Every finding on record at Rosedale Health & Rehabilitation

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement infection control practices for the facility. The findings include: The facility staff failed to follow infection control practices for linen storage. On 4/1/25 at approximately 5:50 AM, ASM (administrative staff member) #1, the administrator and this surveyor were making round of the unit linen closets to review levels. ASM #1 stated, we have more linen than this. They start bringing out the linen cart at 6:45 AM. ASM #1 took me to linen/EVS area and stated, there is more linen on those shelves. Packs of blankets, wrapped in plastic were on shelves next to one blanket and one sheet on open shelf next to environmental services cart and mops. When asked if the linen should be unwrapped next to the environmental services cart, ASM #1 stated, no, it should not be. When asked if it is an infection control issue to have unwrapped linen next to environmental services cart, ASM #1 stated, yes, it is. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. No policy was provided by the facility. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence physician's response to the pharmacist's recommendations on the Medication Regimen Review (MRR) for one of 17 residents in the survey sample, R9. The findings include: The facility staff failed to ensure the physician's response to the pharmacist's recommendations for the 10/25/24 and 2/28/25 MRR for R9. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences. A review of the 10/25/24 MRR recommendation revealed, This resident has been taking antibiotic Fluconazole and Ketoconazole since 10/24. While sometimes indicated, it is recommended that all antibiotics given for a period of more than 30 days be evaluated for appropriateness and duration. No physician response found. A review of the 2/28/25 MRR recommendation revealed, This resident has been taking Protonix 40 mg QD since 10/2024 without a dose reduction. Please consider a trial reduction to 20 mg QD. No physician response found. An interview was conducted on 4/2/25 at 10:00 AM with ASM (administrative staff member) #7, the nurse practitioner. When asked the process for reviewing the MRR, ASM #7 stated, we review the recommendations and then respond to them. When asked where this is documented, ASM #7 stated on the MRR form. On 4/3/25 at 9:00 AM, ASM #1, the administrator, stated, there is nothing else to provide. On 4/2/25 at 4:00 PM, ASM #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Medication Regimen Review policy revealed, Recommendations are acted upon and documented by the facility staff and/or the prescriber. The prescriber accepts and acts upon recommendation or rejects and provides an explanation for disagreeing. No further information was provided prior to exit.

1.The facility staff failed to provide honor dietary and allergy preferences by serving resident products with gluten. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences. A review of the physician's order dated 10/10/24 revealed, Consistent Carbohydrate (CCD/CCHO) diet Regular texture, Regular/Thin consistency, ALLERGIES: Blueberries, Corn, Fish, Potato / Double protein, double vegetable with meals. A review of the 10/17/24 nutrition assessment revealed, Needs are increased d/t morbid obese BMI. RD spoke w/ resident on 10/16 to review diet, food preferences, weight, and PO intakes. Resident requesting double protein and double vegetable w/ meals to increase satiety. Order started and tray card updated accordingly. RD will continue to monitor and follow-up PRN. An interview was conducted on 3/31/25 at 9:30 AM with R9. When asked about her dietary preferences, R9 stated, there are many allergies, I cannot have gluten, and I am Jewish and follow Jewish dietary guideline. They do not seem to understand that and have told me I need to prove to them that I need a gluten free diet and do not understand my Jewish dietary needs. A review of R9's 3/31 lunch meal ticket revealed, ALLERGIES: Blueberries, Corn, Fish, Potato / Double protein, double vegetable with meals. Dislike pancakes, French toast, bread. On her lunch tray were 2 bowls of chicken noodle soup. R9 stated to CNA (certified nursing assistant) #3, I cannot each that soup with the noodles in it. CNA #3 stated, I will go bring you a new tray. CNA #3 came back with new tray with 2 bowls of chicken noodle soup. R9 said, never mind, I will eat something I have here. An interview was conducted on 4/1/25 at 10:00 AM with OSM (other staff member) #3, the director of dietary services. When asked the process for determining a resident's food preferences, OSM #3 stated, the registered dietician and I visit with the resident when they are admitted , the nurse gets the diet order, and we enter it. The residents are told the menus and alternatives for each meal. Food allergies come across electronically and by resident interview. Dining Manager system- prints out meal tickets for residents, allergies and religious dietary restrictions should be on the meal tickets. Dislikes are printed separately. If the resident has an allergy to or Dislike of then we find something else to substitute. When asked if a resident is not to have gluten or is to have double protein are two bowls of chicken noodle soup meeting these requirements and are preferences being honored, OSM #3 stated, no, preferences not being met. On 4/2/25 at 4:00 PM during end of day conference, when told of concern regarding R9's food preferences being honored, ASM #1 the administrator, interrupted and stated, how do you know she is Jewish? Do you know she is Jewish? Did she tell you she was Jewish. We offered to send her to the hospital to have the test for Celiac (gluten) and she said no. When asked if it mattered whether she was Jewish or refused the Celiac test in order to honor her food preferences, ASM #1 stated, no. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Resident's Right to Make Personal Dietary, Food and Meal Choices policy revealed, The facility recognizes the resident's/ resident representative's right to make personal dietary, food and meal choices. The facility also recognizes the right of the resident to receive services in the facility with reasonable accommodations of individual needs and religious, cultural and ethnic preferences. No further information was provided prior to exit. 2. The facility staff failed to provide honor dietary preferences by serving resident eggs. Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hereditary and idiopathic neuropathy, arthritis and chronic kidney disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan dated 9/12/24 revealed, FOCUS: The resident has FUNCTIONAL bladder incontinence related to weakness. INTERVENTIONS: Clean peri-area with each incontinence episode. A review of the physician order dated 9/11/24 reveals, Regular diet Regular texture, Regular/Thin consistency, No Sausage Please Give Bacon. Yogurt QD in between meals for diet. A review of the nutritional risk assessment dated [DATE] revealed, Meal intakes 50-100% (~95%) + yogurt 1x/day = 2258kcal, 91g protein Estimated needs are skewed high r/t morbid obese BMI. Resident continues w/ good meal intakes. Estimated needs are likely being met. No s/s of dehydration noted. No sausage, give bacon. See tray card. No known food allergies. No information in 'special ethnic or cultural needs' or 'religious preferences' sections. An interview was conducted on 4/1/25 at 5:45 AM with R15. R15 stated, they do not serve me the food that I like. On 4/1/25 at 8:10 AM observed R15 breakfast tray and meal ticket. On tray were eggs, meal ticket-dislike eggs. An interview was conducted on 4/1/25 at 10:00 AM with OSM (other staff member) #3, the director of dietary services. When asked the process for determining a resident's food preferences, OSM #3 stated, the registered dietician and I visit with the resident when they are admitted , the nurse gets the diet order, and we enter it. The residents are told the menus and alternatives for each meal. Food allergies come across electronically and by resident interview. Dining Manager system- prints out meal tickets for residents, allergies and religious dietary restrictions should be on the meal tickets. Dislikes are printed separately. If the resident has an allergy to or Dislike of then we find something else to substitute. When asked if a resident is not to have eggs and they are served eggs, are preferences being honored, OSM #3 stated, no, preferences not being met. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Resident's Right to Make Personal Dietary, Food and Meal Choices policy revealed, The facility recognizes the resident's/ resident representative's right to make personal dietary, food and meal choices. The facility also recognizes the right of the resident to receive services in the facility with reasonable accommodations of individual needs and religious, cultural and ethnic preferences. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for three of 17 residents in the survey sample, Residents #1, #4, and #9. The findings include: 1. For Resident #1 (R1), the facility staff failed to follow the physician's order to call the physician for a blood sugar greater than 400, prior to administering insulin. A review of R1's clinical record revealed the following orders: -12/5/24-Insulin Glargine Solostar Subcutaneous Solution Pen-injector 300 UNIT/ML (milliliters). Inject 18 unit subcutaneously at bedtime for diabetes. -12/10/24-Insulin Lispro Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject as per sliding scale before meals and at bedtime for diabetes: if (blood sugar) 150-199=8 units 200-249=9 units 250-299=10 units 300-349=12 units 350-399=15 unit Blood sugars over 400, call MD (medical doctor). A nurse's note dated 12/13/24 (at 12:25 a.m.) documented, Resident blood glucose recording HI (over 400), Rechecked several times. Insulin lispro 15 mls (milliliters) administered subcutaneously, and 18 units of glargine insulin administered. Glucose continued to read high 30 min later. Message sent to NP (nurse practitioner), order to administer an additional 12 units of lispro insulin and recheck the glucose 2 hours later received. On 4/2/25 at 11:19 a.m., the above lispro insulin sliding scale order was reviewed with LPN (licensed practical nurse) #7. LPN #7 stated some sliding scale insulin orders document to give a certain amount of insulin and call the physician for a blood sugar over a certain level, but that order did not. LPN #7 stated the above order documented to call the physician for a blood sugar over 400 so she would immediately call the physician before administering the insulin. On 4/2/25 at 2:23 p.m., an interview was conducted with RN (registered nurse) #3 (the nurse who documented the above nurse's note). RN #3 stated R1's blood sugar read, High so she administered insulin, gave time for the medication to respond, re-checked R1's blood sugar, then contacted the nurse practitioner. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Medication and Treatment Orders documented, 1. Medications will be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. No further information was presented prior to exit. 2. For Resident #4 (R4), the facility staff failed to administer multiple medications in a timely manner. A review of R4's clinical record revealed the following physician's orders: 12/3/24-Gabapentin 100 mg (milligrams). Give one capsule by mouth three times a day for pain. 12/3/24-Furosemide 80 mg. Give one tablet by mouth one time a day for HTN (hypertension [high blood pressure]). 12/3/24-Novolog FlexPen 100 units/ml (milliliter). Inject 22 units subcutaneously one time a day for diabetes. 12/3/24-Tiotropium Bromide 18 mcg (micrograms). One capsule inhale orally one time a day to prevent bronchospasms. 12/3/24-Sennosides-Docusate Sodium 8.6-50 mg. Give one tablet by mouth one time a day for constipation. 12/3/24-MiraLax 17 gm (grams)/scoop. Give one scoop by mouth one time a day for constipation. 12/5/24-Clopidogrel Bisulfate 75 mg. Give 75 mg by mouth one time a day for CVA (cerebrovascular accident [stroke]). A review of a medication administration audit report for December 2024 revealed the following: -Gabapentin was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:13 p.m. on 12/14/24, 1:11 p.m. on 12/15/24, and 1:00 p.m. on 12/16/24. -Furosemide was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:14 p.m. on 12/14/24, 1:11 p.m. on 12/15/24, and 1:00 p.m. on 12/16/24. -Novolog was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:13 p.m. on 12/14/24, 1:11 p.m. on 12/15/24, and 1:09 p.m. on 12/16/24. -Tiotropium bromide was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:13 p.m. on 12/14/24, 1:12 p.m. on 12/15/24, and 1:11 p.m. on 12/16/24. -Sennosides-Docusate Sodium was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:14 p.m. on 12/14/24, 1:12 p.m. on 12/15/24, and 1:09 p.m. on 12/16/24. -MiraLAX was scheduled at 9:00 a.m. and was administered at 3:25 p.m. on 12/13/24, 12:13 p.m. on 12/14/24, 1:12 p.m. on 12/15/24, and 1:09 p.m. on 12/16/24. -Clopidogrel Bisulfate was scheduled at 9:00 and was administered at 3:25 p.m. on 12/13/24, 12:13 p.m. on 12/14/24, 1:11 p.m. on 12/15/24, and 12:57 p.m. on 12/16/24. On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated nurses should administer medications within one hour before or one hour after a medication is scheduled because that is when the medications are ordered. LPN #7 stated medications administered after one hour the medications are scheduled are late and kind of like a medication error. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility pharmacy policy titled, General Guidelines for Medication Administration documented, II. Administration: 12. Medications are administered within 60 minutes of the scheduled administration time . No further information was presented prior to exit. 3.The facility staff failed to meet professional standards by clarifying medication orders and administering medications timely for R9. A. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences. A review of the physician orders dated 10/15/24 revealed, Modafinil Tablet 200 MG Give 1 tablet by mouth one time a day for narcolepsy at 4:00 AM. Modafinil Tablet 200 MG Give 1 tablet by mouth one time a day for narcolepsy at 6:00 AM. An interview was conducted on 3/31/25 at 9:30 AM with R9. When asked if medications were administered timely, R9 stated, no, they are late, particularly the 6:00 AM and evening ones. An interview was conducted on 4/2/25 at 6:15 AM with LPN (licensed practical nurse) #5. When asked about the medication order for Modafinil for R9, how to read it, LPN #5 stated, it is ordered to give it one time a day, but there are two different times for it to be administered. When asked if the order should be clarified, LPN #5 stated, yes, it should be clarified. When asked where evidence of the clarification would be, LPN #5 stated, we usually write it in the physician communication book or in the progress notes. The pharmacy has told us that we run out of the medication because we are giving too much. On 4/2/25 at 8:00 AM, a request of the facility to provide evidence of clarification of this order with the physician/nurse practitioner (NP). An interview was conducted on 4/2/25 at 10:00 AM with ASM (administrative staff member) #6, the nurse practitioner. When asked about the Modafinil order for once a day but ordered for two different times, ASM #6 stated, when she first got here, I changed the order for the Modafinil (treatment for narcolepsy) because she had bradycardia with the full dose. So, I ordered it as once a day at 4:00 AM and 6:00 AM, two hours apart, so I split the order so one at 4:00 AM and one at 6:00 AM. When asked if the order should be clarified, ASM #6 stated, yes, it could be ordered twice a day and specify the times of administration. That would be clearer. When asked if she was aware that per the nurse, pharmacy is not filling the medication to give two doses in one day as currently prescribed, ASM #6 stated, no, I was not aware of that. I will change the order. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's General Guidelines for Medication Administration policy revealed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. No further information was provided prior to exit. B. A review of the physician orders dated 10/8/24 revealed, Acarbose Tablet 25 MG Give 1 tablet by mouth three times a day for diabetes. Metoprolol Tartrate Oral Tablet 50 MG, Give 1 tablet by mouth three times a day for HTN. A review of the physician order dated 10/14/24 revealed, Modafinil Tablet 200 MG Give 1 tablet by mouth one time a day for narcolepsy AND Give 1 tablet by mouth one time a day for narcolepsy. A review of the March 2025 MAR (medication administration record) reveals, Acarbose Tablet 25 MG Give 1 tablet by mouth three times a day for diabetes, scheduled for 9:00 AM, 2:00 PM and 6:00 PM; was administered at: 3/1-7:58 PM, 3/9-8:26 PM, 3/11 8:54 PM, 3/27 12:14 AM (for 6 PM dose 3/26). Metoprolol Tartrate Oral Tablet 50 MG Give 1 tablet by mouth three times a day for HTN, scheduled for 6:00 AM, 2:00 PM and 10:00 PM; was administered at: 3/14-11:41 PM, 3/23 12:57 AM (for 6 PM dose 3/22), 3/27 12:15 AM (for 6 PM dose 3/26). Modafinil Tablet 200 MG Give 1 tablet by mouth one time a day for narcolepsy, scheduled administration time 4:00 AM; was administered at: 3/1-5:45 AM, 3/5-5:56 AM, 3/11-5:32 AM, 3/22-5:50 AM, 3/23-5:20 AM, 3/24-5:35 AM, 3/25-5:36 AM and 3/28-5:26 AM. An interview was conducted on 4/2/25 at 11:20 AM with LPN (licensed practical nurse) #7. When asked the medication administration time frames, LPN #7 stated, the med should be given within one hour before or after the scheduled time of administration. When asked why, LPN #7 stated, because it is when it is ordered. Otherwise, it is late or given outside of order parameters. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's General Guidelines for Medication Administration policy revealed, Medications are administered within 60 minutes of the scheduled administration time. No further information was provided prior to exit.

Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for a dependent resident for one of 17 residents, R8. The findings include: Resident #8 (R8) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CVA (cerebrovascular accident) with hemiplegia, hemiparesis and vascular dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/5/24, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as being dependent for turning. A review of the comprehensive care plan dated 8/21/24 revealed, FOCUS: The resident has an ADL (activities of daily living) self-care performance deficit due to history of CVA, dementia. He is dependent on staff for all ADL needs. INTERVENTIONS: BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed and as necessary. A review of the ADL form for November and December 2024 revealed, the following dates and shifts of missing documentation: Day shift-11/6, 11/7, 11/14, 11/27, 12/14, 12/20, 12/24 and Evening shift-11/9, 11/25, 11/27 and 12/20; Night shift-11/3, 11/8, 11/14, 11/18, 11/29, 11/30, 12/22 and 12/25. An interview was conducted on 3/31/25 at 3:30 PM with CNA #4. When CNA #4 was asked where evidence of the resident being turned and positioned and head of bed elevated would be evidenced. CNA #4 stated, it is documented on the ADL form. When asked if there were blanks in the documentation, was the turning/positioning and head of bed elevated done, CNA #4 stated, no, it was not done. An interview was conducted on 4/1/25 at 5:30 AM with CNA #6. When asked about turning/positioning and head of bed being elevated, CNA #6 stated, we document on the ADL form and if it is not documented, it is not done. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. No further information was provided prior to exit.

