Every finding on record at Spring Creek Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure that residents' drug regimens were free from unnecessary drugs by failing to ensure blood glucose levels were monitored as ordered by a physician for 2 out of 11 sampled residents. Specifically, the facility failed to perform ordered blood glucose checks for 2 residents receiving insulin when the residents were sleeping. The facility failed to document a blood glucose check for one resident on multiple days, and during one incident, it was documented that they ran out of testing supplies. Resident Identifiers: 2 and 4. 1. Resident 2 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including type 2 diabetes mellitus.On 7/28/2026 at 12:46 PM, an interview was conducted with Resident 2, who stated the facility had run out of glucose test strips, so staff could not test her blood sugar or administer insulin to her that day.The surveyors reviewed Resident 2's medical record.Resident 2's Care Plan, initiated 4/23/2025, documented she was at risk for unstable blood glucose levels related to poor dietary choices, with a documented intervention to monitor blood glucose per orders and document trends.Resident 2 had a physician order, initiated on 6/22/26 at 4:00 PM, for Insulin Lispro Injection Solution, to be injected subcutaneously per sliding scale before meals and at bedtime (scheduled for 7:30 AM, 11:00 AM, 4:00 PM, and 9:00 PM) for diabetes, and to call the provider if levels indicated 0-79 or 421-599 mg/dL.Resident 2's July 2026 Medication Administration Record (MAR) was reviewed and documented resident sleeping 25 times as the rationale for why blood glucose was not drawn. The July 2026 MAR further indicated no glucose test strips were in the building on July 28, 2026. Additionally, no documentation was noted on the MAR to indicate Resident 2's blood glucose had been taken at 4:00 PM on July 2, 4, 5, 11, 17, and 18, 2026.2. Resident 4 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and other obesity due to excess calories.The surveyors reviewed Resident 4's medical record.Resident 4 had a physician order, initiated on 5/13/2026 at 12:00 AM, to have blood sugar checks performed every 4 hours for type 2 diabetes and increased blood sugars, with instructions to contact the provider if blood sugar exceeded 400 mg/dL.Resident 4's May 2026 MAR revealed blood glucose checks were not completed on May 13 at 12:00 AM, May 15 at 12:00 PM, and on May 16 at 12:00 AM and 4:00 AM. Additionally, no documentation was noted in the MAR or progress notes to indicate the physician was contacted when Resident 4's blood glucose levels exceeded the 400 mg/dL threshold on May 13 at 8:00 PM and May 14 at 4:00 PM.On 7/30/26, the surveyors interviewed LPN 1 and RN 1, who stated that if blood glucose test strips run low in a medication cart, staff had been instructed to check the medication room or other carts, and that extra insulin was available through the facility medication dispenser. LPN 1 and RN 1 stated the facility should not run out of strips or insulin, and confirmed the expectation that staff must wake sleeping residents to test blood glucose as ordered.On 7/30/2026 at 10:35 AM, the surveyors interviewed the DON, who stated they were responsible for ordering backup testing supplies. The DON stated the facility had previously come close to running out of strips, but received additional supplies within an hour. The DON confirmed that if a physician's order required blood glucose to be tested before meals or at set times, staff had been instructed to wake sleeping residents to complete the testing.

Based on interview and record review, it was determined the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility experienced a sewage flood, and residents were observed coming into contact with the sewage water. Resident Identifiers: 2 and 6.On 7/28/2026, the surveyor reviewed video footage recorded by a staff member during the sewage backup incident on 7/19/2026. The video showed standing sewage water covering portions of the second-floor hallway, with wet bath towels and bedsheets laid across the corridor to soak up the wastewater. The footage also demonstrated water flooding both sides of the hallway and sewage leaking down through the first-floor ceiling into a facility administrative office.On 7/28/2026, the surveyor interviewed a staff member, who stated that flooding occurred on the second floor affecting resident rooms, bathrooms, and the hallway, and was dripping down to the first floor. The staff member noted that although residents were instructed to remain in their rooms, some confused residents were seen walking through the contaminated sewage water in the hallway and their rooms wearing only socks.On 7/28/2026 at 12:46 PM, the surveyor interviewed Resident 2, stated that on 7/19/2026, sewage water containing urine and feces backed up through toilets and shower drains, a ran down the second-floor hallway and into resident rooms on both sides of the corridor, including their own. Resident 2 stated that residents in wheelchairs or wearing socks traversed the contaminated water to go outside and find relief from the odor.On 7/28/2026 at 1:19 PM, the surveyor interviewed Resident 6, who resided on the second floor, and stated that sewage flooded out of the bathrooms into resident rooms and the main hallway, creating a severe odor. Resident 6 stated that staff placed sheets and towels across the hallway floor to soak up the water, and they had to drive their wheelchair directly through the flooded sewage water in the hallway to go outside.On 7/28/2026, the surveyor interviewed the Maintenance Director, who stated residents were instructed to stay in their rooms, but chose not to due to the smell. The Maintenance Director observed residents wheeling their wheelchairs with their hands through the sewage water and subsequently touching their faces.

Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary for a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the facility failed to maintain the main sewer plumbing line in good repair, resulting in raw sewage containing urine and feces backing up through shower drains and toilet bases into resident rooms and corridors. This required the main building water supply to be shut off for over 6 hours, exposing residents to unsanitary conditions, hazardous biohazardous waste, and noxious fumes. Resident Identifiers: 2, 6, and 7.On 7/28/26, the surveyors viewed staff video footage from the incident, which revealed standing sewage water covering portions of the second-floor hallway, with wet bath towels and bedsheets used to soak up the wastewater. The flooding extended to both sides of the hallway and leaked through the first-floor ceiling into an administrative office.On 7/28/26 at 12:46 PM, the surveyors observed stained ceiling tiles in room [ROOM NUMBER]. Resident 2 reported that a clogged toilet occurred about six months prior, causing the observed damage.On 7/28/26 at 11:23 AM, the surveyors interviewed Resident 7, who indicated that approximately one week prior (7/19/26), the facility shut off the building water supply for several hours after a toilet clogged and flooded elsewhere in the facility.On 7/28/26, the surveyors interviewed Resident 2 and Resident 6, who confirmed that sewage water containing urine and feces backed up through toilets and shower drains on 7/19/26, flooding the hallway and resident rooms, including theirs. Both residents stated flooding was a recurring issue, with resident 6 noting another clog on 7/27/26. Both residents, along with a visitor, reported that residents had to drive their wheelchairs through the contaminated water to escape the odor.On 7/28/26, the surveyors interviewed Maintenance 1, who indicated the main sewer drain backs up due to corroded cast-iron piping and flushed wipes. On 7/19/26, Maintenance 1 responded to the flooding, shut off the main water supply for over six hours, and contacted a restoration company to clean and sanitize the areas after the plumbing line was cleared at 4:30 PM. Maintenance 1 confirmed sewage entered resident rooms and that residents in wheelchairs traversed the contaminated water. Another near-backup was noted on 7/27/26.On 7/30/26 at 10:35 AM, the surveyors interviewed the Director of Nursing (DON), who indicated that staff notified the Administrator of the incident on 7/19/26, and restoration teams were called to pump out water, mop, and disinfect the walls and floors.On 7/30/26, the surveyors interviewed the Administrator, who confirmed the main sewer line backed up on 7/19/26 due to pipe separation and flushed wipes. The Administrator stated that staff attempted to divert traffic, kept unaffected residents in their rooms, and distributed masks due to the odor. However, the Administrator confirmed that no medical or clinical assessments were conducted on the residents following their exposure to the sewage and fumes.

Based on interview and record review, it was determined the facility did not ensure that each resident received care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, for 1 out of 11 sampled residents, the facility failed to ensure a resident received a prescribed antidiabetic medication, as ordered by the physician. Resident Identifier 4.Resident 4 was admitted to the facility on [DATE], with a diagnosis which included type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity.Resident 4's physician order, initiated 2/2/26, ordered staff to administer Tradjenta Oral Tablet 5 mg by mouth one time a day. On 5/9/26 at 7:37 AM, a note in the medical record documented that Resident 4's Tradjenta 5 MG was unable to be administered because the medication was out of stock and had been reordered. On 5/11/26 at 10:29 AM, a note in the medical record documented that Resident 4's Tradjenta 5 MG was unable to be administered because the medication was not in stock.On 7/30/26 at 8:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1, who stated that residents should not run out of medications and that staff reorder medications through the electronic Medication Administration Record (eMAR) when five pills remain. LPN 1 added that if a medication was completely out of stock, the staff must notify the provider and pharmacy immediately.On 7/30/26 at 9:05 AM, an interview was conducted with Registered Nurse (RN) 1, who stated that if a medication was stocked in the emergency medication supply system, staff would retrieve it from the system. If it was not in the emergency medication supply system, staff would write the medication down, pull it from the pharmacy, and contact the pharmacy. Deliveries were at 4:00 PM.On 7/30/26 at 10:35 AM, an interview was conducted with the Director of Nursing (DON), who stated that Tradjenta was not available in the emergency medication supply system and staff would be required to order it directly from the pharmacy. The DON reported that Resident 4's prescription was received from the pharmacy on 5/9/26, meaning the medication was in stock at the facility and should have been administered on 5/9/26 and 5/11/26. The DON stated it was unknown why staff did not administer the medication on 5/9/26, after the facility received it, or why staff administered the medication on 5/10/26, but omitted the dose again on 5/11/26.

Based on interview and record review, the facility failed to ensure that each resident was supervised to prevent accidents. Specifically, for 1 out of 11 sampled residents, a resident who was assessed as being unsafe to leave the facility unsupervised had eloped from the facility. Resident Identifier: 1Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia, altered mental status, and schizophrenia. A Community Risk Assessment, dated 9/11/2025, indicated Resident 1 did not know the facility address/phone number, was unaware of basic traffic laws, and lacked awareness of surroundings and safety concerns (inclement weather, road hazards, emergency vehicles, or bike lanes).An Elopement Risk Assessment identified Resident 1 as At-Risk due to exit-seeking behaviors, poor compliance with safety instructions, and non-cooperation with safety plans.A Nursing Note, dated 9/19/2025 at 8:48 AM, was reviewed and documented a CNA had reported seeing Resident 1 operating her wheelchair on the sidewalk at approximately 6:40 AM. The nurse alerted floor staff and searched for the resident. The Director of Nursing (DON), Administrator (Admin), and police were subsequently notified.A Nursing Note, dated 9/19/2026 at 5:17 PM, was reviewed and documented Resident 1 returned via van but refused to leave the ambulance or allow medical staff near her for an assessment. She was subsequently sent to the hospital for an emergency involuntary psychiatric commitment. A Certification for Emergency Commitment, dated 9/19/2026, was reviewed and documented that Resident 1 eloped around 6:50 AM on 9/19/2026 and was located around 3:40 PM. She returned with an altered mental status, hallucinations, dehydration, and a refusal of all care.A Facility Investigation was reviewed and documented that Staff 1 reported responding to an outside kitchen alarm and encountered Resident 1 at the door. Resident 1 claimed she had signed papers to leave and proceeded outside. Staff 1 then sought assistance from other staff members.On 7/30/2026, the surveyor interviewed the DON, who confirmed Resident 1 was confused, expressed unrealistic desires to travel, and was unsafe to leave unsupervised. The DON noted that staff were expected to consult the elopement binder and medical charts to verify whether a resident was cleared for independent exit.

Based on interview and record review, it was determined the facility failed to ensure that each resident was free of any significant medication errors. Specifically, for 1 out of 11 sampled residents, the facility failed to administer a prescribed dose of long-acting insulin, due to the medication being unavailable and the staff failed to access the facility's emergency medication supply. Resident Identifier 4.Resident 4 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity.A physician order, initiated on 2/26/26 at 6:00 AM, prescribed Insulin Glargine Solostar Subcutaneous Solution Pen-injector 300 units/mL, to inject 50 units subcutaneously once daily.On 3/20/26 at 11:19 AM, a Registered Nurse (RN) progress note documented that the insulin was not administered due to the medication being unavailable. On 7/30/26 at 8:40 AM, the licensor interviewed LPN 1, who stated staff should reorder medications via the eMAR when five doses remain. If a medication was completely out, staff must immediately notify the provider and pharmacy, and utilize the emergency medication supply system.At 9:05 AM, the licensor interviewed RN 1, who confirmed that backup insulin was available via the emergency medication supply system in a lockbox within the third-floor refrigerator, and staff should not run out of insulin.At 11:12 AM, the licensor interviewed the Director of Nursing (DON), who confirmed the location of the backup insulin and the medication alert system for pharmacy restocking. The DON noted there was no documentation in the progress notes or Treatment Administration Record (TAR) which explained the omission, and because she was not employed at the facility at the time of the survey, the exact reason for the unavailable medication and omitted dose remained unknown.

Based on observation, interview, and record review, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 4 out of 33 sampled residents, a resident's care plan was not updated to reflect the resident's activities of daily living requirements as they related to the resident's toileting needs; a resident did not have a behavioral health care plan that addressed the resident behavior of disrobing in public; a resident did not have a care plan initiated that addressed the resident's activity preferences and needs; and care plan interventions were not updated after a resident's falls. Resident identifiers: 24, 31, 49, and 54. Findings included: 1. Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis of left side, pneumonitis, type 2 diabetes mellitus, idiopathic epilepsy, chronic obstructive pulmonary disease, morbid obesity, dyspnea, congestive heart failure, blindness one eye, schizoaffective disorder, dissociative identity disorder, and anxiety disorder. On 1/27/25 at 10:23 AM, an interview was conducted with resident 24. Resident 24 stated that he fell out of the bed four weeks ago, and the facility had to call the paramedics to get him back into bed. Resident 24 stated that it took eight firemen to lift him back into bed. Resident 24 stated that he rolled to the left side during care and his left leg slid out of the bed. Resident 24 stated that the momentum took the rest of his body. Resident 24 stated that he had two Certified Nursing Assistants (CNAs) assisting him that day but both CNAs were located on the right side of the bed. Resident 24 stated that he bruised his buttocks and left hip from the fall. Resident 24's medical record was reviewed. On 10/16/24, resident 24's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14/15, which indicated that the resident was cognitively intact. The assessment documented that resident 24 was a total dependence and required a two plus persons physical assist for bed mobility, transfer, and toilet use. On 1/7/25 at 2:30 AM, resident 24's incident report documented that the resident had a witnessed fall. The report documented under notes, 1/7/2025 Res [resident] had a witnessed fall during a brief change. Aide had resident on his left side clean and ready to place a chuck under him. Upon turning to her side to retrieve the chuck aide saw residents' legs off the bed sliding down onto his buttocks, landing slightly more onto his left side. The notes further documented, 1/16/2025 resident is morbidly obese, need to add to care plan 2 staff to be present to all brief changes for safety. On 10/19/22, resident 24 had a care plan initiated for Activities of Daily Living (ADLs) self-care performance deficit related to morbid obesity, major depressive disorder, anxiety, hemiplegia, and muscle weakness. The care plan was last revised on 12/21/23. Interventions identified in the care plan included: resident preferred bed baths; resident required extensive and up to total dependent assistance with most ADLs; encourage the resident to participate to the fullest extent possible with each interaction; encourage the resident to use call light for assistance; and Physical Therapy and Occupational Therapy to evaluate and treat per the physician orders. Resident 24's Kardex report documented under ADLs the resident's preferred bathing schedule. The Kardex did not document the staff support needed or the number of staff required for any ADLs. No other ADLs were addressed in the Kardex. It should be noted that the care plan and Kardex did not document that resident 24 required a two person assist with ADLs. On 1/28/25 at 1:42 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 24 needed full assistance for ADLs. CNA 2 stated that resident 24 needed one to two staff to turn and reposition the resident and he was not able to roll on his own. CNA 2 stated that resident 24 was incontinent of bowel and bladder. CNA 2 stated that resident 24 required a Hoyer lift for transfers but he did not get out of bed often. CNA 2 stated that resident 24 had fallen before, but that he was not a fall risk because he did not move a lot. CNA 2 stated that resident 24 had bed rails to assist with repositioning and they kept the bed lowered. CNA 2 stated the only way resident 24 would fall was if staff rolled him too far. CNA 2 stated that staff needed to take precautions to make sure resident 24 was centered in the bed before rolling him. CNA 2 stated that resident 24's previous fall was due to the resident being rolled too far. CNA 2 stated that she was not present for resident 24's fall but was informed of it. CNA 2 stated that the fire department had to come get resident 24 off of the floor. CNA 2 stated that the fall occurred during the night shift. On 1/30/25 at 10:09 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 24 had filed a grievance against female staff providing incontinence care and that if the staff were female then he wanted two staff to assist. CNA 3 stated that she was told that resident 24 was a two person assist for ADLs because of his grievance, but she was able to reposition and provide incontinence care by herself. CNA 3 stated that the Kardex should tell the staff what resident 24's care needs were and any interventions that were in place to prevent falls but the facility Kardex was not updated. On 1/30/25 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the task communicated the ADL care needs to the staff and the nurse also communicated verbally to the CNAs. The DON stated that when a resident required a two person assist with ADLs this was communicated by the nurse to the CNAs or by management to the CNAs. The DON stated that the task list would show the CNAs if a resident was a one or two person assist for ADLs and the report sheet also listed this. The DON stated that the Kardex was a work in progress and they were working on a way to communicate the information. The DON stated that the CNAs had a report sheet brain that contained the resident assistance needs with eating. The DON stated that she would need to confirm if this sheet also contained if the resident's assistance requirements for toileting, bed mobility, or repositioning. The DON stated that resident 24's fall on 1/7/25, was due to a brief change and his legs fell off the bed and his body followed. The DON confirmed that the fall occurred during incontinence care that was provided by one staff member. The DON stated that resident 24 should have two staff present for incontinence care if the MDS assessment determined he needed it. The DON stated that the care plan should reflect the recommendations from the incident report with the new intervention of two staff members for incontinence care. 2. Resident 31 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of nontraumatic subacute subdural hemorrhage, Down Syndrome, lupus erythematosus, dsyphagia, ventricular septal defect, major depressive disorder, anxiety disorder, and severe intellectual disabilities. On 1/27/25 at 10:31 AM, an observation was made of resident 31. Resident 31 was seated in a wheelchair in the hallway with her brief and trousers pulled down below her buttocks. Resident 31's shirt was pulled up and the abdomen was fully exposed. CNA 4 was observed to assist resident 31 back inside her bedroom. On 1/28/25 at 12:52 PM, resident 31 was observed wheeling herself out of her room with her brief and trousers pulled down below her buttocks. Resident 31's midsection and hips were exposed. Staff were observed to immediately redirect the resident back inside her room. Staff was observed to exit the room with the door closed. On 1/28/25 at 12:53 PM, resident 31 was observed propelling herself back out into the hallway with her brief and trousers still half down. Staff again redirected the resident back inside her room. On 1/28/25 at 1:29 PM, resident 31 was observed in the doorway to her room with her brief and trousers pulled down below the buttocks. Resident 31's abdomen and thighs were exposed. Resident 49 wheeled past resident 31 and stated, can someone help [resident 31]?. Registered Nurse (RN) 9 assisted resident 31 back inside her room. RN 9 did not assist resident 31 with dressing and the resident was still visible from the hallway exposed. RN 9 exited resident 31's room and resident 31 immediately wheeled herself out into the hallway again. RN 9 again wheeled the resident back inside her room. On 2/3/25 at 12:47 PM, resident 31 was observed seated in her wheelchair in the doorway with her brief and trousers pulled down. CNA 2 walked past and instructed resident 31 to go back inside her room to the bathroom. CNA 4 then entered resident 31's room to assist. Resident 31's medical record was reviewed. On 12/8/24, resident 31's quarterly MDS assessment documented that a BIMS exam was not conducted due to the resident was rarely or never understood. The assessment documented that resident 31 required a one person extensive assist for bed mobility and transfers, and was a one person total dependence for toileting assistance. The assessment documented that resident 31 had behavioral symptoms not directed towards others (e. g. such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal symptoms like screaming or disruptive sounds) that occurred every four to six days. Resident 31 had physician's orders for monitoring negative statements to self or verbalizations of sadness, and monitoring for mood swings every shift that were initiated on 4/16/24. No documentation could be found for monitoring resident 31's episodes of disrobing in public. Resident 31's Kardex for Behavior/Mood documented, When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. No documentation or interventions could be found in the Kardex for resident 31's episodes of disrobing in public. Resident 31 had care plans initiated for the following: a. On 3/9/23, a care plan was initiated for delusions and hallucinations. Interventions identified included do not argue, criticize or correct the resident; help the resident to feel safe; and use validation techniques to redirect to another topic or activity. b. On 3/9/23, a care plan was initiated for depression. Interventions identified included social services or resident advocate to provide supportive visits as needed; identify personal strengths and abilities; praise resident for accomplishments; support positive statements made by resident; and encourage resident involvement in hobbies. c. On 9/13/23, a care plan was initiated for anxiety. Interventions identified included to redirect to other activities; assist resident to think about something calm and peaceful; and social services to provide supportive visits as needed. d. On 1/4/23, a care plan was initiated for the resident was verbally and physically aggressive at times. Interventions identified were to assess and anticipate needs for food, thirst, toileting, comfort level, body positioning, and pain; assess resident's coping skills and support system; assess resident's understanding of the situation; allow time for the resident to express self and feelings towards the situation; provider referral for increased agitation; provide positive feedback for good behavior; intervene before agitation escalates; guide away from source of distress; engage calmly in conversation and approach later. It should be noted that no care plans were identified that addressed resident 31's behavior of disrobing in public and no interventions were identified. On 1/28/25 at 1:05 PM, an interview was conducted with CNA 4. CNA 4 stated that resident 31 was able to stand and remove her pants independently. CNA 4 stated that resident 31 had behaviors of being repetitive and sometimes she did not know what she was doing. CNA 4 stated that resident 31 did not have any resident to resident altercations. On 1/28/25 at 1:42 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 31 had behaviors of hitting herself, yelling a lot, and sometimes she would grab inappropriately. CNA 2 stated that resident 31 liked to pull her pants down throughout the day. CNA 2 stated that they had to keep an eye on her to make sure her pants are pulled up. CNA 2 stated that resident 31 pulled her pants down for attention seeking and that resident 31 thought it was funny. CNA 2 stated that resident 31 did this behavior often. CNA 2 stated that sometimes she needed to be assisted with toileting. CNA 2 stated that staff just had her go back into the room and pulled the pants back up. CNA 2 stated that resident 31 could not be left unsupervised. CNA 2 stated that resident 31 was easy to redirect to her room and then they pulled her brief and trousers back up. On 1/29/25 at 2:35 PM, an interview was conducted with RN 6 and Medication Technician (MT) 1. RN 6 stated that resident 31 was alert and oriented x 4 to person, place, situation, and time. RN 6 stated that resident 31 had behaviors of being aggressive, would refuse treatment and medications, and throws things on the floor. RN 6 stated that resident 31 did not have behaviors of disrobing. RN 6 stated that resident 31 pulled her pants down when she needed assistance with dressing and toileting. MT 1 stated that resident 31 had a behavior of pulling her pants down when she needed assistance with toileting or when she wanted attention. MT 1 stated that resident 31 pulled her pants down when she wanted something and it was usually when she wanted to see her mom. MT 1 stated that on Monday resident 31 was calling out for her mom and pulling her pants down. RN 6 stated that she would look in the progress notes for any resident behaviors and the CNAs would know each resident's behavior. RN 6 stated that she would expect to see a care plan with interventions for any behaviors. On 1/30/25 at 10:15 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 31 had behaviors of being aggressive when she was bored or if she wanted food. CNA 3 stated that resident 31 would become agitated and increasingly more upset with her voice becoming louder and she would become repetitive. CNA 3 stated that resident 31 would also undress herself and then come out into the doorway with her shirt up and her pants down. CNA 3 stated that this was done to alert staff that she needed to go to the bathroom. CNA 3 stated that they just kept an eye out for the behavior and she was not aware of any interventions to prevent the behavior. CNA 3 stated that she did not think that resident 31 understood what she was doing. On 1/30/25 at 12:36 PM, an interview was conducted with the DON. The DON stated that resident 31's behaviors were yelling out and sometimes she would wheel herself out of her room with her pants pulled down. The DON stated that they then had to take her back into her room to dress her. The DON stated that behavior tracking was documented on the Treatment Administration Record. The DON stated that they also care planned behaviors. The DON stated that the purpose of the care plan was for resident safety and as a form of communication for the staff. The DON stated that care plans with interventions were accessible by the licensed nurse and interventions were on the Kardex for the CNAs to view. The DON stated that resident 31 did not have a care plan that addressed her behavior of disrobing in public and she would expect to see that behavior care planned. 3. Resident 49 was admitted to the facility on [DATE] with diagnoses which consisted of hemiplegia left side, history of traumatic brain injury, nontraumatic subarachnoid hemorrhage, post-traumatic stress disorder, insomnia, bipolar disorder, generalized anxiety disorder, stimulant abuse, attention-deficit hyperactivity disorder, autistic disorder, conduction disorder, and hypertension. On 1/27/25 at 2:57 PM, an interview was conducted with resident 49. Resident 49 stated that he wished he was not so bored. Resident 49 stated that when he was bored he just hung out and watched what was going on around him. Resident 49 stated that he did not have any activities in his room and he did not participate in bingo today because it was not his style. Resident 49's room was observed with no activities identified at the bedside. On 8/7/24, the activities quarterly review was conducted. The review documented under attendance, Unknown - new Activity Director in building and paperwork not done yet - see daily participation records. The review documented to see the original data collection for interests. Resident 49's progress notes revealed the following: a. On 3/21/24 at 12:32 PM, the Social Service Note documented, [Resident 49] was happy that I took him some art supplies, and a mini chess game. b. On 5/1/24 at 2:08 PM, the Social Service Note documented, resident was having an okay day, he enjoys listening to music and coloring in his anime books. c. On 5/30/24 at 2:22 PM, the Social Service Note documented, talked with resident today to see how he was doing, and he said good. I bought him some new colored pencils and coloring markers for his book, he was very happy to get new ones. d. On 6/10/24 at 1:31 PM, the Social Service Note documented, Resident was talking to me today about his colored pencils, and coloring. e. On 6/18/24 at 1:37 PM. the Social Service Note documented, Had a care confrence [sic] with resident today. He enjoys coloring with his anime. He enjoys living here, He is excited about his birthday coming up on [date omitted]. He has no concerns about his cares or medications at this time. Resident 49's care plans were reviewed and no documentation could be found of a care plan focus area for activities. On 1/29/25 at 12:27 PM, an interview was conducted with the Activities Supervisor (AS). The AS stated that the activity program was based off the recommendations from the Recreation Therapist. The AS stated that she was responsible for completing the assessments and care plans for each resident. The AS stated that the assessment was completed upon admission and quarterly thereafter. The AS stated that resident 49 did not have an assessment completed and he should have had it done upon admission. The AS stated that she started at the facility in September 2024 and was in the process of completing all quarterly evaluations. 4. Resident 54 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of cerebral infarction, status epilepticus, difficulty walking, lack of coordination, major depressive disorder, congestive heart failure, insomnia, encephalopathy, and hypotension. On 1/29/25 at 10:22 AM, an observation was made of resident 54 asleep in bed. The left side of the bed was against the wall and a fall mat was located on the right side of the bed. The bed was lowered to the ground. No side rails were noted. On 12/6/24, a quarterly MDS assessment documented that the resident was a two person total dependence for transfer, one person total dependence for bed mobility and toileting. Resident 54's progress notes and incident reports revealed the following: a. On 4/6/24 at 5:42 AM, the incident report documented, During resident change the Aid [sic] rolled him and he continued to roll off the bed onto the floor hitting the cabinet on the way and causing a red area to his left cheek. No new interventions were identified on the care plan for falls. b. On 8/28/24 at 7:55 AM, the incident report documented, Resident was found on the floor near the chair laying on right side. Fall happened on 8/27 [24] @ 1900 [7:00 PM] No new interventions were identified on the care plan for falls. On 12/6/23, resident 54 had a care plan initiated for at risk for falls due to muscle weakness, unsteadiness on feet, and encephalopathy. Interventions identified included bed alarm implemented (initiated 6/12/24); educate resident to ask for staff assistance with ADLs, transfers, and ambulation (initiated 12/6/23); floor mat to right side of bed and check placement every shift (initiated 1/27/25); frequent checks on rounds (initiated 12/6/23); low bed at all times when in bed (initiated 12/6/23); and physical therapy to evaluate and treat as needed (initiated 12/6/23). On 1/28/25 at 1:42 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 54 had falls. CNA 2 stated that they had a floor mat at the bedside and the bed was lowered to the ground. CNA 2 stated that resident 54 slept throughout the day and he fell when he attempted to get out of bed on his own. CNA 2 stated that resident 54 did not use his call light to ask for help. CNA 2 stated that if they did not check on resident 54 frequently he would fall. On 1/30/25 at 10:46 AM, an interview was conducted with RN 9. RN 9 stated that resident 54 was a big fall risk and had frequently fallen. RN 9 stated that they had placed the bed in the lowest position and they reminded the resident to use his call light to ask for assistance. RN 9 stated that resident 54 did not have good vision and was not able to see the call light. RN 9 stated that he would place the call light in resident 54's hands. RN 9 stated that the staff had to constantly check on resident 54. On 1/30/25 at 2:09 PM, an interview was conducted with the DON. The DON stated that the fall protocol was to document the event, conduct an assessment, notify family and provider, complete risk management and notify management. The DON stated that she would expect to see new interventions identified after each fall to prevent future falls and those new interventions would be located on the care plan.

Based on observation, interview, and record review, the facility did not ensure that the resident's environment was as free of accident hazards as was possible and each resident received supervision and assistance devices to prevent accidents. Specifically, for 3 out of 33 sampled residents, two residents had falls while being repositioned by staff and one resident caught his hair on fire with a lighter that another resident gave him. Resident identifiers: 22, 24, and 54. Findings included: 1. Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis of left side, pneumonitis, type 2 diabetes mellitus, idiopathic epilepsy, chronic obstructive pulmonary disease, morbid obesity, dyspnea, congestive heart failure, blindness one eye, schizoaffective disorder, dissociative identity disorder, and anxiety disorder. On 1/27/25 at 10:23 AM, an interview was conducted with resident 24. Resident 24 stated that he fell out of the bed four weeks ago, and the facility had to call the paramedics to get him back into bed. Resident 24 stated that it took eight firemen to lift him back into bed. Resident 24 stated that he rolled to the left side during care and his left leg slid out of the bed. Resident 24 stated that the momentum took the rest of his body. Resident 24 stated that he had two Certified Nursing Assistants (CNAs) assisting him that day but both CNAs were located on the right side of the bed. Resident 24 stated that he bruised his buttocks and left hip from the fall. Resident 24's medical record was reviewed. On 10/16/24, resident 24's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status score of 14/15, which indicated that the resident was cognitively intact. The assessment documented that resident 24 was a total dependence and required a two plus persons physical assist for bed mobility, transfer, and toilet use. On 1/7/25 at 2:30 AM, resident 24's incident report documented that the resident had a witnessed fall. The immediate action taken documented, Called non-emergency number for assistance with getting resident back into bed. The predisposing factor documented that the resident was incontinent and rolled from the bed. The report documented under notes, 1/7/2025 Res [resident] had a witnessed fall during a brief change. Aide [CNA] had resident on his left side clean and ready to place a chuck under him. Upon turning to her side to retrieve the chuck aide saw residents' legs off the bed sliding down onto his buttocks, landing slightly more onto his left side. Writer entered the room and saw the resident sitting up against his bed facing out his wall/window. Head to toe assessment was done. Non-emergency number was called to assist in lifting the resident back into his bed. The notes further documented, 1/16/2025 resident is morbidly obese, need to add to care plan 2 staff to be present to all brief changes for safety. On 10/19/22, resident 24 had a care plan initiated for Activities of Daily Living (ADLs) self-care performance deficit related to morbid obesity, major depressive disorder, anxiety, hemiplegia, and muscle weakness. The care plan was last revised on 12/21/23. An intervention identified in the care plan was that the resident required extensive and up to total dependent assistance with most ADLs. Resident 24's Kardex report documented under ADLs the resident's preferred bathing schedule. The Kardex did not document the staff support needed or the number of staff required for any ADLs. No other ADLs were addressed in the Kardex. It should be noted that the care plan and Kardex did not document that resident 24 required a two person assist with ADLs. Review of resident 24's ADL task for toilet use from 1/1/25 through 1/30/25, documented that the resident was a one person physical assist for toileting. On 1/28/25 at 1:42 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 24 needed full assistance for ADLs. CNA 2 stated that resident 24 needed one to two staff to turn and reposition the resident and he was not able to roll on his own. CNA 2 stated that resident 24 was incontinent of bowel and bladder. CNA 2 stated that resident 24 required a Hoyer lift for transfers but he did not get out of bed often. CNA 2 stated that resident 24 had fallen before, but that he was not a fall risk because he did not move a lot. CNA 2 stated that resident 24 had bed rails to assist with repositioning and they kept the bed lowered. CNA 2 stated the only way resident 24 would fall was if staff rolled him too far. CNA 2 stated that staff needed to take precautions to make sure resident 24 was centered in the bed before rolling him. CNA 2 stated that resident 24's previous fall was due to the resident being rolled too far. CNA 2 stated that she was not present for resident 24's fall but was informed of it. CNA 2 stated that the fire department had to come get resident 24 off of the floor. CNA 2 stated that the fall occurred during the night shift. On 1/30/25 at 10:09 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 24 had filed a grievance against female staff providing incontinence care and that if the staff were female then he wanted two staff to assist. CNA 3 stated that she was told that resident 24 was a two person assist for ADLs because of his grievance, but she was able to reposition and provide incontinence care by herself. CNA 3 stated that resident 24 was not able to assist in repositioning himself. CNA 3 stated that resident 24 was able to hold onto the bedrail when he was repositioned on his side. CNA 3 stated that resident 24 had one fall in the past month, and it was due to the resident being positioned too close to the edge of the bed. CNA 3 stated that resident 24 rolled off the bed. CNA 3 stated that if she rolled him she would pull the sheet towards her before rolling away from herself so that there was more space for the resident on the other side. CNA 3 stated that she did not have any training on repositioning the resident. CNA 3 stated that fall interventions would be provided in report and sometimes they were in the electronic medical records under tasks. CNA 3 stated that the Kardex should tell the staff what resident 24's care needs were and any interventions that were in place to prevent falls but the facility Kardex was not updated. On 1/30/25 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the task communicated the ADL care needs to the staff and the nurse also communicated verbally to the CNAs. The DON stated that when a resident required a two person assist with ADLs this was communicated by the nurse to the CNAs or by management to the CNAs. The DON stated that the task list would show the CNAs if a resident was a one or two person assist for ADLs and the report sheet also listed this. The DON stated that the Kardex was a work in progress and they were working on a way to communicate the information. The DON stated that the CNAs had a report sheet brain that contained the resident assistance needs with eating. The DON stated that she would need to confirm if this sheet also contained if the resident's assistance requirements for toileting, bed mobility, or repositioning. The DON stated that resident 24's fall on 1/7/25, was due to a brief change and his legs fell off the bed and his body followed. The DON confirmed that the fall occurred during incontinence care that was provided by one staff member. The DON stated that resident 24 should have two staff present for incontinence care if the MDS assessment determined he needed it. The DON stated that the care plan should reflect the recommendations from the incident report with the new intervention of two staff members for incontinence care. 2. Resident 54 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of cerebral infarction, status epilepticus, difficulty walking, lack of coordination, major depressive disorder, congestive heart failure, encephalopathy, and hypotension. On 1/27/25 at 12:59 PM, an observation was made of resident 54. Resident 54 was lying supine in bed. The bed was positioned with the left side against the wall and a fall mat was located on the right side of the bed. The bed was low to the ground. On 1/29/25 at 10:22 AM, an observation was made of resident 54 asleep in bed. The left side of the bed was against the wall and a fall mat was located on the right side of the bed. The bed was lowered to the ground. No side rails were noted. Resident 54's medical record was reviewed. On 12/6/24, resident 54's quarterly MDS assessment documented that the resident was a two person total dependence for transfer, one person total dependence for bed mobility and toileting. On 4/6/24 at 5:42 AM, the incident report documented, During resident change the Aid [sic] rolled him and he continued to roll off the bed onto the floor hitting the cabinet on the way and causing a red area to his left cheek. It should be noted that no new interventions were identified on the care plan for falls. On 12/6/23, resident 54 had a care plan initiated for at risk for falls due to muscle weakness, unsteadiness on feet, and encephalopathy. On 12/6/23, an intervention was identified to educate the resident to ask for staff assistance with Activities of Daily Living (ADLs), transfers, and ambulation. On 1/28/25 at 1:42 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 54 had falls. CNA 2 stated that they had a floor mat at the bedside and the bed was lowered to the ground. CNA 2 stated that resident 54 slept throughout the day and he fell when he attempted to get out of bed on his own. CNA 2 stated that resident 54 did not use his call light to ask for help. CNA 2 stated that if they did not check on resident 54 frequently he would fall. On 1/30/25 at 10:32 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 54 had one fall from his wheelchair and he landed on his face. CNA 3 stated that she was not aware if resident 54 sustained an injury from the fall. CNA 3 stated that interventions to prevent falls were more frequent checks on the resident. CNA 3 stated that the Kardex would list the safety or fall interventions, but the facility Kardex was not updated. CNA 3 stated that the Kardex should tell you what the resident's needs were. On 1/30/25 at 10:46 AM, an interview was conducted with Registered Nurse (RN) 9. RN 9 stated that resident 54 was a big fall risk and had frequently fallen. RN 9 stated that they had placed the bed in the lowest position and they reminded the resident to use his call light to ask for assistance. RN 9 stated that resident 54 did not have good vision and was not able to see the call light. RN 9 stated that he would place the call light in resident 54's hands. RN 9 stated that the staff had to constantly check on resident 54. On 1/30/25 at 2:09 PM, an interview was conducted with the DON. The DON stated that the fall protocol was to document the event, conduct an assessment, notify family and provider, complete the risk management and notify management. The DON stated that she would expect to see new interventions identified after each fall to prevent future falls and those new interventions would be located on the care plan. On 2/3/25 at 1:36 PM, a follow-up interview was conducted with the DON. The DON stated that she would expect the staff to perform turning and repositioning using techniques learned throughout their training as a CNA. The DON stated that she would expect the staff to understand the situation and use good judgement that would not put the resident at risk when providing care. The DON stated that the staff should move the resident in a way that would not hurt the resident and was done safely. 52146 3. Resident 22 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, lack of coordination, type 2 diabetes mellitus, dementia, and nicotine dependence. Resident 22's medical record was reviewed on 1/27/25 through 2/3/25. On 9/18/24 at 6:35 AM, a Sudden change of behavior/mental status note documented Event Type: hair on fire. Date and time of event onset: 09/18/2024 0430 [4:30 AM]. Description of behavior and mental status: literally lit his hair on fire with a lighter another resident have him. Preventative measures already in place if there is a history: removed the lighter. On 9/18/24 at 11:51 AM, a Nurses Note documented Note Text: Resident was assessed for injury and lighter removed from residents possession. DON interviewed resident and assessed for injury. It was noted hair was singed to R [right] side head, no burns were noted to skin on face or scalp. When asked how event happened resident stated 'I leaned over'. When asked where he got the lighter from resident stated 'It's mine'. Resident enforced that lighters must be secured and not to be used in the building. Resident is on supervised smoking schedule. On 9/18/24 at 12:50 PM, a 72 Hour Event Charting documented Type of Event: lit hair on fire. Interventions: Confiscated lighter. Searched his room for any more lighter [sic] or matches. Instructed other residents that smoke not to give him lighter. Resident is supervised smoking only. Resident Reaction to Interventions: Upset, verbally abusive. Stated '[explicative word redacted] you for taking my lighter'. Improvement/Decline: No lighter found in his room, as of now. A Smoking Safety Evaluation dated 6/6/24, documented that resident 22 had not been deemed independent with smoking and could not safely have smoking paraphernalia on person. On 1/28/25 at 2:46 PM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that resident 22 was a smoker and a staff member always accompanied him. NA 1 stated that resident 22's smoking materials were located in the medication cart. On 1/28/25 at 03:29 PM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated that during an admission a nurse would assess physical and cognitive abilities to determine whether a resident's smoking status would be supervised or unsupervised. ADON 2 stated the smoking status should be reassessed if there was a change in a resident ' s condition. ADON 2 stated supervised smokers have scheduled smoking times with the CNAs. ADON 2 stated that residents who were supervised smokers must store their smoking supplies in the locked medication cart. ADON 2 emphasized that supervised smokers were always assisted and supervised with cigarette lighters. ADON 2 stated that unsupervised smokers could smoke outside of the scheduled smoke times, however they must ask for the cigarette lighters due to them being locked in the medication cart. ADON 2 stated that unsupervised residents could keep their cigarettes in between scheduled smoke times. On 1/28/25 at 4:04 PM, an observation was made of NA 1 assisting resident 22 in his wheelchair to the designated smoking area. NA 1 assisted resident 22 and other residents with smoke aprons and the cigarette lighter. The cigarette lighter was never out of NA 1's reach. After NA 1 assisted resident 22 back to his room NA 1 was observed giving the cigarette lighter back to ADON 2. ADON 2 was observed to place the cigarette lighter back in the medication cart. Resident 22 was seated in his wheelchair, in his room, with the door open to the hallway. On 1/30/25 at 3:06 PM, an interview was conducted with RN 2. RN 2 stated that she was on shift the morning of 9/18/24. RN 2 stated that resident 22 was a supervised smoker and should never have a lighter. RN 2 stated that after resident 22 was assisted back to his bedroom RN 2 went on her lunch break. RN 2 stated the cigarette lighter that was used during the smoke break was on RN 2's person during the break. RN 2 stated when she returned to her shift a CNA and RN 2 smelt something burning and ran to resident 22's bedroom. RN 2 stated the fire was already out when they entered the room. RN 2 stated that she had performed an assessment on resident 22 and some of his hair and one eyebrow was singed. The facility document titled Smoking Guideline was reviewed. 4. SMOKING IS ALLOWED IN DESIGNATED SMOKING AREAS ONLY!!! . 6. All lighters/matches and cigarettes must be kept at the nurse's station when newly admitted until the Activity personnel can collect. a. This includes e-cigarettes and All smoking paraphernalia. 7. State law requires you to smoke outside and 25 feet away from any door/windows. 11. If a staff member suspects that I have smoking paraphernalia in my room, I agree to allow staff to search for the related materials and confiscate them in order to keep the building safe from fire related accidents. Lighters/matches and cigarettes brought into the facility by family, friends, etc. will be turned over to the nurse to hold for me. This is a NO SMOKING FACILITY, in that there is no smoking allowed within the building. Matches, lighters, cigarettes, e-cigarettes and all other smoking paraphernalia will be kept at the nurse's station.

2. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, cerebral infarction, metabolic encephalopathy, chronic obstructive pulmonary disease, unsteadiness on feet, difficulty in walking, muscle weakness, history of falling, schizoaffective disorder bipolar type, anxiety disorder, chronic pain, epilepsy, essential hypertension, and dementia. Resident 5's medical record was reviewed on 1/30/25. A physician's order dated 7/27/24, documented hydrOXYzine HCl Oral Tablet 25 MG (Hydroxyzine HCl) Give 1 tablet enterally every 12 hours as needed for Anxiety related to METABOLIC ENCEPHALOPATHY. The medication was discontinued on 1/27/25. It should be noted that the PRN psychotropic medication was extended past 14 days and the prescribing practitioner did not document their rationale in the resident's medical record to extend the medication. A physician's order dated 1/27/25, documented hydrOXYzine HCl Oral Tablet 25 MG (Hydroxyzine HCl) Give 1 tablet enterally every 12 hours as needed for Anxiety related to METABOLIC ENCEPHALOPATHY for 14 Days. The January 2025 Medication Administration Record (MAR) was reviewed. There were no administrations of the PRN medication. On 2/3/25 at 3:00 PM, an interview was conducted with the DON. The DON stated that she spoke with the Pharmacist and resident 5 had not taken the hydroxyzine for the last three months so the Pharmacist gave the okay to discontinue the medication. The DON further stated that resident 5 had a diagnosis in the medical record for schizoaffective disorder. 3. Resident 62 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, malignant neoplasm of right female breast, dementia severe, delusional disorders, urinary tract infections, repeated falls, dysphagia, difficulty in walking, and unsteadiness on feet. Resident 62's medical record was reviewed on 1/28/25. A care plan Focus initiated on 7/10/24, documented [Resident 62] uses psychotropic medications (Risperidone) r/t [related to] severe dementia with behavioral disturbances. The interventions initiated on 7/10/24, included: a. Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. b. Consult with pharmacy and Medical Director to consider dosage reduction when clinically appropriate at least quarterly. c. Monitor/document/report as needed any adverse reactions of psychotropic medications. A care plan Focus initiated on 9/3/24 and revised on 10/7/24, documented [Resident 62] has a PASRR Level 1 Referred for PASRR L2 [Level 2], ruled out per PASRR. The intervention initiated on 9/3/24, documented to resubmit as needed. A physician's order dated 7/9/24, documented risperiDONE Oral Tablet (Risperidone) Give 1 mg by mouth one time a day for delusional disorder. It should be noted that delusional disorder was not an appropriate indication for use. A physician's order dated 7/25/24, documented Sertraline HCl [hydrochloride] Oral Tablet 50 MG (Sertraline HCl) Give 50 mg by mouth one time a day for Depression. It should be noted that resident 62 did not have a diagnosis of depression. On 10/6/24 at 3:53 PM, a Social Service note documented Note: PT [patient] is an [AGE] year old female with Diagnosis of Dementia, anxiety Delusional disorders, Malignant neaplasm [sic] of the right female breast, Muscle weakness, pulmonary embolism, Difficulty in walking and unsteadiness on feet. Was Screened out for a level II due to Dementia. No behaviors. A physician's order dated 10/29/24, documented traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 50 mg by mouth every 24 hours as needed for Agitation. The medication was discontinued on 1/27/25. It should be noted that the PRN psychotropic medication was extended past 14 days and the prescribing practitioner did not document their rationale in the resident's medical record to extend the medication. A physician's order dated 1/27/25, documented traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 50 mg by mouth every 24 hours as needed for Insomnia for 14 Days. The November 2024, December 2024, and January 2025 MAR were reviewed. Resident 62 had received one dose of the PRN trazodone on 11/7/24. The Patient Recommendations Summary dated 12/27/24, documented This resident has orders for Risperidone and Sertraline for dementia, but this is not a labeled indication for these medications. Antipsychotic medications have a black box warning when used off label. This was discussed with the attending psychiatric providers and it was agreed that symptoms of psychosis, depression, anxiety and mood instability are common behavioral symptoms of this condition, and that these medications can be useful in treating these symptoms. It was agreed that the benefits of treatment currently outweigh any potential risks, and no recommendations are needed at this time. On 1/29/25 at 10:12 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 62 had behaviors. CNA 1 stated just this last week she was doing resident 62's shower and resident 62 stated what do you think I am a little girl and I can't shower myself. CNA 1 stated that resident 62 was not going to hit her but resident 62 would get angry. CNA 1 stated that resident 62 could talk with you about stuff that happened in the past. CNA 1 stated that resident 62 did not have hallucinations. On 1/29/25 at 1:35 PM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated that resident 62 would get very confused and anxious. ADON 2 stated that resident 62 was never aggressive. On 1/29/25 at 2:01 PM, an interview was conducted with ADON 3 and the DON. ADON 3 stated that she would prepare all the paperwork before they met with the Medical Director, Resident Advocate, and the Pharmacist for the psychotropic meeting. ADON 3 stated the psychotropic meeting was once a month and either herself or the DON would attend. ADON 3 stated that most of the residents needed a 14 day review for their PRN psychotropics. ADON 3 stated the psychotropic medications should already have a diagnosis, if not she would refer to the PASRR Level I or Level II, the history and physical from where they came from, and Mental Health notes. The DON stated they also look at the Patient Depression Questionnaire. The DON stated for resident 62 she would need to see if the Resident Advocate referred for a Level II. On 1/30/25 at 9:51 AM, an interview was conducted with the DON. The DON stated that resident 62's Risperidone had the diagnosis of delusional disorder as far as dementia. The DON stated that resident 62 was reviewed in October 2024 at psychotropic meeting and there were no changes at that time. The DON stated that on 12/27/24, resident 62 was reviewed again by pharmacy and the recommendation was to remain for delusions. The DON stated that staff were also behavior tracking and resident 62 was still having delusions. On 1/30/25 at 2:20 PM, an interview was conducted with the Pharmacist. The Pharmacist stated that last month she identified that resident 62's risperidone and sertraline did not have the appropriate diagnosis. The Pharmacist stated the only thing that resident 62 had was dementia and resident 62 was just admitted back in July. The Pharmacist stated that she was usually not a big person to do a dose reduction right when a resident admitted . The Pharmacist stated that staff reported that resident 62 was doing well since admission. The Pharmacist stated that she was going to recommend doing a dose reduction next month. The Pharmacist stated that she told the facility about the dose reduction yesterday when they called and asked for the psychotropic review. The Pharmacist stated that she tried to let the resident's acclimate to the facility the first few months before making the reduction. The Pharmacist stated resident 36 could go to 0.5 mg or take it off. Based on interview and record review, the facility did not ensure that residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. In addition, the facility did not ensure that as needed (PRN) psychotropics were limited to 14 days. Specifically, for 3 out of 33 sampled residents, a resident was prescribed an antipsychotic as a treatment for dementia, a resident was prescribed an antipsychotic as treatment for delusional disorder related to dementia, a resident was prescribed a selective serotonin reuptake inhibitor for depression and the resident did not have a diagnosis for depression. In addition, resident's with PRN psychotropics did not have the medications limited to 14 days and there was no justification from the prescribing practitioner to extend beyond 14 days. Resident Identifiers: 5, 22, and 62. Findings Included: 1. Resident 22 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, dementia in other diseases classified elsewhere moderate with other behavior disturbance, epilepsy, major depressive disorder, unspecified mood affective disorder, and anxiety disorder. Resident 22's medical record was reviewed on 1/27/25 through 2/3/25. A physician's order dated 5/10/24 and revised on 5/27/24, documented OLANZapine Oral Tablet (Olanzapine) Give 10 mg [milligrams] by mouth two times day related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, MODERATE, WITH OTHER BEHAVIORAL DISTURBANCE. The Preadmission Screening Resident Review (PASRR) Level II was reviewed. The PASRR Level II did not reveal any history of schizophrenia or bipolar disorder, both of which are Food and Drug Administration (FDA) approved indications for usage of olanzapine. The PASRR Level II revealed a history of major depressive disorder and anxiety. On 1/30/25 at 12:06 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that Resident 22 was prescribed olanzapine for his dementia and conduct behavior issues. RN 5 stated that other residents in the facility take olanzapine to treat schizophrenia. On 1/30/25 at 2:20 PM, an interview was conducted with the Pharmacist. The Pharmacist stated that the facility had attempted to complete gradual dose reductions for resident 22's olanzapine in 2020, 2021, and 2022. The Pharmacist stated that resident 22 did not have a diagnosis of schizophrenia and that he had severe hallucinations. A review of resident 22's olanzapine order history revealed that from 4/21/22 through 5/6/24, resident 22 did not have orders for olanzapine to be administered. A review of resident 22's hospice nursing progress notes revealed that on 5/6/24, resident 22 received orders for olanzapine to be administered. On 2/3/25 at 12:47 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility had attempted three gradual dose reductions since 2020. The DON did not explain why resident 22 had been prescribed olanzapine to treat his dementia.

Based on observation, interview, and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 5 out of 33 sampled residents, a nurse preparing medications used their bare hand to touch the medication and the medication fell on the medication cart and was administered to a resident. Resident's with a peripherally inserted central catheter (PICC) line, urinary catheter, feeding tube, and wound care did not have Enhanced Barrier Precautions (EBP) signage posted on their door and personal protective equipment (PPE) was not available. A resident with Methicillin-resistant Staphylococcus aureus (MRSA) in their wound did not have contact precautions signage posted on their door and PPE was not available. In addition, a nurse was observed to doff their PPE into the wrong garbage receptacle and a resident's PICC line port was improperly sanitized before use. Resident identifiers: 9, 28, 60, 173, and 176. Findings included: 1. On 1/30/25 at 8:34 AM, an observation was conducted with Registered Nurse (RN) 6 preparing medications for resident 28. RN 6 was preparing the calcium tablet and one of the calcium tablets fell out of the medication cup on to the medication cart. RN 6 asked the Surveyor if she could pick up the pill and resident 28 told RN 6 no. RN 6 stated if the resident was okay with her administering the pill she would. RN 6 was observed to get another calcium tablet out of the medication bottle and RN 6 assisted the tablet out of the bottle with her bare finger. RN 6 prepared all of resident 28's medications and prior to administering the medications a calcium tablet fell out of the medication cup onto the medication cart. RN 6 picked up the tablet with a gloved hand and put the tablet in the medication cup and administered the medications to resident 28. On 1/30/25 at 12:18 PM, an interview was conducted with RN 6. RN 6 stated that every time she used the blood glucose monitor or a blood pressure cuff she would sanitize the top of the medication cart. It should be noted that RN 6 did not sanitize the medication cart during the medication administration task. On 1/30/25 at 1:35 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she would like to see the medication carts sanitized before or after every shift. The DON stated it would also depend on what happened at the medication cart. The DON stated if something spilled, were residents coughing, or possible contaminates she would expect the staff to sanitize the medication cart as needed. The DON stated that staff could not touch medications with their bare hands. The DON stated the medications must go into the medication bottle cap or the medication cup. The DON stated if a medication fell on the medication cart the staff should pick up the medication with a glove but the medication was questionable. The DON stated if the medication became dirty it had to be tossed. 48709 2. Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included enterocolitis due to clostridium difficile, hereditary and idiopathic neuropathy, respiratory failure, and congestive heart failure. On 1/28/25 at 8:56 AM, resident 9 was observed to be in her room in bed. A PICC line to resident 9's upper right arm was observed and there was no EBP sign or PPE cart inside or outside of her room. Resident 9's medical record was reviewed on 1/28/25 through 2/3/25. A Nursing: EBP document dated 1/18/25 at 3:29 PM, indicated resident 9 had an Indwelling Medical Devices (Central Line, Urinary Catheter, Feeding Tube, Trach/Vent [tracheostomy/ventilator], etc). It further indicated, Resident is to be placed on Enhanced Barrier Precautions until Indwelling Medical Devices are resolved. Then downgrade to Standard Precautions. On 1/28/25 at 4:10 PM, an interview was conducted with RN 6. RN 6 stated resident 9 was not on any precautions. RN 6 stated she flushed the PICC line that day and that she used standard precautions to access it, which included gloves. On 1/29/25 at 10:36 AM, an interview was conducted with Medication Technician (MT) 1. MT 1 stated she was assigned to resident 9 that day and that she did not know resident 9 had a PICC line. 38031 3. Resident 60 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of acute kidney failure, hypertension, sepsis, and retention of urine. On 1/27/25 at 11:15 AM, an observation was made of resident 60 sleeping in bed. Resident 60's bed was positioned with the right side of the bed against the wall and the resident was lying in bed on the left lateral side. Resident 60's urinary catheter bag was observed on the wheelchair seat next to resident 60's foot of the bed. It should be noted that no sign was posted outside of resident 60's room indicating EBP nor PPE of gloves, gown, and mask readily available outside or inside the resident room. Resident 60's medical record was reviewed. On 11/22/24, resident 60's quarterly Minimum Data Set assessment documented that resident 60 required a one person total dependence for toilet use. On 1/26/25, resident 60 had an order renewed to change the urinary catheter as needed one time a day every 28 days and to change the catheter down drain bag every 23 hours as needed for retention and for catheter-related complications. On 8/19/24, resident 60 had a physician's order initiated for Foley catheter care each shift Start at insertion site and wipe down toward the drainage bag. For men: Start from the top of penis where the catheter goes in, making sure to pull back the foreskin, and wipe back toward your anus. For women: separate the labia, and wipe back toward your anus. For a suprapubic catheter: Wipe the area of your belly around where the catheter goes in. On 4/9/24, resident 60 had a care plan initiated for an indwelling urinary catheter. A goal of the care plan was that resident 60 would show no signs and symptoms of urinary infection through the review date. Interventions identified on the care plan included to change the catheter per the physician orders; monitor for signs and symptoms of discomfort on urination and frequency; and to monitor for signs and symptoms of a urinary tract infection. On 1/29/25 at 2:32 PM, an observation was made of resident 60's urinary catheter bag. The catheter bag was hung on the side of the bed next to the resident's head and the head of the bed was slightly elevated. The bag was above the level of the resident 60's bladder. It should be noted that no sign was posted outside of resident 60's room indicating EBP nor was PPE of gloves, gown, and mask readily available outside or inside the resident room. On 1/30/25 at 10:25 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that catheter care included cleaning resident 60's penis and wiping the catheter tubing where it entered the penis. CNA 3 stated that while they were providing catheter care they should be wearing gloves and a gown. CNA 3 stated that she was educated today on the required PPE to use when providing catheter care. CNA 3 stated that prior to the education provided today she was using gloves and a mask when providing catheter care but did not donn a gown. 4. Resident 173 was admitted to the facility on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, congestive heart failure, and pneumonia. On 1/28/25 at 9:20 AM, an interview was conducted with resident 173. Resident 173 stated that he was having a hard time swallowing and was getting a tube feed for his nutrition. Resident 173 stated that the tube feed was continuous and he could not eat anything by mouth except ice chips. Resident 173's tube feed was observed not running and no formula or water bag was hung at the bedside. It should be noted that no sign was posted outside of resident 173's room indicating EBP nor was PPE of gloves, gown, and mask readily available outside or inside the resident room. Resident 173's medical record was reviewed. Resident 173's physician orders revealed the following: a. On 1/25/25, an order was initiated for Enteral Feed Order two times for aspiration risk promote with fiber water flush 90/25. The order was discontinued on 1/27/25. The January Medication Administration Record documented that the enteral feed was administered four times. b. On 1/28/25, an order was initiated for Enteral Feed two times a day via Pump - Jevity 1.5 80 milliliter (ml) per hour for 18 hours via pump per nasogastric (NG) tube. Free water flush 73 ml/hour for 18 hours. On 1/24/25, the Enhanced Barrier Precautions assessment documented that the resident did not have an indwelling medical device (central line, urinary catheter, feeding tube). On 1/27/25, resident 173 had a care plan initiated for a tube feeding via NG related to aspiration risk and pneumonia infection. Interventions identified included to follow the physician orders for current tube feed and to monitor/document/report any signs and symptoms of aspiration. On 1/28/25 at 11:55 AM, an observation was made of RN 9 administering resident 173's tube feed. RN 9 was observed to connect the tubing from the formula bag to resident 173's NG tube. RN 9 did not donn gloves or a gown while connecting the tube feed to resident 173. RN 9 stated that the tube feed was scheduled to run for 18 hours each day. On 1/29/25 at 9:25 AM, an observation was made of RN 6. RN 6 was observed to administer medication to resident 173 via his NG tube. RN 6 donned gloves but did not donn a gown for the medication administration via the NG tube. On 1/29/25 at 12:14 PM, an interview was conducted with the Infection Preventionist (IP). The IP stated that if a resident was admitted with an infection the staff would be provided verbal education in report of that infection and then it would be passed off to the next shift in report. The IP stated that there should be an order in the chart stating what type of infection it was. The IP stated that a Transmission Based Precautions (TBP) sign indicating the type of precautions or an EBP sign should be posted on the resident door to alert staff as to what type of PPE to wear while providing care. The IP stated that she was the person responsible for posting the sign on the resident door for TBP or EBP and for placing a PPE cart outside of the resident room. On 1/29/25 at 12:58 PM, an interview was conducted with the DON and Assistant Director of Nursing (ADON) 3. The DON stated that they initiated EBP for any infections that could be spreadable. The DON stated that she did not know if a resident with a urinary catheter, NG tube, or PICC line without other infections would require EBP. The DON stated that residents with urinary catheters, NG tubes, or PICC lines were not currently on EBP. The DON stated that any resident on EBP should have a sign posted on the door and cart with PPE should be located outside the room. The DON stated that PPE required for EBP were gloves, gowns, masks, and N95 if necessary. The DON stated that the IP was responsible for placing TBP and EBP signs on resident doors and the PPE cart outside of the room. The DON stated that a resident with a Methicillin-Resisitant Staphylococcus aureus infection should have contact precautions and staff should be donning gloves, gown, and mask. The DON stated that a Clostridium difficile infection required contact precautions and PPE worn should be gloves, gown, and mask. The DON stated that staff should wear gloves when accessing a PICC line. The DON stated that the PICC line ports should have caps on them, and the cap should be changed according to the orders but most of the time it was weekly and was documented on the Treatment Administration Record. The DON stated that the PICC lines should be flushed before and after medication administration and every shift depending on the physician orders. The DON confirmed that the PICC line lumen connectors needed to be cleaned with a new and unused alcohol swab for each connector prior to use. The DON stated that if the resident was not receiving any medication through the PICC line then she would expect the nurse to contact the physician to see if it could be discontinued. The DON stated that the nurse should wear gloves when accessing a NG tube unless the resident had another infection that required more PPE. ADON 3 stated that staff should doff used PPE in the garbage inside the resident room and should be in a separate receptacle. ADON 3 stated that the used PPE should not be doffed into a shared bathroom garbage because there was a potential for spreading the infection and cross contamination. 5. Resident 176 was admitted to the facility on [DATE] with diagnoses which consisted of osteomyelitis, methicillin-resistant staphylococcus aureus infection, open wound on the right lower leg, viral hepatitis C, and stimulant and alcohol abuse. On 1/27/25 at 1:55 PM, an observation was made of resident 176's room. The door to the room did not contain a sign indicating TBP or EBP. A PPE cart was observed located next to the resident door. Inside the cart was a sign for EBP and surgical masks. The PPE cart did not contain any gloves or gown. An observation was made of MT 1 entering the resident room with only a surgical mask donned. Resident 176's physician orders revealed the following: a. On 1/24/25, an order was initiated for WOUND CARE RIGHT LATERAL CALF: Remove dressing, cleanse wound with standard wound care protocol, apply the following order and appropriate dressing: Apply Anasept and collagen followed by Cutimed Sorbact dressing. Change 3x [times] per week and PRN [as needed] for soiled or compromised wound dressing one time a day every Tue [Tuesday], Thu [Thursday], Sat [Saturday] for wound AND every 23 hours as needed. b. On 1/10/25, an order was initiated for Change RIGHT DOUBLE LUME [sic] PICC dressing weekly on Sunday and as needed. one time a day every Sun [Sunday] for maintenance. c. On 1/9/25, an order was initiated for Flush Right Double Lumen PICC with 10 ml NS [normal saline] before and after each medication dose every shift for maintenance. d. On 1/17/25, an order was initiated for cefTRIAXone Sodium Intravenous Solution Reconstituted 2 GM [grams] (Ceftriaxone Sodium) Use 2 gram intravenously one time a day for mrsa. On 1/22/25, resident 176 had a care plan initiated for has a MRSA chronic wound to the RLE [right lower extremity] lateral calf. The care plan identified an intervention to follow the facility protocols for treatment of the injury. On 1/28/25 at 1:18 PM, a list of residents receiving wound care was provided by RN 10. Resident 176 was not listed as being seen by the outside wound care provider. On 1/28/25 at 2:06 PM, an interview was conducted with RN 6. RN 6 stated that resident 176 did not have any wounds but did have a PICC line. On 1/28/25 at 2:53 PM, an interview was conducted with Physician Assistant (PA) 1 for the outside contracted wound care providers. PA 1 stated that she was providing wound care to resident 176 today and that she had MRSA in the wound. On 1/28/25 at 3:21 PM, an interview was conducted with resident 176's wound care providers, PA 1 and Medical Assistant (MA) 1. MA 1 stated that they were using Anasept on the wound bed followed by collagen and Cutimed Sorbact. MA 1 stated that the wound was located on the right lateral calf and on 1/21/25, the wound measured 8.1 centimeters (cm) x 5.1 cm. x 0.4 cm. PA 1 stated that resident 176 had the wound for three years and she had knee and hip surgery for osteomyelitis. MA 1 stated that resident 176 was on contact precautions due to the chronic MRSA in the wound. MA 1 was observed to check the PPE cart outside of resident 176's room and stated that it did not contain the PPE required. On 1/28/25 at 3:37 PM, an interview was conducted with RN 10. RN 10 stated that the wound team asked her for gowns but she did not know who they were for. RN 10 stated that resident 176 needed gowns for wound care on her legs. RN 10 also stated that resident 176 was on contact precautions but she was not sure what for. RN 10 stated that the PPE required for contact precautions were gloves and a gown and that there should be a sign posted outside the resident door indicating this. RN 10 stated that resident 176's room did not have a sign posted for contact precautions. RN 10 stated that the PPE cart outside of resident 176's room had a sign in the top drawer for EBP but not for contact precautions. RN 10 stated that it was not the correct sign. RN 10 stated that she would need to check to see if resident 176 was supposed to be on EBP or contact precautions. RN 10 stated that the PPE cart should contain gowns, gloves, masks, and red disposal bags. RN 10 stated that the PPE cart only contained surgical masks and the EBP sign. On 1/28/25 at 4:00 PM, a follow-up interview was conducted with RN 10. RN 10 stated that resident 176 should be on contact precautions for wound care and staff should be donning a gown and gloves. RN 10 stated that staff did not have to donn a gown and gloves for intravenous antibiotic treatment. It should be noted that per the facility policy on EBP staff should utilize gowns and gloves during resident care activities for central lines such as resident 176's PICC line. On 1/28/25 at 4:04 PM, an interview was conducted with the IP. The IP stated that EBP should be implemented with resident's who had a PICC line and staff should be donning a gown, gloves, and a mask for any care of the indwelling device. On 1/29/25 at 9:54 AM, an observation was made of RN 6 during medication administration for resident 176. RN 6 stated that she was going to administer resident 176 her vancomycin for sepsis. RN 6 donned a gown and gloves prior to entering resident 176's room. Resident 176 had a double lumen PICC line in her left upper arm. RN 6 cleaned the purple port with a new alcohol wipe and flushed the line with a 10 ml of NS. RN 6 picked up the used alcohol swab from the resident's bed and wiped the purple tip again prior to hooking up the intravenous infusion line. RN 6 doffed her gloves, gown, and surgical mask into the garbage bag in the shared bathroom. The garbage sack in the shared bathroom was not a red biohazard bag and a red bag was not observed in the resident room. RN 6 exited the resident room and walked down the hallway to obtain a new mask from the nurse's station. It should be noted that the PPE cart outside of resident 176's room had a supply of surgical masks available. Additionally, the facility was currently experiencing a COVID-19 outbreak and all staff were wearing surgical masks while inside the facility. On 1/29/25 at 12:05 PM, a follow-up interview was conducted with the IP. The IP stated that EBP should be utilized with any resident care of urinary catheters, PICC lines, and NG tubes. The IP stated that staff should donn a gown, gloves, and a mask. The IP stated that EBP were implemented to protect the resident. The IP stated that contact precautions were for infections that were transferred through bodily fluids and it protected the staff and reduced the cross contamination. The IP stated that there should be a sign on the door alerting staff and the PPE cart should contain masks, gloves, gowns, hand sanitizer, and alcohol wipes. The IP stated that staff should doff their used PPE inside the resident room in its own garbage bag and should not be disposed of in a bathroom garbage can that was a shared bathroom. Review of the facility policy and procedure titled Isolation - Categories of Transmission-Based Precautions documented that TBP were initiated when a resident developed signs and symptoms of transmissible infection; arrived for admission with symptoms of an infection; or had a laboratory confirmed infection; and was at risk of transmitting the infection to other residents. The policy documented that when a resident was placed on TBP appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC (Centers for Disease Control and Prevention) precautions(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. The policy further documented, Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident environment. The policy documented that staff and visitors should wear gloves and a gown when they entered the resident room and remove the PPE before exiting the resident room. The policy was last revised in September 2022. Review of the facility policy titled Enhanced Barrier Precautions documented, Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. The policy stated that EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy further stated that high contact resident care activities that required the use of gown and gloves for EBPs included: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). The policy was created in August 2024.

