident's room and she is always assigned to another staff member because of the disrespect by resident towards her. When resident has been asked why she speaks this way by (Former Administrator), she responds 'that's how I was raised.' . Patient's family/RP state they are aware of her behaviors and false allegations, and they do not believe anyone abuse patient (Resident #22). Employee was allowed to return to regular schedule. In an interview on 5/21/25 at 9:46am, Resident #22 said a few months ago, Medication Aide E was in her room talking with her. She said she told her something I did with men and thought she did it, too. I thought we could be friends. She said Medication Aide E then called her white trash. She said she felt insulted because of the comment. In an interview on 5/22/25 at 2:40pm, Medication Aide E, when asked about the comment she made, she said You mean right after she called me a (n-word)? I asked her to describe the incident. She said a few months ago, she had finished changing her brief or feeding her. She said Resident #22 asked her to change the TV channel, and she said she would after she put the tray down. She said then, Resident #22 called her the n-word. She said she told her, What if I called you white trash? How would you feel? She said after that, Resident #22 said she hurt her feelings. She said they have not had any interactions since then. She said she looked at Resident #22 as a friend since she was younger. I felt surprised, she hurt my feelings. If it was an older resident with dementia, it would have rolled off. Resident #43 Record review of Resident #43's face sheet dated June 11, 2025 revealed a [AGE] year-old female who initially admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of moderate dementia with behavioral disturbance, cerebral infarction (stroke), dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, congestive heart failure, Poly osteoarthritis, hypertension (high blood pressure), amaurosis fugax (temporary loss of vision in one or both eyes), reduced mobility, repeated falls, abnormality of gait and mobility, and pain. Record review of Resident #43 ' s Quarterly MDS (Minimum Data Set) dated 6/06/2025 revealed a BIMS Summary Score of 2 indicating severe cognitive impairment. Resident #43 ' s functional abilities revealed substantial/maximal assistance where the helper does more than half the effort for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfers and walking 10 feet was not attempted due to medical condition or safety concerns. Record review of Resident #43 ' s Care Plan dated 6/11/2025 revealed a self-care deficit for bathing, dressing, feeding with interventions to encourage resident to participate in planning day to day care, offer compassionate, empathic, ADL care to resident each day. Project a positive attitude when caring for the resident, provide assistance with ADL ' s as needed .Resident #43 required assistance to perform functional abilities in self-care and mobility with interventions to provide the following self-care assistance: .toilet hygiene, shower/bathe self, upper body dressing, roll left to right, sit to lying, lying to sitting on the side of the bed and with no back support, sit to stand, chair/bed-to-chair transfer, toilet transfer tub/shower required partial/moderate assistance and lower body dressing required substantial maximal assistance. Resident #43 had an ADL self-care performance deficit r/t dementia, and CVA with interventions to provide the following assistance with ADLs in self-performance and staff support for bed mobility with limited- total assist of 1 .transfer with limited- total assist of 1 and toileting with limited- total assist of 1. Resident #43 was at risk for falls and was at risk for increased falls and injury r/t gait/balance problems, poor communication/comprehension, poor safety awareness, psychoactive drug use with interventions to administer pain. Record review of Resident #43 ' s Bed Rails Evaluation assessment dated [DATE] revealed appropriate alternatives were attempted prior to considering bed rails and resident did not have bed rails at this time. Resident #43 was not able to state their preference, responsible party did not request bed rails, the level of consciousness did not fluctuate, but Resident #43 did display poor bed mobility or difficulty moving to a sitting position on the side of the bed, difficulty with balance or poor trunk control, but bed rails were not considered. Interview on 05/20/25 at 9:50AM with Resident #43, she stated that she could not remember A CNA pulling on her roughly or anything that allegedly happened. She stated that she did not remember the incident that took place. The resident does not require Dual help, she has risk of memory loss and delusion and is considered a fall risk, how she is ordered to maintain some areas of independence to aid in maintaining mental state of mind. Interview on 05/20/25 at 10:00 AM with Resident #43 ' s family member #1, she stated that Resident #43 was being assisted by the CNA A, when she heard her Resident #43 scream in what appeared to be pain. She stated that the camera was partially blocked but she could see some movement. She stated that she was unable to email the recordings. Observation and interview on 05/20/2025 at 10:30 AM with Resident# 43 ' s family member #2, revealed camera footage that shows resident #43 laying on the bed while CNA A was attempting to turn her on the bed to change resident #43. Observation revealed that on 04/09/25 7:09 Am Resident #43 was being changed by CNA A at which time CNA A pulled the chuck from under resident #43. The family stated that she saw the CNA pull the chuck from under the resident in a manner hard enough for Resident #43 to scream. Interview on 05/21/2025 at 10:45 AM with the Administrator, she stated that she self-reported the incident with Resident #43 where the CNA was assisting Resident #43 to change, and the former and contacted the family, about the incident that was reported to the agency. She stated she has never been abused and that the family never showed the provider any photos or video. Interview on 05/21/2025 at 12:34 PM with the CNA A, she stated that she worked with Resident #43 for one day. She stated that on 4/9/25 the day of the incident Resident #43 had feces on her and that she was moving the blanket that was under her to avoid her smearing or spreading bowel movement. A former staff member stated that she quit because she was upset that she was being blamed for mistreating Resident #43, when she was complaining that there were no wipes available to clean the resident. Interview on 05/20/25 at 9:15 Am with the Maintenance worker, he stated that the policy required that the beds, if reported that they slide or moving be placed on a TEL, a circular rubber stopper designed to stop the movement of wheels on the bed. Interview on 05/20/25 at 9:30 AM with the Administrator, she stated that it was discussed with the corporate office that the older beds had wheels and locks that were discontinued. She stated that because the locks were discontinued, it was determined that lock pads would be placed as needed on the base of the wheels. Record review of a One-on-One In-service Attendance Record dated 10/30/24 revealed Medication Aide B was in-serviced on abuse, neglect, policies and procedures and abuse coordinator. The in-service was provided by the Former Administrator. In an interview on 5/23/25 at 12:53pm, the Administrator stated the facility in-services staff on abuse and neglect at least once a month and emphasized it during new hire orientation. She said residents would be at risk of mental anguish and depression if they were verbally abused. She said after the incident that occurred with Resident #1, they removed CNA S from the hall, took statements, assessed Resident #1, referred her to psychology services, notified her physician, completed in-services, completed life safety interviews with residents and reported to the staffing agency. She said CNA S was onsite at the facility for about 30 minutes. Record review of the facility's Abuse Neglect and Exploitation Policy dated 1/8/23 and revised on 1/2025 read in part, 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 .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish which can include staff to resident abuse . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administrating of all drugs and biologicals, to meet the needs of each resident for 1 of 8 residents (Resident #45) and 1 of 4 med carts ( 200 Hall Med Aide Cart) reviewed for pharmacy services. - The facility failed to administer Resident #45's Carbidopa/Levodopa (a medication used to treat tremors associated with Parkinson's Disease) on time, resulting in the resident experiencing increased tremors. - The facility failed to ensure that the 200 Hall Med Aide Cart did not contain expired OTC Aspirin 325 mg (about the weight of ten grains of rice). These failures could place residents at risk for adverse drugs reactions, side effects and uncontrolled health conditions. Resident #45 Record review of Resident #45's Face Sheet dated 05/22/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: Parkinsonism (a group of disorders that have tremors like those identified in Parkinson's Disease), anxiety disorder, voice and resonance disorders, mild dementia without behavioral disturbance. Record review of Resident #45's Undated Care plan revealed, focus- resident has Parkinson's disease and is at risk for injury from increased tremors and involuntary muscle movements; interventions- assist with ADL's as needed and give meds per order. Record review of Resident #45's Quarterly MDS dated [DATE] revealed that residents wore corrective lenses and had intact cognition as indicated by a BIMS score of 14 out of 15. Resident #45 needed partial/moderate assistance with toileting, showering, lower body dressing, the resident did not have Parkinson's disease but instead had unspecified Parkinsonism. Record review of Resident #45's Physician's Orders dated 01/17/25 revealed: Carbidopa-Levodopa ER 25-100mg- Give 1 tablet by mouth in the morning at Parkinson's Disease; scheduled at 08:00 AM Carbidopa-Levodopa 25-100 mg (IR)- Give 1 tablet by mouth in the morning at Parkinson's Disease; scheduled at 08:00 AM. Carbidopa-Levodopa 25-100 mg (IR)- Give 1 tablet by mouth in the morning at Parkinson's Disease; scheduled at 12:00 PM. Record review of Resident #45's Medication Administration Record provided by the Administrator of 05/21/25 at 05:47 PM revealed, the facility failed to administer Resident #45's Carbidopa/Levodopa 25-100 mg IR tablets within 1 hour of the scheduled administration time on: 1. 03/31/25 scheduled at 08:00 AM; administered at 09:06 AM. 2. 04/01/25 scheduled at 12:00 PM; administered at 01:08 PM. 3. 04/07/25 scheduled at 08:00 AM; administered at 09:03 AM. 4. 04/09/25 scheduled at 08:00 AM; administered at 09:12 AM. 5. 04/13/25 scheduled at 08:00 AM; administered at 09:08 AM. 6. 04/14/25 scheduled at 08:00 AM; administered at 09:26 AM. 7. 04/15/25 scheduled at 08:00 AM; administered at 09:03 AM. 8. 04/16/25 scheduled at 12:00 PM; administered at 01:03 PM. 9. 04/19/25 scheduled at 08:00 AM; administered at 09:30 AM. 10. 04/21/25 scheduled at 08:00 AM; administered at 09:27 AM. 11. 04/22/25 scheduled at 08:00 AM; administered at 09:01 AM. 12. 04/23/25 scheduled at 08:00 AM; administered at 09:04 AM. 13. 04/24/25 scheduled at 08:00 AM; administered at 09:04 AM. 14. 04/26/25 scheduled at 08:00 AM; administered at 09:01 AM. 15. 04/27/25 scheduled at 08:00 AM; administered at 09:01 AM. 16. 04/28/25 scheduled at 12:00 PM; administered at 01:12 PM. 17. 05/01/25 scheduled at 08:00 AM; administered at 09:14 AM. 18. 05/03/25 scheduled at 08:00 AM; administered at 09:05 AM. 19. 05/03/25 scheduled at 12:00 PM; administered at 01:36 PM. 20. 05/04/25 scheduled at 08:00 AM; administered at 09:02 AM. 21. 05/05/25 scheduled at 08:00 AM; administered at 09:07 AM. 22. 05/08/25 scheduled at 08:00 AM; administered at 09:01 AM. 23. 05/09/25 scheduled at 08:00 AM; administered at 10:18 AM. 24. 05/03/25 scheduled at 08:00 AM; administered at 09:12 AM. 25. 05/12/25 scheduled at 08:00 AM; administered at 09:25 AM. 26. 05/13/25 scheduled at 08:00 AM; administered at 09:05 AM. 27. 05/14/25 scheduled at 08:00 AM; administered at 09:16 AM. 28. 05/15/25 scheduled at 08:00 AM; administered at 09:31 AM. 29. 05/18/25 scheduled at 08:00 AM; administered at 09:08 AM. 30. 05/20/25 scheduled at 08:00 AM; administered at 09:22 AM. Record review of Resident #45's Medication Administration Record provided by the Administrator of 05/22/25 at 12:26 PM revealed, the facility failed to administer Resident #45's Carbidopa/Levodopa 25-100 mg ER tablets within 1 hour of the scheduled administration time on: 1. 03/21/25 scheduled at 08:00 AM; administered at 09:03 AM. 2. 03/22/25 scheduled at 08:00 AM; administered at 10:52 AM. 3. 03/24/25 scheduled at 08:00 AM; administered at 09:36 AM. 4. 03/25/25 scheduled at 08:00 AM; administered at 09:10 AM. 5. 03/29/25 scheduled at 08:00 AM; administered at 09:37 AM. 6. 04/02/25 scheduled at 08:00 AM; administered at 11:37 AM. 7. 04/11/25 scheduled at 08:00 AM; administered at 09:23 AM. 8. 04/17/25 scheduled at 12:00 PM; administered at 09:25 AM. 9. 04/23/25 scheduled at 08:00 AM; administered at 09:04 AM. 10. 04/25/25 scheduled at 08:00 AM; administered at 09:24 AM. 11. 04/27/25 scheduled at 08:00 AM; administered at 09:24 AM. 12. 04/28/25 scheduled at 08:00 AM; administered at 09:12 AM. 13. 05/09/25 scheduled at 08:00 AM; administered at 09:01 AM. 14. 05/20/25 scheduled at 08:00 AM; administered at 09:25 AM. 15. 05/21/25 scheduled at 08:00 AM; administered at 11:11 AM. An observation and and interview on 05/20/25 at 09:10 AM revealed Resident #45 in bed, well dressed, well-groomed in no immediate distress. The resident had her glasses on as she cleaned her eyes with wipes. Resident #45 experienced tremors, as both her legs and hands jerked as she cleaned her eyes. Resident #45 said the facility had failed to administer her medications (Carbidopa/Levodopa) on time and she had Parkinson's Diseases so her medications being on time was important because it controlled her tremors. In an interview on 05/22/25 at 03:55 PM, the Interim DON said resident's diagnoses with Parkinson's Disease suffer from symptoms such as tremors, shuffled walking, and gait. She said Carbidopa/Levodopa was used to keep the symptoms at bay and if it were now administered timely, it would result in the worsening of symptoms. In an interview on 05/22/25 at 04:01 PM, Resident #45 said she was ordered to receive an ER & IR dose of her Carbidopa/Levodopa at 08:00 AM and an IR dose at 12 PM. She said on the previous day (05/21/25) she did not receive her ER dose until 11 AM. Resident #45 said the facility failed to give her Carbidopa/Levodopa on time frequently which caused her tremors to worsen making it difficult for her to complete tasks. An observation and interview on 05/23/25 at 08:55 AM revealed Resident #45 sitting in a wheelchair as she read a book placed on her bedside table. The resident wore glasses and had no visible tremors. Resident #45 said she did not have tremors at the time because she had received her Parkinson's medications on time. She said when she received her medications timely, she had little to no tremors, but when the administration times were not consistent, her tremors would get worse making her unable to do basic things. In an interview on 05/23/25 at 12:15 PM, the Interim DON said all medications must be administered within 1 hour of the scheduled administration time. She said the facility identified concerns that Resident #45 had not received her Carbidopa/Levodopa timely, but she had not reviewed the records to determine how late the medication was administered or how often it was administered late. She said failure to administer Resident #45's Carbidopa/Levodopa on time placed the resident at risk of tremors, rigidity, and pain. 200 Hall Med Aide Cart In an observation and interview on 05/21/25 at 08:17 AM, inventory of the 200 Hall Med Aide Cart with MA A revealed: - An expired, open, and in-use bottle of Aspirin 325 with an expiration date of 03/25/25. MA A said nursing staff are expected to check their carts daily as used for expired medications. She said when medications expired, they could lose potency, have decreased efficacy and if administered could cause side effects in residents such as GI upset. In an interview on 05/23/25 at 09:56 AM, the Interim DON said nursing staff are expected to check their carts daily for expired medications. She said when medications expired there can be a change in their efficacy/potency, so they must be discarded. Record review of the facility policy titled Medication Administration revised 01/2025 revealed, Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 12- Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. a- refer to drug reference if unfamiliar with the medication, including the mechanism of action or common side effects. b- Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. Record review of the Pharmacy and Therapeutics (P &T) journal article titled Delayed Administration and Contraindicated Drugs Place hospitalized Parkinson's Disease Patients at Risk published [DATE] revealed, Patients with Parkinson's disease require strict adherence to an individualized, timed medication regimen of antiparkinsonian agents. Dosing intervals are specific to each individual patient because of the complexity of the disease. It is not unusual for patients being treated with carbidopa/levodopa to require a dose every one to two hours. When medications are not administered on time and according to the patient's unique schedule, patients may experience an immediate increase in symptoms.2 Delaying medications by more than one hour, for example, can cause patients with Parkinson's disease to experience worsening tremors, increased rigidity, loss of balance, confusion, agitation, and difficulty communicating.