2.a. For Resident #1 (R1), the facility staff failed to administer a physician ordered intravenous antibiotic in a timely manner. A review of R1's clinical record revealed a urine culture report dated 11/11/24 that documented the resident presented with a urinary tract infection. Further review of R1's clinical record revealed a physician's order dated 11/11/24 for Ertapenem Sodium Solution- one gram intravenously every 24 hours for infection for seven days. Pharmacy alerts dated 11/11/24 documented a possible drug allergy and a possible drug interaction for Ertapenem. Administration notes dated 11/12/24 and 11/13/24 documented the nurses were waiting for the pharmacy to send Ertapenem. An administration note dated 11/14/24 documented, Pharmacy originally would not fill (Ertapenem) because of an allergy alert. Per NP (nurse practitioner) (name) it is ok for resident to take this drug, as she has been given it before. Per pharmacy medication will be delivered today. A review of R1's November 2024 medication administration record and a nurse's note dated 11/15/24 revealed R1 was not administered the first dose of Ertapenem until 11/15/24 (four days after the medication was ordered). A review of the Omnicell list revealed one-gram vials of ertapenem were available in the Omnicell (a machine in the facility that contains various medications). On 4/2/25 at 10:10 a.m., an interview was conducted with ASM (administrative staff member) #6 (the nurse practitioner). ASM #6 stated the importance of immediately starting an antibiotic is to prevent the resident from going septic. On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that when a nurse activates orders in the computer system and there are possible allergy or drug interactions, the system alerts the nurse before she saves the orders. LPN #7 stated right then and there, the nurse should contact the pharmacy and immediately call the physician or nurse practitioner. On 4/2/25 at 4:09 p.m., ASM #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility pharmacy policy titled, General Guidelines for Medication Administration documented, II. Administration: 2. Medications are administered in accordance with written orders of the prescriber. No further information was presented prior to exit. 2.b. For Resident #1 (R1), the facility staff failed to obtain a blood sugar check per physician's order. A review of R1's clinical record revealed a nurse's note dated 12/13/24 (at 12:25 a.m.) that documented, Resident blood glucose recording HI (over 400), Rechecked several times. Insulin lispro 15 mls (milliliters) administered subcutaneously, and 18 units of glargine insulin administered. Glucose (blood sugar) continued to read high 30 min later. Message sent to NP (nurse practitioner), order to administer an additional 12 units of lispro insulin and recheck the glucose 2 hours later received. A physician's order dated 12/13/24 documented, Recheck blood glucose at 0200 (2:00 a.m.) A review of R1's December 2024 medication administration record revealed the resident's blood sugar was not re-checked on 12/13/24 until 3:59 a.m. On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that if the nurse practitioner orders to re-check a resident's blood sugar at a certain time then the nurse should re-check the resident's blood sugar when the nurse practitioner says to re-check the blood sugar. On 4/2/25 at 2:23 p.m., an interview was conducted with RN (registered nurse) #3 (the nurse who documented the above note). RN #3 stated her shift ended at 11:30 p.m. so she had to give report to the on-coming nurse and go home. On 4/2/25 at 3:23 p.m., an interview was conducted with LPN #9 (the nurse who signed off re-checking R1's blood sugar at 3:59 a.m.) LPN #9 stated she did not remember R1. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Insulin Administration documented, Check blood glucose per physician order . No further information was presented prior to exit. 3. For Resident #4 (R4), the facility staff failed to administer multiple medications per physician's orders. A review of R4's clinical record revealed the following physician's orders: 12/3/24-Basaglar KwikPen Solution Pen-injector 100 unit/ml (milliliters) (Insulin Glargine). Inject 75 unit subcutaneously at bedtime for diabetes. 12/3/24-Gabapentin 100 mg (milligrams). Give one capsule by mouth three times a day for pain. 12/5/24-Trazodone 100 mg. Give one tablet by mouth at bedtime for insomnia related to major depressive disorder. R4's December 2024 MAR (medication administration record) revealed the same physician's orders. Further review of R4's December 2024 MAR failed to reveal Basaglar was administered on 12/18/24 and 12/24/24, Gabapentin was administered on 12/24/24 at 9:00 p.m., and Trazodone was administered on 12/24/24, (as evidenced by blank spaces on the MAR). On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that if a medication is not available for administration, then nurses should check the Omnicell (a machine containing various medications), and if the medication is available in the Omnicell, nurses should obtain the medication and administer it. A review of the Omnicell list revealed insulin glargine 100 unit/1ml, Gabapentin 100mg capsules, and Trazodone 50 mg tablets was available in the Omnicell. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. Based on resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to provide care and services to maintain a resident's highest level of well-being for five of 17 residents in the survey sample, Residents #3, #1, #4, #9 and #15. The findings include: 1. For Resident #3 (R3), the facility staff failed to administer medications as ordered for bowel prep prior to a colonoscopy appointment which were available in the facility in house stock resulting in the procedure being rescheduled and delayed. The physician orders for R3 documented in part, - May use OTC meds from house stock per facility policy. Order Date: 5/18/2024. - Patient has appt October 15th for colonoscopy, patient should have bowel prep on the 13th and 14th of October and also be on clear liquid diet on those days. patient, supervisor and relief nurse all notified. one time only until 10/15/2024 23:59. Order Date: 10/02/2024. Start Date: 10/13/2024. - Mix the entire bottle of Miralax powder (238 grams) with the Gatorade or 64 ounces of lemonade in a large container. Shake to dissolve and place in refrigerator one time only for colonoscopy prep until 10/14/2024 23:59. Order Date: 9/17/2024. Start Date: 10/14/2024. - Gavilax Powder (Polyethylene Glycol 3350) Give 238 gram by mouth every shift for colonoscopy prep for 1 Day drink 8 oz (1 cup) of prep solution every 15 minutes until you have finished half of the prep solution. Order Date: 09/17/2024. Start Date: 10/14/2024. - Gavilax Powder (Polyethylene Glycol 3350) Give 238 gram by mouth every shift for colonoscopy prep for 1 Day drink 8 oz (1 cup) of prep solution every 15 minutes until you have finished half of the prep solution. Order Date: 09/17/2024. Start Date: 10/15/2024. Review of the facility house stock medication list revised 12/13/2023 documented Polyethylene glycol 3350 (Miralax/clearlax) stocked in house at the facility. The eMAR (electronic medication administration record) for R3 documented the Miralax powder not mixed on 10/14/24 and not administered on 10/14/24 night shift. The eMAR documented Other/See Nurses Notes . The nurses notes for R3 documented in part, - 9/11/2024 13:57 (1:57 p.m.) Nursing note. Note Text: Resident made aware of future appts scheduled for Oct. 15, 16, and 17. Copies of the appt given to the resident. Also, instructions for the colonoscopy were given to the resident to be aware. - 10/14/2024 15:53 (3:53 p.m.) Administration note. Note Text: Mix the entire bottle of Miralax powder (238 grams) with the Gatorade or 64 ounces of lemonade in a large container. Shake to dissolve and place in refrigerator. one time only for colonoscopy prep until 10/14/2024 23:59. reorder. MD (medical doctor) made aware. - 10/15/2024 00:09 (12:09 a.m.) Administration note. Note Text: Gavilax Powder Give 238 gram by mouth every shift for colonoscopy prep for 1 Day drink 8 oz (1 cup) of prep solution every 15 minutes until you have finished half of the prep solution. medication did not arrive per previous nurse report, resident told 3-11 nurse his appointment was canceled. - 10/29/2024 15:03 (3:03 p.m.) Nursing note. Note Text: Writer spoke to the scheduling department with [Name of hospital] regarding rescheduling resident Colonoscopy. Per office no available appts for the rest of this year. Once new schedule opens up for Jan/2025 someone will contact the facility with appt date/time. [phone number]. On 4/2/25 at 6:38 a.m., an interview was conducted with LPN (licensed practical nurse) #5 who stated that she had received report from the evening shift nurse on 10/14/24 at R3's bowel prep had not arrived from the pharmacy, and it had not been started as scheduled. She stated that she spoke with R3 who told her the appointment had been canceled because the medication had not been sent from the pharmacy, and he was supposed to have started it the evening prior to her shift. On 4/2/25 at 11:20 a.m., an interview was conducted with LPN #7 who stated that medication was evidenced by signing it off on eMAR. She stated that if the medication was not available the nurse should notify the provider that the medication was not available and call the pharmacy. She stated that if it was a colonoscopy prep the pharmacy may be able to send the medication over stat if they did not have the medication in the stock medications. LPN #7 stated that normally the medication could be sent over in a couple of hours or the physician may change it to something else so the procedure would not have to be rescheduled or canceled. On 4/2/25 at 11:52 a.m., an interview was conducted with LPN #8 who stated that all the nurses should be aware of the in-house medications and how to access them. She stated that Miralax was stocked in the medication rooms and each nurse had access to the room with their medication cart keys. The facility policy Medication and Treatment Orders dated 10/1/21 documented in part, .The facility has sufficient staff and a medication distribution system to ensure safe administration of medication without unnecessary interruptions . If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the emergency kit . On 4/2/25 at 4:08 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were made aware of the concern. No further information was provided prior to exit. 4.The facility staff failed to provide care and services to promote a resident's highest level of wellbeing by providing PICC/midline care for R9. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences. A review of the physician's order dated 11/21/24 revealed, Change PICC/Midline dressing q7days every day shift every 7 day(s). Physician's order dated 3/10/25 revealed, DC PICC one time only for ABX COMPLETED. A review of the progress note dated 3/2/25 at 10:36 PM revealed, Around 1900 patient called me in the room upset yelling and saying her line is contaminated, and it can't be used that I need to hurry up and find another kit to replace it. I was unsuccessful. I told her that I could not find another kit. A review of the progress note dated 3/10/25 at 6:30 PM revealed, Received resident lying in bed on left side with eyes open. Resident informed that I would be removing her PICC line from her right upper arm. Dressing removed, PICC site cleansed, PICC line removed without difficulty. Catheter tip intact and measures 20cm. Resident denies pain or distress, tolerated well. Pressure dressing applied. Resident encouraged to notify charge nurse if site begins to bleed or is painful. Resident stated understanding. An interview was conducted on 4/3/25 at 11:20 AM with LPN (licensed practical nurse) #7. When asked where evidence of PICC/Midline dressing change would be found, LPN #7 stated, it is either on the MAR or TAR. When asked if there is no documentation of the dressing changes, is there evidence of dressing changes being made, LPN #7 state, no, there is not evidence that it was done. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. The facility provided no policy regarding PICC/midline care. No further information was provided prior to exit. 5. The facility staff failed to provide care and services to promote a resident's highest level of wellbeing by making GI (gastrointestinal) appointment for R15 Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hereditary and idiopathic neuropathy, arthritis and chronic kidney disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan dated 9/12/24 revealed, FOCUS: The resident has FUNCTIONAL bladder incontinence related to weakness. INTERVENTIONS: Clean peri-area with each incontinence episode. A review of the physician order dated 12/27/24 reveals, Appt with GI Date:12/30/24 Time: 12:30pm Pick up: 12:00pm Return ride. No evidence of R15 going out to GI appointment in progress notes or elsewhere in the medical record. An interview was conducted on 4/1/25 at 8:15 AM with R15. When asked if she had been out to any physician appointments, R15 stated, not that I remember. A request was made for evidence of R15's physician appointment and transportation. An 4/2/25 at 10:55 AM ASM #2 stated, I called the doctor's office tor R15, about the December 30, 2024, appointment. They did not have any appointment on their book for this resident. When asked if that indicated that the appointment was not made for this resident, ASM #2 stated, yes, it would seem that the appointment had not been made. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. Facility provided no policy related to appointments. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a Foley urinary catheter (1) for one of 17 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to provide Foley catheter care during multiple shifts. R1's diagnoses included but were not limited to neuromuscular dysfunction of the bladder. A review of R1's clinical record revealed a physician's order dated 4/30/24 for catheter care every shift and as needed. A review of R1's TARs (treatment administration records) for September 2024 through November 2024 revealed the same physician's order. Further review of the TARs failed to reveal catheter care was provided on the following dates (as evidenced by blank spaces on the TARs): 9/24/24 during day shift. 9/27/24 during night shift. 9/28/24 during night shift. 10/9/24 during day, evening, and night shifts. 10/18/24 during night shift. 10/19/24 during evening shift. 11/13/24 during day shift. On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated catheter care should be done at least once a shift and consists of cleaning around the catheter with soap and water, and emptying the catheter bag as often as needed. LPN #7 stated nurses evidence that catheter care was provided by signing it off on the TAR. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Urinary Catheter Care documented, Infection Control: 2. Maintain clean technique when handling or manipulating the drainage system .Routine hygiene (e.g. cleansing of the meatal surface during daily bathing or showering) is appropriate .d. Empty the collection bag at least every eight (8) hours .Documentation- The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given . No further information was presented prior to exit. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for two of 17 residents in the survey sample, Residents #4 and #9. The findings include: 1. For Resident #4 (R4), the facility staff failed to administer oxygen per physician's order on multiple shifts. R4's diagnoses included but were not limited to chronic obstructive pulmonary disease (lung disease). A review of R4's clinical record revealed a physician's order dated 12/5/24 for continuous oxygen at two liters per minute every shift. A review of R4's December 2024 TAR (treatment administration record) revealed the same physician's order. Further review of R4's December 2024 TAR failed to reveal oxygen was administered on the following dates (as evidenced by blank spaces on the TAR): 12/14/24 during night shift. 12/16/24 during day shift. 12/19/24 during day shift. 12/24/24 during evening shift. On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated nurses should ensure residents are administered oxygen per physician's orders and should monitor residents' oxygen levels every shift. LPN #7 stated nurses evidence this care is provided by signing it off on the TAR. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Oxygen Administration documented, Preparation- 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Documentation: After completing oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed . No further information was presented prior to exit. 2. The facility staff failed to provide respiratory therapy per physician orders for R9. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences. A review of the physician orders dated 10/8/24 revealed, Oxygen 4 liters via NC (continuous) every shift may need more O2 with exertion. A review of the March 2025 TAR (treatment administration record) revealed, missing documentation of oxygen administration on following shifts: day shift-3/2, 3/7, 3/19, 3/21; evening shift-3/2, 3/3, ¾, 3/11, 3/16, 3/18, 3/29 and night shift-3/18, 3/25. An interview was conducted on 4/2/25 at 12:20 PM with LPN (licensed practical nurse) #8. When asked where oxygen administration per orders is evidenced, LPN #8 stated, it is documented on the TAR. When asked if the documentation is missing, is there evidence of administration, LPN #8 stated, no, there is no evidence. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Oxygen Administration policy revealed, Documentation-after completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: the rate of oxygen flow, route and rationale. No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide snacks during the day and at bedtime for two of 17 residents in the survey sample, R11 and R15. The findings include: 1. The facility staff failed to provide snacks during the day and at bedtime for Resident #11. Resident #11 (R11) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: Parkinson's Disease, convulsions and chronic kidney disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan dated 3/31/25 revealed, FOCUS: The resident is frequently incontinent of bladder and bowels. INTERVENTIONS: Provide substantial/maximal assistance with toileting. Observations in the nourishment Unit 1 and Unit 2 on 3/31/25 at 8:20 AM, 11:15 AM, 3:30 PM and 4/1/25 at 6:10 AM revealed, no snacks available including milk, applesauce, ice cream, crackers, yogurt, peanut butter with exception of 2 milk and 2 yogurts found on Unit 2 at 8:25 AM on 3/31/25. Facility census was 120 on entrance 3/31/25. An interview was conducted on 3/31/25 at 10:35 AM when R11, when asked if he received snacks during the day and at bedtime, R11 stated, no, there are no snacks. We can buy some, but they do not give us any. An interview was conducted on 3/31/25 at 10:40 AM with CNA #3. CNA #3 was leaving the unit nourishment room. When asked if he had snacks for residents, CNA #3 stated, no there are no snacks for the residents on day or evening shift. An interview was conducted on 3/31/25 at 3:30 PM with CNA #4. When asked if she has snacks to provide to residents, CNA #4 stated, the kitchen sends down some PBJ (peanut butter jelly) and cheese sandwiches for the diabetic residents. There are no other snacks for the residents, no crackers, applesauce or milk. An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When asked if night shift had snacks, they need for the residents. CNA #7 stated, we have no snacks for the residents. Opened a cabinet door in nourishment room and stated, look at this, took out 12-ounce jar of peanut butter and opened it. Approximately one teaspoon of peanut butter in the bottom. CNA #7 stated, what do you do with this amount, and we have no crackers. An interview was conducted on 4/1/25 at 10:15 AM with OSM (other staff member) #3, the Director of Dietary Services. When asked what snacks are provided to the residents, OSM #3 stated we send out snack for bedtime, extra sandwiches, PBJ. We offer PBJ and grilled cheese at any time of the day. When asked if milk, applesauce, crackers are stocked for the residents during the day, OSM #3 stated, no, we have never had par levels for nourishment. I was not aware there was an issue. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Between Meal and Bedtime Snacks policy revealed, The purpose of this procedure is to provide the resident with adequate nutrition. No further information was provided prior to exit. 2. The facility staff failed to provide snacks during the day and at bedtime Resident #15. Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hereditary and idiopathic neuropathy, arthritis and chronic kidney disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan dated 9/12/24 revealed, FOCUS: The resident has FUNCTIONAL bladder incontinence related to weakness. INTERVENTIONS: Clean peri-area with each incontinence episode. Observations in the nourishment Unit 1 and Unit 2 on 3/31/25 at 8:20 AM, 11:15 AM, 3:30 PM and 4/1/25 at 6:10 AM revealed, no snacks available including milk, applesauce, ice cream, crackers, yogurt, peanut butter with exception of 2 milk and 2 yogurts found on Unit 2 at 8:25 AM on 3/31/25. Facility census was 120 on entrance 3/31/25. An interview was conducted on 4/1/25 at 5:45 AM with R15. R15 stated, there is no snacks for the residents. Nothing in between meals. An interview was conducted on 3/31/25 at 10:40 AM with CNA #3. CNA #3 was leaving the unit nourishment room. When asked if he had snacks for residents, CNA #3 stated, no there are no snacks for the residents on day or evening shift. An interview was conducted on 3/31/25 at 3:30 PM with CNA #4. When asked if she has snacks to provide to residents, CNA #4 stated, the kitchen sends down some PBJ (peanut butter jelly) and cheese sandwiches for the diabetic residents. There are no other snacks for the residents, no crackers, applesauce or milk. An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When asked if night shift had snacks, they need for the residents. CNA #7 stated, we have no snacks for the residents. Opened a cabinet door in nourishment room and stated, look at this, took out 12-ounce jar of peanut butter and opened it. Approximately one teaspoon of peanut butter in the bottom. CNA #7 stated, what do you do with this amount, and we have no crackers. An interview was conducted on 4/1/25 at 10:15 AM with OSM (other staff member) #3, the Director of Dietary Services. When asked what snacks are provided to the residents, OSM #3 stated we send out snack for bedtime, extra sandwiches, PBJ. We offer PBJ and grilled cheese at any time of the day. When asked if milk, applesauce, crackers are stocked for the residents during the day, OSM #3 stated, no, we have never had par levels for nourishment. I was not aware there was an issue. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Between Meal and Bedtime Snacks policy revealed, The purpose of this procedure is to provide the resident with adequate nutrition. No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide supplies, including urinals, gloves, cup tops for the for two of 17 residents in the survey sample, R11 and R15. The findings include: 1. The facility staff failed to provide supplies, including urinals, gloves, cup tops for Resident #11. Resident #11 (R11) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: Parkinson's Disease, convulsions and chronic kidney disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan dated 3/31/25 revealed, FOCUS: The resident is frequently incontinent of bladder and bowels. INTERVENTIONS: Provide substantial/maximal assistance with toileting. Observations in the supply/linen closets on Unit 1 and Unit 2 on 3/31/25 at 8:20 AM, 3:30 PM and 4/1/25 at 6:10 AM revealed, no urinals or gloves on 3/31 8:20 AM, at 3:30 PM there were 4 urinals and 2 boxes of gloves in each closet and on 4/1 at 6:10 AM there were 2 urinals and 2 boxes of gloves in each closet. Facility census was 120 on entrance 3/31/25. An interview was conducted on 3/31/25 at 9:00 AM with CNA (certified nursing assistant) #1. When asked if they have the supplies they need, CNA #1 stated, no, we run out of supplies. When asked what supplies, CNA #1 stated, sometimes urinals, adult briefs and gloves. We have to get gloves from different resident rooms at times or carry them in our pocket. An interview was conducted on 3/31/25 at 3:25 PM with CNA #5, when asked if she has supplies that she needs for evening shift, CNA #5 stated, no, we are short with gloves, adult diapers and urinals. We did not have urinals and only a few gloves any over the weekend. An interview was conducted on 3/31/25 at 3:30 PM with CNA #4. CNA #4 approached CNA #5 and I in the linen/supply room on Unit 1 and asked CNA #5 if she had found any gloves. CNA #4 stated, in several rooms there are no gloves, are there any here. When asked if they are short of supplies, CNA #4 stated, yes, gloves, urinals, towels, washcloths and sheets. An interview was conducted on 4/1/25 at 5:30 AM with CNA #6. When asked if night shift had any shortages of supplies, CNA #6 stated, we are okay last night with urinals but short on gloves. An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When asked if night shift had supplies, CNA #7 stated, sometimes we are short on gloves and urinals. An interview was conducted on 4/1/25 at 10:57 AM with OSM (other staff member) #4, the central supply supervisor. When asked about the supply process for the facility, OSM #4 stated, the process for ordering supplies, is that the director of nursing goes through the system and orders it. I have only been in this role about 3 weeks. Usually diapers, gloves, wipes, are ordered. I come in everyday and see if we have it in the shed. Shipment came in yesterday; we did not receive any urinals in the order Friday, so they delivered it on Monday. I come to the floors and check the supply closets, if the nurses/aides tell me they need something, I go to shed and if we don't have it, come back in and talk with the DON or ADM to enter order. When ask what happens if there are zero of a needed item, like urinals or gloves, OSM #4 stated, we can do a rush order. Normally we order weekly. I work Monday through Friday. I typically stock Monday & Friday day shift. If they don't have something and I am not here, then they call me, but I try to make sure supplies are in central supply. An interview was conducted on 4/2/25 at 6:00 AM with CNA #7. When asked if there were supply shortages during the night, CNA #7 stated, see these bottles of water, we are giving the residents bottles of water because we have no lids for their water cups. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. No policy regarding supplies was provided by the facility. No further information was provided prior to exit. 2. The facility staff failed to provide supplies, including gloves, cup tops for Resident #15. Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hereditary and idiopathic neuropathy, arthritis and chronic kidney disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan dated 9/12/24 revealed, FOCUS: The resident has FUNCTIONAL bladder incontinence related to weakness. INTERVENTIONS: Clean peri-area with each incontinence episode. Facility census was 120 on entrance 3/31/25. An interview was conducted on 3/31/25 at 9:00 AM with CNA (certified nursing assistant) #1. When asked if they have the supplies they need, CNA #1 stated, no, we run out of supplies. When asked what supplies, CNA #1 stated, sometimes urinals, adult briefs and gloves. We have to get gloves from different resident rooms at times or carry them in our pocket. An interview was conducted on 3/31/25 at 3:25 PM with CNA #5, when asked if she has supplies that she needs for evening shift, CNA #5 stated, no, we are short with gloves, adult diapers and urinals. We did not have urinals and only a few gloves any over the weekend. An interview was conducted on 3/31/25 at 3:30 PM with CNA #4. CNA #4 approached CNA #5 and I in the linen/supply room on Unit 1 and asked CNA #5 if she had found any gloves. CNA #4 stated, in several rooms there are no gloves, are there any here. When asked if they are short of supplies, CNA #4 stated, yes, gloves, urinals, towels, washcloths and sheets. An interview was conducted on 4/1/25 at 5:30 AM with CNA #6. When asked if night shift had any shortages of supplies, CNA #6 stated, we are okay last night with urinals but short on gloves. An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When asked if night shift had supplies, CNA #7 stated, sometimes we are short on gloves and urinals. An interview was conducted on 4/1/25 at 5:45 AM with R15. When asked about supplies, R15 stated, they do not always have my size briefs. An interview was conducted on 4/1/25 at 10:57 AM with OSM (other staff member) #4, the central supply supervisor. When asked about the supply process for the facility, OSM #4 stated, the process for ordering supplies, is that the director of nursing goes through the system and orders it. I have only been in this role about 3 weeks. Usually diapers, gloves, wipes, are ordered. I come in everyday and see if we have it in the shed. Shipment came in yesterday; we did not receive any urinals in the order Friday, so they delivered it on Monday. I come to the floors and check the supply closets, if the nurses/aides tell me they need something, I go to shed and if we don't have it, come back in and talk with the DON or ADM to enter order. When ask what happens if there are zero of a needed item, like urinals or gloves, OSM #4 stated, we can do a rush order. Normally we order weekly. I work Monday through Friday. I typically stock Monday & Friday day shift. If they don't have something and I am not here, then they call me, but I try to make sure supplies are in central supply. An interview was conducted on 4/2/25 at 6:00 AM with CNA #7. When asked if there were supply shortages during the night, CNA #7 stated, see these bottles of water, we are giving the residents bottles of water because we have no lids for their water cups. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. No policy regarding supplies was provided by the facility. No further information was provided prior to exit.

Based on staff interview, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 17 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to document the resident's blood sugar reading on 12/13/24 at 3:59 a.m. A review of R1's clinical record revealed a physician's order dated 12/13/24 that documented, Recheck blood glucose at 0200 (2:00 a.m.) A review of R1's December 2024 medication administration record revealed the resident's blood sugar was re-checked on 12/13/24 at 3:59 a.m. Further review of R1's clinical record (including the December 2024 medication administration record, nurses' notes, and blood sugar summary) failed to reveal documentation of the numerical reading of the resident's blood sugar when it was re-checked on 12/13/24 at 3:59 a.m. On 4/2/25 at 3:23 p.m., an interview was conducted with LPN #9 (the nurse who signed off re-checking R1's blood sugar at 3:59 a.m.) LPN #9 stated that when a nurse checks a resident's blood sugar, the number should be documented on the medication administration record. LPN #9 stated she did not remember R1. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility did not have a policy regarding a complete and accurate clinical record. No further information was presented prior to exit.

Based on staff interview, and facility document review, the facility staff failed to provide dignity and respect for two of 17 residents in the survey sample, Residents #4 and #9. The findings include: 1. For Resident #4 (R4), the facility staff failed to speak to the resident in a respectful and dignified manner. A grievance form regarding R4, dated 12/12/24 documented, Per sister, (name of RN [registered nurse] #4 [agency nurse]) was rude and abrasive (with) resident and sister after waiting for hours for someone. Per (name of sister), (name of RN #4) stated things like, 'I am busy too.' Per sister, not customer service appropriate. Initial Action: Date: 12/11/2024: Spoke (with) (name of RN #4). Per (name of RN #4) felt verbally abused by sister. However was abrasive with this unit manager as well. Follow Up Action: Date: 12/12/2024: RN to be DNR (do not return) from facility. Resident council meeting minutes dated 12/18/24, 1/22/25, 2/19/25, and 3/19/25 documented, Nursing: Customer service issues/staff attitudes. On 4/2/25 at 6:26 a.m., an interview was conducted with CNA (certified nursing assistant) #6. CNA #6 stated the facility employs agency staff and there have been quite a few rude CNAs. CNA #6 stated that sometimes when a resident requests something, a staff member will state, Not now and walk off. CNA #6 stated she has also heard a resident request water and a staff member state, Didn't I just give you water. CNA #6 further stated she has heard a resident request their food be warmed up and a staff member state, No. I'm not warming it up. On 4/2/25 at 12:02 p.m., an interview was conducted with LPN (licensed practical nurse) #8 (the nurse who documented the above grievance form). LPN #8 stated she did not personally hear RN #4 speak to R4 or the resident's sister, but she spoke to RN #4 on the phone regarding the above grievance. LPN #8 stated she did not know if RN #4 was stressed out from demands by R4's family but RN #4 was short, curt, and was not very customer friendly. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Dignity documented, 1. Residents will be treated with dignity and respect at all times. No further information was presented prior to exit. 2. The facility failed to treat R9 in a respectful dignified manner. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences. A review of the facility event synopsis dated 1/8/25 revealed, R9 alleged that aide used profanity when speaking with her. Review of staff interview revealed, R9 stated that she does not want aide in her room because she is rude. Review of interview with R9 on 1/8/25 revealed, The CNA (certified nursing assistant) was very rude. I asked her why she was being rude, and she became verbally aggressive. An interview was conducted on 3/31/25 at 9:30 AM with R9. When asked if she had been treated with dignity and respect, R9 stated, no, there is an aide that does not work with me anymore as she was rude and disrespectful. When asked if she had been treated in a dignified manner, R9 stated, no, I was not. An interview was conducted on 3/31/25 at 12:00 PM with LPN (licensed practical nurse) #1. When asked if she had heard any staff being disrespectful to a resident. LPN #1 stated, yes, occasionally some of the agency staff will be short with the resident or use a hard tone of voice. When asked would this be considered verbal abuse, LPN #1 stated, no, no verbal abuse, just tone of voice mainly. An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When CNA #7 was asked if she had heard any staff talking with residents disrespectfully, CNA #7 stated, yes, some staff do not speak in a nice tone. When asked if the residents are being treated with dignity, CNA #7 stated, no, they are not being treated with dignity. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Dignity policy revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff always speak respectfully to residents, including addressing the resident by his or her name of choice and not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to evidence radiology services as ordered for one of 17 residents, R8. The findings include: Resident #8 (R8) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CVA (cerebrovascular accident) with hemiplegia, hemiparesis and vascular dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/5/24, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as being dependent for turning. A review of the comprehensive care plan dated 8/21/24 revealed, FOCUS: The resident has an ADL (activities of daily living) self-care performance deficit due to history of CVA, dementia. He is dependent on staff for all ADL needs. INTERVENTIONS: BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed and as necessary. A review of the physician's order dated 12/16/24 revealed, CXR one time only for productive cough for 1 day. A review of the progress notes dated 12/18/24 at 12:27 AM revealed, attempted to call to schedule a chest Xray but voice recording says to call back during regular business hours. Will pass this forward to 7-3p shift for action and follow-up with this call. A review of the progress notes dated 12/18/24 at 1:35 PM revealed, Call placed to Dispatch Health Imaging. Per representative, no longer takes new orders 24/7. Only able to place orders up until 11:00 PM. CXR ordered at this time. A review of the chest x-ray results obtained on 12/19/24 at 6:00 AM and resulted on 12/19/24 at 4:45 PM revealed, There has been no significant change compared with the prior exam. Impression: The lungs show no confluent airspace opacity. An interview was conducted on 4/2/25 at 10:35 AM with ASM (administrative staff member) #7, the nurse practitioner. When asked expected time frame for a chest x-ray completion, ASM #7 stated, normally we would get the x-ray and results within 24 hours. I do not know if the imaging calls for critical results. ASM #1, the administrator stated on 4/3/25 at 9:00 AM, there is nothing more to provide to you. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Radiology and Diagnostic Services policy revealed, Radiological and diagnostic testing services are provided by the facility to meet the needs of our residents. The services may be provided on-site or off-site through contracted services of a diagnostic testing provider that is approved to provide the services by Medicare. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide pharmacy services for one of 17 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to obtain medications for administration. A review of R4's clinical record revealed physician's orders dated 12/3/24 for Verapamil 240 mg (milligrams)-one tablet by mouth at bedtime for high blood pressure and Prazosin 2 mg-one capsule by mouth at bedtime for HTN (hypertension [high blood pressure]). R4's December 2024 MAR (medication administration record) revealed the same physician's orders. Further review of R4's December 2024 MAR failed to reveal Verapamil and Prazosin was administered on 12/24/24 (as evidenced by blank spaces on the MAR). On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that if a medication is not available for administration, then nurses should check the Omnicell (a machine containing various medications). LPN #7 stated that if the medication is not available in the Omnicell, then nurses should contact the pharmacy, re-order the medication, and call the provider (physician or nurse practitioner) to obtain an order for an alternative medication or put the medication on hold. A review of the Omnicell list revealed Verapamil and Prazosin was not available in the Omnicell. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility pharmacy policy titled, General Guidelines for Medication Administration documented, II. Administration: 2. Medications are administered in accordance with written orders of the prescriber. No further information was presented prior to exit.

Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop the care plan for one of 17 residents in the survey sample, R9. The findings include: The facility staff failed to develop the comprehensive care plan for PICC (peripherally inserted central catheter) /midline care for R9. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences. There is no evidence of PICC/midline on R9's care plan. A review of the progress note dated 3/10/25 at 6:30 PM revealed, Received resident lying in bed on left side with eyes open. Resident informed that I would be removing her PICC line from her right upper arm. Dressing removed, PICC site cleansed, PICC line removed without difficulty. Catheter tip intact and measures 20cm. Resident denies pain or distress, tolerated well. Pressure dressing applied. Resident encouraged to notify charge nurse if site begins to bleed or is painful. Resident stated understanding. An interview was conducted on 3/31/25 at 9:30 AM with R9. When asked if she had any lines or catheters, R9 stated, there was a PICC line for antibiotics, but it was removed. An interview was conducted on 4/2/25 at 12:20 PM with LPN (licensed practical nurse) #8. When asked the care plan purpose, LPN #8 stated, it is so nursing staff know how to care for the resident. When asked if a midline should be on care plan, LPN #8 stated yes, special needs should be on the care plan. Here nursing team develops the care plan. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. No policy for care plan provided. No further information was provided prior to exit.

Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide a safe/clean and homelike environment for three of 17 residents, R9, R11 and R15. The findings include: 1. The facility staff failed to maintain a clean and homelike environment for Resident #9. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: Identify and honor food preferences. On 3/31/25 at 12:30 PM observed R9's room. Room had peeling wallpaper at the seams, and behind headboard of bed two 8.5 x 11 inches and one approximately 3 x 18 inches of spackled dry wall. When ask about the room and wall spackling, R9 stated, they told me it was due to the bed rubbing on the wall. The plan is for them to renovate room [ROOM NUMBER], then move me to that room and renovate this room. An interview was conducted on 4/2/25 at 9:00 AM with OSM (other staff member) #6, the maintenance director. When shown R9's room with peeling wallpaper at seams and spackling compound over holes in walls behind headboard, OSM #6 stated, the renovation started with the halls and lobby. We will then move to resident rooms. Our plan is to renovate room [ROOM NUMBER], move this resident to that room, then renovate this room. When asked if this is a clean and homelike environment, OSM # stated, no, when you ask those questions, it is not. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Homelike Environment policy revealed, Residents will be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. No further information was provided prior to exit. 2. The facility staff failed to maintain a clean/homelike environment and provide linens for Resident #11. Resident #11 (R11) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: Parkinson's Disease, convulsions and chronic kidney disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan dated 3/31/25 revealed, FOCUS: The resident is frequently incontinent of bladder and bowels. INTERVENTIONS: Provide substantial/maximal assistance with toileting. On 3/31/25 at 1:30 PM observed R11's room. Room had peeling wallpaper at the seams on three walls. When ask about the room and wall spackling, R11 stated, yes, it has been like this for a while. An interview was conducted on 3/31/25 at 8:00 AM with OSM (other staff member) #1, the laundry aide. When asked if there is a stained or torn linen, OSM #1 stated, no, I would not put it out if it were stained or torn. I will be bringing linen out to the unit shortly. Observations on 3/31/25 at 8:20 AM revealed, Unit 1: 4 pillowcases and 1 blanket. Zero towels, washcloths, fitted or flat sheets or gowns; Unit 2: 2 pillowcases and 1 blanket. Zero towels, washcloths, fitted or flat sheets or gowns. An interview was conducted on 3/31/25 at 9:00 AM with CNA (certified nursing assistant) #1. When asked if they have the linen and supplies, they need, CNA #1 stated, no, we do not have enough linen and we run out of supplies. An interview was conducted on 3/31/25 at 10:35 AM when R11, who had rolled his wheelchair up to the nursing station to ask for a towel and washcloth. CNA #3 told R11, we do not have any right now, I will bring you some as soon as we have them. When R11 was asked how often there is not linen, towels/washcloths for him in the morning, R11 stated, it happens a lot, it is late morning before we have linen. An interview was conducted on 3/31/25 at 10:40 AM with CNA #3. CNA #3 was leaving the unit nourishment room. When asked about linens, CNA #3 stated, we are out of linen, and they have not delivered any this morning. We cannot bathe our residents or even provide incontinence care because there are no towels and washcloths. An interview was conducted on 4/2/25 at 9:00 AM with OSM (other staff member) #6, the maintenance director. When shown R11's room with peeling wallpaper at seams, OSM #6 stated, the renovation started with the halls and lobby. We will then move to resident rooms. Our plan is to renovate room [ROOM NUMBER], move a resident into that room and then go down the line in order to renovate the rooms. When asked if this is a clean and homelike environment, OSM # stated, no, when you ask those questions, it is not. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Homelike Environment policy revealed, Residents will be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that are in a good condition. No further information was provided prior to exit. 3. The facility staff failed to provide linens for Resident #15. Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hereditary and idiopathic neuropathy, arthritis and chronic kidney disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/5/25, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan dated 9/12/24 revealed, FOCUS: The resident has FUNCTIONAL bladder incontinence related to weakness. INTERVENTIONS: Clean peri-area with each incontinence episode. An interview was conducted on 3/31/25 at 8:00 AM with OSM (other staff member) #1, the laundry aide. When asked if there is a stained or torn linen, OSM #1 stated, no, I would not put it out if it were stained or torn. I will be bringing linen out to the unit shortly. Observations on 3/31/25 at 8:20 AM revealed, Unit 1: 4 pillowcases and 1 blanket. Zero towels, washcloths, fitted or flat sheets or gowns; Unit 2: 2 pillowcases and 1 blanket. Zero towels, washcloths, fitted or flat sheets or gowns. Observations on 4/1/25 at 6:05 AM revealed, Unit 1: 2 pillowcases and 1 each fitted and flat sheet. Zero towels, washcloths or gowns; Unit 2: 15 pillowcases, 2 washcloths, 9 towels, 3 blanket and 1 gown. Zero fitted or flat sheets or blankets. An interview was conducted on 3/31/25 at 9:00 AM with CNA (certified nursing assistant) #1. When asked if they have the linen and supplies, they need, CNA #1 stated, no, we do not have enough linen and we run out of supplies. An interview was conducted on 3/31/25 at 10:40 AM with CNA #3. CNA #3 was leaving the unit nourishment room. When asked about linens, CNA #3 stated, we are out of linen, and they have not delivered any this morning. We cannot bathe our residents or even provide incontinence care because there are no towels and washcloths. An interview was conducted on 4/1/25 at 5:40 AM with CNA #7. When asked if night shift had supplies, linen and snacks they need for the residents. CNA #7 stated a lot of the time we do not have linen for the residents. CNA #7 stated, there is a resident who wants to speak to the state about snacks and linen, CNA you talk with her. An interview was conducted on 4/1/25 at 5:45 AM with R15. R15 stated, this is the fifth day there has not been linen in the morning. I am so tired of this. I have had to use a pillowcase to wash and dry my face. They cannot clean you up, because there is no linen. On 4/2/25 at 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations was made aware of the findings. A review of the facility's Homelike Environment policy revealed, The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that are in a good condition. No further information was provided prior to exit.