Based on interview and record review, the facility did not ensure that when the facility transferred a resident that the transfer was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. The information provided to the receiving provider must include contact information of the practitioner responsible for care of the resident; resident representative information; Advance Directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, for 1 out of 33 sampled residents, a resident's medical record did not contain the information that was provided to the receiving provider when the resident was transferred to a local hospital for evaluation. Resident identifier: 49. Findings included: Resident 49 was admitted to the facility on [DATE] with diagnoses which consisted of hemiplegia left side, history of traumatic brain injury, nontraumatic subarachnoid hemorrhage, post-traumatic stress disorder, insomnia, bipolar disorder, generalized anxiety disorder, stimulant abuse, attention-deficit hyperactivity disorder, autistic disorder, conduction disorder, and hypertension. On 1/27/25 at 10:53 AM, an interview was conducted with resident 49. Resident 49 stated that he went to the hospital for suicidal ideation. Resident 49's medical record was reviewed. On 1/17/24 at 7:56 PM, the nurse note documented, Resident was heard making threats about killing other residents. He states that he is going to commit suicide if other residents do not stop worrying him. MD [Medical Doctor] notified and ordered resident to be sent to the hospital for psychiatry evaluation. On 1/18/24 at 5:24 AM, the nurse note documented, Resident returned from the [name omitted] hospital. The team at the [name omitted] hospital states that resident has no criteria to admit him. They advised that at this time they do not feel that the resident is not a threat to himself or others. Upon arrival to facility, resident has had constant eyes on him and as of currently, there are no issues/concerns regarding any suicidal ideations or potentially harming others. No documentation could be found of the transfer paperwork for resident 49 or what information was sent to the receiving provider. On 1/30/25 at 10:55 AM, an interview was conducted with Registered Nurse (RN) 9. RN 9 stated for transfers they sent a resident face sheet, medication list, and a Physician's Order for Life Sustaining Treatment (POLST) form to the receiving provider. RN 9 stated that he would document a progress note of the incident or reason for transfer and the location the resident was sent to. RN 9 stated that they completed an e-interact transfer form for the transfer and he would notify the provider of the resident change in condition and then call the hospital to give report. RN 9 stated that he would also notify the family of the resident transfer. RN 9 stated that in an emergency situation he would transfer the resident immediately and then notify the physician. On 1/30/25 at 12:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that during a transfer to the hospital the nurse should send a face sheet, an order summary, and the reason for the visit. The DON stated that the nurse should also document an event or progress note. The DON stated that the note should contain the change of condition, what happened, that the physician and family were notified, and the order to transfer the resident out. The DON stated she would have to check the policy to see if the nurse needed to document what paperwork was sent with the patient to the receiving provider. The DON stated that the current practice was that the nurse did not document what paperwork was sent with the resident to the receiving provider. The DON stated that a POLST form was not part of the current paperwork that was required to be sent to the receiving provider.

Based on observation, interview, and record review, the facility did not ensure that that services provided met professional standards of quality. Specifically, for 1 out of 33 sampled residents, a resident's nasogastric (NG) tube feed did not have the formula bag labeled with the rate of infusion or the nurse initials who initiated the infusion. Resident identifier: 173. Findings included: Resident 173 was admitted to the facility on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, congestive heart failure, and pneumonia. On 1/28/25 09:20 AM, an interview was conducted with resident 173. Resident 173 stated that he was having a hard time swallowing and was getting a tube feed for his nutrition. Resident 173 stated that the tube feed was continuous and he could not eat anything by mouth except ice chips. Resident 173's tube feed was observed not running and no formula or water bag was hung at the bedside. Resident 173's medical record was reviewed. On 1/27/25, resident 173 had a care plan initiated for a tube feeding via NG related to aspiration risk and pneumonia infection. Interventions identified included to follow the physician orders for current tube feed and to monitor/document/report any signs and symptoms of aspiration. On 1/28/25, resident 173's physician ordered an Enteral Feed two times a day via Pump - Jevity 1.5 80 milliliter (ml) per hour for 18 hours via pump per NG tube. Free water flush 73 ml/hour for 18 hours. On 1/28/25 11:55 AM, an observation was made of Registered Nurse (RN) 9 administering resident 173's tube feed. RN 9 was observed to connect the tubing from the formula bag to resident 173's NG tube. RN 9 placed a label on the formula bag that documented the resident name, formula type, resident room number and current date. The label did not contain the licensed nurse's signature or the rate of infusion. The water flush was not labeled. On 1/29/25 at 1:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the tube feed label should contain the date and time the infusion was initiated, the initials of the nurse, and the patient's name. The DON stated that she would have to look at the policy to determine if the formula type and rate of infusion should be documented on the label. Review of the facility policy for Enteral Tube Feeding via Continuous Pump documented under Initiate Feeding that the label should contain .initials, date and time the formula was hung/administered, and initial that the label was checked against the order. The policy further documented under General Guidelines to Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID [identification] and room number; b. Type of formula; c. Date and time formula was prepared; d. Route of delivery; e. Access site; f. Method (pump, gravity, syringe); and g. Rate of administration (mL/Hour). The policy was last revised in November 2024. Review of the Lippincott Nursing Procedures documented under Enteral Gastric, Duodenal, and Jejunal Tube Feedings for implementation to Make sure that the enteral formula container is labeled with the patient's identifiers; formula name (and strength if diluted); date and time of formula preparation; date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of who prepared, hung and checked the enteral formula agianist the order; expiration date and time; dosing weight (if appropriate); and notation ENTERAL USE ONLY--NOT FOR IV USE. Wolters Kluwer. Lippincott Nursing Procedure. Ninth Edition. Philadelphia, PA. (2023), pp. 297.

Based on observation, interview, and record review, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, for 2 out of 33 sampled residents, a resident had a urinary catheter collection bag kept above the level of the bladder. In addition, a resident had a urinalysis (UA) test completed with no follow up and the resident required treatment for a urinary tract infection (UTI). Resident identifiers: 2 and 60. Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included vascular dementia, generalized muscle weakness, urinary tract infections, major depressive disorder, and anxiety. Resident 2's medical record was reviewed on 1/28/25 through 2/3/25. An annual Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 2 was always incontinent of bowel and bladder and was not on a toileting program. The MDS assessment further revealed resident 2 required two plus person extensive assistance with toileting. A care plan dated 12/15/23, revealed [Resident 2] at risk for UTI's d/t [due to] personal history. The goal was [Resident 2] will remain free from infection through the review date. The approaches included Monitor/document/report to MD [Medical Director] s/sx [signs/symptoms] of delirium: Changes in behavior, Altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle. Monitor/document/report PRN [as needed] abnormal laboratory values (e.g. [for example] white blood cell count and differential, serum protein, serum albumin, and cultures. Monitor/document/report PRN any s/sx of infection: fever; redness; drainage or swelling around wounds or catheter sites; cough, respiratory symptoms; dysuria, hematuria, flank pain and foul smelling urine. A physician's order revealed resident 2 was to have a UA, complete blood count (CBC), and complete metabolic panel (CMP) completed on 7/8/24. The July 2024 Medication Administration Record documented the sample of urine was collected on 7/9/24 at 8:24 PM. A Sudden change of behavioral/mental status note dated 7/8/24, documented, . Resident was very confused, not at all oriented to time, place, person or situation . Stat [immediately] CBC, CMP and Urine sample were obtained as per doctors orders. Waiting for the results. The medical record contained results of the CBC and CMP that were received on 7/9/24, no results of the UA were located or provided by the facility. The next note dated 7/20/24, in the medical record was a Lab result/Imaging result documented, the Original lab requisition and reason for lab: UA C & S [culture and sensitivity] to rule out UTI with a result of Detected pathogens are enterococcus spp (faecalis,faecium), Escherichia Coli . Interventions put in place were for resident 2 to Start Nitrofurantoin 100 mg [milligrams] PO [by mouth] BID [twice daily] for 7 days for UTI. On 2/3/25 at 12:43 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when they got an order for labs they put it into the computer, printed off the paperwork, and then put all of that into the lab binder. RN 1 stated if a urine needed to be collected they would use a bed pan, Foley, or straight cath the resident. RN 1 stated after the urine sample was obtained it would be put in the specimen fridge in the medication room if it was not a stat order, if it was a stat order then it would be taken down to the specimen box outside after the lab had been called to inform them of the need to collect it. RN 1 stated the nurse on shift was responsible to watch the fax machine for any results and make the provider aware. RN 1 stated that resident 2 did have UTI's often and they usually had to straight cath her to obtain any samples due to her condition. RN 1 stated she could not remember what happened back in July for this incident or why the result was not in the computer. On 2/3/25 at 1:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses were expected to put any lab orders into the medical record, collect the sample, and call the lab company to come collect the sample(s). The DON stated that nursing management would follow up on any orders to make sure that they were put into the lab binder. The DON stated she was not here at the time of the incident so she was not aware of what happened. The DON stated the nurses watch the fax machine for any results that come through and call the doctor to make them aware and get any new orders. The DON stated the nurse on duty was responsible for following through with any orders that were given by a provider. 38031 2. Resident 60 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of acute kidney failure, hypertension, sepsis, and retention of urine. On 1/27/25 at 11:15 AM, an observation was made of resident 60 sleeping in bed. Resident 60's bed was positioned with the right side of the bed against the wall and the resident was lying in bed on the left lateral side. Resident 60's urinary catheter bag was observed on the wheelchair seat next to resident 60's foot of the bed. The urine observed in the catheter tubing was dark amber with sediment noted. The urinary catheter bag was positioned above the level of the resident's abdomen and the bed was lowered to the ground below the level of the wheelchair seat. Resident 60's medical record was reviewed. On 11/22/24, resident 60's quarterly MDS assessment documented a Brief Interview for Mental Status score of 9/15, which would indicate a moderate cognitive impairment. The assessment documented that resident 60 required a one person total dependence for toilet use. On 1/26/25, resident 60 had an order renewed to change the catheter bag every 23 hours as needed for retention and for catheter-related complications. On 4/9/24, resident 60 had a care plan initiated for an indwelling urinary catheter. A goal of the care plan was that resident 60 would show no signs and symptoms of urinary infection through the review date. Interventions identified on the care plan included to change the catheter per the physician orders; monitor for signs and symptoms of discomfort on urination and frequency; and to monitor for signs and symptoms of a urinary tract infection. On 1/28/25 at 1:01 PM, an interview was conducted with Certified Nurse Assistant (CNA) 4. CNA 4 stated that they emptied resident 60's catheter bag every shift and if they observed urine in the resident's brief they would inform the nurse that there was a possible leak. CNA 4 stated that the nurse would then assess if the catheter needed to be changed. CNA 4 stated that catheter care included cleaning the catheter tubing with a wipe every time there was a brief change. CNA 4 stated that resident 60's urinary catheter bag was supposed to be hooked to the side of the bed in line with his thigh. On 1/29/25 at 2:32 PM, an observation was made of resident 60's urinary catheter bag. The catheter bag was hung on the side of the bed next to the resident's head and the head of the bed was slightly elevated. The catheter bag was above the level of resident 60's bladder. On 1/30/25 at 10:25 AM, an interview was conducted with CNA 3. CNA 3 stated that catheter care included cleaning resident 60's penis and wiping the catheter tubing where it entered the penis. CNA 3 stated the catheter bag should be positioned on the bed frame or wheelchair so the urine output flowed downward away from the body into the collection bag. CNA 3 stated that it was not okay for the catheter bag to be positioned on a chair or attached to the head of the bed if it was not in a position to allow the urine to flow downward. CNA 3 stated, If the urine doesn't flow down it could go back into their body and could cause an infection. On 1/30/25 at 12:04 PM, an interview was conducted with RN 9. RN 9 stated that catheter care was performed every shift and included cleaning the skin on the head of penis and assessing for signs of infection such as redness. RN 9 stated that he would assess the urine output for color, sediment, and odor. RN 9 stated that the urinary catheter down drain bag should be positioned on the side of the bed below the level of the bladder for gravity to assist in drainage. RN 9 stated that if the catheter bag was not positioned correctly it posed the risk of dislodging the tubing and a risk of increased infection. On 1/30/25 at 12:30 PM, an interview was conducted with the DON. The DON stated that nursing staff should provide catheter care every shift which included cleaning the tubing and the head of the penis around the insertion site. The DON stated that the down drain bag should be positioned below the bladder. The DON stated that if it was not positioned below the bladder it could cause backflow, retention, and infections.

Based on observation, interview, and record review, the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, for 1 out of 33 sampled residents, a resident was provided water flushes via his nasogastric (NG) tube that exceeded the physician orders. Resident identifier: 173. Findings included: Resident 173 was admitted to the facility on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, congestive heart failure, and pneumonia. On 1/28/25 at 9:20 AM, an interview was conducted with resident 173. Resident 173 stated that he was having a hard time swallowing and was getting a tube feed for his nutrition. Resident 173 stated that the tube feed was continuous and he could not eat anything by mouth except ice chips. Resident 173's tube feed was observed not running and no formula or water bag was hung at the bedside. Resident 173's medical record was reviewed. On 1/27/25, resident 173 had a physician order initiated for enteral feed flushes with 20 to 30 milliliters (ml) of water before and after administration of medication pass. On 1/27/25, resident 173 had a care plan initiated for a tube feeding via NG related to aspiration risk and pneumonia infection. Interventions identified included to follow the physician orders for current tube feed and to monitor/document/report any signs and symptoms of aspiration. On 1/29/25 at 9:25 AM, an observation was made of Registered Nurse (RN) 6. RN 6 was observed to administer medication to resident 173 via his NG tube. RN 6 stated that the morning medication included resident 173's antibiotic for his respiratory infection. RN 6 donned gloves and filled a pitcher with warm tap water. Resident 173 was observed lying flat in bed and complained of heartburn. RN 6 raised resident 173's head of the bed. Resident 173's tube feed was attached to the NG tube but had completed infusing. RN 6 found the NG tube wrapped around resident 173's leg. Resident 173 requested that the nurse hurry because he did not want to be positioned sitting up. RN 6 disconnected the tube feed from the NG tube and flushed resident 173's NG tube with 30 ml of water. Resident 173 complained of difficulty with breathing and RN 6 lowered the head of the bed slightly. RN 6 then administered approximately 45 mls of medication mixed with water. RN 6 then flushed the NG tube with another 30 ml of water. RN 6 administered another 45 ml of medication mixed with water followed by 50 ml of a water flush. RN 6 administered another 50 ml of medication mixed with water followed by 30 ml of a water flush. Resident 173 complained of shortness of breath and stated that he was fighting for air. Resident 173 requested that the head of the bed be lowered. Resident 173 complained again of heartburn and RN 6 stated that she would see what medication he had ordered for heartburn. It should be noted that RN 6 administered a total fluid volume of 140 mls of medication mixed with water and a total fluid volume of 140 mls of water flushes. An immediate interview was conducted with RN 6 after the completion of the medication administration. RN 6 stated that she assessed the NG tube by checking for placement and verifying that the tube was not dislodged. RN 6 stated that she would aspirate the NG tube prior to medication administration to check for color and volume of what was aspirated. It should be noted that RN 6 did not attempt this prior to medication administration. On 1/29/25 at 1:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the enteral feed water flush amount was determined by the physician order. The DON stated that it was not up to the nurse's discretion to give more volume than was ordered for the water flush. The DON stated if the physician order stated 20 to 30 ml before and after medication administration the nurse should be administering 60 ml per administration. The DON stated that there was a risk of aspiration if the water flushes exceeded the order parameters. The DON stated that the nurse should monitor for signs and symptoms of aspiration such as difficulty breathing, increased respiratory rate, and increased temperature.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, for 1 out of 33 sampled residents, a peripherally inserted central catheter (PICC) line had no physician orders for intravenous fluids, flushes or dressing changes, and had no indication for continued use for one resident. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included enterocolitis due to clostridium difficile, hereditary and idiopathic neuropathy, respiratory failure, and congestive heart failure. On 1/29/25 at 10:21 AM, an observation and interview with resident 9 was conducted. Resident 9 had a locked PICC line to her upper right arm, the dressing was dated 1/16/25. Resident 9 stated she was not currently receiving any medications through the PICC line and the nurses were not flushing it every day. Resident 9's medical record was reviewed from 1/28/25 through 2/3/25. A physician's order dated 1/16/25 at 1:00 PM, indicated, Ampicillin Sodium Intravenous Solution Reconstituted 2 GM [grams] (Ampicillin Sodium) Use 12 gram intravenously in the afternoon for respiratory failure for 2 days. A physician's order dated 1/23/25 at 1:30 PM, indicated, Sodium Chloride Solution 0.9% Use 1000 ml [milliliters] intravenously one time only for low renal function for 1 Day NS [normal saline] at the rate of 150 ml/hr [hour]. No physician orders for PICC line flushes or dressing changes were provided. The Medication Administration Record (MAR) dated January 2025, indicated, Ampicillin Sodium Intravenous Solution Reconstituted 2 GM (Ampicillin Sodium) Use 12 gram intravenously in the afternoon for respiratory failure for 2 Days -Start Date- 01/16/2025 1500 [3:00 PM], was administered on 1/16/25 and 1/17/25. It further indicated, Sodium Chloride Solution 0.9% Use 1000 ml intravenously one time only for low renal function for 1 Day NS at the rate of 150 ml/hr -Start Date- 01/23/2025 1330 [1:30 PM], was administered on 1/23/25 at 1:33 PM. A comprehensive care plan that included the PICC line was not provided. On 1/28/25 at 4:10 PM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated resident 9's PICC line was not currently being used for medications. RN 6 stated the PICC line needed to be flushed once a shift to maintain patency. On 1/29/25 at 10:36 AM, an interview was conducted with Medication Technician (MT) 1. MT 1 stated she did not know resident 9 had a PICC line. MT 1 stated a PICC line needed to be flushed and that she did not see any orders for flushes in the resident's medical record. On 1/29/25 at 1:13 PM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated management placed orders for flushes and dressing changes and assessed for continued need. ADON 2 stated that she would have to look up why resident 9's PICC line had not been discontinued. On 1/29/25 at 1:43 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses on the floor and nurse management should have contacted the doctor if the PICC line was still necessary and that they should have followed up with the doctor after the last dose of the intravenous antibiotics was administered. On 1/29/25 at 2:20 PM, a follow-up interview was conducted with the DON. The DON stated dressing changes were supposed to be done weekly and as needed. The DON stated PICC line flushes should be done before and after medication administration and at least once every shift. The DON stated she was not sure when the last time resident 9's PICC line was flushed. The facility policy was reviewed and documented, Peripheral and Midline IV [intravenous] Dressing Changes, dated 3/24, indicated, 4. Change the dressing it if becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM [transparent semi-permeable membrane] dressing .

Based on interview and record review, the facility did not provide routine and emergency drugs to its residents. Specifically, for 1 out of 33 sampled residents, a resident that was prescribed a hormone based chemotherapy, antipsychotics, selective serotonin reuptake inhibitor, antibiotic, anticoagulant, and a liquid protein did not have those medications available for administration due to pending delivery. Resident identifier: 62. Findings included: Resident 62 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, malignant neoplasm of right female breast, dementia severe, delusional disorders, urinary tract infections, repeated falls, dysphagia, difficulty in walking, and unsteadiness on feet. Resident 62's medical record was reviewed on 1/28/25. On 7/10/24 at 11:24 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg [milligram] by mouth one time a day for breast cancer Pending delivery from pharmacy. On 7/25/24 at 9:20 AM, an Orders - Administration Note documented Note Text: ARIPiprazole Oral Tablet 2 MG Give 1 tablet by mouth one time a day for antipsychotic Supplement to depression medication Pending delivery from pharmacy. Provider notified. On 7/26/24 at 8:07 AM, an Orders - Administration Note documented Note Text: ARIPiprazole Oral Tablet 2 MG Give 1 tablet by mouth one time a day for antipsychotic Supplement to depression medication Pending delivery. On 7/28/24 at 9:28 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer pending delivery. On 7/29/24 at 11:44 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer awaiting pharmacy delivery. MD [Medical Director] and management notified. On 8/2/24 at 7:15 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer pending delivery. On 8/2/24 at 8:30 AM, an Orders - Administration Note documented Note Text: Sertraline HCl [hydrochloride] Oral Tablet 50 MG Give 50 mg by mouth one time a day for Depression pending delivery. On 8/3/24 at 8:35 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer Pending delivery. On 8/4/24 at 7:42 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer pending delivery. On 8/4/24 at 7:45 AM, an Orders - Administration Note documented Note Text: Sertraline HCl Oral Tablet 50 MG Give 50 mg by mouth one time a day for Depression pending delivery. On 10/27/24 at 9:57 PM, an Orders - Administration Note documented Note Text: Cephalexin Oral Tablet 500 MG Give 500 mg by mouth four times a day for Prophylaxis awaiting blood Culture results for 5 Days not available in pyxis. On 11/28/24 at 7:41 AM, an Orders - Administration Note documented Note Text: Eliquis Oral Tablet Give 5 mg by mouth two times a day for DVT [deep vein thrombosis] prevention pending delivery. On 12/17/24 at 8:02 PM, an Orders - Administration Note documented Note Text: risperiDONE Oral Tablet Give 1 mg by mouth one time a day for delusional disorder pending on delivery. On 12/21/24 at 7:58 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer pending delivery. On 12/22/24 at 7:20 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer pending delivery. On 12/23/24 at 8:57 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer med not available, pharmacy notified. On 12/24/24 at 7:19 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer Pharmacy contacted about medication. pending delivery. On 12/25/24 at 10:21 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer pending delivery. pharmacy has been contact. On 12/26/24 at 10:04 AM, an Orders - Administration Note documented Note Text: Anastrozole Oral Tablet Give 1 mg by mouth one time a day for breast cancer PHARMACY NOTIFIED, MED [medication] WILL BE HERE TODAY. On 1/24/25 at 10:22 AM, an Orders - Administration Note documented Note Text: Pro Stat one time a day for Supplement give 45 ml [milliliters] po [by mouth] daily pending delivery. On 1/25/25 at 8:35 AM, an Orders - Administration Note documented Note Text: Pro Stat one time a day for Supplement give 45 ml po daily pending delivery. On 1/26/25 at 10:20 AM, an Orders - Administration Note documented Note Text: Pro Stat one time a day for Supplement give 45 ml po daily pending delivery. On 1/30/25 at 8:45 AM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated she would call the pharmacy if she needed a medication and the pharmacy would deliver. RN 6 stated that sometimes medication refills would be missed. RN 6 stated if there were a few medications left in the medication card she would take the sticker off of the medication card and fax the refill to the pharmacy. RN 6 stated the pharmacy would deliver in an hour or so if she told them she needed it right now. On 1/30/25 at 8:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated when the resident had seven days of medication left, the staff would fax the request refill to the pharmacy. The DON stated that staff would need to call the pharmacy and tell them the fax request had been sent if they did not see the medications. The DON stated the first step was to fax the request to the pharmacy and follow up with a phone call. The DON stated the pharmacy would deliver the medications in a day or two of the refill request. On 1/30/25 at 12:07 PM, an interview was conducted with Assistant Director of Nursing (ADON) 2. The ADON stated the facility had an emergency medication system that was stocked with the basic medications including pain medications and antibiotics. ADON 2 stated Prostat was ordered through a medical supply store. The ADON stated that central supply would order the Prostat with the over the counter medications. The ADON stated the central supply staff member worked nights and would do the stocking before her shift. The ADON stated the central supply staff member would order at the beginning of the week and then she had a stock day. The ADON stated the central supply staff member would order here and there if the nurses need anything.

Based on interview and record review, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director (MD), and the Director of Nursing (DON) were acted upon. In addition, the attending physician must document in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. Specifically, for 1 out of 33 sampled residents, a pharmacy recommendation was not acted upon by the MD and the MD did not document the identified irregularity and what action was taken in the resident's medical record. Resident identifier: 62. Findings included: Resident 62 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, malignant neoplasm of right female breast, dementia severe, delusional disorders, urinary tract infections, repeated falls, dysphagia, difficulty in walking, and unsteadiness on feet. Resident 62's medical record was reviewed on 1/28/25. The Patient Recommendations Summary dated 12/27/24, documented This resident has orders for Risperidone and Sertraline for dementia, but this is not a labeled indication for these medications. Antipsychotic medications have a black box warning when used off label. This was discussed with the attending psychiatric providers and it was agreed that symptoms of psychosis, depression, anxiety and mood instability are common behavioral symptoms of this condition, and that these medications can be useful in treating these symptoms. It was agreed that the benefits of treatment currently outweigh any potential risks, and no recommendations are needed at this time. There was no documentation from the MD in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. On 1/30/25 at 1:17 PM, an interview was conducted with the DON. The DON stated the pharmacist would review the residents and would send the recommendations in an email. The DON stated the pharmacist would review the residents remotely and would come to the facility for the psychotropic meetings. On 1/30/25 at 1:20 PM, an interview was conducted with Assistant Director of Nursing (ADON) 3. ADON 3 stated that she would receive the pharmacist recommendations. ADON 3 stated she would get the orders form the pharmacist, make the changes, and notify the resident. ADON 3 stated that she did not know if the MD signed the recommendations but she thought the recommendations might already be agreed before they came to her. On 1/30/25 at 2:20 PM, an interview was conducted with the Pharmacist. The Pharmacist stated that she did at least a monthly review on the residents. The Pharmacist stated that she reviewed the resident medical records but every month was different. The Pharmacist stated the first month of the quarter, she did anything that required lab work, made sure the labs looked good or needed to be ordered, and made sure all medications were appropriately dosed based on kidney or liver function. The Pharmacist stated if the labs looked good she would look at the drug interactions. The Pharmacist stated the second month she would do blood pressures, sliding scale insulin, anticoagulants, make sure that everything had the appropriate dosage, and get rid of unnecessary medications. The Pharmacist stated the third month was the psychotropic review. The Pharmacist stated that she would make sure she put in the note that the psychotropic medications were reviewed. The Pharmacist stated she would look to see if the provider and nursing staff were documenting the patient had dementia and discussed the risks and benefits. The Pharmacist stated that she believed the benefits outweighed the risk. The Pharmacist stated that last month she identified that resident 62's risperidone and sertraline did not have the appropriate diagnosis. The Pharmacist stated the only thing that resident 62 had was dementia and resident 62 was just admitted back in July.

Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the expiration date when applicable. Specifically, for 2 out of 33 sampled residents, four opened insulin injector pens were not labeled with open dates and they were in the medication cart available for resident use. Resident identifiers: 7 and 24. Findings included: On 1/30/25 at 1:54 PM, an observation was conducted of the third floor East hallway medication cart with Registered Nurse (RN) 7. There were four insulin injector pens in the medication cart that were not labeled with an open dated. RN 7 stated as soon as we get the insulin out of the fridge we would date the insulin with an open date. RN 7 stated that insulin was all ready labeled with the residents name. RN 7 stated the insulin was good for 28 days after opening. 1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy and long term use of insulin. Resident 7's Basaglar KwikPen Solution Pen injector 100 unit/milliliter (ml) (Insulin Glargine) and Humalog Solution 100 unit/ml (Insulin Lispro) were not labeled with an open date and were available for use in the medication cart. 2. Resident 24 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic neuropathy, and long term use of insulin. Resident 24's Insulin Glargineyfgn Solution 100 unit/ml and Insulin Lispro-aabc Injection Solution 100 unit/ml were not labeled with an open date and were available for use in the medication cart. On 1/30/25 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when insulin was opened the staff should date the insulin with an open date and the insulin was good for 28 days.

Based on interview and record review it was determined, for 3 of 38 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was not assessed after a car accident during a facility transport, a hospice resident who fell and experienced a fracture did not have an x-ray completed timely, and a hospice resident was taken off of his antipsychotic medication abruptly and behaviors escalated. Resident identifiers: 19, 170 and 173. Findings included: 1. Resident 170 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, suicidal ideations, type II diabetes mellitus, muscle weakness, lack of coordination, unsteadiness on feet, essential hypertension, bipolar II disorder, generalized anxiety disorder, legal blindness, major depressive disorder, anemia and morbid obesity. Resident 170's medical record was reviewed 1/8/24 through 1/11/24. On 1/8/24 at 9:08 AM, an interview was conducted with resident 170. Resident 170 stated he was in a car accident on the way to dialysis on Halloween. Resident 170 stated the driver was talking on her cellphone and was not paying attention and she ran into a stopped car. Resident 170 stated the airbags deployed and the fire department came. Resident 170 stated he was not sent to the hospital to be checked out because they would not let him, he stated the facility Receptionist (RC) came and hushed him into her personal car and took him to dialysis. Resident 170 stated he told them when he got back from the dialysis that his chest hurt. Resident 170 stated they gave him some pain medication but refused to send him to the hospital to be examined because they said There isn't anything they would do for a cracked sternum, we aren't going to waste our money on that. Resident 170 stated the facility did send him to get checked out about 2 weeks after the incident but only because he threatened to sue them. On 1/10/24 at 9:31 AM, an interview was conducted with Resident Advocate (RA) 2. RA 2 stated she was over transportation when the accident happened. RA 2 stated resident 170 was seatbelted in the front seat because that was where he liked to sit when he went to dialysis. RA 2 stated there was already an accident on the left side of the road and as she approached the stop light she glanced to her left and rear ended the car that was stopped at the light. RA 2 stated all of the airbags deployed on both sides above and at the foot level of the van. RA 2 stated she checked on resident 170 and rolled down the windows. RA 2 stated the ambulance was there already and they came over and checked on them. RA 2 stated from there a police report was completed and RA 2 asked resident 170 if he wanted to go to the hospital and he said no. RA 2 stated she called the Administrator, the Business Office Manager and the Receptionist and they all came to the scene. RA 2 stated she thought they did the incident report and stated she did not do one. RA 2 stated she could not remember if they took resident 170 to dialysis or not, but she was pretty sure they did because after dialysis resident 170 was telling Registered Nurse (RN) 3 he wanted to be checked out at the hospital, the same day as the accident. On 1/10/24 at 10:56 AM, an interview was conducted with the RC. The RC stated on arrival at the scene, they were still with talking to the police, and resident 170 was standing. The RC stated resident 170 stated he did not want to go to hospital and the RC took him to the dialysis appointment. The RC stated resident 170 did not say he was hurting or that he was in pain, he just stated he wanted to go to his dialysis appointment. The RC stated it was her understanding that a report was filled out but she did not do one. The State Survey Agency was not notified of the accident. There were no nursing assessments were located in resident 170's medical record. Resident 170 was transferred to the hospital for evaluation on 11/9/23. Resident 170's progress notes were reviewed and revealed the following: a. A Nurse progress note dated 10/31/2023 at 16:58 (4:58 PM), documented Resident was in a car accident on his way to dialysis, MD [medical doctor] has ordered scheduled Tylenol 1000 mg [milligrams] tid [three times a day] scheduled and Tramadol 50 mg q [every] 6h [hours] as needed for pain for 14 days. b. A Nurse progress note dated 11/1/2023 at 11:43 AM, documented Residents communication form from 10/31/2023 from dialysis was received. Assessment notes read: Pre-weight 268.1 lbs. [pounds] Post weight 261.5 lbs. Amount of fluid removed was 4070 ml. [milliliters] Resident had a pain level of 8/10 post dialysis. He was on his way back to facility where he was given some medication for his pain. c. A Nurse progress note dated 11/2/2023 at 23:25 (11:25 PM), documented Resident requested lidocaine patch for pain and prn [as needed] Tramadol. d. A Nurse progress noted dated 11/9/2023 at 20:07 (8:07 PM) documented, Late Entry for 11/9/2023. Resident returned from the [local] ER [emergency room ] around 2030 [8:30 PM]. X-ray, ECG [electrocardiogram] and Labs were run. Final diagnosis is as follows: Contusion of chest wall unspecified laterally, initial encounter. Only medication orders that were sent back from the hospital were for Tylenol prn and Lidocaine. When resident returned from the hospital visit I asked him how the visit went and he said that he was disappointed because he felt they didn't do anything for him. e. A Nurse progress note dated 11/10/2023 at 13:26 (1:26 PM), documented Provider extended the amount of days this medication could be given. He said to keep it on residents MAR [Medication Administration Record] for another 14 days. This was discussed with the resident. f. A Nurse Progress Note dated 11/9/23 at 12:50 PM, Pt c/o [complained of] chest bone pain r/t [related to] car accident/airbags being deployed on 10/31/23. Pt assessed- no additional pain when palpated or abnormalities in chest noted. Chest x-ray unremarkable. Pt administered PRN pain meds and assessed by nurse practitioner, who did not find reason to send pt out for further assessment. However, pt insisted on going to ER. [Local ambulance service] was called to transport pt [patient] to [local hospital] at 1200. The November 2023 MAR for resident 170 was reviewed and revealed Tramadol was administered for pain at the following times: a. On 11/1/23 given three times b. On 11/2/23 given four times c. On 11/3/23 given one time d. On 11/4/23 given four times e. On 11/5/23 given one time f. On 11/6/23 given three times g. On 11/7/23 given one time h. On 11/8/23 given two times i. On 11/9/23 given three times j. On 11/10/23 given two times k. On 11/11/23 given four times l. On 11/12/23 given one time m. On 11/13/23 given one time The Pain Level Summary documented resident 170 had multiple days with pain measured above a level 5 on the 0-10 pain scale from October 31st through November 9th. No provider assessments were located in resident 170's medical record or provided by the facility from October 31st, the date of the accident, until November 9th, when he was sent to the hospital for evaluation. On 11/9/23 an ER visit note documented that resident 170 was seen for contusion of chest wall, unspecified laterally. With orders to follow up with CT (Computed Tomography) Imaging on November 22nd and have PFT (Pulmonary Function Testing) completed on November 22nd. No results or visit notes for the CT imaging or PFT testing were located in resident 170's medical record. On 1/10/24 at 8:37 AM, an interview was conducted with the Transportation Specialist (TS). The TS stated if there were an accident while he was driving a resident to an appointment the resident should always be checked by emergency medical services. The TS stated there should be an incident report filled out. The TS stated he had driven resident 170 to dialysis and that he did like to sit in the front seat and would wear his seatbelt. On 1/10/24 at 9:43 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated he was the nurse working when resident 170 was in a car accident on his way to dialysis. RN 3 stated they were lucky and no one got hurt. RN 3 stated he did not remember resident 170 returning from dialysis that day but he did remember there was discussion in whether resident 170 was bad enough to be taken into the hospital. RN 3 stated they were checking resident 170's vital signs multiple times a day and they were stable. RN 3 was observed to be unable to find an assessment on resident 170 that was done the day of the accident or days after in the medical record. RN 3 stated they had ordered Tramadol, which he believed was helping. RN 3 stated initially resident 170 was on Tylenol for pain then increased to Tramadol because he was having trouble sleeping from he pain in his sternum. RN 3 stated that resident 170 sometimes liked to embellish on things. RN 3 stated if a resident needed to go to the hospital then the nurse would talk with the Assistant Director of Nursing and collectively they would make the call. RN 3 stated he was unsure why resident 170 was sent to the hospital for evaluation so many days after the accident. On 1/10/24 at 11:16 AM, an interview was conducted with the Business Office Manager (BOM). The BOM stated she was called because there was an accident. The BOM stated when she arrived resident 170 refused to go to the hospital and he was taken to dialysis by the RC. The BOM stated she asked resident 170 if he was ok and he stated his chest hurt but he was ok. The BOM stated the next day resident 170 complained about his chest hurting a lot more and she believed she told the nurse and that he was sent to the hospital the day after the accident. On 1/10/24 at 11:56 AM, an interview was conducted with the Administrator (ADM). The ADM stated they expected transportation to keep everyone safe. The ADM stated he believed resident 170 returned to the facility and did not go to the hospital. The ADM stated there was not any injury from the assessment but resident 170 did say he had some pain. The ADM stated resident 170's pain was addressed. The ADM stated that resident 170 was used to communicating things pretty well and that he was being managed. The ADM stated if pain medications were not working he would have let him know. The ADM stated resident 170 was assessed by a provider and would send over the information. [Note: No additional provider information was provided.] On 1/10/24 at 2:08 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if an accident occurred she would hope they would do an incident report and a general assessment on the resident and notify the family and the doctor. The DON stated there was alert charting or change of condition charting that should have been done to monitor the resident and see how things were going. The DON stated she had an inservice typed up regarding assessments and pain management because they need to work on it. On 1/11/23 at 11:26 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she there the next day or the night shift after the car accident. LPN 1 stated she remembered resident 170 had pain in the sternum or ribs, I think that they had done X-rays, and resident 170 did tell staff that he was in pain and that his sternum hurt. LPN 1 stated staff were using the pain medication to manage his pain. LPN 1 stated that resident 170 did not ask her specifically to go to the hospital but she did remember that they told me that they had done X-rays and that they were normal. LPN 1 stated there was not any problems and that was why there were doing pain managment and nothing else. On 1/11/24 at 3:17 PM, an interview was conducted with the Regional Nurse Consultant (RNC) and the RC. The RNC stated resident 170 called and canceled the appointments to have the CT and PFT completed. The RC stated she called the office but they would not send over any information stating why the appointment was canceled or when it was canceled. The RNC or the RC did not know if the outside transport had come that day or if it had taken the resident anywhere. The RNC stated they needed to figure out why he did not go and why the orders were not updated, and that it was a breakdown in the system, the staff should have known why he did not go. The RNC stated they would find out what happened and why the communication did not happen. 45490 2. Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included fracture of the right femur, chronic obstructive pulmonary disease, muscle weakness, lack of coordination, and epilepsy. On 11/3/23 an exhibit form 358 that was submitted to the State Survey Agency. The form revealed on 10/28/23 at 11:30 PM resident 19 went out to smoke while being supervised by [RN]. Nurse reported that the resident was standing with 4 WW [4 wheeled walker] but was unsteady. This nurse asked the resident if he would take a seat, so he did not fall. The resident stated that he would not sit down. As the nurse moved closer to assist the resident, the resident fell backwards. Nurse assessed the resident. No visible injuries. Resident advised that his body hurt. Nurse administered PRN medications Resident monitored post-fall. Resident sent to [a local hospital] on 10/31/23. Right hip fx [fracture]. Resident 19's medical record was reviewed 1/8/24 through 1/11/24. Resident 19's progress notes revealed: a. An incident note dated 10/28/23 at 12:05 PM, documented Resident was taken outside by nurse to have a cigarette. After repeatedly telling the resident he needed to sit down on the bench he refused. He lost his balance and feel backwards onto the ground .Resident had complaints of body pain. PRN pain medication was given. MD and DON notified . [Note: There was no information located in resident 19's medical record that hospice had been notified.] b. A fall note dated 10/28/23 at 5:18 PM, documented Resident fell today on 10/28. Resident has complains of right thigh pain and says it hurts when he try's to bend his knee. PRN pain medication given and MD notified. c. An alert note dated 10/28/23 at 10:21 PM, documented resident 19 has been grasping L [left] leg in pain . [Resident 19] continues to lay in bed in a stiff position and declined to move/repositioning. Called [Resident 19's] hospice nurse . who will inform his provider for further orders and send a nurse on Sunday 10/29 for evaluation. d. A nurses progress note dated 10/29/23 at 3:25 AM, documented Resident has been yelling out for help. resident stated that he was in pain . gave PRN morphine and resident is now sleeping. notified the on call MD. e. A nurses progress note dated 10/29/23 at 4:22 PM, documented Resident in bed in a stiff position. Yelling I want to go smoke but he won't get off the bed . Hospice nurse in to visit. Ordered hip X-ray. Resident agrees with change in plan of care . C/O not being able to breath. Morphine and Tylenol given . No new adverse reactions noted . f. A nurses progress note dated 10/30/23 at 3:48 PM, documented resident 19 Has spent the day in bed. Is refusing all food and drinks. Still awaiting x ray to be taken . g. A nurses progress note dated 10/31/23 at 7:09 PM, documented hospice nurse in to visit. Tells this nurse resident has a broken right hip and she came in to find out what he wants to do-comfort cares or surgery. Resident decided he wants surgery. Sent to the ER to be evaluated by the hospice nurse. Resident agrees with change in plan of care. Is his own responsible party. [Note: The fall was on 10/28/23 the resident received X-ray results 3 days later on 10/31/23 after complaints of pain.] An x-ray was not located in the resident 19's medical record. On 1/11/24 the RNC provided a copy of an x-ray to resident 19's right femur. The x-ray report revealed the x-ray was completed on 10/30/23 at 4:37 PM. The x-ray report was printed on 1/11/24. A physicians order documented, Morphine sulfate solution 100/5 ml, give 1 mL by mouth every hour as needed for Dx (diagnosis): SOB (shortness of breath). Resident 19's MAR revealed: a. on 10/28/23 at 11: 35 AM resident 19 received Morphine Sulphate, 1 ml. b. On 10/29/2023 at 1:23 AM, resident 19 received Morphine Sulphate, 1 ml. c. On 10/29/2023 at 3:34 AM, resident 19 received Morphine Sulphate, 1 ml. d. On 10/29/2023 at 1:30 PM, resident 19 received Morphine Sulphate, 1 ml. e. On 10/29/2023 at 2:16 PM, resident 19 received Tylenol 650 mg, as needed for break through pain. f. On 10/30/2023 at 10:04 AM, resident 19 received Morphine Sulphate, 1 ml. g. On 10/30/2023 at 4:45 PM, resident 19 received Morphine Sulphate, 1 ml. h. On 10/31/2023 at 9:08 AM, resident 19 received Morphine Sulphate, 1 ml. i. On 10/31/2023 at 11:05 AM, resident 19 received Morphine Sulphate, 1 ml. j. On 10/31/2023 at 11:39 AM, resident 19 received Ativan Oral Tablet 1 MG every 4 hours as needed for anxiet or restless r/t end of life. [Note: Between 10/1/23 to 10/27/23 resident 19 did not request his Morphine Sulphate 1 ml.] On 1/10/24 Hospital discharge note for resident 19 documented, resident 19's primary diagnosis was: Broken Hip. Internal medicine progress note documented, resident 19 was able to have right hip surgery. On 1/10/24 at 11:38 AM, an interview was conducted with RN 5. RN 5 stated the protocol for a hospice resident that fell would be to check vitals, conduct a neurological assessment, notify the DON, Physician, and the hospice agency. RN 5 stated that staff needed to contact a residents hospice agency if the resident experienced a fall so they can assess what the patient would like done. RN 5 stated if the hospice resident had a suspected injury staff let the hospice nurse decide what route to take, such as comfort care or a x-ray. On 1/10/24 at 12:34 PM, an interview was conducted with RN 2. RN 2 stated that if a resident on hospice were to fall she would notify the hospice company, the facility physician, family, and start neurological assessments and complete an incident report. RN 2 stated if the resident was in pain or had a suspected injury she would notify hospice and ask for an x-ray and medicate the resident. RN 2 stated that she would request an x-ray from the facility physician. On 1/11/24 at 9:27 AM, an interview was conducted with the DON. The DON stated that if a hospice resident had a fall and was suspected of an injury she would expect the nurse to make sure the patient was safe and comfortable, notify the doctor, family and hospice any time there was a fall. 30563 3. Resident 173 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, chronic systolic heart failure, thoracic aortic ectasia, atrioventricular block, rheumatic tricuspid insufficiency, sick sinus syndrome. Resident 173's medical record was reviewed 1/9/24 through 1/11/24. Physician's orders revealed the following: a. Quetiapine Fumarate (Seroquel) Oral Tablet. Give 12.5 mg by mouth at bedtime for agitation restlessness from 10/13/23 through 10/25/23. b. Seroquel (Quetiapine Fumarate) Oral tablet 25 mg. Give 1 tablet by mouth in the evening for agitation from 10/31/23 through 11/5/23. c. Quetiapine Fumarate Oral 25 mg. Give 0.5 tablet by mouth one time a day for anxiety, agitation from 11/1/23 through 11/5/23. d. Seroquel oral tablet 25 mg. Give 1 tablet by mouth in the evening for agitation for 7 days from 11/6/23 through 11/8/23. e. Seroquel oral tablet 25 MG. Give 1 tablet by mouth in the evening for agitation from 10/31/23 through 11/5/23. According to the October 2023 MAR resident 173 was administered the following medications: a. Quetiapine 12.5 mg by mouth at bedtime for agitation restlessness was administered 11/13/23 through 11/25/23. On 11/24/23, the medication was refused. b. Seroquel oral tablet 25 mg was administered once on 10/31/23. According to the November 2023 MAR residents 173 was administered the following medications: a. Quetiapine Fumarate Oral tablet 25 mg. Give 0.5 tablet daily was administered on 11/1/23, 11/4/23 and 11/5/23. The medication was refused on 11/2/23 and 11/3/23. b. Seroquel oral 25 mg was refused on 11/6/23 and 11/7/23. c. Seroquel oral tablet 25 mg was administered 11/4/23 and 11/5/23. Resident 173 was sleeping on 11/1/23, there was a progress notes on 11/2/23 and the medication was refused on 11/3/23. Resident 173's progress notes revealed the following: a. On 10/13/23 at 3:40 PM, Hospice gave an order to start resident on Quetiapine at bedtime. Due to Agitation and Restlessness. Residents POA [power of attorney] is aware of this medication being started and agrees with the plan. b. On 10/24/23 at 9:07 PM, Res [resident] refusing medications. Res is showing signs of aggression and cups his meds in hand. Per wife she witnessed medications on the floor and is concerned he is not taking them as ordered. Hospice notified. c. On 10/28/23 at 4:30 AM, Resident was very restless throughout the night. Hospice called in regards to the discontinued order of Quetiapine Fumarate 12.5 mg and asked the hospice nurse [name removed] if we could put the order back in place to help the resident with the restlessness. Hospice nurse states that the discontinued order of Quetiapine should not have occurred. Hospice nurse ordered to administer Quetiapine Fumarate 12.5 mg and stated that if resident is still unable to sleep, to administer another dose of 12.5 mg. A dose of 12.5 mg was given at 0430 [4:30 AM]. Hospice nurse states that resident should be taken the dose of 12.5 mg of Quetiapine Fumarate every night before bed. d. On 10/26/23 at 6:04 PM, a physician's visit revealed .Psychotropic team met to review. Some agitation noted. Patient seen in hall walking with hospice aide. no concerns. ok with plan of care discussed.Provider action: suggest to hospice: schedule Ativan bid and keep PRN daily, adjust PRN. [It should be noted there was no information about discontinuing Seroquel] e. On 11/1/23 at 11:52 AM, The medication Quetiapine had been discontinued by hospice nurse until she was able to discuss medication with hospice MD. Hospice MD gave order to restart the Quetiapine due to residents behaviors of agitation, anxiety and restlessness. This order was given to facility nursing staff on 10/31/23. Medication was restarted. f. On 11/2/23 at 11:07 AM, Hospice RN came by for pt [patient] today and stated that pt Haldol was supposed to be added to their orders for PO [orally] BID [twice daily] and PO Q 6 hr [hours] PRN [as needed] r/t anxiety/increased aggression. Order is in comp [computer]. g. On 11/4/23 at 12:58 AM, Resident had a fall at 0020. No resident statement was made pertaining the incident due to the altered mental status of this resident related to the diagnosis of Alzheimer's. A call was made to the POA but the call would not go through. 2 call attempts made. DON notified and incident noted in the physicians binder. h. On 11/5/23 at 4:00 AM, Resident refused PRN medication (Lorazepam) and became restless. When redirected from wandering into other resident's rooms, he sat on the floor in the hallway and did not want to get up. He became aggressive with staff. EMS [emergency medical services] were able to redirect resident to bed. Hospice notified. Provider notified. POA notified. i. On 11/5/23 at 5:50 PM, LORazepam Intensol Oral Concentrate 2 MG/ML Give 0.5 ml by mouth every 4 hours as needed for anxiety, agitation. At 1330 [1:30 PM] Hospice nurse requested PRN Lorazepam 0.5 ml to prevent the agitation. Lorazepam was mixed with yogurt and resident refused. Tried to administer at 1700 [5:00 PM] again, resident spat out the yogurt. After 1700 resident started to get agitated, moving his nightstand. Tried to administer Lorazepam in water, he didn't drink. Eventually, Lorazepam 0.5 ml was administered in root bear [sic]. Nurse observed him drinking it up. j. On 11/5/23 at 7:18 PM, Resident appeared calm in am. He was compliant with med administration in am. He had his scheduled Quetiapine 12.5 mg and scheduled Lorazepam 0.5 ml in yogurt with no difficulty. At 1330 [1:30 PM] hospice nurse tried to administer PRN Lorazepam 0.5 ml again, which he didn't take. At 1700 [5:00 PM] started getting agitated, moving his nightstand and other furniture in the room. Tried to administer Lorazepam 0.5 ml in yogurt which je [sic] didn't take. Tried to administer in water, he also refused. Finally administered Lorazepam 0.5 ml inroot bear [sic] at 1745 [5:45 PM]. At 1840 [6:40 PM] resident was fond [sic] on the floor between armchairs and bed. Wife said he might of tripped over her feet. Assessment revealed hematoma to left forehead. Ice applied. No other injuries observed at time of assessment. DON notified.Nuro checks started. k. On 11/6/23 at 12:15 AM, Resident has had a fall witnessed by wife; wife states resident tried to get up of bed and fell because he is too weak. Resident being aggressive towards staff and was not letting us get him up to the bed. Resident refusing Vital signs by physically moving or trying to hit us. Daughter in law, and son [name removed] were notified. Resident needing 1:1 care since he is a danger to self, wife and staff. Residents' son came to stay with [resident] for the night and wife [name omitted] was moved to room [ROOM NUMBER] for her safety, resident refusing vitals, only alert to self, moves all extremities with equal strength, unable to assess pupils because of aggressiveness. l. On 11/7/23 at 4:48 AM, Alert Charting following a unwitnessed fall every shift. Res refused vitals became combative with aid. DON and Hospice notified. Res was checked q15 slept throughout the night with PRN Lorazepam 0.5 mg chirrs (sic). m. On 11/7/23 at 11:56 AM, Physician Progress Notes.Reason for visit: Federally required regulatory review Subjective: in bed. He is sleepy today. Hospice staff reporting agitation. Opens eyes briefly. Discussed with hospice goal to avoid sedation and maintain control of agitation.Provider action: Suggested to hospice: trazodone to 50 TID [three times a day] and increase lorazepam. Hold if sleepy. Schedule at night: goal to reduce sun-downing. n. On 11/8/23 at 6:01 AM, Res had a total of four witnessed falls during 1:1, Along with aggressive behavior with agitation. Res was on 1:1. Aide was pushing wheelchair down the hall when they arrived to the conference room resident grabbed the door handles and pushed the door losing his balance falling towards the right. Aide came up to his right side and assisted him down. second fall was at the nurses station on the tile floor aide went to get him a snack and he stood up and fell on to his right side thigh, hip and shoulder thenturning onto his back. Third fall resident was sitting at the foot of the bed and slid onto his buttocks with aide present. fourth fall resident was sitting at the foot of the bed and fell on to a bookcase causing an abrasion to back and skin tear to right arm. Res was aggressive towards staff. Aide helping Res stand up when res became upset and pushed aide onto bed causing him to lose balance falling on top of her. Res refused all medication spitting everything out. Hospice and family notified. o. On 11/8/23 at 11:43 AM, Resident was sent to [local] ER after culmination of 4 falls last night, an additional fall this morning coupled with increased agitation and physical aggression. He had been refusing all medications. Sn [sic] had contacted hospice company and was told nurse was in a meeting. Sn contacted family, updating them on the decision to take him in per request of facility administrator. Wife was quite stressed over the ordeal though was glad that he was being taken into the ER. A psychotropic Medication Monthly Review dated 10/26/23 and locked on 10/31/23 revealed resident 173 was receiving Lorazepam as needed and Quetiapine 12.5 mg. The New Interdisciplinary team recommendations were to scheduled Lorazepam BID 0.5 ml; LORazepam 0.5 ml daily and to discontinue Quetiapine. A hospice nurse visit note report dated 10/31/23, Patient is needing an increase in Seroquel BID as he again is having agitation, anxiety, restlessness, behaviors. Seroquel 25 mg tablet po HS [hours of sleep] AM [morning] agitation. Symptoms management for agitation anxiety restlessness. The for further revealed resident was to be administered Quetiapine 12.5 mg every evening since 10/12/23. A hospice nurse visit note report dated 11/9/23, . objective findings. : [name of hospice medical director] started him on Seroquel 25 MG 0.5 tablet HS on 10/10/23. For anxiety agitation restlessness with director of nursing and administrator [name removed] permission. He was doing well on this medication. The facility discontinued the medication without notifying hospice and he went 5 days without any medication and has since been extremely combative refusing meds very anxious agitated. On 1/11/24 at 11:51 AM, an interview was conducted with RN 4. RN 4 stated when a resident receiving hospice services needed a medication change, the hospice nurse notified nurses of medication changes and then an order was faxed to the facility. RN 4 stated if a resident was unable to take medications, then nursing staff contacted hospice and discussed changes. RN 4 stated the previous DON was handling medication changes with resident 173. RN 4 stated there was a psychotropic meeting, and the decision was made to discontinue the Seroquel. RN 4 stated she did not remember if resident 173 had behavior changes. RN 4 stated resident 173 did have a decline and sustained multiple falls before discharging. RN 4 stated nursing staff were to discuss any medication changes with the hospice nurse. RN 4 stated the hospice nurse notified residents family of medication changes. On 1/11/24 at 8:47 AM, a phone interview was conducted with the hospice RN. The RN stated resident 173 was on Seroquel and the medication was discontinued in October for 5 days. The RN stated she was in the facility and the ADON informed her that the Seroquel had been discontinued by the facility medical director. The RN stated resident 173 was acting out and hospice had not been contacted. The RN stated she was informed by facility staff that Seroquel was not allowed in the facility. The RN stated the hospice medical director contacted the facility medical director multiple times about the Seroquel being discontinued. The RN stated other medications were tried and did not work. The RN stated resident 173 had multiple falls prior to discharging to the hospital. The RN stated that resident 173 needed to be tapered off of the Seroquel and not discontinued. The RN stated resident 173 appeared to be having a psychotic break because he was biting, hitting and became abusive. On 1/11/24 at 1:17 PM, an interview was conducted with the DON and Administrator. The DON stated the facility was having monthly psychotropic meetings. The DON stated all newly admitted residents psychotropic medications were reviewed. The DON stated discontinuing psychotropic medications were decided in the meeting. The DON stated the family and hospice were notified before medications were changed. The DON stated if a medication reduction was recommended for a resident receiving hospice services, then hospice was notified and asked if they were okay with the reduction. The DON stated if not but still feels strongly then will do a talk doctor to doctor. The Administrator stated the facility was following guidelines w [TRUNCATED]

