Every finding on record at Southport Center For Nursing & Rehabilitation Llc

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #68 and 76) reviewed for dental services, for Resident #76, the facility failed to act on recommendations, over a period of 17 months, to have a broken tooth extracted, which resulted in a fistula, and for Resident #68, the facility failed to schedule a consultation with an oral surgeon in a timely manner. The findings include: Resident #76 had diagnoses that included a stroke with hemiplegia (paralysis) of the left side. Nurse’s note dated 12/2/22 identified Resident #76 had his/her own teeth. Mouth and oral mucous membranes were moist with no discomfort noted. The care plan dated 12/6/22 identified Resident #76 was at risk for pain related to physical condition. Interventions included encouraging to report pain and provide medical management of underlying causes. The admission MDS dated [DATE] identified Resident #76 had moderately impaired cognition, was independent with eating and had no dental related concerns. Dental consultation dated 12/15/22 identified Resident #76 was seen for exam only and noted to have a broken #18 tooth which could likely be restored with a filling. No other clinical findings noted. Recommendations were made for a hygiene visit and to formulate a treatment plan. APRN progress note dated 1/16/23 identified Resident #76 had complaints of a toothache with constant pain measured at 8 out of 10 pain level (pain scale used to assess pain with level 0 indicating no pain, 10 indicating severe pain) for the preceding two weeks with no effect on chewing and swallowing. Orders were prescribed for Medicated [NAME] and a dental consultation. APRN progress note dated 8/4/23 identified Resident #76 was complaining of a toothache for two weeks. Orders included a dental consultation and to continue Acetaminophen as needed. APRN progress note dated 11/3/23 at 9:01 AM identified Resident #76 was being seen for medical clearance for dental procedure (extraction of molar #18) scheduled for 11/9/23. Resident #76 was to continue Aspirin 81mg and would not need antibiotics prior to procedure. Physician’s progress note dated 11/8/23 at 1:40 PM identified Resident #76 complained of pain in the left lower tooth. Pain is not in area of said anticipated extraction with no jaw pain, fever, chills, or drainage. The plan included having the dentist check the area of pain on 11/9/23 prior to extraction and continue Acetaminophen as needed. Dental consultation dated 1/18/24 identified Resident #76 was examined. Recommendations were made for referral to an oral surgeon for extraction of #18 tooth. A nurses note dated 6/19/24 at 12:57 PM identified Resident #76 was added to the dental consultation list due to complaint of toothache. Pain relief to continue as needed. Dental consultation dated 3/4/25 identified Resident #76 received a limited oral exam and needed extraction of #18 tooth. Recommendations were made to refer the resident to the oral surgeon to extract #18 tooth. Dental consultation dated 7/14/25 identified Resident #76 was seen for an exam, prophylaxis and fluoride. Soft tissues were noted to have generalized moderate inflammation with a possible abscess of the #18 buccal (side of molar), 18 root tip. Resident #76 has not yet been to an oral surgeon. Recommendations were made to arrange for an oral surgeon to extract #18 tooth. An interview with ADNS on 7/28/25 at 11:41 AM identified nursing staff were responsible to report any resident care concerns to the nursing supervisor. Based on those concerns, a list of residents would be generated for the in-house consultations, including dental, and be provided to nursing staff. The charge nurse was responsible to follow up on consultation recommendations including scheduling appointments with any necessary specialty provider. The nursing supervisor was responsible for overseeing the process to ensure its completion. The ADNS identified Resident #76 needed to be evaluated by an outside oral surgeon. Nursing staff failed to schedule a visit with the oral surgeon for Resident #76 citing an ongoing breakdown in communication among nursing staff. The issue had previously been identified and discussed with the DNS, however, despite ongoing efforts to improve organization, Resident #76 still had not been scheduled with the oral surgeon as an oversight. Interview with the Medical Director on 7/28/25 at 12:32 PM identified he was not aware Resident #76 had not yet been seen by an oral surgeon despite repeated recommendations. As a result, the condition progressed over time likely leading to the development of the abscess. The Medical Director identified he would expect any recommendations made by a specialty provider to be appropriately followed up in a timely manner. An interview with Dental Hygienist #1 on 7/28/25 at 1:34 PM identified she last saw Resident #76 on 7/14/25 for prophylaxis. Dental Hygienist #1 identified she observed inflammation at the gumline and a fistula at the #18 site consistent with signs of infection. The dentist was not onsite to further evaluate; however, previous recommendations for extraction of #18 were documented during earlier visits. Dental Hygienist #1 further identified Resident #76 was first seen on 2/15/22 for a broken #18 tooth that was restorable at the time. The resident was seen again in July 2023 for complaints of pain, at which point it was noted the tooth could no longer be restored and required extraction. Resident #76 was subsequently seen on 8/29/23 for x-rays and again on 11/9/23 where an extraction was attempted but unsuccessful. Recommendations were made for a referral to an oral surgeon for extraction of #18 tooth. Based on the current clinical findings and prior documented recommendations, Dental Hygienist #1 again recommended extraction of the #18 tooth during the 7/14/25 visit. Interview with Dentist #1 on 7/28/25 at 1:33 PM identified he provided dental services to Resident #76 in the past but had not evaluated him/her recently. Dentist #1 identified based on review of the documented clinical findings, he determined that removal of #18 tooth was indicated some time ago, with Resident #76 now presenting with an acute exacerbation of a chronic infection. Dentist #1 further identified the facility had experienced ongoing issues with scheduling appointments. An interview with the DNS on 7/28/25 at 3:28 PM identified in-house consultation, including dental services providers visited the facility at scheduled times. LPN’s and nursing supervisors were responsible for scheduling appointments with outside providers and ensuring all relevant information following that consultation was communicated to the nurse practitioner. The DNS denied prior knowledge of any recommendations for oral surgery that had not been addressed but would be conducting audits and educating staff. A dental consultation dated 8/5/25 identified #18 tooth was noted to have a fistula, was visibly broken and severely decayed with pain at the site. The tooth was successfully extracted. Recommendations included treatment with Amoxicillin and Motrin for pain management with a follow up recall in 6 months. A review of the facility policy for ancillary services directed that services included but not limited to podiatry, dentistry, optometry, audiology and other specialized care. Ancillary services will be provided by the facility or through coordination with qualified external providers. All services will be documented including type of services and outcomes. 2. Resident #68 was admitted to the facility in March 2025 with diagnoses that included hypertension and peripheral vascular disease. The Clinical Note dated 6/4/25 identified Resident #68 complained of soreness on the upper and lower anterior when wearing dentures, bony defect in area of 8/9 from a BB gun accident when he/she was young. Now he/she has large overgrowth of upper lip in vestibule from trauma from denture. The patient has a large soft growth on floor of the mouth, and he/she stated it has been there, no pain. Upper and lower denture adjusted for now; refer to oral surgeon for evaluation/removal of upper excess tissue and biopsy on floor of mouth growth. The quarterly MDS dated [DATE] identified Resident #68 had moderately impaired cognition, and had no mouth or facial pain, discomfort, or difficulty with chewing. The care plan dated 7/18/25 identified Resident #68 should attend appointments with an escort. Interventions included providing resident education about appointment status. Review of the clinical record dated 6/4/25 through 7/29/25 failed to identify documentation that the evaluation with the oral surgeon was scheduled or refused by the resident or resident representative. Interview with Resident #68 on 7/28/25 at 11:00 AM identified that he/she needed a dental appointment, an appointment was put in with the dentist, but the appointment never happened. Interview and clinical record review with the DNS and ADNS on 7/28/25 at 2:50 PM failed to identify documentation that Resident #68’s appointment with the oral surgeon was scheduled. The ADNS indicated that she was unaware that Resident #68 required an oral surgeon consultation. The ADNS further identified that when the Scheduler receives a consult via email, she uploads it into the electronic health record and notifies the unit nurse that a follow up appointment is required. The nurse is responsible to notify the nursing supervisor who would schedule the appointment, once the appointment was scheduled the Scheduler will arrange transportation. The DNS indicated that she would expect to see documentation in the clinical record that the appointment was scheduled or that the resident/resident representative refused the consultation. Interview with the Scheduler on 7/29/25 at 11:18 AM identified that subsequent to surveyor inquiry a dental appointment with the oral surgeon was scheduled on 7/30/25, for Resident #68. The Scheduler indicated that it was an oversight on her part, that Resident #68’s oral surgeon consultation had not been scheduled sooner; she forgot to give the consult to the nurse. Interview with the DNS on 7/30/25 at 5:10 PM identified that consultation appointments should be scheduled or attempted to be scheduled within 24 hours. The DNS further identified that moving forward she will add the ADNS onto the emails containing the consultation appointment information, in addition to the Scheduler; the ADNS will now be responsible to schedule any medical or dental consults. The facility MD Consults/Appointments policy directs that all residents receive timely and coordinated care for outside medical appointments. All outside medical appointments must be arranged, documented, and communicated effectively.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #10, 76 and 122) the facility failed to notify the physician and/or resident representative when required.For 1 of 5 residents (Resident #10) reviewed for unnecessary medications, the facility failed to notify the physician and resident representative of elevated blood sugars and change in condition. For 1 of 4 residents (Resident #76) reviewed for dental services, the facility failed to notify the physician when a dental provider observed moderate inflammation with a possible abscess of the resident's tooth. For 1 of 3 residents (Resident #122) reviewed for closed record, the facility failed to notify the physician when the resident left the facility AMA. The findings include: 1.The hospital Discharge summary dated [DATE] identified Resident #122 was admitted to the hospital on [DATE] with symptoms of generalized weakness with acute on chronic bilateral knee pain, left greater than right, abdominal pain, and diarrhea. Resident #122’s last use of alcohol beverage was the day of admission early in the morning. Resident #122 was unfortunately unhoused. Resident #122 was evaluated and discharged on 6/19/25 to a nursing facility with diagnoses of diarrhea, and alcohol withdrawal. Resident #122 was admitted to the facility on [DATE] with diagnoses that included acute embolism and thrombosis of left popliteal vein, alcohol abuse, opioid use, and pain. The physician’s order dated 6/19/25 directed to transfer out of bed to any surface with limited assist for safety. Apply oxygen via nasal cannula at 2 liters to maintain oxygen saturation at or greater than 90% as needed. Special instructions: (If unable to maintain saturation equal to or greater than 90%, administer oxygen via non-rebreather mask at a minimum of 10 liters). Call the physician for status update and further recommendations. The care plan dated 6/20/25 identified Resident #122 was at risk for falls related to gait difficulty, left knee pain, and alcohol withdrawal. Interventions included for medication review by the pharmacist, assess for pain and rehabilitation screen. Review of a discharge AMA form dated 6/23/25 at 10:15 AM identified Resident #122 signed the form along with SW #1 to leave AMA. Review of the clinical record failed to reflect a physician’s order that directed to discharge the resident against medical advice (AMA). Additionally, the nurse’s note failed to reflect documentation on 6/23/25 regarding Resident #122 leaving the facility AMA and failed to reflect documentation that the physician was notified when Resident #122 left the facility AMA. The social service note dated 6/23/25 at 10:25 AM identified SW #1 spoke with Resident #122 after she was updated that Resident #122 wanted to leave AMA. SW #1 indicated she asked Resident #122 to reconsider staying at the facility for health reasons. SW #1 indicated she spoke in length with Resident #122 about not leaving but Resident #122 indicated he/she had things to do and would like to leave. SW #1 indicated she updated Resident #122 regarding the weather and heat advisory. SW #1 indicated Resident #122 updated SW #1 that his/her ride would be here soon. SW #1 indicated she provided Resident #122 with a bottle of water for his/her trip. Interview with SW #1 on 7/30/25 at 9:10 AM identified she met with Resident #122 and asked the resident to allow the facility couple of days to prepare for a safe discharge back to the community. SW #1 indicated she performed a cognition assessment and failed to document the result. Interview with the DNS on 7/30/25 at 8:00 AM identified she was aware Resident #122 was leaving the facility AMA. The DNS indicated she was not aware that RN #1, and LPN #3 did not notify the physician/APRN that Resident #122 left the facility AMA. The DNS indicated it was the responsibility of the RN Supervisor and the charge nurse to notify the physician/APRN that Resident #122 was leaving or left the facility AMA, and document that information in the clinical record. Although attempted, an interview with RN #1, and LPN #3 were not obtained. Review of the facility discharge against medical advice (AMA) policy identified it is the policy of the facility to respect a resident’s right to self-determination, including the right leave the facility against medical advice (AMA). The facility will take all reasonable measures to inform the resident (or their legal representative) of the risks, document informed refusal, and ensure compliance with federal and state regulations governing safe discharge and resident rights. The policy applies to all nursing, medical, administrative, and social services staff involved in resident discharge planning. Any resident who expresses intent to leave AMA will be assessed immediately by a Registered Nurse (RN) for decision-making capacity. Notification to the attending physician or on-call provider immediately. Evaluated safety risks (e.g. cognitive impairment, mobility limitations). The attending physician/APRN is contacted promptly to discuss the clinical risks of leaving AMA with the resident/legal representative. Provide written medical advice regarding the risks associated with discharge. Document recommendations in the electronic health record (EHR). The resident or legal representative must sign an “AMA Discharge Form”. 2. Resident #10 was admitted to the facility in August 2023 with diagnoses that included traumatic brain injury, dysphagia, and diabetes with hypoglycemia. A physician's order dated 12/11/24 directed to check blood sugars 4 times daily before meals (6:00 AM, 12:00 PM, 6:00 PM, 12:00 AM) and notify the physician when blood sugars are less than 70 or greater than 400. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition, was always continent of bowel and bladder and required supervision with toileting, dressing, and eating. The care plan dated 7/11/25 identified Resident #10 was at risk for abnormal blood sugar levels including hypoglycemia and hyperglycemia due to diabetes. Interventions included to obtain finger sticks as ordered and report abnormal findings to the physician. Interventions also included to monitor the resident for signs and symptoms of hyperglycemia. A nurse’s note dated 7/15/25 at 7:20 PM by RN #3 identified that at 4:30 PM she was informed by the charge nurse that Resident #10 had a blood sugar of 54, was nonverbal and sweating. The note further identified following treatments that included supplementation and Glucagon (a medication used to treat low blood glucose), Resident #10 had a blood sugar of 74 and became more responsive and alert. The note identified that by 7:00 PM, Resident #10’s blood glucose was 267 after dinner. The note also identified the APRN was notified, and the charge nurse was to notify Resident #10's resident representative. A nurse's note dated 7/15/25 at 10:04 PM by LPN #9, the unit charge nurse, identified that Resident #10 had a hypoglycemic reaction during the shift. Further review of the documentation failed to identify that Resident #10's resident representative had been notified of the hypoglycemic episode with need for treatment. Review of the clinical record identified Resident #10’s blood sugar, obtained by LPN #4 on 7/24/25, was 436. Further, the clinical record failed to identify additional documentation including notification of the physician. Interview with APRN #1 on 7/30/25 at 12:07 PM identified that she was not notified of the residents elevated blood sugar of 436 by LPN #4 on 7/24/25. APRN #1 identified that LPN #4 was not the regular nurse assigned to care for Resident #10. APRN #1 also identified that if she had been notified of the elevated blood sugar on 7/24/25 it would have been documented in her notes. APRN #1 also identified that the order in place regarding directed staff to notify her or the physician of any blood glucose levels less than 70 and greater than 400. Interview with LPN #4 on 7/30/25 at 1:14 PM identified she was a float nurse at the facility and did not typically provide care for Resident #10. LPN #4 identified she could not recall if she notified the RN Supervisor on 7/24/25 of the elevated blood sugar but indicated she did notify APRN #1. LPN #4 was unable to identify if she notified APRN #1 in person or via phone and was unable to identify any orders from APRN #1. LPN #4 identified that sometime before the end of her shift at 3:00 PM she rechecked Resident #10’s blood sugar. LPN #4 identified that she took it upon herself to recheck the blood sugar without discussing it with APRN #1 and identified the blood sugar was somewhere around the lower 300’s but could not identify the actual number and was not sure if it was documented. Review of the clinical record failed to identify documentation by LPN #4 related to a recheck of Resident #10's blood sugar level on 7/24/25. Interview with RN #3 on 7/30/25 at 4:55 PM identified she directed LPN #9 to contact and notify Resident #10’s resident representative of the hypoglycemic episode and altered mental status that occurred 7/15/25. RN #3 identified that she did not follow up or speak with LPN #9 any further regarding if she made contact or attempted to notify Resident #10’s resident representative but if it was done LPN #9 would typically document any attempts to contact in her progress note. Interview with the DNS on 7/31/25 at 11:01 AM identified that licensed nurses were responsible to notify the resident representative and document the notification or attempts in the resident’s clinical record. The DNS also identified that the licensed nursing staff was expected to follow the physicians orders including when to notify the physician for abnormal findings. The DNS identified LPN #4 should have notified the RN Supervisor of the elevated blood sugar. The DNS further identified LPN #4 should have also notified the APRN and documented the notification in the clinical record, and it would not have been appropriate for LPN #4 to obtain a blood sugar level without direction from APRN #1. Although multiple attempts were made, an interview with LPN #9 was not obtained. The facility policy on hyperglycemia management directed that the facility would promptly identify, monitor, and treat hyperglycemia in accordance with the physician's orders. The policy further directed that residents with diabetes would have blood sugar monitoring per the physicians orders and staff would recognize signs and symptoms of hyperglycemia. The policy further directed for blood sugar levels greater than 400 with altered mental status, vomiting, small respirations or fruity breath odor, staff would call 911, follow facility emergency response protocol, monitor vital signs and initiate oxygen if indicated, and document interventions and notify family/POA. The policy also directed to record all blood sugar readings, symptoms, interventions, and provider notifications in the clinical record. The facility policy on change of condition directed it was the policy of the facility to ensure that changes in the resident’s conditions were reported to providers and families. The policy further directed that the facility must immediately consult with the residents physician and notify the residents legal representative or interested family member if there was a significant change in the resident’s physical, mental, or psychosocial status or a need to alter treatment significantly. The policy further directed that any resident with the change of condition would receive timely and appropriate intervention. The policy further directed that the LPN was to collect data and administer provider ordered treatments or medications as indicated and that the RN Supervisor would also be notified accordingly, and the RN would assess and determine if a change of condition had occurred. The policy also directed that repeated attempts would be made to reach the attending physician and/or medical director and family until successful. The nurse would document attempts, noting the date and time. 3. Resident #76 had diagnoses that included stroke and hemiplegia (paralysis) of the left side. The care plan dated 12/6/22 identified Resident #76 was at risk for pain related to physical condition. Interventions included encouraging the resident to report pain and provide medical management of underlying causes. The admission MDS dated [DATE] identified Resident #76 had moderately impaired cognition, was independent with eating and had no dental related concerns. A dental consultation dated 7/14/25 identified Resident #76 was seen for an exam, prophylaxis and fluoride. Soft tissues were noted to have generalized moderate inflammation with a possible abscess of the #18 buccal (side of molar) #18 root tip, and the resident had not yet been to an oral surgeon. Recommendations for an oral surgeon to extract #18 tooth. Review of the clinical record dated 7/14/25 through 7/25/25 failed to identify the physician had been notified about the possible abscess of the #18 tooth root tip. Interview with Dental Hygienist #1 on 7/28/25 at 1:34 PM identified she last saw Resident #76 on 7/14/25 for prophylaxis. Dental Hygienist #1 identified she observed inflammation at the gumline and a fistula at the #18 tooth site consistent with signs of infection. The dentist was not onsite to further evaluate, however, previous recommendations for extraction of #18 were documented during earlier visits. Interview with Dentist #1 on 7/28/25 at 1:33 PM identified he provided dental services to Resident #76 in the past but had not evaluated the resident recently. Dentist #1 identified based on review of the clinical findings, Resident #76 had a chronic infection of the area that had exacerbated. Dentist #1 identified the #18 tooth required removal for some time and likely required antibiotics. Dentist #1 would have expected the facility provider to consider an antibiotic after reviewing the consultation. Interview with NP #1 on 7/29/25 at 11:50 AM identified she began providing services in March of 2024 and had not previously been notified of any dental related concerns related to Resident #76. NP #1 further identified she was not notified of the possible abscess noted on the dental consultation of 7/14/25. Based on the clinical findings, NP #1 would have instructed nursing to contact the dental provider to see if they would like treatment with antibiotics or wait to see the oral surgeon prior to extraction. Interview with the DNS on 7/28/25 at 2:30 PM identified she would expect the nurse who received the consultation form back from the dental provider to notify the physician of the changes which included moderate inflammation with a possible abscess. The change of condition policy directed any change in a resident’s baseline is considered a change in condition. All changes in condition will be reported to providers and families and the residents will receive a timely and appropriate intervention.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #3, 8, 21 and 79) reviewed for pre-admission screening and resident review (PASARR), for Residents #3, 8 and 21 the facility failed to notify the State-designated authority when the residents were identified with a new mental health diagnosis and for Resident #79 who had a history of attempted self-harm and physically violent behavior directed as others, the facility failed to incorporate PASARR recommendations that included a crisis/safety plan in the resident's plan of care. The findings include: Resident #79 was admitted to the facility in September 2024 with diagnoses that included schizoaffective disorder and bipolar disorder. The PASARR dated 4/8/25 identified Resident #79 received short term approval without specialized services with an approval period of 120 days. The Connecticut Summary of Findings PASARR dated 4/8/25 identified important symptoms, diagnoses, behaviors, other needs, and history that a provider should know about Resident #79 included: having thoughts that people are out to get him/her, attempted self-harm in the past, physically violent behavior directed towards his/her sibling 5 years ago, and physically violent behavior directed toward his/her parent 20 years ago. It is important staff can recognize the presence of depressive symptoms, thoughts of self-harm, sensations that appear real but are not or changes in behaviors as the early signs of possible need for psychiatric or behavioral intervention. Services and supports the nursing facility staff are required to provide Resident #79 included: supportive counseling from nursing facility staff and a crisis intervention plan/safety plan due to his/her history of self-harm and a history of physically violent behaviors; this plan should include looking for an increase in symptoms or changes in behaviors as well as steps to take for the staff to take when this happens. The care plan dated 6/5/25 identified Resident #79 has been determined a positive Level 2 and has the potential for altered thought process and difficulty adjusting to situations. Interventions failed to identify that a crisis intervention plan/safety plan was in place. The quarterly MDS dated [DATE] identified Resident #79 had intact cognition, had no physical or verbal behavioral symptoms directed towards others over the last 2 weeks, and required supervision while wheeling 50 - 150 feet in a manual wheelchair. Interview with Resident #105 on 7/27/25 at 8:40 AM identified that Resident #79 sings, yells, and screams in the hallway all day long and it drives everyone crazy. Interview with Resident #12 on 7/27/25 at 10:20 AM identified that Resident #79 shouts all night and all day that people are stealing and she shouts indiscriminately that she will (explicative) people up. Resident #12 indicated listening to the behavior was tiring and that he/she has voiced concerns to the DNS and other staff members, but nothing had been done. Interview and review of the clinical record with the Director of Social Services (SW #1) on 7/28/25 at 9:41 AM failed to identify a crisis/safety plan in Resident #79’s clinical record, and she was not aware that the PASARR recommendations included developing a crisis intervention plan/safety plan. SW #1 indicated that it was her responsibility to review PASARR recommendations, but this was an oversight on her part. SW #1 further indicated that she would collaborate with the interdisciplinary team, including nursing, the licensed clinical social worker, and the Psychiatric APRN, as well as Resident #79’s conservator to develop a crisis/safety plan, by tomorrow. The plan would include identifying Resident #79’s triggers and behavior and utilizing recreation, talk therapy, and non-pharmaceutical and pharmaceutical interventions. SW #1 identified that education would be provided to all department heads and the care team so direct care staff could identify early signs of behaviors, triggers, or escalation. Interview with the DNS on 7/30/25 at 5:10 PM identified that she was not aware that Resident 79 did not have a crisis/safety plan, but she would work with the interdisciplinary team in its development and ensure direct care nursing staff would be educated. Interview with the Psychiatric APRN (APRN #2) on 7/30/25 at 6:20 PM identified that prior to the survey process he was not aware of the PASARR recommendation to develop a crisis intervention plan/safety plan for Resident #79, but the plan had been developed, subsequent to surveyor inquiry. APRN #2 indicated that Resident #79 was alert and oriented and stable on his/her current medication regimen and continues to work with psychotherapy. APRN #2 identified that the team was aware of the importance of identifying early triggers and behaviors, and the need to place Resident #79 on a 1:1 or send him/her out for a higher level of psychiatric care, if needed, but currently he/she is stable and will remain on the current medication regimen. The facility’s PASARR policy directs that individuals with a serious mental illness, intellectual disability, or related condition will not be admitted without first undergoing the federally mandated PASARR screening process, consisting of Level 1 and, if applicable Level 2 screening. A Level 2 screening directs for the assessment of the need for specialized services and appropriateness of nursing facility placement. 2. Resident #3 was admitted to the facility in April 2012 with a diagnosis that included personality disorder and dementia. Notice of Level 1 screen dated 6/18/12 was negative and identified Resident #3 had a diagnosis of personality disorder. Additionally, Resident #3 had a diagnosis of dementia and required a comprehensive mental status exam. Resident #3 received long term care approval. The care plan dated 1/21/22 identified Resident #3 had increased risk for altered nutrition secondary to primary diagnosis of dementia, personality disorder, and mood disorder. Interventions included to encourage and monitor food intake. The quarterly MDS dated [DATE] identified Resident #3 had moderately impaired cognition and had a diagnosis of dementia, depression, and major depressive disorder, recurrent. The psychiatric evaluation and consultation dated 1/23/23 identified a diagnosis of mood disorder, severe to moderate, chronic illness and dementia. The psychiatric evaluation and consultation dated 2/4/23 identified a new diagnosis of major depressive disorder. The census report for Resident #3 identified he/she was readmitted from the hospital on 1/9/24 and 4/8/24. Review of the active diagnosis list dated 4/1/24 identified Resident #3 received a diagnosis of major depression disorder, recurrent. The psychosocial evaluation dated 4/1/24 identified Resident #3 has the cognitive ability and verbal capacity to participate and benefit from psychotherapy. The treatment plan and objective identified to treat confusion, depression and irritability. Resident #3 has a diagnosis of major depressive disorder, recurrent. Interview with SW #1 on 7/29/25 at 6:38 AM indicated the social worker was responsible to update the State-designated authority when a resident gets a new mental health diagnosis. SW #1 indicated that upon notification, the State-designated authority will determine if an onsite visit for a level 2 evaluation is needed, or if there are any specialized services the facility needs to provide to the residents. SW #1 indicated Resident #3 had a negative Level 1 screen dated 6/18/12 with a diagnosis listed as dementia and personality disorder. The Level 1 did not list the diagnosis of major depression disorder, recurrent. SW #1 indicated that she was not aware nor could find the comprehensive mental status exam that was recommended at that time. SW #1 indicated that review of the psychiatric notes identified the new diagnosis was given on 2/4/23. SW #1 indicated the prior social worker should have submitted a new Level 1 PASARR to the State-designated authority for review due to the new diagnosis in February 2023. SW #1 indicated when Resident #3 was readmitted on [DATE] or 4/8/25 the social worker should have caught that the major depressive disorder, recurrent was not listed on the PASARR and resubmitted at that time. SW #1 indicated that she will submit and update the State-designated authority today with the new diagnosis and documentation. 3. Resident #8 was admitted to the facility in May 2021 with diagnoses that included anxiety and major depressive disorder. A Notice of Level 1 PASARR determination dated 5/10/21 identified Resident #8 had a diagnosis of dementia with behavioral disturbances. Resident #8 received long-term care approval based on the information provided. A physician’s order dated 11/25/21 directed to administer Seroquel (antipsychotic medication) 50 mg daily at 9:00 AM for depression, and Seroquel 25 mg at bedtime for anxiety, agitation, and paranoia. Additionally, a psychological evaluation and consultation to treat as needed. The quarterly MDS dated [DATE] identified Resident #8 had intact cognition and had a diagnosis of anxiety and major depressive disorder. The Resident #8’s diagnosis list identified a new diagnosis on 5/1/22 of schizoaffective disorder, bipolar type. The annual MDS dated [DATE] identified Resident #8 had intact cognition and had a diagnosis of anxiety and major depressive disorder. Additionally, Resident #8 has a diagnosis of schizoaffective disorder, bipolar type. The psychiatric consultation dated 5/16/22 identified Resident #8 had a diagnosis of anxiety, dementia, and major depression disorder. The psychiatric consultation dated 7/7/22 identified Resident #8 had a new diagnosis schizoaffective disorder, bipolar type. The care plan dated 2/1/23 identified Resident #8 receives antidepressant and antipsychotic medications related to depression. Interventions included attempting gradual dose reduction to lowest dosage. A physician’s order dated 7/14/24 directed to administer Seroquel 50 mg daily and Seroquel 25 mg at bedtime for diagnosis of schizoaffective disorder, bipolar type. The census report identified Resident #8 had returned from the hospital on 7/14/24 and 12/21/24. Interview with SW #1 on 7/29/25 at 6:26 AM indicated Resident #8 only has a PASARR dated 5/10/21 which identified a diagnosis of dementia and anxiety but does not list the major depression or the diagnosis of schizoaffective disorder bipolar type. After clinical record review, SW #1 indicated Resident #8 received the diagnosis of schizoaffective disorder bipolar type on 7/7/22. SW #1 indicated that the social worker at that time should have submitted a notified the State-designated authority due to the new mental health diagnosis and update the care plan. SW #1 indicated that it was not picked up on 7/14/24 or 12/21/24 when the resident was readmitted . SW #1 identified she will be updating the State-designated authority with the new diagnosis of schizoaffective disorder and major depression. 4. Resident #21 was admitted to the facility in February 2021 with diagnoses that included violent behaviors and acute kidney injury. The care plan dated 1/3/22 identified Resident #21 was on antidepressant and antipsychotic medications. Interventions included attempting gradual dose reduction to the lowest therapeutic level. A physician’s order dated 1/4/22 directed to administer Risperidone (antipsychotic medication) 0.5 mg once a day. A physician’s order dated 3/24/22 directed to administer Risperidone 1 mg twice a day. Notice of Level 1 PASARR determination dated 4/4/22 identified Resident #8 had a diagnosis of dementia with behavioral disturbances and delusional disorder. Resident #8 received long-term care approval based on the information provided. There is no evidence of a PASARR condition or serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. The quarterly MDS dated [DATE] identified Resident #21 had moderately impaired cognition. The quarterly MDS dated [DATE] identified Resident #21 had moderately impaired cognition and a diagnosis of schizophrenia. The annual MDS dated [DATE] identified Resident #21 had moderately impaired cognition with a active diagnosis of depression and schizophrenia. A physician’s order dated 8/4/22 directed to administer Risperidone 2 mg twice a day for a diagnosis of schizoaffective disorder. A physician’s order dated 2/5/24 directed to Risperidone 1.5 mg twice a day for a diagnosis of schizoaffective disorder. A physician’s order dated 4/8/25 directed to monitor behaviors every shift for use of psychotropic medication. Monitor for paranoia, agitation, and hallucinations for a diagnosis of schizoaffective disorder depressive type. Interview with SW #1 on 7/29/25 at 6:43 AM identified after clinical record review Resident #21 had received the diagnosis of schizoaffective disorder on 4/11/22. SW #1 indicated that the social worker at that time should have updated the State-designated authority with the new diagnosis of schizoaffective disorder to determine if there were any specialized services needed. SW #1 indicated that when she started at the facility about 4 months ago she was informed there were only 2 residents that had a Level 2 positive PASARR. SW #1 indicated that she did not do any audits to check if it was accurate. SW #1 indicates that she was only reviewing the new admissions to the facility. Interview with the Administrator on 7/29/25 at 6:51 AM identified she has looked at the book that was there for the Level 2's in the facility but has not done an audit yet. The Administrator indicated the social worker is responsible for PASSAR’s. After reviewing the policy, the Administrator indicated that when a resident receives a new mental health diagnosis the social worker is responsible to update the State-designated authority at that time. Review of the PASARR policy identified individuals with a serious mental illness, intellectual disability, or related condition will not be admitted to the facility without first undergoing the federally mandated PASARR screening process, consisting of Level 1 and if applicable Level 2 screening. This is to ensure compliance with federal and state regulations by identifying individuals with serious mental illness, intellectual disabilities, or related conditions prior to admission to the facility and providing appropriate care and services. Level 2 screening is required if a Level 1 screening is positive. Mandatory PASARR Level 2 resubmission for any resident receiving a new diagnosis of mental illness or related condition, regardless of admission date will be communicated within the interdisciplinary team. Notify the PASARR authority if a current resident shows signs of MI or ID not previously identified. Re-screening is also required upon a significant change in condition.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 6 residents (Resident #6 and 125) reviewed for accidents, for Resident #6 the facility failed to provide adequate supervision to a resident who required aspiration precautions and supervision with intake and for Resident #125 the facility failed to provide adequate supervision and care planned interventions for a resident with a known history of substance abuse and a recent drug overdose to prevent a reoccurrence, and for 1 resident (Resident #10) reviewed for tube feeding and aspiration precautions, the facility failed to provide 1:1 feeding assistance and failed to ensure that mechanically altered diet orders were followed. The findings include:1a. Resident #125 was admitted to the facility in March 2024 with diagnoses that included osteomyelitis of vertebra, opioid abuse, anxiety disorder, and dorsalgia. The care plan dated 3/28/24 identified Resident #125 had a history or active diagnoses of substance abuse. Intervention included to offer resident the option of attending substance abuse group. Nursing and social services support as needed. The admission MDS dated [DATE] identified Resident #125 had intact cognition, required setup or clean up assistance with personal hygiene, and independent with eating. Additionally, Resident #125 had no physical and verbal behaviors directed toward others. The physician’s order dated 6/1/24 directed to monitor pain every shift and administer Oxycodone 10mg every 6 hours as needed for pain. The June 2024 identified Resident #125 received the medication Oxycodone 10mg on 6/3/24 at 4:55 PM for pain with good effect. The nurse’s note dated 6/3/24 at 7:00 PM by RN #3 identified around 6:25 PM there was a STAT call to the unit and Resident #125 was noted to be unresponsive to verbal/tactile command. Narcan was administered at 6:30 PM in left nostril times one with good effect. Resident #125 opened their eyes, vital signs were obtained, oxygen saturation was 97% on room air and EMS was called. Resident #125 was verbally responsive, and emergency responders arrived at 6:40 PM. Resident #125 left the facility at 6:50 PM. The APRN was notified, W-10, and the bed hold policy initiated. Message left for the resident representative. Consultation for pain management and mouth check with every medication pass every shift initiated. The reportable event form dated 6/3/24 at 6:25 PM identified Resident #125 became unresponsive and required the use of Narcan. Resident #125 was sent to the hospital for evaluation and monitoring. Resident #125 reported taking 2 doses of his/her pain medication. The Administrator was notified, and an investigation was initiated. The care plan dated 6/3/24 identified Resident #125 had a history or active diagnoses of substance abuse. On 6/3/24 Resident #125 had an unresponsive episode. Intervention included to check mouth with every medication pass on every shift. Pain management consultation. A written statement by LPN #10 dated 6/3/24 identified she was called to Resident #125’s room at around 6:30 PM by NA #17, stating it’s an emergency. Resident #125 was being assisted up in a sitting position by NA #17 who was calling the resident’s name over and over. Resident #125 did not respond. LPN #10 called RN #3 over immediately and Narcan was administered and 911 was called. The hospital discharge document dated 6/3/24 at 11:11 PM identified Resident #125 presented for an accidental overdose. Narcan revival from a nursing facility. Upon examination Resident #125 reported he/she possibly took two of his/her Oxycodone too close together. Resident #125 reported that he/she crushed up two of the Oxycodone today and snorted them. Resident #125 denies this was an intentional overdose. Resident #125 does not require admission or further hospitalization at this time, appropriate for discharge back to nursing home. The summary report dated 6/5/24 identified Resident #125 last received his dose Oxycodone 10mg as needed at 9:56 AM on 6/3/24. Resident #125 indicated he/she saved the earlier dose of medication, then requested a second dose of the day at 4:55 PM. Resident #125 indicated then he/she took both medication pills together. A room search was yielded with no results. This incident has not occurred with Resident #125 before. Resident #125 denies taking any other medications or recreational drug. Resident #125 returned from the hospital with no new orders, and no urinary toxicology screen had been done in the hospital. Resident #125 was seen by the Physiatrist who recommended a consultation with an addiction specialist. Mouth check with all medications administered. Although attempted, an interview with previous Administrator (Administrator #1), previous DNS (DNS #1), LPN #10, and NA #17 were not obtained. b. A physician’s order dated 6/1/24 directed to monitor pain every shift. A physician’s order dated 6/3/24 directed to check the resident’s mouth with every medication pass and obtain a pain medication consultation. The care plan dated 6/3/24 identified Resident #125 had a history or active diagnoses of substance abuse. On 6/3/24 Resident #125 had an unresponsive episode. Intervention included to check the resident’s mouth with every medication pass on every shift. Pain management consultation. A physician’s order dated 6/18/24 directed to administer Oxycodone 10mg every 12 hours for pain. The nurse’s note dated 6/19/24 at 9:50 PM by RN #3 identified at 8:30 PM she was notified by LPN #10 that Resident #125 was unresponsive to verbal and tactile stimulation with eyes closed. RN #3 indicated per Resident #250; Resident #125 was noted on his/her knees and Resident #250 called staff due to Resident #125 was not answering. Narcan was administered in left nostril at 8:37 PM, EMS was activated, and W-10 and bed hold policy initiated. Resident #125 slowly became responsive and alert. The ambulance arrived at 8:50 PM, and Resident #125 left at 9:00 PM for the hospital for evaluation. The physician and resident representative were notified. Room checked with no inappropriate contraband noted. The reportable event form dated 6/19/24 at 8:30 PM identified Resident #125 was observed unresponsive in Resident #250’s room. Narcan was administered time one and 911 was activated. Resident #125 became verbally responsive and alert. Resident #125 transferred to the hospital. The physician, Administrator, DNS, and resident representative were notified. The care plan dated 6/19/24 identified Resident #125 had a history or active diagnoses of substance abuse. On 6/19/24 Resident #125 had an unresponsive episode. Intervention included to check mouth with every medication pass on every shift. Supervised visits with Resident #250. Move resident to another unit. The summary report dated 6/24/24 at 11:22 AM identified at approximately 8:00 PM on 6/19/24, LPN #10 observed Resident #125 going down the hallway with Resident #250. At approximately 8:30 PM Resident #250 yelled down the hallway for help. LPN #10 observed Resident #125 unresponsive and Narcan was administered with positive effect. Investigation initiated. Resident #125 returned from the hospital with no new order, psychiatric and social service support to be provided. Upon the investigation, Resident #250 had gone out on leave of absence. Resident #125 last received his/her Oxycodone 10mg at 8:00 AM on 6/19/24 and did not receive the second dose due to incident. Mouth checks were maintained and care plan included recommendations for addictions services. Resident #125 indicated he/she “took two of the oxycodone’s together.” The previous Maintenance Director privately asked Resident #125 what happened. Resident #125 admitted to taking a Methadone pill but would not admit who gave him/her the pill. Resident #250 declined involvement and did not want to participate in the investigation process. Resident #250 was discharged home per his/her request on 6/20/24. Resident #125 had a planned discharge to home date of 6/21/24 with addiction and home care services. Interventions: Addiction services set up for Resident #125, mouth checks maintained, and last medication administration of Oxycodone schedule was assessed. Both residents were discharged home. Although attempted, an interview with the previous Administrator, (Administrator #1), previous DNS (DNS #1), LPN #10, and the Maintenance Director were not obtained. Review of the facility Narcan administration policy identified the facility will provide emergency treatment for residents who may demonstrate signs and symptoms of opiate overdose. 2. Resident #6 was admitted to the facility on [DATE] with diagnoses that included hemiplegia affecting the right side following a stroke, dysphagia, and dementia. The clinical record identified Resident #6 was hospitalized from [DATE] - 4/20/25 for Covid 19 infection. Review of the 4/20/25 hospital discharge documentation identified Resident #6 required speech therapy evaluation during hospitalization due to issues with swallowing. The documentation also identified Resident #6 had expressive aphasia and was unable to provide any information. The hospital documentation identified Resident #6 had a modified barium swallow and speech therapy evaluation which identified reduced airway closure and silent aspiration with swallowing. Recommendations included 1:1 supervision with intake, slow rate of feeding, single bites/sips, and pureed diet with nectar thickened liquids due to deficits with swallow safety and efficacy. The care plan dated 4/20/25 identified Resident #6 was at risk for aspiration due to noncompliance with diet. Interventions included to counsel and encouraged Resident #6 to be compliant with the plan of care. A physician’s order dated 4/21/25 directed a nectar thick pureed diet. Review of the physician’s orders and nurse aide care card failed to direct aspiration precautions or supervision with meals. The 5-day MDS dated [DATE] identified Resident #6 had moderately impaired cognition, was frequently incontinent of bowel and bladder, required set up for meals and substantial assistance with toileting and bathing. The MDS also identified Resident #6 had issues with swallowing that included coughing or choking during meals. A Speech Therapy discharge note dated 5/25/25 identified Resident #6 received skilled speech therapy services from 4/21/25 - 5/25/25 for dysphagia. The note identified Resident #6 had made gains with speech therapy and was consuming a pureed and nectar thickened liquid diet with no overt signs/symptoms of aspiration with cured strategy use. The note further identified discharge recommendations that included Resident #6 to continue with pureed consistency diet and nectar thick liquids, and close supervision with oral intake. The note also identified that Resident #6 had a good prognosis with consistent staff follow-up. Review of the care plan failed to identify the Speech therapy recommendations of 5/25/25. Observation on 7/27/25 at 8:27 AM identified Resident #6 was in bed, the bedside table located directly next to the left side of the bed with a meal tray on the table. Observation of the meal tray identified eggs and oatmeal were untouched while a small carton of milk and orange juice were empty. During this observation, Resident #6 was observed sleeping, lying flat, and no staff were observed within the vicinity of the room. Interview with LPN #13, an agency nurse, on 7/27/25 at 8:30 AM identified she was unsure of Resident #6’s diet order or supervision level with meals as it was her first shift working on Resident #6’s unit. Interview with NA #13 on 7/27/25 at 8:31 AM identified she was the regular nurse aide on the unit for Resident #6. NA #13 identified Resident #6 ate independently and did not require supervision with meals. Interview with APRN #1 on 7/29/25 at 12:07 PM identified that all residents on aspiration precautions or that required mechanically altered diets were addressed by the facility speech therapy department. APRN #1 identified she would receive emails and updates on these residents but did not write the orders or place the residents on aspiration precautions and this was the responsibility of the speech therapist. Interview with LPN #8 on 7/30/25 at 9:00 AM identified she was the nurse regularly assigned to care for Resident #6 and that the resident was to have supervision with meals and was usually brought to the dining room for all meals. Constant observation on 7/30/25 beginning at 12:20 PM identified Resident #6 seated in the wheelchair in the unit dining room. NA #4 was observed providing meal trays to other residents in the dining room and NA #13 was observed setting up Resident #6’s lunch meal tray and left the tray and table at 12:21 PM. Resident #6 was observed feeding him/herself without supervision beginning at 12:21 PM. NA #4 and NA #13 were observed exiting the dining room to the meal truck located in the hallway of the unit. Resident #6 was observed taking large spoonful’s of food, one after the other, and at 12:23 PM began coughing. At 12:24 PM, NA #4 reentered the dining room, came to Resident #6’s side as he/she was coughing, and directed Resident #6 to take smaller bites. At 12:25 PM, Resident #6 stopped coughing as NA #13 also reentered the dining room, and NA #4 continued to provide prompts to Resident #6 to take smaller bites and requested NA #13 find a smaller spoon because the spoon the resident was using was “too large.” Resident #6 began coughing again with NA #4 standing at his/her side. At 12:26 PM, NA #4 brought a chair next to Resident #6 as Resident #6 stopped coughing. At 12:29 PM NA #4 got up from the chair and began checking on other residents in the dining room. No other nurse aides were in the dining room from this point. At 12:30 PM, NA #4 provided verbal prompts to Resident #4 while circulating the dining room, and at 12:32 PM sat back down at Resident #6’s side and provided prompts to take small sips while drinking his/her milk. NA #4 was observed at Resident #6’s side until 12:36 PM, when the observation ended after Resident #6 declined the remainder of his/her meal. Constant observation on 7/30/25 beginning at 4:56 PM identified Resident #6 seated in the wheelchair in the unit dining room. At 5:00 PM, NA #11 was observed setting up Resident #6’s dinner meal tray and leaving the dining room. Resident #6 was then observed eating his/her meal unsupervised beginning at 5:01 PM. At 5:02 PM, LPN #11 was observed standing in one of 2 entryways of the dining room next to a medication cart also positioned at and blocking the entryway. LPN #11 was positioned opposite Resident 6’s table and seat position. Between LPN #11 and Resident #6 was a residential refrigerator. Observation directly behind Resident #6 failed to visualize LPN #11 due to obstruction by the refrigerator, and LPN #11 was only visible after moving approximately 3 feet to the left of Resident #6’s table to be able to see LPN #11 around the refrigerator and at the entryway. Resident #6 was observed continuing eating unsupervised taking large spoonful’s of food and had multiple coughing episodes at 5:04 PM, 5:07 PM, 5:11 PM, 5:14 PM, and 5:15 PM. During these episodes, LPN #11 continued to remain at the entryway on the opposite side of the refrigerator and did not attempt to observe or check on Resident #6 and was instead observed speaking with other residents regarding medications. At 5:18 PM, Resident #6 had another episode at which time LPN #11 stepped back from the side of refrigerator and into the dining room. LPN #11 asked Resident #6 if he/she was okay. Resident #6 had stopped coughing but did not provide a response. At 5:19 PM LPN #11 stepped back the medication cart at the dining room entryway, again obstructed by the refrigerator. At 5:20 PM, Resident #6 began coughing again after taking in half (2 oz) of thickened apple juice with one attempt. At 5:21 PM, while Resident #6 continued coughing, LPN #11 again stepped from the side of the refrigerator and again asked Resident #6 if he/she was okay. Resident #6 nodded yes and stopped coughing, and at 5:22 PM LPN #11 again stepped back to the medication cart at the dining room entryway. Resident #6 stopped eating and drinking and slightly pushed his/her meal tray away. Observation of the tray identified Resident #6 ate approximately 75% of the meal, which included pureed teriyaki chicken breast, rice, and stir-fried vegetables and 100 % of the thickened liquids, which included 4 oz of apple juice, 4 oz of skim milk, and 4 oz of coffee. No other staff were observed in the vicinity of Resident #6 or in the dining room area during Resident #6’s meal. Interview with LPN #11 on 7/30/25 at 5:22 PM identified she was aware Resident #6 was on aspiration precautions and required supervision with meals, and felt she was providing supervision of Resident #6 due to being in the dining room entryway. LPN #11 did not identify how she provided supervision while passing medications to other residents and being positioned on the opposite side of large appliance. Interview with the DNS on 7/30/25 at 5:24 PM identified Resident #6 should have direct supervision with all meals due to aspiration precautions, and that would include having a facility nurse or nurse aide in the dining room with eyes on Resident #6 for the entirety of his/her meals. The DNS identified Resident #6 was impulsive with eating and drinking and often took large bites and sips but did well if supervised and prompted by staff to take smaller bites and sips. The DNS identified that she would immediately in-service the nursing staff regarding the need to provide supervision to any residents who required aspiration precautions. Interview with SLP #1 on 7/31/25 at 8:03 AM identified that Resident #6 is to have close supervision with all meals due to dysphagia and aspiration risks. SLP #1 identified if Resident #6 opted to eat in his/her room, then the resident would need 1:1 supervision, but if in the dining room, close supervision was sufficient. SLP #1 identified that Resident #6 was impulsive with meals and when he/she ate or drank too fast, he/she would often cough which was a sign of aspiration. SLP #1 also identified that Resident #6 had a history of noncompliance with liquids and would often hang out by the facility vending machine. SLP #1 identified that while Resident #6 was unable to verbalize due to aphasia, other residents would often help and purchase sodas and other liquids from the facility vending machine. SLP #1 identified that she had observed intermittent issues regarding supervision of Resident #6 related to meals and had also observed meal trays in Resident #6’s room without any staff present. SLP #1 identified that she had not placed a specific order for Resident #6 related to aspiration precautions along with Resident #6’s diet order and identified that there may have been some confusion regarding this with some of the staff. Review of the clinical record failed to identify documentation related to Resident #6’s noncompliance related to vending machine items. The facility policy on aspiration precautions directed that the purpose of the policy was to establish standardized procedures for preventing aspiration and residents at risk due to dysphasia, altered mental status, or other conditions ensuring safe feeding practices and maintaining airway integrity. The policy directed that upon admission, quarterly, and with a significant change of condition, residents would be assessed for swallowing ability and aspiration risk including a referral to the speech language pathologist and findings and recommendations would be documented in the resident care plan. The policy also directed that residents identified as high risk for aspiration precautions would receive supervision during meals and snacks along with documentation of the supervision level including 1:1 feeding assistance or close observation, residents would be maintained at a 90° angle during meals and remain upright for at least 30 minutes after a meal, and would be observed for signs of aspiration which included coughing, choking, or respiratory distress. The policy also directed the speech and language pathologist would provide evaluations care plan input and staff training related to aspiration precautions; and nursing and dietary would implement interventions and monitor compliance. The facility policy on therapeutic diets directed that modified diet texture were altered inconsistency including pureed diets for residents with chewing or swallowing difficulties the policy also directed special considerations for dysphagia and aspiration risk included texture modified diets would follow speech language pathology recommendations and thickened liquids would only be used when ordered and proper consistency of the liquid would be verified prior to service the policy also directed that residents may decline therapeutic diet after being informed of potential risks per resident rights and refusals would be documented. The facility policy on a hazard free environment directed that the facility would identify, correct, and prevent environmental hazards to ensure resident safety and regulatory compliance. The policy further directed that all employees shared the responsibility of recognizing, reporting, and removing hazards promptly. The policy further directed that nursing staff would visually inspect resident rooms, hallways, and areas for hazards during routine care. 3. Resident #10 was admitted to the facility in August 2023 with diagnoses that included traumatic brain injury, dysphagia, and diabetes with hypoglycemia. Review of the clinical record identified Resident #10 had a g-tube in place upon admission but had fully transitioned to nutritional intake by mouth in March 2025. A physician’s order dated 3/13/25 directed diet orders that included ground solids and nectar thick liquids with single sips only, 1:1 feeding assistance, aspiration precautions, and encourage use of double swallow. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition, was always continent of bowel and bladder and required supervision with toileting, dressing, and eating. Review of a speech therapy evaluation by SLP #1 dated 7/12/25 identified Resident #10 had a history of dysphasia and aspiration pneumonia. Resident #10 was noted to have coughing with thin liquids, (a clinical sign and symptom of dysphasia), had behaviors impacting safety with meals including uncontrolled talking while eating, impulsive rate, unsafe intake amounts with decreased self-correction, decreased safety awareness, and poor self-monitoring skills. The report recommended to continue baseline diet of ground consistency with nectar thickened liquids, 1:1 supervision with all oral intake, small bites and sips, double swallow, throat clearance, and re-swallow. The note also identified due to documented physical impairments and associated functional deficits, Resident #10 was at risk for aspiration, behavioral outburst, weight loss, pneumonia, and further decline in function. An APRN note dated 7/21/25 at 4:46 PM identified Resident #10 was receiving 100% of caloric intake and medications by mouth and was only receiving g-tube flushes. The note identified a three-day caloric count scheduled from 7/22/25 - 7/24/25 to determine if Resident #10’s oral intake was adequate to establish the removal of the g-tube. Observation on 7/30/25 at 8:05 AM identified Resident #10 was seated in the dining room with several other residents. Resident #10 was observed to consume 100% of the meal by 8:10 AM. During the observation Resident #10 was observed taking large spoonful’s by mouth. Clinical staff were not present and did not provide 1:1 supervision at any time during the meal. Observation on 7/30/25 at 12:21 PM identified Resident #10 was seated in the unit dining room with several other residents. At 12:29 PM, NA #13 was observed setting up Resident #10’s meal tray and exiting the dining room. NA #4, who was assisting other residents in the dining room was present but was not observed providing any supervision to Resident #10. Resident #10 was observed eating his/her meal unsupervised, taking large spoonful’s of food by mouth and began coughing at 12:37 PM for approximately one minute. Resident #10 consumed 75 % of the meal and stopped eating at 12:39 PM and was observed coughing multiple times until 12:40 PM, when NA #4 came to Resident #10’s table. NA #4 left the table and Resident #10 exited the dining room at 12:41 PM while continuing to cough intermittently. Observation on 7/30/25 beginning at 4:56 PM identified Resident #10 seated in his/her wheelchair in the unit dining room with NA #11 who was observed setting up Resident #10’s dinner meal tray and leaving the dining room. Resident #10 was observed eating his/her meal unsupervised beginning 4:57 PM and taking in large spoonful’s of his/her meal. At 5:02 PM, LPN #11 was observed standing in one of the 2 entryways of the dining room next to a medication cart also positioned at and blocking the entryway, directly across from Resident #10. At this time, Resident #10 was observed to have consumed approximately 75 % of his/her meal. At the same time, NA #11 was also observed retrieving 2 clear plastic cups of a red colored liquid from an insulated beverage dispenser located in the dining room. Observation of the liquid identified it was regular thin liquid consistency. NA #11 handed one plastic cup of liquid to another resident and the second cup of liquid to Resident #10 while speaking to LPN #11 requesting medication to treat a headache. Resident #10 drank the entirety of the cup directly in front of LPN #11 in one attempt. At 5:05 PM, Resident #10 was observed to have completed 100% of his/her meal. Interview with LPN #11 on 7/30/25 at 5:22 PM identified she was aware Resident #10 required supervision with meals. LPN #11 was unable to identify if she visualized Resident #10 consuming the thin liquid or if he/she required 1:1 supervision during meals. Interview with the DNS on 7/30/25 at 5:24 PM identified Resident #10 is required to have 1:1 supervision with all meals due to aspiration precautions, was impulsive with eating and drinking, and often took large bites and sips. The DNS identified that Resident #10 also had a history of aspiration pneumonia and non-compliance with his/her diet orders due to often going to the facility vending machines. The DNS also identified even with prompts and 1:1 supervision, Resident #10 was often impulsive and took in large amounts of food and liquids too quickly. The DNS identified that she would immediately in-service the nursing staff regarding the need to provide supervision to any residents with aspiration precautions. Interview with SLP #1 on 7/31/25 at 8:03 AM identified that Resident #10 had multiple issues related to oral intake including behaviors with meals that included impulsivity, inability to self-regulate intake of large amounts of food at one time, poor safety awareness, along with functional and cognitive issues. SLP #1 identified that she had provided therapy to Resident #10 multiple times since his/her admission to the facility in 2023 and Resident #10 had reached his/her baseline in terms of swallowing function. SLP #1 identified that Resident #1 would always need 1:1 supervision with any oral intake due to his/her high risk for aspiration. SLP #1 identified Resident #10 was only to have nectar thickened liquids and should not have any thin liquids due to aspiration risk. The facility policy on aspiration precautions directed that the purpose of the policy was to establish standardized procedures for preventing aspiration and residents at risk due to dysphasia, altered mental status, or other conditions ensuring safe feeding practices and maintaining airway integrity. The policy directed that upon admission, quarterly, and with a significant change of condition, residents would be assessed for swallowing ability and aspiration risk including a referral to the speech language pathologist and findings and recommendations would be documented in the resident care plan. The policy also directed that residents identified as high risk for aspiration precautions would receive supervision during meals and snacks along with documentation of the supervision level including 1:1 feeding assistance or close observation, residents would be maintained at a 90° angle during meals and remain upright for at least 30 minutes after a meal, and would be observed for signs of aspiration which included coughing, choking, or respiratory distress. The policy also directed the speech and language pathologist would provide evaluations care plan input and staff training related to aspiration precautions; and nursing and dietary would implement interventions and monitor compliance. The facility policy on therapeutic diets directed that modified diet texture were altered inconsistency including pureed diets for residents with chewing or swallowing difficulties the policy also directed special considerations for dysphagia and aspiration risk included texture modified diets would follow speech language pathology recommendations and thickened liquids would only be used when ordered and proper consistency of the liquid would be verified prior to service the policy also directed that residents may decline therapeutic diet after being informed of potential risks per resident rights and refusals would be documented.