Based on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (200 Hall Med Aide Cart) and 1 of 8 residents (Resident #45) reviewed for medication storage . The facility failed to ensure Resident #45 did not have unauthorized and unsecured OTC eyedrops at her bedside. The facility failed to ensure that the 200 Hall Med Aide Cart did not contain: loose pills and inappropriately labeled oral and liquid protein supplements. These failures could place residents at risk for adverse drugs reactions, side effects and uncontrolled health conditions. Findings include: Resident #45 Record review of Resident #45's Face Sheet dated 05/22/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: Parkinsonism ( a group of disorders that have tremors like those identified in Parkinson's Disease), anxiety disorder, voice and resonance disorders, mild dementia without behavioral disturbance. Record review of Resident #45's Undated Care plan revealed, focus- resident has Parkinson's disease and is at risk for injury from increased tremors and involuntary muscle movements; interventions- assist with ADL's as needed and give meds per order. Record review of Resident #45's Quarterly MDS dated [DATE] revealed, the use of corrective lenses and intact cognition as indicated by a BIMS score of 14 out of 15. Resident #45 needed partial/moderate assistance with toileting, showering, lower body dressing, the resident did not have Parkinson's disease but instead had unspecified Parkinsonism. Record review of Resident #45's Physician Order dated 05/21/25 at 06:06 PM revealed, Systane eye drops (a lubricant)- 1 drop in both eyes every four hours as needed for dry eyes. Record review of Resident #45's Order Summary Report dated 05/22/25 revealed Resident #45 did not have an order for eye drops prior to 05/21/25. An observation and interview on 05/20/25 at 09:10 AM revealed Resident #45 in bed, well dressed, well-groomed in no immediate distress. The resident had her glasses on as she cleaned her eyes with wipes. Resident #45 experienced tremors, as both her legs and hands jerked as she cleaned her eyes. There was a cart at the resident's bedsides that contained boxes of Refresh Celluvisc and Systane lubricant eye drops. Resident #45 said she had her eyedrops at her bedside and administered the eyedrops herself. She said she had not been trained to self-administer the eyedrops and no one had informed her the eyedrops should not be stored at her bedside. An observation and interview on 05/22/25 at 04:01 PM revealed Resident #45 sitting in a wheelchair beside her bed. The cart beside her bed no longer contained eyedrops. The resident said facility staff had removed her eyedrops yesterday, and she did not know she was supposed to have them. Resident #45 said she had the eyedrops in her room since she was admitted in January of 2025 and they were originally on her bedside table, but the facility staff said she could not place them there, so she moved them to the cart on the side of her bed. Resident #45 said since the eyedrops were an OTC, she did not think it was an issue for her to keep them in her room. In an interview on 05/22/25 at 03:55 PM, the DON said she was not aware of Resident #45 had eyedrops at her bedside until it was identified by the survey team. She said the eyedrops were removed from the resident's room on 05/21/25 and since Resident #45 did not have an order for the medication, her physician entered in an order for lubricant eyedrops in the evening of 05/21/25. She said unauthorized storage of medications could result in interactions and side effects if the medication is used without the provider's knowledge. She said all medications, even those used for residents who self-administer their own medications, should be locked away to ensure residents' safety. In an interview on 05/23/25 at 09:56 AM, the Interim DON said nursing staff are expected to check their carts daily for inappropriately labeled, inappropriately packaged medications and staff are expected to identify and report any unauthorized medications found in resident rooms during their daily rounding. She said all medications should be secured inside their original containers with pharmacy or manufacturer labeling and stored in medication carts/rooms. She said loose pills should be destroyed in the drug buster because they are gross and dirty and their presence could place residents at risk for unintended administration. The Interim DON said medications should not be stored in resident rooms, and they should be secured at all times. She said Resident #45 should not have medications stored at her bedside, and she did not know how long the resident had her eyedrops in her room because she never asked the resident. She said nursing staff are expected to look for any potential hazards when rounding with residents and the resident's unauthorized and unsecured medications were a hazard in case someone gained access to the medication and administered it. 200 Hall Med Aide Cart In an observation and interview on 05/21/25 at 08:17 AM, inventory of the 200 Hall Med Aide Cart with MA A revealed: - An expired, open, and in-use bottle of Aspirin 325 with an expiration date of 03/25/25. - An open and in-use bottle of ProStat concentrated liquid protein with no open date and manufacturer instructions that read Discard 3 months after opening. -4 loose pills of varying sizes and colors -An open and in-use bottle of Fish Oil 1000 mg (about the weight of a small paper clip) soft gel with no visible expiration date. MA A said nursing staff are expected to check their carts daily as they are used for loose pills, inappropriately labeled medications, and expired medications. She said medications should be stored in their original containers with pharmacy and/or manufacturer labeling, and multidose containers like liquid protein must be labeled with the date when opened to track the expiration date. She said when medications expired, they could lose potency, have decreased efficacy and if administered could cause side effects in residents such as GI upset. Record review of the facility policy titled Medication Storage revised 05/2023 revealed, 1-General Guidelines: a- all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.

Based on observation, interview and record review, the facility failed to prepare puree and regular food by methods that conserve nutritive value, flavor, texture and appearance for 3 out of 5 residents reviewed for food and nutrition dietary services (Residents #2, #40, #73). The facility failed to ensure that puree diet and regular diet was prepared by methods that conserve nutritive value, flavor, and appearance. This failure could place residents on regular diet and puree diet at risk of receiving inadequate diet that could affect their health. Findings included: Record review of the face sheet for Resident #2 revealed a [AGE] year-old female with admission date of 01/30/2025 and diagnoses including Type II Diabetes Mellitus (inability of pancreas to produce insulin to lower blood sugar), Hypertension (high blood pressure), Dysphagia (difficulty swallowing, Chronic Kidney Disease (long standing problems with the kidneys function). Record review of Resident #2's admission MDS revealed a BIMS score of 13, indicating intact cognitive ability. Record review of the face sheet for Resident #40 revealed an [AGE] year-old female with admission date of 04/11/2024 and diagnoses including Hypertension (high blood pressure), Cerebrovascular Disease (affect blood flow in the brain), Atherosclerotic Heart Disease (fatty deposits in your arteries). Record review of Resident #40's admission MDS revealed a BIMS score of 13, indicating intact cognitive ability. Record review of the face sheet for Resident #73 revealed an [AGE] year-old female with admission date of 06/20/2024 and diagnoses including Neuropathy (damage, disease, or dysfunction of one or more nerves), Type II Diabetes Mellitus (inability of pancreas to produce insulin to lower blood sugar). Record review of Resident #73's admission MDS revealed a BIMS score of 15, indicating intact cognitive ability. Observation of Surveyors test meal trays on 05/21/2025 at 12:08 pm revealed the pureed okra was too thick. Regular meal revealed the pinto beans was too salty. Interviewed on 05/21/2025 at 3:20 pm, The Dietary manager after he tasted the puree meal, he stated the okra was too thick, the cook did not use enough broth to puree the okra. For the regular meal Dietary manager stated, the pinto beans were too salty. He stated the cook followed the recipe, but he did not taste the food prior to sending the food out. The Dietary Manager stated the cook was nervous during the meal prep as the surveyor had requested 2 trays for taste testing and thinks this was a one time event. The Dietary Manager stated he did not feel the puree food being thick would affect residents on puree diet and too much salt could impact residents blood pressure. Interview on 05/21/2025 at @ 4:04 pm Resident #2 stated the pinto beans were very salty. Interview on 5/21/25 at @ 4:07 pm with Resident #40 regarding the lunch meal today she stated the beans were very salty. Interview on 5/21/25 at @ 4:12 pm with Resident #73 regarding the lunch meal today she stated the beans were too salty. Record Review: Food Preparation Guidelines: Policy Date Reviewed/ Revised: 09/06/2024: It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. Definitions: Food Palatability refers to the taste and/or flavor of the food. Policy Explanation and Compliance Guidelines: 1.The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. 2. Food shall be prepared by methods that conserve nutritive value, flavor and appearance.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 12 residents (Resident #43) reviewed for rights and dignity. - The facility failed to ensure that nursing staff used privacy curtain between the hallway door and the resident, removing resident from public view and prevent exposure of body parts while providing peri care to Resident #43. - The facility failed to ensure that the nursing staff used the privacy curtain between Resident #43 and Resident #45 while providing incontinence care to Resident #43, to prevent exposure of body parts. This failure could place residents at risk for loss of dignity, self-worth, and diminished quality of life. Record review of Resident #43's face sheet dated 06/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and originally admitted on [DATE]. The diagnoses included dementia, stroke, swallowing disorder, language disorder, arthritis, muscle weakness and delusional disorders. Record review of Resident #43's annual MDS dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. She required substantial/maximal assistance with toileting, sit to stand: helper does more than half the effort; helper lifts or holds trunk or limbs and provides more than half the effort. Resident #43 was frequently incontinent of bowel and bladder. Record review of Resident #43's undated care plan revealed: Focus- the resident had impaired cognitive function and impaired thought processes and may miss the intent when spoken to d/t Moderate Dementia with Behaviors. BIMS score of 5; Goal- will maintain current level of decision-making ability by review date. Target date 06/18/25. Interventions included - Communicate with the resident/family/caregivers regarding resident capabilities and needs. Cue, reorient and supervise as needed. Don't argue or correct me if I get confused to reality. Identify yourself at each interaction. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Focus - Resident #43 has an ADL self-care performance deficit r/t Dementia and stroke. Interventions included - Provide the following assistance with ADLs in self-performance and staff support, Transfer - limited-total assist of 1; Toileting - limited-total assist of 1. Focus - Resident #43 is always incontinent of bladder and bowel and requires assistance AEB self-care deficit, confused, disoriented related to dementia disease process. Goal- promote dignity by keeping resident clean, dry, and free from odor every shift through the next review. Target date: 06/18/2025. Resident will not develop any complications associated with incontinence. Observation on 6/18/25 at 2:30 PM of the undated video footage #2 submitted by the RP revealed, CNA-E was performing incontinent care for Resident #43. The privacy curtain was not drawn between the resident and the closed door. The door was not opened during the time the resident was exposed. Observation on 6/18/25 at 2:30 PM of an undated video footage #6 submitted by the RP revealed two unidentified nursing staff performing incontinent care for Resident #43. The curtain between Resident #43 and Resident #45 was not drawn. Resident #45 was sitting next to Resident #43's bed during the incontinent care. The curtain was not drawn between Resident #43's bed and the door to the hallway. During incontinent care, one of the nursing staff partially opened the door and stood at the open door while Resident #43's pants were around her knees and thighs were exposed. Interview on 06/18/25 at 10:30 AM, Resident #43 did not remember any incidents. Telephone interview on 6/18/25 at 3:45 PM, Resident #43's RP stated there were some video footage with the curtain not being closed properly to ensure Resident #43 was not exposed. Interview on 06/20/2025 at 1:05 PM, the Administrator stated a meeting with the RP occurred after the reported incident and the RP shared video footage. The Administrator stated the RP flipped through the video quickly the Administrator was unable to view much of the detail. Interview on 6/20/25 at 2:00 PM the ADON stated she expected when providing incontinent care, the nursing staff should announce themselves, provide privacy by closing doors, pull curtains as much as possible. Interview on 6/20/25 at 2:05 PM, the Corporate Nurse stated she expected nursing staff to provide privacy during incontinent care by closing doors and closing blinds. Record review of the facility investigation report revealed on 5/31/25 the Administrator received a call from the weekend supervisor LVN-E about Resident #43. LVN-E was instructed to call the RP and ask to review the cameras and to send CNA-E home. RP reported customer service issues regarding the CNA. Further review of the facility investigation revealed on 06/02/25 the Administrator and the DON met with Resident #43's RP at 11:00 AM to discuss the care concerns from the previous weekend. The meeting lasted one hour and the discussion included the resident's plan of care, incontinent care and overall needs. Record review of the facility policy for Perineal Care, revised on 1/2024 read in part: .It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed .Policy Explanation and Compliance Guidelines .4. Inform resident on procedure to be performed .5. Provide privacy by pulling privacy curtain or closing room door if a private room . Record review of the facility policy for Promoting/maintaining Resident Dignity, revised on 1/2025 read in part: .it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights 12. Maintain resident privacy .

Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 (Resident #34 and Resident #49) of 10 residents reviewed for resident call system in that: - The facility failed to ensure Resident #34's call light was within reach as it was laid on the floor This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Record review of Resident #34's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility with diagnoses of: dementia, anxiety disorder, schizophrenia, and generalized muscle weakness. Record review of Resident #34's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 13 out of 15, use of a walker and no upper and lower extremity impairments/functional limitations in range of motion. Record review of Resident #34's Care Plan dated [DATE] revealed, focus- risk of increased falls and injury related to psychoactive drug use; intervention- be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. An observation and interview on [DATE] at 09:13 AM revealed, Resident #34 in bed, her room was well organized, and her call light was on the floor. The resident as she rotated her body to get it from the floor as she laid in bed, she appeared to be at risk of falling off the bed. In an interview on [DATE] at 09:33 AM, CNA D said she last checked on Resident #34 30 minutes ago and her call light was within reach. She said the resident's call light as located on the floor was not correct and she picked it up and placed it on the residents bed. CNA D said call lights should be within reach and failure to do so could place residents at risk of falls or not having their needs met. In an interview on [DATE] at 09:56 AM the DON said call lights should be within reach and functional as failure to do so could result in a delay in care, failure to identify changes in condition, worsening of condition or pain. Record review of the facility policy titled Call Lights: Accessibility and Timely Response revised 02/2023 revealed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.).