2.a. For Resident #1 (R1), the facility staff failed to notify the physician or nurse practitioner in a timely manner when the antibiotic medication Ertapenem was not available for administration. A review of R1's clinical record revealed a urine culture report dated 11/11/24 that documented the resident presented with a urinary tract infection. Further review of R1's clinical record revealed a physician's order dated 11/11/24 for Ertapenem Sodium Solution- one gram intravenously every 24 hours for infection for seven days. Pharmacy alerts dated 11/11/24 documented a possible drug allergy and a possible drug interaction for Ertapenem. Administration notes dated 11/12/24 and 11/13/24 documented the nurses were waiting for the pharmacy to send Ertapenem. An administration note dated 11/14/24 documented, Pharmacy originally would not fill (Ertapenem) because of an allergy alert. Per NP (nurse practitioner) (name) it is ok for resident to take this drug, as she has been given it before. Per pharmacy medication will be delivered today. A review of R1's November 2024 medication administration record and a nurse's note dated 11/15/24 revealed R1 was not administered the first dose of Ertapenem until 11/15/24 (four days after the medication was ordered). On 4/2/25 at 10:10 a.m., an interview was conducted with ASM (administrative staff member) #6 (the nurse practitioner). ASM #6 stated the importance of immediately starting an antibiotic is to prevent the resident from going septic. ASM #6 stated she enters medication orders into the computer system then the nurses have to activate the orders. ASM #6 stated that when the nurses activate the orders, the system tells them if there are possible allergies or drug interactions. ASM #6 stated the nurses should call her as soon as they receive the alerts. ASM #6 stated that once she enters an order, she assumes the pharmacy will send the medication and if the medication does not come, it is the nurses' responsibility to notify her. On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that when a nurse activates orders in the computer system and there are possible allergy or drug interactions, the system alerts the nurse before she saves the orders. LPN #7 stated right then and there, the nurse should contact the pharmacy and immediately call the physician or nurse practitioner. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 2.b. For Resident #1 (R1), the facility staff failed to notify the resident representative when the resident's blood sugar read, High and the nurse practitioner ordered additional insulin. A review of R1's clinical record revealed a nurse's note dated 12/13/24 that documented, Resident blood glucose recording HI, Rechecked several times. Insulin lispro 15 mls (milliliters) administered subcutaneously, and 18 units of glargine insulin administered. Glucose continued to read high 30 min later. Message sent to NP (nurse practitioner), order to administer an additional 12 units of lispro insulin and recheck the glucose 2 hours later received. Further review of R1's clinical record failed to reveal R1's representative was notified regarding the high blood sugar and the order for additional insulin. On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated a resident's representative should be called if the resident's blood sugar reads, High and the nurse practitioner orders additional insulin. On 4/2/25 at 2:23 p.m., an interview was conducted with RN (registered nurse) #3 (the nurse who documented the above nurse's note). RN #3 stated she did not remember calling R1's representative when the resident's blood sugar read, High and the nurse practitioner ordered additional insulin. On 4/2/25 at 4:09 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the physician/nurse practitioner and/or the responsible party of resident changes for two of 17 residents in the survey sample, Residents #6 and #1. The findings include: 1. For Resident #6 (R6), the facility staff failed to notify the responsible party and physician of refusal of care and a change in behavior on 7/26/24. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 7/28/24, the resident scored three out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section E documented physical and verbal behaviors directed towards others one to three days during the assessment period. The progress notes for R6 documented in part, - 7/24/2024 21:56 (9:56 p.m.) Note Text: resident arrived via stretcher from home, resident here for respite care. resident alert with some confusion. resident is a high fall risk. skin tear to left forearm. resident takes meds whole. regular diet. hydration at bedside call bell in reach, will cont. to monitor for needs and safety. - 7/25/2024 02:14 (2:14 a.m.) .Cognitive status assessed. Resident is cognitively intact. Oriented to person. Oriented to place. Oriented to time. Behavior/mood evaluated, and the resident is noted to be uncooperative . - 7/26/2024 05:41 (5:41 a.m.) Note Text: Accucheck. one time a day Notify physician for BG <70 or >400 Patient refused, kicking, using derogatory language and spitting at staff. - 7/26/2024 06:42 (6:42 a.m.) Note Text: The resident's behavior became combative, including the use of derogatory language, spitting, kicking, and even biting at the staff. Despite this RN (registered nurse) and a second person nursing assistance inquiring about how they could assist him, the aggression only intensified. The resident began yelling and kicking, complicating the situation further. Additionally, the resident continued to remove his clothes and briefs. In response, this RN and nursing assistant decided to step away from the resident while ensuring his safety, leaving the bed in the lowest position and the call bell within reach. - 7/28/2024 01:11 (1:11 a.m.) .Cognitive status assessed. Resident is cognitively intact. Oriented to person. Oriented to place. Oriented to time. Behavior/mood evaluated, and the resident is noted to be uncooperative . - 7/29/2024 01:51 (1:51 a.m.) .Cognitive status assessed. Resident is cognitively intact. Oriented to person. Oriented to place. Oriented to time. Behavior/mood evaluated, and the resident is noted to be uncooperative . The progress notes failed to evidence documentation of physical behaviors towards others or refusal of care on dates other than 7/26/24. The clinical record failed to evidence notification of the physician or the responsible party of the change in behavior with physical aggression towards staff observed on 7/26/24. On 4/2/25 at approximately 9:00 a.m., ASM (administrative staff member) #1, the administrator stated that the RN (registered nurse) who documented the progress note regarding the physical aggression observed on 7/26/24 no longer worked at the facility and could not be interviewed. On 4/2/25 at 6:09 a.m., an interview was conducted with CNA (certified nursing assistant) #6 who stated that they worked with R6 when they were at the facility. She stated that she remembered that R6 had become very confused and anxious when he woke up that morning and became very upset about something. She stated that when she went in the room he had started yelling, spitting and kicking and she had called for the nurse. She stated that they had not touched R6 and had made sure he was safe and left him in the room to calm down. On 4/2/25 at 11:20 a.m., an interview was conducted with LPN (licensed practical nurse) #7 who stated that the responsible party should be notified of changes in condition or anything out of the normal. She stated that when a resident refused medications or care they attempted at least and if they still refused, they let the physician, and the responsible party know. She stated that if a resident had a change in behavior, they would call the physician with concern for a urinary tract infection or if the resident was a new admission she would contact the family to discuss their normal behavior and see what was done to deescalate the behavior. On 4/2/25 at 1:28 p.m., ASM #2, the director of nursing stated that they did not have any evidence to provide that the RP or MD were notified of the refusal of the accuchecks or the behavioral incident on 7/26/24. She stated that there was no investigation completed into the behavioral incident on 7/26/24. The facility policy, Change in a Residents Condition, documented in part, .The facility will promptly notify the resident, his or her physician/practitioner, and the representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's Attending Physician/practitioner or physician on call when there has been a(an) . d. significant change in the resident's physical, mental, or psychosocial status . Unless otherwise instructed by the resident, a nurse will notify the resident's representative when . b. There is a significant change in the resident's physical, mental, or psychosocial status . On 4/2/25 at 4:08 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were made aware of the above concern. No further information was obtained prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to honor a resident's right to refuse a room change for one of 17 residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to honor a resident's right to refuse a room change on 11/21/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/22/24, the resident scored 15 out of 15 on the (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The assessment further documented no behaviors observed during the assessment period and active discharge planning occurring for the resident to return to the community. The admission record for R3 documented the resident as their own responsible party. The census list for R3 documented an admission to Unit one to a private room with a room change on 11/21/24 to Unit two to a semi-private room. The progress notes for R3 documented in part, - 11/20/2024 16:04 (4:04 p.m.) Nursing note. Note Text: Met with resident in his room with DON (director of nursing), SW (social worker), Administrator, and Admissions Coordinator to discuss plans for rooms change. Resident was given teaching that he does not have a clinical need to remain in a private room and that Medicaid has not paid for him to remain in a private room. Based on these factors he will be moved to another room that is more appropriate for his clinical needs. Resident resistant to moving. He notified ombudsman to mediate. Ombudsman spoke with DON, SW, and Administrator via conference call. Room change deferred pending ombudsman review. - 11/21/2024 13:38 (1:38 p.m.) Social services. Note Text: SW, DOA (director of admissions) and resident CNA (certified nursing assistant) went to resident room to assist in room change. Resident began yelling at DOA, telling her to get out and not to touch any of his things. He continued to yell at staff while they were helping pack his things in his room. As DOSS (director of social services) was trying to assist staff in packing, resident closed the DOSS hand in his dresser drawer while cussing and yelling get out, I don't want you in here. DOSS exited resident room along with DOA. CNA staff continued to pack resident and move him to his new room. On 4/2/25 at approximately 9:00 a.m., ASM (administrative staff member) #1, the administrator, stated that the director of nursing who wrote the nursing note on 11/20/24 at 4:04 p.m. no longer worked at the facility and could not be interviewed. On 4/2/25 at 8:11 a.m., an interview was conducted with OSM (other staff member) #5, the director of social services, who stated that they worked with R3 at the facility. She stated that when a resident's room was going to be changed, she went in to speak to the resident to make sure the resident was going to be okay with the roommate, discuss the room change with both residents in the shared room, discuss it with the family, complete the room change assessment and make sure the residents agree to the room change. She stated that R3 was in a private room and was not paying private room prices. She stated that R3 had converted to LTC (long term care) and was to be moved to a shared space, but he had refused to move for some time. OSM #5 stated that R3 had yelled at the staff, screamed at them and disrespected the staff. She stated that they had gone to R3 as a team to discuss why they had to make the room change and he continued to refuse to move from the private room, saying that he did not have to move. She stated that they discussed discharge home and R3 did not want to leave the facility. OSM #5 stated that on 11/21/24 they had gone into R3's room and talked to him again while the nursing staff were packing his things. She stated that R3 had yelled at her to get out of the room, and she had left the room to leave the nursing staff to complete the move. She stated that she remembered that R3 had viewed the new room prior to the move but she could not say that he had met the new roommate prior to the move. OSM #5 stated that residents could make the choice about room changes and she was certain that the business office manager had offered R3 the ability to keep the private room and given the pricing but he had refused. She stated that the business office manager no longer worked at the facility. On 4/2/25 at 10:30 a.m., an interview was conducted with OSM #8, the director of admissions who stated that R3 was moved on 11/21/24 due to the room being needed for isolation for a new admission. She stated that they had given R3 the option to pay for the private room and he had refused so they had completed the room change later that day. She stated that she did not have any documentation regarding this, but the social worker and former director of nursing had documented this. At that time a request was made to ASM #1, the administrator for evidence of the census on 11/21/24 with available rooms, and evidence of a private isolation room needed for the new resident. On 4/2/25 at 11:52 a.m., an interview was conducted with LPN (licensed practical nurse) #8 who stated that they remembered R3 was not happy with moving from a private to a semiprivate room. She stated that after the first night he was moved he stayed out of the facility and did not notify them and then not long after that he was discharged . She stated that she thought that the room change had to do with a payer change. On 4/2/25 at approximately 1:30 p.m., ASM #1 and OSM #8 provided documents for Resident #17 who was admitted to the facility on [DATE] which failed to evidence an isolation need. Review of R17's clinical record failed to evidence isolation while a resident at the facility. The empty locations list for 11/21/2024 documented two empty semi-private rooms and failed to evidence private rooms. On 4/2/25 at 2:15 p.m., an interview was conducted with ASM #1 who stated that R17 was not on isolation and that the private room need may have been for behaviors. She stated that one of the empty semi-private rooms on Unit one was undergoing renovations on 11/21/24 and was still closed. She stated that the other empty semi-private room could have been an option for R3, but they would have had to look at the size of the room for R3's bed and there were no other private rooms open on 11/21/24. She stated that R3 was not forced out the room because they had explained to him that they needed the room for another resident who could be coming. ASM #1 stated that they had discussed with R3 that if he wanted a private room, he had to pay the private room rate and he basically said no. She stated that he decided to transition to LTC, and she was there the day of the move when there was a lot of cursing and telling them to get out. In a follow up interview at 3:56 p.m., ASM #1 was asked what it meant to transition to LTC. ASM #1 stated that R3 had originally admitted for short term for a stay about 30 days but had decided that he wanted to stay long term. She stated that even though they were dually certified, they tried to keep the LTC residents on Unit 2. She stated that they tried to keep Unit 1 as the post-acute unit. ASM #1 stated that they had 128 beds total, and all beds were dually certified. When asked what the clinical need was for R3 to have the private room on admission, she stated that she was not aware of what it was. The facility policy, Room Change/Roommate Assignment dated 10/01/2021 documented in part, .Residents have the right to refuse to move to another room in the facility if the purpose of the move is: a. To relocate the resident from a skilled nursing unit within the facility to one that is not a skilled nursing unit; b. To relocate the resident from a nursing unit with the facility to one that is a skilled nursing unit; or c. Solely for the convenience of the staff . On 4/2/25 at 4:08 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical operations were made aware of the above concern. No further information was presented prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to meet room change requirements prior to a room change for one of 17 residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to provide a written notice of a room change and ensure the resident consented to the roommate assignment prior to the room change on 11/21/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/22/24, the resident scored 15 out of 15 on the (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The assessment further documented no behaviors observed during the assessment period and active discharge planning occurring for the resident to return to the community. The admission record for R3 documented the resident as their own responsible party. The census list for R3 documented a room change on 11/21/24 from Unit one private room to Unit two semi-private room. The progress notes for R3 documented in part, - 11/20/2024 16:04 (4:04 p.m.) Nursing note. Note Text: Met with resident in his room with DON (director of nursing), SW (social worker), Administrator, and Admissions Coordinator to discuss plans for rooms change. Resident was given teaching that he does not have a clinical need to remain in a private room and that Medicaid has not paid for him to remain in a private room. Based on these factors he will be moved to another room that is more appropriate for his clinical needs. Resident resistant to moving. He notified ombudsman to mediate. Ombudsman spoke with DON, SW, and Administrator via conference call. Room change deferred pending ombudsman review. - 11/21/2024 13:38 (1:38 p.m.) Social services. Note Text: SW, DOA (director of admissions) and resident CNA (certified nursing assistant) went to resident room to assist in room change. Resident began yelling at DOA, telling her to get out and not to touch any of his things. He continued to yell at staff while they were helping pack his things in his room. As DOSS (director of social services) was trying to assist staff in packing, resident closed the DOSS hand in his dresser drawer while cussing and yelling get out, I don't want you in here. DOSS exited resident room along with DOA. CNA staff continued to pack resident and move him to his new room. The clinical record failed to evidence documentation of written notice of a room change was provided to R3 or that R3 consented to the roommate assignment prior to the room change on 11/21/24. On 4/2/25 at approximately 9:00 a.m., ASM (administrative staff member) #1, the administrator, stated that the director of nursing who wrote the nursing note on 11/20/24 at 4:04 p.m. no longer worked at the facility and could not be interviewed. On 4/2/25 at 8:11 a.m., an interview was conducted with OSM (other staff member) #5, the director of social services, who stated that they worked with R3 at the facility. She stated that when a resident's room was going to be changed, she went in to speak to the resident to make sure the resident was going to be okay with the roommate, discuss the room change with both residents in the shared room, discuss it with the family, complete the room change assessment and make sure the residents agree to the room change. She stated that R3 was in a private room and was not paying private room prices. She stated that R3 had converted to LTC and was to be moved to a shared space, but he had refused to move for some time. OSM #5 stated that R3 had yelled at the staff, screamed at them and disrespected the staff. She stated that they had gone to R3 as a team to discuss why they had to make the room change and he continued to refuse to move from the private room, saying that he did not have to move. She stated that they discussed discharge home and R3 did not want to leave the facility. OSM #5 stated that on 11/21/24 they had gone into R3's room and talked to him again while the nursing staff were packing his things. She stated that R3 had yelled at her to get out of the room, and she had left the room to leave the nursing staff to complete the move. She stated that she remembered that R3 had viewed the new room prior to the move but she could not say that he had met the new roommate prior to the move. OSM #5 stated that residents could make the choice about room changes and she was certain that the business office manager had offered R3 the ability to keep the private room and given the pricing but he had refused. She stated that the business office manager no longer worked at the facility. The facility policy, Room Change/Roommate Assignment dated 10/01/2021 documented in part, .Unless medically necessary or for the safety and well-being of the resident(s), a resident will be provided with an advance notice of the room change. Such notice will include the reason(s) why the move is recommended . On 4/2/25 at 4:08 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical operations were made aware of the above concern. No further information was presented prior to exit.