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including Coronavirus Disease 2019 (COVID-19). Specifically, the facility did not have an infection control tracking and trending program, a resident with pneumonia was walking in the hallway without a mask, a nurse touched the medications during administration, hand hygiene was not used during meal times, silverware that was used to close a meal tray cart door was then given to a resident for use, food items were transported through the hallways uncovered, and staff did not wear Personal Protective Equipment (PPE) appropriately when entering an isolation room. Resident identifiers: 6, 20, 35, 40, 52 and 64. Findings include: Infection Control tracking and trending On 1/11/23 at 12:30 PM, the facility was asked to provide the infection control tracking program for the facility. On 1/11/23 at around 2:00 PM, the Regional Nurse Consultant (RNC) reported the entire year of the infection control tracking program had been erased from their system and that there were no hard copies. The RNC stated she could not prove it but it was suspected a terminated employee had erased the files. The RNC stated they were working on getting a back up of the information to provide to the survey team. The RNC stated she had done the previous three months so she could go back in and recreate it, but she was unable to provide any other infection tracking for the facility. On 1/16/24 at 11:57 AM, the Administrator (ADM) provided Infection Preventionist logs for October, November and December 2023. The logs documented when a culture had been completed, the results of the culture and what treatment was provided. It was determined, since the infection control tracking and trending program information was provided after the completion of the survey, the survey team was unable to verify if the program was being utilized correctly. The team did not have access to the necessary records to determine if the prescribed treatment provided to the residents was correct and effective based on the culture results. Pneumonia Resident 40 was admitted on [DATE] with diagnoses which included hemiplegia following cerebral infarction, heart failure, dysphagia, and asthma. On 1/8/24 at 12:53 PM, an interview was conducted with Resident 40. Resident 40 stated she was not feeling well and a chest x-ray was ordered. On 1/8/24 at 1:32 PM, a Nurses Progress Note revealed the following, resident was c/o [complaining of] sore throat and mild chest pain. physician and ADON [Assistant Director of Nursing] were notified. he ordered the stat respiratory panel(rsv. [respiratory syncytial virus]covid,flu,strep) and chest Xray. labs were done and waiting for results. Xray appointment is scheduled . On 1/9/24 at 12:55 PM, an observation was made that resident 40 arrived back to the facility from an outside appointment without a face mask, asked about her lunch, and headed down the hall to the 200 floor dining Room. On 1/10/24 at 1:23 PM, a Nurses Progress Note revealed the following, isolation precautions added to profile per MD [Medical Doctor] for bacterial pneumonia, sign placed on door, isolation cart placed outside room. On 1/10/24 at 1:50 PM, an observation was made of ADON saying out loud, That she needed to set up an isolation room. On 1/10/24 at 1:55 PM, an observation was made of resident 40 at nursing station. The ADON told resident 40 that she would be getting resident some masks for her to wear while she was out of her room. The ADON told resident 40 that they just got the lab results back and resident 40 was on droplet precautions and needed to go to her room and stay in there unless she had a mask on. Resident 40 was then observed inside her room and the ADON said she would let the Certified Nursing Assistants (CNAs) know about the precautions. On 1/10/24 at 2:10 PM, an observation was made of resident 40 in her electric wheelchair in the 200 hallway by the nurses station. Resident 40 did not have a mask on. 45490 PPE On 1/8/24 at 1:19 PM, an observation of CNA 3 was made. CNA 3 went into a contact precaution room. CNA 3 was observed to enter the room applied gloves but did not apply a gown. CNA 3 was observed to be wearing gloves and to take resident 35's water mug out of the isolation room and down the hall to fill it with water. On 1/8/24 at 1:21 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 35 was on droplet precautions. RN 2 stated that if anyone entered resident 35's room they must wear a gown and gloves. RN 2 stated that if the resident needed fresh water in his mug, that staff should get a disposable cup and fill it with ice and water and then take it in to the resident room. RN 2 stated that bringing resident 35's water mug out of his room could be a risk of spreading the infection. On 1/9/24 at 12:30 PM, an observation was made of RN 2. RN 2 was observed to walk into a contact isolation room, resident 35's. RN 2 was observed to be in resident 35's room without a gown on. On 1/11/24 at 9:13 AM, an interview was conducted with the ADON. The ADON stated that if a resident was on contact precautions, the expectation of staff was that they would adhere to the correct precautions. The ADON stated that staff should be wearing a gown and gloves in resident 35's room. On 1/11/24 at 9:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should use PPE according to the precaution signs on a residents door. The DON stated that resident 35 was on precautions and that staff were expected to wear a gown and gloves in the room. Meals On 1/9/24 at 12:12 PM, an observation was made of resident 6. Resident 6 stated she was unable to swallow. The ADON asked resident 6 if she had trouble swallowing before. The ADON stated she was going to change the diet to chop it up in the kitchen. Resident 6 stated she did not want that. The ADON was observed talking loudly in the dining room. At 12:18 PM, the ADON asked resident 6 if she wanted to go back to her room. Resident 6 stated it was too loud in the dining room. The Administrator (ADM) was observed to pick up resident 6's tray and put the lid back on her plate. The ADM was wheeling resident out of the dining room and through the hall with her drinks and desserts uncovered. On 1/9/24 at 1:06 PM, an observation of a resident taking two containers off of a used meal tray that was in the dirty tray bin. CNA 5 observed the resident remove to two containers and stated, Oh you wanted a salad? CNA 5 then laughed and continued walking. On 1/9/24 at 1:07 PM, an interview was conducted with CNA 5. CNA 5 stated that she saw the resident remove the two containers and that the resident knows that those were dirty trays and that he had that choice. On 1/9/24 at 12:30 PM, an observation was made of CNA 1. CNA 1 was observed to take a tray to resident 52 and set it on the bedside table. CNA 1 was observed to arrange the objects on the table. No hand hygiene was used on exiting the room. On 1/9/24 at 12:35 PM, an observation was made of CNA 1. CNA 1 obtained a tray from the meal cart and took it to room [ROOM NUMBER], no hand hygiene was used. On 1/9/24 at 12:40 PM, an observation was made of CNA 1. CNA 1 was observed to remove a packet of silverware from the meal cart. The silverware was observed to be used to close the meal cart door, with the head of the knife and spoon touching the door and was then taken to resident 20 for use. On 1/9/24 at 12:45 PM, an observation was made of CNA 1. CNA 1 was observed to place a dirty meal tray in the meal cart that had two uneaten meal trays in it. The dirty meal tray was placed in the bottom of the cart. One of the uneaten meal trays was then taken to resident 64. 47431 MEDICATIONS On 1/8/24 at 10:00 AM, an observation was made of RN 1 on the 200 hall. RN 1 was observed to push medications from a blister pack into a bare hand. On 1/9/24 at 12:48 PM, an observation was made of RN 1. RN 1 was observed to push medications from a blister pack, placed directly in an ungloved hand, and placed the medications into a dosing cup. On 1/09/24 at 1:02 PM, an interview was conducted with RN 1. RN 1 stated prior to administering any medications she would perform hand hygiene, either by washing her hands with soap and water or using a sanitizer. RN 1 stated when preparing medications, she used universal precautions and explained as performing hand hygiene and putting on procedure gloves, making sure to change gloves between residents or a change in tasks on the same resident. On 1/10/24 at 8:31 AM, an interview was conducted with RN 2. RN 2 stated that you should never touch the medication with your bare hands. RN 2 stated if she ever saw another nurse do that, she would instruct the nurse of universal precautions. RN 2 stated if the nurse continued to touch the resident's medication with bare hands, she would report that to her supervisor. On 1/10/24 at 1:20 PM, an observation was made of RN 3 during lunch medication pass. RN 3 was observed to take medications out of the medication card and place them in the dosing cup using a bare hand, no hand hygiene was observed. On 1/10/24 at 1:39 PM, an observation was made of RN 3 during lunch medication pass. RN 3 was observed to obtain a bottle of medication from the medication cart. RN 3 was observed to place his fingers in the medication bottle, obtain the medication and place it in a medication cup. The medication was then administered to resident in room [ROOM NUMBER]. No hand hygiene was observed. On 1/11/24 at 12:39 PM, an interview was conducted with the DON was conducted. The DON stated nursing staff should not be touching the medications with bare hands. The DON stated medications should go from blister pack or a multi-dose bottle's lid directly into the dosing cup. The DON stated medications should not touch a nurse's bare hands. The DON stated if a medication did touch the nurse's bare hand the medication would need to be discarded. 47432 30563

Based on interview and record review it was determined, for 1 out of 3 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse. Specifically, a resident was physically abused when a Certified Nurse Assistant (CNA) hit and grabbed a resident forcefully. This incident resulted in the resident sustaining a bruise and a skin tear. Resident Identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis, aphasia, dysphagia, chronic kidney disease, hyperlipidemia, benign prostatic hyperplasia, dorsalgia, spinal stenosis, and gastrostomy status. On 3/13/23 resident 1's medical records were reviewed. Review of resident 1's progress notes revealed the following: a. On 2/7/23 at 9:45 PM, the note documented that resident 1 returned from the local hospital. Resident 1 was resting in bed with eyes closed. b. On 2/8/2023 at 12:43 PM, the note documented by the Director of Nursing (DON) documented, Summary from night shift 2/7/2023 1900 [7:00 PM]: Aide spoke to DON and informed her of what was witnessed, aide also notified nurse and described what he had seen, a 2nd aide who was also in the room informed of what she heard while giving cares to the roommate. When writer walked in, she saw a tearful resident. An assessment by a second nurse was done to resident and skin tear to right forearm was observed, some discoloration to neck and a hematoma to left forearm. MD [Medical Doctor] notified, and appropriate personal. CNA was removed from the floor immediately following report. Residents' daughter and house physician were notified. Res [resident] transferred to [local hospital name] for further evaluation. c. On 2/9/23 at 9:34 AM, the Resident Advocate (RA) documented, Daily update: Resident was awake in bed. Stated he had a good night, SS [social service] gave him water, and talked about his Farsi language. Resident appeared to be in a good mood. d. On 2/10/23 at 4:16 PM, the RA documented, Daily update: Resident was awake in bed. Stated he good thus far. Resident wanted to sleep and get some rest. e. On 2/13/23 at 10:20 AM, the RA documented, Daily Note: RA assisted resident with some water. Resident said weekend was good. Expressed no concerns at this time. f. On 2/14/23 at 8:51 AM, the RA documented, RA asked resident how he is even was [sic] Resident appeared to be calm said all is ok. g. On 2/17/23 at 5:16 PM, the RA documented, Daily Note: Resident appeared to be in good spirits. Wife was visiting, expressed no concerns at this time. On 2/7/23 at 6:46 PM, resident 1's incident report documented Physical Abuse. The resident description documented that the resident was tearful and crying, demonstrating hitting motions. The report documented the injuries as a hematoma on the left elbow and a skin tear on the right antecubital. The report documented injury location of neck front also, with no description of that injury. The level of pain was documented as a 4 on the PAINAD score. The PAINAD scale scored the resident as follows: 2 points for Repeated Troubled Calling Out. Loud Moaning or Groaning. Crying. for negative vocalization; 1 point for Sad, Frightened, Frown facial expressions; and 1 point for Distracted or Reassured by Voice or Touch for consolability. The report documented that resident 1 was alert and oriented to self. On 3/7/22 at 7:47 PM, the hospital History & Physical (H & P) documented that resident 1 was seen after being assaulted by another resident at his care facility. Apparently, someone injured his right arm. He has a couple of small skin tears. The physical exam documented, Small skin tear on right upper elbow. No obvious deformity. Able to move arm through range of motion. A little bruising along the upper arm. The emergency room (ER) documented that an x-ray of the right humerus was obtained and the results did not indicate any fracture or dislocation. On 12/23/22, resident 1's Quarterly Minimum Data Set (MDS) documented no to should a Brief Interview for Mental Status (BIMS) assessment be conducted due to the resident was rarely/never understood. The assessment documented that the resident did not have any hallucinations or delusions. A depression screening assessment (PHQ-9) was not completed due to resident was rarely/never understood. Resident 1 was assessed as requiring 2-person extensive assistance for bed mobility, transfers, locomotion on the unit, dressing, and toilet use. Resident 1 was assessed as requiring one person extensive assist for locomotion off the unit, eating, and personal hygiene. On 2/7/23 at 8:14 PM, the facility submitted an initial entity report to the State Agency (SA). The report documented an incident of physical abuse to resident 1 by CNA 1 on 2/7/23 at 6:15 PM. The report documented CNA 2 and CNA 3 were witnesses to the incident and that CNA 1 allegedly hit resident 1 on the left arm. The report documented, Resident has redness on skin around on his chest. There is not clear evidence what caused the redness. Resident sent to [local hospital] for evaluation. The report documented changes in resident 1's behavior as being tearful. The report documented that CNA 1 was sent home and then terminated. On 2/14/23 at 11:10 PM, the facility submitted to the SA the final 5 day investigation report. On 2/7/23 at 6:46 PM, the report documented that the Administrator (ADM) interviewed CNA 3. CNA 3 stated that she had witnessed CNA 1 hit resident 1 on the arm. The report documented that CNA 1 then advised resident 1 that it was ok to cry. CNA 3 stated that she knew what CNA 1 was doing was wrong and she immediately left to go grab the DON. On 2/7/23 at 6:50 PM, the ADM interviewed CNA 2. CNA 2 stated that she was treating resident 1's roommate but did not see CNA 1 hit resident 1. CNA 2 stated that she did hear CNA 1 tell the resident that it was ok to cry. The report documented the corrective action taken as termination of CNA 1 with the instructions to not return to the facility grounds. Review of the facility Abuse Policy documented, Residents must not be subjected to abuse by anyone, including but not limited to facility staff, The policy further defined physical abuse as including hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. The policy identified interventions of preventing abuse that included encouraging staff to talk with supervisors, department heads, Social Services, or the Administrator about residents or situations they found difficult to manage, stressful or frustrating. The policy documented that employees who were suspected of abuse were to be placed on immediate suspension while the matter was under investigation, and in the event that the investigation concluded abuse did occur, appropriate disciplinary action would be taken. This policy was last revised on 10/28/2020. On 3/13/23 at 10:40 AM, an observation was made of resident 1. The resident was sleeping in bed and appeared comfortable. The resident was observed wearing a baseball cap and sunglasses in bed. The resident was covered up to the torso with a sheet. The bed was in the low position and a fall mat was located on the left side of the bed. On 3/13/23 at 11:23 AM, an interview was conducted with resident 1's spouse at the bedside. The spouse stated that resident 1 had a stroke three years ago. The spouse stated that resident 1 could speak Farsi. The spouse was observed to converse with resident 1 and resident 1 was able to respond to questions in Farsi. The spouse stated that she loved the staff and the DON was the best manager. The spouse stated, Everybody loved her husband. The spouse stated that resident 1 had paralysis in the left arm, and too much pain with any movement. The spouse stated that she came to the facility Monday through Friday, and the DON notified her on the weekend on how resident 1 was doing. The spouse stated that resident 1 was not able to use the telephone so she would call to check up on resident 1. The spouse stated that resident 1 loved everyone, and no one had been unkind to him. Everybody is very nice. The spouse stated that the facility staff treated resident 1 like family. The spouse stated that resident 1 went to the hospital, after he was positioned with toileting, and it caused him pain. The spouse stated that staff needed to be gentler with positioning, and any movement and positioning caused resident 1 back pain. The spouse asked resident 1 if the staff treated him well. Resident 1 responded yes; they loved him. On 3/13/23 at 11:41 AM, an interview was conducted with the Social Service Worker (SSW). The SSW stated that the incident between CNA 1 and resident 1 happened over the weekend. The SSW stated that resident 1's spouse told her that a CNA had hit him and had cause a scratch on his arm. The SSW stated that the spouse told her that the ADM was taking care of it. The SSW stated that she was not sure about the injuries, and she was not directly involved in the investigation. The SSW stated that she started doing daily rounds after the incident to see how the resident was doing. The SSW stated that resident 1 did not have good English; he does a lot of pointing. The SSW stated that resident 1 knew Farsi and Arabic, and that she could converse with him in Arabic. The SSW stated that resident 1 could nod his head yes/no, and was able to make his basic needs known with hand gestures and yes/no questions. On 3/13/23 at 12:30 PM, an interview was conducted with the DON. The DON stated that she came into the facility on the afternoon of the incident with resident 1 and CNA 1. The DON stated that it occurred shortly after or during shift change. The DON stated that one of the afternoon CNAs came and reported that resident 1 was crying. The DON stated that CNA 3 stated that she was helping resident 1's roommate and heard resident 1 crying. The DON stated that CNA 3 had reported that CNA 1 was helping resident 1 change his incontinence brief and he was crying. The DON stated that CNA 3 stopped feeding her resident and came around the privacy curtain to see what was going on. The DON stated that CNA 3 witnessed CNA 1 hitting resident 1's arm, and demonstrated with a closed fist striking motion. The DON stated that she went straight to resident 1's room and CNA 1 had already exited. The DON stated that she asked CNA 1 to come to the office, and then told her what was happening. The DON stated that she told CNA 1 that CNA 3 had witnessed her doing a striking motion to resident 1. The DON stated that CNA 1 denied it and said she would never do that. The DON stated CNA 2 was also present, but only heard resident 1 crying and did not see anything. The DON stated she asked CNA 1 what happened in resident 1's room, why was he crying, and she replied oh he always cries. The DON stated that CNA 1 denied hitting resident 1. The DON stated that she was not aware of resident 1 crying a lot. The DON stated that he would call out for his wife if she had not come in. The DON stated that when she went into resident 1's room to get CNA 1, resident 1 was still crying. The DON stated that she asked resident 1 if he was okay and he replied, the girl and did a striking motion and he was very upset. The DON stated that she assessed resident 1 and he had a new bruise starting to form on his right forearm with a small skin tear. The DON stated that the wound was bleeding a small amount. The DON stated that she did not perform any other skin assessment. The DON stated she did not ask if he was struck anyplace else and he did not say. The DON stated that resident 1's arms were red, but the right was more than the left. The DON stated that Licensed Practical Nurse (LPN) 1 transferred resident 1 to the local hospital for an evaluation. The DON stated that the nurse should have performed a head-to-toe skin assessment after an allegation of physical abuse, and it would be documented in a progress note. The DON stated that the process with allegations of abuse was they were to remove the alleged perpetrator and then notify the ADM. The DON stated that she notified the ADM right away. The DON stated that the ADM called the police, and LPN 1 notified the MD and the family. The DON stated that resident 1 returned from the ER that day, and no other findings were determined. The DON stated that she spoke to the spouse afterwards, and the spouse said with broken English that it was very sad, but resident 1 was okay. The DON stated that after she informed the ADM, she was not involved in any of the investigation. The DON stated that abuse training was done upon hire and then again during the in-services periodically. The DON stated that during the abuse training they go over the process, different types of abuse, notification, and any information that was needed. The DON stated that the process was if you witness or are made aware of an incident of abuse, you were to stop it, make sure the resident was safe, notify the nurse, and notify the DON and ADM. The DON stated that the licensed nurse should do the incident report, skin assessment, notification to the MD and DON, and notification to the ADM. On 3/13/23 at 1:49 PM, a interview was conducted with CNA 2 with English/Spanish translator assistance provided by the Admissions Director (AD). CNA 2 stated that she was in resident 1's room assisting the roommate at the time CNA 1 was providing incontinence care to resident 1. CNA 2 stated that she heard resident 1 scream and cry. CNA 2 stated that this screaming and crying was not normal for him. CNA 2 stated that resident 1 normally cried a bit with repositioning, normally a little bit of complaining but this time it was screaming. CNA 2 stated that when she heard the crying she was with CNA 3. CNA 2 stated that CNA 3 went to check on resident 1 and witnessed CNA 1 hitting the resident. CNA 2 stated she stayed with the roommate and CNA 3 went to inform the nurse and DON. CNA 2 stated that resident 1 was crying a lot, and he had blood on his left arm in the antecubital area. CNA 2 stated that within a few minutes the DON came into the room. CNA 2 stated that resident 1 told the DON that CNA 1 had punched him, and he was worried and scared. CNA 2 stated that she had never seen CNA 1 be mean or hurt any residents before. CNA 2 stated that this was the first time she had worked with CNA 1. CNA 2 stated that the DON and ADM stayed with the resident, and she left the room. CNA 2 stated that she could not understand resident 1, but that she communicated with him using gestures and pictures. CNA 2 stated that resident 1 spoke some English and was able to communicate a bit. On 3/13/23 at 2:19 PM, an interview was conducted with CNA 3 with English/Spanish translator assistance provided by the AD. CNA 3 stated she was helping CNA 2 with resident 1's roommate, and she heard resident 1 crying a lot. CNA 3 stated that she went to look around the privacy curtain and witnessed CNA 1 grabbing resident 1. Resident 1 was crying, and CNA 3 stated she heard CNA 1 say, that's fine if you cry. CNA 3 stated that she saw CNA 1 push and grab resident 1's arm. It should be noted that the CNA demonstrated this motion in a forceful way. CNA 3 stated that resident 1 could not move the left side but he was attempting to push CNA 1 away with the right arm. CNA 3 stated that CNA 1 was really upset and was punching resident 1. CNA 3 stated that she went and stopped CNA 1 because she was being too rough with resident 1. CNA 3 stated that CNA 1 had positioned resident 1 in a flat position for the incontinence care. CNA 3 stated that she told CNA 1 that he was positioned wrong and that she needed to call the nurse to stop the tube feed first before positioning him flat. CNA 3 stated that CNA 1 said just leave me alone, this was the way I always do it. CNA 3 stated that she then left to report the incident. CNA 3 stated that she reported it to the DON, and then the DON called the ADM. CNA 3 stated that resident 1 was very difficult to speak with, and what she heard was him screaming. CNA 3 stated that she witnessed CNA 1 hit and then grab resident 1's right arm and then she turned him, she turned him on the right side towards the wall. CNA 3 stated that CNA 1 grabbed resident 1's arm closer to the antecubital. CNA 3 stated that the force the CNA 1 used was hard. CNA 3 stated that resident 1 could not do much other than scream and cry. CNA 3 stated resident 1 tried to defend himself with the right arm but that was when CNA 1 grabbed his arm forcefully. CNA 3 stated that she first heard CNA 1 say it's okay if you cry in English. CNA 3 stated that she could understand English, but she also confirmed this statement with CNA 2. CNA 3 stated that CNA 1 was upset and was acting nervous. CNA 3 stated that CNA 1 was agitated before she went in to help resident 1. CNA 3 stated that this occurred between 5:30 PM and 6:00 PM, because they were assisting the roommate with dinner. CNA 3 stated that she also informed LPN 1 and she took pictures of the wounds, and cleaned them. CNA 3 stated that when CNA 1 grabbed resident 1 she caused a skin tear. CNA 3 stated that when she noticed resident 1 was bleeding, she cleaned the blood and then notified the nurse, and the nurse cleaned the wound. CNA 3 stated that she did this because resident 1 was asking for help. CNA 3 stated that resident 1 showed her the wound while reaching for her. CNA 3 stated when the DON arrived resident 1 started crying more because he felt more comfortable and then he showed the DON what CNA 1 did to him. CNA 3 stated that she had not worked with CNA 1 prior to this. CNA 3 stated that they had never worked together but had worked the same shift. On 3/13/23 at 2:59 PM, an interview was conducted with the ADM. The ADM stated that he was driving nearby when he was informed of the incident by the DON. The ADM stated that the DON reported that CNA 3 had witnessed an incident between CNA 1 and resident 1. The incident was that CNA 1 was hitting resident 1's arm and was telling him that it was okay to cry. The ADM stated that when he talked to resident 1 and the family, they were not able to state why CNA 1 had said that. The ADM stated that he had the impression that CNA 1 was trying to help him, and he was yelling out and she was saying its okay. The ADM stated that he came right to the building and the DON had excused CNA 1 from the building. The ADM stated that LPN 1 did the bulk of the physical assessment for resident 1. The ADM stated that LPN 1 reported that resident 1 had some new injuries and pain in his arm, left arm I think. The ADM stated that resident 1 was sent to the hospital for a complete workup. The ADM stated that before resident 1 was sent out he spoke with the spouse, and she requested that he speak with the daughter. The ADM stated with the phone on speaker, he spoke with the resident and the daughter who was translating. The ADM stated that resident 1 reported that CNA 1 hit his arm, and he was crying throughout the conversation. The ADM stated that resident 1 demonstrated with the good arm a open hand hit. The ADM stated that resident 1 reported that this hurt his arm. The ADM stated that resident 1 was difficult to understand due to the crying and aphasia. The ADM stated that resident 1 was tearful and talking loudly. The ADM stated that resident 1 sometimes cried out during repositioning but was never tearful. The ADM stated that afterwards he interviewed all the residents on that section to see if they had been exposed to any abuse, and no one reported any other abuse. The ADM stated that afterwards he contacted the Police Department. The ADM stated that he spoke to CNA 1 a week later, and CNA 1 was concerned about her paycheck. The ADM stated that CNA 1 was notified that she was not allowed back to the property. The ADM stated that CNA 1 told him that she understood what had happened, and she was told that they could not tolerate that type of behavior. The ADM stated that CNA 1 was suspended immediately and then terminated within a couple of days. The ADM stated that the DON walked the aide out of the building at the time of the incident. The ADM stated that CNA 1 denied the incident and had tried to accuse the other aides of sabotaging her. The ADM stated that CNA 1 had said that they had a disagreement, and that they were ganging up on her and were trying to get her in trouble. The ADM stated that this was not plausible. The ADM stated that he interviewed CNA 3, she was consistent with the recollections, with the holding of the arm, she did the motion of hitting the arm, and reported the aide saying its okay to cry. The ADM stated that CNA 2 reported that she did not see anything, but she heard the resident crying and heard the aide say its okay to cry. The ADM stated that there were no prior reports of conflict between CNA 1, CNA 2, and CNA 3. On 3/13/23 at 4:50 PM, a telephone interview was conducted with LPN 1. LPN 1 stated that she was coming on shift, and one of the aides came to tell her that they were looking for the DON. LPN 1 stated that the DON asked her to go in and do an assessment on resident 1. LPN 1 stated that the aides told her that they were in the room and that CNA 1 was holding resident 1 too tightly, in a hurtful way while changing him, and he was getting upset. LPN 1 stated that CNA 3 notified her, while CNA 2 remained with resident 1. LPN 1 stated that at the time of the incident CNA 2 and CNA 3 were in the room feeding the roommate. LPN 1 stated that CNA 3 reported that CNA 1 was pushing resident 1's arm down and away in an aggressive way, grabbing it, pushing it, and holding it tightly. LPN 1 stated that she took a picture of resident 1's arm, notified the doctor, and wrote the report. LPN 1 stated she asked resident 1 if it hurt, and he was holding onto the right arm and crying. LPN 1 stated that the picture was of the right arm and showed discoloration and there was a skin tear. LPN 1 stated that the wound looked like it may have been an old skin tear that was reopened. LPN 1 stated that this was a new injury and it was bleeding at the time. LPN 1 stated that she sent the photo to the MD directly via a secured phone app. LPN 1 stated that there were other red marks on resident 1's chest right below his neck, and they appeared to be new. LPN 1 described the red marks on the chest as, like when a child was red in the face from crying. LPN 1 stated that the skin tear was the size of a fingernail and was sliced, it was freshly opened, and the skin was frail. LPN 1 stated that resident 1 didn't speak much English and kept pulling his arm away and grimacing. LPN 1 stated that resident 1 was telling her what happened in his language, but she was unable to understand. LPN 1 stated that the ADM called resident 1's daughter to translate. LPN 1 stated that in the photo the wound closest to her hand was an old scab and the one that was further away was the new injury. LPN 1 stated that she notified the MD and he ordered to transport the resident to the ER for evaluation. LPN 1 stated that she filled out the incident report, and she documented the skin assessment on the progress note in the incident report. LPN 1 stated that they called CNA 1 into the office, and she was escorted from the facility within minutes. LPN 1 stated that resident 1 was very tearful and crying. LPN 1 stated that resident 1 would yell out and cry when he was in pain, and that was how she knew when he needed pain medication. LPN 1 stated that this was an indication to her that he was hurting because he was crying and pulling away. LPN 1 stated that she was present when resident 1 returned from the ER, and they did not identify any other injuries in the ER. LPN 1 stated that communication could be difficult with resident 1. LPN 1 stated resident 1 was able to say yes/no, and when reminded to speak in English he could use some words. LPN 1 stated resident 1 could say pain, and gesture at the location. LPN 1 stated that resident 1 was on a tube feed at the time of the incident. LPN 1 stated that CNA 3 had told CNA 1 to turn off the tube feed while she was turning and repositioning resident 1 for incontinence care. LPN 1 stated that CNA 3 reported that she provided instructions to CNA 1 and she did not like it and said she could do it her way.

Based on interview and record review, it was determined for 18 of 51 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, two residents with severe cognitive impairment were engaged in sexual relationships of which the staff were aware, with no assessments to determine if this was consensual, appropriate or safe. Additionally, multiple residents were engaged in verbal and physical abuse altercations with other residents, and interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of verbal and physical abuse between staff and residents, and incidents of neglect with wound care, a resident's change in condition, and a dependent resident was exposed to inclement weather for an extended period of time were identified at a HARM level. Resident identifiers: 4, 6, 14, 16, 18, 20, 21, 22, 23, 25, 29, 31, 37, 43, 47, 51, 53 and 111. On 4/4/22 at 1:10 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally to the facility Administrator (ADM), Corporate Resource Nurse (CRN) 1, and the Regional Vice President (RVP). On 4/12/22, the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/12/22 at 10:00 AM: 1. Resident #14 no longer resides at the community, therefore, the community does not have an individualized plan of correction. Resident #31 was placed on a 1:1 and remains on a 1:1. 2. All residents shall be assessed for signs and symptoms of abuse. The assessments shall be conducted by an LCSW [Licensed Clinical Social Worker] or CSW [Clinical Social Worker] with experience interviewing victims of abuse, as well as a registered nurse or advanced practice clinician. 3. Education was initiated on 4/11/2022 by the consultants regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. Thorough investigations to include immediate protection of the residents, interviewing the alleged victim, alleged assailant, any witnesses, other residents who could potentially be affected by the alleged violation, family/visitors if there are any who may have pertinent information, conducting an assessment of the alleged victim, conducting observations of cares if pertinent, conducting searches if necessary, and implementing pertinent interventions to attempt to prevent recurrence. Progress notes to be reviewed (M-F) by the DON [Director of Nursing]/designee daily to ensure that any allegations of abuse are being reported per community expectations to management and to the appropriate authorities, and that allegations of abuse are thoroughly investigated. Identified concerns to be addressed immediately and investigations initiated. NHA [Nursing Home Administrator] /designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the consultants and the consultants will have access to the report to ensure they are submitted timely to the health department. The consultants provided the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. NHA/designee to complete review of three (3) abuse allegations a week for three (3) months to ensure that the investigation was thorough, that there were interventions implemented to correct the alleged violations, and that there was protection of the alleged victim while the investigation was ongoing. 4. The NHA/designee will report findings from the audits to the QAPI Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed. On 4/12/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/12/22 at 10:00 AM. IMMEDIATE JEOPARDY: 1. Resident to resident sexual abuse Resident 14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 31 was admitted to the facility on [DATE] and readmitted after two days away from the facility on 11/8/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/24/22 at 9:10 AM, Certified Nursing Assistant (CNA) 17 was interviewed. CNA 17 stated that on 2/20/22, she was walking in the hall at the facility when she saw resident 31 in the hallway, walking toward his room. CNA 17 stated that when she returned from going into a resident's room, she came back out and he was not in the hallway anymore. CNA 17 stated that when she looked for resident 31, he was found in resident 14's room, leaning over the side rail of her bed and sucking on her bare breast. CNA 17 reported that she immediately separated the two residents and reported to the other CNA working at that time and to the nurse on duty, Licensed Practical Nurse (LPN) 2. CNA 17 stated that LPN 2 talked to the administrator on duty. CNA 17 stated that resident 31 would lean across residents to brush against their breasts and would smack people on the butt. CNA 17 stated that she texted the Administrator (ADM) when it happened and she had expected to follow up with the ADM the following Monday. On 3/29/22 at 3:55 PM, an interview was conducted with DON 2. DON 2 stated that she was no longer employed at the facility but was the DON at the time of the sexual abuse between residents 14 and 31. DON 2 stated that at breakfast time on 2/20/22 that LPN 2 had received a report from CNA 17 regarding resident 31 being in resident 14's room. DON 2 stated she spoke with LPN 2, and then called the ADM immediately to notify her. DON 2 stated that she was working the day of the incident and the whole day was crazy because I was trying to get another room for [resident 31]. DON 2 stated that the ADM was trying to transfer resident 31 to a different facility. DON 2 stated that she also reported the incident to CRN 1 on 2/28/22. DON 2 provided records from her mobile phone provider to show the phone call from her phone to the Administrator's mobile phone on 2/20/22 at 8:08 AM. The call lasted 12:08 minutes. DON 2 also stated that on 2/22/22 she sent a text message to the Administrator asking the Administrator if she had spoken to CNA 3. The former ADON provided a screenshot of the text message from her mobile phone to the mobile phone of the Administrator. The text was, Did you talk to (CNA 3) today about (resident 31)? On 3/25/22 at 8:35 AM, resident 14 was observed in her room and was immediately interviewed. Resident 14 was pleasant and unable to answer questions about her cares and situation. Resident 14's room smelled strongly of urine and black flecks and smears were observed on the wall above the headboard of the bed. On 4/13/22, medical record reviews were completed for residents 14 and 31. Resident 14's Minimum Data Set (MDS) was completed on 11/12/21, and revealed that her BIMS score was 7, with severely impaired cognition. Resident 31's MDS was completed on 1/28/22, and revealed that his BIMS score was 10, with moderately impaired cognition. Resident 14's nursing notes were reviewed and did not include information about the abuse. Resident 31's nursing notes were reviewed and did not include information about the abuse. Resident 14's care plan was reviewed and did not reveal any interventions regarding the abuse. Resident 31's care plan was reviewed. On 3/30/22, resident 31's care plan was updated to include the following: a focus that he wanders into others' rooms uninvited and may touch them inappropriately. Goals were that the resident would not enter other resident's rooms uninvited, and that he would not touch other residents. The interventions were to Monitor whereabouts closely, ensure his room is close to his smoking area, remind him he cannot go into others' rooms, if actively observed, tell him to 'stop' and notify administrator immediately. Assist him out of room and keep in line of sight monitoring for next hour. Resident 14's monitoring was located in the CNA Task list included monitoring for sexual behaviors. The task list was available for the previous 30 days and included the dates of 3/1/22 to 3/30/22. Resident 14 had two documented sexual behaviors. Resident 31's monitoring was located in the MAR/TAR and revealed that nurses were monitoring for mood swings, sleep, shortness of breath, depression, and pain. Resident 31 did not have monitoring for sexual behaviors. On 3/5/22, an incident report was completed for resident 14. The incident report revealed that on 2/27/22 at 12:00 PM, resident 31 might touch resident 14 inappropriately on her breast area. [Note: The date of the abuse listed on the report was not consistent with the date that the ADM had received the report of the abuse, and the incident report was completed approximately 2 weeks after the incident occurred.] The final investigation completed by the facility documented the following: It was reported to the administrator that a report of abuse was made on 2/27/22 to the nurse and did not get reported to the administrator until a later date. The abuse report was made to the agency nurse that failed to report to the administrator. The administrator talked to CNA (Certified Nursing Assistant) doing the report. CNA said to the administrator she was walking doing her rounds when she saw [resident 31] in [resident 14 ' s] room leaning over and appeared to her the [resident 31] was touching [resident 14 ' s] breast. CNA asked [resident 31] to leave the room and return to his room. CNA reported to the nurse and continued monitoring the resident and making sure [resident 31] did not enter [resident 14 ' s] room. CNA stated since the incident happened until the day it was reported to the administrator, the incident between [resident 31] and [resident 14] hasn ' t occurred again between residents involved or with any other female resident to the CNA ' s knowledge. The Administrator later documented that a CNA witnessed resident 31 with resident 14 ' s breast in his mouth, and that the CNA reported this to the Director of Nursing and Assistant Director of Nursing. The Administrator documented that we substantiated sexual abuse . Both residents are confused and [resident 31] do this out of confusion than a sexual abuse intent. A review was performed of the facility's Entity Report, which was submitted to the State Survey Agency (SSA). The report was submitted at 12:53 AM on 3/6/22. The Administrator documented the incident occurred at 12:00 PM on 2/27/22. The ADM described the allegation as follows: resident 2 (resident 31) allegedly inappropriately touched resident 1's (resident 14) breast area. An investigation into the incident to ensure that the incident actually occurred. physician and family notified. A review of the SSA database revealed that no final report had been submitted. The census for resident 14 revealed that she was in room [ROOM NUMBER] at the time of the abuse. Resident 31's census revealed that he was in room [ROOM NUMBER]. room [ROOM NUMBER] was located between resident 31's room and the smoking patio. Resident 31's census revealed that he was moved to room [ROOM NUMBER] on 3/21/22, 22 days after the abuse occurred. [Note: No evidence could be located to indicate that resident 14 was being appropriately protected from further sexual abuse, that other potential victims had been identified, or that prompt interventions were put into place to prevent sexual abuse perpetrated by resident 31 from re-occurring.] On 3/29/22 Employee (E) 11 was interviewed. E 11 stated that she was working on the day of 2/20/22. E 11 stated that there were no open rooms that day, so resident 31 was not moved away from resident 14. E 11 stated that the ADM did not come to the building to do an investigation that day. E 11 stated that they talked to the ADM the next day and the ADM asked E 11 and the other staff to stop talking about the abuse incident. E 11 stated that they talked to the other staff, and to their knowledge, no staff was interviewed about the incident by the ADM. E 11 stated that the ADM asked CNA 16 to keep an eye on resident 31, but CNA 16 was busy helping other residents. E 11 stated that the Assistant Director of Nursing (ADON) reported to E 11 that resident 31 had also massaged resident 14's breasts in a subsequent encounter after 2/20/22. E 11 stated that when they had reported any issues to the ADM, the ADM would say something like Well I will take care of it because we don't want State in the building right now. On 3/24/22, Employee (E) 13 was interviewed. E 13 stated that there were no official statements made to staff about the abuse from resident 31 to resident 14, but there had been rumors in the facility. E 13 stated that there were no interventions implemented immediately, and they had not been provided specific interventions, monitoring or official reports. E 13 stated that they would have liked to know what monitoring should have been done to protect resident 14. On 3/29/22 at 8:52 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that resident 14 did not have a roommate at the time of the abuse. The ADON stated that at one time, resident 31 was sitting by resident 14's bed with his hand above her breast. The ADON stated that she had heard about the abuse from the previous Director of Nursing (DON 1). The ADON stated that resident 14 was very innocent. The ADON stated that she did not tell other staff about the incident because they were still investigating. The ADON stated that the Administrator wanted resident 31 watched more closely. The ADON stated that whether or not resident 14 and resident 31 were confused, I guess they're both adults. The ADON stated that she did not know what was done with the investigation. The ADON stated that she didn't think abuse had happened so she did not tell other staff about it. The ADON stated that resident 31 went in and was sitting by resident 14's bed and his hand looked like it was above her breast. The ADON stated that because resident 31 was very short of breath, he probably just wanted to sit in resident 14's room for a while, so it probably wasn't anything. On 3/29/22 at 12:42 PM, an interview was conducted with the CRN 1. CRN 1 stated that abuse at the facility was reported to her unless it was just a little scuffle. CRN 1 stated that she was not always notified about abuse. CRN 1 stated that she received an email on 3/3/22 about the abuse between resident 31 and resident 14, but had not heard about the abuse prior to that. CRN 1 stated that she had forwarded this email to the ADM and the RVP that day. CRN 1 stated that the email reported that on the weekend of 2/18/22, a staff member reported that resident 31 was observed to be sucking on resident 14's breasts. CRN 1 stated that she was told that during that weekend, the ADM had placed resident 31 on 1:1 staffing. CRN 1 stated that she was told the ADM had not investigated the abuse before that time. CRN 1 stated that it was reported to her that there was a report of both the sucking on boobies and resident 31 massaging resident 14's breasts twice by the time she became aware of the incident on 2/20/22. CRN 1 stated she was not sure why the ADM had not investigated the sexual abuse incident(s) between residents 14 and 31. On 3/29/22 at 1:32 PM, an interview was conducted with the Administrator (ADM). The ADM stated that she was managing all the abuse, along with complaints, discharges, and social work concerns in the building. The ADM stated that she did not recall when she was notified about the abuse between resident 31 and resident 14. The ADM stated that she investigated the incident in March and had substantiated the abuse. The ADM stated that she had moved the patient around so resident 31 was not close to resident 14. The ADM stated that she moved resident 31 closer to the smoking patio where he smoked. The ADM stated that the CNAs did rounds every two hours, so they would be checking on the residents when they rounded. The ADM stated that both residents were confused, and that resident 31 was too frail to walk down to resident 14's room, so abuse was probably not happening. 2. Resident to resident physcial and verbal abuse A. Resident 20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/25/22 at approximately 10:00 AM, an interview was conducted with resident 20. Resident 20 stated that there was a fight in the hallway between resident 6 and resident 25. Resident 20 stated that resident 6 tried to hit resident 25. Resident 20 stated that she intervened and told resident 6, don't you hit him. Resident 20 stated that resident 6 replied, you shut up you [OBSCENITY] ing [OBSCENITY] or I'll get you next. Resident 20 stated that she returned to her room scared. Resident 20 stated that as a result of the fight, they moved resident 6 away from resident 25, but this move placed resident 6 in a room across the hallway from resident 20. Resident 20 stated that since the room change for resident 6 she was too scared to leave her room. Resident 20 stated that resident 6 was a big guy. Resident 20 stated that she informed the facility Administrator (ADM) of the incident and threat made by resident 6 against her. On 4/4/22 at 2:35 PM, a follow-up interview was conducted with resident 20. Resident 20 stated she was still nervous to leave her room with resident 6 still being around. Resident 20 stated that resident 6 was still residing in the room across the hall from her. Resident 20 stated that the ADM responded to her reports by saying that resident 6 was going to be discharged soon, and that she just needed to hold tight until it happened. On 4/11/22 resident 20's medical records were reviewed. Review of the facility census revealed that resident 20 resided in room [ROOM NUMBER]. It should be noted that resident 20's room was located directly across the hall from resident 6's room. On 1/19/22, a Quarterly Minimum Data Set (MDS) Assessment documented that resident 20's Brief Interview for Mental Status (BIMS) score was a 15, which would indicate that resident 20 was cognitively intact. The assessment documented that resident 20's mood interview (Patient Health Questionnaire-9 or PHQ-9) score was a 1, which would indicate normal or minimal depression. The assessment documented that resident 20 did not have any indicators of hallucinations or delusions and did not exhibit any symptoms of physical or verbal behaviors or behaviors towards others. The assessment documented that resident 20's functional status for locomotion on the unit was a one-person physical assist with supervision and supervisions with setup help only for locomotion off the unit. The assessment documented that resident 20's mobility devices that were utilized was a wheelchair. On 3/28/22, a PreAdmission Screening Resident Review (PASRR) Level II was conducted with resident 20. The PASRR indicated that resident 20 had previously experienced sxs [symptoms] of severe depression after her first marriage ended. She described severe depressive sxs including becoming 'withdrawn and largely nonfunctional'. She reported that the relationship that ended had been abusive; her spouse had been emotionally abusive and critical. When this relationship ended she became depressed, remained in bed, ate only one meal a day, and again experienced severe psychomotor [CONDITION(S)] and loss of motivation. She experienced SI [suicidal ideation] and held a gun to her head;. The current psychiatric functioning documented that resident 20 reported that her mood was up and down .sometimes it's down but I don't want to be ornery and sad, maybe most of the time I fake it At the time of the re-evaluation pt [patient] stated that 'This place is getting to us all' due to problems with other residents being aggressive and fighting; she reported she tends to isolate in her room d/t [due to] things going on at the facility. She stated she 'should be able to go out' but she feels like she is 'on pins and needles' all the time. She does endorse depressive symptoms but does not feel that counseling is the solution for her at this time. On 4/4/22 at 6:54 PM, the Medical Records Director (MRD) documented a progress note that stated, The resident stated she doesn't feel comfortable living close to a resident that fought with another resident. The administrator talked to [resident 20] and offered her to change rooms; [resident 20] will think about it and answer the administrator tomorrow morning. The administrator will follow up with the resident. Review of resident 20's physician orders revealed that the resident was receiving [MEDICATION(S)] 25 milligram (mg) tablet by mouth every 12 hours as needed for anxiety. The order was initiated on 10/14/21. Review of resident 20's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy and procedures on Abuse - Prohibiting defined Verbal Abuse as The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance; regardless of their age, ability to comprehend or disability. The policy further stated that all residents would be screened to determine if there was a prior pattern of abusive behavior. If the interdisciplinary team (IDT) determined that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . If the IDT determines that the facility is able to adequately meet the potential resident's needs without negatively impacting its current residents, the IDT will develop a care plan with behavioral approaches designed to prevent the potential resident from engaging in any abusive behavior. The policy further stated that all employees would receive information pertaining to the definition, prohibition, reporting of abuse, handling stressful situations and managing behavioral challenges. The policy stated that the training would identify potential signs and symptoms of abuse, including behavior changes. The policy was last revised in November 2015. On 4/7/22 at 11:00 AM, an interview was conducted with the Regional Vice President (RVP). The RVP informed the State Survey Agency (SSA) representatives that the facility Administrator was no longer with the company and had been escorted off of the property. On 4/12/22 11:03 AM, a follow-up interview was conducted with the RVP. The RVP stated that he was looking for the facility investigation for resident 20 and resident 6, but he was not hopeful he would find any abuse investigation documentation. B. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/11/22 resident 6's medical records were reviewed. Review of the facility census revealed that resident 6 resided in room [ROOM NUMBER]. It should be noted that resident 6's room was located directly across the hall from resident 20's room. On 4/2/22, a Quarterly MDS Assessment documented that resident 6's BIMS was not conducted due to resident is rarely/never understood. The assessment documented that a resident mood interview or PHQ-9 was not conducted for resident 6 due to resident is rarely/never understood. The assessment documented that resident 6 did not have any indicators of hallucinations or delusions and did not exhibit any symptoms of physical or verbal behaviors or behaviors towards others. The assessment documented that resident 6's functional status for walking in the corridor and locomotion on the unit was setup help only with supervision, and resident 6 did not utilize any mobility devices. On 12/1/20, a PASRR Level II was conducted with resident 6. The PASRR indicated that resident 6 tended to downplay or deny most mental health symptoms, or has varied in what he has reported to the same evaluator. What has been consistent throughout his evaluations and his current SNF [Skilled Nursing Facility] stay has been problems with interpersonal dysfunction, irritability, and anger management. In the past pt has also endorsed excessive worry about many things, difficulty managing feeling of worry, restlessness, sleep disturbance/[CONDITION(S)], trouble concentrating, and irritability due to anxiety. The current psychiatric functioning documented that at the time of the evaluation resident 6 continued to be argumentative. On 1/6/21, resident 6 had a care plan developed for a focus area of struggles with controlling his anger and may become verbally or physically aggressive with others. Interventions identified were: Encourage the resident to focus on achievement of his discharge planning goals; Encourage resident to take time to collect his thoughts when upset with others so he can communicate more effectively; Encourage resident to utilize coping skill such as going for a walk, reading his bible, smoking, listening to music; If agitated allow resident personal space; If resident becomes rude or yelling or intimidating ensure safety and walk away and seek additional staff; and Reinforce verbal praise of any positive behaviors and utilization of coping skills. On 4/6/22 at 1:00 AM, the nursing progress note documented that resident 6 was on 1:1 monitoring due to physical and verbal aggression towards other residents. The note further documented that resident 6 stated to the Nurse Practitioner, You better get me out of this place before I hurt someone. The note documented that resident 6 was taken by ambulance for a behavioral evaluation but did not state the location that resident 6 was discharged to. On 3/22/22 at 11:00 AM, the facility abuse investigation documented an initial entity report of a physical altercation between resident 6 and resident 25. The summary documented a verbal altercation between the residents that resulted in resident 6 attempting to strike resident 25 in the face. The report documented that a facility department head intervened which resulted in resident 6 only brushing resident 25 on the neck. The facility abuse investigation documentation was review and no documentation could be found of the verbal threats made by resident 6 towards resident 20. The facility ADM documented that 3 residents were interviewed, but provided interview summaries for only resident 6 and resident 25. 3. Resident to resident verbal abuse A. Resident 16 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/22 at 10:00 AM, an interview was conducted with resident 16. Resident 16 reported he was fearful of resident 53 because resident 53 regularly entered his room and threatened him. Resident 16 stated that it had happened approximately 4 times in the past month. Resident 16 stated that resident 53 resided in the room next to his. Resident 16 reported resident 53 threatened to hit him while raising his fists. Resident 16 stated he believed resident 53 made the threats because resident 16 speaks with a loud voice. Resident 16 stated he reported resident 53's threats to his assigned certified nurse aide (CNA) every time it happened. Resident 16 stated that the facility staff had removed resident 53 from his room in the past. Resident 16's roommate, resident 38, was present during the interview with resident 16. Resident 38 confirmed that resident 53 came into the room and threatened resident 16. Resident 38 stated he had tried to stand up for resident 16 because resident 16 can not protect himself. Resident 38 stated he was very upset because the facility staff do not do anything about the threats resident 53 made towards resident 16. Resident 16 stated that he had spoken to the Administrator and that she had done nothing. Resident 16 stated that he was afraid that resident 53 would actually hit him. Resident 16 stated that he had observed residents attempt to hit staff and that the staff protected themselves. Resident 16 stated the staff will protect themselves but not the residents. Resident 16 stated that he was bed bound, and had told staff multiple times to assist with the situation. On 3/25/22 at 10:38 PM, an interview with resident 16 was conducted. Resident 16 stated that they moved resident 53 to another room down the hall. Resident 16 stated that this was following an incident on 3/24/22 during the night when resident 53 threatened to hit resident 16 again. On 3/26/22 at approximately 9:30 AM, a follow-up interview was held with resident 16. Resident 16 reported on 3/25/22, that resident 53 came into his room and threatened him again. Resident 16 stated he then called the police. Resident 16's medical records were reviewed. On 1/7/22, a Quarterly MDS Assessment documented that resident 16's BIMS score was a 14, which would indicate cognitively intact. The assessment documented that a resident 16's PHQ-9 score was a 5, which would indicate minimal depression. The assessment documented that resident 16 did not have any indicators of hallucinations or delusions and did not exhibit any symptoms of physical behaviors towards others. The assessment documented that resident 16's functional status for bed mobility, locomotion on the unit, and dressing was an extensive two person assist. Resident 16 was assessed as a extensive one person assist for transfers and toilet use. The assessment documented that resident 16's mobility devices that were utilized was a wheelchair. On 1/28/21, a PASRR Level II was conducted with resident 16. The PASRR documented that resident 16 reported being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 16 reported that he had been involved with psychiatric treatment since childhood and was currently seeing a counselor that he, .mostly just talk on the phone. Resident 16 reported severe depression with anhedonia, decreased motivation and psychomotor [CONDITION(S)] where the patient did not want to get out of bed. Resident 16 also reported chronic and daily anxiety and stated that he was constantly anxious. Resident 16 stated that the anxiety caused him to .worry about many things and difficulty managing feelings of worry, filling tense and on [TRUNCATED]