Based on observation, review of facility documentation, facility policy, manufacturer guidelines and interviews, the facility failed to ensure the level of sanitizing solution in the dishwasher was tested and maintained at an adequate level according to manufacturer guidelines to ensure tableware was sanitized. The findings include: A kitchen service report dated 7/22/25 identified ware washing results for glassware, plates, pots and pans were satisfactory with the sanitizer concentration measured 75 ppm (parts per million) falling within the acceptable range of 50 - 100 ppm.An observation during a test run of the low temperature dishwasher on 7/27/27 at 7:02 AM identified the sanitation strip had a recorded measurement of 0 - 10 ppm.A review of the dishwasher temperature log date 7/1/25 through 7/26/25 identified the wash cycle was recorded at 120. The rinse cycle was recorded at 50.An interview and facility documentation review with the Regional Food Service Director on 7/27/25 at 7:15 AM identified the number recorded under the wash cycle represented the temperature in degrees, while the number under rinse cycle reflected the sanitation concentration in ppm. Although not specifically labeled, staff were expected to understand that rinse reading represented ppm, obtained by submerging a sanitizer test strip in a reservoir of water flowing through the dishwasher to the clean side.An interview with Dietary Staff #1 on 7/27/25 at 7:22 AM identified she routinely operated the dishwasher and documented required readings onto the dishwasher temperature log as part of her assigned duties. Dietary Staff #1 identified she recorded both wash and rinse information based only on the dishwasher gauge (temperature readings) and never used test strips to measure sanitation.An interview with Dietary Staff #3 on 7/27/25 at 7:40 AM identified he routinely operated the dishwasher and documented required readings onto the dishwasher temperature log as part of his assigned duties. Dietary Staff #3 identified he recorded both wash and rinse information based only on the dishwasher gauge (temperature readings) and never used test strips to measure sanitation.An interview with the FSD on 7/27/25 at 7:42 AM identified the dishwasher was last serviced on 7/22/25 and was functioning properly with the appropriate sanitation levels. The FSD further identified she last checked the sanitation the previous morning, with a recorded reading of 50 ppm. The FSD further identified she was responsible to educate dietary staff on dishwasher sanitation procedure; however, was unable to provide any documentation of any prior training.An interview and sanitation strip manufacturer guideline review with Dietary Staff #4 on 7/27/25 at 8:24 AM identified he last checked the dishwasher sanitation at 1:00 PM following lunch the previous day. Dietary Staff #4 identified the reading at the time was within normal range. However, when asked to identify the corresponding range on the test strip. Dietary Staff #4 indicated the range fell between 0 - 10 ppm, despite the manufacturer's guidelines indicating the normal sanitizer range of 50 - 100 ppm.An interview with Dishwasher Technician #2 on 7/27/25 at 1:50 PM identified that a mechanism in the machine was not aligned properly, preventing the sanitizing solution to dispense. Without that mechanism functioning, the plates and utensils were not sanitized. The issue was addressed and subsequently the dishwasher was functioning properly.An interview with Dishwasher Technician #1 on 7/28/2025 at 6:57 AM identified he last provided routine service to the dishwasher on 7/22/25 and there were no identified concerns. Dishwasher Technician #1 identified the wash and rinse cycle gauge measured in degrees only and should be maintained between 115 - 120 degrees F. Sanitation should be measured using strips with a recorded reading of 50 - 100ppm. Any reading outside of those ranges would not offer effective sanitizing.An interview with the FSD on 7/31/2025 at 2:17 PM identified she would expect dietary staff to perform sanitation procedures in accordance with infection control practices.A review of the manufacturer guidelines for the dishwasher identified sanitizer should be maintained at 50 ppm.A review of the manufacturer guidelines for the sanitation strips identified sanitizer should be maintained between 50 -100 ppm.Although requested. A policy for ensuring clean and sanitary plates and utensils was not provided.

Based on review of facility documentation, facility policy, and interview, the facility failed to ensure ongoing tracking and surveillance of antibiotic usage from 1/1/23 to 12/31/24 and failed to ensure staff education on antibiotic stewardship. The findings include: Interview with the Infection Control Nurse (LPN #1) on 7/29/25 at 7:40 AM indicated that she started at the facility in March 2025. LPN #1 identified she was responsible for monitoring and tracking all antibiotic usage and infections based on McGeer's criteria on a daily to weekly basis and consulting with the provider about if the antibiotic was appropriate or not at the time the infection started. LPN #1 indicated when she started working at the facility there were not any monthly surveillance reports of antibiotic use from 1/1/23 through 12/31/24. There were no statistics or monthly infection control meeting minutes to identify that antibiotic usage had been reviewed, reported, or determined to have been appropriately used or not. LPN #1 indicated her position was responsible to educate the residents and staff at least annually on the ongoing stewardship program and if there were concerns with over antibiotic use. LPN #1 indicated there was no documentation regarding antibiotic stewardship education with the residents or staff that she could find. Interview with the DNS on 7/31/25 at 8:20 AM indicated the infection control nurse was responsible to do a daily but at least a weekly review of all antibiotic use and speak with the providers to determine if the appropriate antibiotic was being used for the resident's infection. The DNS indicated the infection control nurse would determine if a resident met the McGeer's criteria for an infection to be eligible to receive the antibiotic. The DNS indicated if the resident did not meet requirements the infection control nurse was expected to contact the provide and document the outcome. The DNS indicated her expectation was the infection control nurse would have a monthly infection control committee meeting to review the antibiotic use and data collected. The DNS indicated the infection control nurse was responsible to present the data quarterly for number of infections, comparisons to other months, and analyzing the data to present with a report at the QAA and medical staff meeting. The DNS indicated she did not have an antibiotic line lists or education for 2023 or 2024. Interview with the Administrator on 7/31/25 at 8:25 AM indicated QAA and QAPI meet quarterly with the medical staff meeting. The Administrator indicated that it was the infection control nurse or DNS's responsibility to present the ongoing infection rates, comparisons to other months or quarters, any outbreaks since prior quarter, and statistics or over prescribing of an antibiotic with the providers. After review from 1/1/23 to 12/31/24 the Administrator could not provide documentation of any infection control report or that the infection control nurse verbally had presented during the meeting based on the minutes from the meetings. The Administrator indicated that the infection control nurse was responsible to present a quarterly report based on her daily, weekly, and monthly surveillance of antibiotic usage and analyzing the data for any trends in infections or antibiotic usage by providers for the antibiotic stewardship program. The Administrator indicated that the infection control nurse did sign in to some of the quarterly QAA meetings, but she did not present any information related to the antibiotic stewardship statistics to the committee. Review of the Antibiotic Stewardship Policy identified the facility shall work to ensure the safe, effective use of antibiotics, and shall actively seek to minimize the inappropriate use of antibiotics through ongoing assessment, education, and leadership activities as part of the facility infection prevention and control program. The facility medical director, in conjunction with the infection preventionist, director of nursing, and consultant pharmacist shall assume the leadership roles in antibiotic stewardship. Antibiotic stewardship activities will be coordinated through the pharmacy committee and the infection control committee. Antibiotic stewardship activities shall include: regular review of antibiotic utilization patterns and sensitivity patterns at the committee meetings, reports from the laboratory on sensitivity and resistant patterns over time (quarterly, yearly, and past years), review of antibiotic utilization over the past (quarter, year, and past years), distribution of educational materials to staff and clinicians on improving safe, effective use of antibiotics as well as material on prevention of overprescribing on a regular basis in conjunction and coordination with annual in-service education. Additionally, reports back to the provider on potential mis-prescribing or over-prescribing as identified by the infection control committee. Review of the Infection Prevention Program Policy identified the infection prevention program will identify, protect, and control infections. The infection prevention and control must maintain and document an infection control program which has its goal the prevention and control of infection and communicable diseases. The facility must maintain surveillance, identification, prevention, control, and investigation of infections and communicable diseases. The facility must provide infection control education to staff, residents, and caregivers. Surveillance data will be collected using the infection prevention report to determine any changes in the trends of infections. Additionally, it will identify the types of infections among its population and staff. If a problem is identified with an outbreak or infection cluster, control measures will be developed, and surveillance continues to determine whether the problem is being controlled. Reporting and analyzing infections will be conducted as required by state law and regulations.