Based on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to implement the care plan for three of 5 residents in the survey sample, R1, R2 and R3. The findings include: 1. The facility staff failed to implement the comprehensive care plan for incontinence care for R1. R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), HIV (human immunodeficiency virus) cancer and malnutrition. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/11/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing; dependent for toileting and supervision for eating. A review of the comprehensive care plan dated 12/9/24 revealed, FOCUS: CONTINENCE: due to generalized weakness, due to severe cognitive impairment, due to severe physical impairment. INTERVENTIONS: Provide substantial/maximal assistance with toileting. Provide toileting hygiene as needed for incontinent episodes. Check and change briefs frequently as needed. A review of the ADL (activities of daily living) record revealed missing documentation for 'bowel and bladder elimination' on the following dates and shifts: December 2024-night shift: 12/1 and 12/29: January 2025-day shift: 1/5, 1/6, 1/7, and 1/8, evening shift: 1/1, 1/8 and 1/9; February 2025-day shift 2/16, evening shift-2/2, 2/16 and night shift 2/1. An interview was conducted on 3/11/25 at 1:55 PM with LPN (licensed practical nurse) #1. When asked the purpose of the care plan, LPN #1 stated, so the resident and the family can talk about needs and anything that the resident needs addressed. When asked if the interventions listed on the care plan are not evidenced, was the care plan implemented, LPN #1 stated, no. On 3/11/25 at 3:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of clinical ops was made aware of the concerns. No further information was provided prior to exit. 2. The facility staff failed to implement the comprehensive care plan for incontinence care for R2. R2 was admitted to the facility on [DATE] with diagnosis that included but were not limited to colitis, DM (diabetes mellitus), hemiplegia and hemiparesis. The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 2/7/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing; dependent for toileting and eating. A review of the comprehensive care plan dated 12/2/24 revealed, FOCUS: CONTINENCE: the resident is frequently incontinent of bladder and bowels and is not a candidate for a toileting program, due to generalized weakness, due to severe physical impairment, due to stress incontinence. INTERVENTIONS: Check and change briefs frequently as needed. Provide toileting hygiene as needed for incontinent episodes. Check and change briefs frequently as needed. Provide toileting hygiene as needed for incontinent episodes. Check and change briefs frequently as needed. A review of the ADL (activities of daily living) record revealed missing documentation for 'bowel and bladder elimination' on the following dates and shifts: January 2025-day shift: 1/3, 1/6, 1/11, 1/27, 1/28, 1/30; evening shift: 1/3, 1/6, 1/11, 1/12, 1/14, 1/19, 1/20, 1/24, 1/27 and night shift: 1/1, 1/25; February 2025- day shift: 2/10, 2/11, 2/16, 2/23; evening shift: 2/11, 2/15, 2/17 and night shift 2/1, 2/11, 2/22; March 2025-evening shift: 3/3, 3/9 and night shift 3/1. An interview was conducted on 3/11/25 at 1:55 PM with LPN (licensed practical nurse) #1. When asked the purpose of the care plan, LPN #1 stated, so the resident and the family can talk about needs and anything that the resident needs addressed. When asked if the interventions listed on the care plan are not evidenced, was the care plan implemented, LPN #1 stated, no. On 3/11/25 at 3:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of clinical ops was made aware of the concerns. No further information was provided prior to exit. 3. The facility staff failed to implement the comprehensive care plan for incontinence care for R3. R3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Rhabdomyolysis, DM (diabetes mellitus) and Spondylosis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/26/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing/toileting and supervision for eating. A review of the comprehensive care plan dated 10/3/24 revealed, FOCUS: The resident has bladder incontinence related to Physical limitations, BPH (benign prostatic hyperplasia). INTERVENTIONS: Clean peri-area with each incontinence episode. Physical assist with all ADLs. A review of the ADL (activities of daily living) record revealed missing documentation for 'bowel and bladder elimination' on the following dates and shifts: January 2025-day shift: 1/6, 1/7, 1/8, 1/9, 1/10; evening shift: 1/19, 1/23 and night shift: 1/1, Jan.4th, 1/5, 1/22, 1/23; February 2025- day shift: 2/2, 2/4, 2/14; evening shift: 2/17 and night shift 2/1, 2/3, 2/18, 2/24, 2/25; March 2025-evening shift: 3/3, 3/4 and night shift 3/2, March 4th, 3/5 and 3/9. An interview was conducted on 3/11/25 at 1:55 PM with LPN (licensed practical nurse) #1. When asked the purpose of the care plan, LPN #1 stated, so the resident and the family can talk about needs and anything that the resident needs addressed. When asked if the interventions listed on the care plan are not evidenced, was the care plan implemented, LPN #1 stated, no. On 3/11/25 at 3:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional director of clinical ops was made aware of the concerns. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow the plan of care for transporting a resident which resulted in an injury for one of 40 residents in the survey sample, Resident #33. The resident sustained a fracture of the right femur (1) which constituted harm, cited at past non-compliance. The findings include: For Resident #33 (R33), the facility staff failed to provide support to the resident's feet while transporting them in the wheelchair in the facility hallway, which resulted in the resident's feet dropping to the floor which caused R33 to fall from the wheelchair and subsequently sustained a fractured femur. On R33's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 8/10/2023, the resident was not assessed for cognition. Section G documented R33 using a wheelchair and having range of motion impairment on one side in the upper and lower extremity. Section GG documented R33 being non-ambulatory and using a manual wheelchair. Section J documented R33 having a fall with fracture related to a fall in the past 6 months. On the residents MDS prior to the injury, a quarterly assessment with an ARD of 5/25/2023, the resident was assessed as being modified independent in making daily decisions. Section G documented R33 using a wheelchair and having range of motion impairment on one side in the upper extremity and both side in the lower extremities. Section GG documented R33 being non-ambulatory and using a manual wheelchair. It further documented R33 being dependent to wheel 50 feet with two turns and wheel 150 feet in a corridor or similar space. Section J documented R33 not having any falls. On 9/21/2023 at 8:34 a.m., an interview was conducted with R33. R33 stated that they had not really been told what happened that day but remembered that their feet were hanging off the wheelchair and they just went forward from the chair onto the floor. The progress notes for R33 documented in part, - 7/28/2023 12:29 (12:29 p.m.) Note Text: CNA (certified nursing assistant) propelling resident to the shower room in her w/c (wheelchair) at 1030am when residents feet with sneakers on fell to the floor and caused resident to fall out of the w/c in the hallway. Assisted from floor by 3 staff members. Denies pain. States she feels fine. ROM (range of motion) performed without any new limitation or pain. RP (responsible party) and DR (doctor) notified. Will cont (continue) to monitor. - 7/28/2023 15:22 (3:22 p.m.) Note Text: Resident c/o (complains of) pain 6/10 (six out of possible ten) to right groin and thigh. Voltaren gel applied to area. NP (nurse practitioner) called and notiifed [sic] with N.O. (new order) Right hip and right femur X-RAY STAT (now) s/p (status post) fall. RP (responsible party) aware. X-ray called in and awaiting arrival. - 7/28/2023 22:47 (10:47 p.m.) Note Text: X-ray to right hip and femur completed this shift, awaiting for result. Resident complained of level 2/10 pain when moving in the bed was medicated with 2 Tylenol with good relief. - 7/29/2023 07:00 (7:00 a.m.) Note Text: Received X ray result finding sub capital fracture acute of the right femoral neck without dislocation left (name of physician) message via on call, waiting for call back. report given to oncoming nurse. - 7/29/2023 07:52 (7:52 a.m.) Note Text: N.O. received to send resident to ED (emergency department) r/t (related to) r (right) femur fx (fracture). - 8/2/2023 15:30 (3:30 p.m.) Note Text: Readmit to facility from Acute Care Hospital for repair and treatment of right hip fracture. Surgical procedure was performed to right hip, dressing dry and intact, no bleeding. Vital signs: 98.7 (temperature),98 (pulse),18 (respirations),118/61 (blood pressure), 94% (oxygen saturation). Skin warm and dry, moving right leg slowly. positive pedal pulses. The comprehensive care plan for R33 documented in part, ADL (activities of daily living) Self care deficit as evidenced by related to weakness, femur fracture. Date Initiated: 05/18/2019. Revision on: 08/02/2023. The care plan further documented, At risk for falls, had an actual fall due to weakness. Date Initiated: 05/18/2019. Revision on: 08/02/2023. Review of the fall investigation completed for R33 dated 7/28/2023 documented in part, .Incident Description: Nursing Description: CNA propelling resident to the shower room in her w/c at 1030am when residents feet with sneakers on fell to the floor and caused resident to fall out of the w/c in the hallway. Assisted from floor by 3 staff members. Denies pain. States she feels fine. ROM performed without any new limitation or pain. RP and DR notified. Will cont to monitor . Immediate Action Taken: Description: Resident did not hit her head. Head to toe assessment done. No visible injury noted. V/S (vital signs) and ROM WNL (within normal limits). Assisted back to w/c. Complaining of right hip, leg pain. NP notified. Order received and carried out to order STAT x-ray of right hip and right femur. RP notified. Pain medication administered. Leg rests provided on wheelchair. Resident taken to Hospital? N (no) .No injuries observed post incident. On 9/20/2023 at 3:38 p.m., ASM (administrative staff member) #1, the administrator, stated that the CNA who was pushing R33 in the wheelchair on 7/28/2023 when the injury occurred no longer worked at the facility and could not be interviewed. ASM #4, the regional nurse consultant stated that the facility had an action plan that had been put in place after R33's injury and would provide it for review. On 9/21/2023 at 9:07 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they were unsure if they were working the day of R33's injury or not. She stated that the team had discussed the fall and injury in their morning meeting after they had been sent out to the hospital. She stated that R33 was wheelchair bound prior to the injury and required staff to push them around the halls. She stated that any residents that were unable to propel themselves in the wheelchair should have leg rests on the chairs to support the feet. On 9/21/2023 at 10:18 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that they were in the building on 7/28/2023. She stated that the staff notified them that they were calling the nurse practitioner and had gotten the order for the stat x-ray. She stated that the staff reported to her that they were taking the resident for their scheduled shower, and they had put their feet down with their shoes on and went forward. She stated that R33 was a one person assist, wheelchair bound and required staff to propel them in the wheelchair prior to the incident. She stated that from their staff interviews and investigation they had determined that the CNA did not have the leg rests on the wheelchair and had the resident holding their feet up. She stated that this led them to put an action plan in place. She stated that the expectation for staff was to make sure that the leg rests were in place prior to transporting the resident. On 9/21/2023 at 10:35 a.m., an interview was conducted with CNA #9. CNA #9 stated that anytime they needed to transport a resident who required them to push their wheelchair they made sure they had leg rests on the chair. She stated that if the resident did not have leg rests, they went to the therapy department to obtain some. She stated that they did this so the resident's feet did not drag because it could cause skin breakdown and was also a safety issue. On 9/21/2023 at 10:41 a.m., an interview was conducted with CNA #10. CNA #10 stated that residents had leg rests on the wheelchair for use during transport by staff unless therapy determined that the resident needed to strengthen their lower extremities by self-propelling. She stated that R33 was able to use their arms to propel themselves in the wheelchair short distances at times. On 9/21/2023 at 11:47 a.m., an interview was conducted with RN (registered nurse) #6. RN #6 stated that they were in the hallway administering medications on 7/28/2023 when the CNA was pushing R33 in the wheelchair. She stated that the CNA came past them with R33 in the wheelchair and then she saw R33 roll out of the chair a few steps in front of her. She stated that R33 did not hit their head, did not complain of any pain, or have any abnormalities in vital signs or the head-to-toe assessment so they had just monitored them at that time. She stated that R33 was in the wheelchair without leg rests with their feet hanging down and had sneaker on with grips on them and they thought when their foot dropped down on the carpet it had gripped the carpet and propelled them forward out of the chair. She stated that she had advised the CNA to go to the room to get the leg rests for the chair, but they could not be located. She stated that R33 was fine until later in the shift when they started to complain of pain, so they had contacted the nurse practitioner and ordered the x-ray. She stated that R33 normally was always propelled in the wheelchair by staff prior to the incident and they had only seen them propel only a few steps in the hallway. On 9/21/2023 at approximately 8:00 a.m., ASM #1, the administrator provided an action plan for R33 with a completion date of 8/4/2023. Review of the action plan documented corrective action plan for R33, identification of other residents potentially affected, measures the facility will take, quality assurance plans to monitor facility performance and a completion date for the action plan. On 9/21/2023 at approximately 8:20 a.m., a request was made to ASM #1, the administrator for evidence of completion of the action plan. On 9/21/2023 at 8:40 a.m., ASM #1 provided a folder with evidence of completion of the action plan. Review of the action plan documented: 1) one on one education to the CNA involved regarding application of leg rest/footrest on any residents that are dependent with locomotion. 2) An audit completed of all residents in the facility identifying other residents potentially affected. 3) Audits completed on 8/11/2023, 8/18/2023, 8/25/2023, 9/1/2023, 9/8/2023 and 9/15/2023 of dependent wheelchair residents to determine if leg rests were available and 25% care plan audits. It further documented education provided to licensed staff members (CNA, LPN, RN) on wheelchair dependent residents- ensure leg rests are available for chair & place order for leg rests if not available conducted by the director of nursing on 8/3/2023. 4) An ad hoc QAPI (quality assurance performance improvement) meeting agenda/summary dated 8/3/2023 documenting the administrator, MDS coordinator, unit manager and director of nursing meeting regarding Management of transporting dependent wheelchair residents in wheelchairs and where wheelchair dependence is documented. Review of the plan of correction provided by ASM #1 for R33's injury on 7/28/2023 documented a date of compliance of 8/4/2023. Verification of the facility plan of correction was completed by observations, staff interviews and review of the facility audits, staff education and resident audits. No concerns were identified. Observations of current residents being transported by facility staff were conducted during the survey dates. There were no current concerns identified. On 9/21/2023 at 12:08 p.m., ASM #1, the administrator and ASM #4, the regional nurse consultant were made aware of the concern for harm. No further information was provided prior to exit. Based on the acceptable plan of correction, all components of the plan verified, and no concerns identified during the survey, this deficient practice is cited at past non-compliance. Reference: (1) femur fracture You had a fracture (break) in the femur in your leg. It is also called the thigh bone. You may have needed surgery to repair the bone. You may have had surgery called an open reduction internal fixation. In this surgery, your surgeon will make a cut to open your fracture. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000166.htm.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to prevent and treat pressure injuries for three of 40 residents in the survey sample, Residents #106, #108 and #96. For Resident #106, the facility staff failed to assess the resident for risk for pressure injuries, failed to document pressure injuries, failed to obtain physician's orders for the treatment of the pressure injuries, and failed to implement interventions to prevent further pressure injuries, which constituted harm. The findings include: 1. For Resident #106 (R106), upon admission on 5/18/23, the facility staff failed to assess the resident for risk for pressure injuries, failed to document pressure injuries on the sacrum, left hip, right heel and left heel, failed to obtain physician's orders for treatments for those pressure injuries, and failed to implement interventions to prevent further pressure injuries. On 6/8/23, the wound care physician identified more unstageable (1) pressure injuries on the right great toe and left great toe. R106 was admitted to the facility on [DATE]. The admission screener assessment dated [DATE] documented R106 presented with no skin issues; however, during an interview with RN (registered nurse) #4, the nurse who documented the admission screener assessment, RN #4 stated R106 refused a skin assessment on 5/18/23 and she did not complete a skin assessment until 5/19/23. RN #4 stated that during the 5/19/23 skin assessment, she identified multiple pressure injuries, and they were later documented in a skin note dated 6/7/23. The pressure injuries documented in RN #4's skin note dated 6/7/23 were an unstageable pressure injury on the sacrum, an unstageable pressure injury on the right heel, an unstageable pressure injury on the left heel, and a stage two (1) pressure injury on the left hip. The facility staff failed to assess the resident's risk for pressure injuries (until 5/23/23 when the resident was assessed as being at moderate risk for pressure injuries), failed to develop a care plan for pressure injuries (until 6/27/23), and failed to obtain physician's orders to implement interventions to prevent and treat pressure injuries (until 6/8/23). On 6/8/23, the wound care physician evaluated R106 and ordered treatments for six different pressure injuries. These pressure injuries included the four pressure injuries documented in RN #4's 6/7/23 skin note; an unstageable pressure injury on the sacrum, an unstageable pressure injury on the left hip, an unstageable pressure injury on the right heel and a deep tissue injury on the left heel, and two new pressure injuries which were an unstageable pressure injury on the right great toe and an unstageable pressure injury on the left great toe. A hospital discharge summary dated 5/18/23 failed to reveal any documentation regarding pressure injuries. R106 was admitted to the facility on [DATE]. No assessment for risk for pressure injuries was completed on the date of admission. R106's admission screener (assessment) dated 5/18/23 documented the resident had no skin issues. The baseline care plan triggers section of the screener revealed no focus, goals, or interventions related to R106's skin integrity. R106's care plan initiated on 5/18/23 failed to document any information regarding skin integrity and pressure injuries, until 6/27/23. A physical therapy evaluation dated 5/19/23 documented R106 was totally dependent with bed mobility and presented with unstageable bilateral heel pressure areas (injuries). Further review of R106's clinical record failed to reveal any further documentation regarding the bilateral heel pressure injuries until 5/22/23. A nurse's note dated 5/22/23 documented, It was reported by therapy that resident has large ulcers on heels. On arrival resident has unstageable ulcers (injuries) on both heels and stage 1 (1) ulcer on both side of the foot and ankle. Wiped down with skin prep. A review of physician's orders, the medication administration record and the treatment administration record for May 2023 failed to reveal any treatments for the pressure injuries. A review of nurse practitioner and physician notes from 5/19/23 through 5/24/23 failed to reveal any documentation regarding pressure injuries. The notes dated 5/19/23, 5/22/23, 5/23/23 and 5/24/23 documented, SKIN: No rash, ulcer or cyanosis. Warm and dry. No induration, nodules, or discoloration . A Braden scale for predicting pressure sore (injury) risk dated 5/23/23 had documented that R106 was at moderate risk for pressure injuries. A review of physician's orders, the medication administration record, and the treatment administration record for May 2023 and June 2023 failed to reveal any treatments for any pressure injuries until 6/8/23. Physician notes dated 6/2/23 and 6/7/23 documented, SKIN: (Name) indicated that patient has dark area on both heels. Wound care team to follow. Warm and dry. No induration, nodules, or discoloration . A skin note dated 6/7/23 and signed by RN (registered nurse) #4 (the nurse who documented the admission screener) documented, Resident was noted to have an unstageable ulcer (pressure injury) measuring 7 cm (centimeters) x 10 cm in circumference in the sacrum. 5 cm x 7 cm stage II (1) ulcer on the lateral aspect of the left upper thigh, fluid filled in the center and surrounding tissues red and irritated. 4 cm x 4.5 cm unstageable ulcer on both heels. Scattered bruises on the left lower leg and foot. Sacral and left hip wound were cleansed with wound cleanser and dry dressing applied. A progress note signed by the wound care physician on 6/8/23 documented, Physical Exam. Constitutional: The pulse has a regular rate and rhythm. The patient is afebrile. The patient appears well nourished and has a normal weight .Wound Assessments(s) -Wound #1 Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 8 cm length x 9 cm width with no measurable depth, with an area of 72 sq (square) cm. There is Moderate amount of serous drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% eschar . -Wound #2 Left Hip is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6 cm length x 3 cm width with no measurable depth, with an area of 18 sq cm. There is a None amount of drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% eschar . -Wound #3 Right Heel is an Unstageable Pressure Injury Obscured full-thickness and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6 cm length x 6 cm width with no measurable depth, with an area of 36 sq cm. There is a None amount of drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% eschar . -Wound #4 Left Heel is a Deep Tissue (1) Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5 cm length x 6 cm width with no measurable depth, with an area of 30 sq cm. There is a None amount of drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% epithelialization . -Wound #5 Right Great Toe is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1 cm length x 1 cm width with no measurable depth, with an area of 1 sq cm. There is a None amount of drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% eschar . -Wound #6 Left Great Toe is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1 cm length x 1 cm width with no measurable depth, with an area of 1 sq cm. There is a None amount of drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100% eschar . Weekly Wound Evaluations with an effective date of 6/8/23 and signed by LPN (licensed practical nurse) #3 on 6/9/23, documented similar assessments for all pressure injuries documented by the wound physician, documented the measurements were obtained by the wound care provider, and documented the pressure injuries as new skin concerns and facility acquired. Treatment orders for all of the pressure injuries were not obtained until 6/8/23 and included: 1. Bactrim DS (double strength) (an antibiotic) 800-160 mg (milligrams)- one tablet by mouth two times a day for wound infection for 14 days. 2. Medihoney (medical grade honey)- Apply to left hip topically every evening shift for skin alteration. Cleanse area with wound cleanser, apply honey, cover with foam dressing. 3. Medihoney- Apply to sacrum topically every evening shift for skin alteration. Cleanse area with wound cleanser, apply medihoney, cover with foam dressing. 4. Paint bilateral great toes with betadine (antiseptic used to treat skin infections) every evening shift for skin alteration. 5. Paint bilateral heels with betadine every evening shift for skin alteration. On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3 (the nurse who documented the 6/8/23 weekly wound evaluations). LPN #3 stated a Braden assessment, and a head-to-toe skin assessment should be completed for all residents upon admission. LPN #3 stated if a resident does present with a pressure injury on admission, then staff have to make sure the resident has an air loss mattress and nurses should check the hospital discharge instructions for wound care orders. LPN #3 stated that if the discharge instructions do not contain wound care orders, then nurses should call the doctor or nurse practitioner to obtain wound care orders. LPN #3 stated that within 24 hours of admission, residents must have a second skin assessment in case the first nurse missed something. LPN #3 stated nurses are supposed to develop a care plan on admission and the care plan should include a risk for skin alteration for all residents and include pressure injuries if the resident has pressure injuries. LPN #3 stated that after residents are admitted , weekly skin observations should be conducted on all residents and nurses are required to look at every resident's skin. LPN #3 stated if a new area is observed, the nurse should assess the pressure injury, document the assessment, notify the doctor, notify the family, initiate a treatment order, and update the care plan. LPN #3 stated assessments of pressure injuries should include a description of the wound, the measurement of the size, any odor, the color, the presence of drainage, and the stage if the nurse is a RN (registered nurse). In regard to evidencing the completion of treatments, LPN #3 stated the nurses evidence treatments are done by signing the treatments off on the electronic treatment administration record. On 9/20/23 at 10:10 a.m., an interview was conducted with RN #4, the nurse who documented the admission screener assessment and the 6/7/23 nurse's note. RN #4 stated R106 refused a skin assessment on the day of admission but per the report she received from the transferring facility, the resident did not have skin issues, so she documented no skin issues on the admission assessment. RN #4 stated the next day, she inspected R106's skin and the resident had a tremendous number of wounds. RN #4 could not remember details about the wounds but stated she documented the wounds in the clinical record. RN #4 stated that after this, the staff got the doctor involved because the doctor has to give orders for how to clean the wounds. (Note: RN #4 did not document a progress note regarding R106's pressure injuries until 6/7/23 and physician's orders were not obtained until 6/8/23 after the wound care physician evaluated the pressure injuries). On 9/20/23 at 10:26 a.m., an interview was conducted with LPN #9, the nurse who documented the 5/22/23 nurse's note. LPN #9 did not remember R106 or any information about R106. On 9/20/23 at 3:19 p.m., an interview was conducted with ASM (administrative staff member) #3 (the wound care physician). ASM #3 stated he could not provide information about R106's pressure injuries before he observed the pressure injuries. ASM #3 stated R106 was highly non-compliant with care, and he could understand why staff could have a tough time determining what treatments to use for R106's pressure injuries because of the amount of pressure injuries. ASM #3 stated he tells the staff to call him anytime and not wait until his weekly visit. On 9/20/23 at 3:37 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concerns and the concern for harm. On 9/21/23 at 11:28 a.m., an interview was conducted with OSM (other staff member) #7 (R106's physical therapist). OSM #7 stated he is not responsible for conducting total body skin assessments, but he completes range of motion assessments and tests residents' strength and mobility so if a resident complains of something unusual or pain, he checks to see the cause of limited mobility or pain. OSM #7 stated on 5/19/23, R106 complained of pain in both feet so he removed the resident's socks and saw unstageable pressure injuries that were closed, looked blackish blue but not yet eschar. OSM #7 stated he reported the pressure injuries to the nursing staff on 5/19/23. On 9/21/23 at 12:18 p.m., a call was placed to R106's nurse practitioner but she was not available for interview. The facility policy titled, Pressure Injury Prevention And Management documented, The intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries, (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: -Promote the prevention of pressure ulcer/injury development; promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and prevent development of additional pressure ulcer/injury. SPECIFIC PROCEDURES/GUIDANCE: Risk Assessments- 1. Pressure ulcer/injury risk assessments will be conducted on admission/re-admission to the nursing facility. a. Upon admission, a risk assessment will be completed weekly for the first four weeks .3. Pressure ulcer/injury risk assessments will be conducted by a licensed/registered nurse and will be documented in the resident's medical record using the facility defined format/tool. 4. Findings from the pressure ulcer/injury risk assessment will be incorporated into the resident's plan of care. Preventative Measures- 1. Preventative interventions will be implemented based on the pressure ulcer/injury risk assessment, other related factors, and resident preferences .Identification- 1. Staff will be encouraged to promptly report any observation of a change in the resident's skin integrity. 2. Weekly skin observations will be conducted by a licensed nurse and findings will be documented in the resident's medical record. 3. Observations of new pressure ulcer/injury will be: a. Reported to the physician/practitioner for further evaluation and treatment. b. Referred to the designated wound nurse as appropriate. Evaluation/Assessments- 1. Evaluation/assessment of pressure ulcer/injury will be completed weekly and with significant change in condition of the ulcer/injury by a licensed nurse and/or practitioner. 2. Documentation of the evaluations/assessment of the pressure ulcer/injury will [sic] maintained in the resident's medical record. Documentation may include: a. Location of ulcer/injury. b. Date that the ulcer/injury was acquired [when known]. c. Description of the ulcer/injury to include stage, measurements [length, width, depth], present/absence of any tunneling or undermining, type of tissue [epithelial, granulation, slough, necrosis, etc.], presence/absence and type of drainage, surrounding tissue description, and presence/absence of pain with the ulcer/injury. d. Treatment and interventions to promote healing .Treatment Protocols- 1. Treatments will be ordered by the physician/practitioner .3. The effectiveness of the pressure ulcer/injury treatment will be evaluated weekly during the weekly evaluation/assessment of the wound. If improvement in the wound is not seen within two weeks, the physician/practitioner will be contacted with the assessment and alternative treatment measures obtained as indicated .5. Treatments, including preventative interventions, will be documented in the resident's medical record .Care Plans- 1. A resident centered care plan will be developed and implemented to address the resident's risk for development of a pressure ulcer/injury and to promote healing if the resident has a pressure ulcer/injury . Reference: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue) . Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister . This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf 2. For Resident #108 (R108), the facility staff failed to complete thorough assessments of the resident's stage four pressure injury (1) in August 2023 and September 2023, failed to assess R108 for self-care of the pressure injury, and failed to provide oversight to ensure treatments were being completed for the pressure injury in August 2023 and September 2023. R108 was admitted to the facility on [DATE] with a diagnosis of a stage four pressure injury on the sacral region. R108's comprehensive care plan dated 6/4/23 documented, I have actual impairment to skin integrity r/t (related to) right ischium (inaccurate documentation of location). Assess/Monitor/Document wound: size, depth, margins: periwound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis per facility protocols. Notify MD (medical doctor) as indicated . On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/8/23/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A weekly wound evaluation dated 7/21/23 documented R108 presented with a stage four pressure injury on the right ischial (inaccurate documentation of location), present on admission, and measuring 4.5 cm (centimeters) in length by 4 cm in width by 2 cm in depth. On 9/20/23 at 1:10 p.m., an interview was conducted with R108. R108 stated he has had a wound on his buttock for over three years. R108 stated the nurses only look at the wound when he asks, and the nurses have not measured the wound, In a while. R108 stated he completes treatment for the wound twice a day and the treatment consists of soaking gauze in saline, putting the gauze in the wound, applying an adhesive bandage then covering that with another adhesive bandage. A review of R108's clinical record failed to reveal thorough assessments of the pressure injury in August 2023 and September 2023. The only documentation regarding the resident's skin was a weekly skin observation dated 8/7/23 that documented no open areas, a weekly skin observation dated 8/15/23 that documented an open area on the left buttock, a weekly skin observation dated 8/21/23 regarding another skin concern but did not contain any documentation regarding the pressure injury, a weekly skin observation dated 8/29/23 that documented no open areas, and a weekly skin observation dated 9/6/23 that documented an open area on the left buttock. The weekly skin observations failed to document a description of the pressure injury (including stage, measurements, presence or absence of any tunneling or undermining, type of tissue, or presence or absence and type of drainage). Further review of R108's clinical record failed to reveal the resident was assessed for self-care of the pressure injury to ensure the resident was capable of caring for the pressure injury, and failed to reveal oversight was provided to ensure the resident was providing care for the pressure injury per the physician's order. A physician's order dated 6/28/23 documented to cleanse the wound to the right buttock with normal saline, apply normal saline soaked gauze to the open area, and cover with a dry adhesive dressing every shift for wound care. A review of R108's August 2023 and September 2023 TARs (treatment administration records) revealed the same physician's order but failed to reveal documentation that the treatments were completed each day for both months. The spaces for nurses to sign off the completion of the treatments were blank. Review of nurses' notes for August 2023 and September 2023 failed to reveal documentation that treatments for R108's pressure injury were completed. The only documentation of refusal of care in August 2023 and September 2023 was a nurse's note dated 8/3/23 that documented R108 declined to be seen by the wound care physician and a nurse's note dated 8/26/23 that documented R108 refused wound treatment with the wound physician. On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that after residents are admitted , weekly skin observations should be conducted on all residents and nurses are required to look at every resident's skin. LPN #3 stated assessments of pressure injuries should include a description of the wound, the measurement of the size, any odor, the color, the presence of drainage, and the stage if the nurse is a RN (registered nurse). In regard to evidencing the completion of treatments, LPN #3 stated the nurses evidence treatments are done by signing the treatments off on the electronic treatment administration record. On 9/21/23 at 9:16 a.m., another interview was conducted with LPN #3. LPN #3 stated an evaluation should be completed to make sure a resident is safe and able to perform his own pressure injury care. LPN #3 stated nurses should make sure the resident has the supplies he needs for wound care, make sure the doctor is aware the resident performs his wound care, and nurses should offer assistance if needed. LPN #3 stated this should be done each time the wound care is due per the physician's order. LPN #3 stated she had not personally assessed R108's pressure injury on the buttock since June or July 2023 but she observed R108 perform wound care on the previous Monday. LPN #3 stated she observed the resident lay on his side and spread out and clean and pack the wound. LPN #3 stated she thought R108 was using a wet to dry dressing and a border gauze for his pressure injury treatment. LPN #3 stated she did not document this observation and needed to complete a late entry. On 9/21/23 at 1:28 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. Reference: (1) Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf 3. For Resident #96 (R96), the facility staff failed to complete thorough assessments of the resident's stage three pressure injury (1) in August 2023 and September 2023, and failed to provide treatments per physician's orders on multiple dates in September 2023. R96 was admitted to the facility on [DATE] with a diagnosis of a stage three pressure injury of the sacral region (1). An admission evaluation dated 8/24/23 documented an open pressure area on the sacrum. A weekly skin observation note dated 8/25/23 documented R96 was admitted with an open area to the sacrum measuring 1.5 cm (centimeters) (length) by 1.5 cm (width). A weekly skin observation dated 9/4/23 documented, Resident was admitted with an open area to sacrum (1.5cm x 1.5cm). A weekly skin observation dated 9/11/23 documented, Open area and Cleanse sacral wound with wound cleanser. Apply calcium alginate (used to treat wounds) to wound bed cover with foam dressing. A weekly skin observation dated 9/19/23 documented, admitted with open area to sacrum. The weekly skin observations failed to document a description of the pressure injury (including stage, measurements [8/24/23, 9/11/23 and 9/19/23], presence or absence of any tunneling or undermining, type of tissue, or presence or absence and type of drainage). Further review of R96's clinical record revealed the following physician's orders: 8/24/23- clean the sacral area with normal saline and cover with form board gauze daily (discontinued 9/8/23). 9/8/23- cleanse the sacral wound with wound cleanser. Apply calcium alginate to wound bed and cover with foam dressing every day shift. A review of R96's September 2023 TARs (treatment administration records) revealed the same physician's orders but failed to reveal documentation that the treatments were completed on 9/1/23, 9/4/23, 9/8/23, 9/10/23, 9/11/23, 9/14/23 and 9/15/23. The spaces for nurses to sign off the treatments had been done were blank. A review of nurse's notes for all dates also failed to reveal documentation that the treatments were completed. On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that after residents are admitted , weekly skin observations should be conducted on all residents and nurses are required to look at every resident's skin. LPN #3 stated assessments of pressure injuries should include a description of the wound, the measurement of the size, any odor, the color, the presence of drainage, and the stage if the nurse is a RN (registered nurse). In regard to evidencing the completion of treatments, LPN #3 stated the nurses evidence treatments are done by signing the treatments off on the electronic treatment administration record. On 9/21/23 at 1:28 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. Reference: (1) Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf

Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure one of 25 residents in the survey sample, (Resident #47), was free of a significant medication error. On the evening of 7/2/2020, Resident #47 was administered all of her multiple physician prescribed evening medications twice, by two nurses, LPN [licensed practical nurse] #4 and RN [registered nurse] #4, resulting in a significant medication error. Resident #47 was subsequently was transferred to a local hospital for evaluation/treatment. The hospital record documented Resident #47 was sleepy, weak and confused in the emergency room , displayed a drop in blood sugar, blood pressure and slow hear rate ([CONDITION(S)]) readings; IV (intravenous) fluids, including [MEDICATION(S)] were administered, the resident was then admitted to the hospital for monitoring due to the medications overdose. The findings include: Resident #47 was admitted to the facility on [DATE] and transferred to the hospital on 7/2/20. Resident #47's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #47's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/15/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as requiring limited assistance with mobility, transfers, dressing; supervision with personal hygiene and bathing and as independent in eating and locomotion. An annual assessment completed on 5/11/20 prior to the incident on 7/2/20 coded the resident as scoring a 9 out of 15 on the BIMS indicating Resident #47 was moderately impaired for cognition. Section N0350 Insulin: coded the resident as receiving insulin injections 7 out of 7 days of the look back period. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Medications scheduled administration time 5:00 PM: - Losartan (anti-hypertensive) (5) 100 milligram table by mouth in the afternoon for hypertension - Multivitamin (dietary supplement) 1 tablet by mouth in the afternoon for supplement, - Divalproax [[MEDICATION(S)]] (anti-epileptic) (6) 625 milligram delayed response tablet twice a day for [CONDITION(S)] prevention, - [MEDICATION(S)] (anti-diabetic) (7) extended release tablet 500 milligram by mouth twice a day for diabetes mellitus, - [MEDICATION(S)] (treats allergic conjunctivitis) (8) solution 0.1% instill 1 drop in both eyes twice a day for allergies, - [MEDICATION(S)] Mix 75/25- inject 50 units subcutaneously twice a day before breakfast and dinner, notify MD if blood sugar less than 60 or greater than 400. Hold [MEDICATION(S)] 75/25 if blood sugar is less than 100. - [MEDICATION(S)] (insulin) (9) 100 units/milliliter inject per sliding scale: if BS (blood sugar) 150-200 =4 units, BS 201-250=6 units, BS 251-300=8 units, BS 301-350=10 units, BS 351-400=12 units. If < 60 or > 350 or greater call physician, subcutaneously before meals for diabetes. Medications scheduled administration time 9:00 PM: - Atorvastin (anti-hyperlipidemic) (10) 10 milligram tablet by mouth at bedtime to lower cholesterol - [MEDICATION(S)] (antihistamine) (11) 5 milligram tablet at bedtime for allergies - [MEDICATION(S)] (anti-epileptic) (12) 600 milligram tablet at bedtime for nerve pain - [MEDICATION(S)] (treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (antipsychotic) (14) 40 milligram capsule at bedtime for [CONDITION(S)] - [MEDICATION(S)] (antihypertensive) (15) 10 milligram twice a day for hypertension A FRI (facility reported incident) with an incident dated 7/2/20, and a reported date of 7/3/20, documented in part, Resident was given evening medication [all medications listed above] twice by two nurses. Resident's nurse practitioner requested the resident be sent to the hospital to be monitored due to the medication and her low blood pressure/pulse. Resident was admitted at the hospital for observation. Patient has no negative outcomes at this time. Employee action initiated or taken: Suspension/removed from schedule while investigation ongoing. Improvement plan and education initiated. If applicable date notification provided to: Responsible party: 7/3/2020, Physician: 7/3/2020, APS [adult protective services]: 7-3-2020, DHP [Department of Health Professions]: 7/3/2020 Review of the FRI investigation and follow up, documented in part, the following: Facility investigation: Completed on: the date 7/8/2020 was handwritten on the form. An included attachment documented in part the following: 7-8-2020 FRI day 5 On 7/2/2020 it was reported that a resident was given medication twice by two different nurses. During the investigation it was found that the resident was written on two different assignment sheets, [name of LPN #4] gave the medication first, without documenting the medication in the system. [Name of RN #2] gave the medication second. The MD [medical doctor] was notified and gave an order to send the resident to the ER [emergency room ]. Resident [#47] was sent to the hospital and remained there two nights under observation status. Resident [#47] returned to the facility on [DATE] with no adverse reactions from the medication error and has remained stable. The DON [director of nursing] removed both nurses from the schedule while the investigation was ongoing, reconfigured the assignment sheets as well as educated the nursing staff on proper medication documentation. The investigation is complete. Another attachment titled, Trigger Call Guideline/Agenda documented in part the following: · Event Type: Medication Error · Date and Time of Event: 7/2/20@ [at] 9pm · Patient Name: [Name of Resident #47] · Cognitive Status/BIMS (date last completed): 9 as of 5/11/20 · Timeline of Events: [Name of LPN #4] (Agency Nurse) administered the following medications to [name of Resident #47] at around 5:20pm: · 4 units of [MEDICATION(S)] insulin · [MEDICATION(S)] Mix 75/25- 50 units · [MEDICATION(S)] ER [extended release] 500 mg (milligram) · MVI (multivitamin) · [MEDICATION(S)] 625 mg · Losarten Potassium 100mg · [MEDICATION(S)] Fumrate 10mg · OlapTADINE HCL ([MEDICATION(S)]) eye gtts (drops) · [Name of LPN #5] administered the following medications around 8pm: · Atrovastin Calcium10mg · [MEDICATION(S)] 600mg · [MEDICATION(S)] 1mg · [MEDICATION(S)] HCL 40mg Around 9pm [Name of RN #2] asked [Name of LPN #4] to compare assignments to make sure that no one was missed. At that time they noticed that they both had [Name of Resident #47] on their assignment sheets and they both had given her [Resident #47] her scheduled medications. They both [RN #2 and LPN#4] both went immediately to assess the resident. The resident [Resident #47] was sleeping. She [Resident #47] was easily aroused and responsive to questions. Vital signs were taken at that time. BP 95/47, 57, 16, 96% on RA [blood pressure, pulse, respirations and oxygen saturation on room air]. [Name of nurse practitioner] was notified immediately and orders were received to sent [Sic] resident to ER [emergency room ]. When EMT's [emergency medical technicians] arrived resident was able to answer questions and she walked to the stretcher. EMS [emergency medical services] took her [Resident #47] blood sugar which was 146. Resident was transported to [Name of hospital]. [Name of RN #2] called report to the ER Nurse to inform her of what medications the resident [Resident #47] received in duplicate. [Name of Resident #47's] Emergency Contact was notified of details of the incident this morning by [name of staff LPN]. DON called [Name of Resident #47's emergency contact] around 10am to explain the incident to her. During the investigation it was discovered that [Name of Resident #47] only received her [MEDICATION(S)] 75/25 50 units once by [Name of LPN #4]. [* Note the sliding scale insulin was administered twice by both nurses for a total of 8 units of [MEDICATION(S)] 100units/ ml]. Education has been initiated on Medication Administration to include signing off medications as you administer them to include giving medications timely as scheduled. The assignments sheets for the units were updated The final investigation included: Statements by RN (registered nurse) #2 and LPN (licensed practical nurse) #4, both involved in the medication error event. The MAR (medication administration record) for July 2020 for Resident #47 with initials sign on code of KO9 corresponding to RN #2. The Assignment sheets for RN #2 and LPN #4. A review of the clinical record failed to evidence any progress notes documenting the events of 7/2/20, regarding a medication error and/ or the residents transfer to the hospital. A review of vital signs on 7/2/20 at 6:23 AM, documented in part, Blood pressure 138/65, pulse 70. Resident #47's blood sugar at 4:30 PM was documented as 179. A review of a Discharge return anticipated MDS assessment with an assessment reference date of 7/2/20, documented in part, Unplanned transfer to acute hospital. A review of the hospital records for Resident #47, evidenced admission to an acute care hospital on 7/2/20-7/4/20. The emergency room record documented in part: EKG: [MEDICATION(S)] [CONDITION(S)] (slow heart rate (16)) rate of 51. Emergency Department (ED) physician notes dated 7/2/20 11:28 PM, documented in part, She [Resident # 47] presents after getting a double dose of her medications which include extended release [MEDICATION(S)] and Losartan. Her blood sugar dropped from 108 to 81. Her blood pressures have been on the soft side with maps (mean arterial pressures) around 65. She is getting a fluid bolus and I have ordered maintenance D5 ([MEDICATION(S)] 5%) normal saline. Virginia Poison Control was contacted and suggests admission as [MEDICATION(S)] was extended release and requires at least 12 hours of observation. She reports feeling sleepy, weak and somewhat confused. The ED (emergency room ) RN [registered nurse) note dated 7/2/20 at 11:00 PM documented in part, RN spoke with 'RN#2' taking care of patient from the facility. States that patient received a double dose of her evening medication. 'RN#2' states patient was given medications around 6:00 PM and again at 9:00 PM. A review of the hospital discharge summary dated 7/4/20, documented in part, admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *] insulin. Discharge Diagnosis/Plan: Accidental overdose-patient now back to baseline. EKG (electrocardiogram) x two with normal QT intervals. Diabetes Type 2-resume sliding scale insulin. Initially insulin held on admission. Hypertension-blood pressure soft due to overdose. Received IV (intravenous) fluids in ED. BP stable at this time. LPN #4, an agency nurse, was not available for an interview and was not employed at the facility. An interview was conducted on 4/22/21 at 4:56 PM with RN #2, the nurse supervisor. RN #2 was the second nurse who administered medications to Resident #47 on 7/2/20. When asked if she remembered the medication error on 7/2/20, RN #2 stated, Oh yes, that was the error with the agency nurse who gave medicines and didn't chart, either time. I came to give the medications to the resident [Resident #47] on my assignment sheet and since they were not signed off, I gave the 6:00 PM and 9:00 PM medications. I did not know we were both assigned to the resident until about 9:00 PM. If I had seen the medications signed off, I would have asked the other nurse about the assignment and the medications. I checked on the resident and saw that she did not look well, so I called the nurse practitioner and we transferred her to the hospital. When asked if she remembered any changes or education that were made because of the medication error, RN #2 stated, Yes, they changed the assignment sheet and the number of medication carts. We also reviewed the medication administration policy. On 4/20/21 at 10:40 AM, during the entrance conference, when asked what standards of practice were followed, ASM (administrative staff member) #2, the director of nursing and ASM #3, the quality consultant stated, We use Lippincott and Perry & Potter. Administrative staff members (ASM) # 1, the administrator was made aware of the above concerns on 4/22/21 at 5:56 PM. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concerns on 4/23/21 at 10:08 AM. According to Basic Nursing, Essentials for Practice, 6th edition (Potter and Perry, 2007, pages 349-360) A medication order is required for you to administer any medication to a patient. Once you receive and process a medication, place the physician's or health care provider's complete order on the appropriate medication form, the MAR. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When transcribing orders, ensure the names of medications, dosages, routes, and times are legible. The nurse checks all orders for accuracy and thoroughness. When orders are transcribed, the same information needs to be checked again by the nurse. It is essential that you verify the accuracy of every medication you give to the patient with the patient's orders. To ensure safe medication administration, be aware of the six rights of medication administration. 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation .Use the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .After you administer medications, indicate which medications you gave on your patient's MAR per agency policy to show that you gave the medications as ordered. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about your patient's care. There are many nursing actions you take to ensure the right documentation. Make sure that the information on your patient's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record the administration of each medication as soon as you give the medication. Never document that you have given a medication until you have actually given it. A review of the facility assessment evidenced the facility Skills Competencies dated 10/2017, which documented in part, Medication management skills evaluation documents validation of medication management techniques and knowledge completed during job specific orientation and annually. The Medication Management Skills Evaluation CLS-228 (5/14), documented in part, Documents at time of administration on MAR/eMAR. Initiates incident report for medication administration errors. A review of the facility's Medication and Treatment Administration Guidelines dated 3/2018, documented in part, Medications and treatments administered are documented immediately following administration or per state specific standards. The facility enacted a plan of correction, which contained the following 5 points: 1. Nurse practitioner was immediately notified of medication administration error on 7/2/20 once discovered. LPN #4 and RN #2 administered medications at 5:00 PM and 9:00 PM. LPN #4 and RN #2 were both assigned to Resident #47. LPN #4 failed to document administration of medications at 5:00 PM and again at 9:00 PM. RN #2 administered 5:00 PM and 9:00 PM medications to Resident #47 as they had not been documented as given and she was unaware that LPN #4 was also assigned to Resident #47. 2. All Residents with medication administration of their prescribed medications including anti-hypertensive, diabetic, anti-[CONDITION(S)], anti-epileptic, anti-psychotic and insulin have the potential to be affected by this deficient practice. 3. All Nurses educated in person or via phone on 7/3/20 regarding the facility's Medication Administration policy dated 3/2018. LPN #4, an agency nurse, the nurse responsible for administration of the first dose of the 5:00 PM and the 9:00 PM medications was second check was terminated from the facility. 4. For the next month, an audit of medication administered and documented were reviewed by the director of nursing. The medication types reviewed included: anti-hypertensive, diabetic/insulin, anti-[CONDITION(S)], anti-epileptic and anti-psychotic. All results and findings were presented and reviewed at the Quality meeting in August 2020. 5. Completion date 7/8/20. The credible evidence including the Plan of Correction, education, in-service sign in sheets, audits and Quality Council minutes were reviewed and found to be in order. Random interviews were conducted with staff on varying shifts regarding medication administration and documentation and failed to reveal any concerns. A medication pour/pass observation was completed during this survey. No further significant medication errors were identified. Review of current residents failed to identify any concerns. Past Noncompliance References: (1) [CONDITION(S)] is a mental disorder characterized by periods of [CONDITION(S)] and depression. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 71. (2) Seizures: a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 137. (3) Diabetes mellitus: inability of insulin to function normally in the body. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 160. (4) Atherosclerosis [CONDITION(S)]: disorder of the cardiac arteries caused by a buildup of plaque which results in the vessels becoming non-elastic. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 52. (5) Losartan potassium tablets are indicated for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The most likely manifestation of overdosage would be [CONDITION(S)] and tachycardia; [CONDITION(S)] could occur from parasympathetic (vagal) stimulation. If symptomatic [CONDITION(S)] should occur, supportive treatment should be instituted. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cda520b7-ae84-4bd7-b298- f4fcc57 (6) [MEDICATION(S)] ER [extended release] is a valproate and is indicated for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Overdosage with valproate may result in somnolence, heart block, deep coma, and [CONDITION(S)]. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0dc024ce-efc8-4690-7cb5-639c728fccac (7) [MEDICATION(S)] [MEDICATION(S)] extended-release tablets are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. BOXED WARNING: Postmarketing cases of [MEDICATION(S)]-associated lactic acidosis have resulted in death, hypothermia, [CONDITION(S)], and resistant bradyarrhythmias This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f0371d2a-276b-4acb-80f8-e24fb8ceae19 (8) Lippincott Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 443. (9) [MEDICATION(S)] is a rapid acting human insulin analog indicated to improve glycemic control in adults and children. 5 Warnings and Precautions: 5.3 [CONDITION(S)]: [CONDITION(S)] is the most common adverse reaction associated with insulins, including [MEDICATION(S)]. 10. Overdosage: Excess insulin administration may cause [CONDITION(S)] and [CONDITION(S)]. Mild episodes of [CONDITION(S)] usually can be treated with oral glucose. More severe episodes may be treated with intramuscular/subcutaneous [MEDICATION(S)] or concentrated intravenous glucose. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8ecbd7a-0e22-4fc7-a503-faa58c1b6f3f (10) Lippincott Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 32. (11) Lippincott Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 67 (12) [MEDICATION(S)] is indicated for: Management of postherpetic neuralgia in adults Adjunctive [MEDICATION(S)] is indicated for: Management of postherpetic neuralgia in adults Adjunctive therapy in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Fatal respiratory depression has been reported with [MEDICATION(S)] overdose, alone and in combination with other CNS depressants. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=f1bce199-9f88-4a94-9006-8e148dedd45f&version=3 (13) Lippincott Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 429. (14) [MEDICATION(S)] capsules are indicated for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Overdoasge: (in part) cardiovascular monitoring should commence immediately and should include continuous electrocardiographic monitoring to detect possible arrhythmias. [CONDITION(S)] . should be treated with appropriate measures such as intravenous fluids. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=6485d78e-ca4e-4217-ad80-c784a15fa6a4&version=7 (15) [MEDICATION(S)] [MEDICATION(S)] is indicated in the management of hypertension. Overdosage: The most common signs expected with overdosage of a beta-blocker are [CONDITION(S)], [CONDITION(S)], congestive heart failure, bronchospasm, and [CONDITION(S)]. This information was obtained from the website https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d b9-3e56-4a2b-8750-cb95ec 5 (16) [CONDITION(S)]: [CONDITION(S)] [brad?e-kahr´de-ah] slowness of the heartbeat, so that the pulse rate is less than 60 per minute. This information was obtained from the website:https://medical-dictionary.thefreedictionary.com/[CONDITION(S)] * This information was obtained from the website: https://medical-dictionary.thefreedictionary.com/iatrogenic

Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards for medication administration for one of 25 residents in the survey sample, (Resident #47). The facility staff failed to provide the care and services in accordance with professional standards of practice for documenting the administration of medications on 7/2/2020 for Resident #47. On the evening of 7/2/2020, Resident #47 was inadvertently assigned to both LPN [licensed practical nurse] #4 and RN [registered nurse] #2. LPN #4 administered the residents prescribed evening medications but failed to document the medications as administered on the eMAR [electronic medication administration record], as a result of this failure, RN #2 administered the same medications a second time to the Resident #47 a second time, resulting in a significant medication error and overdose. Resident #47 was subsequently transferred to a local hospital for evaluation/treatment. IV (intravenous) fluids, including [MEDICATION(S)] were administered to Resident #47, in the emergency room . The resident then required admission to hospital for monitoring. The findings include: Resident #47 was admitted to the facility on [DATE] and transferred to the hospital on 7/2/20. Resident #47's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #47's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/15/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as requiring limited assistance with mobility, transfers, dressing; supervision with personal hygiene and bathing and as independent in eating and locomotion. An annual assessment completed on 5/11/20 prior to the incident on 7/2/20 coded the resident as scoring a 9 out of 15 on the BIMS indicating Resident #47 was moderately impaired for cognition. Section N0350 Insulin: coded the resident as receiving insulin injections 7 out of 7 days of the look back period. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Medications scheduled administration time 5:00 PM: - Losartan (anti-hypertensive) (5) 100 milligram table by mouth in the afternoon for hypertension - Multivitamin (dietary supplement) 1 tablet by mouth in the afternoon for supplement, - Divalproax [[MEDICATION(S)]] (anti-epileptic) (6) 625 milligram delayed response tablet twice a day for [CONDITION(S)] prevention, - [MEDICATION(S)] (anti-diabetic) (7) extended release tablet 500 milligram by mouth twice a day for diabetes mellitus, - [MEDICATION(S)] (treats allergic conjunctivitis) (8) solution 0.1% instill 1 drop in both eyes twice a day for allergies, - [MEDICATION(S)] Mix 75/25- inject 50 units subcutaneously twice a day before breakfast and dinner, notify MD if blood sugar less than 60 or greater than 400. Hold [MEDICATION(S)] 75/25 if blood sugar is less than 100. - [MEDICATION(S)] (insulin) (9) 100 units/milliliter inject per sliding scale: if BS (blood sugar) 150-200 =4 units, BS 201-250=6 units, BS 251-300=8 units, BS 301-350=10 units, BS 351-400=12 units. If < 60 or > 350 or greater call physician, subcutaneously before meals for diabetes. Medications scheduled administration time 9:00 PM: - Atorvastin (anti-hyperlipidemic) (10) 10 milligram tablet by mouth at bedtime to lower cholesterol - [MEDICATION(S)] (antihistamine) (11) 5 milligram tablet at bedtime for allergies - [MEDICATION(S)] (anti-epileptic) (12) 600 milligram tablet at bedtime for nerve pain - [MEDICATION(S)] (treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (antipsychotic) (14) 40 milligram capsule at bedtime for [CONDITION(S)] - [MEDICATION(S)] (antihypertensive) (15) 10 milligram twice a day for hypertension A FRI (facility reported incident) with an incident dated 7/2/20, and a reported date of 7/3/20, documented in part, Resident was given evening medication twice by two nurses. Resident's nurse practitioner requested the resident be sent to the hospital to be monitored due to the medication and her low blood pressure/pulse. Resident was admitted at the hospital for observation. Patient has no negative outcomes at this time. Employee action initiated or taken: Suspension/removed from schedule while investigation ongoing. Improvement plan and education initiated. If applicable date notification provided to: Responsible party: 7/3/2020, Physician: 7/3/2020, APS [adult protective services]: 7-3-2020, DHP [Department of Health Professions]: 7/3/2020 Review of the FRI investigation and follow up, documented in part, the following: Facility investigation: Completed on: the date 7/8/2020 was handwritten on the form. An included attachment documented in part the following: 7-8-2020 FRI day 5 On 7/2/2020 it was reported that a resident was given medication twice by two different nurses. During the investigation it was found that the resident was written on two different assignment sheets, [name of LPN #4] gave the medication first, without documenting the medication in the system. [Name of RN #2] gave the medication second. The MD [medical doctor] was notified and gave an order to send the resident to the ER [emergency room ]. Resident [#47] was sent to the hospital and remained there two nights under observation status. Resident [#47] returned to the facility on [DATE] with no adverse reactions from the medication error and has remained stable. The DON [director of nursing] removed both nurses from the schedule while the investigation was ongoing, reconfigured the assignment sheets as well as educated the nursing staff on proper medication documentation. The investigation is complete. Another attachment titled, Trigger Call Guideline/Agenda documented in part the following: · Event Type: Medication Error · Date and Time of Event: 7/2/20@ [at]9pm · Patient Name: [Name of Resident #47] · Cognitive Status/BIMS (date last completed): 9 as of 5/11/20 · Timeline of Events: [Name of LPN #4] (Agency Nurse) administered the following medications to [name of Resident #47] at around 5:20pm: · 4 units of [MEDICATION(S)] insulin · [MEDICATION(S)] Mix 75/25- 50 units · [MEDICATION(S)] ER [extended release] 500 mg (milligram) · MVI (multivitamin) · [MEDICATION(S)] 625 mg · Losarten Potassium 100mg · [MEDICATION(S)] Fumrate 10mg · OlapTADINE HCL ([MEDICATION(S)]) eye gtts (drops) · [Name of LPN #5] administered the following medications around 8pm: · Atrovastin Calcium 10mg · [MEDICATION(S)] 600mg · [MEDICATION(S)] 1mg · [MEDICATION(S)] HCL 40mg Around 9pm [Name of RN #2] asked [Name of LPN #4] to compare assignments to make sure that no one was missed. At that time they noticed that they both had [Name of Resident #47] on their assignment sheets and they both had given her [Resident #47] her scheduled medications. They both [RN #2 and LPN#4] both went immediately to assess the resident. The resident [Resident #47] was sleeping. She [Resident #47] was easily aroused and responsive to questions. Vital signs were taken at that time. BP 95/47, 57, 16, 96% on RA [blood pressure, pulse, respirations and oxygen saturation on room air]. [Name of nurse practitioner] was notified immediately and orders were received to sent [Sic] resident to ER [emergency room ]. When EMT's [emergency medical technicians] arrived resident was able to answer questions and she walked to the stretcher. EMS [emergency medical services] took her [Resident #47] blood sugar which was 146. Resident was transported to [Name of hospital]. [Name of RN #2] called report to the ER Nurse to inform her of what medications the resident [Resident #47] received in duplicate. [Name of Resident #47's] Emergency Contact was notified of details of the incident this morning by [name of staff LPN]. DON called [Name of Resident #47's emergency contact] around 10am to explain the incident to her. During the investigation it was discovered that [Name of Resident #47] only received her [MEDICATION(S)] 75/25 50 units once by [Name of LPN #4]. [* Note the sliding scale insulin was administered twice by both nurses for a total of 8 units of [MEDICATION(S)] 100units/ ml]. Education has been initiated on Medication Administration to include signing off medications as you administer them to include giving medications timely as scheduled. The assignments sheets for the units were updated The final investigation included: Statements by RN (registered nurse) #2 and LPN (licensed practical nurse) #4, both involved in the medication error event. The MAR (medication administration record) for July 2020 for Resident #47 with initials sign on code of KO9 corresponding to RN #2. The Assignment sheets for RN #2 and LPN #4. A review of the clinical record failed to evidence any progress notes documenting the events of 7/2/20, regarding a medication error and/ or the residents transfer to the hospital. A review of vital signs on 7/2/20 at 6:23 AM, documented in part, Blood pressure 138/65, pulse 70. Resident #47's blood sugar at 4:30 PM was documented as 179. A review of a Discharge return anticipated MDS assessment with an assessment reference date of 7/2/20, documented in part, Unplanned transfer to acute hospital. A review of the hospital records for Resident #47, evidenced admission to an acute care hospital on 7/2/20-7/4/20. The emergency room record documented in part: EKG: [MEDICATION(S)] [CONDITION(S)] (low heart rate) rate of 51. Emergency Department (ED) physician notes dated 7/2/20 11:28 PM, documented in part, She [Resident # 47] presents after getting a double dose of her medications which include extended release [MEDICATION(S)] and Losartan. Her blood sugar dropped from 108 to 81. Her blood pressures have been on the soft side with maps (mean arterial pressures) around 65. She is getting a fluid bolus and I have ordered maintenance D5 ([MEDICATION(S)] 5%) normal saline. Virginia Poison Control was contacted and suggests admission as [MEDICATION(S)] was extended release and requires at least 12 hours of observation. She reports feeling sleepy, weak and somewhat confused. The ED (emergency room ) RN [registered nurse) note dated 7/2/20 at 11:00 PM documented in part, RN spoke with 'RN#2' taking care of patient from the facility. States that patient received a double dose of her evening medication. 'RN#2' states patient was given medications around 6:00 PM and again at 9:00 PM. A review of the hospital discharge summary dated 7/4/20, documented in part, admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *] insulin. Discharge Diagnosis/Plan: Accidental overdose-patient now back to baseline. EKG (electrocardiogram) x two with normal QT intervals. Diabetes Type 2-resume sliding scale insulin. Initially insulin held on admission. Hypertension-blood pressure soft due to overdose. Received IV (intravenous) fluids in ED. BP stable at this time. LPN #4, an agency nurse, was not available for an interview and was not employed at the facility. An interview was conducted on 4/22/21 at 4:56 PM with RN #2, the nurse supervisor. RN #2 was the second nurse who administered medications to Resident #47 on 7/2/20. When asked if she remembered the medication error on 7/2/20, RN #2 stated, Oh yes, that was the error with the agency nurse who gave medicines and didn't chart, either time. I came to give the medications to the resident [Resident #47] on my assignment sheet and since they were not signed off, I gave the 6:00 PM and 9:00 PM medications. I did not know we were both assigned to the resident until about 9:00 PM. If I had seen the medications signed off, I would have asked the other nurse about the assignment and the medications. I checked on the resident and saw that she did not look well, so I called the nurse practitioner and we transferred her to the hospital. When asked if she remembered any changes or education that were made because of the medication error, RN #2 stated, Yes, they changed the assignment sheet and the number of medication carts. We also reviewed the medication administration policy. On 4/20/21 at 10:40 AM, during the entrance conference, when asked what standards of practice were followed, ASM (administrative staff member) #2, the director of nursing and ASM #3, the quality consultant stated, We use Lippincott and Perry & Potter. Administrative staff members (ASM) # 1, the administrator was made aware of the above concerns on 4/22/21 at 5:56 PM. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the quality consultant, were made aware of the above concerns on 4/23/21 at 10:08 AM. According to Basic Nursing, Essentials for Practice, 6th edition (Potter and Perry, 2007, pages 349-360) A medication order is required for you to administer any medication to a patient. Once you receive and process a medication, place the physician's or health care provider's complete order on the appropriate medication form, the MAR. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When transcribing orders, ensure the names of medications, dosages, routes, and times are legible. The nurse checks all orders for accuracy and thoroughness. When orders are transcribed, the same information needs to be checked again by the nurse. It is essential that you verify the accuracy of every medication you give to the patient with the patient's orders. To ensure safe medication administration, be aware of the six rights of medication administration. 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation .Use the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .After you administer medications, indicate which medications you gave on your patient's MAR per agency policy to show that you gave the medications as ordered. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about your patient's care. There are many nursing actions you take to ensure the right documentation. Make sure that the information on your patient's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record the administration of each medication as soon as you give the medication. Never document that you have given a medication until you have actually given it. A review of the facility assessment evidenced the facility Skills Competencies dated 10/2017, which documented in part, Medication management skills evaluation documents validation of medication management techniques and knowledge completed during job specific orientation and annually. The Medication Management Skills Evaluation CLS-228 (5/14), documented in part, Documents at time of administration on MAR/eMAR. Initiates incident report for medication administration errors. A review of the facility's Medication and Treatment Administration Guidelines dated 3/2018, documented in part, Medications and treatments administered are documented immediately following administration or per state specific standards. The facility enacted a plan of correction, which contained the following 5 points: 1. Nurse practitioner was immediately notified of medication administration error on 7/2/20 once discovered. LPN #4 and RN #2 administered medications at 5:00 PM and 9:00 PM. LPN #4 and RN #2 were both assigned to Resident #47. LPN #4 failed to document administration of medications at 5:00 PM and again at 9:00 PM. RN #2 administered 5:00 PM and 9:00 PM medications to Resident #47 as they had not been documented as given and she was unaware that LPN #4 was also assigned to Resident #47. 2. All Residents with medication administration of their prescribed medications including anti-hypertensive, diabetic, anti-[CONDITION(S)], anti-epileptic, anti-psychotic and insulin have the potential to be affected by this deficient practice. 3. All Nurses educated in person or via phone on 7/3/20 regarding the facility's Medication Administration policy [to include proper documentation after administration] dated 3/2018. LPN #4, an agency nurse, the nurse responsible for administration of the first dose of the 5:00 PM and the 9:00 PM medications was second check was terminated from the facility. 4. For the next month, an audit of medication administered and documented were reviewed by the director of nursing. The medication types reviewed included: anti-hypertensive, diabetic/insulin, anti-[CONDITION(S)], anti-epileptic and anti-psychotic. All results and findings were presented and reviewed at the Quality meeting in August 2020. 5. Completion date 7/8/20. The credible evidence including the Plan of Correction, education, in-service sign in sheets, audits and Quality Council minutes were reviewed and found to be in order. Random interviews were conducted with staff on varying shifts regarding medication administration and documentation and failed to reveal any concerns. A medication pour/pass observation was completed during this survey and no concerns were identified including no concerns for the documentation of medications administered. No further significant medication errors were identified. Review of current residents failed to identify any concerns. Past Noncompliance References: (1) [CONDITION(S)] is a mental disorder characterized by periods of [CONDITION(S)] and depression. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 71. (2) Seizures: a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 137. (3) Diabetes mellitus: inability of insulin to function normally in the body. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 160. (4) Atherosclerosis [CONDITION(S)]: disorder of the cardiac arteries caused by a buildup of plaque which results in the vessels becoming non-elastic. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 52. (5) Losartan potassium tablets are indicated for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The most likely manifestation of overdosage would be [CONDITION(S)] and tachycardia; [CONDITION(S)] could occur from parasympathetic (vagal) stimulation. If symptomatic [CONDITION(S)] should occur, supportive treatment should be instituted. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cda520b7-ae84-4bd7-b298- f4fcc57 (6) [MEDICATION(S)] ER [extended release] is a valproate and is indicated for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Overdosage with valproate may result in somnolence, heart block, deep coma, and [CONDITION(S)]. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0dc024ce-efc8-4690-7cb5-639c728fccac (7) [MEDICATION(S)] [MEDICATION(S)] extended-release tablets are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. BOXED WARNING: Postmarketing cases of [MEDICATION(S)]-associated lactic acidosis have resulted in death, hypothermia, [CONDITION(S)], and resistant bradyarrhythmias This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f0371d2a-276b-4acb-80f8-e24fb8ceae19 (8) Lippincott Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 443. (9) [MEDICATION(S)] is a rapid acting human insulin analog indicated to improve glycemic control in adults and children. 5 Warnings and Precautions: 5.3 [CONDITION(S)]: [CONDITION(S)] is the most common adverse reaction associated with insulins, including [MEDICATION(S)]. 10. Overdosage: Excess insulin administration may cause [CONDITION(S)] and [CONDITION(S)]. Mild episodes of [CONDITION(S)] usually can be treated with oral glucose. More severe episodes may be treated with intramuscular/subcutaneous [MEDICATION(S)] or concentrated intravenous glucose. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8ecbd7a-0e22-4fc7-a503-faa58c1b6f3f (10) Lippincott Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 32. (11) Lippincott Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 67 (12) [MEDICATION(S)] is indicated for: Management of postherpetic neuralgia in adults Adjunctive [MEDICATION(S)] is indicated for: Management of postherpetic neuralgia in adults Adjunctive therapy in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Fatal respiratory depression has been reported with [MEDICATION(S)] overdose, alone and in combination with other CNS depressants. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=f1bce199-9f88-4a94-9006-8e148dedd45f&version=3 (13) Lippincott Pocket Drug Guide for Nurses, 2019, Wolters Kluwer, page 429. (14) [MEDICATION(S)] capsules are indicated for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Overdoasge: (in part) cardiovascular monitoring should commence immediately and should include continuous electrocardiographic monitoring to detect possible arrhythmias. [CONDITION(S)] . should be treated with appropriate measures such as intravenous fluids. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=6485d78e-ca4e-4217-ad80-c784a15fa6a4&version=7 (15) [MEDICATION(S)] [MEDICATION(S)] is indicated in the management of hypertension. Overdosage: The most common signs expected with overdosage of a beta-blocker are [CONDITION(S)], [CONDITION(S)], congestive heart failure, bronchospasm, and [CONDITION(S)]. This information was obtained from the website https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d b9-3e56-4a2b-8750-cb95ec 5 * This information was obtained from the website: https://medical-dictionary.thefreedictionary.com/iatrogenic