Based on record review and interview it was determined for 14 of 51 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy Level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 38, 49, 51, 53, and 111. NOTICE: On 4/4/22 at 1:10 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to report all allegations of resident abuse. This notice was given verbally to the facility Administrator (ADM), Regional Vice President (RVP), and the Corporate Registered Dietician (CRD). On 4/12/22, the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/12/22 at 10:00 AM: F609 1, Resident #14 no longer resides at the community, therefore, the community does not have an individualized plan of correction. Resident #31was placed on a 1:1 and remains on a 1:1. 2. All residents shall be assessed for signs and symptoms of abuse. The assessments shall be conducted by an LCSW or CSW with experience interviewing victims of abuse, as well as a registered nurse or advanced practice clinician. 3. Education was initiated on 4/11/2022 by the consultants regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. On 4/11/2022 the consultants provided education and training with the Interdisciplinary Team (IDT) and well as community staff. The NHA/designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the consultants and the consultants will have access to the report to ensure that reports are submitted timely to the health department. Progress notes to be reviewed (M-F) by the DON/designee daily to ensure that any allegations of abuse are being reported per community expectations to management and to the appropriate authorities, and that allegations of abuse are thoroughly investigated. Identified concerns to be addressed immediately and investigations initiated. The consultants provided the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. 4. The NHA/designee will report findings from the audits to the QAPI Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed. On 4/12/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/12/22 at 10:00 AM. IMMEDIATE JEOPARDY 1. Resident to resident sexual abuse Resident 14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 31 was admitted to the facility on [DATE] and readmitted after two days away from the facility on 11/8/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/24/22 at 9:10 AM, Certified Nursing Assistant (CNA) 17 was interviewed. CNA 17 stated that on 2/20/22, she was walking in the hall at the facility when she saw resident 31 in the hallway, walking toward his room. CNA 17 stated that when she returned from going into a resident's room, she came back out and he was not in the hallway anymore. CNA 17 stated that when she looked for resident 31, he was found in resident 14's room, leaning over the side rail of her bed and sucking on her bare breast. CNA 17 reported that she immediately separated the two residents and reported to the other CNA working at that time and to the nurse on duty, Licensed Practical Nurse (LPN) 2. CNA 17 stated that LPN 2 talked to the administrator on duty. CNA 17 stated that resident 31 would lean across residents to brush against their breasts and would smack people on the butt. CNA 17 stated that she texted the Administrator (ADM) when it happened and she had expected to follow up with the ADM the following Monday. On 3/29/22 at 3:55 PM, an interview was conducted with DON 2. DON 2 stated that she was no longer employed at the facility but was the DON at the time of the sexual abuse between residents 14 and 31. DON 2 stated that at breakfast time on 2/20/22 that LPN 2 had received a report from CNA 17 regarding resident 31 being in resident 14's room. DON 2 stated she spoke with LPN 2, and then called the ADM immediately to notify her. DON 2 stated that she was working the day of the incident and the whole day was crazy because I was trying to get another room for [resident 31]. DON 2 stated that the ADM was trying to transfer resident 31 to a different facility. DON 2 stated that she also reported the incident to CRN 1 on 2/28/22. On 3/25/22 at 8:35 AM, resident 14 was observed in her room and was immediately interviewed. Resident 14 was pleasant and unable to answer questions about her cares and situation. Resident 14's room smelled strongly of urine and black flecks and smears were observed on the wall above the headboard of the bed. On 4/13/22, medical record reviews were completed for residents 14 and 31. Resident 14's Minimum Data Set (MDS) was completed on 11/12/21, and revealed that her BIMS score was 7, with severely impaired cognition. Resident 31's MDS was completed on 1/28/22, and revealed that his BIMS score was 10, with moderately impaired cognition. Resident 14's nursing notes were reviewed and did not include information about the abuse. Resident 31's nursing notes were reviewed and did not include information about the abuse. Resident 14's care plan was reviewed and did not reveal any interventions regarding the abuse. Resident 31's care plan was reviewed. On 3/30/22, resident 31's care plan was updated to include the following: a focus that he wanders into others' rooms uninvited and may touch them inappropriately. Goals were that the resident would not enter other resident's rooms uninvited, and that he would not touch other residents. The interventions were to Monitor whereabouts closely, ensure his room is close to his smoking area, remind him he cannot go into others' rooms, if actively observed, tell him to 'stop' and notify administrator immediately. Assist him out of room and keep in line of sight monitoring for next hour. Resident 14's monitoring was located in the CNA Task list included monitoring for sexual behaviors. The task list was available for the previous 30 days and included the dates of 3/1/22 to 3/30/22. Resident 14 had two documented sexual behaviors. Resident 31's monitoring was located in the MAR/TAR and revealed that nurses were monitoring for mood swings, sleep, shortness of breath, depression, and pain. Resident 31 did not have monitoring for sexual behaviors. On 3/5/22, an incident report was completed for resident 14. The incident report revealed that on 2/27/22 at 12:00 PM, resident 31 might touch resident 14 inappropriately on her breast area. [Note: The date of the abuse listed on the report was not consistent with the date that the ADM had received the report of the abuse, and the incident report was completed approximately 2 weeks after the incident occurred.] The final investigation completed by the facility documented the following: It was reported to the administrator that a report of abuse was made on 2/27/22 to the nurse and did not get reported to the administrator until a later date. The abuse report was made to the agency nurse that failed to report to the administrator. The administrator talked to CNA (Certified Nursing Assistant) doing the report. CNA said to the administrator she was walking doing her rounds when she saw [resident 31] in [resident 14 ' s] room leaning over and appeared to her the [resident 31] was touching [resident 14 ' s] breast. CNA asked [resident 31] to leave the room and return to his room. CNA reported to the nurse and continued monitoring the resident and making sure [resident 31] did not enter [resident 14 ' s] room. CNA stated since the incident happened until the day it was reported to the administrator, the incident between [resident 31] and [resident 14] hasn ' t occurred again between residents involved or with any other female resident to the CNA ' s knowledge. The Administrator later documented that a CNA witnessed resident 31 with resident 14 ' s breast in his mouth, and that the CNA reported this to the Director of Nursing and Assistant Director of Nursing. The Administrator documented that we substantiated sexual abuse . Both residents are confused and [resident 31] do this out of confusion than a sexual abuse intent. A review was performed of the facility's Entity Report, which was submitted to the State Survey Agency (SSA). The report was submitted at 12:53 AM on 3/6/22. The Administrator documented the incident occurred at 12:00 PM on 2/27/22. The ADM described the allegation as follows: resident 2 (resident 31) allegedly inappropriately touched resident 1's (resident 14) breast area. An investigation into the incident to ensure that the incident actually occurred. physician and family notified. A review of the SSA database revealed that no final report had been submitted. The census for resident 14 revealed that she was in room [ROOM NUMBER] at the time of the abuse. Resident 31's census revealed that he was in room [ROOM NUMBER]. room [ROOM NUMBER] was located between resident 31's room and the smoking patio. Resident 31's census revealed that he was moved to room [ROOM NUMBER] on 3/21/22, 22 days after the abuse occurred. [Note: No evidence could be located to indicate that resident 14 was being appropriately protected from further sexual abuse, that other potential victims had been identified, or that prompt interventions were put into place to prevent sexual abuse perpetrated by resident 31 from re-occurring.] On 3/29/22 Employee (E) 11 was interviewed. E 11 stated that she was working on the day of 2/20/22. E 11 stated that there were no open rooms that day, so resident 31 was not moved away from resident 14. E 11 stated that the ADM did not come to the building to do an investigation that day. E 11 stated that they talked to the ADM the next day and the ADM asked E 11 and the other staff to stop talking about the abuse incident. E 11 stated that they talked to the other staff, and to their knowledge, no staff was interviewed about the incident by the ADM. E 11 stated that the ADM asked CNA 16 to keep an eye on resident 31, but CNA 16 was busy helping other residents. E 11 stated that the Assistant Director of Nursing (ADON) reported to E 11 that resident 31 had also massaged resident 14's breasts in a subsequent encounter after 2/20/22. E 11 stated that when they had reported any issues to the ADM, the ADM would say something like Well I will take care of it because we don't want State in the building right now. On 3/24/22, Employee (E) 13 was interviewed. E 13 stated that there were no official statements made to staff about the abuse from resident 31 to resident 14, but there had been rumors in the facility. E 13 stated that there were no interventions implemented immediately, and they had not been provided specific interventions, monitoring or official reports. E 13 stated that they would have liked to know what monitoring should have been done to protect resident 14. On 3/29/22 at 8:52 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that resident 14 did not have a roommate at the time of the abuse. The ADON stated that at one time, resident 31 was sitting by resident 14's bed with his hand above her breast. The ADON stated that she had heard about the abuse from the previous Director of Nursing (DON 1). The ADON stated that resident 14 was very innocent. The ADON stated that she did not tell other staff about the incident because they were still investigating. The ADON stated that the Administrator wanted resident 31 watched more closely. The ADON stated that whether or not resident 14 and resident 31 were confused, I guess they're both adults. The ADON stated that she did not know what was done with the investigation. The ADON stated that she didn't think abuse had happened so she did not tell other staff about it. The ADON stated that resident 31 went in and was sitting by resident 14's bed and his hand looked like it was above her breast. The ADON stated that because resident 31 was very short of breath, he probably just wanted to sit in resident 14's room for a while, so it probably wasn't anything. On 3/29/22 at 12:42 PM, an interview was conducted with the CRN 1. CRN 1 stated that abuse at the facility was reported to her unless it was just a little scuffle. CRN 1 stated that she was not always notified about abuse. CRN 1 stated that she received an email on 3/3/22 about the abuse between resident 31 and resident 14, but had not heard about the abuse prior to that. CRN 1 stated that she had forwarded this email to the ADM and the RVP that day. CRN 1 stated that the email reported that on the weekend of 2/18/22, a staff member reported that resident 31 was observed to be sucking on resident 14's breasts. CRN 1 stated that she was told that during that weekend, the ADM had placed resident 31 on 1:1 staffing. CRN 1 stated that she was told the ADM had not investigated the abuse before that time. CRN 1 stated that it was reported to her that there was a report of both the sucking on boobies and resident 31 massaging resident 14's breasts twice by the time she became aware of the incident on 2/20/22. CRN 1 stated she was not sure why the ADM had not investigated the sexual abuse incident(s) between residents 14 and 31. On 3/29/22 at 1:32 PM, an interview was conducted with the Administrator (ADM). The ADM stated that she was managing all the abuse, along with complaints, discharges, and social work concerns in the building. The ADM stated that she did not recall when she was notified about the abuse between resident 31 and resident 14. The ADM stated that she investigated the incident in March and had substantiated the abuse. The ADM stated that she had moved the patient around so resident 31 was not close to resident 14. The ADM stated that she moved resident 31 closer to the smoking patio where he smoked. The ADM stated that the CNAs did rounds every two hours, so they would be checking on the residents when they rounded. The ADM stated that both residents were confused, and that resident 31 was too frail to walk down to resident 14's room, so abuse was probably not happening. 2. Resident to Resident physical and verbal abuse A. Resident 20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/25/22 at approximately 10:00 AM, an interview was conducted with resident 20. Resident 20 stated that there was a fight in the hallway between resident 6 and resident 25. Resident 20 stated that resident 6 tried to hit resident 25. Resident 20 stated that she intervened and told resident 6, don't you hit him. Resident 20 stated that resident 6 replied, you shut up you [OBSCENITY] ing [OBSCENITY] or I'll get you next. Resident 20 stated that she returned to her room scared. Resident 20 stated that as a result of the fight, they moved resident 6 away from resident 25, but this move placed resident 6 in a room across the hallway from resident 20. Resident 20 stated that since the room change for resident 6 she was too scared to leave her room. Resident 20 stated that resident 6 was a big guy. Resident 20 stated that she informed the facility Administrator (ADM) of the incident and threat made by resident 6 against her. On 4/4/22 at 2:35 PM, a follow-up interview was conducted with resident 20. Resident 20 stated she was still nervous to leave her room with resident 6 still being around. Resident 20 stated that resident 6 was still residing in the room across the hall from her. Resident 20 stated that the ADM responded to her reports by saying that resident 6 was going to be discharged soon, and that she just needed to hold tight until it happened. On 4/11/22 resident 20's medical records were reviewed. Review of the facility census revealed that resident 20 resided in room [ROOM NUMBER]. It should be noted that resident 20's room was located directly across the hall from resident 6's room. B. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/11/22 resident 6's medical records were reviewed. Review of the facility census revealed that resident 6 resided in room [ROOM NUMBER]. It should be noted that resident 6's room was located directly across the hall from resident 20's room. On 1/6/21, resident 6 had a care plan developed for a focus area of struggles with controlling his anger and may become verbally or physically aggressive with others. Interventions identified were: Encourage the resident to focus on achievement of his discharge planning goals; Encourage resident to take time to collect his thoughts when upset with others so he can communicate more effectively; Encourage resident to utilize coping skill such as going for a walk, reading his bible, smoking, listening to music; If agitated allow resident personal space; If resident becomes rude or yelling or intimidating ensure safety and walk away and seek additional staff; and Reinforce verbal praise of any positive behaviors and utilization of coping skills. On 4/6/22 at 1:00 AM, the nursing progress note documented that resident 6 was on 1:1 monitoring due to physical and verbal aggression towards other residents. The note further documented that resident 6 stated to the Nurse Practitioner, You better get me out of this place before I hurt someone. The note documented that resident 6 was taken by ambulance for a behavioral evaluation but did not state the location that resident 6 was discharged to. On 4/12/22 11:03 AM, a interview was conducted with the Regional Vice President (RVP). The RVP stated that he was looking for the facility investigation for resident 20 and resident 6, but he was not hopeful he would find any abuse investigation documentation. 3. Resident to resident verbal abuse A. Resident 16 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/22 at 10:00 AM, an interview was conducted with resident 16. Resident 16 reported he was fearful of resident 53 because resident 53 regularly entered his room and threatened him. Resident 16 stated that it had happened approximately 4 times in the past month. Resident 16 stated that resident 53 resided in the room next to his. Resident 16 reported resident 53 threatened to hit him while raising his fists. Resident 16 stated he believed resident 53 made the threats because resident 16 speaks with a loud voice. Resident 16 stated he reported resident 53's threats to his assigned certified nurse aide (CNA) every time it happened. Resident 16 stated that the facility staff had removed resident 53 from his room in the past. Resident 16's roommate, resident 38, was present during the interview with resident 16. Resident 38 confirmed that resident 53 came into the room and threatened resident 16. Resident 38 stated he had tried to stand up for resident 16 because resident 16 can not protect himself. Resident 38 stated he was very upset because the facility staff do not do anything about the threats resident 53 made towards resident 16. Resident 16 stated that he had spoken to the Administrator and that she had done nothing. Resident 16 stated that he was afraid that resident 53 would actually hit him. Resident 16 stated that he had observed residents attempt to hit staff and that the staff protected themselves. Resident 16 stated the staff will protect themselves but not the residents. Resident 16 stated that he was bed bound, and had told staff multiple times to assist with the situation. On 3/25/22 at 10:38 PM, an interview with resident 16 was conducted. Resident 16 stated that they moved resident 53 to another room down the hall. Resident 16 stated that this was following an incident on 3/24/22 during the night when resident 53 threatened to hit resident 16 again. On 3/26/22 at approximately 9:30 AM, a follow-up interview was held with resident 16. Resident 16 reported on 3/25/22, that resident 53 came into his room and threatened him again. Resident 16 stated he then called the police. Resident 16's medical records were reviewed. On 1/7/22, a Quarterly MDS Assessment documented that resident 16's BIMS score was a 14, which would indicate cognitively intact. The assessment documented that a resident 16's PHQ-9 score was a 5, which would indicate minimal depression. The assessment documented that resident 16 did not have any indicators of hallucinations or delusions and did not exhibit any symptoms of physical behaviors towards others. The assessment documented that resident 16's functional status for bed mobility, locomotion on the unit, and dressing was an extensive two person assist. Resident 16 was assessed as a extensive one person assist for transfers and toilet use. The assessment documented that resident 16's mobility devices that were utilized was a wheelchair. On 1/28/21, a PASRR Level II was conducted with resident 16. The PASRR documented that resident 16 reported being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 16 reported that he had been involved with psychiatric treatment since childhood and was currently seeing a counselor that he, .mostly just talk on the phone. Resident 16 reported severe depression with anhedonia, decreased motivation and psychomotor [CONDITION(S)] where the patient did not want to get out of bed. Resident 16 also reported chronic and daily anxiety and stated that he was constantly anxious. Resident 16 stated that the anxiety caused him to .worry about many things and difficulty managing feelings of worry, filling tense and on edge all the time, and trouble sleeping d/t [due to] this anxiety. At the time of the assessment, resident 16 reported constant visual hallucinations that he had learned to put to the side and tried to ignore. Resident 16 also reported chronic auditory hallucinations that could be persucatory in nature. On 4/8/2022 at 7:36 AM, a Social Service Note documented, LCSW [Licensed Clinical Social Worker] met with resident for abuse screening and identification of immediate psychosocial concerns. Resident reported a prior altercation with another resident who 'threatened' him. Resident stated that the other resident moved rooms after the incident and that he feels 'safe' but expressed interest in referral for ongoing counseling. Review of the facility census revealed that resident 16 resided in room [ROOM NUMBER] and resident 53 resided in room [ROOM NUMBER]. Resident 53 was moved from 322 to 307 on 3/25/22. The facility abuse investigation documentation for the incidents between resident 16 and resident 53 were requested. No documentation of the abuse investigations were provided. Review of the State Survey Agency (SSA) entity reports revealed that on 3/26/22 at 7:00 AM, resident 16 woke resident 53 up when he was talking too loudly with another resident. The entity report documented that resident 53 became very angry and went through the bathroom to tell resident 16 to shut up or he's going to break his arm, jaw or leg. It should be noted that the SSA facility reported incidents (FRI) tracking system did not contain a facility final investigation summary report of the incident. B. Resident 53 was admitted on the facility on 8/29/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 53's care plan dated 12/7/21 that the resident is verbally and physically aggressive at times. The goal indicated was verbalize understanding of need to control verbally abusive behavior. No Psychosocial Reviews were completed for resident 53 after 9/6/21. Nursing notes for resident 53 revealed the following: a. On 9/16/21 at 12:06 AM, patient refusing care, refusing pain meds, calling nurse and cna [OBSCENITY] and witch stating thaat (sic) both are liars despite trying to give him care. b. On 9/16/21 at 1:43 AM, patient being verbally abusive, kicking staff out when he requests help for care. c. On 9/16/21 at 2:13 AM, ptient (sic) becoming physically aggressive, charging at nurse and CNA while naked. d. On 9/16/21 at 2:33 AM, Called [name of family member omitted] to see if he will calm down. Patient has been striking his walker against the floor in his room and bathroom. Patient now taling (sic) with daughter and claiming we [NAME] caring for him. I explained to her that we cant physically get near him since he is charging at us. e. On 9/16/21 at 2:35 AM, patient also scaring other patients with behavior. Nursing staff is also fearful. f. On 9/20/21 at 12:00 PM, patient yelling in middle of the night accusing staff of lying how frequently he can have tylenol. Patient waking up residents. Refuses to listen to nurses explanation of why he must wit (sic) for pain medications for 6 hrs (hours). g. On 1/7/22 at 1:40 AM, Resident this NOC (night) got in a verbal altercation with another resident and was very agitated. Denied getting his blood pressure taken this NOC. DON notified to reconsider room assignments. [Note: Review of the facility census revealed that resident 53 resided in room [ROOM NUMBER] from 8/29/21 until 3/25/22.] h. On 1/28/22 at 1:38 AM, Aggression towards staff. Review of resident 53's MARS since admission revealed no monitoring of behaviors for verbal or physical aggression towards others. 4. Resident to resident physical and verbal abuse A. Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/22 at 7:02 AM, an interview was conducted with resident 4. Resident 4 stated that resident 111 and her had an argument in the hallway three days ago. Resident 4 stated that she asked resident 111 to move and resident 111 then threw hot coffee on resident 4's lap. Resident 4 stated that she did not receive any [CONDITION(S)] from the hot liquid. Resident 4 stated that it was witnessed by Licensed Practical Nurse (LPN) 2. Resident 4 stated that she had spoken to the Administrator about this and nothing was being done. Resident 4 stated that this made her feel irritable. On 3/23/22 at 7:38 AM, an interview was conducted with LPN 2. LPN 2 stated that she witnessed the incident between resident 4 and resident 111. LPN 2 stated that resident 4 was moving down the hallway and that resident 111 was standing in front of the medication cart. LPN 2 stated that resident 4 told resident 111 to move and that resident 111 turned and called resident 4 a [OBSCENITY] ing [OBSCENITY] and threw coffee on resident 4's groin area. LPN 2 stated that she separated the two and took resident 4 to her room. LPN 2 examined resident 4's burned area. LPN 2 stated that resident 4 was in pain and had a red raised skin on the area where coffee was thrown on her. LPN 2 stated that resident 4 did not require any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/23/22 at 10:35 AM, an observation was made in the hallway, on the second floor. Resident 4 was propelling herself in an electric wheelchair from her room to the patio. Resident 111 was propelling herself in a wheelchair and was behind resident 4. Resident 111 yelled, Get out of the way, you Mother [OBSCENITY] ! This incident occurred in front of LPN 2 and CNA 17. Neither staff member reacted to the interaction between these residents. Review of the facility initial entity report documented that resident 4 complained of resident 111 .being upset this morning at her and purposely throwing hot chocolate at her face. The report documented that the incident occurred on 2/23/22 at 8:00 AM. The report documented that resident 4 was not injured or burned. The report documented the action taken was to move resident 111 to a different room. Review of the State Survey Agency (SSA) Incident Investigation Report documented, On 03/24/2022 at 12:09 am, the facility reported that, on 03/23/2022 at 8:00 am, resident [4] complained that resident [111] was upset with resident [4], that morning, and purposely threw hot chocolate in her face. The residents were assessed and no injuries or [CONDITION(S)] were found. Resident [111] has been moved to another room. APS [Adult Protective Services] was notified, case# 2. The family and physician was notified. Review of the APS report documented that the incident occurred on 3/23/22 at 8:00 AM and stated, Resident [4] complained of resident [111] being upset this morning at her and purposely throwing hot chocolate at her face. Resident [4] wasn't injured or burned. Resident [111] is OK. It should be noted the inconsistencies between the dates of the incident that were reported on the facility initial entity report, the SSA Incident Investigation Report, and the APS report. Resident 4's medical records were reviewed. On 3/22/22, a Quarterly MDS Assessment documented that resident 4's BIMS was not conducted due to resident is rarely/never understood. The assessment documented that a resident mood interview or PHQ-9 was not conducted for resident 4 due to resident is rarely/never understood. The assessment documented that resident 4 did not have any indicators of hallucinations or delusions and did not exhibit any symptoms of physical or verbal behaviors or behaviors towards others. The assessment documented that resident 4's functional status for transfers and locomotion on and off the unit was supervision with set up help only. The assessment documented that resident 4's mobility devices that were utilized was a wheelchair. On 12/29/21, a Quarterly MDS Assessment documented that resident 4's BIMS score was a 15, which would indicate cognitively intact. On 12/27/21 at 12:02 PM [TRUNCATED]

Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 14 of 51 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA), between 8/22/21 and 3/31/22, the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 37, 49, 51, 53, and 111. NOTICE: On 4/4/22 at 1:10 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices This notice was given verbally to the facility Administrator (ADM), Regional Vice President (RVP), and the Corporate Registered Dietician (CRD) regarding On 4/12/22, the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/12/22 at 10:00 AM: 1. Resident #14 no longer resides at the community, therefore, the community does not have an individualized plan of correction. Resident #31 was placed on a 1:1 and remains on a 1:1. 2. All residents shall be assessed for signs and symptoms of abuse. The assessments shall be conducted by an LCSW or CSW with experience interviewing victims of abuse, as well as a registered nurse or advanced practice clinician. 3. Education was initiated on 4/11/2022 by the consultants regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. Thorough investigations to include immediate protection of the residents, interviewing the alleged victim, alleged assailant, any witnesses, other residents who could potentially be affected by the alleged violation, family/visitors if there are any who may have pertinent information, conducting an assessment of the alleged victim, conducting observations of cares if pertinent, conducting searches if necessary, and implementing pertinent interventions to attempt to prevent recurrence. NHA/designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the consultants and the consultants will have access to the report to ensure that reports are submitted timely to the health department. NHA/designee to complete review three(3) abuse allegations a week for three (3) months to ensure that the investigation was thorough, that there were interventions implemented to correct the alleged violations, and that there was protection of the alleged victim while the investigation was ongoing. The consultants provided the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. 4. The NHA/designee will report findings from the audits to the QAPI Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed. On 4/12/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/12/22 at 10:00 AM. IMMEDIATE JEOPARDY 1. Resident to resident sexual abuse Resident 14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 31 was admitted to the facility on [DATE] and readmitted after two days away from the facility on 11/8/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/24/22 at 9:10 AM, Certified Nursing Assistant (CNA) 17 was interviewed. CNA 17 stated that on 2/20/22, she was walking in the hall at the facility when she saw resident 31 in the hallway, walking toward his room. CNA 17 stated that when she returned from going into a resident's room, she came back out and he was not in the hallway anymore. CNA 17 stated that when she looked for resident 31, he was found in resident 14's room, leaning over the side rail of her bed and sucking on her bare breast. CNA 17 reported that she immediately separated the two residents and reported to the other CNA working at that time and to the nurse on duty, Licensed Practical Nurse (LPN) 2. CNA 17 stated that LPN 2 talked to the administrator on duty. CNA 17 stated that resident 31 would lean across residents to brush against their breasts and would smack people on the butt. CNA 17 stated that she texted the Administrator (ADM) when it happened and she had expected to follow up with the ADM the following Monday. On 3/29/22 at 3:55 PM, an interview was conducted with DON 2. DON 2 stated that she was no longer employed at the facility but was the DON at the time of the sexual abuse between residents 14 and 31. DON 2 stated that at breakfast time on 2/20/22 that LPN 2 had received a report from CNA 17 regarding resident 31 being in resident 14's room. DON 2 stated she spoke with LPN 2, and then called the ADM immediately to notify her. DON 2 stated that she was working the day of the incident and the whole day was crazy because I was trying to get another room for [resident 31]. DON 2 stated that the ADM was trying to transfer resident 31 to a different facility. DON 2 stated that she also reported the incident to CRN 1 on 2/28/22. DON 2 provided records from her mobile phone provider to show the phone call from her phone to the Administrator's mobile phone on 2/20/22 at 8:08 AM. The call lasted 12:08 minutes. DON 2 also stated that on 2/22/22 she sent a text message to the Administrator asking the Administrator if she had spoken to CNA 3. The former ADON provided a screenshot of the text message from her mobile phone to the mobile phone of the Administrator. The text was, Did you talk to (CNA 3) today about (resident 31)? On 3/25/22 at 8:35 AM, resident 14 was observed in her room and was immediately interviewed. Resident 14 was pleasant and unable to answer questions about her cares and situation. Resident 14's room smelled strongly of urine and black flecks and smears were observed on the wall above the headboard of the bed. On 4/13/22, medical record reviews were completed for residents 14 and 31. Resident 14's Minimum Data Set (MDS) was completed on 11/12/21, and revealed that her BIMS score was 7, with severely impaired cognition. Resident 31's MDS was completed on 1/28/22, and revealed that his BIMS score was 10, with moderately impaired cognition. Resident 14's nursing notes were reviewed and did not include information about the abuse. Resident 31's nursing notes were reviewed and did not include information about the abuse. Resident 14's care plan was reviewed and did not reveal any interventions regarding the abuse. Resident 31's care plan was reviewed. On 3/30/22, resident 31's care plan was updated to include the following: a focus that he wanders into others' rooms uninvited and may touch them inappropriately. Goals were that the resident would not enter other resident's rooms uninvited, and that he would not touch other residents. The interventions were to Monitor whereabouts closely, ensure his room is close to his smoking area, remind him he cannot go into others' rooms, if actively observed, tell him to 'stop' and notify administrator immediately. Assist him out of room and keep in line of sight monitoring for next hour. Resident 14's monitoring was located in the CNA Task list included monitoring for sexual behaviors. The task list was available for the previous 30 days and included the dates of 3/1/22 to 3/30/22. Resident 14 had two documented sexual behaviors. Resident 31's monitoring was located in the MAR/TAR and revealed that nurses were monitoring for mood swings, sleep, shortness of breath, depression, and pain. Resident 31 did not have monitoring for sexual behaviors. On 3/5/22, an incident report was completed for resident 14. The incident report revealed that on 2/27/22 at 12:00 PM, resident 31 might touch resident 14 inappropriately on her breast area. [Note: The date of the abuse listed on the report was not consistent with the date that the ADM had received the report of the abuse, and the incident report was completed approximately 2 weeks after the incident occurred.] The final investigation completed by the facility documented the following: It was reported to the administrator that a report of abuse was made on 2/27/22 to the nurse and did not get reported to the administrator until a later date. The abuse report was made to the agency nurse that failed to report to the administrator. The administrator talked to CNA (Certified Nursing Assistant) doing the report. CNA said to the administrator she was walking doing her rounds when she saw [resident 31] in [resident 14 ' s] room leaning over and appeared to her the [resident 31] was touching [resident 14 ' s] breast. CNA asked [resident 31] to leave the room and return to his room. CNA reported to the nurse and continued monitoring the resident and making sure [resident 31] did not enter [resident 14 ' s] room. CNA stated since the incident happened until the day it was reported to the administrator, the incident between [resident 31] and [resident 14] hasn ' t occurred again between residents involved or with any other female resident to the CNA ' s knowledge. The Administrator later documented that a CNA witnessed resident 31 with resident 14 ' s breast in his mouth, and that the CNA reported this to the Director of Nursing and Assistant Director of Nursing. The Administrator documented that we substantiated sexual abuse . Both residents are confused and [resident 31] do this out of confusion than a sexual abuse intent. A review was performed of the facility's Entity Report, which was submitted to the State Survey Agency (SSA). The report was submitted at 12:53 AM on 3/6/22. The Administrator documented the incident occurred at 12:00 PM on 2/27/22. The ADM described the allegation as follows: resident 2 (resident 31) allegedly inappropriately touched resident 1's (resident 14) breast area. An investigation into the incident to ensure that the incident actually occurred. physician and family notified. A review of the SSA database revealed that no final report had been submitted. The census for resident 14 revealed that she was in room [ROOM NUMBER] at the time of the abuse. Resident 31's census revealed that he was in room [ROOM NUMBER]. room [ROOM NUMBER] was located between resident 31's room and the smoking patio. Resident 31's census revealed that he was moved to room [ROOM NUMBER] on 3/21/22, 22 days after the abuse occurred. [Note: No evidence could be located to indicate that resident 14 was being appropriately protected from further sexual abuse, that other potential victims had been identified, or that prompt interventions were put into place to prevent sexual abuse perpetrated by resident 31 from re-occurring.] On 3/29/22 Employee (E) 11 was interviewed. E 11 stated that she was working on the day of 2/20/22. E 11 stated that there were no open rooms that day, so resident 31 was not moved away from resident 14. E 11 stated that the ADM did not come to the building to do an investigation that day. E 11 stated that they talked to the ADM the next day and the ADM asked E 11 and the other staff to stop talking about the abuse incident. E 11 stated that they talked to the other staff, and to their knowledge, no staff was interviewed about the incident by the ADM. E 11 stated that the ADM asked CNA 16 to keep an eye on resident 31, but CNA 16 was busy helping other residents. E 11 stated that the Assistant Director of Nursing (ADON) reported to E 11 that resident 31 had also massaged resident 14's breasts in a subsequent encounter after 2/20/22. E 11 stated that when they had reported any issues to the ADM, the ADM would say something like Well I will take care of it because we don't want State in the building right now. On 3/24/22, Employee (E) 13 was interviewed. E 13 stated that there were no official statements made to staff about the abuse from resident 31 to resident 14, but there had been rumors in the facility. E 13 stated that there were no interventions implemented immediately, and they had not been provided specific interventions, monitoring or official reports. E 13 stated that they would have liked to know what monitoring should have been done to protect resident 14. On 3/29/22 at 8:52 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that resident 14 did not have a roommate at the time of the abuse. The ADON stated that at one time, resident 31 was sitting by resident 14's bed with his hand above her breast. The ADON stated that she had heard about the abuse from the previous Director of Nursing (DON 1). The ADON stated that resident 14 was very innocent. The ADON stated that she did not tell other staff about the incident because they were still investigating. The ADON stated that the Administrator wanted resident 31 watched more closely. The ADON stated that whether or not resident 14 and resident 31 were confused, I guess they're both adults. The ADON stated that she did not know what was done with the investigation. The ADON stated that she didn't think abuse had happened so she did not tell other staff about it. The ADON stated that resident 31 went in and was sitting by resident 14's bed and his hand looked like it was above her breast. The ADON stated that because resident 31 was very short of breath, he probably just wanted to sit in resident 14's room for a while, so it probably wasn't anything. On 3/29/22 at 12:42 PM, an interview was conducted with the CRN 1. CRN 1 stated that abuse at the facility was reported to her unless it was just a little scuffle. CRN 1 stated that she was not always notified about abuse. CRN 1 stated that she received an email on 3/3/22 about the abuse between resident 31 and resident 14, but had not heard about the abuse prior to that. CRN 1 stated that she had forwarded this email to the ADM and the RVP that day. CRN 1 stated that the email reported that on the weekend of 2/18/22, a staff member reported that resident 31 was observed to be sucking on resident 14's breasts. CRN 1 stated that she was told that during that weekend, the ADM had placed resident 31 on 1:1 staffing. CRN 1 stated that she was told the ADM had not investigated the abuse before that time. CRN 1 stated that it was reported to her that there was a report of both the sucking on boobies and resident 31 massaging resident 14's breasts twice by the time she became aware of the incident on 2/20/22. CRN 1 stated she was not sure why the ADM had not investigated the sexual abuse incident(s) between residents 14 and 31. On 3/29/22 at 1:32 PM, an interview was conducted with the Administrator (ADM). The ADM stated that she was managing all the abuse, along with complaints, discharges, and social work concerns in the building. The ADM stated that she did not recall when she was notified about the abuse between resident 31 and resident 14. The ADM stated that she investigated the incident in March and had substantiated the abuse. The ADM stated that she had moved the patient around so resident 31 was not close to resident 14. The ADM stated that she moved resident 31 closer to the smoking patio where he smoked. The ADM stated that the CNAs did rounds every two hours, so they would be checking on the residents when they rounded. The ADM stated that both residents were confused, and that resident 31 was too frail to walk down to resident 14's room, so abuse was probably not happening. 2. Resident to Resident altercation with Verbal Abuse allegation. A. Resident 20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/25/22 at approximately 10:00 AM, an interview was conducted with resident 20. Resident 20 stated that there was a fight in the hallway between resident 6 and resident 25. Resident 20 stated that resident 6 tried to hit resident 25. Resident 20 stated that she intervened and told resident 6, don't you hit him. Resident 20 stated that resident 6 replied, you shut up you [OBSCENITY] ing [OBSCENITY] or I'll get you next. Resident 20 stated that she returned to her room scared. Resident 20 stated that as a result of the fight, they moved resident 6 away from resident 25, but this move placed resident 6 in a room across the hallway from resident 20. Resident 20 stated that since the room change for resident 6 she was too scared to leave her room. Resident 20 stated that resident 6 was a big guy. Resident 20 stated that she informed the facility Administrator (ADM) of the incident and threat made by resident 6 against her. On 4/4/22 at 2:35 PM, a follow-up interview was conducted with resident 20. Resident 20 stated she was still nervous to leave her room with resident 6 still being around. Resident 20 stated that resident 6 was still residing in the room across the hall from her. Resident 20 stated that the ADM responded to her reports by saying that resident 6 was going to be discharged soon, and that she just needed to hold tight until it happened. On 4/11/22 resident 20's medical records were reviewed. Review of the facility census revealed that resident 20 resided in room [ROOM NUMBER]. It should be noted that resident 20's room was located directly across the hall from resident 6's room. B. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/11/22 resident 6's medical records were reviewed. Review of the facility census revealed that resident 6 resided in room [ROOM NUMBER]. It should be noted that resident 6's room was located directly across the hall from resident 20's room. On 1/6/21, resident 6 had a care plan developed for a focus area of struggles with controlling his anger and may become verbally or physically aggressive with others. Interventions identified were: Encourage the resident to focus on achievement of his discharge planning goals; Encourage resident to take time to collect his thoughts when upset with others so he can communicate more effectively; Encourage resident to utilize coping skill such as going for a walk, reading his bible, smoking, listening to music; If agitated allow resident personal space; If resident becomes rude or yelling or intimidating ensure safety and walk away and seek additional staff; and Reinforce verbal praise of any positive behaviors and utilization of coping skills. On 4/6/22 at 1:00 AM, the nursing progress note documented that resident 6 was on 1:1 monitoring due to physical and verbal aggression towards other residents. The note further documented that resident 6 stated to the Nurse Practitioner, You better get me out of this place before I hurt someone. The note documented that resident 6 was taken by ambulance for a behavioral evaluation but did not state the location that resident 6 was discharged to. On 4/12/22 11:03 AM, a interview was conducted with the Regional Vice President (RVP). The RVP stated that he was looking for the facility investigation for resident 20 and resident 6, but he was not hopeful he would find any abuse investigation documentation. 3. Resident to resident verbal abuse A. Resident 16 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/22 at 10:00 AM, an interview was conducted with resident 16. Resident 16 reported he was fearful of resident 53 because resident 53 regularly entered his room and threatened him. Resident 16 stated that it had happened approximately 4 times in the past month. Resident 16 stated that resident 53 resided in the room next to his. Resident 16 reported resident 53 threatened to hit him while raising his fists. Resident 16 stated he believed resident 53 made the threats because resident 16 speaks with a loud voice. Resident 16 stated he reported resident 53's threats to his assigned certified nurse aide (CNA) every time it happened. Resident 16 stated that the facility staff had removed resident 53 from his room in the past. Resident 16's roommate, resident 38, was present during the interview with resident 16. Resident 38 confirmed that resident 53 came into the room and threatened resident 16. Resident 38 stated he had tried to stand up for resident 16 because resident 16 can not protect himself. Resident 38 stated he was very upset because the facility staff do not do anything about the threats resident 53 made towards resident 16. Resident 16 stated that he had spoken to the Administrator and that she had done nothing. Resident 16 stated that he was afraid that resident 53 would actually hit him. Resident 16 stated that he had observed residents attempt to hit staff and that the staff protected themselves. Resident 16 stated the staff will protect themselves but not the residents. Resident 16 stated that he was bed bound, and had told staff multiple times to assist with the situation. On 3/25/22 at 10:38 PM, an interview with resident 16 was conducted. Resident 16 stated that they moved resident 53 to another room down the hall. Resident 16 stated that this was following an incident on 3/24/22 during the night when resident 53 threatened to hit resident 16 again. On 3/26/22 at approximately 9:30 AM, a follow-up interview was held with resident 16. Resident 16 reported on 3/25/22, that resident 53 came into his room and threatened him again. Resident 16 stated he then called the police. Resident 16's medical records were reviewed. On 1/7/22, a Quarterly MDS Assessment documented that resident 16's BIMS score was a 14, which would indicate cognitively intact. The assessment documented that a resident 16's PHQ-9 score was a 5, which would indicate minimal depression. The assessment documented that resident 16 did not have any indicators of hallucinations or delusions and did not exhibit any symptoms of physical behaviors towards others. The assessment documented that resident 16's functional status for bed mobility, locomotion on the unit, and dressing was an extensive two person assist. Resident 16 was assessed as a extensive one person assist for transfers and toilet use. The assessment documented that resident 16's mobility devices that were utilized was a wheelchair. On 1/28/21, a PASRR Level II was conducted with resident 16. The PASRR documented that resident 16 reported being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 16 reported that he had been involved with psychiatric treatment since childhood and was currently seeing a counselor that he, .mostly just talk on the phone. Resident 16 reported severe depression with anhedonia, decreased motivation and psychomotor [CONDITION(S)] where the patient did not want to get out of bed. Resident 16 also reported chronic and daily anxiety and stated that he was constantly anxious. Resident 16 stated that the anxiety caused him to .worry about many things and difficulty managing feelings of worry, filling tense and on edge all the time, and trouble sleeping d/t [due to] this anxiety. At the time of the assessment, resident 16 reported constant visual hallucinations that he had learned to put to the side and tried to ignore. Resident 16 also reported chronic auditory hallucinations that could be persucatory in nature. On 4/8/2022 at 7:36 AM, a Social Service Note documented, LCSW [Licensed Clinical Social Worker] met with resident for abuse screening and identification of immediate psychosocial concerns. Resident reported a prior altercation with another resident who 'threatened' him. Resident stated that the other resident moved rooms after the incident and that he feels 'safe' but expressed interest in referral for ongoing counseling. Review of the facility census revealed that resident 16 resided in room [ROOM NUMBER] and resident 53 resided in room [ROOM NUMBER]. Resident 53 was moved from 322 to 307 on 3/25/22. The facility abuse investigation documentation for the incidents between resident 16 and resident 53 were requested. No documentation of the abuse investigations were provided. Review of the State Survey Agency (SSA) entity reports revealed that on 3/26/22 at 7:00 AM, resident 16 woke resident 53 up when he was talking too loudly with another resident. The entity report documented that resident 53 became very angry and went through the bathroom to tell resident 16 to shut up or he's going to break his arm, jaw or leg. It should be noted that the SSA facility reported incidents (FRI) tracking system did not contain a facility final investigation summary report of the incident. B. Resident 53 was admitted on the facility on 8/29/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 53's care plan dated 12/7/21 that the resident is verbally and physically aggressive at times. The goal indicated was verbalize understanding of need to control verbally abusive behavior. No Psychosocial Reviews were completed for resident 53 after 9/6/21. Nursing notes for resident 53 revealed the following: a. On 9/16/21 at 12:06 AM, patient refusing care, refusing pain meds, calling nurse and cna [OBSCENITY] and witch stating thaat (sic) both are liars despite trying to give him care. b. On 9/16/21 at 1:43 AM, patient being verbally abusive, kicking staff out when he requests help for care. c. On 9/16/21 at 2:13 AM, ptient (sic) becoming physically aggressive, charging at nurse and CNA while naked. d. On 9/16/21 at 2:33 AM, Called [name of family member omitted] to see if he will calm down. Patient has been striking his walker against the floor in his room and bathroom. Patient now taling (sic) with daughter and claiming we [NAME] caring for him. I explained to her that we cant physically get near him since he is charging at us. e. On 9/16/21 at 2:35 AM, patient also scaring other patients with behavior. Nursing staff is also fearful. f. On 9/20/21 at 12:00 PM, patient yelling in middle of the night accusing staff of lying how frequently he can have tylenol. Patient waking up residents. Refuses to listen to nurses explanation of why he must wit (sic) for pain medications for 6 hrs (hours). g. On 1/7/22 at 1:40 AM, Resident this NOC (night) got in a verbal altercation with another resident and was very agitated. Denied getting his blood pressure taken this NOC. DON notified to reconsider room assignments. [Note: Review of the facility census revealed that resident 53 resided in room [ROOM NUMBER] from 8/29/21 until 3/25/22.] h. On 1/28/22 at 1:38 AM, Aggression towards staff. Review of resident 53's MARS since admission revealed no monitoring of behaviors for verbal or physical aggression towards others. 4. Resident to resident physical and verbal abuse A. Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/22 at 7:02 AM, an interview was conducted with resident 4. Resident 4 stated that resident 111 and her had an argument in the hallway three days ago. Resident 4 stated that she asked resident 111 to move and resident 111 then threw hot coffee on resident 4's lap. Resident 4 stated that she did not receive any [CONDITION(S)] from the hot liquid. Resident 4 stated that it was witnessed by Licensed Practical Nurse (LPN) 2. Resident 4 stated that she had spoken to the Administrator about this and nothing was being done. Resident 4 stated that this made her feel irritable. On 3/23/22 at 7:38 AM, an interview was conducted with LPN 2. LPN 2 stated that she witnessed the incident between resident 4 and resident 111. LPN 2 stated that resident 4 was moving down the hallway and that resident 111 was standing in front of the medication cart. LPN 2 stated that resident 4 told resident 111 to move and that resident 111 turned and called resident 4 a [OBSCENITY] ing [OBSCENITY] and threw coffee on resident 4's groin area. LPN 2 stated that she separated the two and took resident 4 to her room. LPN 2 examined resident 4's burned area. LPN 2 stated that resident 4 was in pain and had a red raised skin on the area where coffee was thrown on her. LPN 2 stated that resident 4 did not require any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/23/22 at 10:35 AM, an observation was made in the hallway, on the second floor. Resident 4 was propelling herself in an electric wheelchair from her room to the patio. Resident 111 was propelling herself in a wheelchair and was behind resident 4. Resident 111 yelled, Get out of the way, you Mother [OBSCENITY] ! This incident occurred in front of LPN 2 and CNA 17. Neither staff member reacted to the interaction between these residents. Review of the facility initial entity report documented that resident 4 complained of resident 111 .being upset this morning at her and purposely throwing hot chocolate at her face. The report documented that the incident occurred on 2/23/22 at 8:00 AM. The report documented that resident 4 was not injured or burned. The report documented the action taken was to move resident 111 to a different room. Review of the State Survey Agency (SSA) Incident Investigation Report documented, On 03/24/2022 at 12:09 am, the facility reported that, on 03/23/2022 at 8:00 am, resident [4] complained that resident [111] was upset with resident [4], that morning, and purposely threw hot chocolate in her face. The residents were assessed and no injuries or [CONDITION(S)] were found. Resident [111] has been moved to another room. APS [Adult Protective Services] was notified, case# 2. The family and physician was notified. Review of the APS report documented that the incident occurred on 3/23/22 at 8:00 AM and stated, Resident [4] complained of resident [111] being upset this morning at her and purposely throwing hot chocolate at her face. Resident [4] wasn't injured or burned. Resident [111] is OK. It should be noted the inconsistencies between the dates of the incident that were reported on the facility initial entity report, the SSA Incident Investigation Report, and the APS report. Resident 4's medical records were reviewed. On 3/22/22, a Quarterly MDS Assessment documented that resident

Based on observation, interview, and record review, it was determined for 9 of 51 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, residents had pressure ulcers that were not treated as ordered and one resident's that was not examined by a physician, and residents who underwent change of condition that were not treated timely. These findings were determined to have resulted in Immediate Jeopardy for residents 22, 41, and 61; and Harm for residents 29 and 40. Resident Identifiers: 17, 18, 22, 29, 40, 41, 49, 57, and 61. NOTICE On [DATE] at 1:10 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to provide residents quality of care to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This notice was given verbally to the facility Administrator (ADM), Regional Vice President (RVP), and the Corporate Registered Dietician (CRD) regarding resident 61. On [DATE] notice of the IJ for residents 22 and 41 was given verbally to the ADM. On [DATE], the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on [DATE] at 10:00 AM: 1. Resident #61 expired at the hospital; therefore, no individualized plan of correction is indicated. 2. The community RN's completed resident assessments for changes of condition. Any resident identified with a change from baseline will have the identified change of condition reported to the MD and the plan of care will be revised or implemented with specific interventions to address the concern. The community will begin to review daily progress notes (Monday through Friday) to ensure any documented changes of condition have adequate communication to the physician and responsible person. Residents with a pressure injury have the potential to be affected by this deficient practice. A whole house skin audit was completed by week ending [DATE] by the nurse management team. Any new pressure injury concerns that were identified received orders, treatments,documentation on the pressure injury and the care plans were updated by the DON/designee. 3. The community staff and agency staff received education and training on the Change of Condition Policy. The community also uses the Stop and Watch & SBAR tool to timely identify changes of condition to ensure any changes are quickly identified and reported to the physician. The community will review daily progress notes (Monday through Friday) to ensure any documented changes of condition have adequate communication to the physician and responsible person. The community will have AM huddles with staff after the morning stand up meeting to ensure staff are also aware of these changes of condition for close monitoring. Additionally, education was initiated on [DATE] by the consultants with nursing staff regarding the community pressure injury policy and the expectation of completing and documenting skin assessments and monitoring of skin concerns weekly with each resident. Any time a new skin issue is identified, the physician and responsible party should be notified, new orders should be received and implemented, the care plan should be updated, and monitoring should continue weekly until the area has healed. The consultants also provided training and education specifically on timely notification to the physicians when a pressure injury shows signs and symptoms of worsening condition. The consultants provided the community with a new daily standup meeting agenda. This agenda will include a pressure injury tracking log to track and trend pressure injuries and newly acquired pressure injuries. The DON/designee to complete weekly audit for three (3) months of three (3) residents with pressure injuries to ensure that the resident had a full skin assessment completed, new orders received for the identified areas, pain evaluated to ensure that it was being managed effectively, treatments initiated, documentation completed, positioning appropriate to promote wound healing, care plan accurate, and wound monitoring to be completed weekly until the areas healed. The consultants will be provided with a weekly pressure injury report for review and recommendations. 4. The DON/Designee will be responsible to report findings from the audits for review and recommendations. On [DATE], while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on [DATE] at 10:00 AM. Findings include: IMMEDIATE JEOPARDY 1. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], resident 61's medical record review was completed. On [DATE] at 11:09 AM, resident 61 had discharge orders printed from a regional care facility for wound care. The order for the coccyx wound stated: Bilateral buttocks and coccyx 1. Remove dressing 2. Clean wound with soap and water 3. Apply Santyl [MEDICATION(S)] to the wound bed in a nickel thick consistency. 4. Cut and apply Xeroform or oil emulsion over Santyl. 5. Place large sacral dressing to each buttocks, and silicone bordered foam to coccyx. 6. Please change dressing daily and as needed with hygiene. On [DATE] at 6:32 PM, resident 61 was weight by a mechanical lift at 430 pounds. A regional hospital Progress Notes for [DATE] revealed that resident 61 had 4. Sacral decubitus ulcer, stage III. Chronic ulcer, present on arrival. Sacral wound itself is unstageable with black eschar and purulent sluff. CT showed fat stranding inferior, posterior and right of the midline. Also noted small scattered areas of gas without definitive drainable fluid collection. No signs of [CONDITION(S)]. Plastics was curbsided and agrees with plan for continued wound care. - Continued aggressive wound care. - Patient will need frequent offloading/position changes. On [DATE] at 11:04 AM, the regional hospital Discharge Documentation for Discharge Wound Care Instructions were: coccyx 1. moisten a roll of gauze (kerlix) with Puracyn insert deep into undermining (12 cm toward anus) and depth of wound. On [DATE], a regional hospital discharge Progress Notes revealed that resident 61 had a stage 4 pressure ulcer on his coccyx, measuring 5.3 x 3.0 x 0 cm (centimeters) with undermining extending very close to anus. Description of the sacral ulcer revealed, Chronic ulcer, felt to be the cause of above noted bacteremia at his recent hospital stay. Currently, most wounds are looking reasonably clean without any purulence, exudate, or surrounding [CONDITION(S)]. Sacral wound itself is unstageable with black eschar and purulent sluff . If he is not progressing then we will plan to get a CT (computerized tomography) abdomen and pelvis with contrast to look for deep wound infection. Wound care consultation requested. Patient will need frequent offloading/position changes. An order in resident 61's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 61's Treatment Administration Record (TAR) revealed that this wound care was completed two times, on [DATE] and on [DATE]. On [DATE] at 1:00 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was recorded in the TAR as completed on [DATE] at 8:09 PM. On [DATE] at 4:22 PM, an Admission Summary revealed, .Skin Status/Interventions: Stage IV pressure ulcer to coccyx; cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of dressing .Incontinent of bowel and bladder . On [DATE] at 6:00 PM, an order was created to monitor the pressure ulcer to the coccyx each shift for signs and symptoms of infection or other complications. Nurses charted no complications on all checks, with the exception on ,d+[DATE] and ,d+[DATE] in the mornings, when the assessments were not completed. On [DATE] at 10:06 PM, a 72 hour charting after admission note revealed that resident 61 was adjusting well to returning to facility; appears to be in low spirits .Mental Status/Behavior: appears depressed and in low spirits; no behaviors noted . On [DATE] at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin prep barrier wipe to periwound skin. Pack undermining of wound w/ [MEDICATION(S)] soaked in Puracyn (squeeze out the excess). Apply Venelex to wound bed the apply Xeroform dressing. Secure with ABD (abdominal) pads. To be changed EOD (every other day) & PRN (as needed) if becomes soiled, saturated or accidentally removed one time a day every other day. This order was discontinued on [DATE]. The TAR revealed that this treatment was completed on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. On [DATE] at 9:56 AM, a skin/wound note revealed: Pressure ulcer to coccyx, undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . A referral was sent to a wound healing company to assess and treat. It was noted that the provider would be at the facility on [DATE]. On [DATE] at 11:50 AM, a physician's note revealed that resident 61 had an admission note created by a physician who performed a telehealth visit. A second note was entered at 8:44 PM. Skin status/interventions: Stage IV pressure ulcer to coccyx, cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100 (left lower side), surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . No other physician visits occurred during resident 61's stay. On [DATE] at 11:27 PM, a nurses note revealed: Changed dressing to buttocks. Moderate serosanguineous drainage (clear fluid) with odor. Cleansed peri with wound cleanser and dressing with ABD pads and [MEDICATION(S)] tape. On [DATE] at 9:35 AM, the resident advocate note revealed that resident 61 was admitted to the facility for [CONDITION(S)].According to resident discharge plan is to return home with home health. He is alert and orientated. He is currently using a wheelchair for locomotion and needs extensive assistance . His moods and behaviors have been cooperative, pleasant, and is compliant with cares since admission. On [DATE] at 10:30 AM, a Utilization Review (UR) note revealed that resident 61 .needs wound care (daily and PRN) .goal is to return home with HH (home health) . On [DATE] at 9:15 AM, a social services care conference note was started, and was not completed. Status stated In Progress. The note revealed that .wounds have no s/s (signs/symptoms) of infection .pleasant and cooperative with cares . On [DATE] at 11:00 AM, resident 61 had blood drawn for laboratory tests. On the results, a note was written that resident 61 needed a BMP (basic metabolic panel) completed in 1 week with a date [DATE]. Resident 61 had a white blood cell count of 11,300, with high neutrophils and immature granulocytes. [No additional blood tests were completed for resident 61 until [DATE].] [Wound physician did not see resident 61 on [DATE].] On [DATE] at 5:41 PM, resident 61 had a Nutritional Assessment. The assessment revealed that resident 61 had .increased nutritional needs d/t (due to) skin impairment to coccyx . Recommend adding . Juven BID (twice daily) and liquid protein . to support healing. Will monitor weight, intake, wound healing and will adjust nutritional interventions as needed. [No orders for Juven or liquid protein were initiated for resident 61.] On [DATE], a Mini Nutritional Assessment was completed. Resident 61 was At risk of malnutrition. [Note: No further nutrition assessments were completed.] Resident 61 had a nutritional care plan created on [DATE]. An intervention was to Provide supplements to promote wound healing. Resident 61 did not have a wound care plan included in his care plans. On [DATE], resident 61 was assessed in the Minimum Data Set (MDS) as requiring rehabilitation, urinary incontinence, fluid maintenance, fall risk, pain management, nutritional status management and pressure ulcer management. On [DATE], resident's [MEDICATION(S)] tablet order was not provided due to being out of supply, not in med cart. On [DATE] at 8:09 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 9:32 AM, a MDS skin conditions evaluation that revealed resident 61 had 1 stage 4 pressure ulcer. Resident 61 had a pressure reducing device for the bed. Nutrition or hydration intervention to manage skin problems were noted as being in place. On [DATE] at 5:33 PM, a nurses note revealed that labs drawn [DATE] rec'd (received) w/ (with) noted abnormalities .NP (Nurse Practitioner) reviewed w/ N/O (new order) for BMP recheck in 1 week. [This lab was not redrawn.] On [DATE] at 3:25 PM, a Utilization Review (UR) note revealed that resident 61 .needs skilled wound care (daily and PRN) .goal is to return home with HH (home health) . On [DATE] at 4:30 PM, a skin/wound note revealed: Residents wound remains with deep 2 o'clock tunneling. with 5 X 6 (centimeters) opening. Wound has foul odor. Peri wound has improved. New order to fill wound bed with calcium alginate rope cover with bordered foam. Resident tolerated well . Resident 61 reported the following pain scores (out of 10) without reporting effective pain control: a. On [DATE] at 10:26 AM, 9 b. On [DATE] at 1:06 PM, 8 c. On [DATE] at 1:11 PM, 7 d. On [DATE] at 9:15 PM, 8 e. On [DATE] at 5:06 PM, 7 f. On [DATE] at 9:58 PM, 7 [No new interventions were noted.] On [DATE] at 8:37 PM, a skin/wound note revealed: Change resident dressing daily. Wound is 6 cm X 6.5 cm X 8.5 cm tunnel at 2 o'clock. Lots of blood drainage. Wound nurse's are following dressing change order from the hospital On [DATE] at 1:57 PM, a Utilization Review (UR) meeting revealed that resident 61's plan of care was to work with therapy and to return home with home health. The nursing update included .skilled wound care (daily and PRN), . On [DATE] at 6:28 AM, a nursing note revealed that resident 61's Wound remains open with foul odor. Wound is 6 cm X 5.5 CM x 2 CM. It tunnels at 2 o'clock 8 cm. Wound has necrotic tissue coming out of the tunnel area. Dressing change daily. Dakins soak 30 min. then Calcium alginate rope to tunnel with calcium alginate in wound bed. Cover with ABD pad and foam cover . On [DATE] at 8:15 AM, resident 61 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR revealed that this order was completed on [DATE] and [DATE]. On [DATE] at 8:02 AM, resident 61 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], a Skilled Daily Review was performed for resident 61. Skilled need was wound to coccyx with tunneling at 2:00 position per wound care nurse. Pain mgmt (management). Assist with ADLs (activities of daily living). Resident 61 was incontinent of urine and bowel movements, and wore briefs with peri care provided with each brief change. [Note: There is no documentation about wound care changes with brief changes.] On [DATE] at 3:17 PM, resident complained of sacral pain for which PRN medication was provided. On [DATE] at 11:33 PM, a weekly skin review revealed no new skin integrity problems. The sacral pressure injury was noted. On [DATE] at 9:43 AM, a nurses note revealed that the nurse had received report of resident 61 having increased confusion with shaking, high blood pressure, resident looking to the left to respond to the nurse who was on the left side of the bed, and confusion about how to drink water. Nurse contacted physician who ordered STAT blood and urine tests along with a chest X-ray to rule out infection. Resident was given 1 liter of normal saline over 5 hours. On [DATE], blood pressure obtained was ,d+[DATE], followed by ,d+[DATE]. On [DATE] at 10:36 AM, a nurses notes revealed that resident 61 had an IV (intravenous access line) placed in the right hand for blood draw. On [DATE] at 1:59 PM, a higher-than-normal respiratory rate was noted at 22 breaths per minute and heart rate was 124 beats per minute, irregular, and was identified as a new finding. [There was no documentation that a physician was contacted.] On [DATE], resident 61's lab results were faxed to the facility at 4:43 PM. Resident 61's white blood cell count was 25,100, with segmented neutrophils. RN 1 noted the results on [DATE]. [There was no documentation that this report was forwarded to a medical provider until the following day.] On [DATE] at 7:37 PM, an order was initiated for resident 61 to assess resident 61's pressure ulcer and notify the physician if any complications. On [DATE] at 3:55 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was noted as done by previous shift. [No documentation of providing the results to the physician was noted.] On [DATE] at 4:44 AM, a nursing note revealed a blood pressure of ,d+[DATE], heart rate of 99 beats per minute, and oxygen saturation at 93% on a Continuous Positive Airway Pressure ([CONDITION(S)]) device. The nursing note stated no changes res (resident's) health status from yesterday. Asked res if he would like to go to the hospital for checkup but he refused it. Encouraged res to increase fluid intake. PRN (as needed) pain med was given for pain on both knees. will continue to monitor. On [DATE], on the final lab results report, a note written at the bottom of the report revealed that one of the medical providers made an order to send resident 61 to the Emergency Department. On [DATE] at 11:41 PM, an order was entered/discontinued for a wound care company to eval and tx (treatment) r/t pressure wounds to coccyx and bilateral buttocks. On [DATE] at 12:36 PM, a nursing not revealed that resident 61 was sent to the hospital. On [DATE] at 1:32 PM, a regional hospital Emergency Documentation was initiated for resident 61. The documentation revealed that resident 61 had chief complaints of: a. altered level of consciousness b. high heart rate c. not looking to the right He apparently was acting abnormally this morning according to rehab facility staff but what that means is a little bit unclear. He was transported and there was no mention of increased work of breathing or [CONDITION(S)] I was called to the room because of high heart rate and tachypnea (rapid breathing). Looks like he is in [CONDITION(S)] with RVR (rapid ventricular rate of response) but does not endorse any chest pain at all. He is noted to be with a right-sided neglect. No known vomiting. Given patient status no other history was obtained. Stroke 1 is called. Meds ordered for his high heart rate. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. initiation of end-of-life care b. septic shock c. [CONDITION(S)] d. respiratory failure e. acidosis f. superobesity g. diabetes h. strokelike syndrome i. [CONDITION(S)]/[CONDITION(S)] Medical decision making/differential Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . He presented with [CONDITION(S)], some altered mental status, rapid heart rate with what looked like new onset [CONDITION(S)] (fluttering atria of the heart). He is also quite tacypneic. He already had leuckocytosis yesterday at 26,000. Today it climbed to 32,000. I think this clinical picture was strongly suggestive of septic shock and overwhelming [CONDITION(S)]. His sacral area wound showed a large area of ecchymosis and [CONDITION(S)] and some purulent drainage from the central portion of the ulcer. He seemed to medically stabilize early on but then after resuscitative efforts were towards the tail and the patient actually worsened in status. Long discussion was held with numerous family members .he became medically unstable and worse over time despite antibiotics fluids respiratory support no other [CONDITION(S)] treatment measures. I did not see any obvious reasons to counter patient and family wishes and initiating end-of-life care. The massive area of skin and soft tissue infection with ulceration was the likely source of his infection and massive debridement would be necessary . The course of treatment in the Emergency Department included . Required supplemental oxygen. [CONDITION(S)] protocol enrollment with treatment provided. In addition neurology consultation was required early on given concerns for potential stroke. [A neurologist] did not feel that the patient was under going a stroke syndrome Thereafter [CONDITION(S)] treatment was the focus We evaluated the wound on his backside and it was massive encompassing a large territory of the entire lower lumbar and sacral region with a draining wound and a lot of surrounding necrotic tissue with [CONDITION(S)] extending down to the perineum without obvious drainable abscess. Shortly after evaluating this wound the patient became diaphoretic and more short of breath but remained lucid. Additional oxygen was provided. We had discussed at this point in time about focus of treatment and goals of treatment . An arterial blood gas (ABG) was obtained and resident 61 had worsening acidosis Patient progress towards severe illness and end of life pretty quickly at around 5:30 PM, resident was noted to have agonal respirations and confirmed at this time if we do not act patient will certainly die soon. Again there was consensus with family members present to proceed with comfort measures and monitors were turned off and high flow oxygen was turned off along with vasopressors. Family gathered at the bedside and said their goodbyes and time of death was estimated to be at 6:10 PM. On [DATE] at 11:31 AM, a former DON, DON 2, was interviewed. DON 2 stated that resident 61 had a pretty serious tunneling wound that no doctor had examined while resident 61 was in the facility. DON 2 stated that she spoke with the facility Medical Director, and determined that he was not following resident 61. DON 2 stated that she never spoke with him (the Medical Director) on the phone. He wasn't responding to emails or [messaging app] texts. DON 2 stated that there was a facility Nurse Practitioner (NP), and I cornered [the NP] and said 'Hey this guy needs to be seen. but no one was ordering anything. DON 2 stated that the wound clinic was unable to treat resident 61 because of his insurance, so resident 61 was not seen by any prescribing provider. DON 2 stated that resident 61 had insurance that would provide wound care to their clients in their wound clinic, but resident 61 was not sent out. DON 2 stated that resident did not have orders provided by any clinician, that wound care orders were generated by the wound nurse (now the ADON). DON 2 stated that the ADON was just talking to the wound doctor and he (the wound doctor) would write the orders based on what she said, but no doctor was laying eyes on resident 61's wound. DON 2 stated that she was supposed to take a picture of [a resident's wound] on my phone, and I was supposed to sent to it [the ADON], then she would write an order without any other consult with a physician. DON 2 stated that this was the way the wound care process was during the time she was employed. DON 2 stated that resident 61 never went to wound clinic. He went to the hospital, went septic, and started crashing. On [DATE] at 10:10 AM, the ADON was interviewed. The ADON stated that typically, residents have wound care provided in the facility, depending on their insurance. The ADON stated that resident 61 had an insurance that required him to go out to a specific wound clinic, but resident 61 was not able to be sent out to the clinic. The ADON stated that DON 1 was working on obtaining a different insurance for resident 61 so their providers could follow his wound. The ADON stated that she did not have the authority to send resident 61 out to the clinic when she was the wound nurse. The ADON stated that no physician consulted for resident 61, and all new orders for his wound care were generated by her. The ADON stated that no physician ever laid eyes on resident 61's wound. The ADON stated that I was just doing the best I could as the wound nurse. The ADON stated that the providers wouldn't give an order without seeing resident 61. The ADON stated that resident 61's wound was not getting any better, but he weighed almost 600 pounds so it was difficult to get an ambulance to take him out. The ADON stated that she ordered Dakins solution because the wound had such an odor. The ADON stated that she wanted to order a silver alginate to keep infection away. The ADON stated that she was not aware of resident 61 being discussed in the interdisciplinary team (IDT) meetings. The ADON stated that the order she initiated was for wound care to be performed every other day, but it should have been done daily if possible. The ADON stated that the wound care was possibly done more often than what was charted. The ADON stated that there was so much agency in the building, there were a lot of things they didn't get around to. The ADON stated that the bloody drainage on the 16th was good, because it meant that the wound was healing. The ADON stated that resident 61's bowel movements would get all over the dressings. The ADON stated that she was not wound care certified, and staging a wound was beyond her scope of practice. The ADON stated that on [DATE], there was a foul odor, and she wanted the doctors to provide an antibiotic. The ADON stated that she changed resident 61's wounds, but did not do anything else for him. The ADON stated that resident 61 was not taken out until he went to the hospital on [DATE] with [CONDITION(S)]. The ADON stated that there was no way to determine what wound care was done, that if a nurse signed that they completed the wound care, she would have to believe they did it. On [DATE] at 12:42 PM, the Corporate Resource Nurse (CRN 1) was interviewed. CRN 1 stated that the wound nurse was responsible for communication with the wound care providers and physicians. CRN 1 stated that the wound nurse (now the ADON) would look at wounds and show them to the physicians. CRN 1 stated that the ADON requested orders from physicians, and would enter orders in the computerized record and request physicians to sign the orders. CRN 1 stated that she was not aware if physicians created the orders or signed the orders after the fact. On [DATE] at 1:32 PM, the Administrator (ADM) was interviewed. The ADM stated that the former DON (DON 1) was working on resident 61's insurance. The ADM stated that she assumed that a doctor was following resident 61's wounds, and that the wound nurse would take care of that. The ADM stated that an analysis of preventing resident 61's hospitalization was no completed. The ADM stated that she was not aware of discussing resident 61 in the morning stand-up meetings. The ADM stated that when a resident had a change of condition, staff would discuss what to do, what tests were required and determine if the resident needed to go to the hospital. The ADM stated that she did not believe that resident 61 had a change of condition before he was sent out. On [DATE] at 12:10 PM, the Administrator was re-interviewed. The ADM stated that she had assumed the physician would check on resident 61. The ADM stated that when resident 61 went to the hospital with [CONDITION(S)], she did not complete an analysis of what staff might have done to prevent the hospitalization . The ADM stated that she had not completed an analysis of identifying residents' change of condition timely. The ADM stated that staff were not always very talkative during morning meetings, and she was not clinical, so sometimes she didn't know what was happening with the residents. On [DATE] at 12:20 PM, the ADON was re-interviewed. The ADON stated that prior to the last two weeks, she was acting as the wound care nurse in the building. The ADON stated that her responsibilities as the wound nurse (WN) was to assist the provider on Thursdays with wounds, new orders, and at times, she was also fulfilling the role as a floor nurse. The ADON stated that she was responsible for wound care in the building four days each week, and the floor nurses were responsible the other three days. The ADON stated that she entered the wound care orders for the residents into the computer for the floor nurses to follow. The ADON stated that the wound physician would complete the measurements and staging of the wounds. The ADON stated that when a resident was admitted to the facility, she would create a temporary order for wound care. The ADON stated that she would tell the physician's group Nurse Practitioner what she was going to do for a resident. The ADON stated that she put the order in as a verbal order from the medical director. The ADON stated that she noticed that some wound care treatments had not been completed by the nurses. The ADON stated that It took me an hour to go through the whole building. The ADON stated that she was unsure why the nurses weren't doing their wounds. The ADON stated that for resident 61, she felt like I was screaming into a void on that one. I was very concerned about him and I couldn't get anyone to listen to me. The ADON stated that the Nurse Practitioner told her to get him into a wound clinic to have the wound debrided surgically, but she could not get him into the other clinic because he weighed about 600 pounds. 2. Resident 22 was initially admitted to the facility on [DATE] and again on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:25 PM an interview with resident 22 was conducted. Resident 22 stated that the facility was dysfunctional. Resident 22 stated that she had wounds on her legs which were painful. Resident 22 stated that she did not feel like she received good care at this facility. Resident 22's medical records were reviewed on [DATE]. Resident 22 had an order that started on [DATE] and it stated wound care to right lower extremity, clean wound with wound cleaner or NS [normal saline], pat dry with gauze. Silver alginate to hold at 8'oclock, place [MEDICATION(S)] over the whole wound, cover with bordered foam. Change Q [every] Tuesday, Thursday, Saturday, and PRN [as needed]. The Treatment Administration Record (TAR) for March was reviewed. Documentation for wound care was miss [TRUNCATED]