Based on observation, review of facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #12 and Resident 105) reviewed for choices, the facility failed to ensure that hand soap was not provided as a body/hair wash, per the residents' preferences. The findings include: 1. Resident #12 was admitted to the facility in February 2023 with diagnoses that included paraplegia, morbid obesity, and irritant contact dermatitis due to friction or contact with body fluids. The quarterly MDS dated [DATE] identified Resident #12 had intact cognition, was dependent for bathing, toileting and personal hygiene, and was always incontinent of bowel and bladder.Interview with Resident #12 on 7/27/25 at 8:40 AM identified that the nurse aides use hand soap pink soap and a paper towel (disposable cloth) for bathing, hair washing, and incontinent care. Resident #12 indicated that he/she could no longer use the pink soap provided by the facility because his/her skin became too dry and combing his/her hair hurt following a wash with the pink soap. Resident #12 further indicated that he/she had told multiple staff members about his/her concerns with the pink soap, but the concerns were not addressed. Subsequently a family member has been purchasing hair and body wash products for the nurse aides to use for his/her bathing and incontinent care. 2. Resident #105 was admitted to the facility in August 2024 with diagnoses that included rash and non-specific skin eruption, protein-calorie malnutrition, and enterocolitis due to clostridium difficile. The quarterly MDS dated [DATE] identified Resident #105 had intact cognition and was independent with toileting and personal hygiene. Interview with Resident #105 on 7/27/25 at 9:00 AM identified that the pink soap used in the bathroom for hand washing was the same pink soap that was provided for showers and hair washing. Resident #105 indicated that the pink soap dried out his/her skin, and that he/she would only use water to wash his/her hair because the pink soap tore up his/her hair. Resident #105 identified that for a short (unspecified) time, a body and hair combination wash was provided, but the facility had since returned to the pink soap with a stack of disposable towels for bathing and hair washing. Observation and interview with Housekeeper #1 on 7/29/25 at 7:11 AM identified that he had used the bottle labeled Hand Soap Pink Perfect Mild Lotion Hand Cleaner to stock the entire house: including bathrooms, resident rooms, and shower rooms.Interview with NA #7 and NA #8 on 7/29/25 at 9:15 AM identified that earlier this year the body and hair wash used to bath residents was taken away, and they were informed that the pink soap, stocked in the bathrooms for handwashing, would be used for body and hair washing. NA #7 and NA #8 indicated that residents had complained that it was drying their skin and clumping their hair. NA #7 and NA #8 identified that they had notified the Director of Housekeeping that the pink soap was not working out, and she had indicated that she was told by corporate that was what the facility uses. Interview with Housekeeper #2 on 7/29/25 at 12:10 PM identified that she had been filling all of the shower rooms and bathrooms from the bottle labeled Hand Soap Pink Perfect Mild Lotion Hand Cleaner, for the last few months. Interview with NA #4 on 7/29/25 at 12:13 PM identified that she had been using the pink soap to clean and bathe residents, since May or June of this year.Review of the Product History document dated 7/29/25 identified that 23 gallons of Hand Soap- Pink were purchased between the dates of 4/15/25 through 7/26/25, and 4 gallons of Shampoo and Body Wash had been purchased in the last 2 years, on 6/20/25 and 6/30/25. Interview with the Director of Housekeeping on 7/30/25 at 4:16 PM, hire date 12/10/24, identified that the facility was already using the pink soap when she was first hired, and that the staff had complained to her that they were experiencing dry skin from using the product; it was not communicated to her that the residents were complaining of dry skin due to the pink soap. The Director of Housekeeping indicated that, in response to the staff's feedback, she ordered shampoo and body wash in June of 2025, but the staff had not provided feedback if the shampoo and body wash was an improvement or not, so when it ran out, they resumed using the supply of pink soap. The Director of Housekeeping further indicated that the residents' concerns about the pink soap were not brought to her attention by staff or during any of the resident council meetings that she had attended, but she would circle back to residents and staff for feedback and order whatever they like.Interview with the Administrator on 7/31/25 at 10:35 AM identified that during the 6/6/25 resident council meeting it was brought up that some of the residents did not like the pink soap and liked the shampoo and body wash better. The feedback was discussed with corporate, and he was told that the pink soap was meant to be a full body wash. The Administrator indicated that he was not aware that the soap referred to as pink soap was a hand soap. The Resident Rights policy directs that residents have the right to receive quality care and services with reasonable accommodation of individual needs and preferences, except when the health or safety of others would be endangered by such accommodation.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 6 residents (Resident #43, 65, 99 and 116) reviewed for abuse, the facility failed to protect Resident #43, 65, 99 and 115 from physical abuse by Resident #123, who had a history of resident-to-resident altercations, and injured Resident #99. The findings include:1a. Resident #65 was admitted to the facility in May 2019 with diagnoses that included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, schizophrenia, and obesity.The quarterly MDS dated [DATE] identified Resident #65 had intact cognition and required supervision with transfer, and locomotion on/off unit. Additionally, Resident #65 had no physical and verbal behaviors directed toward others. The care plan dated 3/9/23 identified Resident #65 had diagnoses of dementia and was at risk for impaired decision making. Interventions included to administer medications as ordered. Encourage to attend preferred recreational activities.The physician's order dated 5/1/23 directed Resident #65 was independent with bed mobility, transfer, and ambulation. No assistive device was needed.The nurse's note dated 5/9/23 at 4:57 PM identified RN #5 was called to the front desk. Receptionist #1 reported she observed Resident #65 chasing Resident #123 and grabbed Resident #123 by his/her shirt. Resident #65 said to Resident #123 do not put your hands on me again. Both residents were immediately separated by Receptionist #1. The investigation identified Resident #123 asked Resident #65 at the cafe area for a cigarette and Resident #65 reply no. Resident #123 then kicked Resident #65 on the right leg which led to the chase. RN assessment provided with no redness, no swelling to the right leg. The care plan dated 5/9/23 identified Resident #65 had a resident-to-resident altercation. Resident #65 was kicked by another resident on the right leg and Resident #65 chased the resident and grabbed him/her by the shirt. Interventions included to provide psychiatry and social worker support. Educate and encourage to approach staff and report any incidents for prompt interventionThe psychiatric evaluation and consultation form dated 5/9/23 identified the psychiatric APRN, APRN #2 was asked to evaluate Resident #65 who was alleged to have had an altercation with Resident #123. Resident #65 reported Resident #123 kicked him/her on the leg because he/she had refused to give him/her a cigarette. Resident #65 reported he/she did not hit or kick Resident #123. Resident #65 was placed on 1:1 monitor until evaluated by psychiatrist. Resident #65 was encouraged to talk to the nursing staff if there are issues with another resident. No adjustment of resident medications at this time. Considering Resident #65 was not a danger to himself or other at that time, Resident #65 was cleared. Discontinue 1:1 monitoring. Continue with current psychiatric medication as ordered.The social service note dated 5/9/23 at 4:18 PM identified SW #4 checked with Resident #65 regarding the incident that occurred. Resident #65 reported no issues or complaints.b. Resident #123 was admitted to the facility in July 2020 with diagnoses that included major depressive disorder, anxiety disorder, schizophrenia, paranoid personality disorder, and psychosis. The annual MDS dated [DATE] identified Resident #123 had moderately impaired cognition and required supervision with transfer and locomotion off on/off unit. Additionally, Resident #123 had no physical and verbal behaviors directed toward others. The care plan dated 4/20/23 identified Resident #123 was in a physical altercation with another resident. Interventions included psychiatric services as needed. Encourage the resident to seek out the staff when having difficulty with other residents.The physician's order dated 5/1/23 directed Resident #123 was independent with bed mobility, transfer, and ambulation. No assistive device was needed.A reportable event form dated 5/9/23 at 10:48 AM identified Resident #65 was kicked by Resident #123. Both residents were separated immediately. Resident #65 was placed on 1:1 monitoring. Resident #65 was evaluated by psychiatrist and cleared. The social service note dated 5/9/23 at 2:00 PM identified SW #4 checked with Resident #123 post resident to resident altercation. Resident #123 indicated he/she vehemently pursued Resident #65 because he/she refused to offer him/her a cigarette. Educated interventions of self-control and mood management are ineffective because of diminutive duration, as evidence of Resident #123 inability to preserve focus or maintain presence for an extended period. The nurse's note dated 5/9/23 at 4:37 PM identified RN #5 after the resident to resident altercation Resident #123 was placed on 1:1 monitoring immediately. Resident #123 refused assessment and was not cooperative with further questioning and stated to leave him/her alone he/she was ok. Resident #123 pending PEC (physician's emergency certificate) and to be sent to a facility in AM. The psychiatric evaluation and consultation form dated 5/9/23 identified Resident #123 was with increasing psychosis and assaultive behavior as well as non-adherence to medications. Transfer to inpatient geropsychiatric hospital once a bed is available. Resident #123 has a history of gradual dose reduction failure. At this time Resident #123 is considered a danger to self and others. The care plan dated 5/9/23 identified Resident #123 had acute agitation. Interventions included safeguarding the safety of the resident, or other residents, and others in the area. Help the resident manage their emotions by asking and offering a drink. A verbal statement by Resident #65 written by the previous Administrator #1 with no date and time. Resident #65 indicated Resident #123 asked him/her for a cigarette and he/she told Resident #123 no. Resident #65 indicated Resident #123 kicked him/her and ran and he/she chased Resident 123.A verbal statement by Resident #123 written by the previous Administrator #1 with no date and time. Resident #123 indicated he/she asked Resident #65 for a cigarette and Resident #65 said no. Resident #123 indicated that it was not nice, so I kicked him/her. Resident #123 indicated Resident #65 ran after me and grabbed my shirt.A written statement by Receptionist #1 dated 5/9/23 at 10:39 AM identified she witnessed Resident #123 running towards her saying he's/she's coming. Resident #65 ran after Resident #123 and asked him/her was he/she crazy and told him/her never to put his/her hands on him/her again. Receptionist #1 indicated she intervened and separated both residents and called the supervisor.A written statement by NA #4 dated 5/9/23 at 10:39 AM identified she was walking to the kitchen and heard Receptionist #1 saying no to Resident #65. NA #4 indicated she ran to the front desk area and saw Resident #65 grabbing Resident #123 shirt. The summary form dated 5/16/23 identified RN assessment performed to Resident #65 and resident did not sustain any bruising or skin tear as a result of the incident. Resident #65 did not hit Resident #123. Resident #65 was evaluated by psychiatrist and cleared. Resident #123 was placed on 1:1 monitoring. Both resident care plans had been updated. The summary form dated 5/17/23 identified Resident #123 remained on 1:1 monitoring after the incident until transferred to hospital on 5/10/23.The nurse's note dated 5/26/23 at 8:35 PM identified Resident #123 was readmitted to the facility at 1:30 PM with diagnoses of schizoaffective disorder, aggressive behavior of adult. Resident #123 was noted to have multiple medication adjustments. The APRN and the conservator updated of readmission. Will continue to monitor.Although attempted, an interview with the previous Administrator, (Administrator #1), previous DNS (DNS #1), RN #5, NA #4, and Receptionist #1 was not obtained. Review of the facility abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy identified the policy of the facility is to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation. Physical abuse: the intentional infliction of physical pain, bodily harm, or physical coercion. 2a. Resident #99 was admitted to the facility in June 2021 with diagnoses that included takotsubo syndrome, schizoaffective disorder, anxiety disorder, borderline personality disorder, and obesity. The quarterly MDS dated [DATE] identified Resident #99 had intact cognition and required supervision with transfer and locomotion on/off unit. Additionally, Resident #65 had no physical and verbal behaviors directed toward others. The physician's order dated 9/1/23 directed independent bed mobility, transfers, and ambulation using rollator walker.The nurse's note dated 9/28/23 at 4:30 PM by the ADNS identified she heard a loud sound coming from a resident room. The ADNS observed Resident #99 on the floor with Resident #123 who was hitting Resident #99 on the head. The ADNS immediately separated both residents, provided first aid to Resident #99, and an RN assessment performed. Resident #99 was placed on 1:1 monitoring and sent to the hospital for further evaluation. The hospital documentations dated 9/28/23 identified Resident #99 presented for evaluation after an assault at a nursing facility. Resident #99 fell backwards and struck the back of head, no loss of consciousness. Resident #99 had mild pain to the back of head. Resident #99 had a small laceration with hematoma to the left back of head. The laceration was small and does not require sutures or staples for closure. The laceration was cleansed and closed with Steri-Strips. CT scan of head negative. Resident #99 was discharged back to the nursing facilityThe APRN note dated 9/29/23 at 9:18 AM identified Resident #99 was seen for a follow up hospital visit with diagnoses of laceration of scalp. The CT scan of the head was negative. Resident #99 was doing well this morning and denied headache. b. Resident #123 was admitted to the facility in July 2020 with diagnoses that included major depressive disorder, anxiety disorder, schizophrenia, paranoid personality disorder, and psychosis. The care plan dated 5/9/23 identified Resident #123 had kicked another resident on the leg. Interventions included the resident was educated and encouraged not to hit any peers or staff members, safeguarding the safety of the resident, or other residents, and others in the area. Help the resident manage their emotions by asking and offering a drink. The quarterly MDS dated [DATE] identified Resident #123 had severely impaired cognition and was independent with transfer and locomotion off/on unit. Additionally, Resident #123 had exhibited physical and verbal behaviors toward others. The summary form dated 10/1/23 identified Resident #123 was diagnosed with urinary tract infection and exacerbation of schizophrenia. Resident #123 was treated for urinary tract infection. Resident #99 has a stop sign at his/her room door. Both residents received support from the facility psychiatrist team and social service department. Both resident care plans were updated.Although attempted, an interview with the previous Administrator (Administrator #1), and previous DNS (DNS #1) were not obtained. Review of the facility abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy identified the policy of the facility is to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation. Physical abuse: the intentional infliction of physical pain, bodily harm, or physical coercion. 3a. Resident #116 was admitted to the facility in October 2023 with diagnoses that included schizoaffective disorder, bipolar disorder, and congestive heart failure. The annual MDS dated [DATE] identified Resident #116 had intact cognition and required supervision or touching assistance with bed mobility, transfer and walking 10 feet. Additionally, Resident #116 had no physical and verbal behaviors directed toward others. The nurse's note dated 1/10/24 at 7:03 PM by RN #3 identified at 4:00 PM she was informed by the Director of Recreation that Resident #116 was hit by Resident #123 during smoking break. Both residents were separated immediately and placed on 1:1 monitoring. Resident #116 indicated he/she asked Resident #123 to move, and Resident #123 hit him/her on the mouth. RN assessment performed no redness or swollen noted to mouth. Resident #116 refused to be transferred to the hospital and indicated he/she was ok. Resident #116 is responsible for self. The APRN and the police were notified. The psychiatrist APRN was notified and cleared resident off monitoring. The care plan dated 1/10/24 identified Resident #116 was involved in a resident-to-resident altercation. Interventions included keeping the resident at a designated chair away from the other resident during smoking break. Offer psychiatrist and social services support.b. Resident #123 was admitted to the facility in July 2020 with diagnoses that included major depressive disorder, anxiety disorder, schizophrenia, paranoid personality disorder, and psychosis. The care plan dated 9/28/23 identified Resident #123 had previously hit and kicked other residents. Interventions included safeguarding the safety of the resident, or other residents, and others in the area. Help the resident manage their emotions by asking and offering a drink. The quarterly MDS dated [DATE] identified Resident #123 had severely impaired cognition and was independent with transfer and locomotion off/on unit. Additionally, Resident #123 had exhibited physical and verbal behaviors toward others. The nurse's note dated 1/10/24 at 4:45 PM by RN #3 identified at 4:00 PM she was informed by the Director of Recreation that Resident #123 slapped Resident #116 on the face during smoke break. Both residents were separated immediately and placed on 1:1 monitoring. Resident #123 indicated Resident #116 swore at him/her, so he/she slapped him/her. Resident #123 was transferred to the hospital for psychiatric evaluation at 4:30 PM. The care plan dated 1/10/24 identified Resident #123 had hit another resident during smoking break. Interventions included keep Resident #123 at a designated chair away from the other resident during smoking break. The reportable event form dated 1/10/24 at 4:00 PM identified Resident #123 slapped Resident #116 in the face during smoking break. Resident #123 indicated Resident #116 swore at him/her. A written statement by the Director of Recreation dated 1/10/24 at 4:00 PM identified during smoking break Resident #123 got mad at Resident #116 and hit him/her in the face. The Director of Recreation indicated Resident #123 then left the courtyard. The Director of Recreation indicated both residents were immediately separated, and the supervisor was notified. The summary form dated 1/18/24 identified Resident #116 indicated Resident #123 sat next to him/her during smoke break. Resident #116 indicated he/she asked Resident #123 to move away because he/she attracts bad things. Resident #116 hit him/her in the face. No altercation or disagreement had occurred between the two residents prior to this incident. Resident #123 was currently in an inpatient psychiatric hospital, for medication review and treatment. Resident #123 will receive continued support from psychiatric and social services upon return. Resident #116 had received psychiatric and social services support. Each resident has a designated seat away from each other during smoking breaks.Although attempted, an interview with Administrator #1, and DNS #1 were not obtained. Review of the facility abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy identified the policy of the facility is to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation. Physical abuse: the intentional infliction of physical pain, bodily harm, or physical coercion. 4a. Resident #43 was admitted to the facility in January 2020 with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety disorder, and depressive disorder.The quarterly MDS dated [DATE] identified Resident #43 had severely impaired cognition and was independent with bed mobility, transfer, and ambulation. Additionally, Resident #43 had no physical and verbal behaviors directed toward others. The nurse's note dated 2/2/24 at 3:38 PM by LPN #8 identified at 2:30 PM she observed Resident #43 leaning against the wall. Resident #43 indicated his/her roommate (Resident #123) punched him/her in the face. Resident #43 appeared to be confused. The DNS and the ADNS were notified. Resident #43 was placed on 1:1 and neurological assessment initiated. Resident #43 was transferred to the hospital for further evaluation at 2:30 PM. The nurse's note dated 2/2/24 at 5:06 PM by the ADNS identified Resident #43 reported to a nurse aide that he/she was punched in the face by another resident. Resident #43 was observed with a red mark on the center of his/her face, Resident #43 complained of headache, noted of increased confusion, no bleeding or loss of conscious, neurological assessment started. RN assessment was performed. Resident #43 was separated immediately and placed on 1:1 monitoring. The DNS, Administrator, police, APRN, and the power of attorney were notified. The care plan dated 2/2/24 identified Resident #43 was involved in an altercation where he/she was hit by roommate. Interventions included providing psychiatric and social services support. Allow the resident to talk through stressors and provide reassurance. b. Resident #123 was admitted to the facility in July 2020 with diagnoses that included major depressive disorder, anxiety disorder, schizophrenia, paranoid personality disorder, and psychosis. The quarterly MDS dated [DATE] identified Resident #123 had severely impaired cognition and was independent with transfer and locomotion off/on unit. Additionally, Resident #123 had exhibited physical and verbal behaviors toward others. The care plan dated 1/10/24 identified Resident #123 had hit another resident during smoking break. Interventions included keep Resident #123 at a designated chair away from the other resident during smoking break. The nurse's note dated 2/2/24 at 5:22 PM by the ADNS identified the DNS reported Resident #123 had a physical altercation with Resident #43. Resident #123 hit/punched Resident #43 in the face. Resident #123 believed Resident #43 took his/her bag. Resident #123 was observed with increased agitation and verbally abusive with the DNS. Resident #123 was placed on 1:1 monitoring. Resident #123 was transferred to the hospital for further evaluation. The APRN, police, and Resident #123's power of attorney were notified. The care plan dated 2/2/24 identified Resident #123 hit his/her roommate. Interventions included to remove other residents when Resident #123 is observed to be in an agitated state. If unable to deescalate the situation call 911.The reportable event form dated 2/2/24 at 2:00 PM identified Resident #123 hit Resident #43 in the face. Resident #123 alleges that Resident #43 took his/her bookbag and hid it in his/her purse. Resident #43 reported that he/she was hit in the face by Resident #123. Both residents were separated immediately, placed on 1:1 monitoring, and taken to the hospital for evaluation. The Administrator, police, APRN, and the resident representative were notified.The summary form dated 2/12/24 at 8:15 PM identified Resident #43 has been relocated to another unit. Both residents are receiving psychiatric and social services support. A search has underway to get Resident #123 into a psychiatric long term facility.Resident #123 was discharged to another facility on 3/18/24.Although attempted, an interview with the previous Administrator (Administrator #1), and the previous DNS (DNS #1) were not obtained. Review of the facility abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy identified the policy of the facility is to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation. Physical abuse: the intentional infliction of physical pain, bodily harm, or physical coercion.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 8 residents (Resident #7 and 79) reviewed for range of motion and/or behaviors, the facility failed to develop and implement a comprehensive care plan for a resident with a contracture and a resident exhibiting disruptive behaviors. The findings include: Resident #7 was admitted to the facility in January 2025 with diagnoses that included dementia, cerebral infarction, and adult failure to thrive. The admission observation dated 1/3/25 identified Resident #7’s hand grasp strength was stronger on one side than the other side due to a right-hand contracture: Resident #7 presented with a contracture of the right hand and wrist joint. The care plan dated 7/15/25 failed to address Resident #7’s right-hand contracture and failed to identify therapeutic and nursing interventions and functional goals/outcomes. The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition and had no upper extremity impairment. (The MDS failed to identify the right-hand contracture). Interview with the MDS Coordinator (LPN #14) on 7/30/25 at 5:38 PM identified that Resident #7 was not coded as having a contracture, and therefore she was unaware of the contracture. The ICD code for the diagnoses would have prompted her to document the contracture in the MDS and to create a care plan with appropriate interventions and therapy recommendations, as needed. Interview with the DNS on 7/30/25 at 6:00 PM identified that she would expect a comprehensive, interdisciplinary care plan for Resident #7’s contracture to have been developed. The DNS indicated that it would be the primary responsibility of the MDS Coordinator to develop the care plan, but any nurse could initiate a care plan. The facility’s Nursing Services policy directs that a consistent and interdisciplinary approach to the prevention, identification, treatment, and monitoring of contractures among residents is established. Thereby promoting functional independence, optimizing range of motion, and enhancing quality of life. The policy further directs that for residents at risk or with existing contractures, an individualized care plan shall be developed by the interdisciplinary team and collaboration with the resident and or responsible party. Care plans must address specific joints affected, therapy interventions (e.g., PT/OT), use of splints, positioning aids or orthotics, nursing interventions (e.g., ROM exercises, turning/repositioning schedule), functional goals, and expected outcomes. 2. Resident #79 had diagnoses that included schizoaffective disorder and post-traumatic stress disorder (PTSD). The quarterly MDS dated [DATE] identified Resident #79 required 1 person assist with transfers and toileting and had not exhibited any recent behavior symptoms. The care plan dated 6/5/25 identified Resident #79 had a diagnosis of PTSD and was an active smoker. Interventions included to assess the resident for anxiety and mood swings, identify triggers while addressing resident needs, and ensure the resident abides by the smoking policy. Physician’s order dated 7/10/25 directed to administer Nicotine Lozenge 4mg every 2 hours as needed for nicotine dependence. The July 2025 MAR identified a Nicotine Lozenge was last administered on 7/27/25 at 6:51 PM. Observation on 7/28/25 at 7:40 AM identified Resident #79 self-propelling to the nurse’s station where LPN #12 was inside the medication room visible through a half glass door. Resident #79 requested a lozenge. LPN #12 opened the medication door and informed Resident #79 that he/she would need to take a shower first. In response, Resident #79 began yelling, stating, “I don’t want to shower first, I want my lozenge now.” The nurse continued to repeat the instruction for the resident to shower first while Resident #79 was observed becoming increasingly agitated, yelling and screaming profanities at the nurse and stated “I am not feeling well.” An interview with LPN #12 on 7/28/25 at 7:40 AM identified she was the assigned nurse for the 11:00 PM to 7:00 AM shift 7/27/25 overnight to 7/28/25 and was counting controlled medications with the oncoming nurse. LPN #12 identified she had previously notified the nursing supervisor regarding Resident #79’s behavior but was unable to provide information on interventions to be implemented to address Resident #79’s escalating behaviors. Further observation identified LPN #12 closed the medication room door without any further intervention or redirection in response to Resident #79’s escalating behavior. Resident #79 self-propelled back down the hall, continually yelling and screaming profanities. An interview with RN #1 on 7/28/25 at 7:48 AM identified she was the assigned nursing supervisor for the 11:00 PM to 7:00 AM shift 7/27/25 overnight to 7/28/25. RN #1 identified she had not previously been notified of any concerning behaviors related to Resident #79 during the shift. RN #1 identified Resident #79 could occasionally get loud, disruptive and accusatory, sometimes requiring hospital transfer. RN #1 identified sitting with and allowing Resident #79 to talk about events would help to redirect the residents behaviors. RN #1 further identified Resident #79 should have received the lozenge when requested to prevent the escalating behavior. An interview with LPN #12 on 7/28/25 at 7:55 AM identified she was in the process of counting controlled medications with the oncoming nurse when Resident #79 approached her at the nurse’s station. LPN #12 indicated she put up her finger to gesture she was busy; however, Resident #79 continued to yell and scream profanities. According to LPN #12, she continued to put up her finger towards Resident #79 who should have known to wait. LPN #12 was unable to articulate what interventions should have been implemented to prevent or to de-escalate behaviors during the incident. An interview with the DNS on 7/28/25 at 8:02 AM identified Resident #79 had been known to hallucinate, make accusatory statements, and could become agitated, at times requiring a hospital transfer for evaluation. The DNS identified Resident #79 responded well to redirection through changes in activity or engaging in active listening. The DNS further identified LPN #12 should have paused the task, determined whether the medication could be administered, and notified the nursing supervisor. A subsequent interview with the DNS on 7/30/25 at 2:30 PM identified she would expect staff to follow the care plan regarding Resident #79’s escalating behavior. Although requested a policy for implementing the plan of care was not provided.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #7, 10, 17 and 100) the facility failed to provide care according to professional standards.For 1 of 2 residents (Resident #7) reviewed for range of motion, the facility failed to provide treatment and care in accordance with professional standards, for a resident with a contracture.For 1 of 5 residents (Resident #10) reviewed for unnecessary medications, the facility failed to ensure that a resident with a history of hyperglycemia was assessed by a Registered Nurse following an elevated blood sugar.For 1 of 4 residents (Resident 17) reviewed for medication administration, the facility failed to ensure a self-administration assessment was completed for safety prior to leaving medication at the bedside.For 1 of 3 residents (Resident #100) reviewed for non-pressure ulcer, the facility failed to ensure the physician's orders were followed related to applying ace wraps and weekly skin checks. The findings include: 1. Resident #7 was admitted to the facility in January 2025 with diagnoses that included dementia, cerebral infarction, and adult failure to thrive. The admission observation dated 1/3/25 identified Resident #7’s hand grasp strength was stronger on one side than the other side due to a right-hand contracture: Resident #7 presented with a contracture of the right hand and wrist joint. The admission MDS dated [DATE] identified Resident #7 had severely impaired cognition and had no upper extremity impairment. (The MDS failed to identify a right-hand contracture). The physician’s order dated 3/11/25 directed for skin checks every shift, days, evening, and nights. The care plan dated 7/15/25 identified Resident #7 was at risk for pain. Interventions included observing for non-verbal signs of pain, positioning for comfort, providing medical management for underlying cause of pain, and PT/OT referral as indicated. The care plan failed to address Resident #7’s contracture and failed to identify therapeutic and nursing interventions and functional goals/outcomes. The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition and had no upper extremity impairment. (The MDS failed to identify a right-hand contracture). Review of the physician’s orders failed to identify an interdisciplinary approach to monitor, manage, and treat Resident #7’s contracture. The nurse’s note dated 1/3/25 through 7/29/25 failed to identify documentation of on-going assessments specific to the contracture, monitoring skin integrity of the area of the contracture, or nursing interventions for the care Resident #7’s contracture. Interview with LPN #3 on 7/27/25 at 11:11 AM identified that she had worked for the facility for 6 months. LPN #3 indicated Resident #7’s right hand was contracted and that the resident goes to therapy, but she was not sure if an orthotic or splint had ever been ordered for the resident. Intermittent observations between 7/27/25 and 7/29/25 identified Resident #7’s right hand and wrist are contracted. Digits #2 and 3 are closed tightly with light yellow crust in between. Digit #1 is set under digits #2 and 3. The top portion of digit #1 was exposed in between digit #3 and 4. Digits #4 and #5 were closed tightly with digit #4 slightly laying on top of digit #5 and light-yellow crust in between the digits. Resident #7 exhibited facial grimacing when staff members attempted to gently move any of the digits. Interview and observation with NA #5 on 7/29/25 at 1:55 PM identified that she was not Resident #7’s regular nurse aide; she was a float and worked on this unit about once a week. NA #5 indicated that it was hard to get in between Resident #7’s fingers and palm of the contracted hand because it was so tight and painful. NA #5 identified that the yellow crust between the contracted fingers was not present when she last provided care for the resident approximately 2 weeks ago. NA #5 indicated she had cleaned the area earlier in the morning but could not remove all the crust because it was painful for the resident. NA #2 indicated that she did not notify the nurse of Resident #5’s pain during care because the pain was not new. Interview and observation with LPN #4 on 7/29/25 at 2:06 PM identified that she was not aware of the crust between Resident #7’s contracted fingers, and that usually there is a little piece of gauze in between the fingers and palm; she was unaware of any specific orders for the care of the contracture, but would notify OT that there was crust in the area of the contracture to find out how to best manage the area. Interview and observation with APRN #1 on 7/30/25 at 10:40 AM identified that Resident #7’s contracture was present on admission to the facility. APRN #1 further identified that she has observed some redness and dryness on the skin around the contracture, in the past, but was not aware of the yellow crust between his/her fingers. APRN #1 indicated that she would discuss recommendations with OT to protect the skin from experiencing any breakdown and refer Resident #7 to be seen by the Wound Specialist. APRN #1 further indicated that she was unaware that Resident #7 was having pain during care in the area of the contracture, and she would put in an order for Tylenol for pain management. Interview with the DNS on 7/30/25 at 5:10 PM identified that after OT assessed the contracture, an interdisciplinary plan should have been put in place, then orders would need to be put into the system to prevent further contracture and skin breakdown, based on the OT’s recommendations. The DNS indicated that on-going monitoring of Resident #7’s skin for breakdown in the area of the contracture should be completed every shift and as needed. The DNS indicated that she would sit with OT and the APRN to put appropriate orders in place to prevent skin breakdown and further contracture. Interview with the Medical Director (MD #1) on 7/31/25 at 11:40 AM identified that he would expect a plan between OT and nursing services to be put into motion to ensure Resident #7 had documented interventions in place to maintain skin integrity and to prevent further decline of the contracture. The facility’s Nursing Services policy directs that a consistent and interdisciplinary approach to the prevention, identification, treatment, and monitoring of contractures among residents is established. Thereby promoting functional independence, optimizing range of motion, and enhancing quality of life. The policy further directs that upon admission, nursing and therapy staff shall conduct a comprehensive functional mobility and muscular skeleton assessment. Risk factors for contracture development shall be identified and range of motion shall be evaluated and documented by therapy at admission, quarterly, and with significant change in condition. Therapy services interventions include evaluating for and implementing therapeutic exercises, manual stretching, positioning, and splinting, and training nursing staff and caregivers in techniques for safe range of motion exercises and positioning. Nursing interventions include performing passive/active range of motion exercises per the care plan, at least daily or as ordered, ensuring proper application and monitoring of splints/positioning devices, and maintaining correct body alignment during bed rest and wheelchair use. Monitoring and reassessment interventions should include monitoring skin integrity under devices at least once per shift and monitoring for any signs of pain, skin breakdown, or decline in function and reporting changes immediately to the charge nurse and therapy. All assessments, interventions, and resident responses must be documented and the clinical record. 2. Resident #100 was admitted to the facility in April 2023 with diagnoses that included lymphedema, acute kidney injury, and hypertension. The annual MDS dated [DATE] identified Resident #100 had intact cognition, required maximum assistance for dressing, putting on footwear, and personal hygiene and had 2 venous or atrial ulcers present. The care plan dated 5/20/25 identified Resident #100 has venous ulcers to the bilateral lower extremities. Interventions included providing wound treatments as ordered and wrapping both legs with compression socks. a. A vascular consultation dated 6/17/25 identified Resident #100 needs compression stockings or ace wraps to both legs from the ankle to the knee every morning and remove at bedtime. A wound note, written by MD #2 dated 6/18/25 identified Resident #100 has venous statis dermatitis to both lower extremities and venous statis ulcers to the left lateral leg, right superior leg, right inferior leg, and left inferior leg. Resident #100 was seen by vascular yesterday and recommendations included wrapping legs with compression stockings or ace wraps from the feet to the knees every morning and remove at bedtime. A physician’s order dated 6/19/25 directed to cleanse bilateral lower extremities with soap and water, rinse and dry well. Apply ammonium lactate 12% lotion to intact skin. Apply calcium alginate with silver to open areas, gauze to open wound, and xeroform to any blister and cover with a dry clean dressing twice daily and as needed. Apply ace wraps to bilateral lower extremities from the toes to the base of the knees. Ace wraps on in the morning and off at bedtime. Observation of Resident #100 on 7/27/25 at 10:21 AM identified the resident was seated in his/her wheelchair in the recreation room wearing shorts with feet dependent on the floor. Resident #100 has bilateral lower extremities wrapped with kerlix which is not dated. Resident #100 was without the benefit of ace wraps per the physician’s order. Observation on 7/27/25 at 1:15 PM identified Resident #100 was sitting in his/her wheelchair in the dining room wearing shorts with feet on the floor. The bilateral lower extremities are wrapped with kerlix, and the resident is without the benefit of the ace wraps. Observation on 7/28/25 at 10:00 AM identified Resident #100 was sitting in the unit dining room in the wheelchair wearing shorts with his/her feet on the floor. The bilateral lower extremities are wrapped with kerlix dated 7/27/25 3:00 PM to 11:00 PM, and the resident is without the benefit of the ace wraps. Observation of Resident #100 on 7/28/25 at 12:00 PM, 1:00 PM, and 1:50 PM identified the resident was sitting in the unit dining room in the wheelchair in a pair of shorts with his/her legs dependent wrapped in kerlix, feet on the floor. Resident #100 was without the benefit of ace wraps. Interview with LPN #2 on 7/28/25 at 1:52 PM indicated that the nurse aides got Resident #100 up this morning before she got to do the treatments today because she was busy doing the medication pass this morning and did not have time to do the treatments. LPN #2 indicated that she did not inform the supervisor or ask for assistance. LPN #2 indicated that sometimes she does the treatments in the mornings and sometimes in the afternoons, depending on the day. LPN #2 indicated the physician’s order says to put the ace wraps on in the morning, but the nurse aides sometimes get Resident #100 up out of bed before she can get to do the treatments with the ace wraps. After surveyor inquiry, LPN #2 indicated that she plans on doing Resident #100’s treatments now including putting on the ace wraps. Interview with MD #2 (wound physician) on 7/30/25 at 7:54 AM identified he had spoken with the vascular physician regarding wanting to continue to apply ace wraps versus the compression stockings. MD #1 indicated they decided the ace wraps were better for Resident #100’s edema and vascular wounds. MD #2 indicated the ace wraps must be applied to both legs before Resident #100 gets out of bed to give some compression to reduce edema and help with the venous return and circulation. MD #2 identified without the ace wraps the edema will increase. Interview with the DNS on 7/30/25 at 10:09 AM indicated the charge nurse was responsible to do the treatments on the unit and sometimes the supervisor will help the charge nurse with their treatments if the nurse notifies the supervisor they need assistance. The DNS indicated the ace wraps per the physician’s order should have been applied before Resident #100 gets out of bed daily and removed at bedtime. Review of the Compliance with and Implementation of Physician Orders Policy identified to ensure that all physicians orders are implemented accurately, timely, and in accordance with federal and state regulations. The IDT team, under the direction of the DNS, is responsible for verifying that services ordered by a physician or authorized provider are provided as prescribed. b. A physician’s order dated 4/29/25 directed to perform weekly body audits on shower days scheduled Thursday 7:00 AM to 3:00 PM. Review of the weekly skin checks dated 5/1/25 - 7/30/25 identified 3 out of 13 were completed. Interview with the DNS on 7/30/25 at 10:00 AM indicated that charge nurses were responsible to perform a weekly body audit on every resident based on the physician order. The DNS indicated the nurses must fill out the weekly skin check after inspecting the resident from head to toe. After clinical record review, the DNS indicated that the only completed weekly skin checks completed were done on 5/8, 6/12, and 6/19/25. The DNS indicated the skin checks are done and documented to identify if there are any new skin concerns or breakdown. Interview with APRN #1 on 7/30/25 at 11:01 AM identified the expectation is that nurses follow the physician’s orders. APRN #1 indicated the nurse is responsible to do a weekly head to toe assessment of the residents skin when the resident has a shower. APRN #1 indicated the nurses must document their assessment. Review of the Weekly Skin Check Policy identified this was to ensure residents’ skin is observed and the assessment is documented. Skin checks are completed by the nurse on the resident’s shower day and entered into matrix observation forms. Document all areas of concern on the skin sheet. Notify the wound nurse and physician of all areas of concern. Document in the medical record on the weekly skin check form. 3. Resident #17 was admitted to the facility in June 2024 with diagnoses that included aspiration pneumonia, poor vision, blindness in one eye, cataracts, visual hallucinations, and nicotine dependance. The self-administration assessment dated [DATE] at 11:28 AM identified Resident #17 did not want to self-administer medications. The self-administration assessment for a quarterly evaluation dated 12/16/24 at 10:16 PM identified Resident #17 did not want to self-administer medications. A physician’s order dated 6/14/25 directed to administer Budesonide-Formoterol HFA aerosol inhaler 160-4.5 mcg/actuation give 2 puffs twice a day. The care plan dated 6/24/25 identified at Resident #17 had decreased mobility and poor vision. Interventions included to orient Resident #17 to environment and placement of items. The July 2025 MAR identified Budesonide-Formoterol HFA aerosol inhaler 160-4.5 mcg/actuation was given late 32 out of 61 times and on 7/31/25 at 9:00 AM the medication was not available. The quarterly MDS dated [DATE] identified Resident #17 had intact cognition and required touching assistance with dressing and personal hygiene. The physician’s note dated 7/21/25 identified Resident #17 has acute chronic cough with increased phlegm, dark colored sputum, no blood in sputum. Medication observation on 7/31/25 at 10:20 AM identified RN #1 prepared medication for Resident #17. After RN #1 gave Resident #17 his/her medications, RN #1 informed Resident #17 she did not have the Budesonide-Formoterol Inhaler. Resident #17 indicated he/she was aware because it has been at his/her bedside for about 2 months. Resident #17 reached for the Budesonide-Formoterol Inhaler, which was on the top of the nightstand at the bedside. RN #1 indicated the Budesonide-Formoterol Inhaler was not dated when opened and must be discarded. RN #1 identified she would order a new Budesonide-Formoterol Inhaler from the pharmacy. RN #1 asked Resident #1 which nurse had provided him/her with the Budesonide-Formoterol Inhaler and Resident #17 indicated that he/she did not recall because it has been a couple of months now. Resident #17 indicated he has not used the Budesonide-Formoterol Inhaler for at least a month. Interview with Resident #17 on 7/31/25 12:20 PM indicated that the nurses were not giving him/her the Budesonide-Formoterol Inhaler when he/she needed it so about 2 months ago the nurse left it with him/her to use as needed. Resident #17 indicated that he/she was using the Budesonide-Formoterol Inhaler multiple times a day because when he/she laid down, he/she would get short of breath so he/she would sit up and use the inhaler during the day and at night. Resident #17 indicated that recently his/her physician had made some medication changes, and he/she has not used the Budesonide-Formoterol Inhaler in at least the last month because he/she does not need it any longer. Resident #17 did not know the name of the Budesonide-Formoterol Inhaler or how many times a day it should be taken. Interview with the DNS on 7/31/25 at 10:54 AM identified residents cannot self-administer medications or inhalers with a nurse doing a self-administration assessment first. The DNS indicated if the resident was able to self-administer any inhalers or medications it would be specific on the assessment and the nurse would get a physician order for the medication or inhaler. After clinical record review, the DNS indicated that Resident #17 does not have a self-administration assessment for the Budesonide-Formoterol Inhaler. The DNS indicated if Resident #17 was able to self-administer the Budesonide-Formoterol Inhaler, the charge nurse would be responsible to hand the Budesonide-Formoterol Inhaler to the resident for use only and keep the Budesonide-Formoterol Inhaler in the medication cart when not in use. Review of the facility Self-Administration of Medications Policy identified residents of the facility may self-administer medications if the interdisciplinary team, including a licensed nurse and a prescribing practitioner, determines that it is safe for them to do so. The procedure includes a licensed nurse who will conduct a self-administration assessment to evaluate the resident’s cognitive status, physical ability to handle and take medication, understanding of medication regimen, and willingness to self-administer. A physician’s order or other prescriber must write an order approving self-administration and the order will be specific which medication the resident is allowed to self-administer. The medications must be stored in the nursing medication cart. Each time the resident has a scheduled medication or is requesting medication the nurse is responsible to deliver that medication to the resident for use and then the nurse will place it back into the cart. Residents will be reassessed at least quarterly, upon change in condition, or if concerns about self-administration arise. 4. Resident #10 was admitted to the facility in August 2023 with diagnoses that included traumatic brain injury, dysphagia, and diabetes with hypoglycemia. A physician’s order dated 12/11/24 directed to check blood sugars 4 times daily before meals (6:00 AM, 12:00 PM, 6:00 PM, 12:00 AM) and notify the physician for blood sugars less than 70 and/or greater than 400. A physician's order dated 1/25/25 directed may check blood sugars as needed. A physician’s order dated 2/6/25 directed for Glyxambi (an oral medication used to treat diabetes) 25-5 milligram tablet daily at 9:00 AM. A physician’s order dated 3/13/25 directed a no concentrated sweets/low carb diet to include 1/2 portion of starch with all meals. A physician’s order dated 3/17/25 directed to administer Lantus Insulin (a long-acting Insulin) 38 units nightly at 9:00 PM. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition and received daily Insulin. The care plan dated 7/11/25 identified Resident #10 was at risk for abnormal blood sugar levels including hypoglycemia and hyperglycemia due to diabetes. Interventions included to obtain finger sticks as ordered and report abnormal findings to the physician. Interventions also included to monitor the resident for signs and symptoms of hyperglycemia. Review of the clinical record dated 7/24/25 at 1:44 PM identified the residents blood sugar, obtained by LPN #4, was 436. Further, the clinical record failed to identify any additional documentation including a RN assessment of Resident #10’s condition at that time. Interview with APRN #1 on 7/30/25 at 12:07 PM Resident #10 was routinely non-compliant with diet orders and often purchased snacks and sodas from the facility vending machine. APRN #1 identified that Resident #10 had a recent history of large fluctuations between hypoglycemia and hyperglycemia and had been seen by an endocrinologist outside the facility but was discharged from his care 6/9/25 due to continued dietary noncompliance. APRN #1 also identified that no adjustments would be made to Resident #10’s current diabetic management due to the large fluctuations in blood sugar levels and the dietary noncompliance. APRN #1 identified that the order in place regarding Resident #10’s blood sugar levels was for nursing staff to notify her or the physician of any blood sugar levels less than 70 and greater than 400, especially given the large fluctuations in blood sugar levels. APRN #1 identified that LPN #4 was not the regular nurse assigned to care for Resident #10, and she had not been notified by LPN #4 regarding the high blood sugar on 7/24/25. APRN #1 also identified that if she had been notified of the elevated blood sugar on 7/24/25 it would have been documented in her notes in the clinical record. Interview with LPN #4 on 7/30/25 at 1:14 PM identified she was a float nurse at the facility and did not typically provide care for Resident #10. LPN #4 identified she could not recall if she notified the RN Supervisor of the resident’s high blood sugar but indicated she did notify APRN #1 on 7/24/25. LPN #4 was unable to identify if she notified APRN #1 in person or via phone, and identified she recalled APRN #1 discussing the possibility of additional Insulin for the resident. LPN #4 identified that before the end of her shift at 3:00 PM, she rechecked Resident #10’s blood sugar level without discussion with APRN #1 and identified the blood sugar was somewhere around the lower 300’s but could not identify the number. Review of the clinical record failed to identify documentation by LPN #4 related to a recheck of Resident #10's blood sugar level on 7/24/25 or that the resident had been assessed by a Registered Nurse. Interview with the DNS on 7/31/25 at 11:01 AM identified that the licensed nursing staff was expected to follow the physician’s orders including when to notify for abnormal findings. The DNS identified LPN #4 should have notified the APRN and the RN Supervisor regarding the elevated blood sugar. The facility policy on hyperglycemia management directed that the facility would promptly identify, monitor, and treat hyperglycemia in accordance with the physician's orders and identified hyperglycemia was a blood sugar greater than 180 (persistent or acute); and severe hyperglycemia, a blood sugar greater than 300 or symptomatic (i.e. polyuria, polydipsia, confusion) The policy further directed that residents with diabetes would have blood sugar monitoring per the physicians orders and staff would recognize signs and symptoms of hyperglycemia, which included: increased thirst (polydipsia), frequent urination (polyuria), fatigue, weakness, blurred vision, nausea and vomiting, confusion, or altered mental state. The policy further directed for blood sugar levels greater than 400 with altered mental status, vomiting Kussmaul respirations, or fruity breath odor, staff would call 911, follow facility emergency response protocol, monitor vital signs and initiate oxygen if indicated, and document interventions and notify family/POA. The policy also directed to record all blood sugar readings, symptoms, interventions, and provider notifications in the clinical record.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #77 and 82) reviewed for pressure ulcers, the facility failed to ensure weekly skin audits were completed and documented per the facility policy, and a specialty air mattress was set to the resident's weight per the physician's order. The findings include: Resident #77 was admitted to the facility in September 2021 with diagnoses that included peripheral vascular disease (PVD), obesity, and type 2 diabetes mellitus (DM). The quarterly MDS dated [DATE] identified Resident #77 had intact cognition, was dependent for toileting hygiene and bathing, required supervision for rolling left to right and sitting to lying, refused toilet transfers. Resident #77 had an indwelling catheter, was frequently incontinent of bowel, was at risk for developing pressure ulcers/injuries, and had one unstageable pressure ulcer. The care plan dated 7/20/25 identified Resident #77 was at risk for injury, impaired skin integrity and impaired tissue perfusion related to PVD. Interventions included reporting issues to the physician as needed and providing treatment, care, and lotion as needed for prevention. The care plan further identified Resident #77 had an unstageable pressure ulcer to the left buttock. Interventions included assessing the pressure ulcer first stage, size, and condition of the surrounding skin weekly. Review of the physician’s orders dated 2/1/25 through 7/27/25 failed to identify an order directing weekly skin checks. Subsequent to surveyor inquiry, a physician’s order dated 7/28/25 directed to complete weekly skin checks on shower days; once a day on Tuesdays 3:00-11:00 PM. Review of the clinical record dated 2/1/25 through 7/30/25 failed to identify documentation that weekly skin checks were being completed. Interview with APRN #1 on 7/30/25 at 11:02 AM identified that she would expect nurses to complete and document skin checks weekly and as needed, if a skin concern was identified by a nurse aide. APRN #1 indicated that weekly skin checks were important to monitor for changes occurring week to week. Interview and review of the clinical record with the DNS on 7/30/25 at 6:00 PM failed to identify a physician’s order for weekly skin checks, per the facility policy, and failed to identify documentation that weekly skin checks were being completed. The DNS indicated that she would expect weekly skin check documentation to be completed by nursing on the weekly skin check form; if Resident #77 refused the skin check she would expect to see a progress note documenting the refusal, education provided to the resident on the importance of a skin check, and notification of the refusal made to the nursing supervisor, APRN, and the resident representative, if applicable. Interview with the Medical Director (MD #1) on 7/31/25 identified that a resident with a history of PVD and DM would create a set up for skin issues, further Resident #77 refuses to move. MD #1 indicated Resident #77 should have weekly skin checks ordered The facility’s Weekly Skin Checks policy directs that a resident’s skin is observed by the nurse on shower days and observations documented in the electronic health record: document all areas of concern on the skin sheets, notify the Wound Care Nurse/MD of all areas of concern, document on the 24-hour report to alert the team to areas of concern, and document in the medical record on the weekly skin check form. 2. Resident #82 was admitted to the facility in December 2023 with diagnoses that included spina bifida, hearing loss, and kidney disease. The clinical record identified Resident #82 had a stage 4 facility acquired pressure ulcer on the right ischium first identified on 5/12/24. The quarterly MDS dated [DATE] identified Resident # 82 had intact cognition, was always incontinent of bowel and bladder, required substantial assistance with toileting, partial assistance with bathing and set up for transfers. A physician's order dated 1/6/25 directed staff to complete body audits weekly on Saturdays (shower day). Review of the clinical record for January 2025 identified only 2 weekly body audits had been completed; 1/11/25 and 1/25/25. A physician’s order dated 2/1/25 directed to provide a low air loss mattress with a setting of 150. The order further directed to check placement and function every shift and coordinate with the maintenance department if there was a noticeable malfunction. Review of the clinical record identified weekly body audits were not completed twice in February 2025 and once in March 2025. A care plan dated 4/15/25 directed that Resident #82 had actual skin impairment related to a stage 4 right ischium pressure ulcer. Interventions included weekly skin checks, use of a pressure-relieving mattress if appropriate, and reporting any skin changes to the physician or APRN as necessary. Review of the clinical record identified weekly body audits were not completed once in May 2025, 3 times in June 2025 and twice in July 2025. Review of the clinical record identified Resident #82 had a weight of 111.4 lbs. on 7/9/25. Observation and interview with Resident #82 on 7/27/25 at 10:00 AM identified he/she had a pressure ulcer located on the right buttock that was almost healed, and the facility had provided him/her with an air mattress that would only function intermittently at times. Resident #82 identified he/she had a communication barrier and that staff in the facility could not communicate effectively with him/her. Resident #82 reported during the observation that the air mattress was currently working, and he/she had not reported the issue to facility staff. Observation of the low air loss mattress weight settings identified the mattress was set at 220 lbs. Observation of Resident #82 on 7/29/25 at 11:58 AM identified that the low air loss mattress was set to 60 lbs. During this observation Resident #82 was observed to be sleeping. Observation with MD #2 (wound MD) and the ADNS on 7/30/25 at 7:20 AM identified Resident #82’s pressure ulcer had resolved. Observation with the ADNS immediately following the visit with MD #2 identified the low air loss mattress was set to 60 lbs. The ADNS identified the setting was not correct for Resident #82's weight but identified Resident #82 routinely changed the mattress setting. Observation and interview with Resident #82 on 7/30/25 at 7:30 AM identified the low air loss mattress did not appear to be operating. Resident #82 identified that the mattress had completely stopped working but the resident was unable to indicate the exact time frame. Resident #82 identified he/she was unsure if the facility staff ever checked the mattress. Resident #82 also identified he/she was unsure how to adjust the mattress setting. Observation and interview with RN #1 on 7/30/25 7:40 AM identified Resident #82’s low air loss mattress was not functioning and she would contact maintenance to replace the mattress. Observation on 7/30/25 at 8:45 AM identified Resident #82’s low air loss mattress had been replaced by maintenance. Observation of the replacement mattress settings identified the low air loss mattress was set to 660 lbs. Observation on 7/30/25 at 2:15 PM identify resident #82 low air loss mattress remained set at 660 lbs. Observation and interview on 7/30/25 at 2:25 PM with LPN #8 identified that she had not been notified Resident #82’s low air loss mattress had been changed. LPN #2 initially identified that she checked Resident #82’s mattress at least once during her shift and also identified Resident #82 changed the settings on the mattress regularly. LPN #8 was unable to identify when she had last checked on Resident #82 or observed his/her air mattress during her shift and further identified that while she signed off that she checked the settings daily, sometimes she did not always verify what the actual settings were compared to the physician's order. Subsequent to surveyor inquiry, LPN #8 changed the mattress setting for Resident #82 from 660 lbs. to 150 lbs. Review of the clinical record and care plans failed to identify documentation or a care plan related to Resident #82 changing the mattress settings and/or measures to address such. Review of the clinical record and interview with the ADNS on 7/31/25 at 9:07 AM identified that she was the wound nurse for the facility and identified that Resident #82 should have had weekly skin checks done and documented. The ADNS identified that the documentation related to skin checks required 2 steps. The steps included a sign off on the TAR for the weekly body audits and documentation under the weekly skin check assessments in the clinical record that would include the actual observations made by the nurse. The DNS identified that simply signing the TAR that the body audit was done did not mean that the skin check had been completed. Interview with the DNS on 7/31/25 at 11:01 AM identified that skin checks should be done weekly on the resident’s scheduled shower day and as needed if the nurse aide or licensed nurse identified an issue with the resident’s skin. The DNS identified that the licensed nurse assigned to the resident was expected to complete and document the skin check under the weekly skin assessment check area in the observations section of the clinical record which included the ability to document any changes related to the resident’s skin. The DNS identified the purpose was to ensure that any changes in the resident’s skin were documented week to week. The DNS identified she had been made aware there was an issue related to the nurses completing assessment documentation for the weekly skin checks during the survey and she had planned on providing education to the nursing staff to ensure complete skin assessments were documented in all residents’ clinical records. The DNS also identified that Resident #82’s low air loss mattress should have been set per the physician's order. The DNS identified she and other nursing staff in the facility had completed spot checks of the low air loss mattresses for residents but identified that Resident #82 had been reported by staff to change the settings of his/her air mattress. The DNS was unable to identify any specific incidents related to this or any documentation in the clinical record. The DNS identified that staff should be checking the mattress settings and function of the mattress at least once a shift and report any issues to maintenance per the physician's order. The facility policy on weekly skin checks directed that the policy was to ensure the resident skin was observed and documented on. The policy also directed that skin checks were completed by the nurse on shower days and entered under observations in the clinical record. The facility policy on air mattress overlays directed that an air mattress was used to prevent skin breakdown in accordance with the physician's order. The policy further directed that clinical staff were to verify the physician’s order and after placing the mattress, staff were to evaluate the inflation of the mattress within 20 minutes by performing a hand check and evaluate the mattress's function and proper inflation every shift. The facility policy on skin and wound management directed that the purpose of the policy was to provide guidelines for the structured assessment and identification of residents at risk for developing pressure ulcers/injuries. The policy directed at risk factors that could increase a residents susceptibility to develop or to not heal of pressure ulcers included the resident’s refusal related to some aspects of care and treatment. The policy also directed information that should be recorded in the resident’s medical record should include the type of assessment conducted; the condition of the resident’s skin; if the resident refused treatment including the reason for refusal; observations of anything unusual exhibited by the resident; and documentation in the medical record addressing physician notification if any new skin alterations were noted with a change in the plan of care.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #7) reviewed for range of motion, the facility failed to provide appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for a resident with a hand contracture. The findings include:Resident #7 was admitted to the facility in January 2025 with diagnoses that included dementia, cerebral infarction, and adult failure to thrive. The admission observation dated 1/3/25 identified Resident #7's hand grasp strength was stronger on one side than the other side due to a right-hand contracture: Resident #7 presented with a contracture of the right hand and wrist joint. The Occupational Therapy Discharge Summary dates of service 1/6/25 through 1/29/25 identified a short-term goal was for Resident #7 to tolerate gentle passive range of motion (PROM) to the right hand to open hand slightly for placing of a hand towel/splint to prevent skin breakdown and prevent further contracture. Discharge reason: discharged to the hospital.The Occupational Therapy Discharge Summary dates of service 2/11/25 through 2/26/25 identified a short-term goal was for Resident #7 to tolerate gentle passive range of motion (PROM) to right hand to open hand slightly for placing of a hand towel/splint to prevent skin breakdown and prevent further contracture. Discharge reason: discharged to the hospital.The Occupational Therapy Discharge Summary dates of service 3/11/25 through 4/24/25 failed to identify short-term or long-term goals related to Resident #7's right-hand contracture. Discharge reason: highest practical level achieved.The Occupational Therapy Discharge Summary dates of service 7/10/25 through 7/23/25 failed to identify short-term or long-term goals related to Resident #7's right-hand contracture. Discharge reason: highest practical level achieved.The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition and had no upper extremity impairment. (The MDS failed to identify a right-hand contracture). The care plan dated 7/15/25 failed to identify Resident #7's contracture and failed to identify therapeutic and nursing interventions and functional goals/outcomes.Intermittent observations between 7/27/25 and 7/29/25 identified Resident #7's right hand and wrist are contracted. Digits #2 and 3 are closed tightly with light yellow crust in between. Digit #1 is set under digits #2 and 3. The top portion of digit #1 was exposed in between digit #3 and 4. Digits #4 and #5 were closed tightly with digit #4 slightly laying on top of digit #5 and light-yellow crust in between the digits. Resident #7 exhibited facial grimacing when staff members attempted to gently move any of the digits. Interview and review of the clinical record with the Rehabilitation (Rehab) Services Director on 7/29/25 at 9:40 AM identified that Resident #7's right-hand contracture was chronic, and it was present on admission. The Rehab Director further identified it was the expectation that passive range of motion (PROM) would be completed daily by the nurse aides on the unit, in order for the resident to maintain functional ability, and Resident #7 was previously evaluated for a splint but there was no splint that could accommodate his/her deformity. The Rehab Director identified that she did not see interventions in the physician's orders or in the care plan, but she would expect nursing staff to be performing hand hygiene, ensuring proper positioning of the arm and hand, monitoring to ensure no new contractures develop on the upper arm, and reporting any changes in the condition or decline of the contracture. The Rehab Director indicated that there were limited interventions for OT to implement because Resident #7 would not regain function of the contracted hand; the goal would be to avoid skin breakdown and worsening of the contracture. Interview with OT #1 on 7/29/25 at 9:55 AM identified that she recently added Resident #7's name on a list to be seen by Physiatry for an evaluation due to pain when opening his/her hand or when completing range of motion (ROM) with the elbow and upper arm. OT #1 further indicated that she had encouraged the nurse aides to notify the rehab staff if they had trouble completing daily ADL care so that they could provide assistance, and she also encouraged the nurse aides to soak Resident #7's hand in warm water, as heat can help loosen it up.Interview with the Rehab Director on 7/31/25 at 8:25 AM identified that, subsequent to surveyor inquiry, she notified APRN #1 that Resident #7 had pain in the contracted hand, and he/she will need something for pain management. The Rehab Director indicated that Resident #7 would be seen by the Physiatrist on 8/6/25 to see if there are other interventions that can be attempted. Interview with the Medical Director (MD #1) on 7/31/25 at 11:40 AM identified that he would expect PT/OT to have followed up on Resident #7's right-hand contracture, weekly to start then every other week, and if the contracture remained stable, he would expect it to be seen monthly and as needed. MD #1 indicated that he would expect a plan between OT and nursing services to be put into motion to ensure Resident #7 had documented interventions in place to maintain skin integrity and to prevent further decline of the contracture. The facility's Nursing Services policy directs that a consistent and interdisciplinary approach to the prevention, identification, treatment, and monitoring of contractures among residents is established. Thereby promoting functional independence, optimizing range of motion, and enhancing quality of life. The policy further directs that upon admission, nursing and therapy staff shall conduct a comprehensive functional mobility and muscular skeleton assessment. Risk factors for contracture development shall be identified and range of motion shall be evaluated and documented by therapy at admission, quarterly, and with significant change in condition. Therapy services interventions include evaluating for and implementing therapeutic exercises, manual stretching, positioning, and splinting, and training nursing staff and caregivers in techniques for safe range of motion exercises and positioning.

Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #77) reviewed for indwelling catheter, the facility failed to ensure care according to professional standards for a resident who refused removal of an indwelling catheter over 5 months, that was ordered to be removed after 7 days. The findings include: Resident #77 was admitted to the facility in September 2021 with diagnoses that included urinary tract infection, chronic kidney disease, and acute candidiasis of the vulva and vagina.The quarterly MDS dated [DATE] identified Resident #77 had intact cognition, required maximal assistance for toileting hygiene, was dependent for bathing, required supervision for toilet transfers. Resident #77 was occasionally incontinent of urine, was frequently incontinent of bowel, was at risk for developing pressure ulcers/injuries, and had no pressure ulcer.The care plan dated 1/5/25 identified Resident #77 refused showers and bedding changes, contributing to persistent itchiness; he/she declined hygiene assistance and personal care interventions. The APRN Note dated 2/6/25 at 11:45 AM identified Resident #77 reported a history of nighttime incontinence and requested a foley catheter. However, the resident was able to stand and knowingly urinate on him/herself while in bed. Educate patient on proper toileting habits and the importance of using the restroom when able. Will defer foley at this time.The APRN note dated 2/7/25 at 8:45 AM identified Resident #77 reported a moisture related rash on buttocks and an open wound on left buttocks due to incontinence. The patient requested a foley catheter to help the rash improve, discussed with interdisciplinary team and the decision was made to insert a foley to help the rash and wounds quicker.A physician's order dated 2/7/25 with an end date of 2/14/25 directed foley catheter related to diagnosis of: chronic wound, provide foley catheter care every shift, days, evenings, nights. Review of the nurse's notes dated 2/14/25 failed to identify removal of the foley catheter was attempted, per the APRN's order with an end date of 2/14/25.The nurse's note dated 2/21/25 at 4:47 AM identified that Resident #77's foley catheter was patent and draining yellow urine to gravity.The nurse's note dated 3/19/25 at 1:26 PM identified that Resident #77's foley catheter was in place and patent.The APRN note date 4/9/25 at 9:15 AM identified Resident #77 had an indwelling foley catheter in place to prevent worsening of skin condition. Patient reluctant to have foley catheter removed today, will reevaluate the need for foley catheter in one to two weeks.The nurse's note dated 4/30/25 at 12:48 PM identified that Resident #77's complained to the writer of burning and discomfort around the foley catheter, stated there was a leak when I urinate. Foley catheter removed, clear amber colored urine noted, peri care provided. APRN made aware, waiting for further instructions.The nurse's note dated 4/30/25 at 2:37 PM identified that an order was obtained from the APRN for urinalysis/culture and sensitivity (UA/C&S), reinsert foley, keep it in until final results of urine. Foley catheter in place draining well, resident educated on the importance of perineal care/catheter. Writer informed resident was at risk at keeping foley catheter in place long-term, The foley put the resident at more risk for urinary infection. Resident voiced understanding.The APRN note dated 4/30/25 at 10:45 AM identified Resident #77 was seen today for evaluation of urethral burning and discomfort, as well as for wound care management. Patient reports experiencing increasing discomfort and burning sensation around the urethra where the foley catheter was inserted. The foley catheter was removed and clear amber colored urine was noted. Foley was reinserted and will be kept in place until urine culture results are available. Patient educated on the importance of perineal care, catheter maintenance and risks of long-term catheter use including increased UTI risk.The nurse's note dated 5/22/25 at 6:53 AM identified that Resident #77's foley catheter was draining yellow urine, 1 liter.Review of the Wound Care Specialist progress notes dated 6/11/25 through 7/30/25 identified under the History of Present Illness that Resident #77 had been refusing to get out of bed, the foley spout drain was opened to drain freely into a basin on the floor. Patient was not medically incontinent, however cannot or will not get out of bed to toilet (observation date unknown).The APRN note dated 7/24/25 at 8:58 PM identified Resident #77 reported new onset of right-sided kidney pain and has noticed his/her urine has become foul smelling. The urine in the foley bag was noted to be yellow and cloudy, he/she was also experiencing discomfort in the upper left quadrant of his/her abdomen.A physician's order dated 7/24/25 directed for a UA/C&S-one time. Special instructions: remove foley and replace foley and collect urine for UAC&S.The APRN note dated 7/28/25 at 8:12 PM identified Resident #77 was evaluated 4 days ago, for right kidney pain, foul smelling urine, and left upper quadrant discomfort at that time, his/her urine in the foley bag was noted to be yellow and cloudy. A urinalysis and urine culture were ordered after replacing the foley catheter and results today are indicative of a UTI, will monitor for improvement and adjust treatment based on available options as antibiotics selection is challenging due to multiple allergies and lack of sensitivity testing. Educated patient that indwelling catheters make him/her at higher risk for UTIs.The care plan (with a creation date of 7/30/25, subsequent to surveyor inquiry) identified Resident #77 had a foley catheter. Interventions included monitoring intake and output, providing foley care per facility policy, encouraging fluids, monitoring urine for color, odors, sediment and clogging, keeping foley bag below bladder level, and monitoring for signs and symptoms of infection.A physician's order dated 7/30/25 directed for an abdominal and retroperitoneal ultrasound.Interview and review of the clinical record with the DNS on 7/30/25 at 6:00 PM identified that Resident #77's foley was originally placed to promote wound healing, due to a Stage 3 pressure ulcer on his/her coccyx; now Resident #77 has refused to have it removed. The DNS indicated that the foley was removed on 7/24/25 because the balloon deflated, and Resident #77 began screaming that the nursing staff were violating his/her rights. The DNS further indicated that Resident #77 threatened to call the police if anyone attempted to remove the foley. The DNS identified that Resident #77 refused to see the psychiatric provider, and both the Medical APRN and Wound Specialist have educated him/her about the risks of leaving an indwelling foley catheter in place, over time. The DNS identified that there was no care plan in place for the long-term use of foley catheter, but she would expect there to be a care plan, in particular because Resident #77 refused to have it removed. The DNS identified that there were notes written by nursing and the Medical APRN that Resident #77 was educated on the risks of keeping a foley catheter in place, but she did not see detailed documentation of all of Resident #77's refusals to have the catheter removal.Interview with the Medical Director (MD #1) on 7/31/25 at 11:40 AM identified that he would endorse foley catheter placement in the setting of a significant moisture-associated skin damage (MASD) rash, to prevent further skin breakdown or the onset of a pressure ulcer. MD #1 indicated that keeping an indwelling foley catheter in place for 6 months was problematic and could lead to bigger problems, including a urinary tract infection. MD #1 further identified that he would expect to see documentation in the clinical record of Resident #77's refusals to have the foley catheter removed. MD #1 indicated that a Urology Consult for additional interventions would have been appropriate given Resident #77's refusals for the catheter removal.Interview with APRN #1 on 7/31/25 at 12:10 PM identified that Resident #77's foley catheter was placed in February 2025 related to MASD with incontinence. APRN #1 indicated that there had been several interdisciplinary team meetings to discuss discontinuing the foley, but Resident #77 refused to have it removed, despite education on the risks of long-term use of a foley catheter. APRN #1 identified that there was no medical reason for Resident #77 to still have the indwelling foley catheter; Resident #77 has elective incontinence and does not wasn't to get out of bed and put weight on his/her lower extremities. APRN #1 indicated that she has not sent Resident #77 for a Urology Consult, yet, but has referred him/her for Gastrointestinal (GI) and Gynecology (GYN) consults.The facility's Urinary Catheterization policy directs urinary catheterization to facilitate urinary drainage when medical necessary. Urinary catheters should be evaluated for need and removed promptly when no longer necessary.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #100) reviewed for non-pressure ulcers, the facility failed to ensure hand hygiene was performed when required during the treatment of wounds. The findings include: Resident #100 was admitted to the facility in April 2023 with diagnoses that included lymphedema and acute kidney injury, and hypertension.The annual MDS dated [DATE] identified Resident #100 had intact cognition, required maximum assistance for dressing, putting on footwear, and personal hygiene. Additionally, Resident #100 has 2 venous or atrial ulcers present.The care plan dated 5/20/25 identified Resident #100 has venous ulcers to his/her bilateral lower extremities. Interventions included providing wound treatments as ordered and wrapping bilateral legs with compression socks.A vascular consult dated 6/17/25 directed compression stockings and a venous ultrasound. The physician identified the resident is wheelchair bound and has long standing bilateral lower extremity edema with weeping blisters on legs. Currently there are no signs of cellulitis. Resident #100 needs compression stockings or ace wraps to legs from ankle to knee every morning and take off at bedtime. A physician's order dated 6/19/25 directed to cleanse the bilateral lower extremities with soap and water, rinse and dry well and apply ammonium lactate 12% lotion to intact skin. Apply Calcium Alginate with silver to open wounds, xeroform to any blisters, cover with a dry clean dressing and secure with cling twice a day and as needed. Apply ace wraps every morning from the base of the toes to the base of the knees and remove at bedtime. Monitor for signs and symptoms of infection.Observation of Resident #100 treatment being done on 7/28/25 at 2:05 PM by LPN #2. LPN #2 assisted Resident #100 from the wheelchair to the bed. After washing her hands, LPN #2 put on a new pair of gloves on and removed the dressing on the right leg. With the same gloves on, LPN #2 removed the dressing on the right leg which had visible drainage. With the same gloves, LPN #2 placed a garbage bag in the bedside garbage can and discarded all the old dressings. LPN #2 removed her gloves and without the benefit of hand washing put on a clean disposable gown without tying it around her neck or waist and put on a new pair of gloves. LPN #2 opened treatment supplies onto a clean surface on the overbed table. LPN #2 did not wash the legs with soap and water per the physician order. LPN #2 sprayed the left leg dressing with wound cleanser because it was adhered to the wound and removed the dressing discarding it in the garbage. LPN #2's gown fell forward leaving her upper half exposed. LPN #2 sprayed wound cleaner on the open left leg area and patted it dry 4 x 4 then she sprayed the old dressing on the right lower leg wound cleaner to remove it. LPN #2 removed the dirty gloves and yelled in the hallway for a nurse aide to bring more clean gloves. LPN #2 put on a clean pair of gloves without the benefit of handwashing. LPN #2 placed the Calcium Alginate on left leg followed by an ABD pad and kerlix wrap. LPN #2 placed Calcium Alginate to the left leg followed by an ABD and kerlix wrap. LPN #2 applied the ace wrap to the right and left foot leaving toes exposed bringing the ace wrap to just below the knee. LPN #2 placed Resident #100's grippy socks and shoes on over the ace wraps. LPN #2 removed the supplies off the overbed table, discarded them in the garbage and removed her gloves and gown. LPN #2 left the resident's room with the garbage bag and walked to the utility room. LPN #2 returned to the resident's room, went into the bathroom and washed her hands. Interview with the DNS on 7/30/25 at 10:25 AM indicated the nurse doing a wound treatment is expected to wash his/her hands every time he/she removes their gloves. The DNS indicated that the nurse is expected to wash her hands and apply new gloves prior to removing the old dressing. The DNS indicated after removing the old dressing the nurse is required to remove her gloves, wash her hands and put on a new pair of gloves. The DNS indicated after doing the treatment to one leg the nurse is required to remove gloves, wash hands and put on a new pair of gloves before doing the other treatment and remove gloves and wash her hands again when done. The DNS indicated that if the nurse wanted to wear a gown, she must wear it the right way, tied, and have it cover her front and shoulders. Review of the handwashing policy identified all staff, contractors, volunteers, and visitors must adhere to hand hygiene protocols before and after resident contact, after contact with potentially contaminated surfaces, and as otherwise indicated. The purpose is to prevent the spread of infections by ensuring all healthcare personnel follow proper hand hygiene practices in accordance with CDC and CMS guidelines. Hand hygiene must be performed before and after direct resident contact, before performing aseptic tasks like wound dressing, after exposure to body fluids, before donning and after removing gloves. Review of the wound treatment process policy identified to prepare by gathering treatment supplies per wound order, perform hand hygiene and put on appropriate personal protective equipment. Position the resident for comfort and explain the procedure. Remove the old dressing and assess area. Cleanse wound per order using aseptic technique. Apply ordered dressing. Infection control; utilize standard and transmission precautions. Proper disposal of contaminated dressings in biohazard bags. Hand hygiene before and after all dressing changes.