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to assess, stage, and provide services in a manner to prevent new pressure ulcers from forming, and to prevent current pressure ulcers from worsening, for two of eight residents in the survey sample, Residents #2 and #4. The facility staff failed to prevent, identify, and treat Resident #2's pressure injuries to the sacrum/right buttock prior to being found at an advanced stage (*unstageable), resulting in harm. For Resident #2, the staff failed to measure and include descriptions of Resident #4's, right buttock, pressure ulcer when it was initially discovered on [DATE] and failed to provide treatments to treat the wound and protect the resident's skin from breakdown on multiple dates in (MONTH) and (MONTH) 2019. The findings include: 1. Resident #2 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. On [DATE], the resident was discharged from the facility and was admitted to a local hospital for surgical repair of a broken hip. The resident was readmitted to the facility on [DATE]. On the most recent MDS (minimum data set), a significant change assessment with an assessment reference date of [DATE], Resident #2 was coded as being moderately cognitively impaired for making daily decisions, having scored eight out of 15 on the BIMS (brief interview for mental status). The resident was coded as being completely dependent on the assistance of two staff members for bed mobility and transferring between surfaces. The resident was coded as being dependent on the assistance of two staff members for toileting and bathing. The resident was coded as always being incontinent of bladder and bowel. Resident #2 was coded as being at risk of developing pressure ulcers, and as having no current pressure ulcers. A review of Resident #2's clinical record revealed a Braden Scale for Predicting Pressure Sore Risk (6) dated [DATE]. The resident's score was 15, indicating the resident was at risk for developing a pressure ulcer. A review of Resident #2's nursing progress notes revealed the following note, written [DATE] by LPN (licensed practical nurse) #1: Open area noted to sacrum. 1.5 X 1.3 depth .25. NP (name of ASM (administrative staff member) #4, nurse practitioner) in building informed of area order (sic) received for santyl to slough area every day. Resident RP (responsible party) (name of RP) was informed via phone conversation. Order received to clean area with normal saline and apply santyl to slough area. Cover with dry dressing. Review of the physician orders [REDACTED]. Clean with normal saline and apply santyl to slough area of wound. Review of Resident #2's TARs (treatment administration records) for (MONTH) and (MONTH) 2019 revealed initials in all boxes for this order, indicating the wound care was completed as ordered and that on [DATE], LPN (licensed practical nurse) #1 had changed the resident's pressure ulcer dressing. Further review of Resident #2's clinical record revealed no additional documentation regarding Resident #2's pressure ulcer identified on [DATE]. Resident #2's comprehensive care plan dated [DATE], and updated on [DATE] documented, in part, the following: At risk for alteration in skin integrity related to impaired mobility .decrease/minimize skin breakdown risks . Administer treatment per physician orders [REDACTED].Observe skin condition with ADL (activities of daily living) care daily; report abnormalities .Provide preventative skin care routinely and prn (as needed). The care plan was not updated with specific information about Resident #2's pressure ulcer identified on [DATE]. A physician's orders [REDACTED]. Resident #2 was in the hospital from [DATE] through 11//,[DATE], and there were no additional orders for body audits documented upon Resident #2's readmission to the facility on [DATE], through the beginning of the survey. Further review of Resident #2's physicians' orders, MARs (medication administration records) and TARs for (MONTH) and (MONTH) 2019 failed to reveal any evidence of orders for skin protectant, barrier cream, or other pressure ulcer preventative treatment. On [DATE] at 4:50 p.m., RN (registered nurse) #1, a unit manager, was observed providing wound care to Resident #2. RN #1 removed the old dressing from Resident #2's right buttock, revealing two pressure ulcers, instead of one. One pressure ulcer was higher up on the right buttock. The base of the wound was not visible, as the wound contained slough (4). This wound measured 5 cm (centimeters) X (by) 3.5 cm X 1.5 cm. The second pressure ulcer was located lower on Resident #2's right buttock. The second ulcer was smaller than the first. The wound base was not visible, as it contained eschar (4). RN #1 cleansed both wounds with normal saline, and applied Santyl (5) to the upper wound with a sterile swab. He did not measure or apply any medication to the second ulcer. He covered both wounds with a foam dressing, removed his gloves, washed his hands, and left the room. An interview was conducted with RN (registered nurse) #1 on [DATE] at 5:05 p.m., immediately following the wound care observation. When asked to describe the wounds he observed, RN #1 stated the upper wound contained slough, and had a dark tissue center. He stated the lower wound was dark, with a slight opening on the left edge. When asked how many pressure ulcers he expected to find when he provided wound care to Resident #2, RN #1 stated, Just one. He verified that the lower pressure ulcer was a new wound identified during the wound care. RN #1 stated, I had not seen that one last week when I did rounds. When about asked the process staff follows when a nurse discovers a new pressure ulcer on a resident, RN #1stated, We measure it and document it. Then we call and get an order for [REDACTED]. When asked if he measured the new wound on Resident #2, RN #1 stated, No, I did not. I know I should have. I will do that tomorrow when I make wound rounds. He stated he would call the NP (nurse practitioner) and get an order for [REDACTED].>When asked to describe the facility's process for identifying and assessing wounds, RN #1 stated the floor nurses generally do the daily wound care. If the floor nurses discover a new wound, they measure it, describe it, and write a progress note about it. The floor nurses also communicate with the RP (responsible party) and the MD (medical doctor)/NP for the resident to obtain treatment orders. RN #1 stated that the unit managers make weekly rounds on all residents who have wounds, measuring and describing the wounds in a progress note. When asked who stages the wounds, RN #1 stated, The staging is not done by the nurses. Beyond that, I'm not sure. When asked if it is possible to stage a wound in which the wound base is not visible because of the presence of eschar or slough, RN #1 stated, No, it is not. When asked if both of Resident #2's wounds are *unstageable, RN #1 stated, Yes. When asked if the upper wound was unstageable when initially identified, on [DATE], RN #1 stated he did not know, but he would find out. * Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. On [DATE] at 5:25 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated she has been taking care of Resident #2 on most days when she works. CNA #1 stated, I haven't noticed the other wound. I only really noticed one. She stated Resident #2 is always incontinent of bladder and bowel, and has to be changed pretty often. She stated since the resident returned from the hospital after her broken hip, it has been much more difficult to move and reposition the resident in bed. When asked what she would have done if she had noticed a new wound on Resident #2, she would have reported it to the nurse. On [DATE] at 8:37 a.m., LPN #2, an MDS Coordinator, was interviewed. When asked how often residents are assessed for skin breakdown, LPN #2 stated, On admission, weekly body audits, and on wound rounds. She stated residents are also observed whenever baths are given, and if wound care is done. LPN #2 stated CNAs perform the skin observations during incontinence care and bathing, and floor nurses provide the wound care and the body audits. She stated unit managers are responsible for doing weekly wound rounds. When asked what should be done when a new pressure ulcer is discovered, LPN #2 stated the wound should be assessed, and the doctor and RP should be notified. When asked what a wound assessment should include, LPN #2 stated that the wound, should be described, measured, and it should be determined where the wound came from. When asked who stages the wounds, LPN #2 stated, Our nurses on the floor do not stage. I'm not sure who stages them. She stated the nurse who finds a new wound should write a progress note with the measurements, description, verification of notifying the MD and RP, and any new orders the MD or NP gives for the wound. LPN #2 stated the unit manager writes a weekly progress note describing the wound and giving the measurements. On [DATE] at 9:05 a.m., ASM (administrative staff member) #2, the DON (director of nursing for this facility) was interviewed by phone. She stated she has only been working at this facility for a few months. When asked about the process staff follows for resident skin assessments, ASM #2 stated residents receive head to toe skin assessments with baths/showers twice weekly, and floor nurses perform a skin assessment (body audit) at least weekly. She stated if a resident has a wound, the unit managers perform a weekly assessment on wound rounds, and should be writing a progress note with measurements and a description of the wound. She stated the floor nurses are providing routine wound care. ASM #2 stated Braden assessments are done on admission and readmission. When asked what should be done when a new wound is discovered, ASM #2 stated the wound should be measured and described, the RP and MD should be notified, and a progress note should be written. On [DATE] at 10:35 a.m., LPN #4 was interviewed. When asked what should be documented when a new pressure area is identified on a resident, She stated the MD (medical doctor) and RR (resident representative) should be notified. She stated the nurse who discovers the wound should measure it, and include the measurements and a wound description in a progress note. LPN #4 stated the nurse should get an order from the MD or NP (nurse practitioner), and put the order into the electronic medical record. When asked how often a wound should be assessed, LPN #1 stated it should be assessed at least every day. She stated that she signs off on the TAR once she has completed a resident's wound care. She stated the unit managers do weekly wound rounds, and that sometimes, the NPs do wound rounds with the unit managers, but not always. On [DATE] at 10:55 a.m., RN (registered nurse) #2, a unit manager, was interviewed. She stated she is an agency employee, and has only been at the facility for a few weeks. She stated she would only be staying for one more week at the facility. When asked about the process staff follows for completing resident skin assessments, RN #2 stated, Skin is assessed by the nurses on admission and readmission. She stated every resident should have an order for [REDACTED].#2 stated the nurse should let the MD and the family know. When asked if the floor nurse stages the wound, RN #2 stated, I am not allowed to stage it. The floor nurse is not allowed to stage it. We are only allowed to measure it and describe it. She stated unit managers do weekly wound rounds for residents who have pressure ulcers. RN #2 stated, I keep a wound book. I don't know if anybody else did before I came, or if anybody else is doing one here, because I haven't found anything like that. But when I came, I started a wound book. On [DATE] at 11:46 a.m., RN # 1 was interviewed. He stated he had gone back in to measure the new (lower) buttock wound on Resident #2, and had gotten a new order for both a treatment for [REDACTED]. He stated the lower (new) wound measurements were 2 cm X 1.5 cm X 0.1 cm. When asked if he had staged the new (lower) buttock wound, RN #1 stated, We are not allowed to stage. Only to describe. When asked who is responsible for staging the wounds, RN #1 stated, I really am not sure. When asked if he had done additional documentation other than writing a progress note, RN #1 stated, No. On [DATE] at 11:50 a.m., LPN #1 was interviewed. She stated she had provided Resident #2's wound care on [DATE] (the day before the new wound, was observed by RN #1 and the surveyor). LPN #1 stated, If there was more than one wound there, I didn't see it. When asked what she would have done if she had discovered a new wound, LPN #1 stated, I would have tried to measure it and describe it. I would have called the doctor or the NP. She stated she would have written a progress note. When asked if there is any other documentation for pressure ulcers, LPN #1 stated, No. When asked if she remembered performing weekly or bi-weekly body audits on Resident #2 since the resident returned from the hospital following hip surgery, LPN #1 stated, I don't really remember. You would have to look at the orders and the TAR. When shown the (MONTH) and (MONTH) 2019 TAR for Resident #2, LPN #1 stated, I guess not. On [DATE] at 5:16 p.m., ASM #2 and ASM #3, the DON from a sister facility, were interviewed. When asked the purpose of the body audits ordered for residents, ASM #3 stated, To assess the skin, to identify any areas that are there. When asked if any documentation accompanies the body audits, ASM #3 stated if there are any new areas, these areas are documented in the progress notes. She stated the purpose of the body audits are to identify new skin impairment areas. She stated if a new area is found, it should be measured and assessed, then described by measurement, location, and appearance in a progress note. When asked if there is any reason a resident should not be receiving body audits, ASM #3 stated, No. Everyone receives them. When asked who is responsible for staging pressure ulcers in the facility, ASM #2 stated, The RN on the unit manager. When asked why it is important to stage a pressure ulcer, ASM #2 stated staging is one way to determine whether or not a wound is improving or not. She further stated that with each wound assessment made by the RN/unit manager, there should be a progress note and a PUSH tool (7) update. When asked if all pressure ulcers should be documented using a PUSH tool, ASM #2 stated, Yes, they should. When asked about an acceptable stage for identification of a new pressure sore on a resident, ASM #3 stated, That's hard to say. When asked what she would conclude about a resident having two new wounds identified at an unstageable level within 10 days, ASM #3 stated, Obviously, that is not optimal. When asked if Resident #2 was receiving preventative skin care and body audits prior to the discovery of an unstageable pressure ulcer on [DATE] and [DATE], ASM #3 and ASM #2 stated they would need to check. When asked if a PUSH tool had been initiated for the unstageable pressure ulcer discovered on [DATE], ASM #3 and ASM #2 stated they would need to check. The Pressure Ulcer Scale for Healing (PUSH Tool) was developed by the National Pressure Ulcer Advisory Panel (NPUAP) as a quick, reliable tool to monitor the change in pressure ulcer status over time .The NPUAP recommends use of the PUSH Tool at regular intervals. (7) On [DATE] at 5:30 p.m., ASM #1, the administrator, ASM #2, ASM #3, and LPN #2 were informed of the concern Resident #2's, two pressure wounds were discovered as unstageable within 10 days of each other and of the lack of preventative measures, including body audits and the concern for harm. On [DATE] at 10:38 a.m., RN #1 was interviewed. He stated ASM #4 had seen Resident #2 on [DATE] in the afternoon. He stated she changed the order for the upper wound, and wrote an order for [REDACTED]. It looks like we have been putting Zinc Oxide cream on her once a shift since (MONTH) 1. When asked what sort of interventions should have been implemented to prevent the skin breakdown, RN #1 stated, Some kind of barrier cream, at least. She is always incontinent. He stated that barrier cream should have been applied after each and every incontinent episode. He stated he would get an order for [REDACTED]. When asked if Resident #2's wound identified on [DATE] was being tracked using a PUSH tool, RN #1 stated, We are getting one done now. (ASM #4, the nurse practitioner was unavailable for interview before exit.) On [DATE] at 11:38 a.m., ASM #2 stated the facility relied on their policy as their standard of practice for pressure ulcer management. A review of the policy, Skin Practice Guide, revealed, in part, the following: If a pressure ulcer is identified, a Pressure Ulcer Scale for Healing (PUSH tool) is initiated by a member of the wound team for each site identified. A comprehensive evaluation is completed and documented in the patient's clinical record and may include, but is not limited to: location, depth, appearance of surrounding skin, presence and location of tunneling, presence and location of undermining, evidence of infection, pain. Daily skin evaluations are completed by the licensed nurse for any patient with a pressure ulcer. Weekly skin evaluations are completed by the licensed nurse for any other patient. Skin evaluations are documented in the medical record .Any new ulcer development suggests a need to reevaluate the plan of care of preventing further development of pressure ulcers .Each center establishes a designated wound management team .The wound management team reevaluates pressure ulcers and complex wounds weekly and other types of wounds as clinically indicated. Documentation of findings is completed on the PUSH Tool. When asked who comprises the wound team in the facility, ASM #2 stated, Right now, it's the nurses, the unit manager who makes the weekly rounds. When asked the NP/MD's role in wound care, ASM #2 stated, They provide the orders and they look at the wound when they come in to see the resident. They will stage it then if they look at it. Importance of staging. A pressure ulcer classification system is used to aid in the description of the extent of skin and tissue damage presenting as a pressure ulcer. Numerous classification systems have been developed and used over the years, informed by evolving understanding of the etiology of pressure ulcers; anatomical knowledge of skin, tissue and muscle layers; and diagnostic and assessment technology. The use of a reliable classification system: improves communication between health professionals, contributes to the development of an appropriate pressure ulcer prevention plan, including allocation of pressure redistribution support surfaces; informs the selection of pressure ulcer treatments. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/2014_guideline.pdf. No further information was provided prior to exit. Complaint deficiency References: * This information is taken from the National Pressure Ulcer Advisory Panel website at https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (1) A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. This information is taken from the National Pressure Ulcer Advisory Panel website at https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (2) Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. This information is taken from the National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (3) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. (4) The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in color), or eschar (dry, black, hard necrotic tissue). Such tissue impedes healing. This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 05/ (5) SANTYL Ointment is an FDA-approved prescription medicine that removes dead tissue from wounds so they can start to heal. This information is taken from the manufacturer's website https://www.santyl.com/. (6) The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. It measures functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. Lower levels of functioning indicate higher levels of risk for pressure ulcer development .The Braden Scale is a summated rating scale made up of six subscales scored from ,[DATE] (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from ,[DATE] (one subscale is scored with values of ,[DATE], only). The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levels of risk for pressure ulcer development. This information is taken from the website https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/LNC_BRADEN/. (7) The Pressure Ulcer Scale for Healing (PUSH Tool) was developed by the National Pressure Ulcer Advisory Panel (NPUAP) as a quick, reliable tool to monitor the change in pressure ulcer status over time .The NPUAP recommends use of the PUSH Tool at regular intervals. The AHCPR Treatment Guideline recommends assessments be performed at least weekly and if the condition of the patient or of the wound deteriorates. The PRESSURE ULCER HEALING CHART (which is attached to the PUSH Tool) will allow you to graph PUSH Tool scores over time for each ulcer. You should be able to tell at a glance whether the ulcer is healing, remains unchanged, or is deteriorating. The PUSH Tool is designed to monitor the three critical parameters that are the most indicative of healing. In developing specific treatment plans, you will need to assess additional parameters (e.g., foul odor, color of exudate, undermining, and tunneling). Any increase in the PUSH Tool score (indicating wound deterioration) requires a more complete assessment of the ulcer and the patient's overall condition. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/push_tool_information_form.pdf. 2. Resident #4 was admitted to the facility on [DATE], and was most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a significant change assessment with an assessment reference date of [DATE], she was coded as having both short-term and long-term memory problems, and as being severely cognitively impaired for making daily decisions. The resident was coded as being completely dependent on the assistance of staff for bed mobility, toileting, personal hygiene and bathing. The resident was coded as transferring out of bed only one or two times during the look back period. The resident was coded as having an indwelling urinary catheter, and as being always incontinent of bowel. The resident was coded as being at risk for developing pressure ulcers, and as having one unstageable pressure ulcer. A review of Resident #4's progress notes revealed a note dated [DATE]. The note documented, in part, the following: Apply Hydrogel Gel to buttocks topically every evening shift for wound care. Cleanse affected area of buttocks with normal saline, apply hydrogel and cover with foam dressing daily. Further review of the progress notes revealed the following note dated [DATE] (13 days since the previous wound note): Open area to right buttocks that measures 1.5 cm (centimeters) X 1.0 cm X 0.2 cm, 100% beefy red wound bed, no drainage, no odor. Periwound (area around wound) is normal. Continue with hydrogel and foam dressing. Further review of the clinical record revealed documentation that Resident #4 was discharged to the hospital on [DATE], and was readmitted to the facility on [DATE]. A progress note dated [DATE], which was part of the readmission assessment, documented, in part: Resident readmitted under hospice .DSG (dressing) to coccyx is unstageable, dsg replaced. Review of the full readmission assessment dated [DATE] failed to reveal any additional information regarding Resident #4's pressure ulcer. A progress note dated [DATE] (12 days since the previous note related to Resident #4's pressure ulcer), documented, in part, the following: Late entry for [DATE]. Wound note: Sacral wound measuring 6.5 X 3.0 X 0.2. Wound bed is 95% yellow slough and black exchar (sic) with purulent (containing pus) mild drainage and foul odor. Hospice nurse in at time of dressing change. Current treatment in place. This note, written by RN (registered nurse) #2, a unit manager. A review of Resident #4's (MONTH) 2019 TAR (treatment administration record) revealed blanks on [DATE], [DATE], [DATE] for the following treatment administration: Hydrogel Gel Apply to buttocks topically every evening shift for wound care. Cleanse affected area of buttocks with normal saline, apply hydrogel and cover with foam dressing daily. A review of Resident #4's (MONTH) 2019 TAR revealed the treatment, Barrier cream to peri (perineal) area, buttocks and scar tissue, BID (twice a day) and prn (as needed) after incontinent episodes every day and evening shift. There were blanks for the treatment as evidenced by no staff initials evidencing the treatment was administered on the following dates and shifts: -Day shift: on [DATE], [DATE], [DATE], [DATE], and [DATE]. - Evening shift: on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A review of Resident #4's comprehensive care plan dated [DATE] and updated [DATE] revealed, in part, the following: Right buttocks area .Administer treatment per physician orders [REDACTED]. On [DATE] at 9:05 a.m., ASM (administrative staff member) #2, the DON (director of nursing for this facility) was interviewed by phone. ASM #2 stated she has only been working at this facility for a few months. When asked the process for skin assessment for all residents, ASM #2 stated residents receive head to toe skin assessments with baths/showers twice weekly, and floor nurses perform a skin assessment (body audit) at least weekly. ASM #2 stated if a resident has a wound, the unit managers perform a weekly assessment on wound rounds, and should be writing a progress note with measurements and a description of the wound. On [DATE] at 10:35 a.m., LPN #4 was interviewed. She was asked what should be documented when a new pressure area is identified on a resident. LPN #4 stated the MD (medical doctor) and RR (resident representative) should be notified. She stated the nurse who discovers the wound should measure it, and include the measurements and a wound description in a progress note. LPN #4 stated the nurse should get an order from the MD or NP (nurse practitioner), and put the order into the electronic medical record. When asked how often a wound should be assessed, LPN #4 stated it should be assessed at least every day. She stated that she signs off on the TAR once she has completed a resident's wound care. LPN #4 stated the unit managers do weekly wound rounds, and that sometimes, the NPs do wound rounds with the unit managers, but not always. On [DATE] at 10:55 a.m., RN (registered nurse) #2, a unit manager, was interviewed. She stated she is an agency employee, and has only been at the facility for a few weeks. She stated she would only be staying for one more week at the facility. When asked the process for skin assessment, RN #2 stated, Skin is assessed by the nurses on admission and readmission. She stated every resident should have an order for [REDACTED]. When asked if the floor nurse stages the wound, RN #2 stated, I am not allowed to stage it. The floor nurse is not allowed to stage it. We are only allowed to measure it and describe it. She stated unit managers do weekly wound rounds for residents who have pressure ulcers. RN #2 stated, I keep a wound book. I don't know if anybody else did before I came, or if anybody else is doing one here, because I haven't found anything like that. But when I came, I started a wound book. RN #2 presented a document from a notebook. The document, Pressure Ulcer Healing Chart, contained columns for the date, measurements, tissue type, and progress toward healing for residents' wounds. RN #2 stated she had started this document for Resident #4, beginning with [DATE] when she first observed and assessed Resident #4's wound. She stated she would be adding the next column on [DATE] when she did weekly wound rounds. When asked to review the wound documentation for Resident #4, beginning with [DATE], RN #2 reviewed the notes. RN #2 stated, I can't really speak to what did or didn't happen before I got here. On [DATE] at 11:10 a.m., LPN #5 was interviewed. She stated she was the nurse who had initially discovered Resident #4's pressure ulcer. She stated that usually, when she discovers a new pressure ulcer, she measures it, and includes the measurements and description in a progress note. LPN #5 stated she calls the provider, gets, an order, and then notifies the family. She stated the unit manager does weekly rounds on the wounds, and floor nurses see the wound as often as the w