Based on observation, interview and record review it was determined, for 10 out of 51 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident with a history of suicidal ideation (SI) and major depressive disorder eloped from the facility and was gone for 24 hours before staff notified administration and the local police department, a resident with suicidal ideation and homicidal ideation (HI) was found with multiple weapons in his possession, and a resident was found in the unsecured laundry area near cleaning chemicals and the unlocked broiler room. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level Additionally, a resident sustained a [CONDITION(S)] during a staff assisted transfer, a resident had complaints of increased pain after a fall from a Hoyer lift, and a dependent resident was left outside during inclement/cold weather for an unknown extended period of time by staff. These identified deficient practices were found to have occurred at a Harm Level. Lastly, a resident sustained a fall after slipping on floors that were wet from drainage that had leaked from their wounds, a resident had multiple falls without interventions identified to prevent the falls, and a resident with right sided [CONDITION(S)] was observed ambulating and [NAME] up the stairs while a staff member carried the resident's wheelchair behind them. Resident identifiers: 4, 18, 23, 27, 28, 38, 40, 43, 49, and 51. NOTICE On 4/5/22 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that residents identified at risk for elopement and self-harm and harm towards others were evaluated, that interventions were identified and monitoring for safety was implemented. Additionally, environmental hazards such as unsecured chemicals and the unlocked broiler room posed toxic and caustic hazards for the residents. Notice of the IJ was given verbally to the facility Administrator (ADM) and the Corporate Resource Nurse (CRN) and they were informed of the findings of IJ pertaining to F689 for resident 40 only. On 4/7/22 at 8:28 AM, notice of the IJ for resident 49 was given verbally to the ADM, Regional Vice President (RVP), and the Corporate Registered Dietician (CRD). On 4/7/22 at 3:40 PM, notice of the IJ for resident 28 was given verbally to the Director of Clinical Services (DCS). On 4/12/22, the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/12/22 at 10:00 AM: 1. Resident #40 was placed on a 1:1 for close supervision and oversight. Resident #40 will remain on 1:1 until alternative placement can be found. 2. Resident who have the history of or who have been assessed to be high risk for elopement have the potential to be affected by this deficient practice. The community DON [Director of Nursing] or designee completed an audit of other residents to determine risk factors per H & P [History and Physical] and Elopement Assessments. 3. The staff received education and training on 4/11/12 regarding the Elopement Policy and Procedure. Education to be completed with licensed nursing staff regarding complete minimally every 2 hours visual checks of all residents who are at high risk for eloping to ensure that we know where they are at. If we are unable to locate them, the NHA [Nursing Home Administrator] and DON must be notified immediately and search of the building and surrounding area initiated. Failure to complete q2h [every 2 hour] checks will lead to disciplinary action. The consultants initiated an Elopement Binder on 4/11/2022. An audit will be completed of all resident's Wander Risk assessment to ensure that they completed and anyone identified as High Risk has an appropriate intervention in place, a care plan regarding the high risk, order, and that they are in the Elopement Binder at the front desk and on each nursing station. An audit will be completed on the Elopement Binder to ensure all residents identified as high risk are included in the Elopement binder and Elopement Identification Sheets are current and up to date. Any incidents of Elopement attempts will be reviewed in the IDT [interdisciplinary team] morning meeting including documentation of discussion and care plans will be updated appropriately. Elopement drills will be performed monthly for the following quarter, If the community sustains compliance, elopement drills can be conducted on a quarterly basis. The laundry room door was immediately locked upon identification by the survey team. The identified resident with with (sic) suicidal ideation was sent to the hospital and will not return to the community due to the community cannot provide care and services to meet his psychosocial needs. 4. The community will review with the QAPI [Quality Assurance and Performance Improvement] committee any elopement attempts/exit seeking behavior or reportable missing person occurrence report for the month for review or recommendation to follow up on. The DON or designee will report findings from the elopement drill. The NHA or designee will be responsible to follow up on any recommendations. On 4/12/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/12/22 at 10:00 AM. Findings include: IMMEDIATE JEOPARDY 1. Resident 40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of [CONDITION(S)], malignant neoplasm, [NAME] syndrome, major depressive disorder, suicidal ideation, mood disorder, [CONDITION(S)], [CONDITION(S)] C, acute kidney failure, and [CONDITION(S)]. On 4/5/22 resident 40's medical records were reviewed. Review of resident 40's physician orders revealed that the resident was receiving Trazadone 150 milligrams (mg) each day (qd) for [CONDITION(S)], [MEDICATION(S)] 50 mg qd for anxiety, [MEDICATION(S)] 150 mg qd for major depressive disorder, and [MEDICATION(S)] 400 mg at night and 200 mg in the morning for mood disorder. On 10/20/21, facility staff completed a document entitled Evaluation for Community Access for resident 40. Staff documented that resident 40 should not be in the community alone and based on the evaluation determined the resident was disoriented to person, place, time or situation; and the resident was easily confused. The physician reviewed the evaluation and concurred with the assessment on 10/21/21. On 10/25/21, an Admission Minimum Data Set (MDS) Assessment documented that resident 40's Brief Interview for Mental Status (BIMS) score was a 12, which indicated a moderate cognitive impairment. On 10/26/21, a Montreal Cognitive Assessment (MOCA) was completed for resident 40. The MOCA score documented was a 18/30, which indicated a mild cognitive impairment. On 10/27/21 at 9:52 AM, the Resident Advocate (RA) progress note documented that the resident was deemed unsafe to go into the community without supervision. Evaluation will continue on a routine basis to determine if there is a need for the resident to be accompanied when out of the facility. All paperwork can be found in residents med (medical) records. It should be noted that no other documentation could be found that resident 40 was re-assessed for the ability to safely go out into the community without supervision. On 10/27/21, staff developed a care plan for resident 40 stating that the resident had a history of suicidal statements, feelings of depression, impaired thought processes and delusions. Interventions identified for the focus area of suicidal statements were to monitor resident 40's mood daily for self-isolation and negative statements; giving away of personal possessions or hoarding items to self-harm; initiate immediate referral to a mental health professional; verify that medications were swallowed; if actively concerned for safety initiate transfer to inpatient psychiatric facility; search resident's room for weapons or items to be used for self-harm, place resident on 15 minute safety checks; and provide gentle/sensitive support. Interventions identified for the focus area of depression were that social services would meet with resident 40 for supportive visits as needed; staff would identify personal strengths and abilities; praise resident 40 for accomplishments; support positive statements resident 40 makes; encourage involvement in chosen pursuits and hobbies; and refer for review by [CONDITION(S)] committee and medical doctor (MD) or mental health professional. Interventions identified for the focus area of delusions were, do not argue, criticize or correct the resident, help resident 40 to feel safe, and use validation/therapy techniques to redirect to another topic or activity. Interventions identified for the focus area of impaired thought processes were to communicate with the resident regarding their capabilities and needs, review medications for possible causes of cognitive deficits, and use task segmentation to support short term memory deficits. On 11/18/21, a PreAdmission Screening Resident Review (PASRR) Level II was conducted with resident 40. The PASRR indicated that resident 40 had a history of recurring depression with [CONDITION(S)] and that the resident had been hospitalized multiple times due to depression and suicidal ideation, stating he would cut his throat with his knife or jumping off of a building. The PASRR also indicated a history of suicidal ideation with multiple suicide attempts in the past. Resident 40 had a history of bouts of severe paranoia and visual hallucinations. Resident 40 will see people he believes are following him for unknown reasons who are not there. He has been noted to be suspicious of medical and psychiatric treatment staff who are trying to help and treat him. he reported being diagnosed with [CONDITION(S)] disorder in the past, but he does not 'see myself in the category of schizophrenia'. Notes from resident 40's behavioral health provider dated 11/19/21 documented that resident 40 stated I'm tired of the ruminating thoughts, I need to manage them, and reported multiple psychiatric hospitalization s since his last treatment episode with [name of behavioral health provider] for issues related to 'depression and suicide ideation'. The notes also stated that the resident stated he has multiple personality disorder. On 2/14/22 at 8: 43 AM, a psychosocial review was completed for resident 40. Staff documented that resident 40's mood appeared unstable. He has suicide ideation and has cut his wrists several times in the past. Staff also documented that resident 40 had been diagnosed with major depressive disorder, mood affective disorder, and suicide ideation. On 2/14/22 at 1:25 PM, a Patient Health Questionnaire-9 (PHQ-9) was completed for resident 40. The PHQ-9 indicated that resident 40 had a score of 10, which indicated moderate depression. Review of the facility Policy for Wandering and Elopement documented that the facility would identify residents who were at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The Policy stated that if the resident was identified as at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety. The policy further stated that if a resident was missing, the facility should initiate the elopement/missing resident emergency procedure: a. Determine if the resident was out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident was not located, notify the ADM, DON, the resident's legal representative, the physician, law enforcement, and as necessary volunteer agencies. The policy was last revised in March 2019. On 4/5/22 at 9:25 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the last time she saw resident 40 was at approximately 11:10 AM on 4/4/22. RN 1 confirmed that she worked 6:00 AM to 6:00 PM on 4/4/22. RN 1 stated that she received report from the night nurse at approximately 6:00 AM on 4/5/22 that the resident still had not returned. RN 1 stated that as of the time of the interview, she still had not seen resident 40 in the building. On 4/5/22 at 10:12 AM, a review of the resident Leave of Absence (LOA) book was reviewed. A review of the LOA book at the nurse's station nearest resident 40's room revealed a sheet for resident 40. The sheet was blank with no entries noted. Instructions located on the inside of the booklet stated: Effective immediately for all residents leaving the facility without a staff member; 1. The release of responsibility form must be completed. 2. Nurse must notify the family contact and document in the nurse's notes. 3. If medication is to accompany the resident, medication teaching is to be done and documented. It should be noted that no documentation could be found in the nursing progress notes of resident 40 going on LOA. On 4/5/22 at 10:23 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that when she had arrived to work on 4/4/22 at 10:00 AM, she was told by a facility nurse that resident 40 had left. CNA 1 stated that she did not know where resident 40 had gone. CNA 1 stated that she left work on 4/4/22 at 10:00 PM, and the resident still had not returned to the facility. CNA 1 stated that when she left the facility at 10:00 PM, she informed the nurse on shift that resident 40 still had not returned to the facility, but the nurse already knew about it. CNA 1 stated that she was not sure if she was supposed to do anything differently if residents left the facility. On 4/5/22 at 11:07 AM, a follow-up interview was conducted with RN 1. RN 1 stated that resident 40 usually goes out every day and refused to sign the LOA book. RN 1 stated that sometimes resident 40 did not make staff aware that he was leaving the facility. RN 1 stated usually when he goes then I come back he is here. RN 1 stated that residents often left the building via the first floor because when you push the door for a long time it will open. RN 1 stated that she should have notified the Administrator (ADM) already, because now it is out of the ordinary. He is alert and oriented times 3. RN 1 stated that she was not documenting when resident 40 left the facility. RN 1 stated that resident 40 had reported depression especially after [CONDITION(S)]. RN 1 stated that she had no way of contacting the resident, and that he had never been gone this long. RN 1 stated that resident 40 had left overnight once before, sometime during the winter, but she was not sure when. RN 1 stated that resident 40 knew the door code to be able to exit the building. RN 1 stated that she was not sure if resident 40's absence had been reported to the police. RN 1 stated that when resident 40 left the building on prior occasions he would say it won't be long. RN 1 stated that she should report now because it had been 24 hours and resident 40 had not had his morning medication. On 4/5/22 at 11:24 AM, an interview was conducted with CNA 2. CNA 2 stated that he had last seen resident 40 on 4/4/22 at 7:30 AM. CNA 2 stated that to not see him back by lunch is not normal and especially to be gone overnight. CNA 2 stated he was not aware that resident 40 had been gone from the facility overnight. CNA 2 stated that he spoke to the nurse on shift on 4/4/22 and let her know that resident 40 had not yet returned to the facility. CNA 2 stated that resident 40 did not frequently go out on LOA. On 4/5/22 at 11:29 AM, an interview was again conducted with RN 1. RN 1 stated that she had notified the ADM, and the ADM had stated to document that he was an adult and does not have any issues with his conditions. On 4/5/22 at 11:43 AM, an interview was conducted with the ADM. The ADM stated that she was under the impression that resident 40 had left the faciity on [DATE], not 4/4/22. The ADM stated that no one had notified her that resident 40 had left the facility and not returned on 4/4/22. The ADM stated that resident 40 was cognitively intact. The ADM stated that resident 40 could make his own decisions, but that she would call the police and it sounds like he is leaving AMA (Against Medical Advice). On 4/5/22 at 12:53 PM, a follow-up interview was conducted with the ADM. The ADM confirmed that resident 40 had left the facility yesterday. The ADM stated that she had searched the building and confirmed that the resident was not currently in the building. The ADM also stated that she searched resident 40's room, and it appeared that resident 40 had taken his belongings out of his room. The ADM stated that she had called the police. The ADM stated that if a resident left the building, they were supposed to sign an LOA. The ADM stated that if the resident did not want to sign an LOA form, then the nurse should document the date and time on the LOA form and also document a progress note. The ADM stated that the nurse should also document when the resident returned, as well as notify the ADM, Director of Nursing, Assistant Director of Nursing (ADON), family and physician. The ADM stated she did not know of any other instances when resident 40 had left the facility overnight. The ADM stated she had not notified resident 40's physician that he had left the facility overnight. When asked what prompted her investigation into resident 40 leaving the building, the ADM stated that it was because the State Survey Agency (SSA) representatives had been asking questions. On 4/05/22 at 1:10 PM, a follow-up interview was conducted with CNA 2. CNA 2 stated that the last time he saw resident 40 he was wearing blue jeans, black shoes, and a black leather jacket. CNA 2 stated that resident 40 was independent for all cares, mobility, and transfers. On 4/05/22 at 1:13 PM, RN 1 was interviewed again. RN 1 stated that at the time resident 40 left the facility he had stated that he was going to a local grocery store to get food and he did not say when he would be returning. RN 1 stated she asked resident 40 to sign the LOA book, but resident 40 ignored her request. RN 1 stated that at the time of his departure resident 40's mood was normal per his baseline, but prior to leaving he was upset about the facility and did not want to be there anymore. RN 1 stated that resident 40 took his backpack with him when he departed, but that he always carried it with him. RN 1 stated that she was fearful that the ADM would retaliate against her for disclosing information to the SSA representatives. RN 1 stated that she had informed the ADM initially that resident 40 had been gone since 4/4/22 and the ADM had replied, He's old, he can go out, he doesn't have any medical condition that is concerning. RN 1 stated that the ADM asked again when resident 40 had left the facility after the SSA representative had questioned the ADM about the timing of notification. RN 1 stated that she told the ADM, I told you it was yesterday. RN 1 stated that the ADM acted like she did not know that resident 40 had left the faciity on [DATE]. RN 1 stated that she had told the ADM the complete story, and now she acted like she was not informed. That's fishy. On 4/7/22 at 8:28 AM, a follow-up interview was conducted with the ADM. The ADM stated that resident 40 was readmitted last night around 7 PM. The ADM stated that the plan for resident 40 was to have the resident on 1:1 with a staff member, and they called a Social Service Worker (SSW) consultant to have them come talk to the resident. The ADM stated that 1:1 was a lot of coordinating, but that they would continue with it until resident 40 cleared and did not have any more behaviors. The ADM stated that the emergency room (ER) stated that resident 40 was ready to come back to the facility and he was deemed not a threat to himself or others. The ADM stated they would have a SSW come in today and evaluate him. Review of resident 40's hospital ER summary dated 4/5/22 documented the reason for the visit was a Crisis Evaluation for Suicidal Ideation. The note stated that resident 40 arrived to the ER endorsing severe pain and suicidal ideation with a plan to end his life either with a gun or with a knife. Patient presents alert and oriented x 4 [person, place, time, and situation], fidgety and restless and moves around (standing to sitting and pacing somewhat) while meeting with Crisis Worker. Patient reports feeling 'frustrated' about the amount of pain he is in as well as the state of his physical health and states his body is wearing down and he does not have energy to keep going He reports he has not seen a therapist since December 2021 due to lack of energy and apathy to follow-up. Patient has a history of cutting and stating he has only dealt with emotions as 'tied up or angry' and cuts to release his emotions. Patient reports he does not own a gun currently but states if he did, 'I would not be here right now.' Patient is unable to safety plan and has a knife in his belongings here in the hospital. He reports he attempted suicide in 2006 when he jumped from a second story bridge in [name of state] into the [name of river] River. After this attempt, patient reports he was hospitalized at a county hospital, a private psychiatric hospital, and then a state hospital. The patient history further documented that resident 40 reported that since his [CONDITION(S)] treatment had begun, he had worsening depression and that the [MEDICATION(S)] was no longer working for him. Resident 40 also reported that while living in the skilled nursing facility he had no one to talk to. Resident 40 was screened as a Moderate risk for suicide/self-harm. Resident 40 met the criteria for a voluntary admission and was evaluated as unable to remain safe in a less restrictive environment at this time. 2. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] diagnoses that included [CONDITION(S)], suicidal ideations, major depressive disorder, anxiety disorder, chronic pain syndrome, opioid use, and neuromuscular dysfunction of the bladder. Resident medical record was reviewed between 3/23/22 and 4/13/22. On 3/2/21, facility staff completed an Evaluation for Community Access for resident 49 in which they determined that the resident had a history of being unsafe in the community and had a physical impairment which rendered the resident unsafe in the community. The resident met the criteria determining that resident should not be in community alone. A PASRR level II was completed for resident 49 on 3/22/21. The PASRR documented that resident 49 has a history of treatment for depression and anxiety, along with multiple maladaptive personality traits; all of these have caused pt (patient) significant functional impairment for many years. He also endorsed symptoms of [CONDITION(S)] (Post Traumatic Stress Disorder) that he reports are causing him significant disruption at this time. The PASRR indicated that resident 49 had a history of suicidal ideations and suicide attempts, beginning in his teens. The PASRR indicated that in September 2020, resident 49 was residing at a long term care facility and tried to strangle himself, which led to an inpatient psychiatric hospitalization . The PASRR continues He has also experienced excessive anxiety and worry, difficulty managing feelings of worry, restlessness/fatigue d/t (due to) excessive worry, irritability, tension, and trouble sleeping d/t anxiety. He has been diagnosed with [CONDITION(S)] in the past, but it appears that his symptoms are more consistent with borderline traits vs (versus) true manic sxs (signs and symptoms). he described very rapid mood swings but struggled to identify manic sxs. He has experienced and reported chronic fears of abandonment, a long standing pattern of dysfunctional interpersonal relationships and devaluation/elevations of others in relationships, impulsivity in multiple areas in his life . recurring and often impulsive suicidal gestures or threats (he purchased a knife on the Internet and had it delivered to his prior SNF (skilled nursing facility) in a suicidal gesture and later tried to strangle himself), anger/irritability w/o (without) provocation, and affective instability/emotional reactivity vs true [CONDITION(S)] (he describes going from depressed to angery (sic) very rapidly . ). He has also been diagnosed with antisocial personality disorder given his history of disregard for the rules (smoking marijuana in the SNF setting), being disrespectful to police w/o provocation, irritability and verbal aggression with staff, and reckless disregard for his own safety with his impulsivity and failure to plan ahead. He has taken flights impulsively to various places in the United States where he has no support, unable to provide for himself or without funds to pay for food and shelter. He has left multiple nursing homes AMA (against medical advice) without adequate planning for his needs, resulting in poor outcomes. He has often been deceptive/overreported symptoms in medication seeking behaviors (pain meds (medications) or benzos (benzodiazepenes)). He has also snuck friends into the SNF or has snuck out of SNF's in the past, violating COVID-19 protocols. He has feigned helplessness to get help or sympathy from staff. He has been physically assaulted on multiple occasions, including once being beaten up and left for dead in an abandoned house. Due to this incident among his other altercations he reports sxs of [CONDITION(S)] including recurring nightmares/intrusive memories (The nightmares don't stop and they haunt me), avoidant behaviors, feelings of distrust of others/detachment from others, persistent negative emotions, irritability/anger out of the blue (I don't know why I just get pissed and I want to fight or punch a wall or something), reckless/self-destructive behaviors, and difficulty sleeping d/t his nightmares. The PASRR also stated that Pt stated that he is willing to get a referral for mental health but that it can be difficult to re-establish rapport and trust with new mental health providers. Pt did state that he wants to have someone who can help him in his decision making, such as a guardian or POA (power of attorney) . He recognized that he needs help in his decision making, and stated I have walked away from too many places over nothing, and it is getting to the point where people are going to start saying we can't have him come here. I'm going to be in a lot worse place than where I'm at now If I don't get help. The SNF Resident Advocate was made aware of pt's wishes. Pt is on multiple [CONDITION(S)] medications and he has been compliant in taking them. He reported that he has been depressed ever since leaving his prior SNF and that he hit bottom when he left there. He did not endorse SI (suicidal ideations) at this time; however given his history of impulsivity and multiple suicide attempts (and hospitalization d/t a suicide attempt in 2020) he should be closely monitored for any lethal means/means for self-harm that would be accessible to him. Given his online purchase of a knife in 2020 every package that might come to pt should be opened with staff present to ensure pt's safety. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. He should be referred for outpatient mental health treatment as well to him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. On 3/26/21, facility staff documented that Reported to administrator that resident confided in another resident that he was contemplating suicide. Nursing to monitor resident for behaviors/self harm and/or suicidal verbalizations. On 4/7/21, approximately 12 days later, the facility Licensed Clinical Social Worker (LCSW) Consultant documented the following in resident 49's progress notes: .Monitor resident closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. On 5/6/21, the Resident Advocate (RA) documented that resident 49 was having some hallucinations, and was talking to someone that wasn't there. He stated that a CNA (Certified Nursing Assistant) asked who he was talking to and [resident 49] stated another patients name, and CNA said there's no one here. RA informed DON and [mental health provider]. On 5/27/21, a nursing note entry documented that resident reported to me that 3 weeks after his admit he had swallowed a razor and then threw it up. He states this was a razor that had been ordered [online] to cut his hair. He reported to me that he did not tell anyone at the time but he is now because he is worried that it may be a concerning factor to his recent sx and not feeling well. He denies having any suicidal ideations at this time. This was reported to the DON who stated pt has been having a lot of behaviors lately due to d/c (discharge) of pt's friend and that the bloodwork ordered this shift will be suffice (sic) indication to need for further eval (evaluation) and that she would visit with resident tomorrow. On 6/3/21, the RA entered a note documenting that resident 49 at times he can be verbally aggressive, impulsive and manipulative. [resident 49] has a history of suicidal ideations, but has not reported any recently. On 6/12/21 at 7:09 PM, nursing progress notes indicated that Resident has left the facility and has yet not returned. Night shift RN has communicated with resident via phone conversation. Resident 49 returned to the facility at 9:00 PM. No documentation could be located to indicate why resident 49 was not accompanied by staff out of the facility. On 7/15/21, a nursing progress note was entered indicating that resident 49 was intentionally banging head against wall and trying to throw himself on the floor. Nursing wrned (sic) him of risk of self injury, wctm (will continue to monitor). On 8/3/21 at 3:38 AM, a nursing progress note indicated that the resident was not in the facility, but returned by midnight after the police were called. On 8/11/21 at 4:16 AM, a nursing progress note indicated that resident 49 left the faciity on [DATE] to do community service and did not return to the facility. The facility staff did not document a timeline for the elopement, but did contact the police. On 8/11/21 at 7:34 PM, a nursing progress note indicated that the Resident is still absent from facility, Family member . called to make aware that [resident 49] still hasn't returned back to the facility [family member] states that he felt that he is an endangerment to himself and that in his option he should be committed d/t this continuous behavior. On 8/12/21 at 12:47 AM, a nursing progress note inidcated that the nurse was called by a local deputy office around 9 pm. Patient was found in field, with knife in his possession, had fallen out of his wheelchair and been on the ground for an unknown amount of time. They admitted [name of resident] for 24 hrs with a pink slip to the local . hospital, noting he was a danger to himself. I was contacted later by the social worker, .[the social worker] called back and stated [resident 49]

Based on observation, interview and record review, it was determined the facility did not ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 5 of 51 sample residents. Specifically, wound care was not provided to residents as ordered, and one resident did not have physician evaluations or orders for a pressure injury. The deficient practice identified for resident 61 was found to have occurred at an immediate jeopardy level and deficient practice for residents 1. 15, 17, and 29 were found to have occurred at a harm level. Resident identifiers: 1, 17, 29, 51, and 61. NOTICE: On [DATE] at 1:10 PM, verbal notice of the Immediate Jeopardy findings with regard to F686 was given to the facility Administrator (ADM), Corporate Resource Nurse (CRN) 1, and the Regional Vice President (RVP). On [DATE], the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on [DATE] at 10:00 AM: 1. Resident #61 expired at the hospital; therefore, no individualized plan of correction is indicated. 2. Residents with a pressure injury have the potential to be affected by this deficient practice. A whole house skin assessment audit was completed by week ending [DATE] by the nurse management team. Any new concerns that were identified received orders, treatments, documentation on the pressure injury and the care plans will be updated by the DON/designee. Any residents with a pressure injury will be assessed by consultant RN ' s. 3. Education was initiated on [DATE] by the consultants with nursing staff regarding the community pressure injury policy and the expectation of completing and documenting skin assessments and monitoring of skin concerns weekly with each resident. Any time a new skin issue is identified, the physician and responsible party should be notified, new orders should be received and implemented, the care plan should be updated, and monitoring should continue weekly until the area has healed. The consultant RN ' s will round weekly for the next month to ensure documentation is thorough and complete and the community is following physician ordered treatments. DON/designee to complete weekly audit for three months(3) residents with wounds to ensure that the resident had a full skin assessment completed, new orders received for the identified areas, pain evaluated to ensure that it was being managed effectively, treatments initiated, documentation completed, positioning appropriate to promote wound healing, care plan accurate, and wound monitoring to be completed weekly until the areas healed. The consultants provided the community with a new daily standup meeting agenda. This agenda will include a pressure injury tracking log to track and trend pressure injuries and newly acquired pressure injuries. The consultants will be provided with a weekly pressure injury report for review and recommendations. 4. The DON/designee will report findings from the audits to the QAPI Committee monthly fosix (6) months. The QAPI committee will identify any trends and take corrective action as needed. On [DATE], while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on [DATE] at 10:00 AM. Findings include: IMMEDIATE JEOPARDY 1. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], resident 61's medical record review was completed. On [DATE] at 11:09 AM, resident 61 had discharge orders printed from a regional care facility for wound care. The order for the coccyx wound stated: Bilateral buttocks and coccyx 1. Remove dressing 2. Clean wound with soap and water 3. Apply Santyl [MEDICATION(S)] to the wound bed in a nickel thick consistency. 4. Cut and apply Xeroform or oil emulsion over Santyl. 5. Place large sacral dressing to each buttocks, and silicone bordered foam to coccyx. 6. Please change dressing daily and as needed with hygiene. On [DATE] at 6:32 PM, resident 61 was weight by a mechanical lift at 430 pounds. Resident 61's care plan did not include wound care. A nutrition care plan revealed that resident 61 was to have supplements to aide in wound healing. A regional hospital Progress Notes for [DATE] revealed that resident 61 had 4. Sacral decubitus ulcer, stage III. Chronic ulcer, present on arrival. Sacral wound itself is unstageable with black eschar and purulent sluff. CT showed fat stranding inferior, posterior and right of the midline. Also noted small scattered areas of gas without definitive drainable fluid collection. No signs of [CONDITION(S)]. Plastics was curbsided and agrees with plan for continued wound care. - Continued aggressive wound care. - Patient will need frequent offloading/position changes. On [DATE] at 11:04 AM, the regional hospital Discharge Documentation for Discharge Wound Care Instructions were: coccyx 1. moisten a roll of gauze (kerlix) with Puracyn insert deep into undermining (12 cm toward anus) and depth of wound. On [DATE], a regional hospital discharge Progress Notes revealed that resident 61 had a stage 4 pressure ulcer on his coccyx, measuring 5.3 x 3.0 x 0 cm (centimeters) with undermining extending very close to anus. Description of the sacral ulcer revealed, Chronic ulcer, felt to be the cause of above noted bacteremia at his recent hospital stay. Currently, most wounds are looking reasonably clean without any purulence, exudate, or surrounding [CONDITION(S)]. Sacral wound itself is unstageable with black eschar and purulent sluff . If he is not progressing then we will plan to get a CT (computerized tomography) abdomen and pelvis with contrast to look for deep wound infection. Wound care consultation requested. Patient will need frequent offloading/position changes. An order in resident 61's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 61's Treatment Administration Record (TAR) revealed that this wound care was completed two times, on [DATE] and on [DATE]. On [DATE] at 1:00 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was recorded in the TAR as completed on [DATE] at 8:09 PM. On [DATE] at 4:22 PM, an Admission Summary revealed, .Skin Status/Interventions: Stage IV pressure ulcer to coccyx; cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of dressing .Incontinent of bowel and bladder . On [DATE] at 6:00 PM, an order was created to monitor the pressure ulcer to the coccyx each shift for signs and symptoms of infection or other complications. Nurses charted no complications on all checks, with the exception on ,d+[DATE] and ,d+[DATE] in the mornings, when the assessments were not completed. On [DATE] at 10:06 PM, a 72 hour charting after admission note revealed that resident 61 was adjusting well to returning to facility; appears to be in low spirits .Mental Status/Behavior: appears depressed and in low spirits; no behaviors noted . On [DATE] at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin prep barrier wipe to periwound skin. Pack undermining of wound w/ [MEDICATION(S)] soaked in Puracyn (squeeze out the excess). Apply Venelex to wound bed the apply Xeroform dressing. Secure with ABD (abdominal) pads. To be changed EOD (every other day) & PRN (as needed) if becomes soiled, saturated or accidentally removed one time a day every other day. This order was discontinued on [DATE]. The TAR revealed that this treatment was completed on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. On [DATE] at 9:56 AM, a skin/wound note revealed: Pressure ulcer to coccyx, undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . A referral was sent to a wound healing company to assess and treat. It was noted that the provider would be at the facility on [DATE]. On [DATE] at 11:50 AM, a physician's note revealed that resident 61 had an admission note created by a physician who performed a telehealth visit. A second note was entered at 8:44 PM. Skin status/interventions: Stage IV pressure ulcer to coccyx, cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100 (left lower side), surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . No other physician visits occurred during resident 61's stay. On [DATE] at 11:27 PM, a nurses note revealed: Changed dressing to buttocks. Moderate serosanguineous drainage (clear fluid) with odor. Cleansed peri with wound cleanser and dressing with ABD pads and [MEDICATION(S)] tape. On [DATE] at 9:35 AM, the resident advocate note revealed that resident 61 was admitted to the facility for [CONDITION(S)].According to resident discharge plan is to return home with home health. He is alert and orientated. He is currently using a wheelchair for locomotion and needs extensive assistance . His moods and behaviors have been cooperative, pleasant, and is compliant with cares since admission. On [DATE] at 10:30 AM, a Utilization Review (UR) note revealed that resident 61 .needs wound care (daily and PRN) .goal is to return home with HH (home health) . On [DATE] at 9:15 AM, a social services care conference note was started, and was not completed. Status stated In Progress. The note revealed that .wounds have no s/s (signs/symptoms) of infection .pleasant and cooperative with cares . On [DATE] at 11:00 AM, resident 61 had blood drawn for laboratory tests. On the results, a note was written that resident 61 needed a BMP (basic metabolic panel) completed in 1 week with a date [DATE]. Resident 61 had a white blood cell count of 11,300, with high neutrophils and immature granulocytes. [No additional blood tests were completed for resident 61 until [DATE].] [Wound physician did not see resident 61 on [DATE].] On [DATE] at 5:41 PM, resident 61 had a Nutritional Assessment. The assessment revealed that resident 61 had .increased nutritional needs d/t (due to) skin impairment to coccyx . Recommend adding . Juven BID (twice daily) and liquid protein . to support healing. Will monitor weight, intake, wound healing and will adjust nutritional interventions as needed. [No orders for Juven or liquid protein were initiated for resident 61.] On [DATE], a Mini Nutritional Assessment was completed. Resident 61 was At risk of malnutrition. [Note: No further nutrition assessments were completed.] Resident 61 had a nutritional care plan created on [DATE]. An intervention was to Provide supplements to promote wound healing. Resident 61 did not have a wound care plan included in his care plans. On [DATE], resident 61 was assessed in the Minimum Data Set (MDS) as requiring rehabilitation, urinary incontinence, fluid maintenance, fall risk, pain management, nutritional status management and pressure ulcer management. On [DATE], resident's [MEDICATION(S)] tablet order was not provided due to being out of supply, not in med cart. On [DATE] at 8:09 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 9:32 AM, a MDS skin conditions evaluation that revealed resident 61 had 1 stage 4 pressure ulcer. Resident 61 had a pressure reducing device for the bed. Nutrition or hydration intervention to manage skin problems were noted as being in place. On [DATE] at 5:33 PM, a nurses note revealed that labs drawn [DATE] rec'd (received) w/ (with) noted abnormalities .NP (Nurse Practitioner) reviewed w/ N/O (new order) for BMP recheck in 1 week. [This lab was not redrawn.] On [DATE] at 3:25 PM, a Utilization Review (UR) note revealed that resident 61 .needs skilled wound care (daily and PRN) .goal is to return home with HH (home health) . On [DATE] at 4:30 PM, a skin/wound note revealed: Residents wound remains with deep 2 o'clock tunneling. with 5 X 6 (centimeters) opening. Wound has foul odor. Peri wound has improved. New order to fill wound bed with calcium alginate rope cover with bordered foam. Resident tolerated well . Resident 61 reported the following pain scores (out of 10) without reporting effective pain control: a. On [DATE] at 10:26 AM, 9 b. On [DATE] at 1:06 PM, 8 c. On [DATE] at 1:11 PM, 7 d. On [DATE] at 9:15 PM, 8 e. On [DATE] at 5:06 PM, 7 f. On [DATE] at 9:58 PM, 7 [No new interventions were noted.] On [DATE] at 8:37 PM, a skin/wound note revealed: Change resident dressing daily. Wound is 6 cm X 6.5 cm X 8.5 cm tunnel at 2 o'clock. Lots of blood drainage. Wound nurse's are following dressing change order from the hospital On [DATE] at 1:57 PM, a Utilization Review (UR) meeting revealed that resident 61's plan of care was to work with therapy and to return home with home health. The nursing update included .skilled wound care (daily and PRN), . On [DATE] at 6:28 AM, a nursing note revealed that resident 61's Wound remains open with foul odor. Wound is 6 cm X 5.5 CM x 2 CM. It tunnels at 2 o'clock 8 cm. Wound has necrotic tissue coming out of the tunnel area. Dressing change daily. Dakins soak 30 min. then Calcium alginate rope to tunnel with calcium alginate in wound bed. Cover with ABD pad and foam cover . On [DATE] at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR revealed that this order was completed on [DATE] and [DATE]. On [DATE], a Skilled Daily Review was performed for resident 61. Skilled need was wound to coccyx with tunneling at 2:00 position per wound care nurse. Pain mgmt (management). Assist with ADLs (activities of daily living). Resident 61 was incontinent of urine and bowel movements, and wore briefs with peri care provided with each brief change. [Note: There is no documentation about wound care changes with brief changes.] On [DATE] at 3:17 PM, resident complained of sacral pain for which PRN medication was provided. On [DATE] at 11:33 PM, a weekly skin review revealed no new skin integrity problems. The sacral pressure injury was noted. On [DATE] at 9:43 AM, a nurses' note revealed that the nurse had received report of resident 61 having increased confusion with shaking, high blood pressure, resident looking to the left to respond to the nurse who was on the left side of the bed, and confusion about how to drink water. Nurse contacted physician who ordered STAT blood and urine tests along with a chest X-ray to rule out infection. Resident was given 1 liter of normal saline over 5 hours. On [DATE], blood pressure obtained was ,d+[DATE], followed by ,d+[DATE]. On [DATE] at 10:36 AM, a nurses notes revealed that resident 61 had an IV (intravenous access line) placed in the right hand for blood draw. On [DATE] at 1:59 PM, a higher-than-normal respiratory rate was noted at 22 breaths per minute and heart rate was 124 beats per minute, irregular, and was identified as a new finding. [There was no documentation that a physician was contacted.] On [DATE], resident 61's lab results were faxed to the facility at 4:43 PM. Resident 61's white blood cell count was 25,100, with segmented neutrophils. RN 1 noted the results on [DATE]. [There was no documentation that this report was forwarded to a medical provider until the following day.] On [DATE] at 7:37 PM, an order was initiated for resident 61 to assess resident 61's pressure ulcer and notify the physician if any complications. On [DATE] at 3:55 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was noted as done by previous shift. [No documentation of providing the results to the physician was noted.] On [DATE] at 4:44 AM, a nursing note revealed a blood pressure of ,d+[DATE], heart rate of 99 beats per minute, and oxygen saturation at 93% on a Continuous Positive Airway Pressure ([CONDITION(S)]) device. The nursing note stated no changes res (resident's) health status from yesterday. Asked res if he would like to go to the hospital for checkup but he refused it. Encouraged res to increase fluid intake. PRN (as needed) pain med was given for pain on both knees. will continue to monitor. On [DATE], on the final lab results report, a note written at the bottom of the report revealed that one of the medical providers made an order to send resident 61 to the Emergency Department. On [DATE] at 11:41 PM, an order was entered/discontinued for a wound care company to eval and tx (treatment) r/t pressure wounds to coccyx and bilateral buttocks. On [DATE] at 12:36 PM, a nursing not revealed that resident 61 was sent to the hospital. On [DATE] at 1:32 PM, a regional hospital Emergency Documentation was initiated for resident 61. The documentation revealed that resident 61 had chief complaints of: a. altered level of consciousness b. high heart rate c. not looking to the right He apparently was acting abnormally this morning according to rehab facility staff but what that means is a little bit unclear. He was transported and there was no mention of increased work of breathing or [CONDITION(S)] I was called to the room because of high heart rate and tachypnea (rapid breathing). Looks like he is in [CONDITION(S)] with RVR (rapid ventricular rate of response) but does not endorse any chest pain at all. He is noted to be with a right-sided neglect. No known vomiting. Given patient status no other history was obtained. Stroke 1 is called. Meds ordered for his high heart rate. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. initiation of end-of-life care b. septic shock c. [CONDITION(S)] d. respiratory failure e. acidosis f. superobesity g. diabetes h. strokelike syndrome i. [CONDITION(S)]/[CONDITION(S)] Medical decision making/differential Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . He presented with [CONDITION(S)], some altered mental status, rapid heart rate with what looked like new onset [CONDITION(S)] (fluttering atria of the heart). He is also quite tacypneic. He already had leuckocytosis yesterday at 26,000. Today it climbed to 32,000. I think this clinical picture was strongly suggestive of septic shock and overwhelming [CONDITION(S)]. His sacral area wound showed a large area of ecchymosis and [CONDITION(S)] and some purulent drainage from the central portion of the ulcer. He seemed to medically stabilize early on but then after resuscitative efforts were towards the tail and the patient actually worsened in status. Long discussion was held with numerous family members .he became medically unstable and worse over time despite antibiotics fluids respiratory support no other [CONDITION(S)] treatment measures. I did not see any obvious reasons to counter patient and family wishes and initiating end-of-life care. The massive area of skin and soft tissue infection with ulceration was the likely source of his infection and massive debridement would be necessary . The course of treatment in the Emergency Department included . Required supplemental oxygen. [CONDITION(S)] protocol enrollment with treatment provided. In addition neurology consultation was required early on given concerns for potential stroke. [A neurologist] did not feel that the patient was under going a stroke syndrome Thereafter [CONDITION(S)] treatment was the focus We evaluated the wound on his backside and it was massive encompassing a large territory of the entire lower lumbar and sacral region with a draining wound and a lot of surrounding necrotic tissue with [CONDITION(S)] extending down to the perineum without obvious drainable abscess. Shortly after evaluating this wound the patient became diaphoretic and more short of breath but remained lucid. Additional oxygen was provided. We had discussed at this point in time about focus of treatment and goals of treatment . An arterial blood gas (ABG) was obtained and resident 61 had worsening acidosis Patient progress towards severe illness and end of life pretty quickly at around 5:30 PM, resident was noted to have agonal respirations and confirmed at this time if we do not act patient will certainly die soon. Again there was consensus with family members present to proceed with comfort measures and monitors were turned off and high flow oxygen was turned off along with vasopressors. Family gathered at the bedside and said their goodbyes and time of death was estimated to be at 6:10 PM. On [DATE] at 11:31 AM, a former DON, DON 2, was interviewed. DON 2 stated that resident 61 had a pretty serious tunneling wound that no doctor had examined while resident 61 was in the facility. DON 2 stated that she spoke with the facility Medical Director, and determined that he was not following resident 61. DON 2 stated that she never spoke with him (the Medical Director) on the phone. He wasn't responding to emails or [messaging app] texts. DON 2 stated that there was a facility Nurse Practitioner (NP), and I cornered [the NP] and said 'Hey this guy needs to be seen. but no one was ordering anything. DON 2 stated that the wound clinic was unable to treat resident 61 because of his insurance, so resident 61 was not seen by any prescribing provider. DON 2 stated that resident 61 had insurance that would provide wound care to their clients in their wound clinic, but resident 61 was not sent out. DON 2 stated that resident did not have orders provided by any clinician, that wound care orders were generated by the wound nurse (now the ADON). DON 2 stated that the ADON was just talking to the wound doctor and he (the wound doctor) would write the orders based on what she said, but no doctor was laying eyes on resident 61's wound. DON 2 stated that she was supposed to take a picture of [a resident's wound] on my phone, and I was supposed to sent to it [the ADON], then she would write an order without any other consult with a physician. DON 2 stated that this was the way the wound care process was during the time she was employed. DON 2 stated that resident 61 never went to wound clinic. He went to the hospital, went septic, and started crashing. On [DATE] at 10:10 AM, the ADON was interviewed. The ADON stated that typically, residents have wound care provided in the facility, depending on their insurance. The ADON stated that resident 61 had an insurance that required him to go out to a specific wound clinic, but resident 61 was not able to be sent out to the clinic. The ADON stated that DON 1 was working on obtaining a different insurance for resident 61 so their providers could follow his wound. The ADON stated that she did not have the authority to send resident 61 out to the clinic when she was the wound nurse. The ADON stated that no physician consulted for resident 61, and all new orders for his wound care were generated by her. The ADON stated that no physician ever laid eyes on resident 61's wound. The ADON stated that I was just doing the best I could as the wound nurse. The ADON stated that the providers wouldn't give an order without seeing resident 61. The ADON stated that resident 61's wound was not getting any better, but he weighed almost 600 pounds so it was difficult to get an ambulance to take him out. The ADON stated that she ordered Dakins solution because the wound had such an odor. The ADON stated that she wanted to order a silver alginate to keep infection away. The ADON stated that she was not aware of resident 61 being discussed in the interdisciplinary team (IDT) meetings. The ADON stated that the order she initiated was for wound care to be performed every other day, but it should have been done daily if possible. The ADON stated that the wound care was possibly done more often than what was charted. The ADON stated that there was so much agency in the building, there were a lot of things they didn't get around to. The ADON stated that the bloody drainage on the 16th was good, because it meant that the wound was healing. The ADON stated that resident 61's bowel movements would get all over the dressings. The ADON stated that she was not wound care certified, and staging a wound was beyond her scope of practice. The ADON stated that on [DATE], there was a foul odor, and she wanted the doctors to provide an antibiotic. The ADON stated that she changed resident 61's wounds, but did not do anything else for him. The ADON stated that resident 61 was not taken out until he went to the hospital on [DATE] with [CONDITION(S)]. The ADON stated that there was no way to determine what wound care was done, that if a nurse signed that they completed the wound care, she would have to believe they did it. On [DATE] at 12:42 PM, the Corporate Resource Nurse (CRN 1) was interviewed. CRN 1 stated that the wound nurse was responsible for communication with the wound care providers and physicians. CRN 1 stated that the wound nurse (now the ADON) would look at wounds and show them to the physicians. CRN 1 stated that the ADON requested orders from physicians, and would enter orders in the computerized record and request physicians to sign the orders. CRN 1 stated that she was not aware if physicians created the orders or signed the orders after the fact. On [DATE] at 1:32 PM, the Administrator (ADM) was interviewed. The ADM stated that the former DON (DON 1) was working on resident 61's insurance. The ADM stated that she assumed that a doctor was following resident 61's wounds, and that the wound nurse would take care of that. The ADM stated that an analysis of preventing resident 61's hospitalization was no completed. The ADM stated that she was not aware of discussing resident 61 in the morning stand-up meetings. The ADM stated that when a resident had a change of condition, staff would discuss what to do, what tests were required and determine if the resident needed to go to the hospital. The ADM stated that she did not believe that resident 61 had a change of condition before he was sent out. On [DATE] at 12:26 PM, an interview was conducted with Medical Provider (MP) 1. MP 1 stated that resident 61 had insurance that required him to have his wound care provided at the insurance company's provider. MP 1 stated that the wound nurse had approached him for cares, and he informed her that resident 61 needed surgical debridement. On [DATE] at 12:10 PM, the Administrator was re-interviewed. The ADM stated that she had assumed the physician would check on resident 61. The ADM stated that when resident 61 went to the hospital with [CONDITION(S)], she did not complete an analysis of what staff might have done to prevent the hospitalization . The ADM stated that she had not completed an analysis of identifying residents' change of condition timely. The ADM stated that staff were not always very talkative during morning meetings, and she was not clinical, so sometimes she didn't know what was happening with the residents. On [DATE] at 12:20 PM, the ADON was re-interviewed. The ADON stated that prior to the last two weeks, she was acting as the wound care nurse in the building. The ADON stated that her responsibilities as the wound nurse (WN) was to assist the provider on Thursdays with wounds, new orders, and at times, she was also fulfilling the role as a floor nurse. The ADON stated that when she was the wound nurse, she did not participate in the skin and weight meetings. The ADON stated that she was responsible for wound care in the building four days each week, and the floor nurses were responsible the other three days. The ADON stated that she entered the wound care orders for the residents into the computer for the floor nurses to follow. The ADON stated that the wound physician would complete the measurements and staging of the wounds. The ADON stated that when a resident was admitted to the facility, she would create a temporary order for wound care. The ADON stated that she would tell the physician's group Nurse Practitioner what she was going to do for a resident. The ADON stated that she put the order in as a verbal order from the medical director. The ADON stated that she noticed that some wound care treatments had not been completed by the nurses. The ADON stated that It took me an hour to go through the whole building. The ADON stated that she was unsure why the nurses weren't doing their wounds. The ADON stated that for resident 61, she felt like I was screaming into a void on that one. I was very concerned about him and I couldn't get anyone to listen to me. The ADON stated that the Nurse Practitioner told her to get him into a wound clinic to have the wound debrided surgically, but she could not get him into the other clinic because he weighed about 600 pounds. HARM 2. Resident 29 was initially admitted to the facility on [DATE] and again on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:15 AM an interview with resident 29 was conducted. Resident 29 stated that the staff rarely changed the dressing for his wounds. Resident 29 stated that the last time his dressings for his wounds were changed and cleaned was 3 days ago. On [DATE] an interview with resident 29's family member was conducted. Resident 29's family member stated that once resident 29 returned from the hospital on [DATE], they noticed that resident 29 was always lying in the same position. The family member stated that they asked the staff multiple times if resident 29 could be moved to a different position, along with asking staff if they have noticed any sores on his backside. The family member stated that the Certified Nursing Assistant (CNA) 's reported to her that they have not seen anything. Resident 29's medical record was reviewed on [DATE]. A progress note dated [DATE] revealed that resident 29 had a new order for wound care for a new wound on his coccyx. A document from the wound clinic [DATE] was reviewed. The document stated, Patient has a new wound on his coccyx/sacral area. There is an open area in the center that is into subcutaneous tissue. Therefore we will begin staging at a stage III however, the periwound tissue is dark, non-blanching and has characteristic so of deep tissue injury measuring approximately 15.0 [centimeters] x 15.0 [centimeters]. A review of resident 29's orders for wound care was conducted. A. The initial order for resident 29's wound care began on [DATE] and stated, Cleanse wound with wound cleanser. Cover wound on coccyx and buttock with large bordered foam dressing. Date and initial wound dressing. Change dressing daily. One time a day for wound healing. Start [TRUNCATED]

Based on observation, interview, and record review it was determined, for 6 out of 51 sampled residents, that the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, two residents with mental disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. In addition, other residents with mental disorders had identified behaviors without interventions and behavioral health services implemented to accommodate or support the resident's loss of abilities. Resident identifiers: 4, 40, 43, 46, 49, and 111. NOTICE On 4/6/22 at 4:36 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to ensure that each resident received and that the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to identify that residents at risk for self-harm had interventions identified, implemented and revised, that behavioral health services were provided, that pharmacological interventions were implemented and that continued monitoring for safety was implemented. Notice of the IJ was given verbally to the facility Administrator (ADM) and the Corporate Resource Nurse (CRN), Director of Clinical Services (DCS), CRN 2, Corporate Registered Dietitian (CRD), and the Regional Vice President (RVP) and they were informed of the findings of IJ pertaining to F740 for resident 46. On 4/12/22 at 8:22 AM, notice of the IJ for resident 49 was given verbally to the RVP. On 4/12/22, the facility Consultant Group Member (CGM) 1 provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/12/22 at 10:00 AM: 1. Resident #46 is now receiving medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The DON [Director of Nursing] designee will be responsible to review the current medication regimen for newly admitted residents to ensure residents are receiving the medications ordered by the physician. The community is currently on an admissions hold. A consultant LCSW [Licensed Clinical Social Worker] will complete a review of other residents who trigger for a Level II to ensure mental health services are provided as needed. 3. The licensed nursing staff received education and training 4/11/2022 by the consultants on the importance of completing a comprehensive review on new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDT [Interdisciplinary Team] team will review daily (Monday through Friday) all new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed. The consultants implemented a psych [[CONDITION(S)]] pharmacy meeting. All residents on [CONDITION(S)] medications will be reviewed quarterly and as needed. 4. The community DON or designee will report psych pharm meeting minutes to the QAPI [Quality Assurance and Performance Improvement] committee for review and recommendations. On 4/12/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 4/12/22 at 10:00 AM. Findings include: IMMEDIATE JEOPARDY 1. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/22 resident 46's medical records were reviewed. On 11/12/21, resident 46's discharge orders from the hospital indicated that the resident should continue taking the following medications daily: [MEDICATION(S)] 300 milligrams (mg) each day (qd), [MEDICATION(S)] 40 mg qd, [MEDICATION(S)] 1.5 mg qd, [MEDICATION(S)] ([MEDICATION(S)]) 0.25 mg twice daily, [MEDICATION(S)] 40 mg qd, and [MEDICATION(S)] 500 mg q (every) 6 hours. On 11/12/21, the nursing progress documented that a medication reconciliation was performed with the Nurse Practitioner (NP) for resident 46. The no appropriate indications of use noted in documentation from hospital for use of some of meds; changes made: D/C [discontinue] [MEDICATION(S)] [antipsychotic] . [MEDICATION(S)] [anxiolytic]. [MEDICATION(S)] [antipsychotic]. [MEDICATION(S)] [antipsychotic]. Review of the November 2021, December 2021, January 2022, February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/8/21, a PreAdmission Screening Resident Review (PASRR) Level II was completed for resident 46. The PASRR indicated that resident 46 had a long history of mental health signs and symptoms, and has carried multiple mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She has been hospitalized multiple times d/t [due to] her chronic mental health symptoms. She had her first episode of [CONDITION(S)] in her late teens after her first child was born; she began to experience recurring persucatory [sic] auditory hallucinations. Pt [patient] reports that her auditory hallucinations have persisted to this time. She reported dividing the hallucinations into the 'screamers' and the 'growler', which is a male voice that will growl at her. She has never been able to fully eliminate the AH [auditory hallucinations] even with the trials on multiple antipsychotic medications . ; she does report that she feels [MEDICATION(S)] helped the most. She reports the voices are persucatory [sic] and negative, saying things 'like I'm terrible, I don't deserve anything. that's normal for me.' . she had a suicide attempt by swallowing mercury from a thermometer. She endorses excessive anxiety, worry, difficulty managing feelings of worry, trouble focusing and sleeping d/t anxiety, and feeling restless and tense often. reports seeing a new psychiatrist monthly and a therapist every 2 weeks. Pt's discharge orders from [name of hospital] prescriptions for [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]; however, none of those medications are listed on pt's current SNF [skilled nursing facility] medication list. Per the SNF Resident Advocate it appears these were discontinued d/t concerns the medications were contributing to pt's weakness and falls. When asked if pt had been feeling different as these medications were discontinued she reported ongoing auditory hallucinations which are persucatory [sic] and derrogetory [sic] in nature, saying things such as 'I'm not worth anything, like I'm supposed to be stronger, stuff like that . She reports that 'I hear them all the time '; she feels her constant AH contritube [sic] to poor mood and increased anxiety and worry. She feels the voices have been stronger recently without her typical medications . she stated she 'noticed I haven't been sleeping well' and 'I could hear the voices more 'which has been disruptive to her sleep. Pt reported as she had previously that [MEDICATION(S)] and Lorazapem [sic)] were very helpful in managing the voices and in 'keeping me calm '. She reported feeling 'fairly depressed' and 'You get depressed cause you get depressed in places like this.' . She feels that 'if there's any way I could get back on my meds [medications] that would be good.' She would likely benefit from a phone call with her outpatient mental health provider due to ensure adequate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/5/22 at 2:34 PM, a facility staff documented on a re-admission assessment that resident 46 had scored a 15 on Brief Interview for Mental Status (BIMS), indicating that resident 46 was cognitively intact. On 2/9/22 at 9:23 AM, a physician documented that resident 46 States her voices are getting-scary voices are getting louder- causes anxiety. On 2/16/22 at 11:40 AM, facility staff completed a Personal Health Questionnaire 9 (PHQ-9) for resident 26. Staff documented that resident 46 had a score of 14, which indicated moderate depression. On 2/16/22 at 10:08 PM, nursing staff documented that resident 46 was having multiple episodes of screaming at the staff . at the top of her lungs and wouldn't stop. On 2/23/22 at 8:04 PM, a physician documented Consider antipsychoticsfor [sic] [CONDITION(S)] disorder and return of auditory voices. On 2/26/22 at 9:32 PM, a nursing staff member documented, Patient has History of [CONDITION(S)] schizo affect disorder. and dependent personality disorder. I received a call from the patient's husband tonight he explained that she was on [MEDICATION(S)] 300 mg at HS [bedtime] At home. This is not in the current EMAR [Electronic Medication Administration Record] . Plan call the NP [Nurse Practitioner] or physician and notify. On 3/7/22 at 11:15 PM, a nursing staff member documented, Res [resident] having suicidal ideation's [at] 1820 [6:20 PM]. Aide notified nurses Res had call light around her neck. Aide removed cord from around neck. Nurses had to remove call light from her hand. Res stated she needs her psych meds which is why she did it. Res told aide Goodbye and informed aide that she has also said Goodbye to family. MD [Medical Doctor]/NP, appropriate staff and family notified. During cares Res stated she is losing hope. Res sent out via [name of ambulance company] to [name of hospital] for psych (psychiatric) evaluation. The consultant Licensed Clinical Social Worker (LCSW) notes for the last 6 months were reviewed. The LCSW did not address resident 46's behavioral concerns. Review of resident 46's medical record revealed that the resident did not receive any outside behavioral health services to evaluate her mental illness and medications. Resident 46 was readmitted to the facility on [DATE]. Resident 46 was admitted with the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/7/22, facility staff created a care plan for resident 46's [CONDITION(S)] disorder and generalized anxiety disorder. The care plan indicated that the resident was to have her mental health needs met as outlined per the PASRR recommendations. The care plan also recommended that resident 46 meet with specialized services for mental illness treatment; and meet with outpatient mental health providers as needed while in the facility for psychiatric treatment/support. On 3/23/22 at 10:06 AM, an interview was conducted with the facility ADM. The ADM stated that the facility did not have a resident advocate or a social worker, so I'm doing all the work. On 3/26/22, after the resident returned from the hospital, care plans were developed for the following areas: depression with anxious features, mental health services through a local behavioral health provider, a history of auditory hallucinations, and a history of suicidal statements and actions. On 3/29/22 at 12:42 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 confirmed that the facility did not have a resident advocate. On 3/30/22 at 9:15 AM, an interview was conducted with resident 46. The resident stated that she's upset that there isn't a social worker here, and feel like I'm losing hope. Resident 46 stated that there was one night recently that she was feeling really down so she called the crisis line because there was nobody to talk to here. On 4/04/22 at 9:52 AM, a follow-up interview was conducted with resident 46. Resident 46 stated that she called the suicide hotline a couple of times before attempting suicide in March 2022. Resident 46 stated that she wrapped the cord around her neck. I wanted to hang myself. I'm glad it didn't work now, but I gave up hope . There was no one here to talk to. On 4/6/22 at 10:28 AM, a follow-up interview was conducted with resident 46. The resident stated last month she was having a moment of hopelessness and tried to take her own life, stating they didn't give me my medication. Resident 46 stated that she told them in December that she needed her psychiatric medications, and they said here's this girl talk to her. Resident 46 stated that the staff member was the bookkeeper and not a mental health provider. Resident 46 stated that she asked the Administrator (ADM) to speak to a social worker and the ADM told her they did not have one at the facility. Resident 46 stated that was when she tried to strangle herself with the call light cord. Resident 46 stated that she had to go to the hospital for treatment after that. Resident 46 stated that while at the hospital they started her [CONDITION(S)] medications again. Resident 46 stated that she had been on medications for depression and [CONDITION(S)] since she was [AGE] years old, and then when she came to the facility they took her off all of her [CONDITION(S)] medications. Resident 46 stated that she told the facility nurses and physicians to restart the medications. Resident 46 stated that she thinks that the physician finally wrote it all down, but I couldn't believe how long it took. Resident 46 stated that she noticed changes in her mood while off of her medications the last several months. Resident 46 described these changes as it was up and down, then angry and then sad. It was terrible. They didn't have any social work or therapy services. Resident 46 stated she was seeing a psychiatrist outside of the facility prior to admission. Resident 46 stated that she requested from the ADM and the nurses to see her previous therapist and psychiatrist. Resident 46 stated that she had only seen her previous psychiatrist one time since requesting this. Resident 46 stated that since her suicide attempt facility staff have told her you didn't tell us you wanted to go. Resident 46 stated that after I tried to commit suicide they said we are going to send you to [name of a local behavioral health provider]. Resident 46 stated that before she attempted suicide she had asked to speak to someone about her mental health and was told no one was available, but now there was suddenly someone available. Resident 46 stated that after she attempted suicide, facility staff had restarted the antipsychotic medications she had been asking about. Resident 46 stated that when she attempted suicide she got mad at the staff member for removing the cord from around her neck, but now I thank [NAME] because I feel better. I am so, so happy that I didn't. I think I will get out of here some day, I hope soon. I have a daughter, a son, a grandson, a brother, sisters, a family, a life. I'm fine now, I take my medications and I'm fine. On 4/06/22 at 5:32 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated that she was the aide that was present when resident 46 attempted suicide. I'm the one who found her. CNA 6 stated that on the day of resident 46's attempted suicide she went to answer the resident's call light. CNA 6 stated that when she entered resident 46's room the resident had the call light wrapped around her neck two times, and she was trying to pull on it. CNA 6 stated that the call light was pulled out of the wall. CNA 6 stated that she tried to remove the call light from around resident 46's neck but the resident refused to let her take it. CNA 6 stated that the resident told her that she had already said goodbye to her family, and that she was saying goodbye to her also. CNA 6 stated that resident 46 had given up. CNA 6 stated that the resident had said to her, I don't want to be here. I just lost hope. CNA 6 stated that she calmed the resident down and attempted to take the call light from her, but the resident kept repeating no. CNA 6 stated that at that point she exited the resident room to notify the nurse. CNA 6 stated that when she went back to check on the resident she told her that people loved her and did not want her to die. CNA 6 stated that the resident was upset. CNA 6 stated that she noticed that once resident 46 was moved from the 3rd floor to the 2nd floor she became mad at everyone. CNA 6 stated that the resident would not talk to anyone and stated, I used to be nice, now I'm not. CNA 6 stated that the resident was unhappy at the facility and did not like several of the facility staff. CNA 6 stated that when resident 46 was readmitted she was better, happy, and thankful to me that she was still here. CNA 6 stated that she had not received any training for resident behaviors from the facility. CNA 6 stated that as their caregiver they listen to the residents, and they get to know each person's behavior. I didn't get no training. You just learn as a CNA. The CNA stated that she reported everything to the resident's nurse. CNA 6 stated that they were not informed of any interventions that were available for resident behaviors, and that the nurse's did not provide that information to the aides. CNA 6 stated that the nurse's did not provide any direction on which residents had these types of behaviors or what to do when it occurred. CNA 6 stated that half of the facility staff were agency, we don't have staff. CNA 6 stated that agency staff come and go and they did not know the residents. CNA 6 stated this contributed to nurses not being able to communicate and train the aides on what the resident's behaviors and interventions were. CNA 6 stated, I think the problem is staffing. CNA 6 stated that the facility hired staff and then after the new employees worked, they decide they did not like it and leave. They see the type of behaviors and they run. CNA 6 stated that she had not received education on de-escalating resident behaviors. CNA 6 stated that the facility had a resident advocate (RA) and the residents would look for that person a lot. CNA 6 stated that the previous RA use to address the resident's concerns and handled a lot of their issues and problems. On 4/7/22 at 8:28 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that the facility did not have a Social Service Worker (SSW). The ADM stated that the facility Resident Advocate left the faciity on [DATE]. The ADM stated that she was the staff member who was responsible for working with PASRR, and was unaware of some of the resident's PASRR recommendations until this week. On 3/29/22 at 12:42 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 stated that there was not a resident advocate or social worker employed at the facility. On 4/7/22 at 11:01 AM, an interview was conducted with Employee 1. Employee 1 stated that they believed that much of the resident's behaviors would not have happened had the RA still been at the facility. Employee 1 stated that they recalled the RA giving the ADM grievances and the ADM did not following up on them. Some of the grievances were missing personal property, but some were bigger issues that involved resident behaviors in December 2021 or early January 2022. Employee 1 stated that resident 46 was transferred to the hospital due to a stroke, and progress notes confirmed this occurred in December 2021. Employee 1 stated that after resident 46 was readmitted her demeanor changed and it looked like a conversion disorder. Employee 1 stated that resident 46 appeared more and more off, and then they came to find out that she went to the hospital with suicidal ideation. Employee 1 stated that since resident 46 had returned from the hospital, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Employee 1 stated that resident 46's past medical history and psychiatric history would have been beneficial for them to know so they could identify the resident's behavior and how it would impact the resident's mobility status. On 3/30/22, an interview was conducted with Medical Provider (MP) 3. MP 3 stated that prior to resident 46 being hospitalized , MP 3 had spoken with resident 46 while performing rounds. MP 3 stated that resident 46 reported she was feeling suicidal because they took me off medications and I need to go to the hospital. 2. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 49 was discharged from the facility on 4/10/22. Resident medical record was reviewed between 3/23/22 and 4/13/22. Resident 49's care plan was reviewed. On 3/2/21, after the resident's admission, the facility developed a care plan with regard to the resident becoming anxious. The care plan history revealed that this care plan was not revised throughout resident 49's stay at the facility. On 3/2/21, the facility also developed a care plan with regard to the resident feeling down or depressed. The care plan for depression indicated that the goal was to name at least one positive strength or ability each week. This goal was in place throughout the resident's stay at the facility, although no other documentation could be located to indicate this goal was being accomplished. In addition, interventions for the depression care plan were not revised throughout resident 49's stay at the facility. On 3/25/21, the facility developed a care plan resident 49 with regard to the resident having a PASRR Level II. The goal in place was to have the resident's mental health needs met by facility staff following PASRR II recommendations. In addition, interventions for the PASRR II care plan were not revised throughout resident 49's stay at the facility. On 3/2/21, facility staff completed an Evaluation for Community Access for resident 49 in which they determined that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident met the criteria determining that resident should not be in community alone. A PASRR level II was completed for resident 49 on 3/22/21. The PASRR documented that resident 49 has a history of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . He also endorsed symptoms of [CONDITION(S)] (Post Traumatic Stress Disorder) that he reports are causing him significant disruption at this time. The PASRR indicated that resident 49 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASRR indicated that in September 2020, resident 49 was residing at a long term care facility and tried to strangle himself, which led to an inpatient psychiatric hospitalization . The PASRR continues He has also experienced excessive anxiety and worry, difficulty managing feelings of worry, restlessness/fatigue d/t (due to) excessive worry, irritability, tension, and trouble sleeping d/t anxiety. He has been diagnosed with [CONDITION(S)] in the past, but it appears that his symptoms are more consistent with borderline traits vs (versus) true manic sxs (signs and symptoms). he described very rapid mood swings but struggled to identify manic sxs. He has experienced and reported chronic fears of abandonment, a long standing pattern of dysfunctional interpersonal relationships and devaluation/elevations of others in relationships, impulsivity in multiple areas in his life . recurring and often impulsive suicidal gestures or threats (he purchased a knife on the Internet and had it delivered to his prior SNF (skilled nursing facility) in a suicidal gesture and later tried to strangle himself), anger/irritability w/o (without) provocation, and affective instability/emotional reactivity vs true [CONDITION(S)] (he describes going from depressed to angery (sic) very rapidly . ). He has also been diagnosed with antisocial personality disorder given his history of disregard for the rules (smoking marijuana in the SNF setting), being disrespectful to police w/o provocation, irritability and verbal aggression with staff, and reckless disregard for his own safety with his impulsivity and failure to plan ahead. He has taken flights impulsively to various places in the United States where he has no support, unable to provide for himself or without funds to pay for food and shelter. He has left multiple nursing homes AMA (against medical advice) without adequate planning for his needs, resulting in poor outcomes. He has often been deceptive/overreported symptoms in medication seeking behaviors (pain meds (medications) or benzos (benzodiazepenes)). He has also snuck friends into the SNF or has snuck out of SNF's in the past, violating COVID-19 protocols. He has feigned helplessness to get help or sympathy from staff. He has been physically assaulted on multiple occasions, including once being beaten up and left for dead in an abandoned house. Due to this incident among his other altercations he reports sxs of [CONDITION(S)] including recurring nightmares/intrusive memories (The nightmares don't stop and they haunt me), avoidant behaviors, feelings of distrust of others/detachment from others, persistent negative emotions, irritability/anger out of the blue (I don't know why I just get pissed and I want to fight or punch a wall or something), reckless/self-destructive behaviors, and difficulty sleeping d/t his nightmares. The PASRR also stated that Pt stated that he is willing to get a referral for mental health but that it can be difficult to re-establish rapport and trust with new mental health providers. Pt did state that he wants to have someone who can help him in his decision making, such as a guardian or POA (power of attorney) . He recognized that he needs help in his decision making, and stated I have walked away from too many places over nothing, and it is getting to the point where people are going to start saying we can't have him come here. I'm going to be in a lot worse place than where I'm at now If I don't get help. The SNF Resident Advocate was made aware of pt's wishes. Pt is on multiple [CONDITION(S)] medications and he has been compliant in taking them. He reported that he has been depressed ever since leaving his prior SNF and that he hit bottom when he left there. He did not endorse SI (suicidal ideations) at this time; however given his history of impulsivity and multiple suicide attempts (and hospitalization d/t a suicide attempt in 2020) he should be closely monitored for any lethal means/means for self-harm that would be accessible to him. Given his online purchase of a knife in 2020 every package that might come to pt should be opened with staff present to ensure pt's safety. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. He should be referred for outpatient mental health treatment as well to him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. A second PASRR level II was completed for resident 49 on 3/22/21, that indicated resident 49 has profound motor deficits and has little assistive technology to help him. He would benefit greatly from assistive computer technology and an assistive communication device. He would also benefit from recreational activities that are geared to his age and interests. No indication could be located in the resident's EMR that these recommendations had been put into place. On 3/26/21, facility staff documented that Reported to administrator that resident confided in another resident that he was contemplating suicide. Nursing to monitor resident for behaviors/self harm and/or suicidal verbalizations. On 4/7/21, approximately 12 days later, the facility Licensed Clinical Social Worker (LCSW) Consultant documented the following in resident 49's progress notes: Special concerns and recommendations: 1:1, PRN (as needed), to address any concerns or issues. Provide support and validation. Encourage resident to participate in activities of his preference. Encourage and support family involvement. Remind resident of socially appropriate behavior. Praise resident when he deals with difficulties appropriately. Redirect resident to a quiet place to calm when aggressive or anxious. Encourage and help resident to participate in mental health therapy. Monitor resident closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. On 5/6/21, the Resident Advocate (RA) documented that resident 49 was having some hallucinations, and was talking to someone that wasn't there. He stated that a CNA (Certified Nursing Assistant) asked who he was talking to and [resident 49] stated another patients name, and CNA said there's no one here. RA informed DON and [mental health provider]. On 5/6/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 5/11/21 resident 49 attended a session with a local mental health provider. The provider documented that the resident reported feeling bored and lonelily (sic). We talked about activities to do in the room. On 5/27/21, a nursing note entry documented that resident reported to me that 3 weeks after his admit he had swallowed a razor and then threw it up. He states this was a razor that had been ordered [online] to cut his hair. He reported to me that he did not tell anyone at the time but he is now because he is worried that it may be a concerning factor to his recent sx and not feeling well. He denies having any suicidal ideations at this time. This was reported to the DON who stated pt has been having a lot of behaviors lately due to d/c (discharge) of pt's friend and that the bloodwork ordered this shift will be suffice (sic) indication to need for further eval (evaluation) and that she would visit with resident tomorrow. On 6/3/21, the RA entered a note documenting that resident 49 at times he can be verbally aggressive, impulsive and manipulative. [resident 49] has a history of suicidal ideations, but has not reported any recently. He is being followed by [name of mental health provider], and participates in visits. [Resident 49] was also recently in trouble with the law, and is ordered to take anger management classes. He is actively working on setting up those classes, along with taking online collage (sic) courses. Ra offers help and will assist him when needed. [Note: Per review of the EMR, resident 49 had only seen his mental health provider on 4/9/21, 5/11/21, and 6/3/21. In addition, no evidence of the anger management courses could be located in resident 49's EMR.] On 6/12/21 at 7:09 PM, nursing progress notes indicated that Resident has left the facility and has yet not returned. Night shift RN has communicated with resident via phone conversation. Resident 49 returned to the facility at 9:00 PM. No documentation could be located to indicate why resident 49 was not accompanied by staff out of the facility. On 7/7/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The not [TRUNCATED]