Based on review of facility documentation, facility policy, and interview, the facility failed to ensure that a nurse aide was provided at least 12 hours annual in-service education, and competency evaluations were completed at least annually. The findings include: A review of education and in-service documentation for 2023, 2024, and 2025 failed to identify education and competencies had been completed for NA #14, who began employment at the facility on 12/5/22.Interview with LPN #1 on 7/30/25 at 7:15 AM identified she worked in a dual role as the staff development and infection control nurse. LPN #1 identified that the DNS and ADNS provided assistance to help her with staff development as they were able, but education was done as time allowed. LPN #1 identified that other than the actual in-service sign-in-sheets and competency packets, she did not have any tracking mechanisms to determine which staff required updated annual competencies or in services, or if all nurse aides in the facility had completed the required 12 hours of in-service training annually.Interview with the ADNS on 7/30/25 at 2:41 PM identified that she had provided some assistance to LPN #1 regarding in service and annual competencies for the facility nursing staff, however she was helping as time allowed. The ADNS identified that she was required to fill multiple roles at the facility which included the ADNS role, RN supervisor, wound care nurse, and had recently been tasked with tracking documentation for outside consultations including ophthalmology and dental visits due to issues that had been identified during the survey.Interview with the DNS on 7/31/25 at 9:27 AM identified she was not aware of any issues related to in services and education. The DNS identified she had notified LPN #1 several times that if she needed assistance to please notify the DNS and that the ADNS was also available to assist with education. The DNS identified that all clinical staff should have required education, in-services, and competencies following hire and then annually.The facility assessment tool directed that the facility would provide annual in-servicing, training, and competencies and the staff development nurse would be responsible to maintain competencies. The assessment tool also directed that staff education would be provided upon hire, annually, and as needed.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #55) reviewed for dental, the facility failed to maintain a complete and readily accessible medical record. The findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included partial loss of teeth, anxiety, and obesity. The care plan dated 4/20/25 identified Resident #55 should attend appointments without an escort. Interventions included to provide resident education about appointment status.The quarterly MDS dated [DATE] identified Resident #55 had intact cognition and had no mouth or facial pain, discomfort or difficulty with chewing.Interview with Resident #55 on 7/28/25 at 11:00 AM identified that the facility's Consultant Dentist extracted the incorrect tooth earlier this year (resident could not provide exact dates), and he/she had asked the facility's Scheduler to obtain his/her dental records, but there had been no follow-up from the facility on his/her request. Resident #55 indicated that following that extraction he/she began receiving dental services from a community dentist. Review of Resident #55's clinical record failed to identify documentation of the care and services provided by the Dental Consulting group from 2024 through 2025.Subsequent to surveyor inquiry on 7/28/25, dental records dated 6/12/24 through 7/14/25 were requested from the Consultant Dentist and were accessible on 7/29/25. Clinical Note dated 8/22/24 at 12:32 PM identified Resident #55 complained of pain on lower right, review of x-rays showed #29 had large filling near pulp, #29 was painful to touch, patient wants extraction, please get clearance and consent and we will extract #29 in facility. Clinical Note dated 10/1/24 identified patient having pain in #29. Consent and medical release signed, extracted #29, simple extraction, homeostasis. Consent for Extraction documentation dated 10/1/24 was signed by Resident #55 and identified Tooth #29 was to be extracted. Clinical Note dated 12/30/24 identified Resident #55 was scheduled for a hygiene visit but refused. Patient stated the dentist pulled the wrong tooth and #30 is the tooth that was bothering him/her, stated he/she wanted to see the dentist for pain on #30 and also a full upper denture and partial lower denture. Patient stated he/she had a full upper denture before but doesn't remember when it was made. Dentist to see for pain on #30 and denture evaluation. Reschedule hygiene visit since patient refused today.Interview with the facility's Scheduler on 7/29/25 at 11:18 AM failed to identify that Resident #55 had ever made a request for his/her dental records, and that Resident #55 now sees a community dentist and self-schedules his/her appointments.Interview with the DNS on 7/30/25 at 5:10 PM identified that she would expect Resident #55's dental records from the consulting dental provider to be accessible in his/her clinical record so facility staff could have immediate access. The DNS further identified that she will be having a meeting with all the consultants and re-educating them on the expectation that clinical notes are uploaded into the resident's clinical record after a service is provided, in a timely manner.The facility's Ancillary Services policy directs all ancillary services provided or coordinated will be documented in the resident's medical record, including the type of services and outcome.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure staff followed up with a consulting physician office timely in accordance with hospital discharge directions. The findings include: Resident #1 had a diagnosis of malignant neoplasm of the left breast. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview of Mental Status (BIMS) score of five (5) indicating severely impaired cognition and required assistance with Activities of Daily Living (ADLs). The Resident Care Plan (RCP) dated 2/26/2025 identified a diagnosis of cancer. Interventions directed to monitor for adverse effects if receiving chemotherapy or radiation. Hospital Discharge summary dated [DATE] directed to contact Resident #1's oncology office two (2) weeks post discharge for Stage 4 left breast cancer. No appointments were listed on the discharge summary. The nursing admission note dated 7/30/2024 at 10:44 PM identified to follow up with Resident #1's oncology office within two (2) weeks related to Stage 4 left breast cancer. Record review failed to identify Resident #1's oncology office was contacted two (2) weeks after he/she was discharged from the hospital. Interview with oncology office RN #1 on 4/9/2025 at 10:59 AM identified the office did not receive a call from the facility within two (2) weeks after the resident was discharged from the hospital. Interview and record review with the DNS and Administrator on 4/9/2025 at 11:42 AM identified they were unable to locate documentation that the facility contacted Resident #1's oncology office two (2) weeks after hospital discharge, in accordance with the hospital directions. The interview identified the facility should have followed up with the oncology office, and the DNS and Administrator did not know why the facility did not follow up. Facility follow up appointment policy dated 3/4/2025 directed in part, upon admission the admitting RN will review the resident's chart and identify any follow up appointments needed based on hospital discharge instructions and schedule in a timely manner.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from physical mistreatment. The findings include: Resident #1's diagnoses included schizoaffective disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and was maximal assistance with all ADLs. The Resident Care Plan (RCP) dated 5/31/2024 identified Resident #1 exhibited behaviors as evidenced by being verbally/physically abusive, refusal of care, and aggression related to psychiatric conditions. Interventions directed approach resident in a calm and consistent manner, monitor for changes in mood/behavior and report to the physician, and to provide resident with the opportunity to express feelings through one-to-one and group visits. The facility incident report identified on 7/10/2024 at 6:00 PM identified Resident #2 reported to the DON that he/she witnessed NA #1 kick Resident #1 in the leg. Resident #1 confirmed that NA #1 kicked him/her in the leg. The report did not indicate any injury was noted, indicated NA #1 was sent home pending the investigation, and the local police, physician and family were notified. Record review for Resident #2 identified a quarterly MDS dated [DATE] indicated Resident #2 was alert and oriented. A nursing progress note dated 7/10/2024 at 10:02 PM by DON identified at approximately at 6:00 PM, Resident #1 reported to the Administrator that he/she was kicked in the legs by a staff member. Body assessment showed no signs of bruising, denied pain to his/her legs and was able to move legs within baseline. APRN #1 notified of the incident with orders received to monitor for pain and follow facility protocol. Resident #1's conservator was notified of the event. Facility incident summary dated 7/16/2024 identified the allegation of staff to resident abuse without injury was substantiated; Resident #1 confirmed the allegation that was witnessed by Resident #2. NA #1's employment was terminated. Interview with Resident #1 on 7/30/2024 at 10:25 AM identified NA #1 did kick him/her in the left leg. Interview with Resident #2 on 7/30/2024 at 10:40 AM identified he/she was across the hall from Resident #1 on 7/10/2024 and observed NA #1 assisting Resident #1 and NA #1 kicked Resident #1 in the leg. Resident #2 indicated the kick was not a gentle kick but was indicated it was meant to cause injury or harm. Resident #1 began to scream as per his/her normal baseline behaviors, but Resident #2 felt the kick was to intentional get more of a response out of Resident #1. Resident #2 indicated he/she immediately went to the Administrator and DON to report the incident. Interview with NA #1 on 7/30/2024 at 12:00 AM identified on 7/10/2024 at 5:30 PM, he denied the allegation. Interview with the DON and Administrator on 7/31/2024 at 10:15 AM identified on 7/10/2024, Resident #2 alleged he/she observed NA #1 kick Resident #1. Resident #1 was immediately interviewed, and he/she confirmed what Resident #2 had alleged. The results of the investigation identified the allegation was substantiated, and NA #1's employment was terminated. Review of the Resident Abuse, Mistreatment, Neglect, Exploitation, Misappropriation of Resident Property, and Retaliation Policy dated 9/16/2018 identified the facility will ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of property, and retaliation as per state and federal guidelines. Physical abuse is defined as the intentional infliction of physical pain, bodily harm, or physical coercion. Facility documentation review identified staff education was initiated on 7/10/2024 regarding the facility resident abuse (prevention) policy. Audits were initiated on 7/11/2024, and a QAPI meeting was held on 7/11/2024. Based on review of facility documentation, past non-compliance was identified.

Based on review of the clinical record, facility documentation, facility policy, and interviews for fifteen (15) of nineteen (19) residents (Resident #7, #8, #9, #11 , #12. #13,#14, #16, #18, #19, #20, #22, #23, #24 and #25) who have a history of substance abuse disorder and receive methadone treatment, the facility failed to ensure the residents had orders for Narcan (an opiate overdose reversal medication) administration. The findings include: 1. Resident #7 was admitted to the facility with diagnoses that included metabolic encephalopathy and opioid dependence. The care plan dated 9/21/23 identified Resident #7 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request, nursing support as needed and monitor for signs and symptoms of opioid overdose. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #7 had moderately impaired cognition and was independent with activities of daily living (ADL's). A physician's order dated 12/1/23 directed methadone 22 mg (an opioid agonist, used to treat opioid dependence) once a day. 2. Resident #8 was admitted to the facility with diagnoses that included COPD and opioid dependance. A physician's order dated 11/1/23 directed methadone 50 mg once a day. The quarterly MDS dated [DATE] identified Resident #8 had no impairments in cognition and was independent with ADL's. The care plan dated 10/19/23 identified Resident #8 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request, nursing support as needed and monitor for signs and symptoms of opioid overdose. A physician's order dated 12/1/23 directed methadone 50 mg once a day. 3. Resident #9 was admitted to the facility with diagnoses that included hypertension and opioid dependance. The quarterly MDS dated [DATE] identified Resident #9 had severely impaired cognition and was independent with ADL's. The care plan dated 10/17/23 identified Resident #9 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request, nursing support as needed and monitor for signs and symptoms of opioid overdose. A physician's order dated 12/1/23 directed methadone 75 mg once a day. 4. Resident #11 was admitted to the facility with diagnoses that included cellulitis and opioid dependence. The care plan dated 8/2/23 identified Resident #11 received methadone maintenance treatment. Interventions included to assist the resident with substance abuse counseling, monitor the resident for changes and provide resident with daily dose of methadone. The MDS dated [DATE] identified Resident #11 had moderately impaired cognition and required extensive assistance of one staff for ADL's. A physician's order dated 12/1/23 directed methadone 128 mg once a day. 5. Resident #12 was admitted to the facility with diagnoses that included pneumonia and psychoactive substance abuse disorder. The care plan dated 7/22/23 identified Resident #12 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. The quarterly MDS dated [DATE] identified Resident #12 had moderately impaired cognition and was independent with ADL's. A physician's order dated 12/1/23 directed methadone 75 mg once a day. 6. Resident #13 was admitted to the facility with diagnoses that included fracture of lumbar vertebra and opioid dependence. The quarterly MDS dated [DATE] identified Resident #13 had no impairments in cognition and required limited assistance with ADL's. The care plan dated 10/10/23 identified Resident #13 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. A physician's order dated 12/1/23 directed methadone 80 mg once a day. 7. Resident #14 was admitted to the facility with diagnoses that included hydrocephalus and opioid dependence. The quarterly MDS dated [DATE] identified Resident #14 had severely impaired cognition and required supervision with ADL's. The care plan dated 11/21/23 identified Resident #14 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. A physician's order dated 12/1/23 directed methadone 85 mg once a day. 8. Resident #16 was admitted to the facility with diagnoses that included urinary tract infection and psychoactive substance abuse disorder. The care plan dated 6/21/23 identified Resident #16 received methadone maintenance treatment. Interventions included to assist the resident with substance abuse counseling, monitor the resident for changes and provide resident with daily dose of methadone. The quarterly MDS dated [DATE] identified Resident #16's cognition was not assessed and was independent with ADL's. A physician's order dated 12/1/23 directed methadone 10 mg once a day. 9. Resident #18 was admitted to the facility with diagnoses that included epilepsy and anxiety. The quarterly MDS dated [DATE] identified Resident #18 had no impairments in cognition and required maximum assistance of one staff for ADL's. The care plan dated 12/21/23 identified Resident #18 had a history of substance abuse with interventions included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. A physician's order dated 12/1/23 directed methadone 120 mg once a day. 10. Resident #19 was admitted to the facility with diagnoses that included fracture of the left lower leg and opioid abuse. The care plan dated 9/22/23 identified Resident #19 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. The quarterly MDS dated [DATE] identified Resident #19 had no impairments in cognition and required supervision of one staff for ADL's. A physician's order dated 12/1/23 directed methadone 40 mg once a day. 11. Resident #20 was admitted to the facility with diagnoses that included pneumonia and opioid dependence. The care plan dated 10/18/23 identified Resident #20 received methadone maintenance treatment with interventions that included to assist the resident with substance abuse counseling, monitor the resident for changes and provide resident with daily dose of methadone. The quarterly MDS dated [DATE] identified Resident #20 had no impairments in cognition and was independent with ADL's. A physician's order dated 12/1/23 directed methadone 100 mg once a day. 12. Resident #22 was admitted to the facility with diagnoses that included COPD and psychoactive substance abuse disorder. The MDS dated [DATE] identified Resident #22 had no impairments in cognition and required limited assistance of one staff for ADL's. The care plan dated 11/14/23 identified Resident #22 had a history of substance abuse. Interventions included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. A physician's order dated 12/1/23 directed methadone 80 mg once a day. 13. Resident #23 was admitted to the facility with diagnoses that included fracture of foot and opioid dependence. The care plan dated 11/13/23 identified Resident #23 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. The quarterly MDS dated [DATE] identified Resident #23 had no impairments in cognition and required one staff assistance for ADL's. A physician's order dated 12/1/23 directed methadone 120 mg once a day. 14. Resident #24 was admitted to the facility with diagnoses that included COPD and opioid dependence. The quarterly MDS dated [DATE] identified Resident #24 had no impairments in cognition and was independent with ADL's. The care plan dated 11/28/23 identified Resident #24 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request, and nursing support as needed. A physician's order dated 12/1/23 directed methadone 80 mg once a day. 15. Resident #25 was admitted to the facility with diagnoses that included fracture of right lower leg, cocaine abuse and psychoactive substance abuse disorder. The quarterly MDS dated [DATE] identified Resident #25 had moderately impaired cognition and was independent with ADL's. The care plan dated 11/13/23 identified Resident #25 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request and nursing support as needed. A physician's order dated 12/1/23 directed methadone 115 mg once a day. Review of Residents' #7, #8, #9, #11 #12,#13, #14, #16, #18, #19, #20 and #22, #23, #24 and #25's clinical record failed to identify an order for Narcan administration. Interview with LPN #2 (in charge of the methadone program at the facility) on 12/20/23 at 3:00 PM identified there was a house blanket order for Narcan for residents in the facility. Interview with Medical Director on 12/20/23 at 3:30 PM identified there should be an order for Narcan for any resident's who is on the methadone program. The Medical Director was unaware that Narcan was not in the order set for each resident on Methadone. It is her expectation that each resident on the methadone program have a specific order for Narcan. Subsequent to surveyor inquiry, on 12/21/23 Narcan orders were added to the physician orders for Residents' #7, #8, #9, #11, #12, #13, #14, #16, #18, #19, #20 and #22, #23, #24 and #25. Review of the Narcan policy directed that facility is to provide emergency treatment for residents who may demonstrate signs and symptoms of opiate overdose.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 6 residents (Resident #3, #7, #8) reviewed for resident to resident altercations, the facility failed to create and implement interventions for residents after resident to resident abuse allegations. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that included dementia with behavioral disturbance and anxiety. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition, had verbal behavioral symptoms directed towards others, and required supervision with set up help on for activities of daily living (ADL's). The care plan dated 8/17/23 identified Resident #3 had behavioral symptoms with interventions included to encourage the resident to seek the assistance of staff when in challenging situations, social service to help deescalate upsurging behavior and to create a behavior modification plan through psychiatric services. Review of the accident and incident report (A & I) dated 10/17/23 identified Resident #3 was observed by the receptionist throwing juice in Resident #4's face and calling his/her racial slurs and names. Resident #3 was placed on 1:1 observation and sent to the hospital for an evaluation and was deemed not a danger to self or others by psychiatry. Review of Resident #3's behavioral care plan identified it was updated on 10/17/23 to include on 10/17/23 Resident #3 threw juice onto another resident in the lobby. However, the care plan failed to include new interventions subsequent to the event. 2. Resident #7 was admitted to the facility with diagnoses that included obstructive hydrocephalus (fluid on the brain) and bipolar disorder. The care plan dated 8/17/23 identified Resident #7 had a history of depression, anxiety and bipolar with interventions included behavior monitoring as indicated and monitor for changes in mood/behavior and report to the physician. The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition, had verbal behavioral symptoms directed towards others, had delusions, and required supervision with set up help on for activities of daily living (ADL's). Review of the accident and incident report (A & I) dated 12/5/23 identified Resident #8 was observed grabbing Resident #7's jacket and calling him/her derogatory names. Resident #8 sustained a skin tear to the top of his/her lip. Both residents were placed on 1:1 and transferred to the hospital. Review of Resident #7's care plan failed to include a new care plan and interventions subsequent to the event on 12/5/23. 3. Resident #8 was admitted to the facility with diagnoses that included schizoaffective disorder and delusional disorders. The care plan dated 11/7/23 identified Resident #8 exhibited behaviors as evidenced by verbal/physical abuse, refusal of care, aggression and psychiatric concerns with interventions that included to approach the resident in a calm manner and monitor any changes in mood/behavior and report to the physician. The quarterly MDS dated [DATE] identified Resident #8 had moderately impaired cognition, had verbal behavioral symptoms directed towards others, and required assist of one staff for transfers and ambulated with walker/wheelchair with supervision. Review of the accident and incident report (A & I) dated 12/5/23 identified Resident #8 was observed grabbing Resident #7's jacket and calling him/her derogatory names. Resident #8 sustained a skin tear to the top of his/her lip. Both residents were placed on 1:1 and transferred to the hospital. Review of Resident #8's care plan failed to include a new care plan and interventions subsequent to the event on 12/5/23. An Interview with the DNS and Administrator on 12/20/23 at 4:00 PM identified the expectation is for the nursing supervisor to update the residents' care plans. She identified she would expect a new care plan with intervention to prevent re-occurrence. Review of the resident to resident altercation policy directed if two residents are involved in an altercation, staff will make any necessary changes in the care plan approaches to any or all of the involved individuals and consult psychiatric services as needed for assistance in assessing the resident, identify the causes and developing a care plan for intervention and management as necessary or as may be recommended by the physician or interdisciplinary care team.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #501) reviewed for abuse, the facility failed to ensure a resident was free from physical abuse. The findings include: Resident #501 was admitted to the facility on [DATE] with diagnoses that included chronic pain, anxiety, and major depressive disorder. The admission observation form dated 10/27/22 at 10:11 PM identified Resident #501 was oriented to person, place, and time. A physician's order dated 10/27/22 directed to administer Alprazolam (anti-anxiety medication) 0.5mg three times a day for anxiety disorder and Escitalopram (anti-depressant medication) 10mg once a day for major depressive disorder. The care plan dated 10/30/22 identified Resident #501 is new to the facility and requires a period of adjustment to the new environment. Interventions included to encourage socialization and positive effects/coping mechanisms. Review of a reportable event form dated 10/31/22 at 5:30 AM identified Resident #501 got into an argument with his/her roommate and the roommate allegedly hit Resident #501 with a cane. Resident #501 sustained a 1.0cm by 1.0cm superficial laceration to the forehead. Both residents were immediately separated and Resident #501 was transferred to the hospital for evaluation. Upon return, Resident #501 was moved to another unit and would be evaluated by psychiatry. Review of the summary report dated 11/3/22 at 9:16 PM identified on 10/31/22 at 5:30 AM the staff heard screaming and went to Resident #501 and observed the roommate holding a cane and Resident #501 screaming to call 911. Resident #501 indicated the roommate hit him/her with the cane. Resident #501 was agitated an RN assessment identified 1.0cm by 1.0cm superficial laceration to the forehead. EMS (911) was called and the police arrived and Resident #501 was transferred to the hospital for evaluation. Resident #501 returned to the facility and did not require any closure of the wound as it was diagnosed as superficial skin tear. An investigation was immediately initiated. Resident #501 has been approached by several members of the staff, and the psychiatry team and refused to discuss what happened. The roommate indicated Resident #501 was looking for his/her television remote through the roommate belongings and when the roommate asked Resident #501 to stop Resident #501 started to use profanity. Resident #501's roommate admitted to hitting Resident #501 with a cane. According to staff, the residents had a good relationship prior. A written statement by RN #4 dated 10/31/22 identified Resident #501 alleged the roommate hit him/her in the head with a cane. A written statement by LPN #6 dated 10/31/22 identified at 5:45 AM a resident notified the nurse aide and herself that Resident #501 and his/her roommate were arguing. LPN #6 documented she went to the room and heard Resident #501 and the roommate arguing. LPN #6 documented she observed Resident #501 bleeding and the roommate standing by the bed. LPN #6 documented she immediately notified RN #4 who called the police, and RN #4 separated both residents. RN #4 placed Resident #501 in another room. LPN #6 documented the roommate stated that Resident #501 was going through his/her belonging and when he/she asked Resident #501 to stop Resident #501 spit at him/her, called him/her a (explicative) and threw urine at him/her. The roommate admitted that he/she hit Resident #501 with his/her cane. Review of the hospital discharge summary dated 10/31/22 at 6:42 AM identified Resident #501 arrived at the hospital with bruising present. Resident #501 had a 2.0cm skin tear to the right forehead with dried blood located on the right face and a 4.0cm contusion to right forehead. Resident #501 was discharged from the hospital at 8:29 AM with diagnoses of head trauma, and assault. Interview with Resident #501 on 11/9/22 at 10:55 AM identified he/she got into an argument with his/her roommate while he/she was looking for the television remote control. Resident #501 identified he/she felt scared because the roommate was standing over him/her swinging a cane and hit him/her in the head and he/she had nothing to defend him/herself with. Interview with RN #4 on 11/16/22 at 11:30 AM identified LPN #6 called him and upon arriving at the room, he observed Resident #501 lying in bed and there was blood on his/her head and the roommate was sitting on the side of his/her bed. Both residents were still arguing and were immediately separated. RN #4 indicated he place Resident #501 in the room across the hallway and did an assessment. RN #4 indicated he was trying to send Resident #501 to the hospital immediately due to the bleeding on his/her head. RN #4 indicated Resident #501 stated his/her roommate hit him/her with the cane. Review of the facility resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy directed to ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of property, and retaliation. To ensure that all staff know their responsibility in identifying and reporting any type of abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation as per state and federal guidelines. Physical abuse: the intentional infliction of physical pain, bodily harm, or physical coercion.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to follow their policy for a resident with behaviors who was resistive to care, resulting in a resident fall with an injury. The findings include: Resident #1 had diagnoses that included dementia and was hearing impaired. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and required extensive assistance of one for bed mobility. The care plan dated [DATE] identified Resident #1 had impaired cognition/thought processes related to dementia, and a communication problem. Interventions directed to provide necessary cues, and to stop and return if Resident #1 was agitated, to use alternative communication tools as needed, and write in big letters to communicate. Review of the facility incident report dated [DATE] at 9:50 PM identified Resident #1 asked to be repositioned prior to care, turned in the opposite direction of where the NA was standing and rolled off the bed onto the floor. A statement written by NA #1 identified Resident #1 was agitated because he/she needed care, and NA #1 used the communication board to let Resident #1 know she was going to provide care, and Resident #1 calmed down and turned in the direction away from NA #1. NA #1 was unable to stop Resident #1 from turning in the direction away from NA #1, and Resident #1 fell out of the bed. The plan of care was updated to direct two (2) NAs for care. Nurses noted dated [DATE] indicated that on [DATE] approximately 9:50 PM, RN #1 was called to Residents #1's room and found Resident #1 lying on his/her left side, on the floor next to his/her bed; Resident #1 had rolled out of bed while NA #1 was providing care. NA #1 indicated she was standing on the left side of the bed, and Resident #1 was near the edge of the bed when NA #1 was trying to take off Resident #1's johnny, and Resident #1 rolled out of bed, off the right side of bed. NA #1 reported Resident #1 was agitated. RN assessment (including neurological assessment) was completed and identified Resident #1 was able move upper extremities (right greater than the left), had good bilateral hand grasps and a slight abrasion to the left knee. Resident #1 was lifted back into bed via mechanical lift, APRN #1 was updated with no new orders obtained, and the spouse was notified. Nurses Note dated [DATE] at 11:30 AM, written by LPN #2 identified Resident #1 was not responsive to verbal stimuli when spouse spoke with him/her during visitation. LPN #2 noted a sudden change in mental status, Resident #1 became soft spoken, when asked a question resident took longer than usual to answer and did not react to touch. RN supervisor was notified, 911 was called, and Resident #1 was transferred to the hospital for evaluation. RN #2 nurses note dated [DATE] at 3:59 PM written by RN #2 identified Resident #1 was alert and verbally responsive earlier in shift, became unresponsive to verbal stimuli, had unequal bilateral hands grasps and no facial droop was noted. Hospital admission history and physical identified Resident #1 did not follow any commands, and MRI results showed a cervical spine C5 fracture. Resident #1 was transferred to another hospital for surgical intensive care admission (SICU). Review of hospital record identified Resident #1 was admitted to SICU, had a surgical C4 to T2 posterior spinal decompression and fusion on [DATE] and remained on the SICU floor after surgery on a ventilator (breathing machine). Hospital record further identified a trial removal of the ventilator conducted on [DATE] was unsuccessful. Pleural effusions (fluid in the lungs) were identified on [DATE], and Resident #1's condition deteriorated. A family meeting was held on [DATE] with a decision for comfort care. On [DATE] Resident #1 was extubated (removed from the ventilator) and expired at 9:51 PM. Interview with the Director of Rehab on [DATE] on at 10:34 AM identified Resident #1 required one staff assist for turning and repositioning in bed. Interview with RN #1 on [DATE] at 10:54 AM identified that she was not aware Resident #1 was agitated when NA #1 attempted to provide care before Resident #1 fell out of the bed onto the floor. RN #1 indicated she would have wanted to be notified that Resident #1 was agitated when NA #1 attempted to give care. Interview with LPN #1 on [DATE] at 11:30 AM identified she was the charge nurse on [DATE] when Resident #1 fell out of bed. LPN #1 indicated that she was not aware Resident #1 was agitated when NA #1 attempted to give care. She indicated she would have wanted to be notified and she would have assisted NA #1 with Resident #1's care if she knew Resident #1 was agitated. Interview with NA #1on [DATE] at 9:07 AM identified Resident #1 was deaf and used a white board to communicate. NA #1 indicated upon first entering the room to provide care for Resident #1, Resident #1 was agitated so she left the room to give Resident #1 time to calm down. NA #1 further indicated, when she reapproached Resident #1, he/she was still agitated. NA #1 indicated she wrote on the white communication board to tell Resident #1 what she was there for, and Resident #1 remained agitated. NA #1 indicated that although Resident #1 remained agitated, she continued with care and repositioning, and she did not notify the nurse. NA #1 indicated that she should have called for assistance, but she did not ask other staff for help. NA #1 indicated that while she was standing on one side of the bed, she directed Resident #1 to turn towards her, and Resident #1 turned away from her and fell off the bed onto the floor. NA #1 indicated the height of the bed was approximately three feet above the ground (about waist high for her). Interview, facility documentation review, and clinical record review with the DON on [DATE] at 11:15 AM identified that if a resident is agitated such as hitting, kicking slapping, the NA should stop what they are doing and reapproach later. Review of the Unmanageable Resident Policy dated ,d+[DATE] directed in part, should a resident's behavior become abusive, assaultive or unmanageable in any way that would jeopardize his or her safety or the safety of others every effort should be made to provide for the safety of all concerned. Review of the Care of the Cognitively Impaired Policy directed in part, if the person is resistive or aggressive but is not causing harm to themselves or others, leave them alone giving them time to settle down and reapproach later.

Based on observation, clinical record review, facility documentation review, and interviews, for one (1) of three (3) residents reviewed for abusive behavior (Resident #1), the facility failed to ensure the resident was adequately supervised to protect other residents from potential harm including verbal and sexual abuse, resulting in a finding of Immediate Jeopardy. The Immediate Jeopardy was identified as corrected on 1/2/20 when Resident #1 was placed on one to one (1:1) monitoring. The finding includes: Resident (R) #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility documentation (reportable events) during the period of 1/11/19 through 9/23/19 identified that the resident exhibited verbal threats, sexually inappropriate behaviors and gestures, profane statements and aggressive behaviors toward other residents. Review of R#1's annual minimum data set (MDS) assessment dated [DATE] identified the resident had intact cognition, required supervision with transfers or locomotion, and required limited assistance with ambulation. The MDS identified that the resident exhibited verbal behavioral symptoms directed toward others. a. Reportable Event documentation dated 10/28/19 identified that R#1 was verbally sexually inappropriate with a resident of the opposite sex and exposed him/herself to the other resident. R#1 was sent to the hospital for evaluation. Review of the hospital record dated 10/29/19 identified that R#1 was evaluated by psychiatry and determined not to be a danger to self or others. R#1 returned to the facility on [DATE] at 5:35 PM. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) was updated on 10/30/19 and included to educate R #1 and reinforce what sexually inappropriate behavior consisted of, engage the resident in recreational activities (distraction), redirect R#1 off other units, psychiatric evaluations as needed, medication adjustments, and follow-up with laboratory testing. During the period of 10/30/19 through 11/8/19 the resident remained on 1:1 supervision and on 11/8/19 the resident's level of supervision was decreased to every hour monitoring from 11:00 PM to 7:00 AM and 7:00 AM to 3:00 PM, and 1:1 supervision from 3:00 PM - 11:00 PM, however, the record failed to identify an assessment or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of documentation during the period of 11/8/19 through 11/13/19, indicated R#1 remained on 1:1 monitoring from 3:00 PM-11:00 PM, absent an order to discontinue 1:1 monitoring as directed on 10/29/19. Review of R#1's clinical record for the period of 11/14/19 to 12/11/19 failed to identify that R #1 was supervised on a 1:1 from 3:00 PM - 11:00 PM, absent an order to discontinue 1:1 monitoring as directed on 10/29/19. Review of a psychiatric consultation dated 12/11/19 identified that the resident was seen for follow up related to his/her behaviors. In the psychiatric evaluation Advanced Practice Registered Nurse (APRN-psychiatry) #2 identified that R#1 had not been inappropriate with staff or residents and directed to continue to monitor mood and behavior however the evaluation failed to address the level of supervision that R#1 required. Interview with the Assistant Director of Nurses (ADON) on 1/7/20 at 2:00 PM identified that R#1's monitoring and 1:1 supervision was tapered on 11/8/19 based on the fact that his/her [MEDICATION(S)] levels were within therapeutic range. The ADON indicated that R#1's behaviors were reviewed in morning report however she was unable to provide documentation of the reviews or assessments identifying the rationale why R#1 was no longer provided 1:1 supervision during the 3:00 PM to 11:00 PM shift. The clinical record failed to identify a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] b. Review of a nurse's note dated 12/12/19 identified that at 6:30 PM, a resident reported that R#1 was in the lobby and was bothering R#2. The note identified that when the ADON arrived to the lobby, she observed R#1 sitting next to R#2 and no physical contact was observed between R#1 and R#2. The residents were separated and R#1 was removed from the lobby. R#2 reported that R #1 was verbally sexually abusive to him/her and asked R#2 to lick his/her private parts and indicated that R #2 was his/her significant other. R #1 was placed on 1:1 supervision until s/he was sent to the hospital Emergency Department (ED) for evaluation. R#1 was evaluated in the ED and was deemed not to be a danger to self or others and returned to the facility on [DATE]. Upon return, the facility contacted APRN#1 (medical). The clinical record lacked an assessment or new physician/APRN orders entered upon R#1's return. Review of R#1's clinical record for the period of 12/13/19 to 12/16/19 failed to identify that assessments were completed, new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record identified on 12/16/19, R#1 was evaluated by APRN #1 (medical) at 1:40 PM. The progress note reflected that R#1 had not exhibited behavioral issues since 12/12/19. Review of R#1's RCP, updated on 12/16/19, directed to monitor R#1's behaviors, keep R #1 and R#2 separated, psychiatric services to see R#1, and social services to follow-up as needed. The RCP failed to include the specific monitoring plan and the time frame for the behavioral health follow-up to be completed. Interview with the DON 1/8/20 at 2:30 PM identified that a request for behavioral health follow up is made via a Behavioral Health Request Log. However a review of the log for the period of 12/16/19 to 12/23/19 failed to identify that a request was made for R#1 to be seen by psychiatric services. c. Review of a nurse's note dated 12/16/19 at 7:58 PM, identified that R#1 exhibited inappropriate verbal and sexual gestures towards a staff member, during which s/he asked the staff member to expose her private parts to R#1. The resident was transferred to the ED for evaluation. Review of the hospital record dated 12/16/19 identified that the resident was evaluated by psychiatry and determined not be a danger to self or others. R#1 returned to the facility on [DATE] at 9:40 PM with no new orders. Upon return from the hospital, the facility failed to conduct an assessment to determine the level of supervision R #1 required to maintain safety. Review of R#1's clinical record for the period of 12/17/19 to 12/24/19 identified the resident was monitored every shift and exhibited no inappropriate behaviors during that time however, the facility failed to ensure the clinical record identified the specific level of supervision and frequency of monitoring R#1 required to ensure that other residents were not verbally or sexually abused by R#1. Interview with the Director of Nurses on 1/8/20 identified that the facility had no formal process to assess or evaluate the level of supervision needed for residents who exhibit inappropriate behaviors, however, the resident's level of supervision may be directed in a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . d. Review of a nurse's note dated 12/24/19 at 5:00 PM identified that staff reported that R#1 was observed pulling a visitor (minor child) toward him/her and kissed the child on the cheek. Local law enforcement was notified and R#1 was transferred to the ED for an evaluation. Review of the ED record dated 12/24/19 at 8:16 PM identified that R#1 was evaluated and deemed not an imminent danger to self or others. R#1 returned to the facility at approximately 10:45 PM. The record failed to identify that the physician was notified of the residents return. The facility failed to ensure the clinical record identified an assessment was completed to determine the level of supervision R #1 required to maintain safety and protect other residents from the potential verbal or sexual abuse from R#1. Review of a nurse's note dated 12/25/19 at 4:30 AM identified that R#1 was sleeping on rounds, occasionally self propelling in a wheelchair on the unit and had no inappropriate behaviors. The note identified that R#1 would continue to be monitored, however, failed to identify the level of supervision the resident required to maintain safety. The RCP dated 12/26/19 was updated to reflect the incident on 12/24/19 with interventions that included social service and psychiatry follow-up. The RCP failed to identify the level of supervision the resident required. Review of R#1's clinical record for the period of 12/25/19 to 12/27/19 identified that R#1 was monitored every shift and exhibited no behavioral symptoms, however, the facility failed to ensure the clinical record identified an assessment was completed to determine the level of supervision R #1 required to maintain safety and protect other residents from the potential verbal or sexual abuse from R#1. Review of APRN #1's progress note dated 12/27/19 at 1:04 PM identified that R #1 had impulsive disorder, had been evaluated at the ED on 12/24/19 for inappropriate sexual behavior and was cleared by psychiatry to return to the facility. APRN #1 identified that staff reported the resident had exhibited no inappropriate behaviors since 12/24/19 and noted a plan for psychiatry follow-up and to continue monitoring R#1. APRN #1 failed to direct the level of supervision that the resident required. Interviews with direct care staff on 1/2, 1/7, 1/8, and 1/13/20 (Nursing Assistant, Licensed Practical Nurse, Registered Nurse Supervisor, receptionist, Social Worker) identified that they were aware of Resident #1's sexually inappropriate behaviors and knew to keep an eye on and observe the resident when he/she was with other residents. The staff identified when R#1 exhibited inappropriate behavior and was sent out to the hospital, upon his/her return, they monitored him/her closely. Staff stated that they were aware to redirect the resident when he/she approached other residents or was observed on other units. Staff was unable to identify that R#1's whereabouts were continuously monitored. e. Review of the resident's clinical record for the period of 12/28/19 through 12/30/19 failed to identify that psychiatry was notified that the resident required a follow-up evaluation or that psychiatry had evaluated R#1 during that time. Review of R#1's behavior monitoring record for the period of 12/30/19 to 1/2/20 (7:00 AM to 3:00 PM) identified that no episodes of sexually inappropriate behaviors were exhibited by R#1. However, the clinical record failed to identify R#1 was supervised or monitored during the aforementioned period. Interview with the Director of Nurses (DON) on 1/2/20 at 5:00 PM identified that when the resident returned to the facility on [DATE], staff verified that R#1 was cleared by the hospital psychiatrist and was not a danger to self or others. The DON indicated since the resident's return, staff had been monitoring R#1 however, the DON was unable to verify R#1 was assessed upon return to the facility from the hospital or the level of supervision that was provided to R#1 until 1/2/20 at 3:00 PM when an administrative decision to place the resident on 1:1 supervision was made. Immediate Jeopardy was mitigated on 1/2/20 when R #1 was placed on 1:1 supervision. Resident #1 remained on 1:1 supervision until his/her discharge from the facility on 1/9/20.