Based on interview and record review the facility failed to notify the resident and the resident's representative of a transfer and the reasons for the transfer, effective date, location and statement of resident's appeal rights, and duration of the bed-hold policy in writing for 1 of 4 residents (CR #332) reviewed for transfers. The facility failed to ensure CR #332's representative received a written notice of transfer when she was transferred to a local psychiatric hospital on 2/21/25 and 2/26/25. These failures could place residents at risk of an insufficient preparation or orientation during transfer, inability to use their right to appeal, and lack of information. The findings included: Record review of CR #332's admission Record dated 5/21/25 revealed she was admitted to the facility on [DATE] with diagnoses of dementia (a decline in memory or other thinking abilities that can interfere with daily life), diabetes type II (when the body cannot use insulin correctly, leading to elevated blood sugar levels, major depressive disorder and fractures to the ribs, vertebra, sacrum and left pubic bone. She was [AGE] years of age. Record review of CR #332's Care Plan report (undated) revealed the following focus areas, goals and interventions: - Focus: Impaired coping. Goal: Resident would demonstrate effective coping mechanisms. Target Date: 4/7/25. Interventions: acknowledge awareness of the resident's fear. Encourage resident to verbalize feelings regarding fear and/or anxiety, explain all procedures as appropriate, using simple, concrete terms and monitor the effectiveness of resident's immediate support system. - Focus: Knowledge Deficit. Goal: Educate resident/representative of post-discharge rehabilitation plan. Resident/Representative will Understand and Participate in Treatment Regimen. Target date: 4/7/25. Interventions: Educate resident/representative regarding discharge instructions and follow-up plan, promote the importance of participation/compliance in treatment regimen, provide education regarding goals of treatment regimen. - Focus: CR #332 was an elopement risk/wanderer related to dementia. Goal: The resident's safety would be maintained. Target Date: 4/7/25. Interventions: Distract resident from wandering by offering pleasant diversions, identify patterns of wandering, monitor for fatigue and weight loss, provide structured activities, and report any attempts to exit the facility. Record review of CR #332's admission MDS assessment dated [DATE] revealed she had a BIMS of 3, indicating she had severe cognitive impairment. She had behavioral symptoms not directed toward others, including wandering and rejection of care, that occurred 1-3 days of the review period. The behaviors significantly interfered with the resident's care and intruded on the privacy or activity of others. She required supervision for walking and required setup assistance for self-care activities. Record review of CR #332's Nurse Progress notes revealed she had wandering behaviors on 2/19/25 and refused staff to enter her room and/or refused care on 2/20/25 and 2/21/25. Former Social Worker noted she was accepted to a local psychiatric hospital on 2/21/25 at 4:01pm and was transferred for further treatment and evaluation. She was readmitted on [DATE] at 6:02pm. Further record review of CR #332's Nurse and Social Services Progress notes revealed she had wandering behaviors on 2/24/25 and refused staff to enter her room and/or refused care on 2/25/25 and 2/26/25. On 2/25/25 at 10:27am, Former Social Worker noted she called CR #332's RP regarding the resident's behaviors. RP in agreement to refer resident back to (local psychiatric hospital). She was transferred to the local psychiatric hospital on 2/26/25 at 9:18am. Record review of a Social Services Note written by the Former Social Worker dated 2/26/25 at 11:07am read in part, Spoke to (family member) about resident's behaviors this morning. (Family member) aware that resident was transported to (local psychiatric hospital). Encouraged (family member) to follow through with touring the facilities provided to her previously as well as utilize (Assisted Living placement agency) as previously discussed to find a more appropriate setting for resident. She voiced understanding and asked that the social worker call her today. Consent obtained to box up resident belongings in the meantime. Record review of CR #332's Behavioral Health Discharge summary dated [DATE] revealed the date of CR #332's last service was 2/19/25. She was discharged from services due to her transfer to another facility. At the time of discharge, she was not considered to be at risk of harm to self or others. In an interview on 5/21/25 at 3:00pm, the Administrator stated CR #332 had behaviors and they helped her family members find a more appropriate setting for her like a secure nursing home. She said facility staff encouraged her family members to find placement before she returned to the facility. She said she had not provided CR #332's family members with a discharge notice. She said the resident's family members were agreeable to move her because the facility did not have a secure unit. In an interview on 5/23/25 at 10:14am, CR #332's family member stated the Administrator told her other family member that it would be better if she did not return to the facility because of her agitation and wandering behaviors. She said it felt like they were not welcome back. She said the facility never provided either of them with a written notice of transfer. In an interview of 5/23/25 at 11:45am, the Administrator stated when a resident was transferred to the hospital, they do not provide written documentation to the resident or responsible party. She said there was an assumption that residents were allowed to return to the facility. Record review of the facility's Transfer and Discharge Policy dated 1/2023 and revised on 8/2023 read in part, It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge of the resident from the facility, except in limited circumstances. 'Transfer' refers to the movement of the 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 . #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 include all of the following at the time it is provided: a. the specific reason and basis for transfer or discharge. B. The effective date of transfer or discharge. C. The specific location .to which the resident is to be transferred or discharged . D. An explanation for the right to appeal the transfer discharge to the State. E. The name, address, and telephone number of the State entity which receives such appeal hearing requests. F. Information on how to obtain an appeal form. G. Information on obtaining assistance in completing and submitting the appeal hearing request. H. The name, address, and phone number of the representative of the Office of the State Long-Term Care Ombudsman . In an interview with the Administrator on 5/23/25 at 12:53pm, when asked about their Transfer policy, specifically #4 of their policy, she said they were not completing notices like this for transfers. She said she thought Resident #332's transfer was involuntary. She said they could not meet her needs based on her behaviors, and it was unrealistic in the long run.

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 8 residents (Resident #45 and Resident #49) reviewed for accuracy of assessments. The facility failed to identify Resident #45's diagnosis of Parkinson's Disease in her Quarterly MDS and list of medical diagnosis. The facility failed to identify Resident #49's use of oxygen in her MDS. This failure could place residents at risk of a compromised plan of care. Findings include: Resident #45 Record review of Resident #45's Face Sheet dated 05/22/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: Parkinsonism ( a group of disorders that have tremors like those identified in Parkinson's Disease), anxiety disorder, voice and resonance disorders, mild dementia without behavioral disturbance. Record review of Resident #45's Undated Care plan revealed, focus- resident has Parkinson's disease and is at risk for injury from increased tremors and involuntary muscle movements; interventions- assist with ADL's as needed and give meds per order. Record review of Resident #45's Quarterly MDS dated [DATE] revealed, resident wore corrective lenses and had intact cognition as indicated by a BIMS score of 14 out of 15. Resident #45 needed partial/moderate assistance with toileting, showering, lower body dressing, the resident did not have Parkinson's disease but instead had unspecified Parkinsonism. Record review of Resident #45's Physician's Orders dated 01/17/25 revealed: Carbidopa-Levodopa ER 25-100mg- Give 1 tablet by mouth in the morning at Parkinson's Disease; scheduled at 08:00 AM Carbidopa-Levodopa 25-100 mg (IR)- Give 1 tablet by mouth in the morning at Parkinson's Disease; scheduled at 08:00 AM. Carbidopa-Levodopa 25-100 mg (IR)- Give 1 tablet by mouth in the morning at Parkinson's Disease; scheduled at 12:00 PM. Record review of Resident #45's Medication Administration Record provided by the Administrator of 05/21/25 at 05:47 PM revealed, Resident #45 was administered Carbidopa-Levodopa for Parkinson's Disease. An observation on 05/20/25 at 09:10 AM revealed Resident #45 in bed, well dressed, well-groomed in no immediate distress. The resident had her glasses on as she cleaned her eyes with wipes. Resident #45 experienced tremors, as both her legs and hands jerked as she cleaned her eyes. Resident #45 said she had Parkinson's Disease and received medications to treat her tremors. In an interview on 05/22/25 at 03:55 PM, the Interim DON said resident's diagnoses with Parkinson's Disease suffer from symptoms such as tremors, shuffled walking, and gait. She said Carbidopa/Levodopa was used to keep the symptoms at bay and if it was not administered in a timely manner, it would result in the worsening of symptoms. Resident #49 Record review of Resident #49's Face Sheet dated 05/22/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: bone cancer, shortness of breath, anal cancer, cognitive communication deficit, difficulty swallowing and pressure ulcer on her sacrum (triangular bone at the base of the spine). Record review of Resident #49's undated Care Plan revealed, focus: pneumonia; intervention: monitor/document/report to MD as needed for the following symptoms of pneumonia: fever, chills, cough, fast breathing, low oxygen. Focus: receiving nebulizer breathing treatments; interventions- monitor O2 saturation (levels) as needed or per orders, administer breathing treatments as ordered by MD. Focus: Hospice services due to terminal illness of anal cancer; intervention- assist with ADLs and provide comfort measures as needed, monitor for signs and symptoms of increased pain, discomfort-give medications/treatments monitor for relief. There was no focus area for oxygen administration. Record review of Resident #49's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15 and use of O2 was not indicated. Record review of Resident #49's Change of Condition MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15 and use of O2 was not indicated. Record review of Resident #49's Order Summary Report dated 05/22/25 revealed, Oxygen at 4 L/min via nasal canula as needed for shortness of breath, fast breathing (tachypnea) and respiratory distress. An observation and interview on 05/20/25 at 09:33 AM revealed, Resident #49 received oxygen via nasal canula between 3.5-4 L/min. The resident was dressed in a hospital gown, appeared well fed and in no immediate distress. Resident #49 woke up and said she had no current issues or concerns, and she would talk to the surveyor at a different time. In an interview on 05/23/25 at 10:48 AM, the MDS nurse said she was responsible for completing MDS assessments and entering the diagnosis for residents in the facility. She said she gets their diagnosis from either their recent MD visit or hospital records and that is transcribed into the resident's MDS and diagnosis list. The MDS nurse said after she clinically reviews the resident, she talks to the resident to ensure that their diagnosis match and she contacts their MD if there are any discrepancies. She said Parkinson's Disease is an actual disease while parkinsonism is just the symptoms. The MDS nurse said the items coded in the MDS (that identifies potential problems, needs, or strengths of a nursing home resident) trigger CAAs, which in return move into the resident's care plan. She said if a resident had an active problem that was treated in the facility it should be in her MDS. The MDS nurse said based on Resident #45's hospital records and admission paperwork she admitted with a diagnosis of Parkinson's Disease. The MDS nurse said Resident #45's diagnosis of Parkinson's Disease should have been in her list of her diagnosis and MDS, but it was not there, so she put a plan of correction in place to open a new cycle for Resident #45's MDS to correct the error. The MDS Nurse said failure to have accurate diagnosis and areas triggered in a resident's MDS, and diagnosis list can create resident rights & quality of life issues if a resident did not receive the correct care.

Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 Residents (Resident #49) reviewed for care plans. - The facility failed to identify Resident #49's use of oxygen in her care plan. This failure could place residents at risk of not having their needs met. Findings include: Record review of Resident #49's Face Sheet dated 05/22/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: bone cancer, shortness of breath, anal cancer, cognitive communication deficit, difficulty swallowing and pressure ulcer on her sacrum (triangular bone at the base of the spine). Record review of Resident #49's undated Care Plan revealed, focus: pneumonia; intervention: monitor/document/report to MD as needed for the following symptoms of pneumonia: fever, chills, cough, fast breathing, low oxygen. Focus: receiving nebulizer breathing treatments; interventions- monitor O2 saturation (levels) as needed or per orders, administer breathing treatments as ordered by MD. Focus: Hospice services due to terminal illness of anal cancer; intervention- assist with ADLs and provide comfort measures as needed, monitor for signs and symptoms of increased pain, discomfort-give medications/treatments monitor for relief. There was no focus area for oxygen administration. Record review of Resident #49's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15 and use of O2 was not indicated. Record review of Resident #49's Change of Condition MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15 and use of O2 was not indicated. Record review of Resident #49's Order Summary Report dated 05/22/25 revealed, Oxygen at 4 L/min via nasal canula as needed for shortness of breath, fast breathing (tachypnea) and respiratory distress. An observation and interview on 05/20/25 at 09:33 AM revealed, Resident #49 received oxygen via nasal canula between 3.5-4 L/min. The resident was dressed in a hospital gown, appeared well fed and in no immediate distress. Resident #49 woke up and said she had no current issues or concerns, and she would talk to the surveyor at a different time. In an interview on 05/23/25 at 10:48 AM, the MDS nurse said she was responsible for completing MDS assessments and care plans. The MDS nurse said after she clinically reviews the resident, she talks to the resident to ensure that their diagnosis match and she contacts their MD if there are any discrepancies. She said if a resident had an active problem that was treated in the facility it should be in her MDS. The MDS nurse said the items coded in the MDS (that identifies potential problems, needs, or strengths of a nursing home resident) trigger CAAs, which in return move into the resident's care plan. The MDS Nurse said failure to have accurate diagnosis and areas triggered in a resident's MDS, can create resident rights & quality of life issues if a resident did not receive the correct care.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 12 residents (Resident #43) reviewed for quality of care. - CNA-E failed to transfer Resident #43 using a gait belt as an assistance device to prevent accidents. CNA-E hooked her arm under Resident #43's arm, pulling upward to transfer resident from the bed to the wheelchair. This failure could place residents at risk of pain, injury, or hospitalization. Record review of Resident #43's face sheet dated 06/11/25 revealed a [AGE] year-old admitted to the facility on [DATE] and originally admitted on [DATE]. The diagnoses included dementia, stroke, swallowing disorder, language disorder, arthritis, muscle weakness and delusional disorders. Record review of Resident #43's annual MDS dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. She required substantial/maximal assistance with toileting, sit to stand: helper does more than half the effort; helper lifts or holds trunk or limbs and provides more than half the effort. Resident #43 was frequently incontinent of bowel and bladder. Resident #43 had no functional limitations in range of motion to the upper extremities or lower extremities and used a wheelchair for mobility. Record review of Resident #43's undated care plan revealed: Focus- the resident had impaired cognitive function and impaired thought processes and may miss the intent when spoken to d/t Moderate Dementia with Behaviors. BIMS score of 5. Goal- will maintain current level of decision-making ability by review date. Target date 06/18/25. Interventions included - Cue, reorient and supervise as needed. Don't argue or correct me if I get confused to reality. Identify yourself at each interaction. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Focus - Resident #43 has an ADL self-care performance deficit r/t Dementia and stroke. Interventions included - Provide the following assistance with ADLs in self-performance and staff support, Transfer - limited-total assist of 1; Toileting - limited-total assist of 1. Focus - Resident at risk for falls and injury r/t gait/balance problems. Poor communication/comprehension, poor safety awareness, psychoactive drug use, vision/hearing problems. Goals included - Resident #43 will not sustain serious injury through the review date. Interventions included - anticipate needs, provide prompt assistance with ADLs and other special needs. Record review of Resident #43's Therapist progress note dated 3/24/25 at 2:03 PM and written by the Occupational Therapist read in part: Therapist spoke with RP about resident being a one-person transfer. RP was agreeable. Therapist explained that being a two-person transfer would hinder patients' independence and resident to become more dependent on staff. Therapist findings Minimum assistance from chair to bed, Moderate assistance from bed to chair . Record review of a facility staff in-service dated 3/24/25, for Transfers (Resident #43) and conducted by Therapy revealed Resident #43 was a one person assist; all staff must use gait belt for sit to stand transfers; do not pick resident up from the arms; allow resident to use bedrail or wheelchair to grab on for transfer. Record review of Resident #45's face sheet dated 06/20/2025 revealed a [AGE] year-old admitted to the facility on [DATE]. Diagnoses included fracture of the thigh bone, Parkinson's disease, anxiety, and dementia. Record review of Resident #45's quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. Record review of the facility investigation summary revealed on 05/31/25 Resident #43's roommate Resident #45 reported that she overheard Resident #43 say ouch during incontinent care. The charge nurse assisted with the remaining care and then removed CNA-E from the room to investigate. Resident #43 made no allegations but stated she no longer wanted CNA-E. Resident #43 was immediately assessed, and no injuries or distress was observed. The RP was contacted by the weekend supervisor and notified of the roommate's concern and asked that the camera footage be reviewed. CNA-E was sent home. The RP reported that CNA-E did not seem to know how to put a diaper on but made no further allegations. The facility-initiated interviews with other residents to ensure there were no other concerns as per protocol. Further review of the facility investigation revealed the RP had a meeting with the Administrator and the DON on 6/2/25 to discuss customer service concerns after reviewing the camera footage and reported that the CNA over the weekend was rough with the resident during incontinent care. The CNA was identified as CNA-E. Continued review of the facility investigation included a statement from CNA-E which read in part: .After she was changed, and her clothes was put on I told her we will transfer to the wheelchair, and I needed her assistance to do so. As I sat her up and tried to assist her with standing she began to yell again, and I stopped and went and got the nurse because she did not want to get up. Resident #43 was reassessed, no delayed or new injuries observed, resident continued to deny pain and exhibited no signs or symptoms of psychological distress. The facility notified the Agency service of the allegation. CNA-E had been marked as do not return to the facility. Continued review of the investigation report revealed Resident #43 remained at her baseline with no adverse outcomes. Observation on 6/18/25 at 2:30 PM of the undated video footage #3 submitted by Resident #43's RP revealed that CNA-E had just completed incontinent care for Resident #43 and sat Resident #43 up on the edge of the bed. Resident #43 said I can't do it. CNA-E stated, yes you can, c'mon - one-two-three. CNA-E hooked her arm under Resident #43's right armpit and attempted to assist her in standing up and pulled upward under the arm and at the waist band of the pants. Resident #43 said oww-ouch! CNA-E said, you have to grab the wheelchair, put your had up here - one two three. CNA-E pulled under her arm and at her sweatshirt. Resident #43 said ouch-ouch-ouch, it's killing my thigh, gosh all mighty I don't need you! Resident #43 sat back on the bed. CNA-E stated, you have to hold on to the chair. CNA-E straightened out Resident #43's sweatshirt then walked out of the room and returned with LVN-B. LVN-B gave verbal instructions to Resident #43 and together with CNA-E, Resident #43 was transferred from the bed to the wheelchair without incident. In an observation and interview on 06/18/2025 at 1:45 PM, Resident #43 was sitting in a wheelchair in the TV room. She was very pleasant, calm and in no apparent distress. When asked if anyone was rough with her or made her feel bad, she stated not that she knew of and stated she was having a good day. On 06/19/2025 at 2:30 PM, telephone contact was attempted on three different occasions to reach out to CNA-E. The contact number did not allow to leave a voicemail. Telephone interview on 06/19/2025 at 11:56 AM, LVN-B stated she did not see the incident with CNA-E and Resident #43 and that she only assisted after CNA-E asked for help because the resident was not allowing anyone to help her. LVN-B stated she was attempting to deescalate and that she did not see anything physical. LVN-B stated Resident #43 needed a lot of direction with ADLs and with proper cueing she was able to get up on her own. LVN-B stated if Resident #43 was unable to stand she would try to use a sit-to-stand assistive device. In an interview on 6/20/2025 at 2:05 PM, the Corporate Nurse stated she expected nursing staff to check the resident's Kardex regarding transferring needs: whether a mechanical lift was needed, if resident was a 2 person assist or if the resident required use of a gait belt but not hooking arm under the resident's arm. The Corporate Nurse stated she expected the nursing staff to get help if the resident was not getting up as usual. In an interview on 06/20/2025 at 2:10 PM, Resident #45 stated the curtain was pulled and she thinks it was an aide from the agency who was getting Resident #43 dressed when she heard her say ouch several times. Resident #45 stated she must have been transferring her when she started hollering and saying ouch that hurts. Resident #45 stated that was when the aide went to get help and brought the nurse. Interview on 6/20/2025 at 2:25 PM, the Administrator stated when the surveyors exited the first time on 5/23/25, there was ongoing in-services when abuse and all other areas of concern were substantiated. The Administrator stated abuse in-services started again on 5/30/25, the day before the 5/31/25 incident involving Resident #43. The Administrator stated she added quizzes on abuse and random resident interviews included rights and dignity. Peri-care in-services started due to the initial report from Resident #43's RP that CNA-E did not know how to change briefs and included in-services on Dementia, specific in-service on Resident #43's plan of care. The Administrator stated added in services were in place with the Agency before 5/31/25 and that CNA-E completed all the required inservices on 5/13/25, then worked one day only on 5/31/25. Record review of the facility's staff training excel spread sheet revealed CNA-E completed Abuse training and Expectation and Education training on 5/13/25. Further review of the Expectation and Education training acknowledgement read in part: .You must sign the staffing Binder and the Agency Education Binder when you arrive to the facility each shift. You are expected to understand and comply with all binder contents and will be held to that standard .Expectations: .name tag and Gait belt . Continued review revealed CNA-E signed the acknowledgment. Record review of the facility's staff in-service dated 06/01/25, topic: Resident #43's plan of care, included - always explain to resident what you are doing prior to starting care. Continue to explain as care progresses. Record review of the facility policy and procedure for Safe Resident Handling/Transfers revised on 04/2023 read in part: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines Compliance Guidelines: .5. Handling aids may include gait belts, transfer boards, and other devices 14. Resident lifting transferring will be performed according to the resident's individual plan of care. Record review of the facility in-service dated 6/10/25, topic: Mechanical Lifts, safe Transfers, Gait Belts, Transporting Residents revealed: Gait belts should be used with all transfers not involving a mechanical lift; gait belts are a required part of the CNA uniform .our goal is to help residents improve and maintain their independence.