Based on interview and record review it was determined, for 11 out of 51 sample residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, two residents with mental health disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services, a resident with suicidal ideation (SI) eloped and was hospitalized due to lack of interventions and behavioral health services, and a resident with memory deficits had multiple incidents of distressing behaviors without interventions or services provided. The deficient practice identified was found to have occurred at a harm level. Additionally, residents with behaviors of verbal aggression and sexual contact with other residents did not receive interventions or services from a behavioral health provider. Resident identifiers: 4, 22, 29, 37, 39, 40, 46, 47, 49, 57 and 111. Findings include: HARM 1. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of acute [CONDITION(S)] insufficiency, enterocolitis due to [CONDITION(S)], altered mental status, type 2 diabetes mellitus, [CONDITION(S)], acute kidney failure, major depressive disorder, [CONDITION(S)] disorder, and anxiety disorder. On 4/6/22 resident 46's medical records were reviewed. On 11/12/21, resident 46's discharge orders from the hospital indicated that the resident should continue taking the following medications daily: [MEDICATION(S)] 300 milligrams (mg) each day (qd), [MEDICATION(S)] 40 mg qd, [MEDICATION(S)] 1.5 mg qd, [MEDICATION(S)] ([MEDICATION(S)]) 0.25 mg twice daily, [MEDICATION(S)] 40 mg qd, and [MEDICATION(S)] 500 mg q (every) 6 hours. On 11/12/21, the nursing progress documented that a medication reconciliation was performed with the Nurse Practitioner (NP) for resident 46. The no appropriate indications of use noted in documentation from hospital for use of some of meds; changes made: D/C [discontinue] [MEDICATION(S)] [antipsychotic] . [MEDICATION(S)] [anxiolytic]. [MEDICATION(S)] [antipsychotic]. [MEDICATION(S)] [antipsychotic]. Review of the November 2021, December 2021, January 2022, February 2022 Medication Administration Record (MAR) revealed that resident 46 did not receive Vryalar, [MEDICATION(S)], [MEDICATION(S)] [MEDICATION(S)], or [MEDICATION(S)] during those months. On 12/8/21, a PreAdmission Screening Resident Review (PASRR) Level II was completed for resident 46. The PASRR indicated that resident 46 had a long history of mental health signs and symptoms, and has carried multiple mental health diagnoses over the years, including [CONDITION(S)] disorder, paranoid [CONDITION(S)], personality disorders, generalized anxiety disorder, depression and [CONDITION(S)]. She has been hospitalized multiple times d/t [due to] her chronic mental health symptoms. She had her first episode of [CONDITION(S)] in her late teens after her first child was born; she began to experience recurring persucatory [sic] auditory hallucinations. Pt [patient] reports that her auditory hallucinations have persisted to this time. She reported dividing the hallucinations into the 'screamers' and the 'growler', which is a male voice that will growl at her. She has never been able to fully eliminate the AH [auditory hallucinations] even with the trials on multiple antipsychotic medications . ; she does report that she feels [MEDICATION(S)] helped the most. She reports the voices are persucatory [sic] and negative, saying things 'like I'm terrible, I don't deserve anything. that's normal for me.' . she had a suicide attempt by swallowing mercury from a thermometer. She endorses excessive anxiety, worry, difficulty managing feelings of worry, trouble focusing and sleeping d/t anxiety, and feeling restless and tense often. reports seeing a new psychiatrist monthly and a therapist every 2 weeks. Pt's discharge orders from [name of hospital] prescriptions for [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]; however, none of those medications are listed on pt's current SNF [skilled nursing facility] medication list. Per the SNF Resident Advocate it appears these were discontinued d/t concerns the medications were contributing to pt's weakness and falls. When asked if pt had been feeling different as these medications were discontinued she reported ongoing auditory hallucinations which are persucatory [sic] and derrogetory [sic] in nature, saying things such as 'I'm not worth anything, like I'm supposed to be stronger, stuff like that . She reports that 'I hear them all the time '; she feels her constant AH contritube [sic] to poor mood and increased anxiety and worry. She feels the voices have been stronger recently without her typical medications . she stated she 'noticed I haven't been sleeping well' and 'I could hear the voices more 'which has been disruptive to her sleep. Pt reported as she had previously that [MEDICATION(S)] and Lorazapem [sic] were very helpful in managing the voices and in 'keeping me calm '. She reported feeling 'fairly depressed' and 'You get depressed cause you get depressed in places like this.' . She feels that 'if there's any way I could get back on my meds [medications] that would be good.' She would likely benefit from a phone call with her outpatient mental health provider due to ensure adequate treatment of her psychiatric symptoms and to avoid decompensation from a psychiatric standpoint. On 1/5/22 at 2:34 PM, a facility staff documented on a re-admission assessment that resident 46 had scored a 15 on Brief Interview for Mental Status (BIMS), indicating that resident 46 was cognitively intact. On 2/9/22 at 9:23 AM, a physician documented that resident 46 States her voices are getting-scary voices are getting louder- causes anxiety. On 2/16/22 at 11:40 AM, facility staff completed a Personal Health Questionnaire 9 (PHQ-9) for resident 26. Staff documented that resident 46 had a score of 14, which indicated moderate depression. On 2/16/22 at 10:08 PM, nursing staff documented that resident 46 was having multiple episodes of screaming at the staff . at the top of her lungs and wouldn't stop. On 2/23/22 at 8:04 PM, a physician documented Consider antipsychoticsfor [sic] [CONDITION(S)] disorder and return of auditory voices. On 3/7/22 at 11:15 PM, a nursing staff member documented, Res [resident] having suicidal ideation's [at] 1820 [6:20 PM]. Aide notified nurses Res had call light around her neck. Aide removed cord from around neck. Nurses had to remove call light from her hand. Res stated she needs her psych meds which is why she did it. Res told aide Goodbye and informed aide that she has also said Goodbye to family. MD [Medical Doctor]/NP, appropriate staff and family notified. During cares Res stated she is losing hope. Res sent out via [name of ambulance company] to [name of hospital] for psych (psychiatric) evaluation. The consultant Licensed Clinical Social Worker (LCSW) notes for the last 6 months were reviewed. The LCSW did not address resident 46's behavioral concerns. Review of resident 46's medical record revealed that the resident did not receive any outside behavioral health services to evaluate her mental illness and medications. On 1/7/22, facility staff created a care plan for resident 46's [CONDITION(S)] disorder and generalized anxiety disorder. The care plan indicated that the resident was to have her mental health needs met as outlined per the PASRR recommendations. The care plan also recommended that resident 46 meet with specialized services for mental illness treatment; and meet with outpatient mental health providers as needed while in the facility for psychiatric treatment/support. On 3/23/22 at 10:06 AM, an interview was conducted with the facility ADM. The ADM stated that the facility did not have a resident advocate or a social worker, so I'm doing all the work. On 3/29/22 at 12:42 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 confirmed that the facility did not have a resident advocate. On 3/30/22 at 9:15 AM, an interview was conducted with resident 46. The resident stated that she's upset that there isn't a social worker here and feel like I'm losing hope. Resident 46 stated that there was one night recently that she was feeling really down so she called the crisis line because there was nobody to talk to here. On 4/04/22 at 9:52 AM, a follow-up interview was conducted with resident 46. Resident 46 stated that she called the suicide hotline a couple of times before attempting suicide in March 2022. Resident 46 stated that she wrapped the cord around her neck. I wanted to hang myself. I'm glad it didn't work now, but I gave up hope . There was no one here to talk to. On 4/6/22 at 10:28 AM, a follow-up interview was conducted with resident 46. The resident stated last month she was having a moment of hopelessness and tried to take her own life, stating they didn't give me my medication. Resident 46 stated that she told them in December that she needed her psychiatric medications, and they said, here's this girl talk to her. Resident 46 stated that the staff member was the bookkeeper and not a mental health provider. Resident 46 stated that she asked the Administrator (ADM) to speak to a social worker and the ADM told her they did not have one at the facility. Resident 46 stated that was when she tried to strangle herself with the call light cord. Resident 46 stated that she had to go to the hospital for treatment after that. Resident 46 stated that while at the hospital they started her [CONDITION(S)] medications again. Resident 46 stated that she had been on medications for depression and [CONDITION(S)] since she was [AGE] years old, and then when she came to the facility, they took her off all her [CONDITION(S)] medications. Resident 46 stated that she told the facility nurses and physicians to restart the medications. Resident 46 stated that she thinks that the physician finally wrote it all down, but I couldn't believe how long it took. Resident 46 stated that she noticed changes in her mood while off her medications the last several months. Resident 46 described these changes as it was up and down, then angry and then sad. It was terrible. They didn't have any social work or therapy services. Resident 46 stated she was seeing a psychiatrist outside of the facility prior to admission. Resident 46 stated that she requested from the ADM and the nurses to see her previous therapist and psychiatrist. Resident 46 stated that she had only seen her previous psychiatrist one time since requesting this. Resident 46 stated that since her suicide attempt facility staff have told her You didn't tell us you wanted to go. Resident 46 stated that after I tried to commit suicide, they said we are going to send you to [name of a local behavioral health provider]. Resident 46 stated that before she attempted suicide, she had asked to speak to someone about her mental health and was told no one was available, but now there was suddenly someone available. Resident 46 stated that after she attempted suicide, facility staff had restarted the antipsychotic medications she had been asking about. Resident 46 stated that when she attempted suicide, she got mad at the staff member for removing the cord from around her neck, but now I thank [NAME] because I feel better. I am so, so happy that I didn't. I think I will get out of here someday; I hope soon. I have a daughter, a son, a grandson, a brother, sisters, a family, a life. I'm fine now, I take my medications and I'm fine. On 4/06/22 at 5:32 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated that she was the aide that was present when resident 46 attempted suicide. I'm the one who found her. CNA 6 stated that on the day of resident 46's attempted suicide she went to answer the resident's call light. CNA 6 stated that when she entered resident 46's room the resident had the call light wrapped around her neck two times, and she was trying to pull on it. CNA 6 stated that the call light was pulled out of the wall. CNA 6 stated that she tried to remove the call light from around resident 46's neck, but the resident refused to let her take it. CNA 6 stated that the resident told her that she had already said goodbye to her family, and that she was saying goodbye to her also. CNA 6 stated that resident 46 had given up. CNA 6 stated that the resident had said to her, I don't want to be here. I just lost hope. CNA 6 stated that she calmed the resident down and attempted to take the call light from her, but the resident kept repeating no. CNA 6 stated that she had not received any training for resident behaviors from the facility. CNA 6 stated that as their caregiver they listen to the residents, and they get to know each person's behavior. I didn't get no training. You just learn as a CNA. The CNA stated that she reported everything to the resident's nurse. CNA 6 stated that they were not informed of any interventions that were available for resident behaviors, and that the nurses did not provide that information to the aides. CNA 6 stated that the nurse's did not provide any direction on which residents had these types of behaviors or what to do when it occurred. CNA 6 stated that half of the facility staff were agency, we don't have staff. CNA 6 stated that agency staff come and go, and they did not know the residents. CNA 6 stated this contributed to nurses not being able to communicate and train the aides on what the resident's behaviors and interventions were. CNA 6 stated, I think the problem is staffing. CNA 6 stated that the facility hired staff and then after the new employees worked, they decide they did not like it and leave. They see the type of behaviors and they run. CNA 6 stated that she had not received education on de-escalating resident behaviors. CNA 6 stated that the facility had a resident advocate (RA) and the residents would look for that person a lot. CNA 6 stated that the previous RA use to address the resident's concerns and handled a lot of their issues and problems. On 4/7/22 at 8:28 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that the facility did not have a Social Service Worker (SSW). The ADM stated that the facility Resident Advocate left the faciity on [DATE]. The ADM stated that she was the staff member who was responsible for working with PASRR and was unaware of some of the resident's PASRR recommendations until this week. On 3/29/22 at 11:10 AM, an interview was conducted with the ADON. The ADON stated that the facility had not had a social worker or resident advocate for a couple of months. On 3/29/22 at 12:42 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 stated that there was not a resident advocate or social worker employed at the facility. On 4/7/22 at 11:01 AM, an interview was conducted with Employee 1. Employee 1 stated that they believed that much of the resident's behaviors would not have happened had the RA still been at the facility. Employee 1 stated that they recalled the RA giving the ADM grievances and the ADM did not following up on them. Some of the grievances were missing personal property, but some were bigger issues that involved resident behaviors in December 2021 or early January 2022. [Cross-refer F740] 2. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] diagnoses that included [CONDITION(S)], suicidal ideations, major depressive disorder, anxiety disorder, chronic pain syndrome, opioid use, and neuromuscular dysfunction of the bladder. Resident 49 was discharged from the facility on 4/10/22. Resident medical record was reviewed between 3/23/22 and 4/13/22. A PASRR level II was completed for resident 49 on 3/22/21. The PASRR documented that resident 49 has a history of treatment for depression and anxiety, along with multiple maladaptive personality traits; all of these have caused pt (patient) significant functional impairment for many years. He also endorsed symptoms of [CONDITION(S)] (Post Traumatic Stress Disorder) that he reports are causing him significant disruption at this time. The PASRR indicated that resident 49 had a history of suicidal ideations and suicide attempts, beginning in his teens. The PASRR indicated that in September 2020, resident 49 was residing at a long term care facility and tried to strangle himself, which led to an inpatient psychiatric hospitalization . The PASRR continues He has also experienced excessive anxiety and worry, difficulty managing feelings of worry, restlessness/fatigue d/t (due to) excessive worry, irritability, tension, and trouble sleeping d/t anxiety. He has been diagnosed with [CONDITION(S)] in the past, but it appears that his symptoms are more consistent with borderline traits vs (versus) true manic sxs (signs and symptoms). he described very rapid mood swings but struggled to identify manic sxs. He has experienced and reported chronic fears of abandonment, a long standing pattern of dysfunctional interpersonal relationships and devaluation/elevations of others in relationships, impulsivity in multiple areas in his life . recurring and often impulsive suicidal gestures or threats (he purchased a knife on the Internet and had it delivered to his prior SNF (skilled nursing facility) in a suicidal gesture and later tried to strangle himself), anger/irritability w/o (without) provocation, and affective instability/emotional reactivity vs true [CONDITION(S)] (he describes going from depressed to angery (sic) very rapidly . ). He has also been diagnosed with antisocial personality disorder given his history of disregard for the rules (smoking marijuana in the SNF setting), being disrespectful to police w/o provocation, irritability and verbal aggression with staff, and reckless disregard for his own safety with his impulsivity and failure to plan ahead. He has taken flights impulsively to various places in the United States where he has no support, unable to provide for himself or without funds to pay for food and shelter. He has left multiple nursing homes AMA (against medical advice) without adequate planning for his needs, resulting in poor outcomes. He has often been deceptive/overreported symptoms in medication seeking behaviors (pain meds (medications) or benzos (benzodiazepenes)). He has also snuck friends into the SNF or has snuck out of SNF's in the past, violating COVID-19 protocols. He has feigned helplessness to get help or sympathy from staff. He has been physically assaulted on multiple occasions, including once being beaten up and left for dead in an abandoned house. Due to this incident among his other altercations he reports sxs of [CONDITION(S)] including recurring nightmares/intrusive memories (The nightmares don't stop and they haunt me), avoidant behaviors, feelings of distrust of others/detachment from others, persistent negative emotions, irritability/anger out of the blue (I don't know why I just get pissed and I want to fight or punch a wall or something), reckless/self-destructive behaviors, and difficulty sleeping d/t his nightmares. The PASRR also stated that Pt stated that he is willing to get a referral for mental health but that it can be difficult to re-establish rapport and trust with new mental health providers. Pt did state that he wants to have someone who can help him in his decision making, such as a guardian or POA (power of attorney) . He recognized that he needs help in his decision making, and stated I have walked away from too many places over nothing, and it is getting to the point where people are going to start saying we can't have him come here. I'm going to be in a lot worse place than where I'm at now If I don't get help. The SNF Resident Advocate was made aware of pt's wishes. Pt is on multiple [CONDITION(S)] medications and he has been compliant in taking them. He reported that he has been depressed ever since leaving his prior SNF and that he hit bottom when he left there. He did not endorse SI (suicidal ideations) at this time; however given his history of impulsivity and multiple suicide attempts (and hospitalization d/t a suicide attempt in 2020) he should be closely monitored for any lethal means/means for self-harm that would be accessible to him. Given his online purchase of a knife in 2020 every package that might come to pt should be opened with staff present to ensure pt's safety. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. He should be referred for outpatient mental health treatment as well to him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. A second PASRR level II was completed for resident 49 on 3/22/21, that indicated resident 49 has profound motor deficits and has little assistive technology to help him. He would benefit greatly from assistive computer technology and an assistive communication device. He would also benefit from recreational activities that are geared to his age and interests. No indication could be located in the resident's EMR that these recommendations had been put into place. On 3/26/21, facility staff documented that Reported to administrator that resident confided in another resident that he was contemplating suicide. Nursing to monitor resident for behaviors/self harm and/or suicidal verbalizations. On 4/7/21, approximately 12 days later, the facility Licensed Clinical Social Worker (LCSW) Consultant documented the following in resident 49's progress notes: Special concerns and recommendations: 1:1, PRN (as needed), to address any concerns or issues. Provide support and validation. Encourage resident to participate in activities of his preference. Encourage and support family involvement. Remind resident of socially appropriate behavior. Praise resident when he deals with difficulties appropriately. Redirect resident to a quiet place to calm when aggressive or anxious. Encourage and help resident to participate in mental health therapy. Monitor resident closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. On 5/6/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 5/11/21 resident 49 attended a session with a local mental health provider. The provider documented that the resident reported feeling bored and lonelily (sic). We talked about activities to do in the room. On 6/3/21, the RA entered a note documenting that resident 49 at times he can be verbally aggressive, impulsive and manipulative. [resident 49] has a history of suicidal ideations, but has not reported any recently. He is being followed by [name of mental health provider], and participates in visits. [Resident 49] was also recently in trouble with the law, and is ordered to take anger management classes. He is actively working on setting up those classes, along with taking online collage (sic) courses. Ra offers help and will assist him when needed. [Note: Per review of the EMR, resident 49 had only seen his mental health provider on 4/9/21, 5/11/21, and 6/3/21. In addition, no evidence of the anger management courses could be located in resident 49's EMR.] On 7/7/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 7/15/21, a nursing progress note was entered indicating that resident 49 was intentionally banging head against wall and trying to throw himself on the floor. Nursing wrned (sic) him of risk of self injury, wctm (will continue to monitor). On 8/12/21 at 12:47 AM, a nursing progress note indicated that the nurse was called by a local deputy office around 9 pm. Patient was found in field, with knife in his possession, had fallen out of his wheelchair and been on the ground for an unknown amount of time. They admitted [name of resident] for 24 hrs with a pink slip to the local . hospital, noting he was a danger to himself. I was contacted later by the social worker, .[the social worker] called back and stated [resident 49] had been medically cleared and that we had to readmit him to the facility tonight. They didn't run a tox (toxicology) screen on him. Our administrator states he is evicted and can no longer return. Social worker states we have to take him back and I referred her to our administrator to clarify that we would not accept him back. If social worker calls back, please refer them to our Administrator and do not take patient back. Social worker called again and stated we have to take him back. I told her they would need to contact us in the morning and that we cannot take him tonight. She will tell us we have to take him back. [Note: No hospital documentation was included in resident 49's EMR to indicate what the hospital's findings and/or recommendations were upon discharge.] On 8/18/21, a facility physician evaluated resident 49 and stated that the resident refuses psychiatric outpatient care. On 8/27/21, a History and Physical was completed by a hospital physician for resident 49. The hospital notes indicated that on 8/20/21, resident 49 was pink sheeted to the hospital because he eloped from the nursing home and his electric scooter and drove up to the ninth floor of a parking structure where he was attempting to throw himself off in a suicide attempt. Police intervened and brought him to the hospital. Per the report, pt was combative with police who were pulling him away from the edge of the building . Pt reports feeling acutely suicidal for the past few weeks and that tonight is his 2nd suicide attempt this month. Pt states he 'planned every second' of the attempt and made sure no one at his care center knew. Pt states I had it. and they took it away from me, meaning, he was almost successful in ending his life and the police took that peace away from him. Pt reports feeling frustrated about his quality of life and that he has no reason to live. Pt is frustrated his plan was interrupted and still wishes to die. Pt will require IP (inpatient) psychiatric admission for stabilization. The resident was subsequently hospitalized and then transferred to a behavioral health bed at a different hospital for further assessment and treatment of his underlying psychiatric illness. The notes also indicated that resident 49 does report feeling depressed and also has no support from family or other sources and feels isolated. The notes documented that when another provider at the hospital saw resident 49, he states he has been having suicidal ideation for the last few weeks and this is his second attempt to kill himself in the last month. Evidently he left the care facility and was headed towards a lake in order to drowned (sic) himself before and was seen in the ER (emergency room ) and then sent back to the care facility. the patient endorses depressed mood, low interest, loss of pleasure, feeling hopeless and worthless, isolative behavior, and has suicidal but no homicidal ideation. The hospital notes indicated that the resident had been scheduled for an involuntary commitment hearing. The hospital notes indicated that The nursing facility also said they are going to increase his supervision where he will not have any opportunity to go out on his own for instance. [Note: There were no notes entered into the resident's EMR regarding this event. The resident was readmitted to the facility on [DATE].] Per review of the care plan, when the resident returned on 9/1/21, the exact same interventions were included in the anxiety and depression care plans for resident 49 that had been in place prior to the resident's hospitalization . On 9/3/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 9/6/21, facility staff completed a Psychosocial Review for resident 49. The review indicated that the resident had experienced suicidal ideations in the past and could be manipulative. The review also documented that the resident had been verbally aggressive and treatening (sic) towards staff. The Special Concerns and Recommendations included: make sure resident had access to media and his phone, staff would help with redirection and validation, and staff would monitor the resident's mood while keeping administration updated. [Note: This was only one of two psychosocial reviews completed for resident 49 during his 13 month stay, despite ongoing behaviors and increasing suicidality.] On 9/8/21, resident 49 had an updated PASRR level II completed. The updated PASRR indicated due to the resident's recent suicide attempt and hospitalization , a significant change PASRR evaluation was completed. The PASRR documented, When asked about why he left the care center and went to the parking structure in his suicide attempt . He stated that he got to the point where he felt that 'I had no choice but to try and kill myself' as dying by natural causes would 'take too long'. he feels he would benefit from increased frequency of counseling and maybe a [CONDITION(S)] medications review as he's not sure how much his [CONDITION(S)] medications are helping. He reports poor sleep . he only eats one meal a day . He tends to isolate in his room . he stated he tried to go to SNF activities but didn't find them enjoyable. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts. He should be referred for increased mental health services from his outpatient mental health treatment providers at [name of mental health provider]. This can hopefully help him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. On 9/14/21, the facility RA entered a progress note indicating that resident 49 at times he can be verbally aggressive, impulsive and manipulative. [Resident 49] has a history of suicidal ideations, and was recently hospitalized twice due to having those thoughts. When [resident 49] returned from his last hospital stay he stated that he feels much better. He is being followed by [name of mental health provider] . He is actively taking online collage (sic) courses. Ra offers help and will assist him as needed. Care plans reviewed. [Note: No documentation could be located in resident 49's EMR to indicate he had been seen by his mental health provider since 6/3/21.] On 10/7/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. LCSW Consultant notes for October 2021 were reviewed. No recommendations were documented with regard to resident 49. On 11/8/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. LCSW Consultant notes for November 2021 were reviewed. No recommendations were documented with regard to resident 49. LCSW Consultant notes for December 2021 were reviewed. No recommendations were documented with regard to resident 49. On 12/1/21 at 5:26 PM, a nursing progress note indicated that resident 49 complained to the nurse that he didn't want a roommate. Resident 49 stated he doesn't want to have to share and that there's limited space for the 2 of them to share. res then asked if he doesn't get move [TRUNCATED]

Based on observation, interview, and record review, it was determined, for 4 of 51 sample residents, that the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a residents were not given pain medication prior to a wound care treatment and residents with consistent high pain scores were given no additional pain management. The findings were cited at a harm level for all four residents. Resident identifiers: 1, 16 29, and 38. Findings included: HARM 1. Resident 29 was initially admitted to the facility on [DATE] and again on 1/24/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/22 at 11:15 AM an interview with resident 29 was conducted. Resident 29 stated that the staff rarely changed the dressing for his wounds. Resident 29 stated that the last time his dressings for his wounds were changed and cleaned was 3 days ago. An observation of would care for resident 29 was conducted on 4/6/22 at 1:35 PM. Licensed Nurse Practitioner (LPN) 1 was conducting the wound care order. Once resident was turned on his side, it was observed that there was no previous dressing on resident 29's pressure ulcer. LPN 1 stated that resident 29 required a daily change of his dressing. LPN 1 stated, maybe the previous dressing came off. Resident 29 was observed to be in pain during the treatment. Resident 29 was continuing to say ow and stop during the cleaning and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] ? and resident 29 replied, Yes. It was observed that LPN 1 cleared fecal matter from the wound prior to packing the wound with Dakins soaked gauze and finishing the treatment. Resident 29's medical records were reviewed on 4/7/22. A document from the wound clinic dated 3/24/22 was reviewed. The document stated that the wound on resident 29's coccyx had been adjusted to a stage IV pressure ulcer do to exposed muscle and fossa in the wound bed base. The document also had recommendations for a surgical consult and debridement, a wound VAC, and nutritional interventions. The wound was measured at 10 centimeters (cm) by 4 cm by 0.00 cm. Resident 29's pain medications were reviewed. 1. 600 milligrams (mg) of Ibuprofen every 8 hours as needed for pain 2. 5 mg of [MEDICATION(S)] every 4 hours as needed for pain The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The pain medication was administered after the wound care treatment that occurred at 1:35 PM. Resident 29's care plan dated 4/6/22 included a focus are for the pressure injury to his coccyx. The goal of this focus area was [Resident 29] will have no complications from pressure injury through the review date. One of the interventions for this focus area was to, Assess for s/sx [signs/symptoms] pain with wound care. Schedule/administer analgesic prior to tx [treatment] as applicable. It was observed on 4/6/22 during the wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/11/22 at 12:20 PM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that resident 29 had expressed that he had pain when his coccyx wound dressing changes were completed. The ADON stated that resident 29 was very resistant to cares, and required pain medication before he will allow nurses to change his dressings. The ADON stated that resident 29 expressed pain with brief changes, and had nearly constant pain. The ADON stated that resident 29 also had anxiety, and therefore his anxiolytic medication was also helpful. 2. Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/27/22 at 3:44 PM, resident 1 was observed in the hall, asking a nurse for a cotton swab. Resident 1 was immediately interviewed, and stated that he had foot pain on his left foot, on his second and third toe. Resident 1's foot was observed to be uncovered, and resident 1's toes had some black areas (eschar) on them, particularly between the second and third toes. Resident 1 stated that he wanted to put ointment on his toes and needed to have a swab or stick to apply it. The ADON was observed to tell resident 1 that the nurse would perform the wound care. Resident 1 stated that it hurt too much when the nurses performed the wound care. The ADON told resident 1 that the nurse would provide pain medication before completing his wound care. Resident 1 was observed to go with the nurse to his room. The nurse was not observed to take medication from the medication cart for resident 1. [Note: Resident 1's [MEDICATION(S)] had an administration time of 3:54 PM.] On 4/13/22, resident 1's medical record review was completed. On 3/2/22 at 4:12 PM, hospital discharge orders revealed the following wound care order: Every other day place foam dressing between the interspaces to keep them to becoming macerated with the dry broken down skin, and I would also recommend painting the interspaces with [MEDICATION(S)] bilaterally [on toes] 1 through 4 if there is lambswool available in the hospital floor apply this in between the interspaces, if not the pink/white foam or gauze. For the left dorsal foot wound I recommend Iodosorb or [MEDICATION(S)] gauze covered with foam. Recommend applying [MEDICATION(S)] or some other moisturizer cream that the hospital has the bilateral lower extremities to prevent breakdown of skin due to being too dry. On 3/24/22 at 6:00 PM, an order was initiated at the facility for Wound to Left Second Toe, Clean, apply [MEDICATION(S)], Apply calcium Alginate between toes daily. Resident 1's care plan did not include wound care. A diabetic foot ulcer was identified, but no treatments were included in the care plan. On resident 1's Treatment Administration Record (TAR), the order for wound care was initiated on 3/24/22. The TAR for March revealed that resident 1 refused treatment on 3/26/21. Resident 1 was not offered wound care on any other day. On 3/26/2022 at 1:16 AM, a nurses' note revealed that resident 1 was .complaining of pain to lower extremities and has no [MEDICATION(S)] 5 mg tablets on hand. I was instructed to go to 2nd floor if I needed pain medication pulled from the E Kit. The nurse on the second floor contacted the pharmacy and he did not have prescription on file for [MEDICATION(S)] 5mg tablet. The pharmacist was able to authorize [MEDICATION(S)] 50 mg tablet which was active but not in system. Nurse on second floor pulled medication from E Kit and I administer [MEDICATION(S)] 50 mg tablet PO at this time [1:16 AM] for pain to the lower extremities with facial grimacing 7/10. Will continue to monitor. Will report to day nurse at 0600. Will sent [MEDICATION(S)] to MD for signing. A nursing note on 3/28/22 at 4:32 AM revealed, Patient was up most of the night complaining of his toe hurting. Please follow up with doctor to see if they would like the wound nurse to come in and help with treatment. Resident 1's pain scores revealed that in April, 2022, resident 1 reported pain 10/10 on 4 occasions. Resident 1's TAR for the month of April revealed that resident 1 did not receive wound care on the following dates: a. 4/2/22 b. 4/3/22 c. 4/4/22 d. 4/5/22 e. 4/12/22 Nursing notes included a new order on 4/11/22 at 9:02 AM. Order was for the wound to Left Second Toe, Scrub wound bed and 10-20 cm of peri wound with wound cleanser for 30-60 seconds. Apply skinprep peri wound. Apply alginate to base of the wound, cover with border dressing, change daily and as needed for accidental removal, saturation and/or soiling. one time a day, educate patient with keeping wound dressing in place until nurse care. The nurse noted that the wound was odorous and had some drainage. On 3/29/22 at 8:52 AM, the ADON was interviewed. The ADON stated that for resident 1, he did not have much of a pedal pulse and was aware that he had used a stick on his wound. The ADON stated that his wound would not be as painful to him if it wasn't vascular. The ADON stated that when she was informed of the wound, she assessed it, put honey and a foam dressing on it, and let the provider know there was an issue. The ADON stated that the order for the honey and foam was not ordered by a physician, but honey is my number one best, it doesn't hurt anything. On 3/29/22 at approximately 10:00 AM, Employee (E) 12 was interviewed. E 12 stated that they worked with resident 1 and the left foot injuries appeared infected and was concerned that resident 1 may require amputation. E 12 stated that the wounds had been there since admission, but were not treated. E 12 stated that the wound nurse, who was now the Assistant Director of Nursing (ADON) did not follow up on staff member's concerns. On 3/29/22 at 12:42 PM, the Corporate Resource Nurse (CRN 1) was interviewed. CRN 1 stated that she was the acting infection preventionist at the facility. CRN 1 stated that she had not spoken to the Nurse Practitioner who comes to the building to see the resident, and did not assist with wound care. The CRN stated that the ADON was going to receive wound care training, and had been the wound nurse. CRN 1 stated that the ADON was not wound care certified. CRN 1 stated that resident 1 had necrotic areas on his feet due to his shoes, and a doctor should see his feet. CRN 1 stated that she noticed resident 1 did not wear slippers on his feet on Sunday. On 3/30/22 at 12:26 PM, an interview was conducted with Medical Provider (MP) 1. MP 1 stated that a wound care team worked in the building to address the residents' wound care needs, and the former wound nurse, now ADON coordinated those visits. MP 1 stated that residents had told him that their wound care was not completed by the nurses. On 4/6/22 at 10:47 AM, an interview was conducted with the Maintenance Director. The maintenance director stated that resident 1 had an appointment to see a podiatrist on 4/11/22. 3. Resident 38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/29/22 at approximately 9:00 AM, resident 38 was observed in his room. Resident 38 was interviewed and stated that he did not always receive his pain medications when requested. Resident 38 stated that he had 7 or 8 falls while at the facility and had increased pain from the falls. On 4/13/22, resident 38's medical records review was completed. Resident 38's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 38's Treatment Administration Record (TAR) revealed that for April 1 through April 12, 2022, resident 38 requested [MEDICATION(S)] every day. On 4/1/22, resident 38 requested [MEDICATION(S)] for severe pain four times, the maximum number of opportunities. Additionally, on five days, resident 38 requested [MEDICATION(S)] three times daily. Resident 38 was provided acetaminophen on three occasions between 4/1/22 and 4/12/22 for two episodes of pain at 8/10 and 1 episode of pain 3/10. In March, 2022, resident 38 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This medication was discontinued on 3/16/22. Resident 38 requested the maximum number of doses on three days between 3/1/22 and 3/15/22, and three days with three doses. On 3/30/22 at 10:51 PM, a nurses' note revealed: Pt. has one behavioral episode in regards to his pain medication not being administered more frequently through out the day and night shifts. Explain to Pt. that he can only have the pain medication when it is due at the time provided in the MAR . The MAR for March 30, 2022 revealed that resident 38 had an [MEDICATION(S)] administered at 2:15 AM. With the order stated to administer as needed every 6 hours, The note at 9:37 AM, would be after the 6 hour wait time from the previous dose. Resident 38 received the next dose of [MEDICATION(S)] at 4:31 PM. Resident 38's care plan revealed that resident 38 had the following: a. On 11/8/21, a focus that resident 38 had impaired mobility and .pain limits activity involvement . b. On 11/2/21 and revised on 2/6/22, a focus that resident 38 had activities of daily living self-care deficits related to several factors including pain. c. On 2/6/22, a focus that resident 38 was at increased risk of altered mood related to cognitive impairment related to several factors including pain. d. On 11/2/21, a focus that resident 38 was at increased risk of pain related to conditions and diagnoses. The goal was that resident 38 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included: Administer analgesia as per orders. Give 1/2 hour before treatments or care. Another intervention was to Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Resident 38 had two fall reports, one dated 11/12/21 and 3/3/22. Additional nursing notes revealed incident reports with fall monitoring. On 3/24/22 at 11:31 AM, an interview was conducted with a former Director of Nursing (DON 2). DON 2 stated that resident 38 had increased pain due to falls. DON 2 stated that resident 38 was a good historian. On 3/29/22 at 10:10 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that residents were provided pain medication to help them remain in good spirits. The ADON stated that the nurses were mostly agency, and some had a more difficult time getting to medications timely. On 3/30/22 at 12:26 PM, Medical Provider 1 (MP 1) was interviewed. MP 1 stated that that he was aware of when the facility ran out of a resident's opioid medication and borrowed from another resident. MP 1 stated that a non-ordered opioid administration was illegal. 4. Resident 16 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/22 at 10:31 an interview with resident 16 was conducted. Resident 16 stated that he is in constant pain because of the [CONDITION(S)] in his body. Resident 16 stated that he was receiving [MEDICATION(S)] 5 mg every 6 hours, but stated that the medication starts to wear off at 4 hours and has requested from the nurse and physician to have a [MEDICATION(S)] to help when the [MEDICATION(S)] wears off. Resident 16 stated that they are not helping to keep his pain under control. On 4/6/22 a review of residents record was conducted. According to resident 16's care plan: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness. According to MAR: Tylenol given 3x325 three times a day. [MEDICATION(S)] Three times a day (TID), [MEDICATION(S)] 5 mg to be given every 6 hours as needed. Pain scores are recorded as 9-10 regularly for the past two months.

Based on observation, interview and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These findings resulted in harm to multiple residents. In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. Resident identifiers: 4, 16, 17, 18, 19, 22, 27, 28, 29, 37, 40, 41, 43, 44, 46, 47, 49, 51, 57, 61 and 111. Findings include: HARM 1. Resident 27 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross refer to F689] 2. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross-refer F580, F684 IJ, F686 IJ]. 3. Resident 40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross-refer F689 IJ] 4. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross-refer F740 IJ] 5. Resident 22 was initially admitted to the facility on [DATE] and again on 1/19/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross refer F684 IJ] 6. Resident 29 was initially admitted to the facility on [DATE] and again on 1/24/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross refer F684, F686 IJ, F688] 7. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross refer F689 IJ, F740 IJ] 8. Resident 41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross refer to F684 IJ] 9. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross refer F 686 and F689 IJ] 10. Resident 51 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/24/22 at 10:08 AM, an interview was conducted with resident 51. Resident 51 stated that the staffing is horrible. Resident 51 stated that they don't have time to do anything. [Cross refer F689] 11. Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross refer F689 IJ] 12. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross refer to F689] POTENTIAL FOR HARM 13. Resident 16 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/22 at 8:05 an interview was conducted with resident 16. During this interview, resident 16 stated that the nurses are shorthanded and sometimes don't get to cares that are required. Resident 16 stated that the two Certified Nursing Assistants (CNA) on duty are great, but that is the exception. Resident 16 stated that the call light wait times are 30-45 minutes at any time, and some times up to an hour or two. Resident 16 stated that he is waiting long times for a brief change. Resident 16 stated that weekends are the worst with staffing, and that he is frequently missed with bed baths because they don't have enough staff. [Cross refer F690] RESIDENT TO RESIDENT ALTERCATIONS 14. A. Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Resident 37 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Resident 47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross refer to F600] 15. Resident 111 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [Cross-refer F600] RESIDENT INTERVIEWS 16. Resident 44 was initially admitted to the facility on [DATE] and again on 6/4/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/22 at 9:43 AM, an interview was conducted with resident 44. Resident 44 stated that most staff had responded to her call light quickly, however, resident 44 stated that Certified Nursing Assistant (CNA) 19, who was an agency CNA, takes a long time to answer her call light. Resident 44 stated that she had to wait 2 hours for her briefs to be changed the day prior. Resident 44 stated that she can see the clock, on the opposite wall from her bed and she watched the clock so she knows how long it took. Resident 44 stated it always takes a long time for CNA 19 to respond to her call light when she works. Resident 44 stated she had not seen CNA 19 that day. Resident 44 stated she had spoken to two nurses about the long call light waits but that nothing had been done about it. 17. Resident 57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/28/22 at 12:52 AM, in interview was conducted with resident 57. Resident 57 stated that the facility was understaffed, and it had been hard to get medication for his headache. Resident 57 stated he had requested Tylenol at 8:45 PM the night prior but didn't receive the Tylenol until 11:15 PM. 18. Resident 19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/28/22 at 2:48 PM, an interview was conducted with resident 19. Resident 19 stated most staff are very helpful, but she was not getting the showers she wanted. 19. Resident 43 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/22 at 7:20 an interview with resident 43 was conducted. During this interview, resident 43 stated that the facility is frequently understaffed, and that it is particularly on nights and weekends. Resident 43 stated that usually the floor has one to two CNA's and one Nurse to pass medications. Resident 16 stated that he has heard of mistakes with medications happen, and that he thinks he has gotten someone else's medications. Resident 43 stated that this is because they are so short staffed. Resident 43 stated that agency CNA's frequently ignore the call lights. STAFF INTERVIEWS 22. On 4/5/22 at 12:14 PM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that the workload was too much, and she was having difficulty getting everything done. RN 2 stated that she talked to the Assistant Director of Nursing (ADON), who told her another nurse would be there at shift change. RN 2 stated that she was not able to complete the medication administration requirements in the hours when another nurse was assisting with medications, and therefore had to pick up the slack of the other nurse, finish her medication administration, and complete treatments in 6 hours. RN 2 stated that she was answering residents' questions, answering phone calls, and separating and evaluating residents after fights. RN 2 was observed assisting resident 22 who had fallen repeatedly at 12:20 PM. RN 2 stated that she talked to the ADON but was not allowed to send the resident out. RN 2 stated that the ADON had spoken to the Administrator, and they were sending the resident out at 2:26 PM. RN 2 was observed assisting the resident until Emergency Medical Services (EMS) arrived at 2:46 PM. RN 2 assisted the EMS team to help that resident to the hospital. RN 2 was observed telling the EMS team that the resident had spent most of the night on the floor (with repeated falls). At approximately 2:55 PM, the resident was sent to the hospital and RN 2 was observed to return to passing medications. 23. On 4/6/22 Employee 14 (E 14) was interviewed. E 14 stated that there were so many behaviors in the building, it was difficult to complete the work. E 14 stated that one resident played in her poo, throws it, and she wants to touch you. E 14 stated that most of the nurses were from agency, and didn't know the residents. E 14 stated that agency staff could not train and did not know the procedures. E 14 stated that there are no facility staff to educate the agency staff. E 14 stated that not all residents received showers, brief changes, or wound care. E 14 stated that there were a lot of fights between residents, which required a lot of time. E 14 stated that they were never provided orientation when they started working. E 14 stated This facility has always been short staffed. E 14 stated that when agency staff arrive and see the type of behaviors the residents have, they run. E 14 stated that residents on the West side of the 200 hall required extra time for cares because they were larger, yelled, accused staff of stealing things, and refused cares. E 14 stated that the longer a task took, the less time they had for other residents. E 14 stated There is not enough staff to get everything done. E 14 stated that many days, CNAs would call off shift, and the facility was missing a lot of key personnel. E 14 stated that there was no restorative aide, wound nurse, resident advocate, discharge planner, infection preventionist, MDS coordinator, or Director of Nursing. E 14 stated that when there was no other staff, those who were working were expected to pick up the slack, and things fell through the cracks. 24. On 4/6/22 at 5:45 PM, CNA 6 was interviewed. CNA 6 stated that sometimes residents had to wait 45 minutes for assistance if a CNA didn't show up for their shift. CNA 6 stated that it was frequent that someone didn't come in, and the CNAs were told to just make it work. CNA 6 stated that there were supposed to be four CNAs on shift for the 200 hall, but usually, there were only 3 scheduled. CNA 6 stated that with 44 residents on the hall, they really needed 4 staff, because the residents were really complex. 25. On 4/11/22 at 12:40 PM, CNA 14, the scheduler was interviewed. CNA 14 stated that corporate structure determined staffing. CNA 14 stated that nurses told him they could not get everything done on their shifts. CNA 14 stated that there were other nurses working who could assist the floor nurse. CNA 14 stated that if he saw CNAs standing around, he would decrease the number of aides. CNA 14 stated that the Administrator also had asked him to decrease staff at times. CNA 14 stated that sometimes he would schedule extra CNAs because someone would usually call off. 26. On 4/13/22 at 9:31 AM, the Medical Records Director (MRD) was interviewed. The MRD stated that she was put in charge of the COVID vaccine coordination because she was the staff member who got things done. The MRD stated that she had trained herself to do the work, because there was no one there to train her. The MRD stated that the previous DONs had performed the COVID-19 immunization tracking, but since the facility didn't have a DON, she was doing that task. 27. On 3/29/22 at 11:10 AM, an interview was conducted with the ADON. When asked about staffing levels, the ADON stated There's so much agency, that we have to go back and do the assessments that the agency nurses did not know how to complete. The ADON stated that because of that, labs were not being performed as ordered sometimes as well. 28. On 3/30/22, an interview was conducted with Medical Provider (MP) 3. MP 3 stated that she typically did rounds at the facility and checked in with the floor nurses. However, MP 3 stated that if she had questions or needed to have further discussion, I have tried to find nursing administration and that's a challenge . there have been periods of time where that's difficult to find a higher level of administration. There were times when I couldn't find a nurse for the floor or rarely could find the same person twice. MP 3 stated I currently am not sure who is the DON (Director of Nursing). MP 3 stated that there were times when she was performing rounds at the facility and there was one nurse for the whole building, or one nurse per floor. MP 3 stated that resident 29 had stated that he was not getting dressing changes as ordered. 29. On 4/7/22 at 2:03 PM, an interview was conducted with the laundry staff (LS). A Spanish speaking SSA representative assisted in translating for the interview with the LS. The LS stated that the door to the laundry area closes but did not lock. The LS stated that she worked from 6:00 AM to 4:30 PM or 5:30 PM daily, and afterwards there was no one watching the laundry area. The LS stated that she had worked at the facility for 8 years. The LS stated that she worked 7 days a week. The LS stated that she took one day off on a Sunday and the facility Administrator (ADM) told her that if she took another day off she would fire her. The LS stated that the facility had one other laundry staff that worked 5 hrs a week, and that they hired a new staff member yesterday. The LS stated that she was also the facility housekeeper. The LS stated that she would put a load of laundry in the washing machine and then leave the laundry room to go upstairs to the resident rooms to clean. The LS stated that in between cleaning she would wash the laundry. The LS stated that when she last went on vacation and was gone for 4 days she returned and found that someone, presumably a resident, had entered the laundry area and had thrown out all the laundry chemicals onto the floor. The LS provided photographs of the spilled buckets of detergent and Clorox and the images were dated 1/4/22. The LS stated that one day in December the ADM made her work as a Nurse Assistant (NA). The LS stated that she started work at 6:00 AM with laundry and housekeeping and then at 5:00 PM she transitioned to being a NA until approximately 10:00 PM. The LS stated that she was told to pass water and when a resident pressed the call light to just go and see what the resident wanted. The LS stated that she was left alone on the 2nd floor for 3 hours with no other aide until agency arrived. The LS stated that there were some residents that she had to change their diaper. The LS stated that she had no training as a nursing assistant. The LS stated that this occurred before Christmas 2021. The LS time card was reviewed for the month of December 2021 and revealed that on 12/21/21 the LS clocked in at 6:56 AM, clocked out at 12:56 PM, clocked back in at 1:26 PM, and clocked out for the day at 9:29 PM. The total hours worked on 12/21/21 were documented as 14.55 hours. 30. On 3/26/22 at 6:19 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. During this interview, LPN 3 stated that there were only 2 CNA's on night shift. 31. On 3/26/22 at 6:24 AM, during an interview with LPN 2, she stated that she only has 2 CNA's on day shift, and that they are supposed to have 4. LPN 2 stated that they usually have a hard time staffing in the mornings and nights. 32. On 3/26/22 at 10:06 AM an interview was conducted with both the Administrator and the Assistant Director of Nursing. The ADON stated that staffing was based on residents medical acuity. The ADON stated that they did not take into account residents behaviors while calculating acuity for the facility. The Administrator stated that they sometimes use agency nurses to fill in the gaps. 33. On 3/29/22 at 10:38 AM, an interview with the Administrator was conducted. During this interview the Administrator stated that there is no RNA program in the facility. The Administrator stated that she used to have one, and the RNA was being pulled to assist the Certified Nursing Assistant's (CNA) with their duties, until the RNA did not have time to do RNA activities and was just helping the CNA's. [Cross refer to F688] 34. On 4/7/22 at 8:28 AM, an interview was conducted with the ADM, Regional Vice President (RVP), and Corporate Registered Dietitian (CRD). The ADM stated that staffing levels were determined according to Patient Per Day (PPD) costs and were depending on resident census. The ADM stated that the nursing staffing was broken down into a PPD of 1.5 and 2.0 for a census of 66, which would total 3.5 PPD. The ADM stated that this basically meant that they would try to staff each floor with 4 CNAs on the day shift, 3 CNAs on the afternoon shift, and 2 CNAs on the night shift. The ADM stated that the licensed nurses were scheduled with one full time nurse and one Medpass nurse who worked a 4 hour shift for both the day and night on the second floor. The ADM stated that the 3rd floor was scheduled with one full time nurse for each shift and they did not have a Medpass nurse for that floor yet. The RVP stated that corporate provided the PPD numbers for the ADM to staff the facility by, and the PPD numbers were established by corporate leadership based on acuity and census. The RVP stated that those numbers could be adjusted based on acuity and that was just a conversation that needed to happen with leadership. The RVP stated that this was something that needed to be discussed with the Director of Nursing (DON) and the nursing staff and if they were reporting they needed more help then they could adjust. The ADM stated that some days they reported that they needed more, some yes, some no. On 4/7/22 at 10:41 AM, a follow-up interview was conducted with the CRD and the Director of Clinical Services (DCS). The DCS stated that the company was growing. The DCS stated that the PPD and budget was run by the Chief Compliance Officer and the RVP with the input from nursing management. The DCS stated that they would never go below a PPD of 3 for licensed nurses and CNA. The DCS stated that there was no way that you could provide the care with a lower PPD, and that was assuming that everyone showed up. The DCS stated that was without taking into consideration the behaviors and higher acuity. The DCS stated with these other issues the PPD would need to flex. The DCS stated that every building needed to be held accountable for their own needs. The DCS stated that a staffing ratio of one licensed nurse to 40 residents did not sound like an appropriate number. The DCS stated, I just wanted to make sure that we weren't smashing things. That every budget number needs to change based on acuity. It should be noted that based on the ADM interview the PPD did not go below 3 as the DCS had suggested and the PPD did not flex to accommodate the higher acuity and resident population with behaviors.