Based on observation, clinical record review, facility documentation review, and interviews for one (1) of three (3) residents reviewed for provision of adequate supervision (Resident #1), the facility failed to ensure that the resident was assessed to determine the level of supervision the resident required after the resident exhibited high risk sexually inappropriate behavior, and the facilty failed to ensure interventions were initiated to address the potential risk to other residents and individuals resulting in a finding of Immediate Jeopardy. The Immediate Jeopardy was identified as corrected on 1/2/20 when Resident #1 was placed on one to one (1:1) monitoring. The finding includes: Resident (R) #1 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], pituitary [CONDITION(S)], and major depressive disorder. Review of facility documentation (reportable events) during the period of 1/11/19 through 9/23/19 identified that the resident exhibited verbal threats, sexually inappropriate behaviors and gestures, profane statements and aggressive behaviors toward other residents. Review of R#1's annual minimum data set (MDS) assessment dated [DATE] identified the resident had intact cognition, required supervision with transfers or locomotion, and required limited assistance with ambulation. The MDS identified that the resident exhibited verbal behavioral symptoms directed toward others. a. Reportable Event documentation dated 10/28/19 identified that R#1 was verbally sexually inappropriate with a resident of the opposite sex and exposed him/herself to the other resident. R#1 was sent to the hospital for evaluation. Review of the hospital record dated 10/29/19 identified that R#1 was evaluated by psychiatry and determined not to be a danger to self or others. R#1 returned to the facility on [DATE] at 5:35 PM. A physician's order dated 10/29/19 directed 1:1 monitoring (one staff member monitoring R#1 only) every shift due to exhibited inappropriate behaviors. The Resident Care Plan (RCP) was updated on 10/30/19 and included to educate R #1 and reinforce what sexually inappropriate behavior consisted of, engage the resident in recreational activities (distraction), redirect R#1 off other units, psychiatric evaluations as needed, medication adjustments, and follow-up with laboratory testing. During the period of 10/30/19 through 11/8/19 the resident remained on 1:1 supervision and on 11/8/19 the resident's level of supervision was decreased to every hour monitoring from 11:00 PM to 7:00 AM and 7:00 AM to 3:00 PM, and 1:1 supervision from 3:00 PM - 11:00 PM, however, the record failed to identify an assessment or physician orders for the change in R#1's supervision status from continuous 1:1 to a least restrictive level of supervision. Review of documentation during the period of 11/8/19 through 11/13/19, indicated R#1 remained on 1:1 monitoring from 3:00 PM-11:00 PM, absent an order to discontinue 1:1 monitoring as directed on 10/29/19. Review of R#1's clinical record for the period of 11/14/19 to 12/11/19 failed to identify that R #1 was supervised on a 1:1 from 3:00 PM - 11:00 PM absent an order to discontinue 1:1 monitoring as directed on 10/29/19 or physician's order to discontinue 1:1 supervision. Interview with the Assistant Director of Nurses (ADON) on 1/7/20 at 2:00 PM identified that R#1's monitoring and 1:1 supervision was tapered on 11/8/19 based on the fact that his/her [MEDICATION(S)] levels were within therapeutic range. The ADON indicated that R#1's behaviors were reviewed in morning report however she was unable to provide documentation of the reviews or assessments identifying the rationale why R#1 was no longer provided 1:1 supervision during the 3:00 PM to 11:00 PM shift. The clinical record failed to identify a physician order to decrease monitoring. b. Review of a nurse's note dated 12/12/19 identified that at 6:30 PM, a resident reported that R#1 was in the lobby and was bothering R#2. The note identified that when the ADON arrived to the lobby, she observed R#1 sitting next to R#2 and no physical contact was observed between R#1 and R#2. The residents were separated and R#1 was removed from the lobby. R#2 reported that R #1 was verbally sexually abusive to him/her and asked R#2 to lick his/her private parts and indicated that R #2 was his/her significant other. R #1 was placed on 1:1 supervision until s/he was sent to the hospital Emergency Department (ED) for evaluation. R#1 was evaluated in the ED and was deemed not to be a danger to self or others and returned to the facility on [DATE]. Upon return, the facility contacted APRN#1 (medical). The clinical record lacked an assessment or new physician/APRN orders entered upon R#1's return. Review of R#1's clinical record for the period of 12/13/19 to 12/16/19 failed to identify that assessments were completed, new physician orders addressing P#1's supervision level were entered in the clinical record, and that R#1's plan of care was revised to include interventions to protect (R#2) and other residents from being verbally and potentially sexually, abused. The clinical record identified on 12/16/19 R#1 was seen by APRN #1 (medical) at 1:40 PM. The progress note reflected that R#1 had not exhibited behavioral issues since 12/12/19. Review of R#1's RCP, updated on 12/16/19, directed to monitor R#1's behaviors, keep R #1 and R#2 separated, psychiatric services to see R#1, and social services to follow-up as needed. The RCP failed to include the specific monitoring plan and the time frame for the behavioral health follow-up to be completed. Interview with the DON 1/8/20 at 2:30 PM identified that a request for behavioral health follow up is made via a Behavioral Health Request Log. However a review of the log for the period of 12/16/19 to 12/23/19 failed to identify that a request was made for R#1 to be seen by psychiatric services. c. Review of a nurse's note dated 12/16/19 at 7:58 PM, identified that R#1 exhibited inappropriate verbal and sexual gestures towards a staff member, during which s/he asked the staff member to expose her private parts to R#1. The resident was transferred to the ED for evaluation. Review of the hospital record dated 12/16/19 identified that the resident was evaluated by psychiatry and determined not be a danger to self or others. R#1 returned to the facility on [DATE] at 9:40 PM with no new orders. Upon return from the hospital, the facility failed to conduct an assessment to determine the level of supervision R #1 required to maintain safety. On 12/17/19 APRN #1 evaluated R#1 and directed to discontinue the resident's [MEDICATION(S)] due to the thought the [MEDICATION(S)] was contributing to R#1's inappropriate sexual behaviors. Review of R#1's clinical record for the period of 12/17/19 to 12/24/19 identified the resident was monitored every shift and exhibited no inappropriate behaviors during that time however, the facility failed to ensure the clinical record identified the specific level of supervision and frequency of monitoring R#1 required to ensure that other residents were not verbally or sexually abused by R#1. Interview with the Director of Nurses on 1/8/20 identified that the facility had no formal process to assess or evaluate the level of supervision needed for residents who exhibit inappropriate behaviors, however, the resident's level of supervision may be directed in a physician's order or residents are discussed during morning meetings and a clinical decision is made based on the residents needs and behavior. d. Review of a nurse's note dated 12/24/19 at 5:00 PM identified that staff reported that R#1 was observed pulling a visitor (minor child) toward him/her and kissed the child on the cheek. Local law enforcement was notified and R#1 was transferred to the ED for an evaluation. Review of the ED record dated 12/24/19 at 8:16 PM identified that R#1 was evaluated and deemed not an imminent danger to self or others. R#1 returned to the facility at approximately 10:45 PM. The record failed to identify that the physician was notified of the residents return. The facility failed to ensure the clinical record identified an assessment was completed to determine the level of supervision R #1 required to maintain safety and protect other residents from the potential verbal or sexual abuse from R#1. Review of a nurse's note dated 12/25/19 at 4:30 AM identified that R#1 was sleeping on rounds, occasionally self-propelling in a wheelchair on the unit and had no inappropriate behaviors. The note identified that R#1 would continue to be monitored, however, failed to identify the level of supervision the resident required to maintain safety. The RCP dated 12/26/19 was updated to reflect the incident on 12/24/19 with interventions that included social service and psychiatry follow-up. The RCP failed to identify the level of supervision the resident required. Review of R#1's clinical record for the period of 12/25/19 to 12/27/19 identified that R#1 was monitored every shift and exhibited no behavioral symptoms, however, the facility failed to ensure the clinical record identified an assessment was completed to determine the level of supervision R #1 required to maintain safety and protect other residents from the potential verbal or sexual abuse from R#1. Review of APRN #1's progress note dated 12/27/19 at 1:04 PM identified that R #1 had impulsive disorder, had been evaluated at the ED on 12/24/19 for inappropriate sexual behavior and was cleared by psychiatry to return to the facility. APRN #1 identified that staff reported the resident had exhibited no inappropriate behaviors since 12/24/19 and noted a plan for psychiatry follow-up and to continue monitoring R#1. APRN #1 failed to direct the level of supervision that the resident required. Interview with direct care staff on 1/2, 1/7, 1/8, and 1/13/20 (Nursing Assistant, Licensed Practical Nurse, Registered Nurse Supervisor, receptionist, Social Worker) identified that they were aware of the resident's sexually inappropriate behaviors and knew to keep an eye on and observe the resident when he/she was with other residents. The staff identified when R#1 exhibited inappropriate behavior and was sent out to the hospital, upon his/her return, they 'monitored him/her closely'. Staff stated that they were aware to redirect the resident when he/she approached other residents or was observed on other units. Staff was unable to identify that R#1's whereabouts were continuously monitored. e. Review of the resident's clinical record for the period of 12/28/19 through 12/30/19 failed to identify that psychiatry was notified that the resident required a follow-up evaluation or that psychiatry had evaluated R#1 during that time. Review of R#1's behavior monitoring record for the period of 12/30/19 to 1/2/20 (7:00 AM to 3:00 PM) identified that no episodes of sexually inappropriate behaviors were exhibited by R#1. However, the clinical record failed to identify R#1 was supervised or monitored during the aforementioned period. Review of a nurse's note dated 1/2/20 at 5:17 PM identified that R#1 was alert, oriented, and able to make his/her needs known. The note identified that R#1 self-propelled ad lib throughout the facility and was monitored closely. The note indicated the plan was to continue to monitor R#1 however, failed to identify the level of supervision or frequency of monitoring. On 1/2/20 at 5:00 PM, R#1 was observed in his/her room and Nursing Assistant (NA) #1 was at the resident's bedside. Interview with the Director of Nurses (DON) on 1/2/20 at 5:00 PM identified that when the resident returned to the facility on [DATE], staff verified that R#1 was cleared by the hospital psychiatrist and was not a danger to self or others. The DON indicated since the resident's return, staff had been monitoring R#1 however, the DON was unable to verify R#1 was assessed upon return to the facility from the hospital or the level of supervision that was provided to R#1 until 1/2/20 at 3:00 PM when an administrative decision to place the resident on 1:1 supervision was made. Immediate Jeopardy was mitigated on 1/2/20 when R #1 was placed on 1:1 supervision. Resident #1 remained on 1:1 supervision until his/her discharge from the facility on 1/9/20. Interview with psychiatry APRN #2 on 1/2/20 at 5:55 PM identified that she was familiar with R#1 and had been treating him/her for behaviors. APRN #2 stated that she was informed of the incident on 12/24/19 and was aware that the resident was being sent to the ED for psychiatric evaluation, was cleared, and sent back to the facility the same night. APRN #2 identified that she had not seen or evaluated the resident since the incident and was not aware that the resident had been placed on 1:1 on 1/2/20. APRN #2 stated that she expected to see R#1 on 1/3/20. Interview with the Administrator on 1/2/20 at 6:20 PM identified that R#1 was seen by and cleared by the hospital psychiatrist at the time of the incident on 12/24/19. The Administrator identified that initially the incident was described as R#1 pulled the child toward him/her and kissed the child's cheek. The Administrator identified that staff was aware of the incident and knew to closely monitor the resident. The Administrator identified that R#1 was discussed almost daily during morning report, although this information was not documented in the clinical record, and had no further behaviors since 12/24/19. The Administrator identified that as he was informed of additional details regarding the incident by the police detective and potential criminal charges against R#1, the decision to increase the resident's supervision to 1:1 was made on 1/2/20. Interview with the Director of Nurses on 1/8/20 identified that the facility had no formal process to assess or evaluate the level of supervision for residents, however, the resident's level of supervision may be directed in a physician's order or residents are discussed during the morning meeting and a clinical decision is made based on the residents needs and behavior. Immediate Jeopardy was mitigated on 1/2/20 when R #1 was placed on 1:1 supervision.

Based on observation, review of the clinical record, facility documentation and interviews on 1 of 4 units (Unit A), and for 1 resident (Resident #72) the facility failed to ensure staff followed the manufacturer guidelines on required cleaning and disinfecting of a multi-use glucometer (monitoring device to test the amount of glucose (sugar) in blood), to prevent the possible transmission of blood borne pathogens between residents, which resulted in the finding of Immediate Jeopardy and/or the facility failed to ensure new employees were evaluated for the two-step PPD (Purified Protein derivative, the PPD skin test for [MEDICAL CONDITION]) according to facility policy. The findings included: 1. Resident #72's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified moderately impaired cognition, required extensive assistance with care and received Insulin 5 of 7 days. The care plan dated 9/4/18 identified Resident #72 had Diabetes Mellitus type 1 and utilized a sliding scale for insulin administration. Interventions included to monitor and/or document Resident #72's and/or the family ability to manage the treatment program, i.e. medications, dietary, glucose monitoring, exercise and knowledge of complications. Physician's monthly orders dated (MONTH) (YEAR) directed to check Resident #72's blood sugar 4 times daily at 6:30 AM, 11:30 AM, 4:30 PM and 9:00 PM. Observation on 11/27/18 at 11:45 AM identified LPN #1 tested Resident #72's blood sugar with an Evencare G2 glucometer. After LPN #1 completed the blood sugar monitoring, he/she wiped the glucometer with an alcohol pad. Interview with LPN #1 at the time of the observation identified he/she had performed a blood sugar test on one other resident prior to performing the blood sugar on Resident #72. LPN #1 indicated although he/she was educated during orientation to disinfect the glucometer after each use with the cleaning wipes as per the manufacturer guidelines, following orientation, when LPN #1 worked independently, he/she decided to use an alcohol pad to clean the glucometer because the manufacturer recommended wipes caused him/her to become nauseous. Additionally, LPN #1 identified he/she did not report to the administration, his/her practice of using alcohol pads to clean the glucometer because the recommended wipes caused him/her to become nauseous. Interview with the VP of Clinical Services on 11/27/18 at 12:15 PM identified it is the responsibility of licensed staff to use the manufacturer recommended wipes to disinfect glucometers. Additionally, the VP of Clinical Services identified if LPN #1 was experiencing nausea from one of the recommended wipes, an alternative recommended wipe could have been provided. Review of facility documentation identified LPN #1's date of hire was 10/16/18 and he/she received classroom orientation on 10/16/18 and received clinical orientation during the 7:00 AM - 3:00 PM shift on Unit D on 10/22, 10/24, and 10/25/18. The facility documentation failed to reflect that LPN #1 had been provided education and/or competencies related to the cleaning and disinfecting of the Evencare G2 glucometer. A review of facility documentation identified LPN #1 worked independently on the following dates: 11/3, 11/4, 11/12, 11/17, 11/18, 11/19, 11/21 and 11/27/18. During those shifts, LPN #1 utilized the multi-use glucometer to monitor the blood sugar of multiple residents at the facility approximately 30 times. Review of the facility policy identified to disinfect the glucometer, clean the meter surface with one of the approved disinfecting wipes. Other EPA registered wipes may be used for disinfecting. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry, or allow to air dry. Review of the manufacturer's guidelines for the Evencare G2 glucometer identified cleaning and disinfecting the glucometer and lancing device is very important in the prevention of infectious disease. Cleaning allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface. The Evencare G2 glucometer and lancing device are validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products are validated for disinfecting the Evencare G2 meter and lancing device: Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration number -10), Medline Micro-Kill (Trademark) disinfecting, deodorizing cleaning wipes with alcohol, (EPA Registration Number -10), Clorox Healthcare Bleach Germicidal and Disinfectant wipes (EPA Registration Number -12), and Medline Micro-Kill Bleach Germicidal Bleach Wipes (EPA Registration Number -1). 2. Interview and review of facility documentation with RN #2 on 11/30/18 at 9:10 AM indicated the facility has had 40 new hires between 6/4/18 to 11/7/18. RN #2 indicated he/she was unable to find documentation to reflect the new employees had been evaluated for the two-step PPD testing. RN #2 further indicated he/she is new to the position as the Infection Control Nurse (ICN). According to the Infection Control Employee Health Policy, upon hire, each employee will undergo a two-step PPD test for detection of [MEDICAL CONDITION]. All employees will be offered immunizations in accordance with current federal, state and local requirements and/or recommendations.

Based on review of the clinical record, facility documentation, facility policy and staff interview for 3 of 6 residents (Resident #68, 461 and 42) reviewed for accidents, the facility failed to implement interventions, including adequate supervision, to reduce hazards and to prevent multiple falls with resulting injury and/or an elopement. The findings include: 1. Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #68 had severely impaired cognition, required supervision with bed mobility and transfers, required limited assistance with walking in the room and corridor, and limited assistance with locomotion on and off the unit. The care plan dated 10/18/18 identified Resident #68 was at risk to fall related to an unsteady gait, bilateral knee buckling, tremors and [DIAGNOSES REDACTED]. Interventions included to provide assistance of 1 staff, utilize a wheelchair for fatigue, be sure the call light is within reach and encourage Resident #68 to use if, ensure proper footwear, follow-up with the neurologist for frequent falls, obtain a physical therapy evaluation provide treatment as needed, and toilet Resident #68 every 2 hours. A nurses note dated 10/11/18 identified Resident #68 was out of bed ad lib (as much as one desires), needs constant redirecting and continues to go into other resident rooms and the nursing station. A nurse's note dated 10/18/18 identified Resident #68 was getting increasingly agitated, can get physical, is very confused and difficult to redirect. Additionally, Resident #68's legs buckle and give out. A nurse's note dated 10/27/18 indicated Resident #68 was observed sitting in the hallway disoriented. Upon assessment, Resident #68 had partial range of motion to the left lower extremity with swelling and limited movement. Subsequent to physician notification, an x-ray of the left foot was ordered. A reportable event form dated 10/27/18 indicated Resident #68 was observed sitting on the floor in the hallway. Interventions included to complete neurologic vital signs for 48 hours, vital signs every 8 hours for 72 hours, and frequent rounding to Resident #68's room for toileting and safety. An x-ray report dated 10/27/18 indicated there was no displacement or dislocation. Review of an interdisciplinary referral to rehabilitation dated 10/29/18 identified Resident #68 was seen subsequent to a fall on 10/27/18. The note indicated Resident #68 was at high risk to fall and constant supervision is necessary. Further, the note indicated Resident #68 was at baseline and did not require physical therapy. A nurse's note dated 10/31/18 indicated Resident #68's left foot remained swollen and eccymotic. Additionally, Resident #68 walked constantly and was noncompliant with rest and elevation. A repeat left foot x-ray was ordered. An x-ray report dated 10/31/18 indicated the third and fourth metatarsals may reflect fractures of uncertain age. The distal second phalanx may reflect a nondisplaced fracture line. Recommendations included further evaluation of these findings, correlate with a CT scan or MRI of the left foot. A nurse's note dated 11/1/18 identified Resident #68 was walking ad lib, non-compliant with rest and elevation, his/her foot remained swollen and bruised. Subsequent to APRN notification, Resident #68 was sent to the hospital for evaluation. Review of a CT scan of the left foot dated 11/1/18 identified a very abnormal examination with findings compatible with a Lisfranc fracture/dislocation. An acute osseous and ligamentous injury are within differential considerations, however, given the degree of numerous ossicles and some being rather smooth, an additional component of more indeterminate/chronic age could also be present such as overall acute superimposition on chronic injuries. Additionally, the CT scan identified a mild deformity suspicious for a small fracture along the medial navicular tarsal bone. A nurse's note dated 11/1/18 at 10:02 PM identified Resident #68 returned from the hospital with a [DIAGNOSES REDACTED]. Instructions included no weight bearing to the left foot, wear jones dressing and hard soled shoe, and follow-up with an orthopedic physician for a CAM (controlled ankle motion) boot. Review of nurse's note dated 11/2/18, 11/5/18, and 11/8/18 indicated Resident #68 was non-compliant with non-weight bearing to the left foot. A physician's orders [REDACTED]. Review of nurse's notes dated 11/10/18 and 11/11/18 indicated Resident #68 was non-compliant with non-weight bearing. A nurse's note dated 11/12/18 indicated Resident #68 was standing at the door and went down to the floor. A reportable event form dated 11/12/18 indicated Resident #68 was observed standing at the door way and went on the floor. Resident #68 had no apparent injury, and no new interventions were noted on the reportable event form, investigation and/or care plan. Review of an interdisciplinary referral to rehabilitation dated 11/12/18 indicated Resident #68 was at baseline and there was no need for physical therapy. A nurse's note dated 11/15/18 indicated Resident #68 was found by the dining room door and suddenly his/her knees buckled and the staff lowered the resident to the floor. Resident #68 sustained a 1.7cm by 2.2cm abrasion to the right knee. A reportable event form dated 11/15/18 indicated Resident #68 was lowered to the floor after he/she stood from the wheelchair and his/her knees buckled. Resident #68 sustained an abrasion to the right knee. The reportable event form identified Resident #68 was non weight bearing to the left toot and required total support with nightly care. The investigation indicated to monitor the resident, continue to redirect and assist the resident to the wheelchair. Review of nurse's notes dated 11/16/18, 11/17/18, and 11/18/18 indicated Resident #68 was noncompliant with non-weight bearing and the resident takes the CAM boot off at times. A nurse's note dated 11/20/18 at 12:30 PM indicated Resident #68 was found lying on the bed side table trying to get up with a bruise on his/her chin that measured 2.0cm by 2.0cm. The note indicated at 1:30 PM Resident #68 was found on the floor, indicating he/she was trying to get to the bathroom. The note indicated staff were unable to educate Resident #68 due to cognition. Review of an interdisciplinary referral to rehabilitation dated 11/21/18 indicated Resident #68 was seen for a fall. The resident is at baseline and no need for therapy. A nurse's note dated 11/21/18 indicated Resident #68 was noncompliant with non-weight bearing. A nurse's note dated 11/22/18 indicated Resident #68 was found lying on his/her back on the floor. Resident #68 indicated he/she went to the bathroom. The note indicated to continue every 2 hour and as needed toileting. A reportable event form dated 11/22/18 indicated staff heard a resident call out get out of my room. Resident #68 was found on his/her back on the floor in room [ROOM NUMBER] and had no injury. The investigation indicated Resident #68 required the assistance of 2 for transfers and interventions included to continue interventions on the risk plan, including to keep the residents bed in low position, keep the call bell in reach and encourage Resident #68 to use the call bell, and obtain a physical therapy screen. A nurse's note dated 11/24/18 indicated Resident #68 was non-compliant with non-weight bearing and the CAM boot. A nurse's note dated 11/26/18 indicated Resident #68 was noted on the floor in the bathroom. A reportable event form dated 11/26/18 indicated staff heard a noise and found Resident #68 on the floor in the bathroom with no apparent injury. Resident #68 was barefoot and without a wheelchair. The investigation indicated Resident #68 required complete assistance with all care and was non weight bearing to the left foot. Additionally, the intervention was to continue the interventions on the risk plan and obtain a PT screen. Review of an interdisciplinary referral to rehabilitation dated 11/26/18 indicated Resident #68 was seen for a fall. Resident #68 is at baseline and no need for physical therapy services. A nurse's note dated 11/27/18 indicated the orthopedic doctor was notified of Resident #68's noncompliance with weight bearing status and CAM boot to the left foot. The note indicated that Resident #68's poor mental status and safety awareness persists. A reportable event form dated 11/28/18 identified staff found Resident #68 kneeling by his/her roommate's bed. Left lower extremity swelling, redness and bruising were noted. An intervention documented on the reportable event form directed to encourage Resident #68 to use the call bell. A nurse's note dated 11/28/18 at 7:40 AM indicated Resident #68 was found kneeling on the floor at the foot of the roommate's bed with left lower leg swelling. At approximately 9:30 AM an assessment identified left lower extremity swelling, redness and bruising that measured approximately 15.0cm by 12.0cm. Subsequent to APRN notification, Resident #68 was sent to the hospital. The hospital record dated 11/28/18 indicated Resident #68 was diagnosed with [REDACTED]. Clinical information identified trauma. Discharge recommendation included to follow up with orthopedic surgery to evaluate need for surgery. A nurse's note dated 11/28/18 at 4:38 PM indicated Resident #68 returned from the hospital with a half cast with ace wrap. Resident #68 continued to be noncompliant with transfers and non-weight bearing and was placed on 1:1 monitoring for safety. A review of the clinical record and interview on 11/29/18 at 2:30 PM with the DNS indicated although Resident #68's care plan identified that the resident was at risk for falls, and should have been non weight bearing on the left foot, the DNS was unable to provide documentation that the care plan was reviewed and revised after each fall to implement measures to prevent further falls. Additionally, although an interdisciplinary referral to rehabilitation dated 10/29/18 identified Resident #68 required constant supervision, the plan of care failed to reflect that the resident received constant supervision. Subsequent physical therapy screens dated 11/12/18, 11/21/18, and 11/26/18 provided no recommendations to prevent further falls, only indicating therapy was not indicated. A policy and procedure on fall management indicated in the event of a fall, the facility will investigate the factors contributing to the fall and develop a plan of action to minimize further falls. The facility failed to implement and/or monitor the effectiveness of and/or modify interventions to reduce Resident #68's risk for falls and protect the resident from injury. Resident #68 had severely impaired cognition and fell on [DATE] with a resulting [MEDICAL CONDITION] foot. Although an interdisciplinary referral to rehabilitation dated 10/29/18 indicated constant supervision of Resident #68 was necessary, the resident was without the benefit of adequate supervision and fell again on 11/12, 11/15, 11/20, 11/22 and 11/26/18. Further, on 11/28/18, and without the benefit of adequate supervision, Resident #68 was found kneeling on the floor at the foot of the roommate's bed and sustained a new distal oblique fibular fracture, required hospital evaluation and subsequent follow up to an orthopedic surgeon. 2. Resident #461's [DIAGNOSES REDACTED]. Review of a fall care plan dated 11/7/17 identified that the resident was at risk for falls related to confusion, and a history of falls with interventions that included to anticipate the resident's needs, and ensure prompt response to all requests for assistance. Review of the 90 day minimum (MDS) data set [DATE] identified that the resident had severe cognitive impairment, and required extensive to total care with activities of daily living. Review of a fall risk assessment dated [DATE] identified that the resident was a high risk for falls. Review of a nurse's note dated 1/20/18 at 11:49 PM identified that the resident was restless throughout the shift, and had attempted to get out of bed several times. The resident was taken out of bed and placed in the wheelchair between 9:00 PM-9:30PM and was supposed to be monitored by a Nurse Aide (NA) for safety. At 10:15 PM, the resident was observed on the floor and transferred to the hospital for evaluation. Review of a nurse's note dated 1/20/18 at 7:08 AM identified that the charge nurse had informed him that the resident had fallen, upon arrival to the unit the resident was found lying in the hallway on his/her left side, bleeding from the nose and mouth, an assessment was completed and the resident was sent to the hospital for an evaluation. Review of a hospital discharge summary dated 1/25/18 identified that the resident was admitted to the hospital with [REDACTED]. Interview with LPN #10 on 11/29/18 at 9:30 am identified that on 1/20/18 the resident was very restless and was continually trying to get out of bed. NA #6 took the resident of bed and placed him/her in the wheelchair between 9:00PM-9:30PM. Once the resident was placed in the wheelchair, the resident continued attempting to get out of the wheelchair. LPN#10 stated that he assigned NA #6 to sit with the resident and continually monitor the resident because the resident was so restless. LPN # 10 stated that when he came out of another patient's room around 10:00 PM, he found Resident #461 on the hallway floor. LPN#10 further identified that although he had assigned NA#6 to continuously monitor the resident, NA #6 had left the resident unattended to answer another resident's call light. Interview with NA #6 on 11/29/18 at 10:30 AM identified that he was assigned to Resident #461 on 1/20/18, and the resident was continually trying to get out of bed, so he took him/her out of bed and placed the resident in the wheelchair and brought him/her into the hallway. Resident #461 continued to be restless once in the wheelchair, so he sat with her to monitor her safety. NA #6 identified that either a call light and/or an alarm went off, and he left Resident #461 unattended to check on another resident and the resident then fell on the floor. NA#6 could not recall what LPN #10 had told him about the monitoring of Resident #461, but he did not think he had to monitor the resident continually. Interview with the RN #3 on 11/29/18 at 12:10 PM identified that he was unaware that the resident was exhibiting restless behavior and/or that LPN #10 has assigned NA #6 to continually monitor the resident, he only became aware of the issue when he was alerted by the charge nurse that the resident was on the floor. Interview with the Previous Director of Nurses (PDON), RN #2, on 11/29/18 at 1:45 PM identified that the supervisor should have been notified of the resident's behavior and need for continual monitoring so staffing could have been adjusted to meet the needs of the unit. The PDON further identified that if the resident was exhibiting restless behavior, the patient should be placed on continuous monitoring, and should not be left unattended. Additionally, the PDON identified that subsequent to Resident #461's fall on 1/20/18, the staff on the unit were educated on ensuring a resident who exhibiting restless behavior be monitored with one to one supervision and not be left unattended. 3. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of elopement risk assessments dated 5/31/18 and 9/18/18 identified Resident #42 did not exhibit wandering behavior. The quarterly MDS dated [DATE] identified Resident #42 had intact cognition, and did not exhibit wandering behavior. Additionally, the MDS identified Resident #42 required supervision, set up only with bed mobility and transfers, limited 1 person assistance with ambulation and locomotion on and off the unit, and supervision set up only with personal care. The care plan dated 10/17/18 identified Resident #42 had a self-care deficit related to weakness, and history of [MEDICAL CONDITION] due to a stroke. Interventions included to provide the assistance of one with personal care, and obtain a PT/OT evaluation and treatment per physician's orders [REDACTED].>A reportable event form dated 10/26/18 identified at 11:20 PM, Resident #42 keyed the code into the security alarm of the main entrance and left the building on a motor scooter. Subsequent to police notification, Resident #42 was returned to the facility uninjured. An investigative statement dated 10/26/18 identified a nurse aide monitored the door the night of 10/26/18. At approximately 11:25 PM, Resident #42 came speeding down from B wing toward the lobby, entered the code in the keypad to the main door and opened the door. Attempts at redirection were ineffective. The nurse aid reported the incident to the nursing supervisors who were both in the office at the time. A nurse's note dated 10/26/18 identified that at approximately 11:20 PM, Resident #42 keyed the combination lock to the main entrance and took off on a motorized scooter. The door monitor could not stop the resident and notified the nursing supervisor during the change of shift. The police were alerted of the possible elopement, a description was provided to the police who arrived immediately. Resident #42 initially refused to go inside stating his/her roommate smelled bad and he/she cannot be in the room. After further discussion, Resident #42 agreed to return to his/her room. No injury observed, denied pain. Resident #42 was offered an empty bed, but refused. Observation on 11/26/18 at 6:55 AM identified Resident #42 exited the building on a motor scooter and returned a short time later escorted by staff. Interview with NA #2 on 11/26/18 at 7:20 AM identified he/she was stationed at the main door to monitor visitors, employees and residents entering and exiting the building. NA #2 indicated Resident #42 used the code to exit the building. Additionally, NA #2 indicated Resident #42 frequently would use the code to open the door and exit the building and that the administration was aware of Resident #42's behavior. Interview on 11/26/18 at 8:16 AM with Resident #42 identified he/she was upset about his/her roommate, (Resident #95), who repeatedly urinated on Resident #42's clothing. Additionally, Resident #42 further reported that Resident #95 engages in this type of behavior often, also urinating on the bathroom floor and in the garbage pail. Resident #42 indicated he/she has reported this concern to facility staff who offered a room change, which he/she declined. Interview with the Administrator on 11/27/18 at 10:55 AM identified that while he/she believed Resident #42 had exited the facility in the past, he/she was uncertain if a care plan had previously been put in place following those incidents to address the concern. The Administrator also reported Resident #42 rammed the front door with his/her scooter and exited the facility on the evening of 11/26/18 after becoming increasingly upset when the evaluating APRN suggested he/she be evaluated at the emergency room . The Administrator remained with Resident #42 in the driveway, and contacted the police who refused to transport the resident to the emergency room when Resident #42 declined to go. A reportable event form dated 11/26/18 detailed both incidents of Resident #42's elopements. Interventions identified in the report included 1:1 monitoring and a code change to the main entrance. Resident #42 was evaluated by psychiatry and met with social services. An interview with RN #4 on 11/27/18 at 2:15 PM identified he/she was responsible for overseeing updates to the plan of care when there is a change of condition, however any licensed staff can update the plan of care. An interview with RN #2 on 11/28/18 at 2:45PM identified that although she was aware of the incident of elopement that took place on 10/26/18, she had repeatedly requested the reportable event form from the supervisor on duty and had not received it. RN #2 indicated she did not follow up because administrative roles were changing and the new Administrator and Director of Nursing would be overseeing the investigation. An interview with the Administrator on 11/28/18 at 3:00 PM identified he was unaware of the incident of elopement that had taken place on 10/26/18 and had taken over responsibly of the facility as of 11/5/18. The policy for elopement directed all residents to be assessed upon admission, quarterly and when there was a change in status for risk of elopement. The policy further directed that in the event of an elopement, the resident's physician and family would be notified by the charge nurse regarding the suspected or actual elopement and what measures have been put in place to prevent another elopement. The facility failed to implement and/or monitor the effectiveness of and/or modify interventions to reduce Resident #42's risk for elopement. The facility failed to reassess Resident #42's elopement risk and/or revise the plan of care after Resident #42 eloped on 10/26/18. Further, while the access codes to the main entrance were changed following the incident of elopement on 11/26/18, there was no documentation to reflect that the code to the front entrance was changed to prevent Resident #42 from exiting the building after the 10/26/18 incident of elopement.