Based on facility staff interview, law enforcement staff interview, facility document review, clinical record review, and in the course of a complaint investigation it was determined that the facility staff failed to protect a resident's right to be from abuse resulting in harm for one of 11 residents in the survey sample, Resident #102. Resident #102 expired in the facility from a fatal injury allegedly inflicted by the resident's roommate, Resident #101. On [DATE], between 10:15 p.m. and 10:45 p.m., Resident #101 allegedly slit Resident #102's throat with a knife, resulting in Resident #102's death. Resident #101 is currently in police custody, and has been charged with second degree murder of Resident #102. The findings include: Resident #102, was originally admitted to the facility on [DATE]; and was most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of [DATE], Resident #102 was coded as having no impairments with making himself understood and with understanding others. He was coded as having moderate cognitive impairment for daily decision-making, having scored 10 out of 15 on the BIMS (brief interview for mental status). Resident #102 was coded as having demonstrated no behavioral symptoms during the look back period. He was coded as requiring supervision only for transferring between surfaces, and as requiring limited assistance of one staff member for bed mobility. Resident #102 was coded as requiring extensive assistance of one staff member for dressing, toileting, personal hygiene, and bathing. He was coded as not having walked in his room during the look back period, and as requiring supervision only for locomotion on and off the unit. He was coded as using both a walker and a wheelchair for mobility. Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS, a quarterly assessment with an assessment reference date of [DATE], Resident #101 was coded as having no impairments with making himself understood and with understanding others. He was coded as having no cognitive impairment for making daily decisions according to his score of 15 out of 15 on the BIMS. Resident #101 was coded as having demonstrated no evidence of an acute onset of mental status change during the look back period. He was coded as having scored a zero out of 27 on the resident mood interview, indicating no difficulties with mood. Resident #101 was coded as having demonstrated no behavioral symptoms curing the look back period. He was coded as being independent for all ADLs (activities of daily living), except for requiring set up for eating, and supervision for toilet use. He was coded as needing no mobility devices for locomotion. Resident #101 was coded as not having a PEG tube. He was coded as having received an antipsychotic medication on seven out of seven days during the look back period. A gradual dose reduction (GDR) in Resident #101's antipsychotic medication was coded as being contraindicated per his physician. A review of Resident #102's clinical record revealed the following progress note, written on [DATE] at 1:59 p.m. by RN (registered nurse) #3: Resident complained of right sided pain unrelieved by Tylenol. (Name of nurse practitioner) notified and ordered and given [MEDICATION NAME] (8) 50 mg (milligrams) one time order. The next note in Resident #102's progress notes was written by ASM (administrative staff member) #2, the director of nursing, with the effective date of [DATE] at 10:44 p.m. The note documented, Resident was found covered in blood in his bed unresponsive by (LPN (licensed practical nurse) #3) around 10:30 p.m. Immediate call to 911 was placed for EMTs (emergency medical technicians) and Police. EMTs and Police arrived at 2255 (10:55 p.m.) assessed the situation and secured the scene. The Coroner picked up the remains at around 3 am. There were no additional progress notes in Resident #102's record. A review of Resident #102's comprehensive care plan dated [DATE], and of all of Resident #102's progress notes since Resident #101 became his roommate, revealed no documentation regarding any difficulties with, or complaints about, Resident #101 being Resident #102's roommate, and no documented requests for to have an alternate roommate. A review of Resident #101's admitting history and physical, dated [DATE], revealed, in part, the following: History of Present Illness: The patient is a [AGE] year-old Caucasian male with a past medical history significant for [MEDICAL CONDITIONS], hypertension (high blood pressure), and [MEDICAL CONDITION] disorder. He was admitted to (name of local hospital) for shortness of breath. He was found to have a laryngeal mass .He has a significant damage in his larynx from this [MEDICAL CONDITION]. He was also placed on a PEG tube .I am seeing here in (name of facility). He is doing well .Assessment and plan: .[MEDICAL CONDITION] disorder. He is on [MEDICATION NAME] and [MEDICATION NAME] and doing well. A review of Resident #101's clinical record revealed the following progress note, dated [DATE] at 3:25 p.m., written by OSM (other staff member) #1, the social worker: IDT (interdisciplinary team) held care plan meeting this date with social services, nursing, and dietician. Resident invited but declined to attend. Nursing reviewed medications and diagnosis. Patient has not had any falls or hospitalization s this quarter. Dietician reports patient is on a regular diet, regular texture. He eats between 50% - 100% of his meals. He weighs about 172.8 lbs (pounds). Social services reports patient is a full code. He has not had any behaviors this quarter. He does not have a POA (power of attorney). He is at this facility for long term care. Staff will continue to assist and support. Review of Resident 101's clinical record revealed the following progress note, written [DATE] by OSM #1 (the Social Services Coordinator): SS (social services) quarterly: SS met with patient to complete quarterly assessment. Patient is alert, verbal, and pleasant. Patient scored a BIM (sic) of 15 and a PHQ9 (name of a mood assessment) of 0. Patient has not displayed any behaviors this quarter. Patient is a full code. Patient does not have a POA (power of attorney). Patient will remain at this facility for long term care. SS will continue to assist and support. The final progress note in Resident #101's record was dated [DATE] at 11:00 p.m., and was written by ASM #2, the director of nursing: Late Entry: Resident was escorted out of the facility by the (name of local police department) around 11:00 p.m. A review of Resident #101's comprehensive care plan, dated [DATE], with a target date of [DATE], revealed, in part the following: At risk for changes in mood r/t (related to) [MEDICAL CONDITION] . Will accept care and medication as prescribed .Administer medication per physician orders [REDACTED].Offer choices to enhance sense of control. Further review all of Resident #101's progress notes since Resident #102 became his roommate revealed no documented information related to any difficulties with, complaints about, Resident #102 as a roommate or any requests for an alternate roommate. A review of the facility SCREENING FOR MENTAL ILLNESS, MENTAL [MEDICAL CONDITION]/INTELLECTUAL DISABILITY, OR RELATED CONDITIONS, completed [DATE], revealed no evidence that Resident #101 qualified for a secondary assessment. A review of the attending physician's most recent progress note, dated [DATE], revealed, in part, the following: (Resident #101) is doing well in the nursing home. He is still smoking. He is not able to quit smoking. He has [MEDICAL CONDITION], no cough, cold, no wheezing .[MEDICAL CONDITION] disorder, on [MEDICATION NAME] (9) and [MEDICATION NAME] (10), doing well. A review of Resident #101's medication orders revealed the following: [MEDICATION NAME] Tablet 1 mg Give 2 mg by mouth at bedtime for [MEDICAL CONDITION]. The order was written [DATE]. A review of Resident #101's MARs (medication administration records) for the past 12 months revealed no missed doses of [MEDICATION NAME], and no nurse notes related to the resident ever refusing the medication. A review of Resident #101's Medication Regimen Reviews completed by a pharmacist revealed that in June of 2017, Resident #101's [MEDICATION NAME] was discontinued, and the [MEDICATION NAME] was increased to 2 mg daily at bedtime. A review of the consultant Psychiatric Evaluations for Resident #101 revealed an evaluation dated [DATE]. The evaluation, written by RN (registered nurse) #5, the consultant psychiatric nurse practitioner, a PhD, documented, in part, the following: Past Medical History: Malignant neoplasm (cancer) of the larynex (sic), .[MEDICAL CONDITION] .Past Psychiatric Admission: He denies any hospitalization s but this is questionable with the [DIAGNOSES REDACTED]. Past Suicide Attempt: Denies. Past Use of [MEDICAL CONDITION] medications: [REDACTED]. Legal History: Did not identify any legal difficulties .Type of Visit: Initial evaluation .Information Obtained From: Patient, Chart Review, Nursing Staff .Chief Complaint/Nature of Presenting Problem: [MEDICAL CONDITION]. History of Present Illness: [AGE] year-old male with [DIAGNOSES REDACTED]. Today he is seen in the room, fair eye contact and interaction appropriate but limited at times and a little guarded. He denies any difficulty with eating or sleeping, denies any significant symptoms of anxiety or depression and denies suicidality. He denies any current hallucinations and there is no evidence of him respond (sic) to internal stimuli, cognition appears to be grossly intact. No noted or reported side effects to medications. He identifies that he is doing well and has no concerns. No distress noted and staff identified no behavioral issues. Support given during interview .Current Psychiatric Medications General [MEDICATION NAME] (11) 2 mg po (by mouth) nightly for EPS (extra-pyramidal side effects) (12). [MEDICATION NAME] 2 mg po nightly for [MEDICAL CONDITION] .Mood Symptoms: He denies any significant symptoms of anxiety or depression, no psychotic symptoms noted, denies suicidality, no agitation or aggression noted or reported, cognition appears to be grossly intact, no evidence of pseudobulbar (13) affect symptoms and no reports of noncompliance with medications or treatments .Appearance/Behaviors: Calm, cooperative, groomed .Mood: pleasant, Affect: appropriate, Thought process: organized, Hallucinations: none evident, Delusions: none evident, Short-term memory: fair to good, Long-term memory: fair to good, Concentration: fair, Insight: fair, Judgment: fair, Suicidal ideation: denies, Homicidal ideation: denies .Description of Associations: intact .Recommendations: Continue medication(s) as prescribed, the patient is stable at current dose. Dose reduction attempted and/or reduction will cause decompensation of patient. Monitor for changes in mood or behaviors and notify (name of psychiatric services provider). Will continue to follow and provide consultation. Follow up: as needed. Review of Resident #101's clinical record revealed psychiatric evaluations completed by RN #5 on [DATE], [DATE] and [DATE]. These evaluations contained no deviations from the findings and recommendations for care as documented in the evaluation from [DATE]. RN #5's final psychiatric evaluation of Resident #101 was dated [DATE]. This evaluation documented, in part: History of Present Illness: [AGE] year-old male with [DIAGNOSES REDACTED]. Today he is seen in the room, fair eye contact and interaction appropriate. He denies any difficulty with eating or sleeping, denies any significant symptoms of anxiety or depression and denies suicidality. He denies any current hallucinations and there is no evidence of him responding to internal stimuli, cognition appears to be grossly intact. No noted or reported side effects to medications. He identifies that he is doing well and has no concerns other than being ready to go smoking at 10:30 a.m., smiled as he related this. Presents in a positive manner and denies any difficulties, no distress noted. Staff identified no behavioral issues. Support given during interview .Current Psychiatric Medications General [MEDICATION NAME] (11) 2 mg po (by mouth) nightly for EPS (extra-pyramidal side effects) (12). [MEDICATION NAME] 2 mg po nightly for [MEDICAL CONDITION] .Appearance/Behaviors: Calm, cooperative, adequately groomed .Mood: pleasant, Affect: appropriate, Thought process: organized, Hallucinations: none evident, Delusions: none evident, Short-term memory: fair to good, Long-term memory: fair to good, Concentration: fair, Insight: fair, Judgment: fair, Suicidal ideation: denies, Homicidal ideation: denies .Description of Associations: intact .Recommendations: He is currently stable on his [MEDICATION NAME] for his [MEDICAL CONDITION]. Dose reduction attempted and/or reduction will cause decompensation of patient. Monitor for changes in mood or behaviors and notify (name of psychiatric services provider). Will continue to follow and provide consultation. Follow up: as needed. A review of the facility's safe smoking assessment dated [DATE] revealed, in part, the following: Conclusion: Independent Smoker. Capable and independent, requires no supervision to smoke. Interviews were attempted with staff who were familiar with the care of both Resident #101 and Resident #102, and with staff who were working on [DATE] and the two days prior. Not all attempts were successful. The results of the staff interviews conducted by the survey team are as follows. On [DATE] at 7:39 a.m., an interview was conducted with CNA (certified nursing assistant) #2. She stated she was experienced in caring for both Resident #101 and Resident #102. She stated Resident #102 was alert, and was able to communicate his needs. CNA #2 stated he could get up and walk a short distance with his cane, but spent most of the time in his wheelchair. CNA #2 stated Resident #101 was independent with everything. CNA #2 stated he (Resident #101), slept at night. CNA #2 that stated sometimes she smelled smoke in his bathroom when she worked the night shift, but she never found any smoking materials in his room. She stated she reported the smell to the nurse, and the nurse would come in the room to determine what she could smell. CNA #2 stated she never observed any cigarettes, butts, or lighters in the room. She stated she had never seen a weapon of any kind in Resident #101's possession. CNA #2 stated she took care of both residents (Resident #102 and #101) on Monday, [DATE], and there was nothing out of the ordinary. On [DATE] at 7:50 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated she was very familiar with both residents. She stated Resident #102, was well- loved, and was a joy to take care of. He was alert, able to follow directions, and needed more ADL (activities of daily living) assistance in recent months due to some falls. LPN #2 stated he frequently used the call bell, and stated she felt certain that if he had been aware of any danger, he would have told staff members or rung the call bell. When asked about Resident #101, LPN #2 stated that even though she had taken care of him for quite a while, she did not feel like she had gotten to know him. She stated that he was independently up and around the unit, and that he went out to smoke in the designated areas at the designated times. She stated there was no back and forth conversation with Resident #101, and that he only communicated if he was asked a direct question or if he needed something. When asked if he demonstrated any signs or symptoms of [MEDICAL CONDITION] behavior in all the months, she had cared for him, LPN #2 stated, Absolutely not. She stated she worked the night shift on [DATE], and observed no signs of agitation, or of either resident being upset with the other. She stated that she usually worked the same shifts as CNA #2, and she remembered several occasions of CNA #2 reporting a smell of cigarette smoke in Resident #101's and #102's bathroom. However, LPN #2 stated she could never prove Resident #101 was smoking in the bathroom. She stated it may have been his clothing that still contained the cigarette smoke from the designated smoking times, in which Resident #101 participated. She stated she could not remember precisely the last time she had smelled smoke in the residents' bathroom. LPN #2 stated she had no knowledge or observation of a weapon of any kind in Resident #101's possession or room. On [DATE] at 8:27 a.m., RN #2 was interviewed. She stated Resident #102 was able to make his needs known. When asked if Residents #101 and #102 had any sort of relationship, RN #2 stated, They did not have much interaction at all. She stated she did not witness them having conversations. She stated Resident #102 never expressed any concerns to her about Resident #101 smoking in the bathroom. RN #2 stated Resident #101 was always polite and kept to himself. She stated she provided him with supplies for his [MEDICAL CONDITION] care, and that he performed his own care. RN #2 stated he went out on smoke breaks with other residents. She denied smelling smoke in the bathroom, and seeing any evidence of any kind of weapon in the room, or on Resident #101's person. On [DATE] at 8:50 a.m., RN #3 was interviewed. She stated she was very familiar with both Residents #101 and #102. She stated Resident #102 had experienced some cognitive decline in recent months. He was cooperative, and conversational, and he was well-able to make his needs known. She stated there appeared to be no relationship between the residents. RN #3 stated, They were just roommates. RN #3 stated Resident #102 never reported to her that Resident #101 was smoking in the bathroom. She stated Resident #101 made only minimal eye contact, and that his affect was flat. She stated he would not carry on a conversation, but he was able to make his needs known. RN #3 stated Resident #101 performed his own [MEDICAL CONDITION] care. She stated he went outside for smoke breaks with other facility smokers at the designated times. When asked if Resident #101 ever displayed any signs or symptoms of [MEDICAL CONDITION], RN #3 stated, He one pulled out [MEDICAL CONDITION]. That was a long time ago. She stated Resident #101 never said why he pulled it out. RN #3 stated Resident #101 never exhibited any behaviors, or signs of agitation or being upset. She stated one of the CNAs reported smelling smoke in the residents' bathroom. She looked all around the bathroom and the room, and did not see any evidence of smoking. RN #3 stated, He had long hair. His clothes smelled like smoke whenever he came in from a smoke break. She stated she never saw any evidence of a weapon in the room or on Resident #101's person. On [DATE] at 9:09 a.m., CNA #1 was interviewed. She stated Resident #102 was sweet and conversational. She stated she never heard Residents #101 and #102 have any kind of conversation. CNA #1 stated Resident #102 frequently told her that Resident #101 smelled like smoke. She stated this was often true. However, she was never able to locate any smoking materials or evidence of smoking in the room. CNA #1 stated Resident #101 wanted his television off at night, and that Resident #102 liked to have his television on at night. CNA #1 denied knowledge of the residents discussing this issue. She stated she regularly supervised resident smoke breaks. CNA #1 stated Resident #101 always returned his smoking materials without complaint with the smoke breaks were over. She stated Resident #101 was quiet, and said no more than was necessary to answer a question or express a need. CNA #1 stated that despite smelling smoke in the bathroom on one occasion many months ago, she stated no staff member was ever able to locate the source of the smell other than the residents' clothes. CNA #1 stated she never observed a weapon in the residents' room or on Resident #102's person. On [DATE] at 9:30 a.m., CNA #3 was interviewed. She stated she regularly supervised smoke breaks, as well as caring for Residents #101 and #102 on the evening shift. She stated Resident #101 was never rude to her or to any other resident. CNA #3 stated the residents (#101 and #102) had no real relationship, and that she had no memory of ever seeing them have a conversation. CNA #3 stated she remembered one night in the past when she smelled cigarette smoke in the residents' bathroom. She stated she and the nurse searched the room and bathroom, and never found evidence of any smoking materials. CNA #3 stated Resident #102 never complained to her about the smoke smell in the bathroom. CNA #3 stated she worked the evening shift on [DATE], and there was nothing out of the ordinary. She stated she was assigned to Residents #101 and #102 on [DATE] on the evening shift (3:00 p.m. to 11:00 p.m.). CNA #3 stated it was a normal evening shift, as best she could remember. She stated there was nothing new or different between the residents. CNA #3 stated that after dinner, Resident #102 went into his room, just as he always did. She started making last rounds at 10:00 p.m. CNA #3 stated that at 10:15 p.m., she saw the call light for Resident #102's room. She went in, and Resident #102 asked her for a drink of water and a snack. She provided these to Resident #102 and continued her rounds in other rooms. CNA #3 stated another CNA assisted her with repositioning a resident in another room. She stated she thought that Resident 102's door was partially open at that time. CNA #3 stated, The last time I saw him (Resident #102) alive was at 10:15 (p.m.). (Resident #101)'s curtain was closed and he was lying on his bed. He always closed the curtain. She stated she next remembered the nurse yelling and calling us to come to (Resident #102)'s room. CNA #3 stated, There was blood everywhere. Everywhere on his body. I just stood at the door. CNA #3 stated someone - she did not remember who - asked Resident #101 what happened. Resident #101 was in the room, watching television. CNA #3 stated Resident #101 did not answer. She stated the police and EMS were called. She stated she stayed at the facility until after 11:00 p.m., and then was called to come back in to the facility in the very early morning hours of [DATE] to be interviewed by the local police. When asked if anything, at any time, ever triggered her to think that Resident #101 might want to, or be capable of, hurting Resident #102, CNA #3 stated, Nothing. On [DATE] at 11:35 a.m., RN #5, the consultant psychiatric nurse practitioner, was interviewed. When asked, whether, or not Resident #101 had been recently receiving both [MEDICATION NAME] and [MEDICATION NAME], as the attending physician had documented, RN #5 stated, No. [MEDICATION NAME] is just a refined form of [MEDICATION NAME]. He was not to be receiving both. She stated she had been treating Resident #101 for less than a year. She stated when she first met Resident 101 on [DATE]; he was very reserved and quiet. RN #5 stated, He definitely had a [MEDICAL CONDITION] presentation. She stated the classic [MEDICAL CONDITION] is reserved until the resident gets to know you, is polite, and answers questions when asked. She stated she always asked Resident #101 if he was hearing any voices, and if so, what the voices were telling him. RN #5 stated Resident #101 always denied hearing voices, as well as denying any hallucinations. She stated that in recent visits, Resident #101 felt comfortable enough to smile and to interact somewhat spontaneously with her. She stated she specifically asked him if anyone was bothering him, which the resident denied. RN #5 stated that on her last visit with Resident #101, in [DATE], he was very positive, again denying hallucinations and hearing voices. When asked if she observed any interactions between Residents #101 and #102, RN #5 stated, I didn't always see the roommate, but Resident #101 never expressed anything negative to her about Resident #102. RN #5 stated, I didn't see (Resident #101) interacting with other people. When asked if she thought Resident #101, was appropriately placed in a long term care facility, RN #5 stated he could not care for himself because of his ([MEDICAL CONDITION]) diagnosis. She stated his cognitive abilities were limited in higher-level thinking, such as judgment and reasoning. She stated Resident #101 was a very concrete thinker, and had limited ability to think in the abstract. She stated she did not think any other setting, in which he would have had more independence, would have been appropriate for him. When asked if she had ever had any reason to suspect that Resident #101 was a danger to himself or to anyone else, RN #5 stated, No. On [DATE] at 1:37 p.m., RN #4, an MDS nurse, was interviewed. RN #4 stated, I had a close relationship with (Resident #101). She stated he was a true [MEDICAL CONDITION] in that conversation was difficult. She stated that, once a week, she and sometimes her children would come to visit him. RN #4 stated, He was a simple guy, a veteran. She stated he never talked about his experiences in military service. She stated that in April, the software the facility uses to scrub its MDS assessments identified Resident #101 as being independent, and as needing an alternative placement other than a nursing home. RN #4 stated she alerted social services, and they took it from there. RN #4 stated she had never observed any evidence of anxiety, hallucinations, or delusions from Resident #101. She stated she had not observed any interaction between Resident #101 and Resident #102. On [DATE] at 1:52 p.m., LPN #3 was interviewed. She stated she frequently supervised resident smoke breaks. She stated Resident #101 always participated in the smoke breaks, and always willingly returned his smoking materials to her. She stated that the only symptom she ever observed with Resident #101, and she could not remember the last time she had seen it, was an increase in a tick, which she described as an itching motion on his upper body. She stated she had not observed this any time recently, and that the resident always denied needing any intervention or having any difficulties. LPN #3 stated Resident #102 never asked about or suggested that Resident #101 was smoking in the bathroom. LPN #3 stated, He (Resident #101) never showered because of the trach, and sometimes (Resident #102)'s family asked about the smell. LPN #3 stated she never saw any smoking materials or any kind of weapons in the room. She stated she was assigned to both residents for the evening shift on [DATE]. LPN #3 stated there was nothing out of the ordinary for either resident during the shift, and there was no indication from either resident of conflict or difficulty. LPN #3 stated she was the one who discovered Resident #102's dead body. She stated she was going in the room at approximately 10:30 p.m. She did not remember whether, the door was partially or completely, closed. LPN #3 stated when she first entered the room and looked at Resident #102, there was copious blood around his throat and on his chest. She stated all the color had drained from his face, and that it was clear that he was dead. LPN #3 stated at first, she thought he had vomited blood, but realized that was not the case when she was the blood pooled on the floor and in other locations in the room. LPN #3 stated she was so focused on Resident #102 and on getting help from other staff members, that she does not remember looking to see where Resident #101 was at the time. LPN #3 stated she went to the phone and dialed EMS. It was at that point that one of the CNAs (she does not remember which one) came out of the room and told her that Resident #102's throat had been cut. As EMS and police began arriving, Resident #101 just stayed over there. LPN #3 stated once the police arrived, Resident #101 sat up on his bed and put his shoes on. She stated Resident #101 never spoke a word, and never attempted to leave the room. LPN #3 stated she had never observed any indication that Resident #101 was experiencing [MEDICAL CONDITION] symptoms or behaviors. On [DATE] at 2:04 p.m., RN #1, the unit manager, was interviewed. He stated that he had only been employed at the facility for four or five weeks, and did not know either Resident #101 or #102 very well. He stated Resident #101 was always helpful at smoke break times with other residents. He stated Resident #101 would help other residents with wheelchairs or walkers to get to the smoke break area. He stated he never observed any interaction between Residents #101 and #102. He stated that on [DATE] before he left the facility around 5:00 p.m., he had talked to both residents. RN #1 stated Resident #102 had reported pain in his right side, and the nurse had gotten an order for [REDACTED]. On [DATE] at 2:21 p.m., OSM #1, the Social Services Coordinator, was interviewed. She stated Resident #101 was a resident when she began working at the facility. He had no family or friends to her knowledge. OSM #1 stated Resident #101 was not very social at first, but that, as time went by, he began going out more on smoke breaks, and speaking to people when he walked in the hallways. OSM #1 stated the MDS staff alerted her that a scrub report had triggered a concern that Resident #101 was too independent for the nursing home, and may need alternative placement. She stated this happens frequently, and that OSM #2, the social services director, often helps her with exploring alternative placement. She stated she believed that OSM #2 was the person who actively looked for alternative placement for Resident #101, and she remembered that they were unsuccessful finding alternative placement for Resident #101 because of his [MEDICAL CONDITION] and because of his finances. OSM #1 stated she writes a monthly note on all smokers, and that she had never had any concerns with Resident #101. She stated he always turned in his smoking materials without complaint or comment. She stated she saw Resident #101 almost every day because he was on her patient load. OSM #1 stated he had never triggered any concerns as a result of his cognition, behaviors, or mood interviews on the MDS. OSM #1 presented the surveyor with the following progress note, written by OSM #2, the director of social services on [DATE]: SW left voicemail for ombudsman office to assist with alternative placement for this resident. SW hasn't spoken with resident yet regarding alternative placement needs. On [DATE] at 2:48 p.m., OSM #3, the ombudsman, was interviewed. She stated she had no memory of Resident #101 in any capacity. When shown the [DATE] note detailed above, OSM #3 stated, I don't know who she left the voicemail for. When they are really anxious to get somebody out, they will hound me. She stated she would check her records and get back to the surveyor if she discovered anything pertinent. On [DATE] at 3:14 p.m., OSM #2, the social services director, was interviewed. OSM #2 stated the MDS staff had run a report and alerted the social workers that Resident #101 might be too independent, and may need to have alternate placement. She stated she has a list of providers who will come and assess residents. She stated OSM #3, (the ombudsman) had come in on [DATE], and OSM #2 had spoken to OSM #3 about Resident #101. She stated OSM #3 instructed her to leave an office voicemail for her to remind her. OSM #2 provided credible evidence, including emails evidencing Resident #