Based on observation, interview, and record review it was determined, for 4 out of 51 sample residents, that the facility did not ensure that the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents with wounds did not have their wound care followed by a physician and the facility wound care nurse was a Licensed Practical Nurse (LPN) who was not wound care certified. Additionally, that LPN ordered and directed the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, an obese resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 17, 18, 27, and 61. Findings include: HARM 1. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/2/22 resident 17's medical records were reviewed. Review of resident 17's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Wound to outer aspect of left malleolus/ankle area. Clean, apply skin prep to peri wound, apply calcium alginate, and cover with bordered foam dressing. Change every day (QD) and as needed (PRN). The order was initiated on 3/24/22. b. Wound to outer aspect of left malleolus/ankle area. Clean, apply skin prep to peri wound, apply calcium alginate, and cover with bordered foam dressing. Change 3 times (x) week and PRN, one time a day every Tuesday, Thursday, and Saturday. The order was initiated on 2/22/22 and discontinued on 3/23/22. c. Wound to medial top great toe. Clean with wound cleaner or normal saline (NS) and pat dry. Apply oil emulsion gauze cut to fit and a small bordered foam dressing, and cover with her sock. Monitor and change dressing daily (QD) and PRN one time a day for wound care. The order was initiated on 1/15/22 and was discontinued on 4/6/22. d. Gently clean left great outer toe with wound cleaner and gauze. Check for blanching around the wound. Gauze dressings are keeping moisture in and increased risk for infection. Please apply an adhesive strip (band aide) and report any signs and symptoms (s/sx) of infection, two times a day for preventing infection. The order was initiated on 1/21/22 and was discontinued on 2/19/22. e. Left Buttocks wound, clean and apply zinc-based cream two times a day for wound care. The order was initiated on 1/29/22. Review of resident 17's progress notes revealed the following: a. On 7/9/21 at 5:49 PM, the admission note documented that resident 17 was admitted with [CONDITION(S)] and a right below the knee amputation (R BKA) and Left posterior heel has pressure ulcer that is almost healed. b. On 10/4/2021 at 9:19 PM, the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Tablet 1 MG [milligram] -Nephro Vitamins Tablet 0.8 MG (B Complex-C-[MEDICATION(S)]) -[MEDICATION(S)] [[MEDICATION(S)]] Tablet 100 MG -Vitamin D3 Tablet ([MEDICATION(S)]) c. On 11/3/2021 at 1:01 AM, the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Tablet 1 MG -Nephro Vitamins Tablet 0.8 MG (B Complex-C-[MEDICATION(S)]) -[MEDICATION(S)] Tablet 100 MG -Vitamin D3 Tablet ([MEDICATION(S)]) d. On 12/27/2021 at 11:47 AM, the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . e. On 1/15/2022 at 6:39 AM, the note documented, . left big toe appeared to have an abrasion which she received during the transport to the SNF [Skilled Nursing Facility]. The wound is addressed and dressing is applied. f. On 1/15/2022 at 12:26 PM, the note documented, Wound to left great toe, resident had this wound on arrival from [name of receiving facility]. They claimed they hit her toe in transfer. Wound is Approximately 2.5 CM [centimeters] X [by] 1 CM X 0.0 CM. it is on the left Great toe medial top side. It looks bubbled and red in color. Clean carefully, apply oil emulsion gauze and covered with bordered foam. Will Monitor daily. g. On 1/29/2022 at 11:46 AM, the note documented, New pressure injury wound to left buttocks. Red, Warm, and painful 10 cm x 8cm. Non Blanchable. Applied zinc based cream. h. On 2/19/2022 at 4:15 PM, the note documented, New wound on resident, Left Outer aspect of malleolus/ankle area. Wound is firm, No drainage. Red center with brown peri wound. 2 cm [centimeter] x 1.4 cm. Cleaned wound, applied Calcium Alginate, Covered with bordered foam dressing. Management ordering a air mattress for pressure wound. Dressing to be changed 3 x week and prn [as needed]. i. On 2/22/2022 at 5:42 AM, the note documented, Res [resident] refused airbed x10 by aides and nurse. Son was called and notified to help translate. Son stated he had translated earlier and to continue trying. Multiple attempts until son spoke to nurse once again and stated to place mom on regular mattress. He stated Res did not feel safe on air mattress and feels as though she is falling out. Son and Res aware of risk vs [verses] benefits. Res was placed on a regular mattress. j. On 3/9/2022 at 9:01 AM, the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Tablet 1 MG -[MEDICATION(S)] Tablet 100 MG -Vitamin D3 Tablet ([MEDICATION(S)]) Chronic ulcer left foot with necrosis of muscle. It should be noted that no documentation was noted in the provider note regarding treatment orders for the care of the ankle wound, toe wound or buttocks wound. k. On 3/10/2022 at 10:44 AM, the note documented, Resident has a pressure wound to outer aspect of her left ankle. Wound is 1.5 CM X 1.2 CM X 0.0 CM. It is draining serosanguinous. Wound cleaned with wound cleaner, [MEDICATION(S)] placed and covered with foam dressing. To be done Tuesday, Thursday and Saturday. Resident is non compliant with off loading foot, Facility has had a air mattress for her that she refused to lay in, off loading boots have been tried and resident refused. Pillow have been ordered and placed to raise her foot off the mattress and resident has refused. l. On 3/17/2022 at 5:10 PM, the note documented, Resident went to a podiatrist [provider name omitted] on the [location of clinic omitted] for her ankle wound, New orders placed for wound dressing and [MEDICATION(S)]. Podiatrist stated the wound needs to be offloaded when at rest by floating the foot with pillows under the legs.We have tried this many times and resident has refused to have her legs floated on pillows she has also refused the air mattress we had for her and offered her many times. Family is aware for her refusal. Will follow MD [Medical Doctor] orders for ABX [antibiotics] and Dressing change. m. On 3/25/2022 at 1:56 PM, the note documented, Wound to out aspect of left ankle. Resident is non compliant with off loading. Dressing change daily. Wound is open stage 3, 1 cm x1 cm x 0 cm. Wound is without drainage. n. On 4/5/2022 at 6:39 PM, the note documented, Resident went out to podiatrist today, returned with order for ABX [MEDICATION(S)] 500/125 BID [two times a day] x 10 days, will start HS [at bedtime] shift. Follow up in one week. Dressing is to stay CDI [clean, dry, and intact]. Offload left ankle. Call to Schedule MRI [Magnetic resonance imaging]. o. On 4/5/2022 at 6:55 PM, the note documented, Resident in to see podiatrist for ankle wound. Note at return claims wound is 12x13x10 with serous drainage. Dressing in place MD note ordered to leave dressing in place, keep Clean, dry and intact. Order to off load the ankle, resident has signed a Riskvs (sic) Benefits for not off loading ankle however we will keep encouraging this. Resident has also refused air mattress several times. On 4/11/22 at 12:20 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that prior to becoming the ADON she was the facility wound care nurse and was a Licensed Practical Nurse (LPN). The ADON stated as the wound care nurse she would round with the wound care doctor on Thursday, worked as a nurse on the floor, and then would do all the wounds on the floor 4 days a week. The ADON stated that the previous Director of Nursing (DON) and ADON were responsible for revising the resident's care plans, but that she guessed she did that now. The ADON stated she was able to get all the wound care completed. The ADON stated that she would track the wounds by the orders that were in the MAR and what the wound care doctor told her on Thursday. The ADON stated that as the wound care nurse she would only document in the TAR that the wound care was completed but would not document the wound characteristics or take measurements. The ADON stated that she would make the changes in the electronic medical record for the wound order treatment. The ADON stated that the floor nurses would send her pictures of the resident's wound. The ADON stated that there were a few times she would tell the floor nurse what wound treatment to do, and then she would have the wound doctor look at the wound the next time he came to the facility. The ADON stated she would notify the facility Nurse Practitioner (NP) of a resident's wound and he would say have the wound doctor look at it. The ADON stated that she has sent the wound doctor pictures of wounds in the past and he had given a verbal order on what treatment to initiate. The ADON stated that she would document this in the progress notes as a verbal order. The NP stated that the wound doctor did not have his name on the provider list, so she would enter the orders under the facility Medical Doctor (MD). The ADON stated that resident 17's ankle wound had been there for a month or two. The ADON stated that resident 17 had a stage one PU on her buttock that developed once in a while. The ADON stated that resident 17 had a BKA and was at risk for skin breakdown. The ADON stated that she was not sure what interventions were in place prior to the development of the pressure ulcer, but afterwards they asked for an air mattress and a podus boot. The ADON stated that she did not know if resident 17 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . I imagine she does since she had an amputation. The ADON stated that resident 17 went on a leave of absence with her family overnight usually on a weekly occurrence. The ADON stated that the nurses should be gathering calcium alginate and bordered foam dressing for wound care to be completed while at home. The ADON stated that the nurse should provide instructions on wound care for the family when she goes home. The ADON stated that most of the time I tell them to do a new dressing before they leave. The ADON stated that the ankle wound was closed for quite a while, then it started opening and we would put honey and a foam dressing on it. The ADON stated that the tracking of the wound would be in the TAR. The ADON stated that the podiatrist at the time could not see her. The ADON stated that she sent a referral to the wound care clinic, and they denied it. The ADON stated that she recalled charting that the wound was 1 x 1 cm but closed and then it started opening again. The ADON then stated that she also documented the wound characteristics and measurements in the progress notes. The ADON stated that the NP refused to see any resident's wounds, and instead stated that resident 17 needed to be seen by the wound clinic. The NP refused to see the wounds and the wound clinic denied the referral. The ADON stated that she notified the DON that the NP was not assessing the resident's condition, and the MD did not come into the building. The ADON stated that they were able to get resident 17 in with a podiatrist but that took a couple of weeks. The ADON stated that since she had been at the facility, she had never seen the NP assess a resident's wounds. The ADON stated that the wound care orders came from her. I know I am not qualified. The ADON stated she was not wound care certified. The ADON stated she would tell the NP we can do this, and he would say yes. The ADON stated we do the best we can. The ADON stated that the NP had never seen a resident wound with her. 2. Resident 27 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 27's medical record was reviewed between 3/23/22 and 4/13/22. Review of nurses progress notes for resident 27 revealed the following entry on 2/22/22 at 10:00 PM by LPN 3, Res (resident) had a witnessed fall during cares [at 9:50 PM]. Res on the floor near bed. Res was assessed and pressure applied to head to stop the bleeding. Res was awake, alert and verbally responsive. Skin warm to touch. Resp (respirations) even and unlabored. No SOB (shortness of breath) noted. Res expressed pain with groaning and facial grimacing. Skin laceration to Rt (right) side of forehead. Res sent out via [ambulance]. [Note: The incident report for this event was reviewed. No additional information was documented on the incident report such as how the resident fell or interventions implemented to prevent further occurrences.] Review of nurses progress notes for resident 27 revealed the following entry on 2/23/22 at 4:26 AM, Res returned from [name of local hospital] via ambulance [name of ambulance company] [at 2:50 AM]. Stiches (sic) were placed on Rt eyebrow and Rt forehead. [Note: The hospital report was not available from the facility to determine how many stitches the resident required or his disposition upon arrival to the emergency room .] On 4/13/22 at 9:20 AM, an interview was conducted with LPN 3. LPN 3 stated that she remembered the incident with resident 27 on 2/22/22. LPN 3 stated that resident 27 was receiving cares, and was being rolled on his side. LPN 3 stated that the resident was rolled too far and fell out of bed, hitting his head on the dresser. LPN 3 stated that there should have been two staff members providing cares for safety for this resident, but there was only one staff member present. When asked who the staff member was, LPN 3 stated that she didn't remember the staff member's name, but that it was a CNA from an agency. LPN 3 stated that because it was an agency CNA providing cares for resident 27, the CNA did not know that the resident required the assistance of two people. LPN 3 stated that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/24/22 at 3:38 PM, resident 18 was interviewed. Resident 18 stated that another resident, resident 49 ran into his leg with his power wheelchair. Resident 18 stated that resident 49 told him to Shut the [OBSCENITY] up and rammed into his legs on purpose. Resident 18 stated that he also rubbed his legs against his sheets, and now had a wound on his leg. Resident 18 stated that staff put a dressing and some honey on it. Resident 18 stated that at one point, he fell while in the Hoyer lift. Resident 18 stated that he'd had more pain since the fall. On 4/13/22, resident 18's medical record review was completed. On 11/16/21 at approximately 8:00 PM, an incident note revealed that resident 18 fell from the Hoyer lift while being transferred to bed. Pt fell on back and hit his head on the floor and his left arm on his electric wheelchair Administered pain medication as ordered .transported pt to . hospital for evaluation. The WhattsApp dialogue was provided and revealed that the previous DON, DON 1, communicated with the Maintenance Director and Administrator about resident 18's fall on 11/17/21. A Clinical Summary dated 4/7/22 at 10:22 AM, revealed that resident 18 had a CT (computer tomography) of the spine at 10:45 PM and an xray of the left knee on 11/16/21 at 10:37 PM. Resident had internal fixation hardware that was non-displaced. No fractures or acute injuries were noted. A work related injury report was completed on 11/17/21 that revealed that resident 18 required a larger lift than the one that staff were utilizing to transfer resident 18. Resident 18's Minimum Data Set (MDS) quarterly assessment revealed that resident 18 required extensive assistance with two persons for transfers. On 4/6/22 at 12:37 PM, CNA 9 was interviewed. CNA 9 stated that when resident 18 fell with the Hoyer lift, there were only two lifts. CNA 9 stated that the handle of the Hoyer was unstable due to a piece that was very loose. CNA 9 stated that the CNAs had attempted to get the Hoyer lift fixed, but there were problems with it. On 4/6/22 at 5:32 PM, an interview was conducted with CNA 6. CNA 6 stated that on 11/16/21, there were two Hoyer lifts in the facility. CNA 6 stated that one of the lifts was rated for 700 pounds and the other for 450 pounds. CNA 6 stated that the 700 pound capacity lift (Hoyer 1) was not working properly, and appeared to have a bad connection. CNA 6 stated that the lift would go up and stop, then not move. CNA 6 stated that the only reliable lift was the 450 pound lift (Hoyer 2), which was too close to resident 18's weight to feel comfortable using. CNA 6 stated that she and another CNA got Hoyer 1 to work and were able to transfer resident 18 out of bed. CNA 6 stated that when it was time for resident 18 to go back to bed, Hoyer 1 was not working again. CNA 6 stated that resident 18 told her he could not spend the night in his wheelchair, and requested to be put to bed. CNA 6 stated that she asked a previous DON (DON 1) what they should do. CNA 6 stated that DON 1 gave the CNAs permission to use Hoyer 2, making sure to keep the legs wide on the lift. CNA 6 stated that the CNAs were able to get resident 18 out of his wheelchair, but the legs of Hoyer 2 would not fit under resident 18's bed. CNA 6 stated that the bed was not functioning properly to be raised high enough for Hoyer 2, so CNA 6 pulled resident 18 away from the bed and were rotating resident 18 toward his chair when Hoyer 2 tipped over. CNA 6 stated that she attempted to brace resident 18, and resident 18 fell on her arm. CNA 6 stated that they called the paramedics and had resident 18 transferred to a hospital to make sure he was OK. CNA 6 stated that resident 18 had a hurt back. CNA 6 stated that no staff members asked for her input to create an incident report. CNA 6 stated that there was no other option to put resident 18 back to bed, but having a guy that weighs 420 pounds in a 450 pound rated Hoyer, I didn't trust it. CNA 6 stated that she was traumatized and wanted to get the equipment fixed. CNA 6 stated that she immediately sent a text to the Maintenance Director to get the Hoyer fixed. CNA 6 stated that sometimes it took a while to get equipment working. CNA 6 stated that Hoyer 1 was old and hadn't worked correctly for a while. On 4/6/22 at 10:58 AM, an interview was conducted with the Maintenance Director (MD). The MD stated that he had purchased a new Hoyer that was being rented by the facility. The MD provided a receipt for a Hoyer lift on 1/31/22. A Hoyer had been rented on 12/20/21 by the facility that was rated to 600 pounds. On 4/6/22 at 1:00 PM, an interview was conducted with the Director of Rehab (DOR). The DOR stated that the MD was responsible to make sure lifts, wheelchairs, and other equipment were in good working order. The DOR stated that therapy staff helped order new equipment for residents. The DOR stated that the lift that tipped was a really light weight lift and staff had to stand on the opposite side of the lift to balance heavier residents. The DOR stated that the big blue lift was not working at the time resident 18 fell . The DOR stated that she was not told at the time that resident 18 fell , or therapy staff would have changed their approach in working with him. 4. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/13/22, resident 61's medical record review was completed. On 12/21/21 at 11:09 AM, resident 61 had discharge orders printed from a regional care facility for wound care. The order for the coccyx wound stated: Bilateral buttocks and coccyx 1. Remove dressing 2. Clean wound with soap and water 3. Apply Santyl [MEDICATION(S)] to the wound bed in a nickel thick consistency. 4. Cut and apply Xeroform or oil emulsion over Santyl. 5. Place large sacral dressing to each buttocks, and silicone bordered foam to coccyx. 6. Please change dressing daily and as needed with hygiene. On 12/21/21 at 6:32 PM, resident 61 was weight by a mechanical lift at 430 pounds. Resident 61's care plan did not include wound care. A nutrition care plan revealed that resident 61 was to have supplements to aide in wound healing. [Resident 61 did not have supplements ordered.] A regional hospital Progress Notes for 1/1/22 revealed that resident 61 had 4. Sacral decubitus ulcer, stage III. Chronic ulcer, present on arrival. Sacral wound itself is unstageable with black eschar and purulent sluff. CT showed fat stranding inferior, posterior and right of the midline. Also noted small scattered areas of gas without definitive drainable fluid collection. No signs of [CONDITION(S)]. Plastics was curbsided and agrees with plan for continued wound care. - Continued aggressive wound care. - Patient will need frequent offloading/position changes. On 1/1/22 at 11:04 AM, the regional hospital Discharge Documentation for Discharge Wound Care Instructions were: coccyx 1. moisten a roll of gauze (kerlix) with Puracyn insert deep into undermining (12 cm toward anus) and depth of wound. [Puracyn is a pH-balanced wound cleanser designed to work in conjunction with wound irrigation, debridement and dressing procedures . puracynpluspro.com] Resident 61's Treatment Administration Record (TAR) revealed that resident 61 had puracyn wound changes on 1/2/22, 1/4/22, 1/6/22, 1/8/22, 1/10/22, and 1/12/22. There is no record that resident 61 received this treatment after 1/12/22. On 1/1/22, a regional hospital discharge Progress Notes revealed that resident 61 had a stage 4 pressure ulcer on his coccyx, measuring 5.3 x 3.0 x 0 cm (centimeters) with undermining extending very close to anus. Description of the sacral ulcer revealed, Chronic ulcer, felt to be the cause of above noted bacteremia at his recent hospital stay. Currently, most wounds are looking reasonably clean without any purulence, exudate, or surrounding [CONDITION(S)]. Sacral wound itself is unstageable with black eschar and purulent sluff . If he is not progressing then we will plan to get a CT (computerized tomography) abdomen and pelvis with contrast to look for deep wound infection. Wound care consultation requested. Patient will need frequent offloading/position changes. An order in resident 61's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 61's Treatment Administration Record (TAR) revealed that this wound care was completed two times, on 1/2/22 and on 1/9/22. [Santyl ointment has been shown to help wounds progress toward closure through byproducts that contribute to the migration and proliferation of fibroblasts, keratinocytes and endothelial cells. sandyl.com/hcp] On 1/1/22 at 1:00 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was recorded in the TAR as completed on 1/9/22 at 8:09 PM. On 1/1/22 at 4:22 PM, an Admission Summary revealed, .Skin Status/Interventions: Stage IV pressure ulcer to coccyx; cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of dressing .Incontinent of bowel and bladder . [Note: Venelex was not ordered by a health care provider for the coccyx wound.] On 1/1/22 at 6:00 PM, an order was created to monitor the pressure ulcer to the coccyx each shift for signs and symptoms of infection or other complications. Nurses charted no complications on all checks, with the exception on 1/18 and 1/21 in the mornings, when the assessments were not completed. On 1/1/22 at 10:06 PM, a 72 hour charting after admission note revealed that resident 61 was adjusting well to returning to facility; appears to be in low spirits .Mental Status/Behavior: appears depressed and in low spirits; no behaviors noted . On 1/2/22 at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin prep barrier wipe to periwound skin. Pack undermining of wound w/ [MEDICATION(S)] soaked in Puracyn (squeeze out the excess). Apply Venelex to wound bed the apply Xeroform dressing. Secure with ABD (abdominal) pads. To be changed EOD (every other day) & PRN (as needed) if becomes soiled, saturated or accidentally removed one time a day every other day. This order was discontinued on 1/13/22. On 1/3/22 at 9:56 AM, a skin/wound note revealed: Pressure ulcer to coccyx, undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . A referral was sent to a wound healing company to assess and treat. It was noted that the provider would be at the facility on 1/6/22. On 1/3/22 at 11:50 AM, a physician's note revealed that resident 61 had an admission note created by a physician who performed a telehealth visit. A second note was entered at 8:44 PM. Skin status/interventions: Stage IV pressure ulcer to coccyx, cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100 (left lower side), surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . No other physician visits occurred during resident 61's stay. On 1/4/22 at 11:27 PM, a nurses note revealed: Changed dressing to buttocks. Moderate serosanguineous drainage (clear fluid) with odor. Cleansed peri with wound cleanser and dressing with ABD pads and [MEDICATION(S)] tape. On 1/5/22 at 9:35 AM, the resident advocate note revealed that resident 61 was admitted to the facility for [CONDITION(S)].According to resident discharge plan is to return home with home health. He is alert and orientated. He is currently using a wheelchair for locomotion and needs extensive assistance . His moods and behaviors have been cooperative, pleasant, and is compliant with cares since admission. On 1/5/22 at 10:30 AM, a Utilization Review (UR) note revealed that resident 61 .needs wound care (daily and PRN) .goal is to return home with HH (home health) . On 1/6/22 at 9:15 AM, a social services care conference note was started, and was not completed. Status stated In Progress. The note revealed that .wounds have no s/s (signs/symptoms) of infection .pleasant and cooperative with cares . On 1/6/22 at 11:00 AM, resident 61 had blood drawn for laboratory tests. On the results, a note was written that resident 61 needed a BMP (basic metabolic panel) completed in 1 week with a date 1/12/22. Resident 61 had a white blood cell count of 11,300, with high neutrophils and immature granulocytes. [No additional blood tests were completed for resident 61 until 1/23/22.] [The wound care physician did not see resident 61 on 1/6/22.] On 1/7/22 at 5:41 PM, resident 61 had a Nutritional Assessment. The assessment revealed that resident 61 had .increased nutritional needs d/t (due to) skin impairment to coccyx . Recommend adding . Juven BID (twice daily) and liquid protein . to support healing. Will monitor weight, intake, wound healing and will adjust nutritional interventions as needed. [No orders for Juven or liquid protein were initiated for resident 61.] On 1/7/22, a Mini Nutritional Assessment was completed. Resident 61 was At risk of malnutrition. [Note: No further nutrition assessments were completed.] Resident 61 had a nutritional care plan created on 1/7/22. An intervention was to Provide supplements to promote wound healing. Resident 61 did not have a wound care plan included in his care plans. On 1/8/22, resident 61 was assessed in the Minimum Data Set (MDS) as requiring rehabilitation, urinary incontinence, fluid maintenance, fall risk, pain management, nutritional status management and pressure ulcer management. On 1/8/22, resident's [MEDICATION(S)] tablet order was not provided due to being out of supply, not in med cart. On 1/9/22 at 8:09 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [This order was not initiated by a physician.] On 1/10/22 at 9:32 AM, a MDS skin conditions evaluation that revealed resident 61 had 1 stage 4 pressure ulcer. Resident 61 had a pressure reducing device for the bed. Nutrition or hydration intervention to manage skin problems were noted as being in place. [Resident 61 had no nutrition supplements provided.] On 1/12/22 at 5:33 PM, a nurses note revealed that labs drawn 1/6/22 rec'd (received) w/ (with) noted abnormalities .NP (Nurse Practitioner) reviewed w/ N/O (new order) for BMP recheck in 1 week. [This lab was not redrawn.] On 1/12/22 at 3:25 PM, a Utilization Review (UR) note revealed that resident 61 .needs skilled wound care (daily and PRN) .goal is to return home with HH (home health) . [No wound care was provided from 1/13/22 until 1/22/22.] On 1/13/22 at 4:30 PM, a skin/wound note revealed: Residents wound remains with deep 2 o'clock tunneling. with 5 X 6 (centimeters) opening. Wound has foul odor. Peri wound has improved. New order to fill wound bed with calcium alginate rope cover with bordered foam. Resident tolerated well . [There was no order for alginate provided by a physician. This order was not initiated and there was no charting that this was completed.] Resident 61 reported the following pain scores (out of 10) without reporting effective pain control: a. On 1/15/22 at 10:26 AM, 9 b. On 1/15/22 at 1:06 PM, 8 c. On 1/15/22 at 1:11 PM, 7 d. On 1/15/22 at 9:15 PM, 8 e. On 1/21/22 at 5:06 PM, 7 f. On 1/21/22 at 9:58 PM, 7 [No new interventions were noted.] On 1/16/22 at 8:37 PM, a sk [TRUNCATED]

Based on interview, and record review it was determined, for 8 out of 51 sampled residents, that the facility did not ensure that it had sufficient staff who provided direct services with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, nursing staff were not provided training to care for residents with mental and psychosocial disorders and non-pharmacological interventions were not implemented. The deficient practice identified was found to have occurred at a harm level. Resident identifiers: 4, 37, 40, 43, 46, 47, 49, and 111. Findings include: HARM 1. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/22 resident 46's medical records were reviewed. On 11/12/21, resident 46's discharge orders from the hospital indicated that the resident should continue taking the following medications daily: [MEDICATION(S)] 300 milligrams (mg) each day (qd), [MEDICATION(S)] 40 mg qd, [MEDICATION(S)] 1.5 mg qd, [MEDICATION(S)] ([MEDICATION(S)]) 0.25 mg twice daily, [MEDICATION(S)] 40 mg qd, and [MEDICATION(S)] 500 mg q (every) 6 hours. On 11/12/21, the nursing progress documented that a medication reconciliation was performed with the Nurse Practitioner (NP) for resident 46. The no appropriate indications of use noted in documentation from hospital for use of some of meds; changes made: D/C [discontinue] [MEDICATION(S)] [antipsychotic] . [MEDICATION(S)] [anxiolytic]. [MEDICATION(S)] [antipsychotic]. [MEDICATION(S)] [antipsychotic]. Review of the November 2021, December 2021, January 2022, February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/8/21, a PreAdmission Screening Resident Review (PASRR) Level II was completed for resident 46. The PASRR indicated that resident 46 had a long history of mental health signs and symptoms, and has carried multiple mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She has been hospitalized multiple times d/t [due to] her chronic mental health symptoms. She had her first episode of [CONDITION(S)] in her late teens after her first child was born; she began to experience recurring persucatory [sic] auditory hallucinations. Pt [patient] reports that her auditory hallucinations have persisted to this time. She reported dividing the hallucinations into the 'screamers' and the 'growler', which is a male voice that will growl at her. She has never been able to fully eliminate the AH [auditory hallucinations] even with the trials on multiple antipsychotic medications . ; she does report that she feels [MEDICATION(S)] helped the most. She reports the voices are persucatory [sic] and negative, saying things 'like I'm terrible, I don't deserve anything. that's normal for me.' . she had a suicide attempt by swallowing mercury from a thermometer. She endorses excessive anxiety, worry, difficulty managing feelings of worry, trouble focusing and sleeping d/t anxiety, and feeling restless and tense often. reports seeing a new psychiatrist monthly and a therapist every 2 weeks. Pt's discharge orders from [name of hospital] prescriptions for [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]; however, none of those medications are listed on pt's current SNF [skilled nursing facility] medication list. Per the SNF Resident Advocate it appears these were discontinued d/t concerns the medications were contributing to pt's weakness and falls. When asked if pt had been feeling different as these medications were discontinued she reported ongoing auditory hallucinations which are persucatory [sic] and derrogetory [sic] in nature, saying things such as 'I'm not worth anything, like I'm supposed to be stronger, stuff like that . She reports that 'I hear them all the time '; she feels her constant AH contritube [sic] to poor mood and increased anxiety and worry. She feels the voices have been stronger recently without her typical medications . she stated she 'noticed I haven't been sleeping well' and 'I could hear the voices more 'which has been disruptive to her sleep. Pt reported as she had previously that [MEDICATION(S)] and Lorazapem [sic] were very helpful in managing the voices and in 'keeping me calm '. She reported feeling 'fairly depressed' and 'You get depressed cause you get depressed in places like this.' . She feels that 'if there's any way I could get back on my meds [medications] that would be good.' She would likely benefit from a phone call with her outpatient mental health provider due to ensure adequate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/5/22 at 2:34 PM, a facility staff documented on a re-admission assessment that resident 46 had scored a 15 on Brief Interview for Mental Status (BIMS), indicating that resident 46 was cognitively intact. On 2/9/22 at 9:23 AM, a physician documented that resident 46 States her voices are getting-scary voices are getting louder- causes anxiety. On 2/16/22 at 11:40 AM, facility staff completed a Personal Health Questionnaire 9 (PHQ-9) for resident 26. Staff documented that resident 46 had a score of 14, which indicated moderate depression. On 2/16/22 at 10:08 PM, nursing staff documented that resident 46 was having multiple episodes of screaming at the staff . at the top of her lungs and wouldn't stop. On 2/23/22 at 8:04 PM, a physician documented Consider antipsychoticsfor [sic] [CONDITION(S)] disorder and return of auditory voices. On 3/7/22 at 11:15 PM, a nursing staff member documented, Res [resident] having suicidal ideation's [at] 1820 [6:20 PM]. Aide notified nurses Res had call light around her neck. Aide removed cord from around neck. Nurses had to remove call light from her hand. Res stated she needs her psych meds which is why she did it. Res told aide Goodbye and informed aide that she has also said Goodbye to family. MD [Medical Doctor]/NP, appropriate staff and family notified. During cares Res stated she is losing hope. Res sent out via [name of ambulance company] to [name of hospital] for psych (psychiatric) evaluation. On 1/7/22, facility staff created a care plan for resident 46's [CONDITION(S)] disorder and generalized anxiety disorder. The care plan indicated that the resident was to have her mental health needs met as outlined per the PASRR recommendations. The care plan also recommended that resident 46 meet with specialized services for mental illness treatment; and meet with outpatient mental health providers as needed while in the facility for psychiatric treatment/support. On 3/23/22 at 10:06 AM, an interview was conducted with the facility ADM. The ADM stated that the facility did not have a resident advocate or a social worker, so I'm doing all the work. On 3/29/22 at 12:42 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 confirmed that the facility did not have a resident advocate. On 3/30/22 at 9:15 AM, an interview was conducted with resident 46. The resident stated that she's upset that there isn't a social worker here and feel like I'm losing hope. Resident 46 stated that there was one night recently that she was feeling really down so she called the crisis line because there was nobody to talk to here. On 4/04/22 at 9:52 AM, a follow-up interview was conducted with resident 46. Resident 46 stated that she called the suicide hotline a couple of times before attempting suicide in March 2022. Resident 46 stated that she wrapped the cord around her neck. I wanted to hang myself. I'm glad it didn't work now, but I gave up hope . There was no one here to talk to. On 4/06/22 at 5:32 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated that she was the aide that was present when resident 46 attempted suicide. I'm the one who found her. CNA 6 stated that on the day of resident 46's attempted suicide she went to answer the resident's call light. CNA 6 stated that when she entered resident 46's room the resident had the call light wrapped around her neck two times, and she was trying to pull on it. CNA 6 stated that the call light was pulled out of the wall. CNA 6 stated that she tried to remove the call light from around resident 46's neck, but the resident refused to let her take it. CNA 6 stated that the resident told her that she had already said goodbye to her family, and that she was saying goodbye to her also. CNA 6 stated that resident 46 had given up. CNA 6 stated that the resident had said to her, I don't want to be here. I just lost hope. CNA 6 stated that she calmed the resident down and attempted to take the call light from her, but the resident kept repeating no. CNA 6 stated that she had not received any training for resident behaviors from the facility. CNA 6 stated that as their caregiver they listen to the residents, and they get to know each person's behavior. I didn't get no training. You just learn as a CNA. The CNA stated that she reported everything to the resident's nurse. CNA 6 stated that they were not informed of any interventions that were available for resident behaviors, and that the nurses did not provide that information to the aides. CNA 6 stated that the nurse's did not provide any direction on which residents had these types of behaviors or what to do when it occurred. CNA 6 stated that half of the facility staff were agency, we don't have staff. CNA 6 stated that agency staff come and go, and they did not know the residents. CNA 6 stated this contributed to nurses not being able to communicate and train the aides on what the resident's behaviors and interventions were. CNA 6 stated, I think the problem is staffing. CNA 6 stated that the facility hired staff and then after the new employees worked, they decide they did not like it and leave. They see the type of behaviors and they run. CNA 6 stated that she had not received education on de-escalating resident behaviors. CNA 6 stated that the facility had a resident advocate (RA) and the residents would look for that person a lot. CNA 6 stated that the previous RA use to address the resident's concerns and handled a lot of their issues and problems. On 4/7/22 at 8:28 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that the facility did not have a Social Service Worker (SSW). The ADM stated that the facility Resident Advocate left the faciity on [DATE]. The ADM stated that she was the staff member who was responsible for working with PASRR and was unaware of some of the resident's PASRR recommendations until this week. On 3/29/22 at 12:42 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 stated that there was not a resident advocate or social worker employed at the facility. On 4/7/22 at 11:01 AM, an interview was conducted with Employee 1. Employee 1 stated that they believed that much of the resident's behaviors would not have happened had the RA still been at the facility. Employee 1 stated that they recalled the RA giving the ADM grievances and the ADM did not following up on them. Some of the grievances were missing personal property, but some were bigger issues that involved resident behaviors in December 2021 or early January 2022. [Cross-refer F740] 2. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 49 was discharged from the facility on 4/10/22. Resident medical record was reviewed between 3/23/22 and 4/13/22. A PASRR level II was completed for resident 49 on 3/22/21. The PASRR documented that resident 49 has a history of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . He also endorsed symptoms of [CONDITION(S)] (Post Traumatic Stress Disorder) that he reports are causing him significant disruption at this time. The PASRR indicated that resident 49 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASRR indicated that in September 2020, resident 49 was residing at a long term care facility and tried to strangle himself, which led to an inpatient psychiatric hospitalization . The PASRR continues He has also experienced excessive anxiety and worry, difficulty managing feelings of worry, restlessness/fatigue d/t (due to) excessive worry, irritability, tension, and trouble sleeping d/t anxiety. He has been diagnosed with [CONDITION(S)] in the past, but it appears that his symptoms are more consistent with borderline traits vs (versus) true manic sxs (signs and symptoms). he described very rapid mood swings but struggled to identify manic sxs. He has experienced and reported chronic fears of abandonment, a long standing pattern of dysfunctional interpersonal relationships and devaluation/elevations of others in relationships, impulsivity in multiple areas in his life . recurring and often impulsive suicidal gestures or threats (he purchased a knife on the Internet and had it delivered to his prior SNF (skilled nursing facility) in a suicidal gesture and later tried to strangle himself), anger/irritability w/o (without) provocation, and affective instability/emotional reactivity vs true [CONDITION(S)] (he describes going from depressed to angery (sic) very rapidly . ). He has also been diagnosed with antisocial personality disorder given his history of disregard for the rules (smoking marijuana in the SNF setting), being disrespectful to police w/o provocation, irritability and verbal aggression with staff, and reckless disregard for his own safety with his impulsivity and failure to plan ahead. He has taken flights impulsively to various places in the United States where he has no support, unable to provide for himself or without funds to pay for food and shelter. He has left multiple nursing homes AMA (against medical advice) without adequate planning for his needs, resulting in poor outcomes. He has often been deceptive/overreported symptoms in medication seeking behaviors (pain meds (medications) or benzos (benzodiazepenes)). He has also snuck friends into the SNF or has snuck out of SNF's in the past, violating COVID-19 protocols. He has feigned helplessness to get help or sympathy from staff. He has been physically assaulted on multiple occasions, including once being beaten up and left for dead in an abandoned house. Due to this incident among his other altercations he reports sxs of [CONDITION(S)] including recurring nightmares/intrusive memories (The nightmares don't stop and they haunt me), avoidant behaviors, feelings of distrust of others/detachment from others, persistent negative emotions, irritability/anger out of the blue (I don't know why I just get pissed and I want to fight or punch a wall or something), reckless/self-destructive behaviors, and difficulty sleeping d/t his nightmares. The PASRR also stated that Pt stated that he is willing to get a referral for mental health but that it can be difficult to re-establish rapport and trust with new mental health providers. Pt did state that he wants to have someone who can help him in his decision making, such as a guardian or POA (power of attorney) . He recognized that he needs help in his decision making, and stated I have walked away from too many places over nothing, and it is getting to the point where people are going to start saying we can't have him come here. I'm going to be in a lot worse place than where I'm at now If I don't get help. The SNF Resident Advocate was made aware of pt's wishes. Pt is on multiple [CONDITION(S)] medications and he has been compliant in taking them. He reported that he has been depressed ever since leaving his prior SNF and that he hit bottom when he left there. He did not endorse SI (suicidal ideations) at this time; however given his history of impulsivity and multiple suicide attempts (and hospitalization d/t a suicide attempt in 2020) he should be closely monitored for any lethal means/means for self-harm that would be accessible to him. Given his online purchase of a knife in 2020 every package that might come to pt should be opened with staff present to ensure pt's safety. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. He should be referred for outpatient mental health treatment as well to him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. A second PASRR level II was completed for resident 49 on 3/22/21, that indicated resident 49 has profound motor deficits and has little assistive technology to help him. He would benefit greatly from assistive computer technology and an assistive communication device. He would also benefit from recreational activities that are geared to his age and interests. No indication could be located in the resident's EMR that these recommendations had been put into place. On 3/26/21, facility staff documented that Reported to administrator that resident confided in another resident that he was contemplating suicide. Nursing to monitor resident for behaviors/self harm and/or suicidal verbalizations. On 4/7/21, approximately 12 days later, the facility Licensed Clinical Social Worker (LCSW) Consultant documented the following in resident 49's progress notes: Special concerns and recommendations: 1:1, PRN (as needed), to address any concerns or issues. Provide support and validation. Encourage resident to participate in activities of his preference. Encourage and support family involvement. Remind resident of socially appropriate behavior. Praise resident when he deals with difficulties appropriately. Redirect resident to a quiet place to calm when aggressive or anxious. Encourage and help resident to participate in mental health therapy. Monitor resident closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. On 5/6/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 5/11/21 resident 49 attended a session with a local mental health provider. The provider documented that the resident reported feeling bored and lonelily (sic). We talked about activities to do in the room. On 6/3/21, the RA entered a note documenting that resident 49 at times he can be verbally aggressive, impulsive and manipulative. [resident 49] has a history of suicidal ideations, but has not reported any recently. He is being followed by [name of mental health provider], and participates in visits. [Resident 49] was also recently in trouble with the law, and is ordered to take anger management classes. He is actively working on setting up those classes, along with taking online collage (sic) courses. Ra offers help and will assist him when needed. [Note: Per review of the EMR, resident 49 had only seen his mental health provider on 4/9/21, 5/11/21, and 6/3/21. In addition, no evidence of the anger management courses could be located in resident 49's EMR.] On 7/7/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 7/15/21, a nursing progress note was entered indicating that resident 49 was intentionally banging head against wall and trying to throw himself on the floor. Nursing wrned (sic) him of risk of self injury, wctm (will continue to monitor). On 8/12/21 at 12:47 AM, a nursing progress note indicated that the nurse was called by a local deputy office around 9 pm. Patient was found in field, with knife in his possession, had fallen out of his wheelchair and been on the ground for an unknown amount of time. They admitted [name of resident] for 24 hrs with a pink slip to the local . hospital, noting he was a danger to himself. I was contacted later by the social worker, .[the social worker] called back and stated [resident 49] had been medically cleared and that we had to readmit him to the facility tonight. They didn't run a tox (toxicology) screen on him. Our administrator states he is evicted and can no longer return. Social worker states we have to take him back and I referred her to our administrator to clarify that we would not accept him back. If social worker calls back, please refer them to our Administrator and do not take patient back. Social worker called again and stated we have to take him back. I told her they would need to contact us in the morning and that we cannot take him tonight. She will tell us we have to take him back. [Note: No hospital documentation was included in resident 49's EMR to indicate what the hospital's findings and/or recommendations were upon discharge.] On 8/18/21, a facility physician evaluated resident 49 and stated that the resident refuses psychiatric outpatient care. On 8/27/21, a History and Physical was completed by a hospital physician for resident 49. The hospital notes indicated that on 8/20/21, resident 49 was pink sheeted to the hospital because he eloped from the nursing home and his electric scooter and drove up to the ninth floor of a parking structure where he was attempting to throw himself off in a suicide attempt. Police intervened and brought him to the hospital. Per the report, pt was combative with police who were pulling him away from the edge of the building . Pt reports feeling acutely suicidal for the past few weeks and that tonight is his 2nd suicide attempt this month. Pt states he 'planned every second' of the attempt and made sure no one at his care center knew. Pt states I had it. and they took it away from me, meaning, he was almost successful in ending his life and the police took that peace away from him. Pt reports feeling frustrated about his quality of life and that he has no reason to live. Pt is frustrated his plan was interrupted and still wishes to die. Pt will require IP (inpatient) psychiatric admission for stabilization. The resident was subsequently hospitalized and then transferred to a behavioral health bed at a different hospital for further assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes documented that when another provider at the hospital saw resident 49, he states he has been having suicidal ideation for the last few weeks and this is his second attempt to kill himself in the last month. Evidently he left the care facility and was headed towards a lake in order to drowned (sic) himself before and was seen in the ER (emergency room ) and then sent back to the care facility. the patient endorses depressed mood, low interest, loss of pleasure, feeling hopeless and worthless, isolative behavior, and has suicidal but no homicidal ideation. The hospital notes indicated that the resident had been scheduled for an involuntary commitment hearing. The hospital notes indicated that The nursing facility also said they are going to increase his supervision where he will not have any opportunity to go out on his own for instance. [Note: There were no notes entered into the resident's EMR regarding this event. The resident was readmitted to the facility on [DATE].] Per review of the care plan, when the resident returned on 9/1/21, the exact same interventions were included in the anxiety and depression care plans for resident 49 that had been in place prior to the resident's hospitalization . On 9/3/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 9/6/21, facility staff completed a Psychosocial Review for resident 49. The review indicated that the resident had experienced suicidal ideations in the past and could be manipulative. The review also documented that the resident had been verbally aggressive and treatening (sic) towards staff. The Special Concerns and Recommendations included: make sure resident had access to media and his phone, staff would help with redirection and validation, and staff would monitor the resident's mood while keeping administration updated. [Note: This was only one of two psychosocial reviews completed for resident 49 during his 13 month stay, despite ongoing behaviors and increasing suicidality.] On 9/8/21, resident 49 had an updated PASRR level II completed. The updated PASRR indicated due to the resident's recent suicide attempt and hospitalization , a significant change PASRR evaluation was completed. The PASRR documented, When asked about why he left the care center and went to the parking structure in his suicide attempt . He stated that he got to the point where he felt that 'I had no choice but to try and kill myself' as dying by natural causes would 'take too long'. he feels he would benefit from increased frequency of counseling and maybe a [CONDITION(S)] medications review as he's not sure how much his [CONDITION(S)] medications are helping. He reports poor sleep . he only eats one meal a day . He tends to isolate in his room . he stated he tried to go to SNF activities but didn't fond them enjoyable. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts. He should be referred for increased mental health services from his outpatient mental health treatment providers at [name of mental health provider]. This can hopefully help him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. On 9/14/21, the facility RA entered a progress note indicating that resident 49 at times he can be verbally aggressive, impulsive and manipulative. [Resident 49] has a history of suicidal ideations, and was recently hospitalized twice due to having those thoughts. When [resident 49] returned from his last hospital stay he stated that he feels much better. He is being followed by [name of mental health provider] . He is actively taking online collage (sic) courses. Ra offers help and will assist him as needed. Care plans reviewed. [Note: No documentation could be located in resident 49's EMR to indicate he had been seen by his mental health provider since 6/3/21.] On 10/7/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. LCSW Consultant notes for October 2021 were reviewed. No recommendations were documented with regard to resident 49. On 11/8/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. LCSW Consultant notes for November 2021 were reviewed. No recommendations were documented with regard to resident 49. LCSW Consultant notes for December 2021 were reviewed. No recommendations were documented with regard to resident 49. On 12/1/21 at 5:26 PM, a nursing progress note indicated that resident 49 complained to the nurse that he didn't want a roommate. Resident 49 stated he doesn't want to have to share and that there's limited space for the 2 of them to share. res then asked if he doesn't get moved then he will just have to handle him. asked res what he meant by handle him, res refused to say the meaning behind his statement. res encouraged to try to get along with roommate and management team will look for further ability to move either resident into better accommodations, told res to be patient . On 12/6/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 12/8/21, the RA documented that resident 49 can be verbally aggressive, impulsive and manipulative. [Resident 49] has had a few verbal and physical encounters with other residents this quarter. Patient is being followed by [name of mental health provider] and is working on his anger issues and how to deal with situations more appropriately. [Note: No documentation could be located in resident 49's EMR to indicate he had been seen by his mental health provider since 6/3/21.] On 1/6/22, a facility physician evaluated resident 49, after the resident requested a visit related to his anger. States that he has been having a hard time w (with) his temper. Having visual and auditory hallucinations - states is currently clean but used drugs as recently as December 5th. States that voices are telling him to kill himself or others. I really just want to feel like myself again . hallucinations. recent drug use likely contributing. Has had recent psych stays within the last 2 years, last from attempting to drive wheelchair off parking structure. Discussed that I am concerned about his health patient agrees. Sending for acute psych evaluation patient agrees that this is for the best tonight and hopes for help . During conversation tonight, patient revealed 2 knives attached to wheelchair. He voluntarily surrendered them to me. Following this, he continued to express desire to seek help in order to feel like himself and get hallucinations to stop. He agreed to voluntarily be transferred for inpatient psychiatric evaluation. Facility administration notified regarding findings of weapons within the facility. Hospital notes dated 1/6/22 for resident 49 were reviewed. Per the documentation, resident 49 initially presented to a local hospitalER on [DATE], was subsequently evaluated and stayed in the ER until 1/8/22. The ER notes indicated that the resident started feeling more depressed this (sic) just before the holiday, got hit by a car over his left foot just after the holiday resulting in an injury and a fracture which is hurting him. He is not in any sort of splint is wondering if that might help. Will go ahead and provide this for him. With regards to his depression he says like (sic) he is hearing voices and he is not sure whether people that were residence (sic) at the care facility are talking to home (sic) or whether it is voices and they are making him more depressed and want to kill himself. He was found at the home tonight with knives apparently threatening suicide and therefore is transported to our facility. Patient seen evaluated (sic) by crisis. He continues to endorse SI. Recommends admission . A psychiatric evaluation completed on 1/6/22 for resident 49 while at the hospital revealed that the resident had depression, disorganized thought processes, hallucinations and suicidal thoughts. The evaluation also indicated that the degree of incapacity was severe and had been worsening. The documentation also revealed that on 1/8/22 Patient had been in the emergency department for approximately 2 days and was discharged about 1 hour ago. He

Based on interview and record review, the facility did not ensure that 3 of 51 sample residents maintained acceptable parameters of nutritional status. Specifically, three residents experienced weight loss without timely interventions. The findings for all three residents were determined to have occurred at a harm level. Resident identifiers: 29, 32, and 49. Findings include: HARM 1. Resident 32 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 32's medical record was reviewed between 3/23/22 and 4/13/22. Resident 32's weights were documented as follows: a. 12/9/21 - 127.9 pounds (lbs) b. 1/7/22 - 121.4 lbs c. 2/8/22 - 104.4 lbs d. 3/10/22 - 102.6 lbs e. 3/15/22 - 96 lbs f. 3/23/22 - 101 lbs [Note: These were the only weights listed in resident 32's electronic medical record between 12/9/21 and 3/23/22.] On 1/7/22, facility staff completed a Skin and Weight Review for resident 32. Resident 32's weight was listed as 121.4 lbs, as compared to 12/9/21 when his weight was 127.9 lbs. This weight loss was determined to be at least a 5% loss in 30 days. The facility staff documented that they would change resident 32's diet to a fortified diet, add a high calorie supplement of 60 milliliters (mls) every day, and weigh the resident weekly. [Note: Per review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the resident was not weighed again until 2/8/22, at which time his weight was 104.4 lbs.] On 1/22/22, a nurses note documented that the resident had Poor nutritional intake, encouraged to eat meals, state (sic) he doesn't like the taste. Noted visible weight loss, refuse (sic) to drink provided supplement. On 1/25/22, a nurses note documented that the resident's physician was contacted, and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/9/22, one month after the last skin and weight review identified significant weight loss for resident 32, the facility staff completed a Skin and Weight Review for resident 32. Resident 32's weight was listed as 104.4 lbs, as compared to 121.4 lbs on 1/7/22. This weight loss was determined to be at least a 5% loss in 30 days. The facility documented that they would increase resident 32's high calorie supplement to 60 mls three times a day, and weigh the resident weekly. The resident was listed as having a fortified diet. [Note: The resident was not weighed again until 3/10/22, at which time his weight was 102.6 lbs. The order for the high calorie supplement was implemented on 2/4/22, but was only for 60 ml twice daily instead of three times daily as ordered.] On 2/24/22, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No nurses notes or documentation could be located to indicate why the change was ordered. On 3/16/22, more than one month after the last skin and weight review identified significant weight [NAME] for resident 32, facility staff completed a Skin and Weight Review for resident 32. Resident 32's weight was listed as 96 lbs, as compared to 104.4 lbs on 2/9/22. This weight loss was determined to be at least a 5% loss in 30 days, and at least a 7.5% loss in 90 days. The facility documented that they would increase resident 32's high calorie supplement to 120 mls three times a day and continue weekly weights. The notes also indicated that resident 32 was receiving a fortified diet, even though it had been changed in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [Note: Per review of the MAR, the order was not entered to increase the high calorie supplement to 120 mls three times a day until 3/22/22.] Resident 32's care plan was reviewed. The resident's nutrition care plan was updated on 1/7/22 when the resident experienced a significant weight loss. No updates had been completed since 1/7/22 despite the ongoing significant weight loss. On 4/11/22 at 2:45 PM, an interview was conducted with the facility Registered Dietitian (RD). The RD stated that the process for coordinating interventions for residents with weight loss and/or skin issues had changed with each Director of Nursing (DON), and there had been quite a few DONs recently. The RD stated that the facility had not been conducting consistent skin and weight meetings. The RD stated that each week, she was supposed to pull the weight reports to determine if any residents had experienced a significant weight change in the past 1, 3, and/or 6 months. The RD stated that she would initiate a skin and weight assessment in the EMR, complete her portion, and then inform the DON. The RD stated that she would also email a summary of her recommendations to the DON, so that any orders could be placed into the EMR by the DON. The RD stated that the DON would then complete the skin portion of the assessments. The RD stated that if a resident was found to have a wound, that information should be shared with her as soon as possible so that she could make appropriate nutritional recommendations. The RD stated that she was aware of the delays with staff inputting her recommendations into the EMR, but she was not sure what the cause was. The RD stated that she was unsure why there were no weekly assessments when resident 32 was experiencing significant weight loss between January and March 2022. 2. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 49's medical record was reviewed between 3/23/22 and 4/13/22. Resident 49's weights were documented as follows: a. 10/7/21 - 158.8 lbs b. 10/15/21 - 147.4 lbs c. 11/6/21 - 140.6 lbs d. 12/9/21 - 132.8 lbs e. 2/2/22 - 113.4 lbs f. 2/18/22 - 114.8 lbs g. 3/15/22 - 105.2 lbs h. 3/30/22 - 103 lbs [Note: These were the only weights listed in resident 49's electronic medical record between 10/7/21 and 3/30/22.] No Skin and Weight Review Assessments were completed for resident 49 between 8/18/21 and 11/8/21, despite resident 49 experiencing significant weight loss in October 2021. On 11/8/21, facility staff completed a Skin and Weight Review for resident 49. Resident 49's weight was listed as 140.6 lbs, as compared to 10/15/21 when his weight was 147.4 lbs. This weight loss was determined to be at least a 5% loss in 30 days, at least a 7.5% loss in 90 days, and at least a 10% loss in 180 days. The facility staff documented that they would add 60 mls of a high calorie supplement twice a day, change the resident's diet to a fortified diet, and weigh the resident weekly. [Note: The resident was not weighed again until 12/9/22, at which time his weight was 132.8 lbs.] On 12/9/21, facility staff completed a Skin and Weight Review for resident 49. Resident 49's weight was listed as 132.8 lbs, as compared to 11/8/21 when his weight was 140.6 lbs. This weight loss was determined to be at least a 5% loss in 30 days, at least a 7.5% loss in 90 days, and at least a 10% loss in 180 days. The facility staff documented that they would increase his high calorie supplement to 120 ml twice daily and continue to weigh the resident weekly. [Note: The resident was not weighed again until 2/2/21, at which time his weight was 113.4 lbs.] No Skin and Weight Review was completed for resident 49 between 12/9/21 and 3/16/22, despite resident 49 experiencing significant weight loss between those dates. On 3/16/21, facility staff completed a Skin and Weight Review for resident 49. Resident 49's weight was listed as 105.2 lbs, as compared to 12/6/21 when his weight was 132.8 lbs. This weight loss was determined to be at least a 5% loss in 30 days, at least a 7.5% loss in 90 days, and at least a 10% loss in 180 days. facility staff documented that they would increase the high calorie supplement to 120 mls three times daily. On 4/11/22 at 2:45 PM, an interview was conducted with the facility RD. With regard to resident 49, the RD stated that she was unsure as to why the resident was not assessed between 12/9/21 and 3/16/22. 3.Resident 29 was initially admitted to the facility on [DATE] and again on 1/24/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 29's medical record was reviewed on 4/11/22. A document from the wound clinic identified six non-pressure wounds on resident 29's bilateral lower extremities (BLE) on 1/6/22. On 3/10/22, the wound clinic identified a stage III pressure ulcer on resident 29's coccyx. Resident weights were reviewed a. 10/2/21 resident 29 weighed 253.2 pounds (lbs) b. 11/6/21 resident 29 weighed 261.4 lbs c. 12/9/21 resident 29 weighed 265.2 lbs d. 1/7/22 resident 29 weighed 265.8 lbs e. 2/2/22 resident 29 weighed 230.4 lbs f. 3/1/22 resident 29 weighed 211.0 lbs g. 4/8/22 resident 29 weighed 184.4 lbs It should be noted that resident 29 weighed 253.2lbs on 10/2/21. Resident 29's weight approximately six months later was 211.0 on 3/1/22. This was 16% weight loss in six months. Resident 29's weight approximately one month later, on 4/8/22, was 184.4 lbs which was a 12% weight loss from 3/1/22. Skin and weight reviews were held on the following dates. 1. 10/7/21 2. 1/28/22 3. 2/4/22 4. 3/3/22 5. 3/9/22 6. 3/20/22 7. 3/24/22 According to the skin and weight review from 2/4/22, Med pass was recommended on 2/4/22. According to resident 29's orders, the med pass BID (twice a day) started on 2/7/22. Resident 29's current orders revealed that Med pass 2.0 was increased to three times a day on 3/27/22. According to a dietary progress note on 4/8/22, zinc 220 milligrams (mg) once a day (QD) for 14 days and Juven 1 packet BID was recommended by the Registered Dietitian (RD) on 4/8/22. On 4/11/22 at 12:19 PM, an interview was the ADON was conducted. The ADON stated that when she was the wound nurse, she did not participate in the skin and weight meetings. On 4/11/22 at 2:45 PM, an interview with the RD was conducted. The RD stated that the skin and weight meetings often did not occur. The RD stated that she filled out her section of the paperwork for the skin and weight meeting and then sent it to nursing. The RD stated that she recommended a multivitamin, vitamin C, zinc, Juven, and a fortified diet for residents with wounds. The RD stated that she recommended starting the supplements for wound care as soon as wounds are identified. The RD stated that the nurses were expected to inform her about resident wounds. The RD stated that she did not recommend zinc and Juven until 4/8/22 because she did not know the severity of resident 29's wounds earlier. [Cross refer 684 and 686]

Based on interview, record review, and observation, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, F770, and F841. Resident identifiers: 1, 2, 4, 6, 14, 16, 17, 18, 19, 20, 22, 23, 25, 27, 28, 29, 30, 31, 32, 37, 38, 38, 39, 40, 41, 43, 44, 46, 47, 49, 51, 53, 55, 57, 61 and 111. Findings include: 1. Based on interview, observation and record review the facility did not notify the physician for 3 of 51 sample residents after the residents experienced a significant change in condition or a need to alter treatment. Specifically, one resident who needed wound care did not see a provider and declined to the point of death, a resident who left the faciity on leave did not have needed medications, and abnormal vital signs were not provided to the physician. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17, 29, 38, 40, 49, 53, 61 and 111. [Cross refer to F580] 2. Based on interview and record review, it was determined for 17 of 51 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, two residents with severe cognitive impairment were engaged in sexual relationships of which the staff were aware, with no assessments to determine if this was consensual, appropriate or safe. Additionally, multiple residents were engaged in verbal and physical abuse altercations with other residents, and interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of verbal and physical abuse between staff and residents, and incidents of neglect with wound care, a resident's change in condition, and a dependent resident was exposed to inclement weather for an extended period of time were identified at a HARM level. Resident identifiers: 4, 6, 14, 16, 18, 20, 22, 23, 25, 29, 31, 37, 43, 47, 51, 53 and 111. [Cross refer to F600] 3. Based on record review and interview it was determined for 14 of 51 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy Level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 38, 49, 51, 53, and 111. [Cross refer to F609] 4. Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 14 of 51 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA), between 8/22/21 and 3/31/22, the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 37, 49, 51, 53, and 111. [Cross refer to F610] 5. Based on interview and record review it was determined for 2 of 51 sampled residents that the facility did not incorporate the recommendations from the Pre-Admission Screening Resident Review (PASRR) Level II into the resident's assessment, care planning and transitions of care. Specifically, a PASRR Level II evaluation identified that residents needed mental health services and the facility did not arrange for those services. The findings for residents 46 and 49 were determined to have occurred at a harm level. Resident identifiers: 46 and 49. [Cross refer to F644] 6. Based on observation, interview, and record review, it was determined for 9 of 51 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, residents had pressure ulcers that were not treated as ordered and one resident's that was not examined by a physician, and residents who underwent change of condition that were not treated timely. Resident Identifiers: 17, 18, 22, 29, 40, 41, 49, 57, and 61. [Cross refer to F684] 7. Based on observation, interview and record review, it was determined the facility did not ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 5 of 51 sample residents. Specifically, wound care was not provided to residents as ordered, and one resident did not have physician evaluations or orders for a pressure injury. The deficient practice identified for resident 61 was found to have occurred at an immediate jeopardy level and deficient practice for residents 1. 15, 17, and 29 were found to have occurred at a harm level. Resident identifiers: 1, 17, 29, 51, and 61. [Cross refer to F686] 8. Based on observations, interviews, and record review it was determined that the facility did not ensure a 3 of 51 sample resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease in range of motion. Specifically, a resident who arrived to the facility with the ability to walk was not provided with treatment and services to increase their range of motion or to prevent further decrease in range of motion and the facility did not provide a restorative nurse assistant (RNA) to residents. This finding resulted in a harm deficiency for resident 29. Resident identifiers: 29, 30, and 55. [Cross refer to F688] 9. Based on observation, interview and record review it was determined, for 10 out of 51 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident with a history of suicidal ideation (SI) and major depressive disorder eloped from the facility and was gone for 24 hours before staff notified administration and the local police department, a resident with suicidal ideation and homicidal ideation (HI) was found with multiple weapons in his possession, and a resident was found in the unsecured laundry area near cleaning chemicals and the unlocked broiler room. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level Additionally, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . These identified deficient practices were found to have occurred at a Harm Level. Lastly, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 4, 18, 23, 27, 28, 38, 40, 43, 49, and 51. [Cross refer to F689] 10. Based on interview and record review, the facility did not ensure that 3 of 51 sample residents maintained acceptable parameters of nutritional status. Specifically, three residents experienced weight loss without timely interventions. The findings for all three residents were determined to have occurred at a harm level. Resident identifiers: 29, 32, and 49. [Cross refer to F692] 11. Based on observation, interview, and record review, it was determined, for 4 of 51 sample residents, that the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a residents were not given pain medication prior to a wound care treatment and residents with consistent high pain scores were given no additional pain management. The findings were cited at a harm level for all four residents. Resident identifiers: 1, 16, 29, and 38. [Cross refer to F697] 12. Based on interview and record review, the facility did not ensure that for 2 of 51 sample residents, the medical care was supervised by a physician. Specifically, appropriate oversight for wound care was not provided, and resident 61 subsequently passed away. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17 and 61. [Cross refer to F710] 13. Based on observation, interview and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These findings resulted in harm to multiple residents. In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. Resident identifiers: 4, 16, 17, 18, 19, 22, 27, 28, 29, 37, 40, 41, 43, 44, 46, 47, 49, 51, 57, 61 and 111. [Cross refer to F725] 14. Based on observation, interview, and record review it was determined, for 4 out of 51 sample residents, that the facility did not ensure that the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents with wounds did not have their wound care followed by a physician and the facility wound care nurse was a Licensed Practical Nurse (LPN) who was not wound care certified. Additionally, that LPN ordered and directed the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, an obese resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 17, 18, 27, and 61. 15. Based on observation, interview, and record review it was determined, for 6 out of 51 sampled residents, that the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, two residents with mental disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. In addition, other residents with mental disorders had identified behaviors without interventions and behavioral health services implemented to accommodate or support the resident's loss of abilities. Resident identifiers: 4, 40, 43, 46, 49, and 111. [Cross refer to F740] 16. Based on interview, and record review it was determined, for 8 out of 51 sampled residents, that the facility did not ensure that it had sufficient staff who provided direct services with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, nursing staff were not provided training to care for residents with mental and psychosocial disorders and non-pharmacological interventions were not implemented. The deficient practice identified was found to have occurred at a harm level. Resident identifiers: 4, 37, 40, 43, 46, 47, 49, and 111. [Cross refer to F741 17. Based on interview, observation and record review, the facility did not ensure that 2 of 51 sample residents who displayed or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident expressing suicidal ideations was not treated appropriately. This finding was determined to have occurred at a harm level. In addition, one resident was not assisted in making an appointment with a mental health provider, despite multiple requests. Resident identifiers: 43 and 49. [Cross refer to F742] 18. Based on interview and record review it was determined, for 11 out of 51 sample residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, two residents with mental health disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services, a resident with suicidal ideation (SI) eloped and was hospitalized due to lack of interventions and behavioral health services, and a resident with memory deficits had multiple incidents of distressing behaviors without interventions or services provided. The deficient practice identified was found to have occurred at a harm level. Additionally, residents with behaviors of verbal aggression and sexual contact with other residents did not receive interventions or services from a behavioral health provider. Resident identifiers: 4, 22, 29, 37, 39, 40, 46, 47, 49, 57 and 111. [Cross refer to F745] 19. Based on interview and record review it was determined for 4 of 51 sample residents that the facility did not obtain laboratory services to meet the needs of its residents. Specifically, resident had orders to obtain lab draws that were not completed. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 2, 17, 30, and 61. [Cross refer to F770] 20. Based on interview, observation, and record review, the facility did not ensure that the medical director implemented resident care policies, and coordinated care in the facility. Multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, and F770. Resident identifier: 61. [Cross refer F841] On 3/29/22, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the Corporate Resource Nurse (CRN) 1 was at the facility hardly ever to provide oversight. On 3/30/22 at 10:50 AM, an interview was conducted with the Medical Director (MD). When asked about the QA process, the MD stated There's no QA. They haven't had QA in over 6 months, probably 8 months plus. On 3/29/22 the resident council notes for the previous six months were requested from the Administrator (ADM). On 3/29/22 at 1:40 PM, an interview was conducted with the ADM. The ADM stated that she had been employed at the facility since September 2021, and that no resident council meeting had been conducted since she had started her employment. The ADM stated that she had not made any plans to correct the issue. The ADM was also asked about resident 61's hospitalization . The ADM stated that she did not do any type of root-cause analysis to ensure other residents' changes in condition were addressed appropriately. When asked about any oversight by the Regional Vice President (RVP), the ADM stated that he has no involvement. On 3/29/22, at 12:42 PM, an interview was conducted with CRN 1. CRN 1 stated that she was aware the ADM was not conducing QA meetings, and that the ADM kept promising she would start the next month. CRN 1 stated that she checked on this, even though she was not really supposed to oversee the ADM. CRN 1 stated that the RVP oversaw the ADM, and she wasn't sure if the RVP was aware that the QA meetings were not occurring. On 4/7/22 at 8:30 AM, an interview was conducted with the ADM. The ADM confirmed that she had not had any QA meetings since she began employment at the facility in September 2021. The ADM stated that she was aware that the regulation required a minimum of quarterly QA meetings, but still had not implemented the QA meetings. The ADM presented a QAPI plan that she intended on using going forward, but had not developed or implemented a QAPI plan during her employment at the facility.