Based on 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 #22) reviewed for pain management. The facility failed to ensure Resident #22'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 5/22/25 indicated Resident #22 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Unspecified Cerebrovascular Disease, Chronic Gout, Contracture in left and right hands, Rheumatoid Arthritis, Contracture of Muscles right and left lower legs, and Other Chronic Pain. Record review of Resident #22's Quarterly MDS assessment dated [DATE] revealed resident had a BIMS Summary Score of a 15 (cognitively intact). Section J0300 for Pain Presence was coded as 0 pain in the last 5 days. Record review of Resident #22's care plan dated 4/16/25 indicated the resident had a risk for pain related to history of gout, and limited mobility due to traumatic brain injury. The physician was to be notified if current pain medications and non-pharmacological interventions were ineffective. The care plan also indicated the resident will maintain an adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress, verbalizing satisfaction with level of comfort. Record review of Resident #22's physician orders revealed the pain medication order was changed on 4/17/25. Order dated 1/6/25 was for two Hydrocodone-Acetaminophen 5-325 Mg tablets to be given by mouth every 6 hours as needed for Other Chronic Pain. This order was discontinued on 4/17/25 and replaced with an order for one Hydrocodone-Acetaminophen 5-325 Mg tablet to be given by mouth every 6 hours as needed for Other Chronic Pain. Record review of Resident #22's MAR dated 5/22/25 revealed resident was administered one Hydrocodone-Acetaminophen 5-325 Mg tablet on 4/23/25 at 5:36 AM by LVN A when she reported a pain level of 6 out of 10. At a follow-up assessment 2 hours later, resident reported the medication was ineffective. No other medication or intervention was offered until 6:12 PM when resident was given one Hydrocodone-Acetaminophen 5-325 Mg tablet. On 4/26/25 at 7:30 PM, resident was administered one Hydrocodone-Acetaminophen 5-325 Mg tablet when she reported a pain level of 7 out of 10. At a follow-up assessment 2 hours later, resident reported the medication was ineffective. No other medication or intervention was offered until 4/27/25 at 1:17 AM, when resident was given one Hydrocodone-Acetaminophen 5-325 Mg tablet. During an interview on 5/23/25 at 9:30 AM, Resident #22 reported she was satisfied with the pain management offered at the facility. She reported they give her medication when she asks and do what they can to help her. She does not have any complaints in that area. Sometimes the pain medication does not take all the pain away but she has learned to live with it. She did not recall any instances where she complained of pain and staff did not assist her in some way. During an interview on 5/23/25 at 9:45 AM, the Administrator reported that Resident #22 does not complain about pain very often but when she does, repositioning has helped. She was so constricted that she has pain and moving her sometimes takes care of the pain. The Administrator did not know why staff did not document interventions given when the resident reported the medication was ineffective. Review of the facility's policy Pain Management, dated 11/2023, 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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 dining room reviewed for essential equipment. The facility failed to keep the ice machine and water machine free of leaks. This failure could place the residents at risk of slipping on spilled water on the floor and consuming water and ice from equipment which may be contaminated due to malfunction. Findings included: During observation on 5/20/25 at 1:10 PM, the ice and water dispenser in the dining room had a full tray of water below the spickets. When the drawer below the machine was opened, water and dust was found in the bottom of the drawer. Water was also found in the cabinet below. Observation on 5/21/25 at 1:05 PM in the dining room, the ice and water dispenser had out of order sign. Water was no longer in the tray, the drawer, or below the machine. During an interview on 5/21/25 at 3:29 PM, the Dietary Manager reported they were in the process of letting the ice melt so the machine can be moved out and replaced. It had been leaking when the ice melted so the staff will not be using it anymore. An out of order sign has been placed on the machine to remind staff not to use it. A new machine was ordered and it should be there in a day or so. During observation on 5/22/25 at 12:30 PM, observed the out of order sign still on ice and water dispensing machine. During an interview on 5/23/25 at 11:20 AM with the Maintenance Director, he reported he was not made aware of the ice and water dispenser in the dining room was malfunctioning until Tuesday, 5/20/25. He also reported that he disconnected the machine immediately and put an out of order sign on it. The ice that was remaining in the machine was melting and the water was draining out so it could be moved. He has been emptying the tray since he was informed that it was leaking. He also cleaned out the drawer that had the water in it. It can no longer dispense anything so staff and residents can't use it. Approval to purchase a new machine and a new countertop has just been attained so new equipment will be ordered shortly. Policy on maintaining equipment in safe operating condition requested from the Administrator on 5/23/25 at 3:38 PM. The policy was not received.

Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1( Resident #49) of 10 residents reviewed for resident call system in that: - The facility failed to ensure Resident #49'scall light was in working order leaving the resident in pain. This failure could leave residents in pain due to their call light not functioning. Findings included: Resident #49 Record review of Resident #49's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: bone cancer, shortness of breath, anal cancer, cognitive communication deficit, difficulty swallowing and pressure ulcer on her sacrum (triangular bone at the base of the spine). Record review of Resident #49's undated Care Plan revealed, focus: pneumonia; intervention: monitor/document/report to MD as needed for the following symptoms of pneumonia: fever, chills, cough, fast breathing, low oxygen. Focus: receiving nebulizer breathing treatments; interventions- monitor O2 saturation (levels) as needed or per orders, administer breathing treatments as ordered by MD. Focus: Hospice services due to terminal illness of anal cancer; intervention- assist with ADLs and provide comfort measures as needed, monitor for signs and symptoms of increased pain, discomfort-give medications/treatments monitor for relief. There was no focus area for oxygen administration. Record review of Resident #49's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15 and use of O2 was not indicated. Record review of Resident #49's Change of Condition MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15 and use of O2 was not indicated. The resident was on hospice, Pain was present with rare impact on sleep, rare interference with therapy activity and occasional interference with day-to-day activities. Record review of Resident #49's Hospice RN Comprehensive Visit dated [DATE] revealed, Resident #49 was experiencing pain. was uncomfortable due to her pain and her pain was located on her rectum. Mental status: disoriented, withdrawn, forgetful, unable to report anxiety/depression due to not responding. Resident #49 was co-operative, indifferent, and showed abnormal behavior/mood and effect because she was withdrawn. Record review of Resident #49's Order Summary Report dated [DATE] revealed, Admit to Hospice. Hospice Care effective [DATE]; diagnosis: anal cancer and other conditions of cancer spread to the bone. Oxycodone w/ Acetaminophen 5-325 mg- give 1 tablet every 12 hours for pain management. Oxycodone w/ Acetaminophen 5-325 mg- give 1 tablet every 6 hours as needed for pain level 7-10. Morphine 20 mg/ml- give 0.25 ml by mouth every 6 hours for severe pain. Morphine 20 mg/ml- give 0.25 ml by mouth every 4 hours as needed for pain and shortness of breath. The record indicated that Oxycodone was discontinued when the resident was started her Morphine Sulfate on [DATE]. An observation on [DATE] at 02:45 PM revealed, Resident #49 in bed grimacing from pain. The resident said she could not think because of her pain and the pain was due to an ulcer on her bottom. She said the pain was so severe that she could not sleep, and she pressed the call light, but no one answered. The resident and the surveyor both pressed the call light and the light that indicated a call did not work. At 02:55 PM, the Administrator entered Resident #49's room after the surveyor notified her of the malfunctioning call light. She first pressed the call light to verify it was not working, then she unplugged and re-plugged the call light , and at that time the call light became functional. The resident did not communicate any other form of distress beyond the pain from her sacral ulcer; she would not elaborate further on her mental state or feelings. The Administrator said the call light must have malfunctioned, and it was working now once she unplugged and re-plugged it. In an interview on [DATE] at 02:59 PM, CNA X said she had just checked on Resident #49 recently and the resident expressed some discomfort as she repositioned her and at that time her call light was working. She could not say exactly when that occurred, but it was earlier in the day. In an interview on [DATE] at 03:00 PM, LVN D said she provided service to the resident recently and was unaware her call light was not working. She said the resident was in pain and needed repositioning because she had been lying on be bottom with her body titled towards the window. An observation and Interview on [DATE] at 03:24 PM revealed, Resident #49 received wound care with the Wound Care Nurse and CNA F. The resident was on her right side with support from CNA F and wound care was completed with good technique. Resident #49 said her pain medication had been working and was received regularly. In an interview on [DATE] at 09:56 AM the DON said call lights should be within reach and functional as failure to do so could result in a delay in care, failure to identify changes in condition, worsening of condition or pain. Record review of the facility policy titled Call Lights: Accessibility and Timely Response revised 02/2023 revealed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.).

Based on observation, interview, 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 4 residents (Resident #1) reviewed for infection. -The facility failed to ensure LVN A (Head Charge Nurse) performed hand hygiene during wound care on Resident #1. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. Finding included: Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), hypertension (a condition in which the force of the blood against the artery walls is too high) and urinary tract infection (an infection in any part of the urinary system). Record review of Resident #1's Entry MDS, dated [DATE], revealed there was no section for BIMS score, functional status, urinary incontinence, and bowel incontinence. Record review of Resident #1's care plan, initiated 3/25/2024 revealed the following: Care Plan Description: At risk for skin breakdown d/t weakness, parkinson's and immobility, 4/7/24 skin tear to gluteal fold measures 1.2x0.6cm noting fingernails long and jagged with nail care provided. 4/15 improved. Care Plan Goal: will minimize risk for skin breakdown daily and ongoing over the next 90 days. Monitor skin daily during care report any issues MD. Record review of Resident #1's physician order dated 5/11/24 revealed an order to cleanse sacrum with wound cleaner, when dry apply skin prep and calcium AG with boarder gauze dressing QA until resolved. In a telephone interview on 5/10/24 at 5:31p.m., with Resident #1's family member, he said the resident noted to have developed a bed sore on her sacrum, about the size of a quarter. It looks red. It was unknown if the resident was receiving wound care. He said he was concerned the wound could get infected as he had seen staff going in and out of the room not performing hand hygiene. Observation on 5/11/24 at 10:34a.m., revealed LVN A provided Resident #1 with wound care. LVN A was assisted by ADON. LVN A gathered the supplies at the treatment cart in the hallway before bringing them into Resident's room. Supplies included 1 wound cleanser bottle, 1 package of skin prep, 1 package of T drainage sponge, 1 package of boarder dressing and an opened package of Calcium Alginate. Prior to initiation of the treatment ADON asked LVN A to wash her hands. LVN A applied double gloves, closed curtain for privacy and assisted resident on to her right side. LVN A unfasten the resident's brief and removed one pair of gloves. LVN A removed the resident's soiled sacral area wound dressing and placed in the clear bag taped on the bedside table. There was no date visible on the dressing. Continued observation revealed an open area of approximately 1.0 centimeters in diameter. LVN A removed the 2nds pair of soiled gloves and without sanitizing/washing her hands LVN A applied clean gloves. LVN A sprayed the wound with the wound cleanser, opened the T drainage sponge packet and pat dried the wound with the T drainage sponge. LVN A then opened the skin prep package and applied the skin prep on to the wound. LVN A took small piece of calcium alginate from the opened calcium alginate package and applied that to the wound and covered it with dry boarder dressing. LVN A said, I have to hold the dressing for 10 seconds for it to adhere. LVN A pressed and held on to the dressing and counted for 10 seconds out loud. LVN A completed wound care and with the same soiled gloves on, touched the Resident's clean shirt, brief, sheet, and blanket. Observation on 5/11/24 at 10:45a.m., revealed ADON came out of Resident#1's room and used the hand sanitizer sitting on top of the treatment cart placed outside of Resident#1's room. Observation and interview on 5/11/24 at 10:47a.m., revealed LVN A came out of Resident#1's room opened the treatment cart placed outside of Resident#1's room. Unlocked the cart, took out sanitizing wipe out of the individual packaging and rubbed it over all areas of the hands for about 5 seconds. LVN A said she performed wound care on the weekends. She said she recalled doing competency check off for wound care about 3 months ago with the Corporate Nurse but could not recall the exact date. When asked LVN A if she double gloved when performing wound care. LVN A said, I don't like touching [NAME] she came back from the hospital last night and to protect myself I have cancer I double glove. At this time Surveyor asked if LVN A had the hand sanitizer in the room. LVN A said she did not like taking the hand sanitizer bottle in the room and preferred to use the sanitizing wipes. Surveyor shared the wound care observation from earlier explaining that no hand hygiene was observed during the wound care. LVN A said her actions in not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-service on infection control 3 month ago but could not recall the exact date. In an interview on 5/11/24 at 11:09a.m., with the ADON, she said LVN A should not have double gloved it's not the policy. LVN A should not have double gloves for patients protection. LVN A needed to get new set of gloves the discharge from the wound treatment can get on the other gloves and cross contaminate. In an interview on 5/11/24 at 1:29p.m., with the DON and the ADON. The DON said the expectation was to maintain infection control throughout the process. She said staff received in-service on infection control once or twice a month. She said wound care Nurse were provided training and competency check offs annually and as needed if noted concerns. DON said LVN A should not have double gloved she needed to use standard precautions. DON said LVN A preformed wound care on weekends. DON said LVN A was spot check by the wound care nurse that worked Monday through Friday. DON said she would do another competency check off and in-service LVN A. The DON said as per LVN A she opened the skin prep and the hand sanitizing wipes at the same time. At this time the Surveyor explained to the DON and the ADON that the Surveyor did not see the sanitizing wipes in the resident's room and did not observe LVN A using the wipe to rub it over all areas of the hands. The Surveyor further explained that LVN A should have performed hand hygiene prior to donning clean gloves. LVN A contaminated the wound. LVN A cleaned the wound with T drainage sponge and with the same soiled gloves, applied skin prep and Calcium Alginate. Record review of facility's Skills Check list for Wound Care dated 2/16/24 for LVN A revealed read in part: .9. Put on clean gloves 10. Remove soiled dressing and discard in red bag 11. Wash hands or use alcohol gel 12. Put on clean gloves 13. Clean wound following physician's orders 14. Wash hands or use alcohol gel 15. Apply ordered treatment to wound 16. Apply dressing and secure with tape, Date and initial dressing 17. Remove gloves and dispose into red bag, along with any unused supplies 18. Wash hands . Record review of facility's Policies and Practices - Infection Control dated (Revised July 2014) read in part: .Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . Record review of facility's Handwashing/Hand Hygiene policy dated (August July 2015) read in part: .Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves . Record review of facility's Wound Care policy dated (Revised January 2022) read in part: .Steps in the procedure: 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves .

Based on observation, interview and record review, the facility failed to ensure for 1 of 3 residents (Resident #1) who needed respiratory care was provided care consistent with professional standards of practice reviewed for respiratory care, in that: - Resident #1 was observed to be administered oxygen PRN, but nurses did not document the times PRN oxygen was given . - LVN D reported Resident #1's oxygen dipping low at times but did not document change of conditions and times in which PRN oxygen was needed. This failure placed Resident #1 at risk of not receiving adequate respiratory care. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with cerebral palsy, shortness of breath, epilepsy, dementia and muscle wasting atrophy. Observations on 04/09/2024 at 10:34AM, revealed Resident #1 lying in bed with her nasal cannula on receiving oxygen from her oxygen concentrator set on 2L/min. The humidifier attached was labeled with date 04/07/24. Resident was observed have unlabored breathing. Record review of Resident #1's comprehensive MDS, dated [DATE], revealed the resident was not noted to have oxygen therapy while a resident. Record review of Resident #1's care plan, not dated, revealed the resident was at risk for shortness of breath and coughing up yellow phlegm due to acute diagnosis of acute bronchitis, resolved 05/05/2021 status post COVID and intervention listed included to administer oxygen as ordered. Record review of Resident #1's vital signs revealed from 03/29/2024 - 04/10/2024, the resident was documented to have O2 sat% of at least 95% or above. Record review of Resident #1's physician's orders revealed the resident had an order to: - Check humidifier and change PRN when water level is low, starting 10/13/2022. - Administer Oxygen at 2-4L/minute via nasal cannula or mask PRN for SOB/Cyanosis, starting 10/13/2022. - Check humidifier and change PRN when water level is low, starting 10/19/2022. Record review of Resident #1's Nurse MAR from March - April 2024 revealed the resident was not documented to have received any PRN oxygen. In an interview with MDS Nurse on 04/11/24 at 03:09 PM, she stated Resident used the oxygen PRN in the past but referred to recent documentation in MAR/TAR or notes to see if the oxygen was administered. She said it was sometimes missed by the nurses to document when the oxygen therapy was used, and she likely did not mark the resident's MDS for oxygen therapy use because of that reason. She stated her recent observations of Resident #1 revealed the resident was not receiving oxygen. In an interview with LVN A on 04/11/24 at 03:27PM, she stated since she had been working with Resident #1 for the past 2-3 months and she had been administering oxygen to the resident as needed while she was in bed. She stated the oxygen was not needed by the resident at all times, but periodically, when checking her oxygen saturation levels, and she found her oxygen was low she put the resident on oxygen, so it was important for staff to know the necessity of oxygen therapy for the resident. LVN A refused to specify how low her oxygen got. When asked what the risk of not documenting use of oxygen was, she did not answer the question, but instead stated she knew it was important to document oxygen-use, but she just forgot to do so. In an interview with the DON on 04/11/24 at 04:00PM, she stated it was important for nurses document use of oxygen in the nurses notes to show continuity of care and for accuracy of assessments related to necessity of oxygen therapy. She stated if the nurse noticed the resident was having any shortness of breath, dip in oxygen saturation or a change of condition, details should have been noted in the nurses' notes. She stated she also did not believe the MAR was the best place to document oxygen administration use because of lack of ability to distinguish at what times that oxygen was in use. In an interview with the DON on 04/11/2024 at 4:45PM, she stated she had to retrain LVN A today on documenting a change of condition and reporting to the physician, because after interview with surveyor, she learned from LVN that Resident #1's oxygen dipped below 90% but did not yet document it because LVN A was swamped with other issues involving other residents. The facility's policy on 04/11/2024 at 3:48PM, was requested by the surveyor to the Administrator per email but was not provided prior to exit.

Based on interview, record review, and observation, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 resident (Resident #1) reviewed for accidents. The facility did not provide supervision to prevent Resident #1 from having a witnessed fall, when CNA A failed to ensure the resident was secured and placed appropriately in her bed prior to plugging in her bed. As a result the resident sustained a fracture. This failure could place residents at risk for inadequate supervision resulting in injuries. The findings included: Record review of Resident #1's admission record dated, 03/28/2024, revealed she was an [AGE] year old female, with an initial date of 06/26/2014, and her diagnosis included: Other bacterial infections of unspecified site, Acute cough, Dysphagia, oropharyngeal phase(swallowing problems occurring in the mouth and/or throat), Cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it), Wedge compression fracture of unspecified lumbar vertebra , subsequent encounter for fracture with routine healing . Record review of Resident #1's significant change MDS assessment dated [DATE], revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 0 which indicated her cognition was not intact and she was unable to speak. She required 1 person assistance for all ADLs (Activities of Daily Living), with extensive assistance for dressing, toilet use and personal hygiene. She required limited assistance with bed mobility and supervision for transfers, walking in room, walking in corridor, locomotion on the unit, locomotion off the unit, and for eating. Record review of Resident #1's Comprehensive Care Plan initiated 03/07/2024 revealed: Focus: Resident #1 had a history of falling and a history of CVA (Cerebrovascular accident) with right sides weakness He had gait/balance problems. Poor cognition with [NAME] safety awareness noted. Interventions included: Keep bed in lowest position. Keep call light in reach and encourage to use. Assure that are is adequately lit and free from clutter. Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. Assist with one staff member for all ambulation. Goal: Will minimize risk for falls daily and ongoing over the next 90 days. Record review of Resident #1's fall incident dated 03/07/2024 at 09:52AM completed by DON Incident date: 03/02/2024 Incident Type: Fracture Location: Resident Room Incident Level: Non-witnessed Description: Approximately @ about 7:00PM nurse was alerted to room by CNA A. Resident noted to be on the floor lying on her left side near the bed. Resident alert nonverbal responding to touch stimulation; no obvious distress, resp. even and unlabored, skin pink, bruise to left knee, small cut to the lip. No swelling, pain 5/10, Tylenol PO given and ordered. Vital signs taken and staff assist x3 resident back to bed with wedges in place. transfer to hospital. Immediate Actions Taken: Assessed; assisted off of the floor, V/S skin, neuro check, assist x2, Notifications made to family, Administrator/ DON; Doctor who gave orders to transfer resident to hospital for further evaluation. Record review of Resident #1's fall incident follow-up dated 03/07/2024 at 9:53AM completed by DON 24-Hour Follow-up Resident condition after 24 hours: hospitalized 24-Hour condition and injury appearance: Bruise to left knee, small superficial cut to lip. Per hospital resident noted with hip fracture and knee fracture, Tylenol administered for pain 5/10. Additional Follow-ups: 03/04/2024: IDT Meeting held; resident was noted to roll out of bed and was transferred to the hospital for further evaluation. Resident had just received peri-care. CNA A was attempting to lower residents' bed, but bed was noted unplugged. 03/04/2024: Therapy notified of residents fall out of bed. Bed re-assessed; resident would benefit from a scoop mattress for positioning/comfort; CNA A re-educated to ensure bed is close to outlet to prevent bed from becoming unplugged; re-education on fall prevention. Record review of Radiology Results dated 03/04/2024 revealed: Patient laboratory studies in the ED show creatinine 1.21 with GFR 42. CT of the brain shows acute renal abnormality. CT of the cervical spine shows acute fracture. CT pelvis shows acute abnormality x-ray of the knee shows mild displaced impacted distal femoral fracture. X-ray femur shows distal supracondylar femur CT of the knee shows mildly comminuted distal impacted distal femoral fracture nondisplaced patella fracture demineralized bones. Observation on 03/28/2024 at 11:37AM. Resident #1 in bed awake, bed in low position and floor mats to both side of bed. Call light in reach to left side of bed. Room and restroom free of clutter. Resident did not respond to any of my questions. In an interview on 03/28/2024 at 12:05PM with CNA A, she stated she went in Resident #1's room to complete incontinent care and prior to starting she lifted the resident's bed. She stated she noticed that the bed was unplugged when she went to lower the bed, she stated she made sure the resident was secured and she tried to plug the bed back in, and the resident fell . She stated the resident was on her side when she reached to plug the bed back in. When asked why she did not lay the resident on her back prior to plugging the bed back in she stated, she did not know. She stated Resident #1 was a one person assist. She stated the risk of not having the bed plugged in was that the resident had a fall. She stated she was the only person that witnessed the incident. She stated she was providing incontinent care, so the residents curtain was closed. She stated the she now checks the plug prior to giving care to residents. She stated there was an in-service after the incident occurred. In an interview on 03/28/2024 at 12:41 PM with DON, she stated she was not working the day the incident occurred, but she completed the investigation of the incident. She stated CNA A was completing incontinent care with when the resident had a fall. She stated CNA- A had completed incontinent care and laid the resident flat and CNA A was done providing incontinent care. She stated CNA A noticed the bed was unplugged and reached to plug the bed back in and the resident fell . She stated CNA A never informed her that the resident was lying on her side, she stated she was under the impression that the resident was laid down flat and the staff member was done providing care. She stated the outlet in the residents' room was loose and it is what caused the bed to become unplugged. She stated maintenance replaced the outlet in the resident's room. The DON stated Resident #1 was immediately sent to the hospital when the incident occurred and stated the staff were in-serviced. She stated she did not think the incident should have been reported to state because it was a witnessed fall, but the facility decided to report it anyway. In an interview on 03/28/2024 at 1:15PM with CNA A and the DON, the DON informed the surveyor that she wanted to clear up the misunderstanding of what occurred the day of the incident. CNA A denied that she informed surveyor that Resident #1 was lying on her side when she had a fall. CNA A reported that Resident #1 was laying flat when she rolled out of bed. In an interview on 03/28/2024 at 1:30PM with the Maintenance Director, he stated on the day that the incident occurred, he received a notification from the DON on that there was something wrong with the outlet, in Resident #1's room; he stated the outlet had come loose. He stated he changed out the outlet and put a new panel on it. He stated the outlet looked as if it was a bit worn. He stated it was the first report received regarding the outlet in the resident's room. He stated he did a check of other outlets as well to ensure there was no issues with outlets in other rooms and he reported he did not find any issues with any other outlets. In an interview on 03/28/2024 at 2:50PM with Administrator, she stated CNA A was completing incontinent care with Resident #1 and when she went to lower the bed back down, she noticed the bed was unplugged. She stated when CNA A went to plug the bed back in, the resident rolled out of bed. She stated CNA A had already completed incontinent care with the resident. She stated it was an accident and reported the incident could have still occurred even if the bed was in a lower position. She stated the incident was a witnessed fall by the CNA A. Record Review of the facility's undated Falls and Fall Risk, Managing Policy reflected: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review, the facility failed to consult with the physician for changes in condition for 1 of 8 residents (CR #5) reviewed for physician consultation. LVA A failed to consult with the physician when CR #5 experienced respiratory and also failed to notify the physician after the resident had died . This deficient practice affected one resident and had the potential to place 28 residents on 200 Hall at risk for not having the physician consulted when having a change of condition which could result in a decline in their medical condition. Findings include: Intake # 8 Record review of CR #5's clinical record revealed he was [AGE] years of age and was admitted to the facility at 5:00 PM on [DATE] with the following Diagnoses: [REDACTED]. Record Review of the facility's admission report for CR #5 dated [DATE] revealed he was full code, on Oxygen ,[DATE] liters / minute, is continent, he needed a urinal at bedside, physical assist times 2. This document revealed CR #5 arrived at the facility via EMS from a local hospital along with his family. This document revealed he was continent of bowel and bladder and required assistance from staff for ambulating to and from the restroom due to weakness from pneumonia and [MEDICAL CONDITION]. This document also revealed he was on 4 liters oxygen using a nasal cannula and upon admission had an oxygen saturation level of 97. His lower extremities were [MEDICAL CONDITION] with his right leg having [MEDICAL CONDITION]. His vital signs upon admission were blood pressure: ,[DATE], pulse - 80. respiration - 22, and temperature was 98.4. Record Review of CR #5's Admission Care Plan dated [DATE] revealed Resident was able to communicate his want and needs, and would be as comfortable as possible for pain with facility interventions of monitoring pain, administer pain meds as ordered and complete pain assessment. The Pneumonia care plan included chest x-ray as ordered, monitoring every shift, antibiotics as ordered, Oxygen as ordered, nebulizers as ordered, and encourage turning, cough, and deep breathing every 2 hours and as needed. Record Review of Admission Nursing Evaluation revealed CR #5 was at risk for falls, his pain was relieved by medication and he was on a scheduled pain regimen using [MEDICATION NAME] ER 15mg twice daily and [MEDICATION NAME] ,[DATE] as needed . Record review of handwritten physician's orders [REDACTED]. Record review of CR #5's admission orders [REDACTED] [MEDICATION NAME] 1.25mg/3ml - 1 vial per nebulizer every 4 hours while awake for shortness of breath [MEDICATION NAME] 500mcg/2.5ml one vial per nebulizer every 4 hours while awake for shortness of breath [MEDICATION NAME]/[MEDICATION NAME] ,[DATE] - 1 tablet every 4 hours as needed for pain [MEDICATION NAME] 15mg ER 1 tablet twice daily for pain [MEDICATION NAME] 37.5mg ER - 1 tablet daily for depression Record Review of LVN A's nurses notes read in part; [DATE] at midnight, resident in bed laying with head elevated on oxygen at 4 liters. Nebulizer treatment given, gave resident 1 dose of [MEDICATION NAME] (no strength noted) for pain. Resident lying with eyes closed, will monitor. [DATE] - 1:30am patient called to go to restroom for urination; CNA went to help patient. Patient not able to stand with assistance of 2 aides. Patient stated he will use the bedside urinal. Cleaned and left patient sitting in bed. [DATE] at 4:00am, patient called for pain medication. Stated that he is having pain all over his body. Gave another dose of [MEDICATION NAME] tablet. Checked patient ,[DATE] minutes later when patient stated he was feeling little better. Patient had turned the oxygen up to 4.5 Liters. Resident looked very tired. Resident breathing very heavy, nebulizer treatment given for shortness of breath. [DATE], 4:30am Resident breathing heavy. Lungs sound - can hear rales very clearly, Resident wanted another nebulizer treatment. He was still on 4.5 liters oxygen, sitting up in bed at 90 degree angle head up. Residents eyes open, will check back (end of nurses notes by LVN A). Continued record review of CR #5's nurses notes dated [DATE] at 5:23 AM read; Received call from charge nurse (LVN A) stated resident had expired and needed to be pronounced. documented by unknown nurse. Nurses notes revealed no documentation showing LVN A or facility staff contacted the physician after the resident had died . Record Review of LVN A's witness statement dated [DATE] read in part; LVN A went into CR #5's room at 3:00am. CR #5 said he needed a nebulizer treatment because he could not breath. (No record of whether another treatment was started) During an interview with LVN A at 9:00am on [DATE], he stated he was CR#5 ' s nurse on the night he died . He stated he did not contact the physician at any time during the night regarding CR #5. When asked if he performed CPR on Resident CR #5 when he found him on the floor. He stated he did not because CR #5 was already dead, he was turning blue and his arms were already stiff. During an interview with LVN B at 5:15am on [DATE] she stated she was on duty the same shift as LVN A. She was covering the 100 Hall. She stated around 5:00am or 5:30am, she heard LVN A yell he needed help in CR #5 ' s room. She stated she grabbed the crash cart and rushed to the room. She stated LVN A stopped her and said he needed help getting his body in bed, he already died . She went in the room and CR #5 was lying partly in the bathroom and partly in the living room. She stated he was already turning blue and she could tell rigor mortis had already set in. During an interview with ADON on [DATE] at 7:30am, she stated she received a call from LVN A around 5:00am informing her that he just found CR#5 on the floor and he had expired. She stated she went to the facility and LVN A had not called 911 or performed CPR. She said when she examined CR #5 upon arrival, he said he was blue and it looked like rigor mortis had already set in. During an interview with the DON on [DATE] at 3:35pm she was asked if she knew whether LVN A ever contacted the physician or considered sending to the emergency room regarding Resident CR # 5 ' s condition during the evening. She stated according to the nurses notes; they did not contact the physician or attempt to send the resident to the emergency room . Record review of the facility ' s policy on Acute Condition Changes read in part: .5. The nursing staff will contact the Physician based on the urgency of the situation .Treatment and Management: 2. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending Physician will authorize transfer to an acute hospital or another appropriate setting. Record review of the facility ' s policy on Change in Condition - When to report to the MD/NP/PA read in part; .Immediate notification when any symptom, sign or apparent discomfort that is: Acute or sudden in onset, and a marked change in relation to usual signs and symptoms, or unrelieved by measures already prescribed. According to the facility's census list, there were 28 residents living on hall 200.