Based on facility staff interview, law enforcement staff interview, facility document review, clinical record review, and in the course of a complaint investigation it was determined that the facility staff failed to protect a resident's right to be from abuse resulting in harm for one of 11 residents in the survey sample, Resident #102. Resident #102 expired in the facility from a fatal injury allegedly inflicted by the resident's roommate, Resident #101. On [DATE], between 10:15 p.m. and 10:45 p.m., Resident #101 allegedly slit Resident #102's throat with a knife, resulting in Resident #102's death. Resident #101 is currently in police custody, and has been charged with second degree murder of Resident #102. The findings include: Resident #102, was originally admitted to the facility on [DATE]; and was most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of [DATE], Resident #102 was coded as having no impairments with making himself understood and with understanding others. He was coded as having moderate cognitive impairment for daily decision-making, having scored 10 out of 15 on the BIMS (brief interview for mental status). Resident #102 was coded as having demonstrated no behavioral symptoms during the look back period. He was coded as requiring supervision only for transferring between surfaces, and as requiring limited assistance of one staff member for bed mobility. Resident #102 was coded as requiring extensive assistance of one staff member for dressing, toileting, personal hygiene, and bathing. He was coded as not having walked in his room during the look back period, and as requiring supervision only for locomotion on and off the unit. He was coded as using both a walker and a wheelchair for mobility. Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS, a quarterly assessment with an assessment reference date of [DATE], Resident #101 was coded as having no impairments with making himself understood and with understanding others. He was coded as having no cognitive impairment for making daily decisions according to his score of 15 out of 15 on the BIMS. Resident #101 was coded as having demonstrated no evidence of an acute onset of mental status change during the look back period. He was coded as having scored a zero out of 27 on the resident mood interview, indicating no difficulties with mood. Resident #101 was coded as having demonstrated no behavioral symptoms curing the look back period. He was coded as being independent for all ADLs (activities of daily living), except for requiring set up for eating, and supervision for toilet use. He was coded as needing no mobility devices for locomotion. Resident #101 was coded as not having a PEG tube. He was coded as having received an antipsychotic medication on seven out of seven days during the look back period. A gradual dose reduction (GDR) in Resident #101's antipsychotic medication was coded as being contraindicated per his physician. A review of Resident #102's clinical record revealed the following progress note, written on [DATE] at 1:59 p.m. by RN (registered nurse) #3: Resident complained of right sided pain unrelieved by Tylenol. (Name of nurse practitioner) notified and ordered and given [MEDICATION NAME] (8) 50 mg (milligrams) one time order. The next note in Resident #102's progress notes was written by ASM (administrative staff member) #2, the director of nursing, with the effective date of [DATE] at 10:44 p.m. The note documented, Resident was found covered in blood in his bed unresponsive by (LPN (licensed practical nurse) #3) around 10:30 p.m. Immediate call to 911 was placed for EMTs (emergency medical technicians) and Police. EMTs and Police arrived at 2255 (10:55 p.m.) assessed the situation and secured the scene. The Coroner picked up the remains at around 3 am. There were no additional progress notes in Resident #102's record. A review of Resident #102's comprehensive care plan dated [DATE], and of all of Resident #102's progress notes since Resident #101 became his roommate, revealed no documentation regarding any difficulties with, or complaints about, Resident #101 being Resident #102's roommate, and no documented requests for to have an alternate roommate. A review of Resident #101's admitting history and physical, dated [DATE], revealed, in part, the following: History of Present Illness: The patient is a [AGE] year-old Caucasian male with a past medical history significant for [MEDICAL CONDITIONS], hypertension (high blood pressure), and [MEDICAL CONDITION] disorder. He was admitted to (name of local hospital) for shortness of breath. He was found to have a laryngeal mass .He has a significant damage in his larynx from this [MEDICAL CONDITION]. He was also placed on a PEG tube .I am seeing here in (name of facility). He is doing well .Assessment and plan: .[MEDICAL CONDITION] disorder. He is on [MEDICATION NAME] and [MEDICATION NAME] and doing well. A review of Resident #101's clinical record revealed the following progress note, dated [DATE] at 3:25 p.m., written by OSM (other staff member) #1, the social worker: IDT (interdisciplinary team) held care plan meeting this date with social services, nursing, and dietician. Resident invited but declined to attend. Nursing reviewed medications and diagnosis. Patient has not had any falls or hospitalization s this quarter. Dietician reports patient is on a regular diet, regular texture. He eats between 50% - 100% of his meals. He weighs about 172.8 lbs (pounds). Social services reports patient is a full code. He has not had any behaviors this quarter. He does not have a POA (power of attorney). He is at this facility for long term care. Staff will continue to assist and support. Review of Resident 101's clinical record revealed the following progress note, written [DATE] by OSM #1 (the Social Services Coordinator): SS (social services) quarterly: SS met with patient to complete quarterly assessment. Patient is alert, verbal, and pleasant. Patient scored a BIM (sic) of 15 and a PHQ9 (name of a mood assessment) of 0. Patient has not displayed any behaviors this quarter. Patient is a full code. Patient does not have a POA (power of attorney). Patient will remain at this facility for long term care. SS will continue to assist and support. The final progress note in Resident #101's record was dated [DATE] at 11:00 p.m., and was written by ASM #2, the director of nursing: Late Entry: Resident was escorted out of the facility by the (name of local police department) around 11:00 p.m. A review of Resident #101's comprehensive care plan, dated [DATE], with a target date of [DATE], revealed, in part the following: At risk for changes in mood r/t (related to) [MEDICAL CONDITION] . Will accept care and medication as prescribed .Administer medication per physician orders [REDACTED].Offer choices to enhance sense of control. Further review all of Resident #101's progress notes since Resident #102 became his roommate revealed no documented information related to any difficulties with, complaints about, Resident #102 as a roommate or any requests for an alternate roommate. A review of the facility SCREENING FOR MENTAL ILLNESS, MENTAL [MEDICAL CONDITION]/INTELLECTUAL DISABILITY, OR RELATED CONDITIONS, completed [DATE], revealed no evidence that Resident #101 qualified for a secondary assessment. A review of the attending physician's most recent progress note, dated [DATE], revealed, in part, the following: (Resident #101) is doing well in the nursing home. He is still smoking. He is not able to quit smoking. He has [MEDICAL CONDITION], no cough, cold, no wheezing .[MEDICAL CONDITION] disorder, on [MEDICATION NAME] (9) and [MEDICATION NAME] (10), doing well. A review of Resident #101's medication orders revealed the following: [MEDICATION NAME] Tablet 1 mg Give 2 mg by mouth at bedtime for [MEDICAL CONDITION]. The order was written [DATE]. A review of Resident #101's MARs (medication administration records) for the past 12 months revealed no missed doses of [MEDICATION NAME], and no nurse notes related to the resident ever refusing the medication. A review of Resident #101's Medication Regimen Reviews completed by a pharmacist revealed that in June of 2017, Resident #101's [MEDICATION NAME] was discontinued, and the [MEDICATION NAME] was increased to 2 mg daily at bedtime. A review of the consultant Psychiatric Evaluations for Resident #101 revealed an evaluation dated [DATE]. The evaluation, written by RN (registered nurse) #5, the consultant psychiatric nurse practitioner, a PhD, documented, in part, the following: Past Medical History: Malignant neoplasm (cancer) of the larynex (sic), .[MEDICAL CONDITION] .Past Psychiatric Admission: He denies any hospitalization s but this is questionable with the [DIAGNOSES REDACTED]. Past Suicide Attempt: Denies. Past Use of [MEDICAL CONDITION] medications: [REDACTED]. Legal History: Did not identify any legal difficulties .Type of Visit: Initial evaluation .Information Obtained From: Patient, Chart Review, Nursing Staff .Chief Complaint/Nature of Presenting Problem: [MEDICAL CONDITION]. History of Present Illness: [AGE] year-old male with [DIAGNOSES REDACTED]. Today he is seen in the room, fair eye contact and interaction appropriate but limited at times and a little guarded. He denies any difficulty with eating or sleeping, denies any significant symptoms of anxiety or depression and denies suicidality. He denies any current hallucinations and there is no evidence of him respond (sic) to internal stimuli, cognition appears to be grossly intact. No noted or reported side effects to medications. He identifies that he is doing well and has no concerns. No distress noted and staff identified no behavioral issues. Support given during interview .Current Psychiatric Medications General [MEDICATION NAME] (11) 2 mg po (by mouth) nightly for EPS (extra-pyramidal side effects) (12). [MEDICATION NAME] 2 mg po nightly for [MEDICAL CONDITION] .Mood Symptoms: He denies any significant symptoms of anxiety or depression, no psychotic symptoms noted, denies suicidality, no agitation or aggression noted or reported, cognition appears to be grossly intact, no evidence of pseudobulbar (13) affect symptoms and no reports of noncompliance with medications or treatments .Appearance/Behaviors: Calm, cooperative, groomed .Mood: pleasant, Affect: appropriate, Thought process: organized, Hallucinations: none evident, Delusions: none evident, Short-term memory: fair to good, Long-term memory: fair to good, Concentration: fair, Insight: fair, Judgment: fair, Suicidal ideation: denies, Homicidal ideation: denies .Description of Associations: intact .Recommendations: Continue medication(s) as prescribed, the patient is stable at current dose. Dose reduction attempted and/or reduction will cause decompensation of patient. Monitor for changes in mood or behaviors and notify (name of psychiatric services provider). Will continue to follow and provide consultation. Follow up: as needed. Review of Resident #101's clinical record revealed psychiatric evaluations completed by RN #5 on [DATE], [DATE] and [DATE]. These evaluations contained no deviations from the findings and recommendations for care as documented in the evaluation from [DATE]. RN #5's final psychiatric evaluation of Resident #101 was dated [DATE]. This evaluation documented, in part: History of Present Illness: [AGE] year-old male with [DIAGNOSES REDACTED]. Today he is seen in the room, fair eye contact and interaction appropriate. He denies any difficulty with eating or sleeping, denies any significant symptoms of anxiety or depression and denies suicidality. He denies any current hallucinations and there is no evidence of him responding to internal stimuli, cognition appears to be grossly intact. No noted or reported side effects to medications. He identifies that he is doing well and has no concerns other than being ready to go smoking at 10:30 a.m., smiled as he related this. Presents in a positive manner and denies any difficulties, no distress noted. Staff identified no behavioral issues. Support given during interview .Current Psychiatric Medications General [MEDICATION NAME] (11) 2 mg po (by mouth) nightly for EPS (extra-pyramidal side effects) (12). [MEDICATION NAME] 2 mg po nightly for [MEDICAL CONDITION] .Appearance/Behaviors: Calm, cooperative, adequately groomed .Mood: pleasant, Affect: appropriate, Thought process: organized, Hallucinations: none evident, Delusions: none evident, Short-term memory: fair to good, Long-term memory: fair to good, Concentration: fair, Insight: fair, Judgment: fair, Suicidal ideation: denies, Homicidal ideation: denies .Description of Associations: intact .Recommendations: He is currently stable on his [MEDICATION NAME] for his [MEDICAL CONDITION]. Dose reduction attempted and/or reduction will cause decompensation of patient. Monitor for changes in mood or behaviors and notify (name of psychiatric services provider). Will continue to follow and provide consultation. Follow up: as needed. A review of the facility's safe smoking assessment dated [DATE] revealed, in part, the following: Conclusion: Independent Smoker. Capable and independent, requires no supervision to smoke. Interviews were attempted with staff who were familiar with the care of both Resident #101 and Resident #102, and with staff who were working on [DATE] and the two days prior. Not all attempts were successful. The results of the staff interviews conducted by the survey team are as follows. On [DATE] at 7:39 a.m., an interview was conducted with CNA (certified nursing assistant) #2. She stated she was experienced in caring for both Resident #101 and Resident #102. She stated Resident #102 was alert, and was able to communicate his needs. CNA #2 stated he could get up and walk a short distance with his cane, but spent most of the time in his wheelchair. CNA #2 stated Resident #101 was independent with everything. CNA #2 stated he (Resident #101), slept at night. CNA #2 that stated sometimes she smelled smoke in his bathroom when she worked the night shift, but she never found any smoking materials in his room. She stated she reported the smell to the nurse, and the nurse would come in the room to determine what she could smell. CNA #2 stated she never observed any cigarettes, butts, or lighters in the room. She stated she had never seen a weapon of any kind in Resident #101's possession. CNA #2 stated she took care of both residents (Resident #102 and #101) on Monday, [DATE], and there was nothing out of the ordinary. On [DATE] at 7:50 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated she was very familiar with both residents. She stated Resident #102, was well- loved, and was a joy to take care of. He was alert, able to follow directions, and needed more ADL (activities of daily living) assistance in recent months due to some falls. LPN #2 stated he frequently used the call bell, and stated she felt certain that if he had been aware of any danger, he would have told staff members or rung the call bell. When asked about Resident #101, LPN #2 stated that even though she had taken care of him for quite a while, she did not feel like she had gotten to know him. She stated that he was independently up and around the unit, and that he went out to smoke in the designated areas at the designated times. She stated there was no back and forth conversation with Resident #101, and that he only communicated if he was asked a direct question or if he needed something. When asked if he demonstrated any signs or symptoms of [MEDICAL CONDITION] behavior in all the months, she had cared for him, LPN #2 stated, Absolutely not. She stated she worked the night shift on [DATE], and observed no signs of agitation, or of either resident being upset with the other. She stated that she usually worked the same shifts as CNA #2, and she remembered several occasions of CNA #2 reporting a smell of cigarette smoke in Resident #101's and #102's bathroom. However, LPN #2 stated she could never prove Resident #101 was smoking in the bathroom. She stated it may have been his clothing that still contained the cigarette smoke from the designated smoking times, in which Resident #101 participated. She stated she could not remember precisely the last time she had smelled smoke in the residents' bathroom. LPN #2 stated she had no knowledge or observation of a weapon of any kind in Resident #101's possession or room. On [DATE] at 8:27 a.m., RN #2 was interviewed. She stated Resident #102 was able to make his needs known. When asked if Residents #101 and #102 had any sort of relationship, RN #2 stated, They did not have much interaction at all. She stated she did not witness them having conversations. She stated Resident #102 never expressed any concerns to her about Resident #101 smoking in the bathroom. RN #2 stated Resident #101 was always polite and kept to himself. She stated she provided him with supplies for his [MEDICAL CONDITION] care, and that he performed his own care. RN #2 stated he went out on smoke breaks with other residents. She denied smelling smoke in the bathroom, and seeing any evidence of any kind of weapon in the room, or on Resident #101's person. On [DATE] at 8:50 a.m., RN #3 was interviewed. She stated she was very familiar with both Residents #101 and #102. She stated Resident #102 had experienced some cognitive decline in recent months. He was cooperative, and conversational, and he was well-able to make his needs known. She stated there appeared to be no relationship between the residents. RN #3 stated, They were just roommates. RN #3 stated Resident #102 never reported to her that Resident #101 was smoking in the bathroom. She stated Resident #101 made only minimal eye contact, and that his affect was flat. She stated he would not carry on a conversation, but he was able to make his needs known. RN #3 stated Resident #101 performed his own [MEDICAL CONDITION] care. She stated he went outside for smoke breaks with other facility smokers at the designated times. When asked if Resident #101 ever displayed any signs or symptoms of [MEDICAL CONDITION], RN #3 stated, He one pulled out [MEDICAL CONDITION]. That was a long time ago. She stated Resident #101 never said why he pulled it out. RN #3 stated Resident #101 never exhibited any behaviors, or signs of agitation or being upset. She stated one of the CNAs reported smelling smoke in the residents' bathroom. She looked all around the bathroom and the room, and did not see any evidence of smoking. RN #3 stated, He had long hair. His clothes smelled like smoke whenever he came in from a smoke break. She stated she never saw any evidence of a weapon in the room or on Resident #101's person. On [DATE] at 9:09 a.m., CNA #1 was interviewed. She stated Resident #102 was sweet and conversational. She stated she never heard Residents #101 and #102 have any kind of conversation. CNA #1 stated Resident #102 frequently told her that Resident #101 smelled like smoke. She stated this was often true. However, she was never able to locate any smoking materials or evidence of smoking in the room. CNA #1 stated Resident #101 wanted his television off at night, and that Resident #102 liked to have his television on at night. CNA #1 denied knowledge of the residents discussing this issue. She stated she regularly supervised resident smoke breaks. CNA #1 stated Resident #101 always returned his smoking materials without complaint with the smoke breaks were over. She stated Resident #101 was quiet, and said no more than was necessary to answer a question or express a need. CNA #1 stated that despite smelling smoke in the bathroom on one occasion many months ago, she stated no staff member was ever able to locate the source of the smell other than the residents' clothes. CNA #1 stated she never observed a weapon in the residents' room or on Resident #102's person. On [DATE] at 9:30 a.m., CNA #3 was interviewed. She stated she regularly supervised smoke breaks, as well as caring for Residents #101 and #102 on the evening shift. She stated Resident #101 was never rude to her or to any other resident. CNA #3 stated the residents (#101 and #102) had no real relationship, and that she had no memory of ever seeing them have a conversation. CNA #3 stated she remembered one night in the past when she smelled cigarette smoke in the residents' bathroom. She stated she and the nurse searched the room and bathroom, and never found evidence of any smoking materials. CNA #3 stated Resident #102 never complained to her about the smoke smell in the bathroom. CNA #3 stated she worked the evening shift on [DATE], and there was nothing out of the ordinary. She stated she was assigned to Residents #101 and #102 on [DATE] on the evening shift (3:00 p.m. to 11:00 p.m.). CNA #3 stated it was a normal evening shift, as best she could remember. She stated there was nothing new or different between the residents. CNA #3 stated that after dinner, Resident #102 went into his room, just as he always did. She started making last rounds at 10:00 p.m. CNA #3 stated that at 10:15 p.m., she saw the call light for Resident #102's room. She went in, and Resident #102 asked her for a drink of water and a snack. She provided these to Resident #102 and continued her rounds in other rooms. CNA #3 stated another CNA assisted her with repositioning a resident in another room. She stated she thought that Resident 102's door was partially open at that time. CNA #3 stated, The last time I saw him (Resident #102) alive was at 10:15 (p.m.). (Resident #101)'s curtain was closed and he was lying on his bed. He always closed the curtain. She stated she next remembered the nurse yelling and calling us to come to (Resident #102)'s room. CNA #3 stated, There was blood everywhere. Everywhere on his body. I just stood at the door. CNA #3 stated someone - she did not remember who - asked Resident #101 what happened. Resident #101 was in the room, watching television. CNA #3 stated Resident #101 did not answer. She stated the police and EMS were called. She stated she stayed at the facility until after 11:00 p.m., and then was called to come back in to the facility in the very early morning hours of [DATE] to be interviewed by the local police. When asked if anything, at any time, ever triggered her to think that Resident #101 might want to, or be capable of, hurting Resident #102, CNA #3 stated, Nothing. On [DATE] at 11:35 a.m., RN #5, the consultant psychiatric nurse practitioner, was interviewed. When asked, whether, or not Resident #101 had been recently receiving both [MEDICATION NAME] and [MEDICATION NAME], as the attending physician had documented, RN #5 stated, No. [MEDICATION NAME] is just a refined form of [MEDICATION NAME]. He was not to be receiving both. She stated she had been treating Resident #101 for less than a year. She stated when she first met Resident 101 on [DATE]; he was very reserved and quiet. RN #5 stated, He definitely had a [MEDICAL CONDITION] presentation. She stated the classic [MEDICAL CONDITION] is reserved until the resident gets to know you, is polite, and answers questions when asked. She stated she always asked Resident #101 if he was hearing any voices, and if so, what the voices were telling him. RN #5 stated Resident #101 always denied hearing voices, as well as denying any hallucinations. She stated that in recent visits, Resident #101 felt comfortable enough to smile and to interact somewhat spontaneously with her. She stated she specifically asked him if anyone was bothering him, which the resident denied. RN #5 stated that on her last visit with Resident #101, in [DATE], he was very positive, again denying hallucinations and hearing voices. When asked if she observed any interactions between Residents #101 and #102, RN #5 stated, I didn't always see the roommate, but Resident #101 never expressed anything negative to her about Resident #102. RN #5 stated, I didn't see (Resident #101) interacting with other people. When asked if she thought Resident #101, was appropriately placed in a long term care facility, RN #5 stated he could not care for himself because of his ([MEDICAL CONDITION]) diagnosis. She stated his cognitive abilities were limited in higher-level thinking, such as judgment and reasoning. She stated Resident #101 was a very concrete thinker, and had limited ability to think in the abstract. She stated she did not think any other setting, in which he would have had more independence, would have been appropriate for him. When asked if she had ever had any reason to suspect that Resident #101 was a danger to himself or to anyone else, RN #5 stated, No. On [DATE] at 1:37 p.m., RN #4, an MDS nurse, was interviewed. RN #4 stated, I had a close relationship with (Resident #101). She stated he was a true [MEDICAL CONDITION] in that conversation was difficult. She stated that, once a week, she and sometimes her children would come to visit him. RN #4 stated, He was a simple guy, a veteran. She stated he never talked about his experiences in military service. She stated that in April, the software the facility uses to scrub its MDS assessments identified Resident #101 as being independent, and as needing an alternative placement other than a nursing home. RN #4 stated she alerted social services, and they took it from there. RN #4 stated she had never observed any evidence of anxiety, hallucinations, or delusions from Resident #101. She stated she had not observed any interaction between Resident #101 and Resident #102. On [DATE] at 1:52 p.m., LPN #3 was interviewed. She stated she frequently supervised resident smoke breaks. She stated Resident #101 always participated in the smoke breaks, and always willingly returned his smoking materials to her. She stated that the only symptom she ever observed with Resident #101, and she could not remember the last time she had seen it, was an increase in a tick, which she described as an itching motion on his upper body. She stated she had not observed this any time recently, and that the resident always denied needing any intervention or having any difficulties. LPN #3 stated Resident #102 never asked about or suggested that Resident #101 was smoking in the bathroom. LPN #3 stated, He (Resident #101) never showered because of the trach, and sometimes (Resident #102)'s family asked about the smell. LPN #3 stated she never saw any smoking materials or any kind of weapons in the room. She stated she was assigned to both residents for the evening shift on [DATE]. LPN #3 stated there was nothing out of the ordinary for either resident during the shift, and there was no indication from either resident of conflict or difficulty. LPN #3 stated she was the one who discovered Resident #102's dead body. She stated she was going in the room at approximately 10:30 p.m. She did not remember whether, the door was partially or completely, closed. LPN #3 stated when she first entered the room and looked at Resident #102, there was copious blood around his throat and on his chest. She stated all the color had drained from his face, and that it was clear that he was dead. LPN #3 stated at first, she thought he had vomited blood, but realized that was not the case when she was the blood pooled on the floor and in other locations in the room. LPN #3 stated she was so focused on Resident #102 and on getting help from other staff members, that she does not remember looking to see where Resident #101 was at the time. LPN #3 stated she went to the phone and dialed EMS. It was at that point that one of the CNAs (she does not remember which one) came out of the room and told her that Resident #102's throat had been cut. As EMS and police began arriving, Resident #101 just stayed over there. LPN #3 stated once the police arrived, Resident #101 sat up on his bed and put his shoes on. She stated Resident #101 never spoke a word, and never attempted to leave the room. LPN #3 stated she had never observed any indication that Resident #101 was experiencing [MEDICAL CONDITION] symptoms or behaviors. On [DATE] at 2:04 p.m., RN #1, the unit manager, was interviewed. He stated that he had only been employed at the facility for four or five weeks, and did not know either Resident #101 or #102 very well. He stated Resident #101 was always helpful at smoke break times with other residents. He stated Resident #101 would help other residents with wheelchairs or walkers to get to the smoke break area. He stated he never observed any interaction between Residents #101 and #102. He stated that on [DATE] before he left the facility around 5:00 p.m., he had talked to both residents. RN #1 stated Resident #102 had reported pain in his right side, and the nurse had gotten an order for [REDACTED]. On [DATE] at 2:21 p.m., OSM #1, the Social Services Coordinator, was interviewed. She stated Resident #101 was a resident when she began working at the facility. He had no family or friends to her knowledge. OSM #1 stated Resident #101 was not very social at first, but that, as time went by, he began going out more on smoke breaks, and speaking to people when he walked in the hallways. OSM #1 stated the MDS staff alerted her that a scrub report had triggered a concern that Resident #101 was too independent for the nursing home, and may need alternative placement. She stated this happens frequently, and that OSM #2, the social services director, often helps her with exploring alternative placement. She stated she believed that OSM #2 was the person who actively looked for alternative placement for Resident #101, and she remembered that they were unsuccessful finding alternative placement for Resident #101 because of his [MEDICAL CONDITION] and because of his finances. OSM #1 stated she writes a monthly note on all smokers, and that she had never had any concerns with Resident #101. She stated he always turned in his smoking materials without complaint or comment. She stated she saw Resident #101 almost every day because he was on her patient load. OSM #1 stated he had never triggered any concerns as a result of his cognition, behaviors, or mood interviews on the MDS. OSM #1 presented the surveyor with the following progress note, written by OSM #2, the director of social services on [DATE]: SW left voicemail for ombudsman office to assist with alternative placement for this resident. SW hasn't spoken with resident yet regarding alternative placement needs. On [DATE] at 2:48 p.m., OSM #3, the ombudsman, was interviewed. She stated she had no memory of Resident #101 in any capacity. When shown the [DATE] note detailed above, OSM #3 stated, I don't know who she left the voicemail for. When they are really anxious to get somebody out, they will hound me. She stated she would check her records and get back to the surveyor if she discovered anything pertinent. On [DATE] at 3:14 p.m., OSM #2, the social services director, was interviewed. OSM #2 stated the MDS staff had run a report and alerted the social workers that Resident #101 might be too independent, and may need to have alternate placement. She stated she has a list of providers who will come and assess residents. She stated OSM #3, (the ombudsman) had come in on [DATE], and OSM #2 had spoken to OSM #3 about Resident #101. She stated OSM #3 instructed her to leave an office voicemail for her to remind her. OSM #2 provided credible evidence, including emails evidencing(TRUNCATED)