Based on clinical record reviews, review of facility documents, review of facility policies, observations and interviews for 1 of 3 residents who required total care and had communication difficulties (Resident #2), the facility failed to ensure that the resident remained free from abuse. The finding includes: Resident #1's [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that the resident ambulated with a walker with supervision on the unit, cognition was intact and the resident was responsible for self. Resident #2's [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that the Resident required total assistance for care to include bed mobility, was non- ambulatory, always incontinent of bowel and bladder, cognition was severely impaired and had no speech. Review of nursing narratives and/or the facility investigation dated 1/21/18 indicated that R#1's walker was observed outside of R#2's room, R#2's privacy curtain was closed by NA #3 at approximately 10:00 AM and NA #2 observed the privacy curtain half open and R #1exiting R #2's room at approximately 10:15 AM. The investigation further noted that NA #1 saw R #1 exit R#2's room, found R#2's brief had been undone on the left side at approximately 10:30 AM and reported this to the nurse. Following an immediate psychiatric evaluation by MD #1 (psychiatrist) of R #1, both residents were placed on every 15 minute checks beginning 10:30 AM on 1/21/18, the Residents' family and physician as well as required local authorities were notified of the incident on 1/21/18. R#1's clinical record identified that R#1 reported that he/she visited R#2 (on 1/21/18) and only went in the room to say Hi. R#1 was sent to ED #1 for psychiatric assessment and testing on 1/21/18. Review of hospital documentation for R#1 dated 1/23/18 noted that R#1 stated that he/she kissed R#2 and touched R#2's genitalia. The 15 minute checks were discontinued on 1/23/18 and the resident was placed on 1:1 observation on 1/23/18 following evaluation by MD #1. R#1 was placed back on 1:1 observation on 2/27/18 at 7:00 PM following additional information reported to the facility by Detective #1. R #2 was discharged from the facility on 3/5/18 per the wishes of R #2's family. Review of the police report dated 8/6/18 identified that R#1 will be charged with sexual assault in the fourth degree and reckless endangerment. Interviews with facility staff on 3/15/18 indicated that R#1 did not have a history of sexually inappropriate behaviors prior to 1/21/18. Interview with NA #1 on 3/15/18 at 11:40 AM noted that she observed R#1 exiting R#2's room and when she went to provide care to R#2 at approximately 10:30 AM, she noticed the left side of R#2's brief undone and slightly apart exposing skin on the Resident's left side. NA #1 further indicated that R#2's brief was intact at 8:00 AM. Interview with R#1 on 3/15/18 at 1:05 PM (with interpreter present) identified that he/she held R#2's hand, kissed R#2's hand and did not touch R#2 inappropriately.

Based on clinical record reviews, facility documentation review, facility policy review, and interviews for one of three sampled residents (Resident #395) reviewed for a change in condition, the facility failed to ensure that the resident was immediately assessed when s/he exhibited signs of respiratory distress and/or failed to ensure licensed staff immediately went to the bedside when informed the resident was no longer breathing resulting in a delay in the initiation of CPR which resulted in Immediate Jeopardy and /or for one of three sampled residents (Resident #72) who was require assistance with personal care, the facility failed to ensure the resident's choice of care givers was honored as outlined in the plan of care. and /or two of six residents reviewed for accidents (Residents #16 and Resident #66), the facility failed to ensure vital signs and/or neurological assessments were performed after an unwitnessed fall . The findings included: 1.Resident #395's [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified that Resident #395 was alert and oriented, had no cough or respiratory symptoms, and had clear breath sounds. A physician's orders [REDACTED]. APRN notes dated ,[DATE], ,[DATE], and [DATE] identified that the resident's lung sounds were clear to auscultation. The nurse's note written by LPN #6, dated [DATE], labeled addendum for [DATE], identified at approximately 6 AM upon entering R #395's room, R #395 was lying flat on his/her back in bed and complained of difficulty breathing. LPN #6 instructed R #395 to put the head of the bed up, and the resident stated s/he was going to sit on the side of the bed. LPN #6 started the IV antibiotic, and R #395 continued to complain of difficulty breathing. LPN #6 exited the room to retrieve oxygen and a NA was sitting at R #395's bedside. Upon return to the room, LPN #6 found R #395 unresponsive. Oxygen was applied at 5 liters a minute via a nasal cannula, CPR was initiated, and supervisor was called to the unit. Paramedics arrived about 6:10 AM and took over CPR. R #395 left the unit at approximately 6:20 AM for transfer to the hospital. During interaction with R #395 color was at baseline with no cyanosis observed, no diaphoresis, and blood sugar was 168. Review of the ambulance (EMS) run sheet dated [DATE] identified a 911 call was received from the facility at 6:11 AM and EMS staff arrived on scene at 6:21 AM, (not at 6:10 AM, as documented in LPN #6's nurse's note). LPN #6's note further identified that the resident left the unit at 6:20 AM, although the EMS record noted they arrived on scene at 6:21 AM. EMS documentation identified R #395 had no pulse or respirations, and pupils were fixed and dilated. EMS personnel were informed that the resident had complained of difficulty breathing and was found in [MEDICAL CONDITION]. Bloody, frothy sputum was noted in and around the mouth, and CPR was started with a Lucas Device and 15 liters of oxygen were administered. R #395 was intubated with equal bilateral lung sounds, two doses of [MEDICATION NAME] were administered, a pulse then was palpable and CPR was stopped. Ventilation was continued and R #395 was transported to the hospital at 6:43 AM. Review of the hospital discharge summary dated [DATE] identified R #395 was admitted after found in asystolic arrest one hour after receiving [MEDICATION NAME] by mouth, and supplemental oxygen for respiratory distress, downtime not entirely clear but presumed no longer than 1 hour, CPR was initiated by EMS with return to spontaneous circulation within 10 minutes. Chest x-ray with evidence of [MEDICAL CONDITIONS], and CT scan of head identified diffuse [MEDICAL CONDITIONS]. Discussion with family for hospice services. R #395 expired shortly after extubated on [DATE]. Review of autopsy report dated [DATE] identified the cause of death was diabetes mellitus leading to acute [MEDICAL CONDITION] infarction. Interview and review of the clinical record with LPN #6 on [DATE] at 10:18 AM identified she entered the resident's room at 6:00 AM on [DATE], and the resident stated s/he was having a hard time breathing and was short of breath. LPN #6 stated she told R #395 she was going to put the head of the bed up but the resident declined as s/he would prefer to sit on the side of the bed. LPN #6 further stated while she obtained the blood sugar and hung the IV, R #395 was breathing heavy, and described the breathing pattern as heavy like if you ran up a flight of stairs. LPN #6 stated she told R #395 to relax and she would go get oxygen, and before she left the room R #395 stated s/he was anxious and could not breathe. LPN #6 identified although she could have designated someone else to call for help when the resident had difficulty breathing, she requested that a nurse aide stay with the resident while she obtained the oxygen and when she was returning with the oxygen the nurse aide told her to hurry up because R #395 was not breathing. LPN #6 stated she was aware that R #395 was not breathing, returned to the nursing station and called the three other nursing units to locate the nursing supervisor and alert the other nurses that R #395 needed CPR. LPN #6 indicated she entered R #395's room immediately ahead of the supervisor, and CPR was initiated. LPN #6 stated she did not obtain vital signs (pulse, respirations, blood pressure or pulse oximetry) and/or listen to the resident's lung sounds when R #395 complained of difficulty breathing at 6:00 AM. The facility failed to ensure that the resident was immediately assessed when s/he exhibited signs of respiratory distress at 6:00 AM including but not limited to obtaining vital signs and listening to the resident's lungs. Although Resident #395 was in respiratory distress, LPN #6 proceeded to administer the resident's IV antibiotic, and obtained a finger stick. Further, LPN #6 failed to immediately go into R #395's room to start CPR, when informed by the nurse aide that the resident was no longer breathing and/or send the nurse aide for help, but instead, LPN #6 went to the nursing station and called three other nursing units to locate the nursing supervisor and alert the other nurses that R #395 needed CPR. LPN #6 was unable to give a specific accounting of the time frame from when she left the room to obtain oxygen, to when Resident #395 stopped breathing, to when CPR was initiated. Interview and review of the clinical record with the DON on [DATE] at 11:36 AM identified that LPN #6 should have obtained vital signs, should have directed someone else to call the nursing supervisor and obtain the oxygen, should not have left R #395, and should not have obtained the blood sugar and administered the IV when R #395 complained of difficulty breathing. Interview with RN #6 (Nursing supervisor on duty on [DATE] during the 11 PM-7AM shift) on [DATE] at 10:16 AM stated LPN #6 should have evaluated the resident's breathing status first before proceeding with hanging the IV and checking the resident's blood sugar and notified her immediately when the resident complained s/he was having trouble breathing. RN #6 further identified that by the time she got to the bedside, it was too late and all she could do was CPR. Interview and review of the clinical record with Physician #1 on [DATE] at 1:59 PM identified LPN #6 should have obtained vital signs and assessed R #395, and should not have administered the IV and obtained the blood sugar. Physician #1 identified there could have been a negative outcome due to no timely assessment, would have wanted to be notified of the change in condition when R #395 complained of difficulty breathing, and would have directed staff to transfer R #395 to the hospital at that time. Review of the CPR policy, effective ,[DATE], identified that the facility will provide basic life support, including CPR - Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services. Prompt initiation of CPR is essential as brain death begins four to six minutes following [MEDICAL CONDITION] if CPR is not initiated within that time. The policy further directed in part, employee will check for resident response, tap or shake shoulder of resident asking, Are you okay and simultaneously assess the resident for breathing and pulse for 10 seconds. Shout for nearby help or pull the call button for assistance. Activate emergency response system. 2. Resident #72's [DIAGNOSES REDACTED].#72 had no memory and/or cognitive deficits, required extensive to total one (1) to two (2) person assistance with transfer in and/or out of the bed and chair, personal hygiene, toilet use, repositioning while in bed, and dressing, and had functional limitation in range of motion in both upper and lower extremities. The Resident Care Plan dated [DATE] identified the resident was resistive to male caregivers. Interventions directed to allow the resident to make decisions about treatment and a sense of control, and the resident preferred not to have male nurse aides provide care. Review of the resident care card identified no male aides. Interview on [DATE] at 10:35 AM Resident #72 identified back on [DATE] a male nurse aide responded to the call light. Resident #72 stated she requested a female nurse aide and after mumbling a comment under his breath the nurse aide left and a female nurse aide came in. Resident #72 identified that staff were aware that no males nurse aides to care for her. Interview with the social worker on [DATE] at 12:15 PM identified that Resident #72 had informed her of the incident, the resident was upset and she relayed the information to the Director of Nursing and Administrator. 3. Resident #16's [DIAGNOSES REDACTED]. The initial Resident Care Plan (RCP) dated [DATE] identified R #16 was at risk for falls. Interventions directed to anticipate and meet resident needs and follow facility fall protocol. The 30-day MDS assessment dated [DATE] identified that Resident #16 was alert and oriented, and required extensive assistance of two staff for transfers. i. Review of facility documentation dated [DATE] identified at 12 Noon R #16 made an allegation regarding a NA remark made toward R #16 and not receiving medication timely. Additional review of the report identified a written statement signed by the Director of SS that the resident had an unwitnessed fall, and that s/he threw him/herself on the floor and RN #1 helped him/her off the floor. Review of the clinical record failed to identify that vital signs and/or neurological assessments were completed after the fall. Interview and clinical record review with the DON on [DATE] at 9:18 AM identified that vital signs and/or neurological assessments were not obtained after the fall on [DATE] and stated they should have been completed for an unwitnessed fall. ii. Review of facility documentation dated [DATE] at 9:30 PM identified R #16 had an unwitnessed fall in his/her room while attempting to grab an item from the garbage can. A nurse's note dated [DATE] at 10:57 PM identified R #16 was found on the floor in his/her room, no pain or discomfort, and will continue to monitor. Review of neurological assessment flow sheet identified although vital signs were obtained at 9:30 PM, none were recorded after that date, and neurological assessments were obtained on [DATE] at 9:30, 9:45, 10, 10:15 and 10:45 PM only. Interview and clinical record review with the DON on [DATE] at 9:18 AM identified that vital signs and/or neurological assessments were not obtained in accordance with facility policy. b. Review of a nurse's note dated [DATE] at 6 PM identified R #16 reported he/she fell twice while on leave of absence from the facility and got him/herself off the ground. Additional review of the clinical record failed to identify vital signs or neurological assessments were completed after the fall was reported. Interview and clinical record review with the DON on [DATE] at 9:18 AM identified vital signs and/or neurological assessments were not obtained after the fall was reported on [DATE]. The DON stated vital signs and neurological assessments should have been completed for an unwitnessed fall. 4. Resident #66's [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified that Resident #66 was alert, oriented to person and place, and required extensive assistance with transfers. The Resident Care Plan (RCP) dated [DATE] identified an ADL deficit, and received [MEDICAL CONDITION] medication. Interventions directed to assist with bed mobility, and monitor for adverse reactions/unsteady gait. The nurse's note dated [DATE] at 12:31 PM identified R #66 was found sitting on the floor in front of his/her wheelchair, no bruises or redness noted, vital signs were stable, and R #66 denied hitting his/her head. The record reflected that neurological assessments and vital signs were monitored on [DATE]. Further review of the clinical record noted that vital signs were monitored on [DATE] during the ,[DATE] shift, however, not every eight (8) hours for 48 hours in accordance with facility policy. The record failed to identify that neurological assessments were documented on [DATE], [DATE] and/or [DATE]. Interview, clinical record review, and facility documentation review with RN #3 and RN #4 on [DATE] at 9:23 AM identified vital signs should be monitored after a fall for three days, and neurological assessments should be monitored every 15 minutes for 1 hour, every thirty minutes for 2 hours, every two hours for 8 hours, every four hours for 16 hours, and every eight hours for 48 hours. RN #3 and RN #4 stated the vital signs and neurological assessments were completed on the day of the fall ([DATE]) but not completed for subsequent shifts. Review of facility Falls Management Policy, directed in part, if a fall was unwitnessed or a head injury is suspected, neurological signs will be monitored. Review of facility Neurological Assessments Policy directed in part, to evaluate the residents level of consciousness, pupil response, motor functions, hand grasps, extremity strength, blood pressure, temperature, pulse and respirations every 15 minutes for 1 hour, every thirty minutes for 2 hours, every two hours for 8 hours, every four hours for 16 hours, and every eight hours for 48 hours.

Based on clinical record review, review facility documentation, review of policy and procedures and interviews for one sampled resident reviewed for pain, (Resident #345), the facility failed to ensure a resident who required pain medication received the medication that was consistent with professional standard of practice. The finding include: Resident #345's [DIAGNOSES REDACTED]. A review of the clinical record identified Resident # 345 was admitted on [DATE]. The admission nursing assessment dated [DATE] indicated Resident #345 was cognitively intact and the resident was totally dependent on the nursing home staff for ADL task. A review of the admission orders [REDACTED]. The resident's admission care plan dated 5/7/18 identified Resident #345 has chronic pain secondary [MEDICAL CONDITION]. Interventions included: to administer medication as prescribe by physician, to assess for side effects, to notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Interview with Resident #345 on 5/7/18 at 11:40 A.M. indicated she/he had to wait over twelve hours for pain medication when she/he arrived on 4/30/18. Resident #345 indicated that she/he was in tears due to his/her pain/discomfort. The nurse's notes dated 5/1/18 through 5/9/18 failed to document on the location of the resident's pain and or the effectiveness of any intervention provided. A review of the Medication Administration Record [REDACTED].M. on 5/1/18; indicating Resident #345 missed a 6:00 A.M. and a 12:00 pm administration of the [MEDICATION NAME] 100mg administration. Review of the MAR indicated [REDACTED]. A review of the Medication Administration Record [REDACTED]. Further review of the MAR for (MONTH) (YEAR) documented that 10 of the 10 times when Resident #345 was assessed the resident pain level was 10 out of 10 ( one a scale 1-10). However a review of the facility's narcotic E-box list and controlled drug receipt record disposition form for 4/30/18 and 5/1/18 with RN # 4 during the survey failed to identify [MEDICATION NAME] IR 60mg was available to the staff on 4/30/18 and or 5/1/18. Review of the narcotic E-box list and the controlled drug receipt record disposition form identified that only the long acting [MEDICATION NAME] was available, indicating Resident #345 was medicated with [MEDICATION NAME] 60mg orally. Interview with LPN # 16 on 5/9/18 at 10:30 A.M. identified she/he could not determine why the pain assessment for 12 shifts were not completed. Interview with Dietitian #1 on 5/9/18 at 11:15 A.M. indicated the resident would not eat because Resident #345 was in too much pain. Interview with LPN # 15 on 5/9/10 at 11:45 A.M. indicate the pharmacy questioned the dosage of the [MEDICATION NAME] 100mg and it took a while for the dosage to be confirmed and or delivered. LPN # 15 also indicated that she/he did not report the medication delay to the physician and attempted to treat Resident #345's pain with the [MEDICATION NAME] Immediate Release (IR) 60mg. Interview with the DNS on 5/10/18 at 12:00 P.M. and review of the facility's emergency medication box identified that on 4/30/18 through 5/1/18 the staff signed out 60mg of [MEDICATION NAME] (the long acting medication) and not 60 mg of the [MEDICATION NAME] I.R. (Immediate Release). [MEDICATION NAME] 100mg (long acting) was not identified as being signed out and or administered as directed by the physician. Interview with the Director of Nurses and review of the facility's policy on 5/10/18 at 11:40 A.M. indicated that residents are assessed every shift for pain. The policy also indicated the staff is directed to document the interventions and or the effectiveness of the intervention in the nursing notes. Interview with the DNS on 5/10/18 at 1:40 P.M. indicated that the resident was not medicated as ordered in error. The DNS indicated that the staff would be in-serviced to prevent additional errors. Interview with Pharmacist #1 on 5/10/18 at 1:15 P.M. indicated that [MEDICATION NAME] 60mg is less potent and or requires more time to achieve pain relief than the ordered [MEDICATION NAME] 100mg and or the [MEDICATION NAME] 60mg IR.

Based on review of the clinical records, facility documentation, and interviews the facility failed to establish and maintain an Infection Control Program in accordance with industry standards designed to provide a safe, sanitary environment to help prevent the development and transmission of disease and infection when Legionella was identified in the water system resulted in the finding of immediate jeopardy. The findings include: Review of the Legionella Experts Special Pathogen Laboratory Report dated 7/31/17 identified swab and water sample testing was conducted on only one unit in the facility on 7/21/17 subsequent to Resident #101 contracting Legionnaires disease at the facility in March 2017. The report identified that water tested in three resident bathrooms and the clean utility room had tested positive for blue/white Legionella bacteria. On 8/8/17, it was noted that residents continued to reside in rooms that had tested positive for Legionella bacteria on 7/31/17. Review of the resident clinical records noted the following: 1. Resident #111's [DIAGNOSES REDACTED]. A hospital discharge summary dated 7/13/17 noted the resident was hospitalized from 6/29-7/13/17 with MRSA sepsis and respiratory distress from multi-lobar pneumonia requiring urgent intubation. Nurse's notes dated 8/3/17 identified that the resident was observed in respiratory distress, hypoxic, pale, and with a pulse ox of 65% (normal over 95%). The resident was transferred to the hospital and admitted with rule out pneumonia. 2. Resident #49's [DIAGNOSES REDACTED]. 3. Resident #108's [DIAGNOSES REDACTED]. A hospital discharge summary dated 7/17/17 identified that the resident had been hospitalized with sepsis due to unspecified organism and acute [MEDICATION NAME] from 7/4-7/17/17. Review of the facility investigation into the origin of the Legionnaire's disease and identification of Legionella bacteria in the water system with the Administrator and DNS on 8/8/17 at 10:00AM failed to provide documentation that the resident's residing in the rooms that tested positive for the Legionella bacteria on 7/31/17 had been assessed for signs of disease and/or that any plans/ interventions had been implemented to protect or remove the residents from potential harm due to the Legionella bacteria in their bathrooms. Further review noted the facility failed to contract with an environmental contractor as directed by both Environmental Health and Epidemiology for further testing and/or remediation of the bacteria. Only one unit was tested in the facility although the water system is all one unit. Review of the Infection Control Program on 8/8/17 at 9:00AM failed to reflect that a Legionella policy and procedure was developed after the identification of Legionella in the facility water system on 7/31/17 and/or that a line list that identified residents with healthcare -associated pneumonia was developed. Interview with the Medical Director on 8/8/17 at 10:30AM identified he/she received notification from the administrator of the positive testing of Legionella bacteria in the facility. The Medical Director indicated that although he/she was aware of the positive testing for Legionella, an assessment of the residents residing in the rooms positive was not conducted. The Medical Director further indicated that to date, collaboration with facility leadership, staff, and consultants regarding the implementation of resident care policies and procedures that reflect current standards of practice for Legionella management including clinical guidance was not provided to the facility. Interview with the current Infection Control Nurse on 8/8/17 at 11:00AM identified she/he was recently hired by the facility. The INC indicated some in-service education was provided to staff about Legionella bacteria and disease after a case was identified in the facility. The facility did not however, develop a line list of cases, perform an environmental assessment, identify residents with [DIAGNOSES REDACTED]. Further, the INC did not conduct testing for Legionnaire's disease on residents with healthcare-associated pneumonia and failed to develop a Legionella policy and procedure as part of the facility infection control program. The INC indicated residents were not assessed to ascertain if current respiratory symptoms were present. The CDC guidelines direct a facility to perform a full investigation for the source of Legionella when one (1) case of definite healthcare-associated Legionnaire's disease is identified. Key elements of a full investigation include: working with local and/or state health department, reviewing medical and microbiology records, actively identifying all new and recent patients with healthcare -associated pneumonia and testing them for Legionella using both culture of lower respiratory secretions and urine [MEDICATION NAME] test, developing a line list, evaluating potential environmental exposures, performing an environmental sampling, subtyping and comparing clinical environmental isolates, decontaminating environmental sources, and reviewing and possible revising the water management program. Subsequent to surveyor inquiry and identification of immediate jeopardy, the facility contracted with an environmental consultant to begin an assessment of the facility's water system, obtain samples, conduct remediation to protect the residents, and assessments were conducted by the APRN of all residents to identify signs and symptoms of Legionnaire's disease. Further, residents who were identified acutely vulnerable will be provided with bed baths, bottled water, hand sanitizer, a wash basin and pitcher for hand washing through the testing phase and 14 days after. The rooms that were tested positive will be vacated and prohibit entry from staff or other residents and visitors. The failure of the facility to establish a water system testing program when Legionella was identified in the water system and the failure to establish and maintain an Infection Control Program designed to provide a safe, sanitary environment to help prevent the development and transmission of disease and infection when Legionella was identified in the water system resulted in the finding of immediate jeopardy. In addition to the immediate jeopardy noted above, the following deficiencies were identified: Based on clinical record review, interviews, review of infection prevention records, facility documentation and and review of policies and procedures, the facility failed to have an adequate and appropriate Infection Control Program per regulatory standards. The findings include 1. The Infection Control Policy and Procedure Manual that was provided for review failed to contain appropriate policies and procedures that addressed all areas of infection prevention. Further review noted that it had not been updated and reviewed by the facility Administrator, The Medical Director, and the Infection Control Nurse for the last year. 2. Review of the Infection Control documentation failed to identify that quarterly Infection Control Committee meetings occurred from November 2016 through July of 2017 and/or that quarterly statistics on infections were gathered, analyzed, completed and/or discussed. Interview with the Infection Control Nurse (ICN) on 8/9/17 at 10:00AM stated that h/she was new to the position and that the former Director of Nursing Services (DNS) was responsible for the Infection Control Program. H/she also stated that most of the documentation was kept on the former DNS's computer and once h/she started in the ICN role, could not access any of that information. The ICN stated that h/she is aware that this is a problem and moving forward will be addressing this issue. 3. Review of the IC line list failed to reflect that monthly active infections in the facility were documented and/or investigated, and/or monitored from November 2016 to July 2017. Only August of 2017 identified active infections in the facility. Interview with the ICN on 8/9/17 at 10:00 AM noted that h/she could not find any evidence of an active line list and developed the current line list in August of 2017 after reviewing the facility's resident's charts. The ICN could not determine if there were any outbreaks during the last year. 4. Review of the credentials of current ICN identified that the ICN is a licensed practical nurse (LPN). Interview with the ICN on 8/9/17 at 10:00AM stated that h/she has been working for the company since February of 2017 at another facility and is at the current facility helping out with the Infection Control Program. H/she further stated that the facility is in the process of hiring a registered nurse for the ICN position but previously the DNS was in charge of the Infection Control Program. 5. Resident #108 resided in one of the rooms that tested positive for the Legionella bacteria. A progress note completed by APRN#1 dated 8/8/17 stated that per request of administration, to examine the resident related to possible exposure to legionella. Assessment/Plan: 1. No evidence of legionella pneumonia, lungs clear, no cough, afebrile. 2. Test the urine for legionella. Resident #108 was sent to the emergency room per the responsible parties request not related to the legionella. Interview and record review with the DNS on 8/9/17 at 7:53AM failed to reflect that the hospital was informed of the potential possible exposure to legionella. The DNS further stated that the resident was sent to the hospital and it was not related to the legionella. H/she further stated that the hospital should have been informed of the possible exposure to legionella and that h/she will be contacting the hospital immediately. 6. Resident # 39's [DIAGNOSES REDACTED].# 39 was without cognitive impairment and required limited assistance with personal hygiene. The Resident Care Plan (RCP) dated 7/25/17 identified R # 39 was receiving IV medications for MRSA bacteremia. Interventions directed to observed dressing and change as ordered, monitor, document and report signs or symptoms of infection at the site. Intermittent observations on 8/7/17 from 6:45 AM to 11:50 AM identified an isolation cart outside R # 39's room and a sign directing staff/visitors to see the nurse before entering the room. Interview and observation with LPN # 1 on 8/7/17 at 11:50 AM identified R # 39's isolation had been discontinued, and the sign directing staff/visitors to see the nurse before entering the room and the isolation cart should have been removed. LPN # 1 entered R # 39's room with surveyor and introduced surveyor to R # 39. Interview and review of the clinical record with LPN # 1 on 8/7/17 at 12:05 PM identified LPN # 1 was unable to locate a physician's current order for isolation precautions, and stated the precautions were discontinued by a physician order [REDACTED].# 1, a visitor approached LPN # 1 and asked if he/she could enter the room to visit R # 39 because there was a cart outside the room. LPN # 1 informed visitor he/she could visit, and the cart did not need to be there as R # 39 was not on precautions. Upon further review of the clinical record with LPN # 1, LPN # 1 stated he/she was not sure if R # 39 should or should not be on precautions because he/she was currently receiving IV antibiotics for bacteremia. Interview and review of the clinical record with the ADON on 8/7/17 at 12:40 PM identified although the nurse should know if a resident should be on isolation precautions, the ADON was not sure if R # 39 should be on isolation precautions. Subsequent to surveyor inquiry, observation of R # 39's room on 8/8/17 at 7:05 AM identified an isolation cart outside R # 39's room and a sign directing staff/visitors to see the nurse before entering the room. Review of the clinical record identified a physician order [REDACTED]. During an interview with LPN # 1 on 8/7/17 at 7:20 AM, LPN # 1 stated R # 39 was on isolation precautions for bacteremia. Interview, review of the clinical record and review of facility policy with Regional RN # 1/Infection Control Nurse on 8/9/17 at 12:10 PM identified R # 39 should not be on isolation precautions. Regional RN # 1/Infection Control Nurse stated based on the facility policy, R # 39 should be on standard precautions. Subsequent to surveyor inquiry, a physician order [REDACTED]. Review of facility Isolation Policy directed in part, residents with [DIAGNOSES REDACTED] disease require standard precautions. Additional review of policy identified if the multi-drug resistant organism is colonized, standard precautions are required. 7. Based on interviews, resident clinical record excerpts, and review of facility documentation, the facility failed to ensure nursing staff received timely resident-specific education regarding infections. The findings include: Review of resident clinical record excerpts, and review of facility documentation identified Legionella was identified on 3/22/17. Review of facility staff education documentation identified that although education was provided for staff, no education was provided regarding Legionella and/or pneumonia. Interview and review of facility documentation and facility staff education documentation with the DON on 8/22/17 at 10:44 AM, the DON was unable to provide documentation that staff were provided education regarding Legionella and/or pneumonia prior to 7/25/17. The DON stated disease specific education should have been provided when the Legionella was identified on 3/22/17. Facility did not provide a policy for surveyor review.

Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for four sampled residents (Resident # 108, 73, 157, 58) reviewed for care and services, the facility failed to ensure physician orders [REDACTED]. The findings included: 1. Resident # 108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment identified that the resident was cognitively impaired, dependent on staff for all mobility and ADL's, and incontinent of bowel and bladder. The admission/interim care plan dated 6/7/17 identified the need for assistance with toileting. Physician orders [REDACTED]. The admission MDS assessment dated [DATE] identified that Resident #108 was severely cognitively impaired, dependent on staff for all ADL's including toileting and personal hygiene, and incontinent of bowel and bladder. Review of the clinical record identified no bowel movements were noted from 6/27/17 through transfer to the hospital on [DATE]. The medication administration records failed to document administration of any of the laxatives as directed by the physician orders. Nurse's notes identified R #108 was discharged to the hospital on [DATE] with a temperature of 103, and labored breathing. The hospital discharge summary dated 7/17/17 identified a CT scan of the abdomen found impacted stool in the rectum with peri-rectal free fluid possibly indicative of stercoral [MEDICAL CONDITION]. Interview and review of clinical record with LPN # 5 on 8/9/17 at 9:09 AM identified R # 108 was admitted to the hospital, and stated when he/she became aware of the [DIAGNOSES REDACTED]. LPN # 5 further stated the bowel movements should have been recorded. During a phone interview with Physician # 1 on 8/10/17 at 9:48 AM, Physician # 1 explained that the stercoral [MEDICAL CONDITION] is caused by the impacted stool in the rectum. S/he noted that the impaction causes an inflammation that causes [MEDICAL CONDITION]. Interview and review of the clinical record with the DON on 8/10/17 at 11:05 AM failed to provide documentation that any bowel movements were recorded, and/or that the PRN laxatives for constipation were administered per physician orders. Review of facility Bowel Protocol Policy directed in part, use of Milk of Magnesia as needed for constipation, [MEDICATION NAME] suppository if Milk of Magnesia was ineffective, and Fleet Enema if [MEDICATION NAME] suppository was ineffective. 2. Resident #73's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified that the resident was without cognitive impairment and required limited assistance with ADL's. Physician orders [REDACTED]. Review of the medication administration kardex noted that the resident was to receive the [MEDICATION NAME] injections on 3/7/17 and 3/14/17. Further review noted that the Medication Administration Record [REDACTED]. The back of the kardex and nurse's notes failed to document reasons why the medication was not administered. Review of the resident's lab work noted that upon transfer to the hospital on [DATE], the resident's hemoglobin and hematocrit were 7.7 and 26.6. Interview with RN#4 on 08/10/2017 1:51:45 PM failed to provide documentation that the resident ever received the medication as ordered by the physician although the pharmacy records indicated that the drug was ordered and delivered. 3. Resident #157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified that the resident was alert and oriented and experienced acute pain in the left leg at a level of 7 out of 10. Admission physician orders [REDACTED]. Physician orders [REDACTED]. The physical therapy evaluation dated 2/10/17 indicated the resident had intense amount of pain on left lower extremity with movement. Review of the Medication Administration Record [REDACTED]. A written statement by Person #3 on 2/15/17 with email verification on 8/10/17, indicated that on 2/10/17 at 6:30 AM, R#157 was found sitting up in bed in pain and stated that s/he had been ringing the bell since 4:30 AM for pain medication and no one came. Person #3 indicated that the nurse was found at the desk using a cell phone, indicated that the resident never rang the call bell, and was asked by Person #3 to get the resident pain medication. Person #3 indicated that it took 15 more minutes before the resident received the medication. It was also noted that the call bell was broken and a hand bell provided to the resident after Person #3 noted the lack of call bell response. Interview and review of the clinical record with RN#4 on 8/10/17 8:30 AM failed to provide documentation that the resident received pain medication in a timely manner. RN#4 indicated that the call bell in that room had been broken for a long time. Although Person #3 noted that the resident didn't receive the medication until approximately 6:45 AM, the nurse documented on the kardex that the resident received the medications at 6 AM. Requests by the surveyor to review the narcotic proof of use sheets were not met; the facility was unable to locate the narcotic sign out records for the resident's pain medications. 4. Resident #58's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #58 was without cognitive impairment, and required extensive assistance with bed mobility and transfers and supervision with eating. The Resident Care Plan (RCP) dated 7/26/17 identified the resident had a potential nutritional problem related to a [DIAGNOSES REDACTED]. Review of the NA care card dated 8/2/17 failed to identify the resident was currently on a fluid restriction. In an interview with NA #3 on 8/9/17 at 8:30 AM identified that he/she gets resident care information from the day nurse, 11-7 NA and/or the NA care card and he/she thought that Resident #58 was on a 1500 cc fluid restriction. NA#3 identified that he/she was allowed to give Resident #58 a total of 780 cc on his/her shift; 180 cc of coffee and 120 cc of milk at breakfast, 120 cc of milk, 180 cc of coffee and 120 cc of juice at lunch and up to 60 cc of additional water during the shift. NA#3 was unable to identify if the resident took lunch and fluids with him/her on [MEDICAL TREATMENT] days. Additionally, NA#3 was unsure what the resident received from the nurse during the day and thought that it would have been a good idea for the fluid restriction to have been on the care card because care cards are used to tell the NA's how to care for someone who doesn't know. Observation of Resident #58 on 8/9/17 at 8:51 AM identified the resident in bed eating breakfast. On the resident's tray was a container of [MEDICATION NAME] milk, and on the bedside stand, a cup of coffee and an almost full water pitcher. Interview and review of facility documentation with the Dietary Manager on 8/9/17 at 9:48 AM identified that fluids were distributed according to what was on the dietary ticket. Review of the dietary ticket identified that the resident was to have 240 cc of coffee at breakfast and 240 cc at lunch. Additionally, he/she was not sure why the container of lactose milk was placed on the tray and/or given to the resident, but that the resident should not have received additional fluids on his/her tray. Interview and review of facility documentation with RN#5 on 8/917 at 9:08 AM identified that residents on fluid restrictions should not have water pitchers available at the bedside and that [MEDICAL TREATMENT] resident's should have fluid restrictions determined on admission. RN#5 further identified that when a resident has a fluid restriction, there is usually a sheet in the intake and output section to identify the amount of fluid the resident is allowed per shift, but that no sheet could be found. RN#5 identified that if a resident is on a fluid restriction it should documented on the NA care card, but the fluid restriction was not identified there. Additionally, RN#5 identified that since the resident had an AV fistula, the site not only should be monitored, but safety interventions directing emergency care should be in the MD orders and in the resident's care plan but this was also not found. In an interview and review of facility documentation with LPN#5 on 8/9/17 at 1 PM, he/she identified that he/she had carried over the 1500 cc fluid restriction from previous admissions (8/7/14) because that was what the resident had always been on, but could not find current documentation in the clinical record and/or from the hospital record of a fluid restriction until 7/20/17 (7 days after admission). Additionally, LPN #5 was unable to locate directions on the care plan for per shift fluid guide and/or any information regarding the emergency care of the resident's AV fistula. Review of facility [MEDICAL TREATMENT] Policy identified that if the resident is placed on a fluid restriction, monitor intake and output and allocate fluids to be given by nursing and dietary and amounts per shift. Emergency care identified in the event of bleeding from the AV Fistula, apply pressure, notify MD immediately, and notify [MEDICAL TREATMENT] unit and family of change in condition. Additionally included in the [MEDICAL TREATMENT] policy was that care planning would include risk factors and emergency care.

Based on clinical record reviews, observations, review of facility policy and interviews for two of four sampled residents (Resident #55, 40) reviewed for pressure ulcers, the facility failed to develop a plan of care to prevent pressure sores in a resident at risk, and/or failed to initiate interventions to aide in healing a pressure sore once developed, and/or failed to ensure a newly identified pressure area was assessed. The findings include: 1. Resident # 55's [DIAGNOSES REDACTED].#55 was severely cognitively impaired, required extensive assistance for bed mobility, transfers, and dressing, total care for personal hygiene and was at risk for pressure ulcers. The Resident Care Plan (RCP) dated 7/17/17 failed to identify interventions to prevent pressure ulcers with the exception of turning and repositioning with incontinent care. A physician's orders [REDACTED]. The APRN note dated 8/3/17 identified the resident had a 1.2 cm blister on the right foot. A physician's orders [REDACTED]. Observations on 8/7, 8/8, and 8/9/17 throughout the day identified the resident sitting in a wheelchair, frequently moving his/her legs and rubbing the feet together with only gripper socks on. No devices were present to alleviate pressure or reduce friction and shearing on the feet while out of bed. Interview with LPN#6 on 8/8/17 at 12:28 PM identified that although s/he documented the blister on the report sheet, s/he was rushing and forgot to document the blister in the clinical record. S/he further identified that s/he did not think s/he had to measure the wound because the blister was intact and it was caused by friction from the resident rubbing the feet together. Interview and clinical record review with APRN#1 on 8/8/17 at 12:30 PM, identified the blister was caused by friction because the resident's usual behavior is to rub his/her feet together. Interview and record review with the DNS on 8/9/17 at 2:30 PM identified that R#55 should have had a care plan in place identifying interventions to prevent the blister from developing, and care plans should be updated quarterly and with any changes. S/he further identified that when the blister was identified, it should have been assessed by the nurse, measured and documented in a nurse's note and/or weekly wound measurement log, updated the care plan, and the family should have been notified. Additionally, record review identified the last Braden Scale for determining the resident's risk for pressure ulcers was completed at time of admission on 6/21/16. The DNS identified Braden Scales should be done quarterly. Observation and interview with LPN #4 on 8/10/17 at 11:00 AM identified that s/he is responsible for wound assessment and tracking, and s/he was not aware of the wound until surveyor inquiry on 8/10/17. S/he identified if s/he had been aware of the wound prior to 8/10/17 s/he would have documented it on the pressure ulcer documentation flow sheet, and implemented an intervention to reduce the friction to the resident's feet. Observation of the wound with LPN#4 identified a reabsorbing blister measuring 2 cm x 2.5 cm on the inner part of the resident's right foot. Review of facility Pressure Ulcer Policy identified, Stage II pressure ulcer presents clinically as an abrasion, intact or open serum-filled blister and the Facility shall provide care, treatment and services to promote the prevention of pressure ulcer development and promote healing if present, including identifying residents at risk using quarterly Braden Scales, implementing individualized care plans, and weekly assessment and documentation of the wounds. 2. Resident # 40 ' s [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that Resident # 40 had both long and short term memory problems and was severely impaired for daily decision making. Resident #40 was totally dependent on staff for bed mobility, was at risk for pressure sores and did not currently have a pressure sore. A physician's order [REDACTED]. The Resident Care Plan (RCP) dated 8/1/17 identified a potential for pressure ulcer development related to immobility, and actual pressure area. Interventions directed to turn and reposition every two hours, and treatment as ordered. Review of the clinical record failed to identify any wound assessment and/or wound measurements had been obtained when the pressure ulcer was identified on 7/27/17. The first assessment was by the wound consultant on 8/3/17. Interview and review of the clinical record with RN # 5 on 8/10/17 at 9 AM identified the pressure area was first identified on 7/27/17, and although a physician ' s treatment order was obtained, RN # 5 was unable to provide documentation that the pressure area was assessed when identified. RN # 5 stated an assessment should have been completed when the pressure area was identified on 7/27/17. Review of facility Pressure Ulcer Prevention Program Policy directed in part, to document wound initially and weekly.

Based on clinical record review, facility documentation, and interviews, for 1 of 3 residents reviewed for accidents, Resident #1 (R#1), the facility failed to prevent an injury of unknown origin. The findings include: R#1 had a [DIAGNOSES REDACTED].#1 was cognitively impaired and required total assistance for activities of daily living (ADL's), including transfers. A resident care plan (RCP) dated 1/8/16 identified that the resident had limited physical mobility with interventions to transfer the resident with a mechanical lift. A care plan dated 1/8/16 identified that the resident was at risk for skin impairment and dependent on for staff for mobility with interventions that included using a lifting device to move the resident, and to use caution during transfers to prevent striking arms and legs on a hard surface. Review of a reportable event dated 2/27/16 identified that R#1 was noted with bruising to the right leg and pain with touch and movement. The resident was assessed and medicated for pain and an x-ray was taken on 2/27/16 that identified an acute right proximal tibia fracture. The investigation conducted by the facility identified that, although the cause of the fracture was inconclusive, after observing mechanical lift transfers with staff, it was identified that R#1's leg may have hit the bar on the Hoyer bar and sustained the injury. The facility's reportable event investigation failed to consider any other possible cause. A nurse's note dated 2/27/16 at 2:15 PM identified that the right lower extremity was noted with bruising and pain when touched, the physician was contacted and an x-ray was taken of the right leg. A nurse's note dated 2/27/16 identified that the x-ray of the right leg identified an acute tibia fracture, the Advanced Practiced Registered Nurse (APRN) was updated and ordered an orthopedic consult for 2/29/16 and to medicate for pain with Ultram every 4 hours. Review of the radiology report dated 2/27/16 completed by MD#1 of x-rays taken of the right tibia and fibula identified an acute oblique fracture of the proximal tibia. Interview with Licensed Practical Nurse (LPN) #4 on 8/11/16 at 12:30 PM identified that he/she was informed by the Nurse Aide (NA) #1 on 2/27/16 that the resident had a bruise to the right lower extremity, the nursing supervisor was called and an assessment of the right leg was done, the resident was guarding the right leg and had facial grimacing, and was medicated for pain with Tylenol. The physician was called and an x-ray was ordered of the right leg. Interview with RN # 4 on 8/11/16 at 2:00 PM identified that LPN#4 had reported to him/her that R#1 had a bruise on the right leg. The area was assessed, the resident had complained of pain when touched, the resident was medicated and the physician was called and an x-ray was ordered. A statement obtained from the facility from NA#1 on 3/4/16 (multiple attempts were made unsuccessfully to contact NA#1) identified that he/she did not care for the resident but went in to check on R#1 because he was passing by the resident and saw that R#1's leg was flexed in an awkward position and saw the bruise and reported it to the nurse. Review of a facility statement given by NA#3 on 3/4/16 ( attempts to contact NA#3 were unsuccessful) identified that he/she cared for R# 1 on 2/26/16 on the 11:00 PM-7:00 AM shift and did not transfer the resident, and/or observe any pain or bruising to the right leg. Interview with NA#4 on 8/26/16 at 10:00 AM identified that he/she had cared for R#1 on 2/26/16 on the 3:00-11:00 PM shift and did not recall the resident in any pain and/or note any bruising, he/she did transfer R#1 with the Hoyer lift but extremities did not come into contact with the Hoyer lift. Interview with NA#5 on 8/26/16 on 1:30 PM identified that he/she had cared for R#1 on 2/26/16 on the 7:00 AM-3:00 PM shift identified that he/she could not recall if he/she had transferred the resident and/or if R#1 had complained of pain, or had bruising to the right extremity. Interview with MD#2 on 8/25/16 who was the physician who read R#1's x-ray on 2/27/16 identified that the right tibia had an acute oblique fracture. MD#1 further identified that the fracture on the x-ray had no signs of healing, therefore would be considered acute, subtle signs of healing will appear in 3-5 days. MD#2 further identified that an oblique fracture is described as a fracture that occurs on an angle, and is usually due to a trauma or a fall. Additionally MD#2 stated that it could be a possibility that the fracture occurred if the resident's leg came into contact with the Hoyer lift bar. Interview with the Director of Nurses (DNS) on 8/26/16 at 11:00 AM identified that after R#1 ' s fracture was identified, the facility conducted observations of residents who required mechanical lifts, and came to the conclusion that the fracture could have occurred when R#1 ' s leg came into contact with the Hoyer lift bar. The DNS further identified that all NA's were in-serviced and competencies were conducted for Hoyer lift transfers and padding was added to the Hoyer lift bar. Review of the Hoyer lift guidelines identify that when lowering the resident the NA should gently push on the knees while resident to ensure correct positioning.

Based on clinical record reviews, observations and interviews for two of five residents (R) reviewed for elopement (R#4 and R#5), the facility failed to implement measures to keep residents' safe which resulted in a finding of immediate jeopardy on 9/16/15.The findings include: 1. R#4 ' s [DIAGNOSES REDACTED]. Review of the elopement assessment dated [DATE] identified R#4 had an elopement potential based on evidence of goal directed wandering, observable anxiety and frustration. Review of the physician orders [REDACTED]. Review of the Resident Care Plan (RCP) supplementary notes dated 5/13/15 identified that R#4 demonstrated exit seeking behaviors and stated that he/she wanted to go home and believed that he/she will be picked up today, on 5/13/15 by family and returned home. Review of the RCP dated 5/13/15 identified R#4 was an elopement risk with a history of wandering at home, poor safety awareness and limited insight into illness and limitations. R#4 was identified as being impulsive with interventions to identify pattern of wandering. Review of a facility investigation dated 5/17/15 identified at 2:10 AM, the D-Wing, back exit alarm sounded and R#4 was found outside of the building and was brought back into the facility. Review of RN #3's statement dated 5/17/15 identified that he/she was alerted that the alarm sounded at the D-Wing back exit. A resident check was conducted and it was identified that R#4 was not on the unit. Shortly thereafter (the investigation does not identify the exact length of time) the resident was located down the road and was returned by RN#3. Review of interventions implemented identified R#4 was placed on one-to-one monitoring upon return to the facility on [DATE], which was discontinued on 5/18/15 at 3:45 PM when R#3 was reviewed by psychiatry and was transfered to an acute care facility for behavioral disturbances and altered mental status. The resident returned to the facility on [DATE] without changes to his/her treatment plan. R#4 was maintained on either every 15 minute or every 30 minute checks from return from the hospital on [DATE] through 6/1/15. Review of the nurse's notes dated identified R#4 attempted to elope on 5/20, 5/22, 5/25, 5/26, 5/27, 5/28 and 5/31/15 through doors that had sensor alarms, but did not have a wanderguard. Review of the progress notes dated 6/1/15 identified R#4 was placed on a one-to one monitoring because the resident became agitated and combative and was transferred to an acute care facility at 3:00 AM and was returned to the facility on [DATE] at 4:00 PM with an increase of Risperidone to 1.0 milligram, twice a day. The resident was placed on every 30 minute checks upon return from the acute care setting. Review of facility investigation dated 6/2/15 at 4:05 AM identified R#4 wandered from the facility and was located by a staff member walking down the street. R#4 had rung a neighbor's door bell and the neighbor called the police. The resident told the police that he/she did not want to remain at the facility and he/she was transported to an acute care facility. Further review of the facility documentation and interviews failed to identify a facility investigation addressing the alarm and/or that the alarm did not sound. Review of the police case/incident report dated 6/2/15 identified that at 4:49 AM the police responded to a call and located R#4 in front of a residence. R#4 was with a male who was attempting to get him/her into his car. That male was Nurse Aide (NA)# 1 from the facility. It was related that the resident went missing a half hour ago and the nurse aide was sent to look for him/her. R#4 had walked out of the facility undetected. R#4 did not wish to return to the facility, so an ambulance was dispatched and the resident was transported to an acute care facility. Interview with NA#1 on 9/16/15 at 10:30 AM identified that on 6/2/15, R#4 was not on one-to-one monitoring but staff were trying to watch him/her all the time. There were two nurse aides on the floor and the other nurse aide told him that she could not locate the resident. NA#1 further identified that the alarm did not sound. 2. R#5 [DIAGNOSES REDACTED]. The MDS dated [DATE] identified R#5 with severe cognitive impairment, wandering behavior which occurred every 1-3 days and that put the resident at significant risk, and required supervision for transfers and ambulation. The RCP dated 4/30/15 identified R#5 was a wander risk and exit seeks. It further identified that the resident been noted to wander in and out of rooms, had set off door alarms on the and had increased exit seeking behavior in the evening. Interventions were identified for family to consider a memory impaired unit closer to home, keep resident in high visible areas when not in bed and maintain frequent checks. Review of the nurse's progress notes dated 4/23/15 through 6/19/15 identified R#5 with wandering behaviors and difficulty redirecting. On 4/23/15 the progress notes reflected R#5 has had increased wandering into resident's rooms and had opened the side door (not wanderguard functioning), and set off the sensor alarm. Review of the nurse's notes dated 5/23/15 and 6/10/15 described R#5 had attempted to elope by opening doors and setting off alarms. Review of the nurse's notes dated 6/19/15 identified that the nursing supervisor was called to the unit by a staff member who reported that the resident was observed outside around 7:55 PM as the staff member was driving into work. R#5 was observed standing at the bottom of the driveway talking to a woman in a car who he/she did not know. One-to -one monitoring was implemented and then decreased to every fifteen minute checks during the evening shift. The facility investigation failed to address what door the resident may have exited and whether an alarm sounded. Interview with NA#5 on 9/17/15 at 11:00 AM identified that she was called into work because of staffing issues and observed R#5 talking to the driver of a car out on the street, approximately 1/4 mile away. She recognized the resident and proceeded to bring the resident back to the facility. Interview with the nursing supervisor, RN#1, on 9/17/15 at 11:40 AM identified that there was no way of determining what door the resident exited and she did not hear an alarm sound. R#5 has had a history of [REDACTED]. Interview and observations on 9/ 15 /15 at 1:15 PM with the Director of Maintenance identified that the front door and the 2 double doors to the service corridor are wanderguard alarmed. These double doors lead to a service corridor which leads to an exit to the outside. The double door on the A/B corridor was alarmed on the right side, but not on the left to allow for staff to enter the service corridor easily. The observation further identified that when the door was tested on the right side of the A/B corridor, it did not alarm. The left side of the double door was observed to be open and no alarm was noted. There are nine doors with direct exit to the outside that are alarmed, but not with a wanderguard system. These are equipped with a variable alarm system, which is scaled from a loud alarm to a barely audible alarm called a chime. The staff had the ability to turn the alarm to chime when they reset the alarm. Observations of these nine doors identified two doors had the alarm set to the barely audible chime function. Interview with the Director of Maintenance on 9/15/15 at 1:00 PM identified that he/she cannot recall the exact date, but it was brought to his attention that the front door wanderguard alarm was intermittently not functioning. A request for service was obtained on 7/8/15. The Director of Maintenance further stated that a maintenance staff member checked the side doors, the doors not equipped with a wanderguard system, for function every day. The interview further identified there is no system in place for checking the wanderguard doors. Interview with the Administrator on 9/15/15 at 3:00 PM identified that the issue with the doors were explored secondary to R#4's elopement on 6/2/15, as a part of their quality program and bids were requested for a new system. However, the new system had not been implemented, nor had interventions been put in place to assure the current system was functional. Review of maintenance documentation dated 6/22/15 identified that a request was made for service for the wanderguard system because the front door was not always detecting bracelets. Interview with the compliance manager of the security service provider on 9/17/15 at 10:00 AM identified that service was scheduled for 7/8/15 and at that time it was determined that nothing could be done to repair the door because of the old age of the system and the inability to obtain parts. A quote was submitted for a new system on 7/8/15. On 9/16/15, the facility was notified on 9/16/15 that immediate jeopardy had been identified as a result of the facility's failure to ensure that resident's at risk for elopement received adequate supervision, once the facility became aware that the wanderguard system was only intermittently functioning.

Based on observations, clinical record reviews, and interviews for the only sampled resident (Resident # 67) reviewed for hospice care, the facility failed implement physician orders [REDACTED].#26), the facility failed to follow physician orders [REDACTED]. The findings include: 1. Resident #67's [DIAGNOSES REDACTED]. A hospice note dated 1/21/14 recommended to increase the [MEDICATION NAME] Patch from 25 mcg/hr to 37 mcg/hr. Physician orders [REDACTED].) A nursing note dated 1/29/14 identified that a request for a pharmacy precription, needed to obtain the 12mcg/hour [MEDICATION NAME] Patch, was put in the APRN book. A hospice note dated 1/30/14 identified that the [MEDICATION NAME] Patch 12 mcg/hr (to make the 37 mcg/hr) had not been initiated (9 days after the physician ordered the increase). Additionally, the resident was noted with facial grimacing during personal care and at times of rest. Hospice recommendations dated 1/30/14 directed to obtain the prescription necessary to obtain [MEDICATION NAME] Patch 12 mcg/h as part of 37 mcg/hour. Interview with RN#2 on 2/21/14 at 1:00 PM identified that the [MEDICATION NAME] Patch was not obtained for over 9 days because the facility was without an APRN for 1 - 2 weeks. It was in that time that staff were waiting for a prescription to be written for the [MEDICATION NAME] Patch. Interview with Pharmacist #1 on 2/21/14 at 11:20 AM identified that the facility did not fax the prescription for the [MEDICATION NAME] Patch unitl 1/31/14, and the order was filled the same day. Interview with RN#2 on 2/21/14 at 1:00PM identified the [MEDICATION NAME] Patch 37 mcg/hour was started on 2/1/14. 2. Resident #26's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The orders also instructed to obtain the following laboratory tests: CBC, LFTs and BMP every 2 months, (Dec., Feb., April, June,, Aug. and Oct.), HgA1c every 3 months, (Jan., April, July, and Oct.), and VPA level every 6 months, (Nov. and May). Review of the clinical record identified December 2013, CBC, BMP and LFTs were not drawn as well as the July 2013 and October 2013 labs. Interview with the ADNS on 2/21/14 at 11:45 AM failed to identify why the December 2013, CBC, BMP and LFTs were not drawn as well as the July 2013 and October 2013. After surveyor inquiry, a physician order [REDACTED].

Based on clinical record reviews, review of reportable event investigations, and interviews for four of six sampled residents reviewed for incidents/accidents (R#1, 2, 4, 6), the facility failed to ensure that the residents were supervised when agitated, and/or transferred in a safe manner, and/or that the environment was safe to prevent injuries to the residents. The findings include: 1. Resident #2's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified that the resident was severely cognitively impaired, displayed no problem behaviors, was totally dependent on staff for all ADL's, and had no history of falls. The care plan dated 1/9/12 identified that the resident required a mechanical lift for transfers. Interventions included using the assistance of two staff for transfers, and to inspect the bed, lift and chair for safety issues including sharp edges, and loose objects. A facility investigation/reportable event dated 2/1/12 at 4:30 PM indicated that during a mechanical lift transfer back to bed, the resident's left leg made contact with the wheelchair leg rest causing a laceration that required 15 sutures at the hospital. The report indicated that the wheelchair was immediately removed from service and repaired "as necessary". Interview with the DNS and review of maintenance logs on 10/10/12 at 12:15 PM noted that the resident's wheelchair was repaired after the injury. Further review noted that the resident's leg should not strike the wheelchair during mechanical lift transfers. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] indicated that the resident was alert and oriented, and continent of bowel and bladder. The admission MDS dated [DATE] identified that the resident was without memory or cognitive impairments, required assistance with transfers and ambulation and had no history of falls. Physician orders [REDACTED]. On 6/28/12 at 4:30 AM, the resident was observed sitting on the floor in his/her room. A large laceration was noted on the right forearm. The resident stated at that time that he/she hit his/her arm on the door frame, sustained the laceration and then sat on the floor. The resident was sent to the emergency department and returned with 27 staples to the laceration. A follow up report to the incident indicated that the door jam was repaired after the resident's injury. Observation of the room/bathroom door on 10/9/12 at 10 AM noted that the metal strike plate on the bathroom door frame was curved around the frame and not protruding. Interview with the Maintenance Director on 10/10/12 at 7:25 AM noted that the plates on the door frames were sticking out straight (metal strike plates), and that subsequent to the resident's injury, the plates were bent around the frames (curved) so that they no longer protruded. 3. Resident #4's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident had severe cognitive impairment, no problem behaviors, and required the extensive assistance of one person with bed mobility and personal hygiene. The care plan dated 5/2/12 identified the potential for falls and injury. Interventions included provide assistance with ADL's, assistive devices, and floor pads. Facility documentation dated 2/13/12 and 2/27/12 identified that R#4 had bruises to the left eye, and/or cheek and jaw. Interventions for future protection included applying side-rail pads. Facility documentation dated 6/19/12 at 4:00 PM identified R#4 sustained a laceration on the right eyebrow measuring 1 inch by 0.5 inch. Additionally, the documentation identified while NA #1 was providing care, the resident was turned and the resident's head hit the side rail causing the laceration to the right eyebrow. The care plan identified that on 6/18/12, side rail pads were added as a "new" intervention. Interview with NA #1 on 10/10/12 at 11 AM identified that while providing care to R# 4, the resident turned to the side and hit his/her head on the side rail, causing the laceration to the eye. Additionally, NA #1 stated that at that time, the resident's side rails were not padded and she was unaware that they should have been. Interview with LPN#1 on 10/10/12 at 11:10 AM noted that NA #1 reported to her that R #4's head struck the side rail and that when she entered the room, the pads were not on the side rails. Additionally, LPN#1 stated that she was unaware that the resident was to have pads on the side rails. 4. Resident #1's [DIAGNOSES REDACTED]. The resident care plan dated 7/18/12 identified the potential for falls related to resident is non ambulatory. Interventions included keep items within reach, orient to surroundings, and to re-enforce safety teaching. Nurse's notes dated 9/9/12 at 10 PM identified that R#1 was found sitting on the floor in front of the wheelchair. A laceration was noted below the right eye and a bump measuring 3.0 x 4.0 cm on the right forehead, with the right eye starting to swell. The resident was assessed, the physician was notified, and the resident was sent to the hospital for an evaluation. Review of the discharge report from the hospital dated 9/26/12 identified upon assessment, R#1 had multiple areas of ecchymosis on the body with a large amount on the face. Facility documentation dated 9/9/12 at 9:50 PM identified that R#1 was found sitting on the floor in front of the wheelchair in the dining room. The resident was noted to have a laceration under the right eye and a bump to the right forehead measuring 3.0 x 4.0 cm. Additionally, the documentation identified R #1 had been restless and/or agitated, attempting to get out of bed during the shift. Interview with NA #4 on 10/10/12 at 12:30 PM identified that R #1 was restless while in bed and attempting to climb out of bed so NA #4 assisted the resident to the wheelchair and placed him/her in the dining room. Additionally, NA #4 stated that although she is aware that she should not leave a resident alone when they are restless, she thought the resident was calmer and felt she could leave her alone. Interview with LPN #2 on 10/11/12 at 12:05 PM noted that R#1 was assisted out of bed because the resident was attempting to get out of bed several times. Additionally, LPN # 2 stated that NA #4 did not tell her the resident was in the dining room alone, and that normally, residents who are restless are brought to the nursing desk so they can be monitored more closely. Interview with RN #3 on 10/10/12 at 12:40 PM noted that when NA #4 placed R#1 in the wheelchair because the resident was restless, the NA should have stayed with the resident or placed the resident at the nursing station where the charge nurse could have monitored the resident more closely.

Based on clinical record review and interview for the only resident (R# 7) who required IV antibiotic therapy, the facility failed to ensure that the antibiotics were obtained and administered in accordance with the physician's orders [REDACTED]. a. Resident #7's [DIAGNOSES REDACTED]. A significant change in condition Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had severely impaired cognition and was dependent on staff for activities of daily living. The resident was hospitalized from [DATE] to 4/10/11 [MEDICAL CONDITION] pneumonia that required ventilator support and intubation. An Interagency Patient Referral Report and discharge summary from the hospital dated 4/10/11 identified that the resident received the last dose of Aztreonam 1 gram IV at 8:59 AM and [MEDICATION NAME] 750 mg at 11:30 AM on 4/10/11. The discharge summary directed that the resident was to continue the IV antibiotic therapy upon return to the facility. The resident was readmitted to the facility on [DATE] at 2:30 PM. A care plan dated 4/10/11 identified that the resident was at risk for elevated temperature related to an infection. Interventions included to administer medications as ordered and monitor temperature as needed. Physician orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation was lacking to indicate that the resident ever received doses of [MEDICATION NAME] andor Aztreonam on 4/10/11 as directed. A nurse's note dated 4/11/11 at 3:45 AM identified that [MEDICATION NAME] was infusing however the record failed to identify the dosage and/or the time that the medication was initiated. A nurse's note dated 4/11/11 identified that the pharmacy was contacted to regarding the resident's antibiotic and that the 2:00 PM dose was not given. The note identified that the physician was contacted, however failed to identify the specific antibiotic that was not administered. A nurse's note dated 4/11/10 at 3:20 PM identified that the resident was diaphoretic and had a temperature of 104 degrees Farenheit. The resident was transferred to the Emergency department at 3:30 PM. Review of an Emergency department report dated 4/10/11 identified that the resident was admitted to the acute care hospital with a [DIAGNOSES REDACTED]. Interview with the ADNS on 8/23/11 at 2:15 PM identified that the resident's Aztreonam was not available because the pharmacy had not delivered it. The ADNS stated that the resident should have received a dose of [MEDICATION NAME] at 8:00 PM on 4/10/11 and 4:00 AM on 4/11/11 however he/she was unable to provide documentation of when and/or if the doses had been administered. The ADNS identified that the resident did not receive any doses of Azethreonam on 4/10 and/or 4/11/11 because it was not available (missed total of 4 doses).

Based on clinical record review, review of facility policy and interview for one of three residents at risk for fluid volume deficit (R#4), the facility failed to assess the resident's intake and output, conduct physical assessments when intake was noted to be declining, and/or inform the physician of the lack of adequate fluid intake. The finding included: a. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was blind and had [MEDICAL CONDITION]. A care plan dated 10/20/10 identified that the resident had altered gastrointestinal status with s/p colon resection. Interventions included recording intake and output per policy, observing for signs and symptoms of dehydration and report changes to physician. Review of the clinical record for the period of 10/20/10 through 10/26/10 failed to identify that the resident's intake and output had been recorded. A laboratory report dated 10/21/10 identified that the resident BUN was 19 mg/dL (7-25 mg/dL), creatinine was 1.21 (0.76-1.46 mg/dL) and Sodium was 136 (135-146 mmo/L). A initial nutritional assessment dated [DATE] identified that the resident consumed 50-100% of meals, required extensive assistance with eating and had fluid needs of 1450-1740 per day. Review of the clinical record for the period of 10/26/10 through 11/4/10 failed to identify that the the resident's intake and output was documented. Review of a progress note dated 11/5/10 identified that the resident was seen for discharge. The progress note identified that the resident's appetite was good. A physician's orders [REDACTED]. Nurse's notes and flow records for the period of 11/5/10 through 11/8/10 identified that the resident had a poor appetite, consumed 25% or less of evening meals and consumed an average of 50 % of Ensure Plus 120 mls three times daily. The record failed to document the resident's meal intakes for breakfast and lunch and/or that the resident was provided assistance with meals, in accordance with the resident's plan of care. Review of Intake and Output records for the period of 11/5/10 through 11/7/10 identified that the resident's intake ranged from 480 cc - 1260 cc daily, below his/her documented fluid needs of 1450-1740 per day. Review of the clinical record failed to identify that the physician was informed that the resident did not meet fluid requirements and/or that the resident's hydration status was reassessed. Review of a discharge summary dated 11/8/10 failed to identify that the dietary summary was completed and/or the resident's nutritional/fluid needs were addressed. The resident was discharged home on[DATE] at 1:00 PM and was transferred to the Emergency Department on 11/9/10 at 10:00 AM. Review of the Emergency Department Record dated 11/9/10 identified that the resident had a BUN of 125, [MEDICATION NAME] of 5.0 and sodium of 167. The resident was admitted to the acute care hospital with acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. The hospital record indicated that the resident had a fluid deficit of 5 liters and had dry mucous membranes. Interview with Acting Director of Nurses on 8/23/11 at 1:00 PM identified that the resident's Intake and output should have been recorded and if the resident had not met the goals a hydration evaluation should have been completed. The ADON was unable to provide documentation of the resident's intake and output for the period of 10/20/10 through 11/4/10 and/or documentation that the physician was notified that the resident did not meet his/her fluid requirements prior to discharge. During an interview on 8/25/11 at 1:20 PM, MD#1 identified that he/she was unable to recall if he/she was notified that the resident did not meet fluid needs prior to discharge. Review of the facility's Hydration Policy and Intake and Output Policy identified, in part that intake and output monitoring is indicated when a resident is admitted and that CNA's will record the percent of fluids consumed at meals. Intake and Output monitoring is required for all residents who are fed by staff and the nurse will notify the MD if a resident's fluid intake is less than their estimated requirements for 3 days.