Based on Interview, record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of eight residents reviewed for quality of care. LVA A failed to consult with the physician when CR #5 experienced respiratory and also failed to notify the physician after the resident had died . These failures affected 1 resident and placed 28 residents on Hall 200 at risk of not receiving care and services, delay in treatment, complications, and hospitalization . Findings include: Intake # 8 Record review of CR #5's clinical record revealed he was [AGE] years of age and was admitted to the facility at 5:00 PM on [DATE] with the following Diagnoses: [REDACTED]. Record Review of CR #5 Admission report dated [DATE] revealed he was full code, on Oxygen ,[DATE] liters / minute, is continent, he needed a urinal at bedside, physical assist times 2. This document revealed CR #5 arrived at the facility via EMS from a local hospital along with his family. This document revealed he was continent of bowel and bladder and required assistance from staff for ambulating to and from the restroom due to weakness from pneumonia and [MEDICAL CONDITION]. This document also revealed he was on 4 liters oxygen using a nasal cannula and upon admission had an oxygen saturation level of 97. His lower extremities were [MEDICAL CONDITION] with his right leg having [MEDICAL CONDITION]. His vital signs upon admission were blood pressure: ,[DATE], pulse - 80. respiration - 22, and temperature was 98.4. Record Review of CR #5's Admission Care Plan dated [DATE] revealed Resident was able to communicate his want and needs, and would be as comfortable as possible for pain with facility interventions of monitoring pain, administer pain meds as ordered and complete pain assessment. The Pneumonia care plan included chest x-ray as ordered, monitoring every shift, antibiotics as ordered, Oxygen as ordered, nebulizers as ordered, and encourage turning, cough, and deep breathing every 2 hours and as needed. Record Review of Admission Nursing Evaluation dated [DATE] revealed CR #5 was at risk for falls, pain evaluation that pain was relieved by medication and he was on a scheduled pain regimen using [MEDICATION NAME] ER 15mg twice daily and [MEDICATION NAME] ,[DATE] as needed . Record review of CR #5's admission orders [REDACTED] [MEDICATION NAME] 1.25mg/3ml - 1 vial per nebulizer every 4 hours while awake for shortness of breath [MEDICATION NAME] 500mcg/2.5ml one vial per nebulizer every 4 hours while awake for shortness of breath [MEDICATION NAME]/[MEDICATION NAME] ,[DATE] - 1 tablet every 4 hours as needed for pain [MEDICATION NAME] 15mg ER 1 tablet twice daily for pain [MEDICATION NAME] 37.5mg ER - 1 tablet daily for depression Record Review of LVN A's nurses notes read in part; [DATE] at midnight, resident in bed laying with head elevated on oxygen at 4 liters. Nebulizer treatment given, gave resident 1 dose of [MEDICATION NAME] (no strength noted) for pain. Resident lying with eyes closed, will monitor. [DATE] - 1:30am patient called to go to restroom for urination; CNA went to help patient. Patient not able to stand with assistance of 2 aides. Patient stated he will use the bedside urinal. Cleaned and left patient sitting in bed. [DATE] at 4:00am, patient called for pain medication. Stated that he is having pain all over his body. Gave another dose of [MEDICATION NAME] tablet. Checked patient ,[DATE] minutes later when patient stated he was feeling little better. Patient had turned the oxygen up to 4.5 Liters. Resident looked very tired. Resident breathing very heavy, nebulizer treatment given for shortness of breath. [DATE], 4:30am Resident breathing heavy. Lungs sound - can hear rales very clearly, Resident wanted another nebulizer treatment. He was still on 4.5 liters oxygen, sitting up in bed at 90 degree angle head up. Residents eyes open, will check back (end of nurses notes). Continued record review of CR #5's nurses notes dated [DATE] at 5:23 AM read; Received call from charge nurse (LVN A) stated resident had expired and needed to be pronounced. documented by unknown nurse. Nurses notes revealed no documentation showing LVN A or facility staff contacted the physician after the resident had died . Record Review of LVN A's witness statement dated [DATE] read in part; LVN A went into CR #5's room at 3:00am. CR #5 said he needed a nebulizer treatment because he could not breath. (No record of whether another treatment was started) During an interview with LVN A at 9:00am on [DATE], he stated he was CR#5 ' s nurse on the night he died . He stated he did not contact the physician at any time during the night regarding CR #5. When asked if he performed CPR on CR #5 when he found him on the floor. He stated he did not because CR #5 was already dead, he was turning blue and his arms were already stiff. During an interview with LVN B at 5:15am on [DATE] she stated she was on duty the same shift as LVN A. She was covering the 100 Hall. She stated around 5:00am or 5:30am, she heard LVN A yell he needed help in CR #5 ' s room. She stated she grabbed the crash cart and rushed to the room. She stated LVN A stopped her and said he needed help getting his body in bed, he already died . She went in the room and CR #5 was lying partly in the bathroom and partly in the living room. She stated he was already turning blue and she could tell rigor mortis had already set in. During an interview with ADON on [DATE] at 7:30am, she stated she received a call from LVN A around 5:00am informing her that he just found CR#5 on the floor and he had expired. She stated she went to the facility and LVN A had not called 911 or performed CPR. She said when she examined CR #5 upon arrival, LVN A said he was blue and it looked like rigor mortis had already set in. Record review Resident CR # 5 ' s MAR indicated [REDACTED]. Record review of the facility Controlled Drug Receipt/Record/Disposition Form on [DATE] revealed a page for [MEDICATION NAME] Sul Tab 15mg, quantity received: 120, signed as received by LVN A and LVN B. It revealed that a dose was given at midnight on [DATE] and another dose at 4:00am on [DATE]. The amount given was one tablet each time and the amount left was deducted correctly from the amount received. Record review of the Pharmacy Packing slip on [DATE] at 3:30pm revealed that the [MEDICATION NAME] was delivered and signed for by LVN A at 1:40am on [DATE] During an interview with the DON on [DATE] at 3:35pm she was asked if she knew whether LVN A ever contacted the physician or considered sending to the emergency room regarding Resident CR # 5 ' s condition during the evening. She stated according to the nurses notes; they did not contact the physician or attempt to send the resident to the emergency room . Record review of the facility ' s policy on Acute Condition Changes read in part: .5. The nursing staff will contact the Physician based on the urgency of the situation .Treatment and Management: 2. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending Physician will authorize transfer to an acute hospital or another appropriate setting. Record review of the facility ' s policy on Change in Condition - When to report to the MD/NP/PA read in part; .Immediate notification when any symptom, sign or apparent discomfort that is: Acute or sudden in onset, and a marked change in relation to usual signs and symptoms, or unrelieved by measures already prescribed. A review of the facility ' s policy on Oxygen Administration states: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis 2. Signs or symptoms of [MEDICAL CONDITION] 3. Signs or symptoms of oxygen toxicity 4. Vital signs 5. Lung sounds 6. Arterial blood gases and oxygen saturation if applicable and 7. Other lab results if applicable According to the facility's census list, there were 28 residents living on hall 200.

Based on observation, interview and record review the facility failed to ensure 3 of 6 residents ( Residents #1, #3 and #6) reviewed for care provided, were provided care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. -Resident #1 entered that facility without a pressure sore; acquired a pressure sore at the facility on 2/10/2015 that was initially identified as a stage 3 that increased in size and deteriorated in 17 days. -Resident #3 did not receive the correct amount of enteral feeding as ordered by the physician. -Resident #6 did not receive the correct amount of enteral feeding as ordered by the physician and was lying on her left buttocks pressure sore and had a pressure sore on her right buttocks that had not been assessed by the facility and a pressure sore to her sacrum that had not been identified by the facility. . This failure affected 3 residents and placed an additional 101 residents at risk of developing new or worsening pressure sores, infection, pain, malnourishment, dehydration or a decline in their quality of life. Findings include: Resident #1 Record review of the face sheet revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #1's Braden scale for predicting pressure sore risk, dated 12/2/2014, signed by wound care nurse LVN A, revealed a score of 15 indicating mild risk for pressure sores. Further review revealed assessment dated [DATE] with a score of 11 indicating high risk for pressure sores. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS score was 9, which meant she was moderately impaired; required extensive assistance of one person physical assist for bed mobility, transfer, dressing, eating and total dependence of one person assist for toilet use, personal hygiene and bathing; was always incontinent of bowel and bladder. Resident #1 was identified at risk of developing pressure ulcers and did not have a pressure sore. Further review revealed Resident #1 required a pressure reducing device for bed and did not have a pressure reducing device for her chair. Resident #1 was not on a turning and repositioning program. Record review of Resident #1's comprehensive care plan dated 02/11/2015 revealed in part: Date ulcer discovered: 2/11/2015 - Problem: Skin integrity, impaired: Sacral stage 3, measuring 0.8 x 0.5 cm - Interventions: Provide pressure relieving mattress to decrease pressure / irritation to skin. Record review of Resident #1's wound care specialist initial evaluation dated 2/16/2015 revealed in part: an unstageable pressure sore to the coccyx. - Wound size (L x W x D): 1.5 x 2.0 x Not Measurable cm - Exudate: moderate serous. -Yellow necrotic: 100%. Record review revealed an additional evaluation dated 2/23/2015 revealed in part: an unstageable necrosis pressure sore to the coccyx. - Wound size: size (L x W x D): 1.0 x 2.0 x Not Measurable cm - Exudate: moderate serous. -Yellow necrotic: 100%. Record review of Resident #1's nursing notes dated 2/22/2015 at 5:30 p.m. read in part: family member of Resident #1 in facility. CNA (no name provided) helped place foam mattress on bed. Record review of Resident #1's nursing notes dated 2/27/2015 at 11:15 a.m. read in part: "on 2/26/2015 ulcer measured 1.0 x 2.0 x not measurable cm and now the ulcer has declined necrotic tissue surrounded by purple discoloration site measured and currently 4.0 x 3.0 x not measurable cm..called MD to inform of changes of sacral wound (decline). Answering service stated they will have MD to call the facility". Record review of Resident #1's telephone order dated 2/27/2015 at 5:00 p.m. revealed order for [MEDICATION NAME] 500 mg one by mouth everyday for 10 days for decline in wound. Observation on 2/27/2015 at 10:05 am revealed Resident #1 lying in bed with her eyes closed facing the door on an egg crate mattress pad that was on top of her mattress. In an interview on 2/27/2015 at 11:25 a.m. Wound care nurse A said Resident #1 had a facility acquired pressure sore on her sacral area. She said the wound measured 1.0 x 2.0 cm When wound care nurse A was asked about the egg crate mattress pad where Resident #1 was lying on and she said "I didn't know she had it, I just saw it yesterday, we don't provide those mattresses, I don't know who brought it". Observation on 2/27/2015 at 12:00 p.m. during wound care of Resident #1 revealed a large circular wound to her sacrum; wound base yellow and dark brown and reddened surrounding tissue. Wound care nurse A measured the wound to sacrum area and described the wound base as "necrotic tissue" with measurements of 4.0 x 3.0 cm In an interview at that time, Wound Care Nurse A said the surrounding tissue looked more red, and was different from yesterday, the wound was smaller, and she would notify the doctor. When asked if the mattress that Resident #1 was laying on was appropriate for her wound condition she replied "I will get her an air mattress, we don't use egg crate mattresses, I did not know she had it". In continued interview, Wound Care Nurse A stated she did not know why Resident #1's pressure sore had increased in size in one day. In an interview on 2/27/2015 at 4:00 p.m. the DON said the facility did not provide egg crate mattresses and she was not aware that Resident #1 was lying on an egg crate mattress. She said that was not on her plan of care and now that Resident #1's pressure sore had increased in size, she would provide an air loss mattress. Observation at that time revealed a family member of Resident #1's was also in the room. The family member said they got the special cushion for Resident #1's bed because she always complained the mattress the facility had provided was very hard and was causing pain to her sore. The family member stated "she is spending a lot of time in bed and now the sore has gotten worse". In continued interview with the DON, she stated "the MD had been notified of the increased in size of the pressure sore and will come and see Resident #1. We will put her on an air mattress today". Observation on 2/27/2015 at 4:50 p.m. revealed facility staff was inflating an air mattress inside room of Resident #1. Observation on 2/28/2015 at 7:45 a.m. revealed Resident #1 was still lying on an egg crate mattress pad that was on top of her mattress and the inflated air mattress was resting on the wall at the end Resident #1's bed. In an interview at that time, Resident #1 was asked why she was not laying on the air loss mattress , she stated "I don't know" . When asked if she would like to lay on top of the air loss mattress instead and she responded " It'll be nice, this mattress gets hard and hurts my sore". Continued observation at that time revealed LVN B entered the room of Resident #1 and was asked about the air loss mattress that was resting on the wall at the end of the bed of Resident #1. LVN B said she did not know who the mattress was for, nobody told her anything, but she thought they probably brought it for Resident #1. LVN B then walked out of the room. Observation on 2/28/2015 at 8:45 a.m. revealed MA C assisting Resident #1 to lay on the low air loss mattress. Further observation and interview, MA C stated the mattress was malfunctioning, it was not inflated evenly. She said that was probably why they didn't put it on her bed last night. MA C said "we need to put her back on her regular bed again". In an interview on 2/28/2015 at 10:15 a.m. the DON, she said she did not know the air loss mattress was not functioning properly and further said "we will get her a new mattress, we already ordered it and it will come today". In an interview on 3/16/2015 at 11:55 a.m. Staff K stated the facility had 4 in house air loss mattresses. Staff K stated the mattress the facility gave to Resident #1 on 2/27/2015 was from the ones the facility had and she did not know it was malfunctioning. She further said "we destroyed that mattress already and we rented one for Resident #1 that arrived on 2/28/2015". -Resident #3: Record review of the facility's face sheet for resident #3 revealed a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 02/20/2015 at 1:32 PM revealed Resident #3 in bed with the head of the bed elevated at 45 degrees. Further observation revealed Resident #3 was connected to a feeding pump with a feeding that read DiabetSource AC and the feeding pump was not running and was beeping and the pump screen had a message that read "flow error, clog in line downstream of pump". Observation on 02/20/2015 at 1:45 PM revealed Resident #3's feeding pump still not running and was beeping with a message at the pump screen that read "flow error, clog in line downstream of pump". Observation revealed 2 facility staff members passing by the room of Resident #3 while the feeding pump was beeping. Observation on 02/20/2015 at 1:50 PM revealed LVN F exiting Resident #3's room and closed the door half way. Continued observation revealed feeding pump still beeping. Observation on 02/20/2015 at 2:01 PM revealed Resident #3's feeding pump still not running and was beeping with a message at the pump screen that read "flow error, clog in line downstream of pump". In an interview at that time with LVN F, who was observed passing by Resident #3's room, she was asked about the beeping of the pump. At that time, she stated "let me go and check with the nurse" and walked away. Observation and interview on 02/20/2015 at 2:05 PM revealed LVN F returned to room of Resident #3 and said "let me make sure it is not plugged". Continued observation revealed LVN F kept pushing buttons on the pump and checked the placement of the gastrostomy tube of Resident #3. Further observation revealed LVN G and LVN H entered the room of Resident #3 and LVN H started pushing buttons on the pump until the pump stop beeping and stated "it is running well now". In an interview at that time, LVN F was asked about the 72 hour history of the feeding pump for Resident #3. While reading the feeding pump 72 hour history for Resident #3, LVN F said the intake of formula was 3,469 ml in 72 hours and an intake of water of was 2340 ml in the 72 hour history of the feeding pump. LVN F stated "she is supposed to have the pump running at 62 ml per hour" . When asked how many hours per day the pump was supposed to run, LVN F said "I need to see the orders". In continued interview, when asked how long the pump had been beeping, LVN F said "the feeding pump had been running well". Record review of dietary progress note dated 1/15/2015 for Resident #3 revealed in part: Sacral wound unstageable 2.0 x 3.0 x 0.1. Tube feeding on [MEDICATION NAME] at 62 mls/22 hrs with 45 ml x 22 hours flush providing 1637 Kcal. and 2161 ml fluid. Resident #3 with increased needs secondary to wound. Record review of resident #3's quarterly MDS assessment dated [DATE] documented that Resident #3 had unclear speech and required extensive assistance of two person for bed mobility, transfers and dressing and extensive assistance of one person for eating and had a feeding tube. Record review of Resident #3's Care Plan revised 01/23/2015 revealed in part - Problem: enteral nutrition feeding tube. At risk for dehydration due to tube feeding. - Approaches: Provide enteral feeding as ordered. Record review of Resident #3's Physician order [REDACTED]. On at 2 a.m. and off at 12 noon. G tube water flush at 45 ml / 22 hrs. In an interview on 02/20/2015 at 2:30 PM the DON, she said Resident #3 was on [MEDICATION NAME] AC liquid at 62 ml/hr for 22 hours and water flush 45 ml/hr for 22 hours. Observation at that time, upon entering Resident #3's room with the DON revealed Resident #3's feeding pump was not running and was beeping with a message at the pump screen that read "flow error, clog in line downstream of pump". The DON while reading the feeding pump 72 hour history for Resident #3 revealed the intake of formula was 3,469 ml in 72 hours and an intake of water was 2340 ml in the 72 hour history of the feeding pump. At that time the DON was asked if Resident #3 had the ordered amount of formula in the last 72 hours and the DON said "we might need to change the pump". Resident # 6 Record review of the face sheet revealed Resident #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's Care Plan dated 02/09/2015 revealed in part - Problem: enteral nutrition feeding tube. - Approaches: Provide enteral feeding as ordered. Record review of Resident #6's Physician order [REDACTED]. G tube flush with 175 ml water twice a day. Record review of Resident #6's Braden scale for predicting pressure sore risk dated 02/9/2015 and signed by wound care nurse LVN A, revealed a score of 12 indicating high risk for pressure sores. Record review of an additional pressure sore assessment dated [DATE] revealed a score of 9 indicating severe risk for pressure sores. Record review of Resident #6's comprehensive care plan dated 02/23/2015 read in part: "Date ulcer discovered: 2/23/2015 - Problem: Skin integrity, impaired: pressure ulcer present related to physical immobilization. - Location: left buttocks, measuring 3.0 x 5.0 cm, unstageable." Record review of Resident #6's Treatment Administration Record dated 2/23/2015 read in part: "Cleanse unstageable deep tissue injury to left buttocks with normal saline, pat dry, apply calcium alginate, dressing, every day and as needed." Record review of Resident #6's wound care specialist initial evaluation dated 2/23/2015 read in part: "an unstageable deep tissue injury pressure sore to left buttocks. - Wound size (L x W x D): 3.0 x 5.0 x Not Measurable cm - Exudate: moderate sero - sanguineous." Further record review revealed, "Recommendation: off-load wound". In continued record review revealed, "additional information: explained that this wound could have occurred over a period of an hour or 2, on air mattress, monitor setting". Observation on 2/27/2015 at 5:00 p.m. revealed Resident #6 on an air loss mattress, on her back with the head of the bed elevated at 45 degrees. Observation on 2/28/2015 at 7:40 a.m. revealed Resident #6 in an air loss mattress, on her back with the head of the bed elevated at 45 degrees. Observation on 2/28/2015 at 8:25 a.m. revealed Resident #6 still on her back with the head of the bed elevated at 45 degrees. In an Interview with LVN B on 2/28/2015 at 8:25 am, she said Resident #6 had a pressure sore on her buttocks area. Observation on 2/28/2015 at 9:00 a.m. revealed Resident #6 in bed on her back, with the head of the bed elevated at 45 degrees. Observation, with the assistance of LVN B and LVN D during wound care, revealed a large dressing to her right buttocks and a large dressing to her left buttocks. Continued observation revealed LVN D removed the dressings and there was a large dark reddened area to her left buttocks approximately 10.0 x 8.0 cm with 6 open areas scatted on the reddened area with wound base red. The right buttocks area with a dark reddened area approximately 5.0 x 5.0 cm with an open area in the middle that was approximately 1.5 cm x 0.5 cm with wound base red. Further observation revealed an open area to Resident #6's sacrum approximately 1.0 x 3.0 cm surrounding area was dark purple in color. LVN D stated "there is no treatment order for the sacrum area, but I think there is a treatment order for the right buttocks". In an interview on 2/28/2015 at 9:15 a.m., LVN D was asked if there were any orders for the right buttocks open area, she replied "oh, I see, only the left buttocks". When asked why there was a dressing to the right buttocks area if there was no treatment orders, LVN B and LVN D replied "we work the weekend only" and LVN D stated "I don't know". Observation on 2/28/2015 at 9:20 a.m. revealed LVN D measured the wound to sacrum area of Resident #6 and described the wound base as white with measurements of 1.0 x 3.0 cm and the dark purplish discoloration on the sacrum with measurements of 4.0 x 1.0 cm and further measured the right buttocks open area with measurements of 1.5 x 0.5 cm and described the wound base as red and surrounding site reddened. In an interview at that time, LVN D said she would call the doctor to get orders for the right buttocks and sacrum pressure sores. LVN D further said "Resident #6 was supposed to be turned and repositioned every 2 hours and needed to be turned away from the pressure areas". Observation on 2/28/2015 at 10:10 a.m. revealed Resident #6 was on her back with the head of the bed elevated at 45 degrees. In an interview and observation on 2/28/2015 at 10:20 a.m. CNA E , who was inside of Resident #6's room, said she had just provided morning care to Resident #6. Observation revealed Resident #6 was on her back with the head of the bed elevated at 45 degrees. CNA E stated "she needs to be turned on her sides because of her bottom". CNA E was asked if Resident #6 was on her side now and she replied as she grabbed a pillow that was located at the end of the bed "I can put the pillow on her side now". In an interview on 2/28/2015 at 10:25 a.m., the DON and Administrator said the facility provided pillows so residents could be turned and repositioned while in bed. They stated residents who were not able to move by themselves, needed to be moved more frequently and that Resident #6 was on the list for turning. Record review of Resident #6's daily custodial/skilled nursing notes dated 2/28/2015 at 9:00 a.m. and signed by LVN D revealed in part: "Resident #6 observed with inner sacral opening. MD ordered to cleanse area with normal saline, apply triple antibiotic ointment every day and as needed. Daughter notified. Resident #6 observed with unstagable to right buttocks. MD ordered to cleanse area with normal saline, pat dry, apply calcium alginate dressing every day and as needed". Observation on 03/16/2015 at 8:41 AM revealed Resident #6 in bed with the head of the bed elevated at 45 degrees and connected to a feeding pump with a feeding that read [MEDICATION NAME] HN (high nitrogen). The feeding bag was dated 3/15/2015 at 10:30 a.m. had 450 cc remaining from the initial 1000 cc. The water bag was dated 3/14/2015 had 750 cc remaining. In an interview on 03/16/2015 at 9:28 AM, LVN I was asked about the 72 hour history of the feeding pump for Resident #6. While reading the feeding pump 72 hour history for Resident #6, LVN F said the intake of formula was 3,352 ml in 72 hours and an intake of water of was 350 ml in the 72 hour history of the feeding pump. LVN F stated "she is supposed to have the feeding pump running at 60 ml per hour continuously and the water 175 cc twice a day". When asked how many cc of formula and water Resident #6 is supposed to have in a 72 hour period, she responded "she is supposed to have 4,320 cc of formula and 1,050 cc of water". Surveyor then asked LVN I if Resident #6 had the total feeding as ordered and she responded "I am not familiar with Resident #6, let me get somebody else". In an interview on 03/16/2015 at 9:58 AM, RN J was asked about the 72 hour history of the feeding pump for Resident #6. While reading the feeding pump 72 hour history for Resident #6, RN J said the intake of formula was 3,352 ml in 72 hours and an intake of water of was 350 ml in the 72 hour history of the feeding pump. She further stated as she looked at the feeding pump and the feeding bag "the orders are for 60 cc of feeding per hour continuously and water 175 cc twice per day, the feeding bag reads that the feeding was hanged 3/15/2015 at 10:30 a.m. still about 400 cc on the bag, I don't know why there is still feeding on the bag, the bag should had been gone already". In continued interview and observation, as Unit manager J used her cellular phone to do the calculation for the feeding, she stated "there are 968 cc missing". Record review of the significant change in status MDS assessment dated [DATE] revealed Resident #6's had unclear speech-slurred or mumbled words, sometimes understood-ability is limited to making concrete requests. She required extensive assistance of one person physical assist for eating and had a feeding tube. Record review of dietary progress note dated 2/12/2015 for Resident #6 revealed in part:Tube feeding on [MEDICATION NAME] HN at 60 mls/24 hrs with 175 ml of water flush twice daily. Approximately 1728 Kcal/day from tube feeding. Kcal Needs= 1545 to 1795 calories. Monitor for wound healing. In an interview on 03/16/2015 at 10:30 a.m. with the DON revealed she was not able to explain why the difference of the 72 hour formula intake feeding and what Resident #6 was supposed to have and why at 24 hours after the bag was hanged for Resident #6 there was still approximately 400 cc of formula remaining on the 1000 cc formula bag. DON further said while looking at the feeding pump and the feeding formula bag hanged for Resident #6 "it is what it is". Record review of facility policy and procedure titled Enteral Formula Feedings revised 4/2007 revealed in part: Policy statement: Adequate nutritional support through enteral feeding will be provided to residents unable to consume adequate nutritional intake by mouth. Record review of the undated policy and procedure with title "wound/skin" read in part: " ... each resident with skin breakdown/pressure sores will receive the services and treatment to decrease risks of prevention of infection, promote early wound healing, if possible and prevent new pressure sores from developing if possible". According to the CMS 672 form there were 8 residents in the facility on tube feedings and 10 residents with pressure ulcers (excluding stage 1)..

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent new pressure sores from developing for two of ten residents (Resident #1 and #6) reviewed for pressure sores, as evidenced by: : - Resident #1 entered that facility without a pressure sore; acquired a pressure sore at the facility on 2/10/2015 that was initially identified as a stage 3 that increased in size and deteriorated in 17 days. - Resident #6 was lying on her left buttocks pressure sore and had a pressure sore on her right buttocks that had not been assessed by the facility and a pressure sore to her sacrum that had not been identified by the facility. This failure affected two residents and could place an additional 102 residents at risk of developing new or worsening pressure sores, infection, pain or a decline in their quality of life. Findings include: Intake # 0 Resident #1 Record review of the face sheet revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #1's Braden scale for predicting pressure sore risk, dated 12/2/2014, signed by wound care nurse LVN A, revealed a score of 15 indicating mild risk for pressure sores. Further review revealed assessment dated [DATE] with a score of 11 indicating high risk for pressure sores. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS score was 9, which meant she was moderately impaired; required extensive assistance of one person physical assist for bed mobility, transfer, dressing, eating and total dependence of one person assist for toilet use, personal hygiene and bathing; was always incontinent of bowel and bladder. Resident #1 was identified at risk of developing pressure ulcers and did not have a pressure sore. Further review revealed Resident #1 required a pressure reducing device for bed and did not have a pressure reducing device for her chair. Resident #1 was not on a turning and repositioning program. Record review of Resident #1's comprehensive care plan dated 02/11/2015 revealed in part: Date ulcer discovered: 2/11/2015 - Problem: Skin integrity, impaired: Sacral stage 3, measuring 0.8 x 0.5 cm - Interventions: Provide pressure relieving mattress to decrease pressure / irritation to skin. Record review of Resident #1's wound care specialist initial evaluation dated 2/16/2015 revealed in part: an unstageable pressure sore to the coccyx. - Wound size (L x W x D): 1.5 x 2.0 x Not Measurable cm - Exudate: moderate serous. -Yellow necrotic: 100%. Record review revealed an additional evaluation dated 2/23/2015 revealed in part: an unstageable necrosis pressure sore to the coccyx. - Wound size: size (L x W x D): 1.0 x 2.0 x Not Measurable cm - Exudate: moderate serous. -Yellow necrotic: 100%. Record review of Resident #1's nursing notes dated 2/22/2015 at 5:30 p.m. read in part: family member of Resident #1 in facility. CNA (no name provided) helped place foam mattress on bed. Record review of Resident #1's nursing notes dated 2/27/2015 at 11:15 a.m. read in part: "on 2/26/2015 ulcer measured 1.0 x 2.0 x not measurable cm and now the ulcer has declined necrotic tissue surrounded by purple discoloration site measured and currently 4.0 x 3.0 x not measurable cm..called MD to inform of changes of sacral wound (decline). Answering service stated they will have MD to call the facility". Record review of Resident #1's telephone order dated 2/27/2015 at 5:00 p.m. revealed order for [MEDICATION NAME] 500 mg one by mouth everyday for 10 days for decline in wound. Observation on 2/27/2015 at 10:05 am revealed Resident #1 lying in bed with her eyes closed facing the door on an egg crate mattress pad that was on top of her mattress. In an interview on 2/27/2015 at 11:25 a.m. Wound care nurse A said Resident #1 had a facility acquired pressure sore on her sacral area. She said the wound measured 1.0 x 2.0 cm When wound care nurse A was asked about the egg crate mattress pad where Resident #1 was lying on and she said "I didn't know she had it, I just saw it yesterday, we don't provide those mattresses, I don't know who brought it". Observation on 2/27/2015 at 12:00 p.m. during wound care of Resident #1 revealed a large circular wound to her sacrum; wound base yellow and dark brown and reddened surrounding tissue. Wound care nurse A measured the wound to sacrum area and described the wound base as "necrotic tissue" with measurements of 4.0 x 3.0 cm In an interview at that time, Wound Care Nurse A said the surrounding tissue looked more red, and was different from yesterday, the wound was smaller, and she would notify the doctor. When asked if the mattress that Resident #1 was laying on was appropriate for her wound condition she replied "I will get her an air mattress, we don't use egg crate mattresses, I did not know she had it". In continued interview, Wound Care Nurse A stated she did not know why Resident #1's pressure sore had increased in size in one day. In an interview on 2/27/2015 at 4:00 p.m. the DON said the facility did not provide egg crate mattresses and she was not aware that Resident #1 was lying on an egg crate mattress. She said that was not on her plan of care and now that Resident #1's pressure sore had increased in size, she would provide an air loss mattress. Observation at that time revealed a family member of Resident #1's was also in the room. The family member said they got the special cushion for Resident #1's bed because she always complained the mattress the facility had provided was very hard and was causing pain to her sore. The family member stated "she is spending a lot of time in bed and now the sore has gotten worse". In continued interview with the DON, she stated "the MD had been notified of the increased in size of the pressure sore and will come and see Resident #1. We will put her on an air mattress today". Observation on 2/27/2015 at 4:50 p.m. revealed facility staff was inflating an air mattress inside room of Resident #1. Observation on 2/28/2015 at 7:45 a.m. revealed Resident #1 was still lying on an egg crate mattress pad that was on top of her mattress and the inflated air mattress was resting on the wall at the end Resident #1's bed. In an interview at that time, Resident #1 was asked why she was not laying on the air loss mattress , she stated "I don't know" . When asked if she would like to lay on top of the air loss mattress instead and she responded " It'll be nice, this mattress gets hard and hurts my sore". Continued observation at that time revealed LVN B entered the room of Resident #1 and was asked about the air loss mattress that was resting on the wall at the end of the bed of Resident #1. LVN B said she did not know who the mattress was for, nobody told her anything, but she thought they probably brought it for Resident #1. LVN B then walked out of the room. Observation on 2/28/2015 at 8:45 a.m. revealed MA C assisting Resident #1 to lay on the low air loss mattress. Further observation and interview, MA C stated the mattress was malfunctioning, it was not inflated evenly. She said that was probably why they didn't put it on her bed last night. MA C said "we need to put her back on her regular bed again". In an interview on 2/28/2015 at 10:15 a.m. the DON, she said she did not know the air loss mattress was not functioning properly and further said "we will get her a new mattress, we already ordered it and it will come today". In an interview on 3/16/2015 at 11:55 a.m. Staff K stated the facility had 4 in house air loss mattresses. Staff K stated the mattress the facility gave to Resident #1 on 2/27/2015 was from the ones the facility had and she did not know it was malfunctioning. She further said "we destroyed that mattress already and we rented one for Resident #1 that arrived on 2/28/2015". Resident # 6 Record review of the face sheet revealed Resident #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was [AGE] years of age. Record review of Resident #6's Braden scale for predicting pressure sore risk dated 02/9/2015 and signed by wound care nurse LVN A, revealed a score of 12 indicating high risk for pressure sores. Record review of an additional pressure sore assessment dated [DATE] revealed a score of 9 indicating severe risk for pressure sores. Record review of the significant change in status MDS assessment dated [DATE] revealed Resident #6's had unclear speech-slurred or mumbled words, sometimes understood-ability is limited to making concrete requests. She required extensive assistance of one person physical assist for bed mobility and transfer and total dependence of two person assist for toilet use. She was always incontinent of bowel and bladder. Resident #6 was identified at risk of developing pressure ulcers and had one stage 2 pressure sore. Resident #6 required a pressure reducing device for bed and chair and was on a turning and repositioning program. Record review of Resident #6's comprehensive care plan dated 02/23/2015 read in part: "Date ulcer discovered: 2/23/2015 - Problem: Skin integrity, impaired: pressure ulcer present related to physical immobilization. - Location: left buttocks, measuring 3.0 x 5.0 cm, unstageable." Record review of Resident #6's Treatment Administration Record dated 2/23/2015 read in part: "Cleanse unstageable deep tissue injury to left buttocks with normal saline, pat dry, apply calcium alginate, dressing, every day and as needed." Record review of Resident #6's wound care specialist initial evaluation dated 2/23/2015 read in part: "an unstageable deep tissue injury pressure sore to left buttocks. - Wound size (L x W x D): 3.0 x 5.0 x Not Measurable cm - Exudate: moderate sero - sanguineous." Further record review revealed, "Recommendation: off-load wound". In continued record review revealed, "additional information: explained that this wound could have occurred over a period of an hour or 2, on air mattress, monitor setting". Observation on 2/27/2015 at 5:00 p.m. revealed Resident #6 on an air loss mattress, on her back with the head of the bed elevated at 45 degrees. Observation on 2/28/2015 at 7:40 a.m. revealed Resident #6 in an air loss mattress, on her back with the head of the bed elevated at 45 degrees. Observation on 2/28/2015 at 8:25 a.m. revealed Resident #6 still on her back with the head of the bed elevated at 45 degrees. In an Interview with LVN B on 2/28/2015 at 8:25 am, she said Resident #6 had a pressure sore on her buttocks area. Observation on 2/28/2015 at 9:00 a.m. revealed Resident #6 in bed on her back, with the head of the bed elevated at 45 degrees. Observation, with the assistance of LVN B and LVN D during wound care, revealed a large dressing to her right buttocks and a large dressing to her left buttocks. Continued observation revealed LVN D removed the dressings and there was a large dark reddened area to her left buttocks approximately 10.0 x 8.0 cm with 6 open areas scatted on the reddened area with wound base red. The right buttocks area with a dark reddened area approximately 5.0 x 5.0 cm with an open area in the middle that was approximately 1.5 cm x 0.5 cm with wound base red. Further observation revealed an open area to Resident #6's sacrum approximately 1.0 x 3.0 cm surrounding area was dark purple in color. LVN D stated "there is no treatment order for the sacrum area, but I think there is a treatment order for the right buttocks". Observation on 2/28/2015 at 9:15 a.m. revealed LVN D looked through the Treatment Administration Record of Resident #6. In an interview at that time, LVN D was asked if there were any orders for the right buttocks open area, she replied "oh, I see, only the left buttocks". When asked why there was a dressing to the right buttocks area if there was no treatment orders, LVN B and LVN D replied "we work the weekend only" and LVN D stated "I don't know". Observation on 2/28/2015 at 9:20 a.m. revealed LVN D measured the wound to sacrum area of Resident #6 and described the wound base as white with measurements of 1.0 x 3.0 cm and the dark purplish discoloration on the sacrum with measurements of 4.0 x 1.0 cm and further measured the right buttocks open area with measurements of 1.5 x 0.5 cm and described the wound base as red and surrounding site reddened. In an interview at that time, LVN D said she would call the doctor to get orders for the right buttocks and sacrum pressure sores. LVN D further said "Resident #6 was supposed to be turned and repositioned every 2 hours and needed to be turned away from the pressure areas". Observation on 2/28/2015 at 10:10 a.m. revealed Resident #6 was on her back with the head of the bed elevated at 45 degrees. In an interview and observation on 2/28/2015 at 10:20 a.m. CNA E , who was inside of Resident #6's room, said she had just provided morning care to Resident #6. Observation revealed Resident #6 was on her back with the head of the bed elevated at 45 degrees. CNA E stated "she needs to be turned on her sides because of her bottom". CNA E was asked if Resident #6 was on her side now and she replied as she grabbed a pillow that was located at the end of the bed "I can put the pillow on her side now". In an interview on 2/28/2015 at 10:25 a.m., the DON and Administrator said the facility provided pillows so residents could be turned and repositioned while in bed. They stated residents who were not able to move by themselves, needed to be moved more frequently and that Resident #6 was on the list for turning. Record review of Resident #6's daily custodial/skilled nursing notes dated 2/28/2015 at 9:00 a.m. and signed by LVN D revealed in part: "Resident #6 observed with inner sacral opening. MD ordered to cleanse area with normal saline, apply triple antibiotic ointment every day and as needed. Daughter notified. Resident #6 observed with unstagable to right buttocks. MD ordered to cleanse area with normal saline, pat dry, apply calcium alginate dressing every day and as needed". Record review of the undated policy and procedure with title "wound/skin" read in part: " ... each resident with skin breakdown/pressure sores will receive the services and treatment to decrease risks of prevention of infection, promote early wound healing, if possible and prevent new pressure sores from developing if possible". The facility CMS 672 form revealed 10 residents with pressure ulcers (excluding stage 1).

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and/or psychological well-being in accordance with the comprehensive assessment and plan of care for 1 of 10 residents (Resident # 102) reviewed for pain. The nursing and therapy staff failed to assess for and recognize resident #102's pain. The nursing staff also failed to order and ensure delivery of [MEDICATION NAME] ordered by the attending physician for Resident # 102's pain from 01/13/2015 through 01/22/2015. This failure affected one resident (Resident # 102) and placed the remaining 47 residents on a pain management program at risk of pain and/or a decline in the resident ' s health status. Findings include: Record review of Resident # 102 ' s face sheet revealed he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He was [AGE] years of age. An observation of Resident # 102 ' s wound care was conducted on 01/20/2015 at 2:10 PM. Resident # 102 was observed to have a stage 3 sacral wound. He was rolled onto his left side by LVN E who was assisted by LVN X. Resident # 102 grimaced several times during the wound care. Staff continued with and completed the wound care. An observation of Resident # 102 on 01/21/2015 at 9:50 AM revealed him to be sitting in a wheel chair in the physical therapy room. He was grimacing and trying to reposition himself in the wheel chair while waiting for the physical therapy attendant to begin his therapy session. Resident's wheelchair seat did have a cushion. In an interview on 01/21/2015 at 9:50 AM with Resident #102, while sitting in a wheelchair awaiting the start of this physical therapy Resident # 102 stated that he has an aching butt and that he was hurting. When questioned, he said his pain was a 7 on a scale of 1-10. He also said he did not know if he had been medicated for pain prior to the start of his daily physical therapy. Record review of Resident #102's "Wound Care Flow Sheets" dated 1/14-19/2015 revealed the resident had 2 wounds, a stage 3 sacral wound and a stage 2 wound to the inner right buttock. Record review of Resident #102's clinical record revealed no documentation of daily pain assessments by nursing staff. In an interview on 01/21/2015 at 10:00 AM with LVN X, she stated Resident # 102 has an order for [REDACTED].# 102's pain medication had not been ordered by the facility. LVN X also stated that based on her chart review, Resident #102 had not received any Hydocodone pain medication either scheduled or on an as needed basis since admission to the facility on [DATE]. In an interview with Resident #102 on 01/22/2015 at 10:20 AM, he said since he had been in the facility, he had told several different staff members about his pain. He said he did receive medication for pain yesterday. Record review of Resident #102 ' s admission orders [REDACTED]. [MEDICATION NAME] 10/325 was ordered 1 tablet as needed for pain every four hours; as well as, [MEDICATION NAME] 10/325 was ordered 1 tablet thirty minutes prior to therapy Monday through Friday. Record review of Resident #102 ' s January 2015 MAR indicated [REDACTED]. Record review of Resident #102 ' s Admission Nursing Evaluation dated 01/13/2015, revealed Resident 102's Pain Frequency was assessed as " Frequently " over the last 5 days. Record review of Resident #102 ' s Pain Evaluation dated 01/13/2015, revealed Resident # 102 ' s pain medication(s) in use was [MEDICATION NAME] 10/325 30 min prior to PT. Record review of Resident #102 ' s Physical Therapy Evaluation and Plan of treatment for [REDACTED].#102's pain at rest intensity was rated as a 5 of 10 and Resident # 102's pain with movement was rated as a 8 of 10. In an interview on 01/20/2015 at 2:10 PM with LVN E, she stated during wound care as far as she knew, Resident # 102 had not needed any pain medication. LVN E stated that normally she would ask the resident prior to would care if he/she was experiencing any pain. LVN E also stated she did not ask Resident # 102 on 1/20/2015 if he was experiencing any pain prior to beginning his would care at 2:10 PM. In an interview on 01/21/2015 at 11:25 AM with Unit Manager C, she stated she was not sure why Resident #102 was not given his scheduled [MEDICATION NAME] pain medication thirty minutes prior to physical therapy as per physician order [REDACTED]. Unit Manager C stated that order should have been followed. In an interview on 1/21/2015 at 11:40 AM with DON, she stated Resident 102 did not receive [MEDICATION NAME] in the facility either as schedule or on an as needed basis since his admission on 01/13/2015. DON stated that a 24 hour chart check system is in place within the facility. Stated this system should have prevented Resident 102 from not receiving his [MEDICATION NAME]. DON stated she cannot explain the system break down. DON stated she has spent a great deal of time speaking and training staff on administration of pain medication. Record review of Resident #102's physical therapy progress report revealed he received PT services on the following dates: 1/14/2015, 1/15/2015, 1/16/2015, 1/17/2015, 1/19/2015 and 1/20/2015. No documentation noted that a pain assessment was conducted during this time. Record review of Resident #102's occupational therapy progress report revealed he received OT services on the following dates: 1/14/2015, 1/15/2015, 1/16/2015, 1/17/2015, 1/19/2015 and 1/20/2015. No documentation noted that a pain assessment was conducted during this time. In an interview on 01/21/2015 at 12:15 pm with PT, she stated that the physical therapist or occupational therapist working with a resident would determine if a resident was pre medicated with a scheduled pain medication prior to commencing therapy. PT stated that Resident #102 was not being medicated with pain medication prior to therapy as Resident #102 ' s pain medication was ordered on an as needed basis. PT stated that she was aware that Resident # 102 had been reporting pain in the sacral area the last few days. PT stated that the staff was working with Resident # 102 on repositioning techniques to help relieve his sacral pain. In an interview on 01/21/2015 at 12:25 pm with OT, she stated Resident # 102 ' s pain should have been evaluated prior to any physical therapy or occupational therapy session and if ordered scheduled pain medication should be given as ordered prior to commencing a therapy session. She stated she did not believe a pain scale rating of 1-10 was performed on Resident # 102 prior to commencing a therapy session. She said if a resident displayed signs of pain during a session would speak with nurse about Resident ' s pain medication. In an interview on 01/21/2015 at 04:35 pm with LVN G, she stated that she transcribed the order for Resident # 102 when admitted to the facility on the evening of 01/13/2015. She stated Resident #102 was admitted from a local rehabilitation hospital. She stated the morning nurse should have followed up to make sure Resident #102 received his scheduled [MEDICATION NAME] prior to his therapy sessions. She stated based on review of Medication Administration Record [REDACTED]. Record review of the facility ' s Pain Assessment policy revealed the following under section Documentation: " The person performing this procedure should record the following information in the resident 's medical record: 3. Daily assessment of pain. " According to the facility, there were 48 residents on a pain management program.