Based on interview, record review, and observation, the facility did not appoint an administrator who reported to, and is accountable to the governing body. In addition, the governing body did not establish and implement policies regarding the management and operation of the facility. Specifically, multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, F770, and F841. Resident identifiers: 1, 2, 4, 6, 14, 16, 17, 18, 19, 20, 22, 23, 25, 27, 28, 29, 30, 31, 32, 37, 38, 38, 39, 40, 41, 43, 44, 46, 47, 49, 51, 53, 55, 57, 61 and 111. Findings include: 1. Based on interview, observation and record review the facility did not notify the physician for 3 of 51 sample residents after the residents experienced a significant change in condition or a need to alter treatment. Specifically, one resident who needed wound care did not see a provider and declined to the point of death, a resident who left the faciity on leave did not have needed medications, and abnormal vital signs were not provided to the physician. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17, 29, 38, 40, 49, 53, 61 and 111. [Cross refer to F580] 2. Based on interview and record review, it was determined for 17 of 51 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, two residents with severe cognitive impairment were engaged in sexual relationships of which the staff were aware, with no assessments to determine if this was consensual, appropriate or safe. Additionally, multiple residents were engaged in verbal and physical abuse altercations with other residents, and interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of verbal and physical abuse between staff and residents, and incidents of neglect with wound care, a resident's change in condition, and a dependent resident was exposed to inclement weather for an extended period of time were identified at a HARM level. Resident identifiers: 4, 6, 14, 16, 18, 20, 22, 23, 25, 29, 31, 37, 43, 47, 51, 53 and 111. [Cross refer to F600] 3. Based on record review and interview it was determined for 14 of 51 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy Level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 38, 49, 51, 53, and 111. [Cross refer to F609] 4. Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 14 of 51 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA), between 8/22/21 and 3/31/22, the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 37, 49, 51, 53, and 111. [Cross refer to F610] 5. Based on interview and record review it was determined for 2 of 51 sampled residents that the facility did not incorporate the recommendations from the Pre-Admission Screening Resident Review (PASRR) Level II into the resident's assessment, care planning and transitions of care. Specifically, a PASRR Level II evaluation identified that residents needed mental health services and the facility did not arrange for those services. The findings for residents 46 and 49 were determined to have occurred at a harm level. Resident identifiers: 46 and 49. [Cross refer to F644] 6. Based on observation, interview, and record review, it was determined for 9 of 51 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, residents had pressure ulcers that were not treated as ordered and one resident's that was not examined by a physician, and residents who underwent change of condition that were not treated timely. Resident Identifiers: 17, 18, 22, 29, 40, 41, 49, 57, and 61. [Cross refer to F684] 7. Based on observation, interview and record review, it was determined the facility did not ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 5 of 51 sample residents. Specifically, wound care was not provided to residents as ordered, and one resident did not have physician evaluations or orders for a pressure injury. The deficient practice identified for resident 61 was found to have occurred at an immediate jeopardy level and deficient practice for residents 1. 15, 17, and 29 were found to have occurred at a harm level. Resident identifiers: 1, 17, 29, 51, and 61. [Cross refer to F686] 8. Based on observations, interviews, and record review it was determined that the facility did not ensure a 3 of 51 sample resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease in range of motion. Specifically, a resident who arrived to the facility with the ability to walk was not provided with treatment and services to increase their range of motion or to prevent further decrease in range of motion and the facility did not provide a restorative nurse assistant (RNA) to residents. This finding resulted in a harm deficiency for resident 29. Resident identifiers: 29, 30, and 55. [Cross refer to F688] 9. Based on observation, interview and record review it was determined, for 10 out of 51 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident with a history of suicidal ideation (SI) and major depressive disorder eloped from the facility and was gone for 24 hours before staff notified administration and the local police department, a resident with suicidal ideation and homicidal ideation (HI) was found with multiple weapons in his possession, and a resident was found in the unsecured laundry area near cleaning chemicals and the unlocked broiler room. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level Additionally, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . These identified deficient practices were found to have occurred at a Harm Level. Lastly, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 4, 18, 23, 27, 28, 38, 40, 43, 49, and 51. [Cross refer to F689] 10. Based on interview and record review, the facility did not ensure that 3 of 51 sample residents maintained acceptable parameters of nutritional status. Specifically, three residents experienced weight loss without timely interventions. The findings for all three residents were determined to have occurred at a harm level. Resident identifiers: 29, 32, and 49. [Cross refer to F692] 11. Based on observation, interview, and record review, it was determined, for 4 of 51 sample residents, that the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a residents were not given pain medication prior to a wound care treatment and residents with consistent high pain scores were given no additional pain management. The findings were cited at a harm level for all four residents. Resident identifiers: 1, 16, 29, and 38. [Cross refer to F697] 12. Based on interview and record review, the facility did not ensure that for 2 of 51 sample residents, the medical care was supervised by a physician. Specifically, appropriate oversight for wound care was not provided, and resident 61 subsequently passed away. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17 and 61. [Cross refer to F710] 13. Based on observation, interview and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These findings resulted in harm to multiple residents. In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. Resident identifiers: 4, 16, 17, 18, 19, 22, 27, 28, 29, 37, 40, 41, 43, 44, 46, 47, 49, 51, 57, 61 and 111. [Cross refer to F725] 14. Based on observation, interview, and record review it was determined, for 4 out of 51 sample residents, that the facility did not ensure that the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents with wounds did not have their wound care followed by a physician and the facility wound care nurse was a Licensed Practical Nurse (LPN) who was not wound care certified. Additionally, that LPN ordered and directed the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, an obese resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 17, 18, 27, and 61. 15. Based on observation, interview, and record review it was determined, for 6 out of 51 sampled residents, that the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, two residents with mental disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. In addition, other residents with mental disorders had identified behaviors without interventions and behavioral health services implemented to accommodate or support the resident's loss of abilities. Resident identifiers: 4, 40, 43, 46, 49, and 111. [Cross refer to F740] 16. Based on interview, and record review it was determined, for 8 out of 51 sampled residents, that the facility did not ensure that it had sufficient staff who provided direct services with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, nursing staff were not provided training to care for residents with mental and psychosocial disorders and non-pharmacological interventions were not implemented. The deficient practice identified was found to have occurred at a harm level. Resident identifiers: 4, 37, 40, 43, 46, 47, 49, and 111. [Cross refer to F741 17. Based on interview, observation and record review, the facility did not ensure that 2 of 51 sample residents who displayed or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident expressing suicidal ideations was not treated appropriately. This finding was determined to have occurred at a harm level. In addition, one resident was not assisted in making an appointment with a mental health provider, despite multiple requests. Resident identifiers: 43 and 49. [Cross refer to F742] 18. Based on interview and record review it was determined, for 11 out of 51 sample residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, two residents with mental health disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services, a resident with suicidal ideation (SI) eloped and was hospitalized due to lack of interventions and behavioral health services, and a resident with memory deficits had multiple incidents of distressing behaviors without interventions or services provided. The deficient practice identified was found to have occurred at a harm level. Additionally, residents with behaviors of verbal aggression and sexual contact with other residents did not receive interventions or services from a behavioral health provider. Resident identifiers: 4, 22, 29, 37, 39, 40, 46, 47, 49, 57 and 111. [Cross refer to F745] 19. Based on interview and record review it was determined for 4 of 51 sample residents that the facility did not obtain laboratory services to meet the needs of its residents. Specifically, resident had orders to obtain lab draws that were not completed. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 2, 17, 30, and 61. [Cross refer to F770] 20. Based on interview, observation, and record review, the facility did not ensure that the medical director implemented resident care policies, and coordinated care in the facility. Multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, and F770. Resident identifier: 61. [Cross refer F841] On 3/29/22, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the Corporate Resource Nurse (CRN) 1 was at the facility hardly ever to provide oversight. On 3/30/22 at 10:50 AM, an interview was conducted with the Medical Director (MD). When asked about the QA process, the MD stated There's no QA. They haven't had QA in over 6 months, probably 8 months plus. On 3/29/22 the resident council notes for the previous six months were requested from the Administrator (ADM). On 3/29/22 at 1:40 PM, an interview was conducted with the ADM. The ADM stated that she had been employed at the facility since September 2021, and that no resident council meeting had been conducted since she had started her employment. The ADM stated that she had not made any plans to correct the issue. The ADM was also asked about resident 61's hospitalization . The ADM stated that she did not do any type of root-cause analysis to ensure other residents' changes in condition were addressed appropriately. When asked about any oversight by the Regional Vice President (RVP), the ADM stated that he has no involvement. On 3/29/22, at 12:42 PM, an interview was conducted with CRN 1. CRN 1 stated that she was aware the ADM was not conducing QA meetings, and that the ADM kept promising she would start the next month. CRN 1 stated that she checked on this, even though she was not really supposed to oversee the ADM. CRN 1 stated that the RVP oversaw the ADM, and she wasn't sure if the RVP was aware that the QA meetings were not occurring. On 4/7/22 at 8:30 AM, an interview was conducted with the ADM. The ADM confirmed that she had not had any QA meetings since she began employment at the facility in September 2021. The ADM stated that she was aware that the regulation required a minimum of quarterly QA meetings, but still had not implemented the QA meetings. The ADM presented a QAPI plan that she intended on using going forward, but had not developed or implemented a QAPI plan during her employment at the facility.

Based on interview, observation, and record review, the facility did not ensure that the medical director implemented resident care policies, and coordinated care in the facility. Multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, and F770. Resident identifier: 61. Findings include: 1. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/13/22, resident 61's medical record review was completed. On 12/21/21 at 11:09 AM, resident 61 had discharge orders printed from a regional care facility for wound care. The order for the coccyx wound stated: Bilateral buttocks and coccyx 1. Remove dressing 2. Clean wound with soap and water 3. Apply Santyl [MEDICATION(S)] to the wound bed in a nickel thick consistency. 4. Cut and apply Xeroform or oil emulsion over Santyl. 5. Place large sacral dressing to each buttocks, and silicone bordered foam to coccyx. 6. Please change dressing daily and as needed with hygiene. On 12/21/21 at 6:32 PM, resident 61 was weight by a mechanical lift at 430 pounds. Resident 61's care plan did not include wound care. A nutrition care plan revealed that resident 61 was to have supplements to aide in wound healing. A regional hospital Progress Notes for 1/1/22 revealed that resident 61 had 4. Sacral decubitus ulcer, stage III. Chronic ulcer, present on arrival. Sacral wound itself is unstageable with black eschar and purulent sluff. CT showed fat stranding inferior, posterior and right of the midline. Also noted small scattered areas of gas without definitive drainable fluid collection. No signs of [CONDITION(S)]. Plastics was curbsided and agrees with plan for continued wound care. - Continued aggressive wound care. - Patient will need frequent offloading/position changes. On 1/1/22 at 11:04 AM, the regional hospital Discharge Documentation for Discharge Wound Care Instructions were: coccyx 1. moisten a roll of gauze (kerlix) with Puracyn insert deep into undermining (12 cm toward anus) and depth of wound. On 1/1/22, a regional hospital discharge Progress Notes revealed that resident 61 had a stage 4 pressure ulcer on his coccyx, measuring 5.3 x 3.0 x 0 cm (centimeters) with undermining extending very close to anus. Description of the sacral ulcer revealed, Chronic ulcer, felt to be the cause of above noted bacteremia at his recent hospital stay. Currently, most wounds are looking reasonably clean without any purulence, exudate, or surrounding [CONDITION(S)]. Sacral wound itself is unstageable with black eschar and purulent sluff . If he is not progressing then we will plan to get a CT (computerized tomography) abdomen and pelvis with contrast to look for deep wound infection. Wound care consultation requested. Patient will need frequent offloading/position changes. An order in resident 61's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 61's Treatment Administration Record (TAR) revealed that this wound care was completed two times, on 1/2/22 and on 1/9/22. On 1/1/22 at 1:00 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was recorded in the TAR as completed on 1/9/22 at 8:09 PM. On 1/1/22 at 4:22 PM, an Admission Summary revealed, .Skin Status/Interventions: Stage IV pressure ulcer to coccyx; cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of dressing .Incontinent of bowel and bladder . On 1/1/22 at 6:00 PM, an order was created to monitor the pressure ulcer to the coccyx each shift for signs and symptoms of infection or other complications. Nurses charted no complications on all checks, with the exception on 1/18 and 1/21 in the mornings, when the assessments were not completed. On 1/1/22 at 10:06 PM, a 72 hour charting after admission note revealed that resident 61 was adjusting well to returning to facility; appears to be in low spirits .Mental Status/Behavior: appears depressed and in low spirits; no behaviors noted . On 1/2/22 at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin prep barrier wipe to periwound skin. Pack undermining of wound w/ [MEDICATION(S)] soaked in Puracyn (squeeze out the excess). Apply Venelex to wound bed the apply Xeroform dressing. Secure with ABD (abdominal) pads. To be changed EOD (every other day) & PRN (as needed) if becomes soiled, saturated or accidentally removed one time a day every other day. This order was discontinued on 1/13/22. The TAR revealed that this treatment was completed on 1/2, 1/4, 1/6, 1/8, 1/10, and 1/12/22. On 1/3/22 at 9:56 AM, a skin/wound note revealed: Pressure ulcer to coccyx, undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . A referral was sent to a wound healing company to assess and treat. It was noted that the provider would be at the facility on 1/6/22. On 1/3/22 at 11:50 AM, a physician's note revealed that resident 61 had an admission note created by a physician who performed a telehealth visit. A second note was entered at 8:44 PM. Skin status/interventions: Stage IV pressure ulcer to coccyx, cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100 (left lower side), surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . No other physician visits occurred during resident 61's stay. On 1/4/22 at 11:27 PM, a nurses note revealed: Changed dressing to buttocks. Moderate serosanguineous drainage (clear fluid) with odor. Cleansed peri with wound cleanser and dressing with ABD pads and [MEDICATION(S)] tape. On 1/5/22 at 9:35 AM, the resident advocate note revealed that resident 61 was admitted to the facility for [CONDITION(S)].According to resident discharge plan is to return home with home health. He is alert and orientated. He is currently using a wheelchair for locomotion and needs extensive assistance . His moods and behaviors have been cooperative, pleasant, and is compliant with cares since admission. On 1/5/22 at 10:30 AM, a Utilization Review (UR) note revealed that resident 61 .needs wound care (daily and PRN) .goal is to return home with HH (home health) . On 1/6/22 at 9:15 AM, a social services care conference note was started, and was not completed. Status stated In Progress. The note revealed that .wounds have no s/s (signs/symptoms) of infection .pleasant and cooperative with cares . On 1/6/22 at 11:00 AM, resident 61 had blood drawn for laboratory tests. On the results, a note was written that resident 61 needed a BMP (basic metabolic panel) completed in 1 week with a date 1/12/22. Resident 61 had a white blood cell count of 11,300, with high neutrophils and immature granulocytes. [No additional blood tests were completed for resident 61 until 1/23/22.] [Wound physician did not see resident 61 on 1/6/22.] On 1/7/22 at 5:41 PM, resident 61 had a Nutritional Assessment. The assessment revealed that resident 61 had .increased nutritional needs d/t (due to) skin impairment to coccyx . Recommend adding . Juven BID (twice daily) and liquid protein . to support healing. Will monitor weight, intake, wound healing and will adjust nutritional interventions as needed. [No orders for Juven or liquid protein were initiated for resident 61.] On 1/7/22, a Mini Nutritional Assessment was completed. Resident 61 was At risk of malnutrition. [Note: No further nutrition assessments were completed.] Resident 61 had a nutritional care plan created on 1/7/22. An intervention was to Provide supplements to promote wound healing. Resident 61 did not have a wound care plan included in his care plans. On 1/8/22, resident 61 was assessed in the Minimum Data Set (MDS) as requiring rehabilitation, urinary incontinence, fluid maintenance, fall risk, pain management, nutritional status management and pressure ulcer management. On 1/8/22, resident's [MEDICATION(S)] tablet order was not provided due to being out of supply, not in med cart. On 1/9/22 at 8:09 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/10/22 at 9:32 AM, a MDS skin conditions evaluation that revealed resident 61 had 1 stage 4 pressure ulcer. Resident 61 had a pressure reducing device for the bed. Nutrition or hydration intervention to manage skin problems were noted as being in place. On 1/12/22 at 5:33 PM, a nurses note revealed that labs drawn 1/6/22 rec'd (received) w/ (with) noted abnormalities .NP (Nurse Practitioner) reviewed w/ N/O (new order) for BMP recheck in 1 week. [This lab was not redrawn.] On 1/12/22 at 3:25 PM, a Utilization Review (UR) note revealed that resident 61 .needs skilled wound care (daily and PRN) .goal is to return home with HH (home health) . On 1/13/22 at 4:30 PM, a skin/wound note revealed: Residents wound remains with deep 2 o'clock tunneling. with 5 X 6 (centimeters) opening. Wound has foul odor. Peri wound has improved. New order to fill wound bed with calcium alginate rope cover with bordered foam. Resident tolerated well . Resident 61 reported the following pain scores (out of 10) without reporting effective pain control: a. On 1/15/22 at 10:26 AM, 9 b. On 1/15/22 at 1:06 PM, 8 c. On 1/15/22 at 1:11 PM, 7 d. On 1/15/22 at 9:15 PM, 8 e. On 1/21/22 at 5:06 PM, 7 f. On 1/21/22 at 9:58 PM, 7 [No new interventions were noted.] On 1/16/22 at 8:37 PM, a skin/wound note revealed: Change resident dressing daily. Wound is 6 cm X 6.5 cm X 8.5 cm tunnel at 2 o'clock. Lots of blood drainage. Wound nurse's are following dressing change order from the hospital On 1/19/22 at 1:57 PM, a Utilization Review (UR) meeting revealed that resident 61's plan of care was to work with therapy and to return home with home health. The nursing update included .skilled wound care (daily and PRN), . On 1/20/22 at 6:28 AM, a nursing note revealed that resident 61's Wound remains open with foul odor. Wound is 6 cm X 5.5 CM x 2 CM. It tunnels at 2 o'clock 8 cm. Wound has necrotic tissue coming out of the tunnel area. Dressing change daily. Dakins soak 30 min. then Calcium alginate rope to tunnel with calcium alginate in wound bed. Cover with ABD pad and foam cover . On 1/21/22 at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR revealed that this order was completed on 1/22/22 and 1/23/22. On 1/21/22, a Skilled Daily Review was performed for resident 61. Skilled need was wound to coccyx with tunneling at 2:00 position per wound care nurse. Pain mgmt (management). Assist with ADLs (activities of daily living). Resident 61 was incontinent of urine and bowel movements, and wore briefs with peri care provided with each brief change. [Note: There is no documentation about wound care changes with brief changes.] On 12/21/22 at 3:17 PM, resident complained of sacral pain for which PRN medication was provided. On 1/22/22 at 11:33 PM, a weekly skin review revealed no new skin integrity problems. The sacral pressure injury was noted. On 1/23/22 at 9:43 AM, a nurses' note revealed that the nurse had received report of resident 61 having increased confusion with shaking, high blood pressure, resident looking to the left to respond to the nurse who was on the left side of the bed, and confusion about how to drink water. Nurse contacted physician who ordered STAT blood and urine tests along with a chest X-ray to rule out infection. Resident was given 1 liter of normal saline over 5 hours. On 1/23/22, blood pressure obtained was 139/127, followed by 155/60. On 1/23/22 at 10:36 AM, a nurses notes revealed that resident 61 had an IV (intravenous access line) placed in the right hand for blood draw. On 1/23/22 at 1:59 PM, a higher-than-normal respiratory rate was noted at 22 breaths per minute and heart rate was 124 beats per minute, irregular, and was identified as a new finding. [There was no documentation that a physician was contacted.] On 1/23/22, resident 61's lab results were faxed to the facility at 4:43 PM. Resident 61's white blood cell count was 25,100, with segmented neutrophils. RN 1 noted the results on 1/23/22. [There was no documentation that this report was forwarded to a medical provider until the following day.] On 1/23/22 at 7:37 PM, an order was initiated for resident 61 to assess resident 61's pressure ulcer and notify the physician if any complications. On 1/24/22 at 3:55 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was noted as done by previous shift. [No documentation of providing the results to the physician was noted.] On 1/24/22 at 4:44 AM, a nursing note revealed a blood pressure of 98/50, heart rate of 99 beats per minute, and oxygen saturation at 93% on a Continuous Positive Airway Pressure ([CONDITION(S)]) device. The nursing note stated no changes res (resident's) health status from yesterday. Asked res if he would like to go to the hospital for checkup but he refused it. Encouraged res to increase fluid intake. PRN (as needed) pain med was given for pain on both knees. will continue to monitor. On 1/24/22, on the final lab results report, a note written at the bottom of the report revealed that one of the medical providers made an order to send resident 61 to the Emergency Department. On 1/24/22 at 11:41 PM, an order was entered/discontinued for a wound care company to eval and tx (treatment) r/t pressure wounds to coccyx and bilateral buttocks. On 1/24/22 at 12:36 PM, a nursing not revealed that resident 61 was sent to the hospital. On 1/24/22 at 1:32 PM, a regional hospital Emergency Documentation was initiated for resident 61. The documentation revealed that resident 61 had chief complaints of: a. altered level of consciousness b. high heart rate c. not looking to the right He apparently was acting abnormally this morning according to rehab facility staff but what that means is a little bit unclear. He was transported and there was no mention of increased work of breathing or [CONDITION(S)] I was called to the room because of high heart rate and tachypnea (rapid breathing). Looks like he is in [CONDITION(S)] with RVR (rapid ventricular rate of response) but does not endorse any chest pain at all. He is noted to be with a right-sided neglect. No known vomiting. Given patient status no other history was obtained. Stroke 1 is called. Meds ordered for his high heart rate. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. initiation of end-of-life care b. septic shock c. [CONDITION(S)] d. respiratory failure e. acidosis f. superobesity g. diabetes h. strokelike syndrome i. [CONDITION(S)]/[CONDITION(S)] Medical decision making/differential Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . He presented with [CONDITION(S)], some altered mental status, rapid heart rate with what looked like new onset [CONDITION(S)] (fluttering atria of the heart). He is also quite tacypneic. He already had leuckocytosis yesterday at 26,000. Today it climbed to 32,000. I think this clinical picture was strongly suggestive of septic shock and overwhelming [CONDITION(S)]. His sacral area wound showed a large area of ecchymosis and [CONDITION(S)] and some purulent drainage from the central portion of the ulcer. He seemed to medically stabilize early on but then after resuscitative efforts were towards the tail and the patient actually worsened in status. Long discussion was held with numerous family members .he became medically unstable and worse over time despite antibiotics fluids respiratory support no other [CONDITION(S)] treatment measures. I did not see any obvious reasons to counter patient and family wishes and initiating end-of-life care. The massive area of skin and soft tissue infection with ulceration was the likely source of his infection and massive debridement would be necessary . The course of treatment in the Emergency Department included . Required supplemental oxygen. [CONDITION(S)] protocol enrollment with treatment provided. In addition neurology consultation was required early on given concerns for potential stroke. [A neurologist] did not feel that the patient was under going a stroke syndrome Thereafter [CONDITION(S)] treatment was the focus We evaluated the wound on his backside and it was massive encompassing a large territory of the entire lower lumbar and sacral region with a draining wound and a lot of surrounding necrotic tissue with [CONDITION(S)] extending down to the perineum without obvious drainable abscess. Shortly after evaluating this wound the patient became diaphoretic and more short of breath but remained lucid. Additional oxygen was provided. We had discussed at this point in time about focus of treatment and goals of treatment . An arterial blood gas (ABG) was obtained and resident 61 had worsening acidosis Patient progress towards severe illness and end of life pretty quickly at around 5:30 PM, resident was noted to have agonal respirations and confirmed at this time if we do not act patient will certainly die soon. Again there was consensus with family members present to proceed with comfort measures and monitors were turned off and high flow oxygen was turned off along with vasopressors. Family gathered at the bedside and said their goodbyes and time of death was estimated to be at 6:10 PM. On 3/24/22 at 11:31 AM, a former DON, DON 2, was interviewed. DON 2 stated that resident 61 had a pretty serious tunneling wound that no doctor had examined while resident 61 was in the facility. DON 2 stated that she spoke with the facility Medical Director, and determined that he was not following resident 61. DON 2 stated that she never spoke with him (the Medical Director) on the phone. He wasn't responding to emails or [messaging app] texts. DON 2 stated that there was a facility Nurse Practitioner (NP), and I cornered [the NP] and said 'Hey this guy needs to be seen. but no one was ordering anything. DON 2 stated that the wound clinic was unable to treat resident 61 because of his insurance, so resident 61 was not seen by any prescribing provider. DON 2 stated that resident 61 had insurance that would provide wound care to their clients in their wound clinic, but resident 61 was not sent out. DON 2 stated that resident did not have orders provided by any clinician, that wound care orders were generated by the wound nurse (now the ADON). DON 2 stated that the ADON was just talking to the wound doctor and he (the wound doctor) would write the orders based on what she said, but no doctor was laying eyes on resident 61's wound. DON 2 stated that she was supposed to take a picture of [a resident's wound] on my phone, and I was supposed to sent to it [the ADON], then she would write an order without any other consult with a physician. DON 2 stated that this was the way the wound care process was during the time she was employed. DON 2 stated that resident 61 never went to wound clinic. He went to the hospital, went septic, and started crashing. On 3/29/22 at 10:10 AM, the ADON was interviewed. The ADON stated that typically, residents have wound care provided in the facility, depending on their insurance. The ADON stated that resident 61 had an insurance that required him to go out to a specific wound clinic, but resident 61 was not able to be sent out to the clinic. The ADON stated that DON 1 was working on obtaining a different insurance for resident 61 so their providers could follow his wound. The ADON stated that she did not have the authority to send resident 61 out to the clinic when she was the wound nurse. The ADON stated that no physician consulted for resident 61, and all new orders for his wound care were generated by her. The ADON stated that no physician ever laid eyes on resident 61's wound. The ADON stated that I was just doing the best I could as the wound nurse. The ADON stated that the providers wouldn't give an order without seeing resident 61. The ADON stated that resident 61's wound was not getting any better, but he weighed almost 600 pounds so it was difficult to get an ambulance to take him out. The ADON stated that she ordered Dakins solution because the wound had such an odor. The ADON stated that she wanted to order a silver alginate to keep infection away. The ADON stated that she was not aware of resident 61 being discussed in the interdisciplinary team (IDT) meetings. The ADON stated that the order she initiated was for wound care to be performed every other day, but it should have been done daily if possible. The ADON stated that the wound care was possibly done more often than what was charted. The ADON stated that there was so much agency in the building, there were a lot of things they didn't get around to. The ADON stated that the bloody drainage on the 16th was good, because it meant that the wound was healing. The ADON stated that resident 61's bowel movements would get all over the dressings. The ADON stated that she was not wound care certified, and staging a wound was beyond her scope of practice. The ADON stated that on 1/20/22, there was a foul odor, and she wanted the doctors to provide an antibiotic. The ADON stated that she changed resident 61's wounds, but did not do anything else for him. The ADON stated that resident 61 was not taken out until he went to the hospital on 1/24/22 with [CONDITION(S)]. The ADON stated that there was no way to determine what wound care was done, that if a nurse signed that they completed the wound care, she would have to believe they did it. On 3/29/22 at 12:42 PM, the Corporate Resource Nurse (CRN 1) was interviewed. CRN 1 stated that the wound nurse was responsible for communication with the wound care providers and physicians. CRN 1 stated that the wound nurse (now the ADON) would look at wounds and show them to the physicians. CRN 1 stated that the ADON requested orders from physicians, and would enter orders in the computerized record and request physicians to sign the orders. CRN 1 stated that she was not aware if physicians created the orders or signed the orders after the fact. On 3/29/22 at 1:32 PM, the Administrator (ADM) was interviewed. The ADM stated that the former DON (DON 1) was working on resident 61's insurance. The ADM stated that she assumed that a doctor was following resident 61's wounds, and that the wound nurse would take care of that. The ADM stated that an analysis of preventing resident 61's hospitalization was no completed. The ADM stated that she was not aware of discussing resident 61 in the morning stand-up meetings. The ADM stated that when a resident had a change of condition, staff would discuss what to do, what tests were required and determine if the resident needed to go to the hospital. The ADM stated that she did not believe that resident 61 had a change of condition before he was sent out. On 3/30/22 at 12:26 PM, an interview was conducted with Medical Provider (MP) 1. MP 1 stated that resident 61 had insurance that required him to have his wound care provided at the insurance company's provider. MP 1 stated that the wound nurse had approached him for cares, and he informed her that resident 61 needed surgical debridement. On 04/4/22 at 12:10 PM, the Administrator was re-interviewed. The ADM stated that she had assumed the physician would check on resident 61. The ADM stated that when resident 61 went to the hospital with [CONDITION(S)], she did not complete an analysis of what staff might have done to prevent the hospitalization . The ADM stated that she had not completed an analysis of identifying residents' change of condition timely. The ADM stated that staff were not always very talkative during morning meetings, and she was not clinical, so sometimes she didn't know what was happening with the residents. On 4/11/22 at 12:20 PM, the ADON was re-interviewed. The ADON stated that prior to the last two weeks, she was acting as the wound care nurse in the building. The ADON stated that her responsibilities as the wound nurse (WN) was to assist the provider on Thursdays with wounds, new orders, and at times, she was also fulfilling the role as a floor nurse. The ADON stated that when she was the wound nurse, she did not participate in the skin and weight meetings. The ADON stated that she was responsible for wound care in the building four days each week, and the floor nurses were responsible the other three days. The ADON stated that she entered the wound care orders for the residents into the computer for the floor nurses to follow. The ADON stated that the wound physician would complete the measurements and staging of the wounds. The ADON stated that when a resident was admitted to the facility, she would create a temporary order for wound care. The ADON stated that she would tell the physician's group Nurse Practitioner what she was going to do for a resident. The ADON stated that she put the order in as a verbal order from the medical director. The ADON stated that she noticed that some wound care treatments had not been completed by the nurses. The ADON stated that It took me an hour to go through the whole building. The ADON stated that she was unsure why the nurses weren't doing their wounds. The ADON stated that for resident 61, she felt like I was screaming into a void on that one. I was very concerned about him and I couldn't get anyone to listen to me. The ADON stated that the Nurse Practitioner told her to get him into a wound clinic to have the wound debrided surgically, but she could not get him into the other clinic because he weighed about 600 pounds. On 3/30/22 at 10:50 AM, Medical Provider (MP) 2 was interviewed. MP 2 stated that the medical group's policy is to see all residents, regardless of their insurance. MP 2 stated that he was not always informed about what was happening with the patients at the facility, and has concerns for a lot of the patients. MP 2 stated that he understood there was a lot of illicit drug use and resident-to-resident altercations. MP 2 stated that they did not always receive official reports, and just had hearsay about incidents. MP 2 stated that he was informed about resident 31's physical altercation, but not his sexual abuse allegation. MP 2 stated that there were no quality assurance meetings in the past 8 months or so. MP 2 stated that the facility was understaffed, and that orders were not done, labs were not obtained, and residents did not go to appointments. MP 2 stated that wound care was not performed, and antibiotics were not being administered. On 3/30/22 at 12:26 PM, MP 1 was interviewed. MP 1 stated that residents had expressed that wounds weren't changed and nurses expressed that they did not have the wound care supplies needed. MP 1 stated that staff did not contact the provider group when there were missed treatments, changes of condition, and when they had difficulty getting out to appointments. MP 1 stated that the providers were not notified about abuse. MP 1 stated that after the resident advocate left, the physicians were not consulted about any plans for the residents. MP 1 stated that if an antibiotic was ordered, staff talked to the Corporate Resource Nurse (CRN 1) who made the decisions. MP 1 stated that the Administrator did not solve problems. [Cross refer F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, and F770]

Based on interview, record review, and observation, the facility did not present a Quality Assurance and Performance Improvement (QAPI) plan to the State Agency. In addition, multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, F770, and F841. Findings include: On 3/28/22, a copy of the QAPI plan was requested from the Administrator (ADM). On 4/4/22 at 3:00 PM, a copy of the QAPI plan was again requested from the ADM. On 4/7/22 at 8:30 AM, an interview was conducted with the ADM. The ADM confirmed that she had not had any QA meetings since she began employment at the facility in September 2021. The ADM stated that she was aware that the regulation required a minimum of quarterly QA meetings, but still had not implemented the QA meetings. The ADM presented a QAPI plan that she intended on using going forward, but had not developed or implemented a QAPI plan during her employment at the facility. [Cross refer to F867 and F868]

Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, multiple system failures were identified, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, F770, and F841. In addition, the QAA meetings were not being conducted, nor was the Medical Director involved in the QAA process. Resident identifiers: 1, 2, 4, 6, 14, 16, 17, 18, 19, 20, 22, 23, 25, 27, 28, 29, 30, 31, 32, 37, 38, 38, 39, 40, 41, 43, 44, 46, 47, 49, 51, 53, 55, 57, 61 and 111. Findings include: 1. Based on interview, observation and record review the facility did not notify the physician for 3 of 51 sample residents after the residents experienced a significant change in condition or a need to alter treatment. Specifically, one resident who needed wound care did not see a provider and declined to the point of death, a resident who left the faciity on leave did not have needed medications, and abnormal vital signs were not provided to the physician. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17, 29, 38, 40, 49, 53, 61 and 111. [Cross refer to F580] 2. Based on interview and record review, it was determined for 17 of 51 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, two residents with severe cognitive impairment were engaged in sexual relationships of which the staff were aware, with no assessments to determine if this was consensual, appropriate or safe. Additionally, multiple residents were engaged in verbal and physical abuse altercations with other residents, and interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of verbal and physical abuse between staff and residents, and incidents of neglect with wound care, a resident's change in condition, and a dependent resident was exposed to inclement weather for an extended period of time were identified at a HARM level. Resident identifiers: 4, 6, 14, 16, 18, 20, 22, 23, 25, 29, 31, 37, 43, 47, 51, 53 and 111. [Cross refer to F600] 3. Based on record review and interview it was determined for 14 of 51 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy Level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 38, 49, 51, 53, and 111. [Cross refer to F609] 4. Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 14 of 51 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA), between 8/22/21 and 3/31/22, the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 37, 49, 51, 53, and 111. [Cross refer to F610] 5. Based on interview and record review it was determined for 2 of 51 sampled residents that the facility did not incorporate the recommendations from the Pre-Admission Screening Resident Review (PASRR) Level II into the resident's assessment, care planning and transitions of care. Specifically, a PASRR Level II evaluation identified that residents needed mental health services and the facility did not arrange for those services. The findings for residents 46 and 49 were determined to have occurred at a harm level. Resident identifiers: 46 and 49. [Cross refer to F644] 6. Based on observation, interview, and record review, it was determined for 9 of 51 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, residents had pressure ulcers that were not treated as ordered and one resident's that was not examined by a physician, and residents who underwent change of condition that were not treated timely. Resident Identifiers: 17, 18, 22, 29, 40, 41, 49, 57, and 61. [Cross refer to F684] 7. Based on observation, interview and record review, it was determined the facility did not ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 5 of 51 sample residents. Specifically, wound care was not provided to residents as ordered, and one resident did not have physician evaluations or orders for a pressure injury. The deficient practice identified for resident 61 was found to have occurred at an immediate jeopardy level and deficient practice for residents 1. 15, 17, and 29 were found to have occurred at a harm level. Resident identifiers: 1, 17, 29, 51, and 61. [Cross refer to F686] 8. Based on observations, interviews, and record review it was determined that the facility did not ensure a 3 of 51 sample resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease in range of motion. Specifically, a resident who arrived to the facility with the ability to walk was not provided with treatment and services to increase their range of motion or to prevent further decrease in range of motion and the facility did not provide a restorative nurse assistant (RNA) to residents. This finding resulted in a harm deficiency for resident 29. Resident identifiers: 29, 30, and 55. [Cross refer to F688] 9. Based on observation, interview and record review it was determined, for 10 out of 51 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident with a history of suicidal ideation (SI) and major depressive disorder eloped from the facility and was gone for 24 hours before staff notified administration and the local police department, a resident with suicidal ideation and homicidal ideation (HI) was found with multiple weapons in his possession, and a resident was found in the unsecured laundry area near cleaning chemicals and the unlocked broiler room. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level Additionally, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . These identified deficient practices were found to have occurred at a Harm Level. Lastly, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 4, 18, 23, 27, 28, 38, 40, 43, 49, and 51. [Cross refer to F689] 10. Based on interview and record review, the facility did not ensure that 3 of 51 sample residents maintained acceptable parameters of nutritional status. Specifically, three residents experienced weight loss without timely interventions. The findings for all three residents were determined to have occurred at a harm level. Resident identifiers: 29, 32, and 49. [Cross refer to F692] 11. Based on observation, interview, and record review, it was determined, for 4 of 51 sample residents, that the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a residents were not given pain medication prior to a wound care treatment and residents with consistent high pain scores were given no additional pain management. The findings were cited at a harm level for all four residents. Resident identifiers: 1, 16, 29, and 38. [Cross refer to F697] 12. Based on interview and record review, the facility did not ensure that for 2 of 51 sample residents, the medical care was supervised by a physician. Specifically, appropriate oversight for wound care was not provided, and resident 61 subsequently passed away. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17 and 61. [Cross refer to F710] 13. Based on observation, interview and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These findings resulted in harm to multiple residents. In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. Resident identifiers: 4, 16, 17, 18, 19, 22, 27, 28, 29, 37, 40, 41, 43, 44, 46, 47, 49, 51, 57, 61 and 111. [Cross refer to F725] 14. Based on observation, interview, and record review it was determined, for 4 out of 51 sample residents, that the facility did not ensure that the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents with wounds did not have their wound care followed by a physician and the facility wound care nurse was a Licensed Practical Nurse (LPN) who was not wound care certified. Additionally, that LPN ordered and directed the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, an obese resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 17, 18, 27, and 61. 15. Based on observation, interview, and record review it was determined, for 6 out of 51 sampled residents, that the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, two residents with mental disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. In addition, other residents with mental disorders had identified behaviors without interventions and behavioral health services implemented to accommodate or support the resident's loss of abilities. Resident identifiers: 4, 40, 43, 46, 49, and 111. [Cross refer to F740] 16. Based on interview, and record review it was determined, for 8 out of 51 sampled residents, that the facility did not ensure that it had sufficient staff who provided direct services with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, nursing staff were not provided training to care for residents with mental and psychosocial disorders and non-pharmacological interventions were not implemented. The deficient practice identified was found to have occurred at a harm level. Resident identifiers: 4, 37, 40, 43, 46, 47, 49, and 111. [Cross refer to F741 17. Based on interview, observation and record review, the facility did not ensure that 2 of 51 sample residents who displayed or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident expressing suicidal ideations was not treated appropriately. This finding was determined to have occurred at a harm level. In addition, one resident was not assisted in making an appointment with a mental health provider, despite multiple requests. Resident identifiers: 43 and 49. [Cross refer to F742] 18. Based on interview and record review it was determined, for 11 out of 51 sample residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, two residents with mental health disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services, a resident with suicidal ideation (SI) eloped and was hospitalized due to lack of interventions and behavioral health services, and a resident with memory deficits had multiple incidents of distressing behaviors without interventions or services provided. The deficient practice identified was found to have occurred at a harm level. Additionally, residents with behaviors of verbal aggression and sexual contact with other residents did not receive interventions or services from a behavioral health provider. Resident identifiers: 4, 22, 29, 37, 39, 40, 46, 47, 49, 57 and 111. [Cross refer to F745] 19. Based on interview and record review it was determined for 4 of 51 sample residents that the facility did not obtain laboratory services to meet the needs of its residents. Specifically, resident had orders to obtain lab draws that were not completed. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 2, 17, 30, and 61. [Cross refer to F770] 20. Based on interview, observation, and record review, the facility did not ensure that the medical director implemented resident care policies, and coordinated care in the facility. Multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, and F770. Resident identifier: 61. [Cross refer F841] On 3/29/22, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the Corporate Resource Nurse (CRN) 1 was at the facility hardly ever to provide oversight. On 3/30/22 at 10:50 AM, an interview was conducted with the Medical Director (MD). When asked about the QA process, the MD stated There's no QA. They haven't had QA in over 6 months, probably 8 months plus. On 3/29/22 the resident council notes for the previous six months were requested from the Administrator (ADM). On 3/29/22 at 1:40 PM, an interview was conducted with the ADM. The ADM stated that she had been employed at the facility since September 2021, and that no resident council meeting had been conducted since she had started her employment. The ADM stated that she had not made any plans to correct the issue. The ADM was also asked about resident 61's hospitalization . The ADM stated that she did not do any type of root-cause analysis to ensure other residents' changes in condition were addressed appropriately. When asked about any oversight by the Regional Vice President (RVP), the ADM stated that he has no involvement. On 3/29/22, at 12:42 PM, an interview was conducted with CRN 1. CRN 1 stated that she was aware the ADM was not conducing QA meetings, and that the ADM kept promising she would start the next month. CRN 1 stated that she checked on this, even though she was not really supposed to oversee the ADM. CRN 1 stated that the RVP oversaw the ADM, and she wasn't sure if the RVP was aware that the QA meetings were not occurring. On 4/7/22 at 8:30 AM, an interview was conducted with the ADM. The ADM confirmed that she had not had any QA meetings since she began employment at the facility in September 2021. The ADM stated that she was aware that the regulation required a minimum of quarterly QA meetings, but still had not implemented the QA meetings. The ADM presented a QAPI plan that she intended on using going forward, but had not developed or implemented a QAPI plan during her employment at the facility.

Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee met quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary. In addition, the Medical Director was not involved in the QAA process. Specifically, multiple system failures were identified, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, F770, and F841. Resident identifiers: 1, 2, 4, 6, 14, 16, 17, 18, 19, 20, 22, 23, 25, 27, 28, 29, 30, 31, 32, 37, 38, 38, 39, 40, 41, 43, 44, 46, 47, 49, 51, 53, 55, 57, 61 and 111. Findings include: 1. Based on interview, observation and record review the facility did not notify the physician for 3 of 51 sample residents after the residents experienced a significant change in condition or a need to alter treatment. Specifically, one resident who needed wound care did not see a provider and declined to the point of death, a resident who left the faciity on leave did not have needed medications, and abnormal vital signs were not provided to the physician. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17, 29, 38, 40, 49, 53, 61 and 111. [Cross refer to F580] 2. Based on interview and record review, it was determined for 17 of 51 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, two residents with severe cognitive impairment were engaged in sexual relationships of which the staff were aware, with no assessments to determine if this was consensual, appropriate or safe. Additionally, multiple residents were engaged in verbal and physical abuse altercations with other residents, and interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of verbal and physical abuse between staff and residents, and incidents of neglect with wound care, a resident's change in condition, and a dependent resident was exposed to inclement weather for an extended period of time were identified at a HARM level. Resident identifiers: 4, 6, 14, 16, 18, 20, 22, 23, 25, 29, 31, 37, 43, 47, 51, 53 and 111. [Cross refer to F600] 3. Based on record review and interview it was determined for 14 of 51 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy Level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 38, 49, 51, 53, and 111. [Cross refer to F609] 4. Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 14 of 51 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA), between 8/22/21 and 3/31/22, the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level. Resident identifiers: 4, 6, 14, 16, 18, 20, 23, 25, 31, 37, 49, 51, 53, and 111. [Cross refer to F610] 5. Based on interview and record review it was determined for 2 of 51 sampled residents that the facility did not incorporate the recommendations from the Pre-Admission Screening Resident Review (PASRR) Level II into the resident's assessment, care planning and transitions of care. Specifically, a PASRR Level II evaluation identified that residents needed mental health services and the facility did not arrange for those services. The findings for residents 46 and 49 were determined to have occurred at a harm level. Resident identifiers: 46 and 49. [Cross refer to F644] 6. Based on observation, interview, and record review, it was determined for 9 of 51 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, residents had pressure ulcers that were not treated as ordered and one resident's that was not examined by a physician, and residents who underwent change of condition that were not treated timely. Resident Identifiers: 17, 18, 22, 29, 40, 41, 49, 57, and 61. [Cross refer to F684] 7. Based on observation, interview and record review, it was determined the facility did not ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 5 of 51 sample residents. Specifically, wound care was not provided to residents as ordered, and one resident did not have physician evaluations or orders for a pressure injury. The deficient practice identified for resident 61 was found to have occurred at an immediate jeopardy level and deficient practice for residents 1. 15, 17, and 29 were found to have occurred at a harm level. Resident identifiers: 1, 17, 29, 51, and 61. [Cross refer to F686] 8. Based on observations, interviews, and record review it was determined that the facility did not ensure a 3 of 51 sample resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease in range of motion. Specifically, a resident who arrived to the facility with the ability to walk was not provided with treatment and services to increase their range of motion or to prevent further decrease in range of motion and the facility did not provide a restorative nurse assistant (RNA) to residents. This finding resulted in a harm deficiency for resident 29. Resident identifiers: 29, 30, and 55. [Cross refer to F688] 9. Based on observation, interview and record review it was determined, for 10 out of 51 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident with a history of suicidal ideation (SI) and major depressive disorder eloped from the facility and was gone for 24 hours before staff notified administration and the local police department, a resident with suicidal ideation and homicidal ideation (HI) was found with multiple weapons in his possession, and a resident was found in the unsecured laundry area near cleaning chemicals and the unlocked broiler room. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level Additionally, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . These identified deficient practices were found to have occurred at a Harm Level. Lastly, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 4, 18, 23, 27, 28, 38, 40, 43, 49, and 51. [Cross refer to F689] 10. Based on interview and record review, the facility did not ensure that 3 of 51 sample residents maintained acceptable parameters of nutritional status. Specifically, three residents experienced weight loss without timely interventions. The findings for all three residents were determined to have occurred at a harm level. Resident identifiers: 29, 32, and 49. [Cross refer to F692] 11. Based on observation, interview, and record review, it was determined, for 4 of 51 sample residents, that the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a residents were not given pain medication prior to a wound care treatment and residents with consistent high pain scores were given no additional pain management. The findings were cited at a harm level for all four residents. Resident identifiers: 1, 16, 29, and 38. [Cross refer to F697] 12. Based on interview and record review, the facility did not ensure that for 2 of 51 sample residents, the medical care was supervised by a physician. Specifically, appropriate oversight for wound care was not provided, and resident 61 subsequently passed away. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17 and 61. [Cross refer to F710] 13. Based on observation, interview and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These findings resulted in harm to multiple residents. In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. Resident identifiers: 4, 16, 17, 18, 19, 22, 27, 28, 29, 37, 40, 41, 43, 44, 46, 47, 49, 51, 57, 61 and 111. [Cross refer to F725] 14. Based on observation, interview, and record review it was determined, for 4 out of 51 sample residents, that the facility did not ensure that the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents with wounds did not have their wound care followed by a physician and the facility wound care nurse was a Licensed Practical Nurse (LPN) who was not wound care certified. Additionally, that LPN ordered and directed the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, an obese resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 17, 18, 27, and 61. 15. Based on observation, interview, and record review it was determined, for 6 out of 51 sampled residents, that the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, two residents with mental disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. In addition, other residents with mental disorders had identified behaviors without interventions and behavioral health services implemented to accommodate or support the resident's loss of abilities. Resident identifiers: 4, 40, 43, 46, 49, and 111. [Cross refer to F740] 16. Based on interview, and record review it was determined, for 8 out of 51 sampled residents, that the facility did not ensure that it had sufficient staff who provided direct services with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, nursing staff were not provided training to care for residents with mental and psychosocial disorders and non-pharmacological interventions were not implemented. The deficient practice identified was found to have occurred at a harm level. Resident identifiers: 4, 37, 40, 43, 46, 47, 49, and 111. [Cross refer to F741 17. Based on interview, observation and record review, the facility did not ensure that 2 of 51 sample residents who displayed or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident expressing suicidal ideations was not treated appropriately. This finding was determined to have occurred at a harm level. In addition, one resident was not assisted in making an appointment with a mental health provider, despite multiple requests. Resident identifiers: 43 and 49. [Cross refer to F742] 18. Based on interview and record review it was determined, for 11 out of 51 sample residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, two residents with mental health disorders required hospitalization after attempting suicide due to lack of interventions and behavioral health services, a resident with suicidal ideation (SI) eloped and was hospitalized due to lack of interventions and behavioral health services, and a resident with memory deficits had multiple incidents of distressing behaviors without interventions or services provided. The deficient practice identified was found to have occurred at a harm level. Additionally, residents with behaviors of verbal aggression and sexual contact with other residents did not receive interventions or services from a behavioral health provider. Resident identifiers: 4, 22, 29, 37, 39, 40, 46, 47, 49, 57 and 111. [Cross refer to F745] 19. Based on interview and record review it was determined for 4 of 51 sample residents that the facility did not obtain laboratory services to meet the needs of its residents. Specifically, resident had orders to obtain lab draws that were not completed. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 2, 17, 30, and 61. [Cross refer to F770] 20. Based on interview, observation, and record review, the facility did not ensure that the medical director implemented resident care policies, and coordinated care in the facility. Multiple system failures were identified during the survey, and the facility was found to be in non-compliance with F600, F609, F610, F684, F686, F689, and F740 at an Immediately Jeopardy level, indicating substandard quality of care. In addition, the facility was found to have been cited at a harm level for F580, F644, F688, F692, F697, F710, F725, F726, F741, F742, F745, and F770. Resident identifier: 61. [Cross refer F841] On 3/29/22, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the Corporate Resource Nurse (CRN) 1 was at the facility hardly ever to provide oversight. On 3/30/22 at 10:50 AM, an interview was conducted with the Medical Director (MD). When asked about the QA process, the MD stated There's no QA. They haven't had QA in over 6 months, probably 8 months plus. On 3/29/22 the resident council notes for the previous six months were requested from the Administrator (ADM). On 3/29/22 at 1:40 PM, an interview was conducted with the ADM. The ADM stated that she had been employed at the facility since September 2021, and that no resident council meeting had been conducted since she had started her employment. The ADM stated that she had not made any plans to correct the issue. The ADM was also asked about resident 61's hospitalization . The ADM stated that she did not do any type of root-cause analysis to ensure other residents' changes in condition were addressed appropriately. When asked about any oversight by the Regional Vice President (RVP), the ADM stated that he has no involvement. On 3/29/22, at 12:42 PM, an interview was conducted with CRN 1. CRN 1 stated that she was aware the ADM was not conducing QA meetings, and that the ADM kept promising she would start the next month. CRN 1 stated that she checked on this, even though she was not really supposed to oversee the ADM. CRN 1 stated that the RVP oversaw the ADM, and she wasn't sure if the RVP was aware that the QA meetings were not occurring. On 4/7/22 at 8:30 AM, an interview was conducted with the ADM. The ADM confirmed that she had not had any QA meetings since she began employment at the facility in September 2021. The ADM stated that she was aware that the regulation required a minimum of quarterly QA meetings, but still had not implemented the QA meetings. The ADM presented a QAPI plan that she intended on using going forward, but had not developed or implemented a QAPI plan during her employment at the facility.

Based on interview and record review it was determined for 2 of 51 sampled residents that the facility did not incorporate the recommendations from the Pre-Admission Screening Resident Review (PASRR) Level II into the resident's assessment, care planning and transitions of care. Specifically, a PASRR Level II evaluation identified that residents needed mental health services and the facility did not arrange for those services. The findings for residents 46 and 49 were determined to have occurred at a harm level. Resident identifiers: 46 and 49. Findings include: HARM 1. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 49 was discharged from the facility on 4/10/22. Resident 49's medical record was reviewed between 3/23/22 and 4/13/22. On 3/25/21, the facility developed a care plan resident 49 with regard to the resident having a PASRR Level II. The goal in place was to have the resident's mental health needs met by facility staff following PASRR II recommendations. In addition, interventions for the PASRR II care plan were not revised throughout resident 49's stay at the facility. A PASRR level II was completed for resident 49 on 3/22/21. The PASRR documented that resident 49 has a history of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . He also endorsed symptoms of [CONDITION(S)] (Post Traumatic Stress Disorder) that he reports are causing him significant disruption at this time. The PASRR indicated that resident 49 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASRR indicated that in September 2020, resident 49 was residing at a long term care facility and tried to strangle himself, which led to an inpatient psychiatric hospitalization . The PASRR continues He has also experienced excessive anxiety and worry, difficulty managing feelings of worry, restlessness/fatigue d/t (due to) excessive worry, irritability, tension, and trouble sleeping d/t anxiety. He has been diagnosed with [CONDITION(S)] in the past, but it appears that his symptoms are more consistent with borderline traits vs (versus) true manic sxs (signs and symptoms). he described very rapid mood swings but struggled to identify manic sxs. He has experienced and reported chronic fears of abandonment, a long standing pattern of dysfunctional interpersonal relationships and devaluation/elevations of others in relationships, impulsivity in multiple areas in his life . recurring and often impulsive suicidal gestures or threats (he purchased a knife on the Internet and had it delivered to his prior SNF (skilled nursing facility) in a suicidal gesture and later tried to strangle himself), anger/irritability w/o (without) provocation, and affective instability/emotional reactivity vs true [CONDITION(S)] (he describes going from depressed to angery (sic) very rapidly . ). He has also been diagnosed with antisocial personality disorder given his history of disregard for the rules (smoking marijuana in the SNF setting), being disrespectful to police w/o provocation, irritability and verbal aggression with staff, and reckless disregard for his own safety with his impulsivity and failure to plan ahead. He has taken flights impulsively to various places in the United States where he has no support, unable to provide for himself or without funds to pay for food and shelter. He has left multiple nursing homes AMA (against medical advice) without adequate planning for his needs, resulting in poor outcomes. He has often been deceptive/overreported symptoms in medication seeking behaviors (pain meds (medications) or benzos (benzodiazepenes)). He has also snuck friends into the SNF or has snuck out of SNF's in the past, violating COVID-19 protocols. He has feigned helplessness to get help or sympathy from staff. He has been physically assaulted on multiple occasions, including once being beaten up and left for dead in an abandoned house. Due to this incident among his other altercations he reports sxs of [CONDITION(S)] including recurring nightmares/intrusive memories (The nightmares don't stop and they haunt me), avoidant behaviors, feelings of distrust of others/detachment from others, persistent negative emotions, irritability/anger out of the blue (I don't know why I just get pissed and I want to fight or punch a wall or something), reckless/self-destructive behaviors, and difficulty sleeping d/t his nightmares. The PASRR also stated that Pt stated that he is willing to get a referral for mental health but that it can be difficult to re-establish rapport and trust with new mental health providers. Pt did state that he wants to have someone who can help him in his decision making, such as a guardian or POA (power of attorney) . He recognized that he needs help in his decision making, and stated I have walked away from too many places over nothing, and it is getting to the point where people are going to start saying we can't have him come here. I'm going to be in a lot worse place than where I'm at now If I don't get help. The SNF Resident Advocate was made aware of pt's wishes. Pt is on multiple [CONDITION(S)] medications and he has been compliant in taking them. He reported that he has been depressed ever since leaving his prior SNF and that he hit bottom when he left there. He did not endorse SI ([CONDITION(S)]) at this time; however given his history of impulsivity and multiple suicide attempts (and hospitalization d/t a suicide attempt in 2020) he should be closely monitored for any lethal means/means for self-harm that would be accessible to him. Given his online purchase of a knife in 2020 every package that might come to pt should be opened with staff present to ensure pt's safety. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. He should be referred for outpatient mental health treatment as well to him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. A second PASRR level II was completed for resident 49 on 3/22/21, that indicated resident 49 has profound motor deficits and has little assistive technology to help him. He would benefit greatly from assistive computer technology and an assistive communication device. He would also benefit from recreational activities that are geared to his age and interests. No indication could be located in the resident's EMR that these recommendations had been put into place. On 3/26/21, facility staff documented that Reported to administrator that resident confided in another resident that he was contemplating suicide. Nursing to monitor resident for behaviors/self harm and/or suicidal verbalizations. On 4/7/21, approximately 12 days later, the facility Licensed Clinical Social Worker (LCSW) Consultant documented the following in resident 49's progress notes: Special concerns and recommendations: 1:1, PRN (as needed), to address any concerns or issues. Provide support and validation. Encourage resident to participate in activities of his preference. Encourage and support family involvement. Remind resident of socially appropriate behavior. Praise resident when he deals with difficulties appropriately. Redirect resident to a quiet place to calm when aggressive or anxious. Encourage and help resident to participate in mental health therapy. Monitor resident closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. On 5/6/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 5/11/21 resident 49 attended a session with a local mental health provider. The provider documented that the resident reported feeling bored and lonelily (sic). We talked about activities to do in the room. On 6/3/21, the RA entered a note documenting that resident 49 at times he can be verbally aggressive, impulsive and manipulative. [resident 49] has a history of [CONDITION(S)], but has not reported any recently. He is being followed by [name of mental health provider], and participates in visits. [Resident 49] was also recently in trouble with the law, and is ordered to take anger management classes. He is actively working on setting up those classes, along with taking online collage (sic) courses. Ra offers help and will assist him when needed. [Note: Per review of the EMR, resident 49 had only seen his mental health provider on 4/9/21, 5/11/21, and 6/3/21. In addition, no evidence of the anger management courses could be located in resident 49's EMR.] On 7/7/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 7/15/21, a nursing progress note was entered indicating that resident 49 was intentionally banging head against wall and trying to throw himself on the floor. Nursing wrned (sic) him of risk of self injury, wctm (will continue to monitor). On 8/12/21 at 12:47 AM, a nursing progress note indicated that the nurse was called by a local deputy office around 9 pm. Patient was found in field, with knife in his possession, had fallen out of his wheelchair and been on the ground for an unknown amount of time. They admitted [name of resident] for 24 hrs with a pink slip to the local . hospital, noting he was a danger to himself. I was contacted later by the social worker, .[the social worker] called back and stated [resident 49] had been medically cleared and that we had to readmit him to the facility tonight. They didn't run a tox (toxicology) screen on him. Our administrator states he is evicted and can no longer return. Social worker states we have to take him back and I referred her to our administrator to clarify that we would not accept him back. If social worker calls back, please refer them to our Administrator and do not take patient back. Social worker called again and stated we have to take him back. I told her they would need to contact us in the morning and that we cannot take him tonight. She will tell us we have to take him back. [Note: No hospital documentation was included in resident 49's EMR to indicate what the hospital's findings and/or recommendations were upon discharge.] On 8/18/21, a facility physician evaluated resident 49 and stated that the resident refuses psychiatric outpatient care. On 8/27/21, a History and Physical was completed by a hospital physician for resident 49. The hospital notes indicated that on 8/20/21, resident 49 was pink sheeted to the hospital because he eloped from the nursing home and his electric scooter and drove up to the ninth floor of a parking structure where he was attempting to throw himself off in a suicide attempt. Police intervened and brought him to the hospital. Per the report, pt was combative with police who were pulling him away from the edge of the building . Pt reports feeling acutely suicidal for the past few weeks and that tonight is his 2nd suicide attempt this month. Pt states he 'planned every second' of the attempt and made sure no one at his care center knew. Pt states I had it. and they took it away from me, meaning, he was almost successful in ending his life and the police took that peace away from him. Pt reports feeling frustrated about his quality of life and that he has no reason to live. Pt is frustrated his plan was interrupted and still wishes to die. Pt will require IP (inpatient) psychiatric admission for stabilization. The resident was subsequently hospitalized and then transferred to a behavioral health bed at a different hospital for further assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes documented that when another provider at the hospital saw resident 49, he states he has been having suicidal ideation for the last few weeks and this is his second attempt to kill himself in the last month. Evidently he left the care facility and was headed towards a lake in order to drowned (sic) himself before and was seen in the ER (emergency room ) and then sent back to the care facility. the patient endorses depressed mood, low interest, loss of pleasure, feeling hopeless and worthless, isolative behavior, and has suicidal but no homicidal ideation. The hospital notes indicated that the resident had been scheduled for an involuntary commitment hearing. The hospital notes indicated that The nursing facility also said they are going to increase his supervision where he will not have any opportunity to go out on his own for instance. [Note: There were no notes entered into the resident's EMR regarding this event. The resident was readmitted to the facility on [DATE].] Per review of the care plan, when the resident returned on 9/1/21, the exact same interventions were included in the anxiety and depression care plans for resident 49 that had been in place prior to the resident's hospitalization . On 9/3/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 9/6/21, facility staff completed a Psychosocial Review for resident 49. The review indicated that the resident had experienced [CONDITION(S)] in the past and could be manipulative. The review also documented that the resident had been verbally aggressive and treatening (sic) towards staff. The Special Concerns and Recommendations included: make sure resident had access to media and his phone, staff would help with redirection and validation, and staff would monitor the resident's mood while keeping administration updated. [Note: This was only one of two psychosocial reviews completed for resident 49 during his 13 month stay, despite ongoing behaviors and increasing suicidality.] On 9/8/21, resident 49 had an updated PASRR level II completed. The updated PASRR indicated due to the resident's recent suicide attempt and hospitalization , a significant change PASRR evaluation was completed. The PASRR documented, When asked about why he left the care center and went to the parking structure in his suicide attempt . He stated that he got to the point where he felt that 'I had no choice but to try and kill myself' as dying by natural causes would 'take too long'. he feels he would benefit from increased frequency of counseling and maybe a [CONDITION(S)] medications review as he's not sure how much his [CONDITION(S)] medications are helping. He reports poor sleep . he only eats one meal a day . He tends to isolate in his room . he stated he tried to go to SNF activities but didn't fond them enjoyable. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts. He should be referred for increased mental health services from his outpatient mental health treatment providers at [name of mental health provider]. This can hopefully help him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. On 9/14/21, the facility RA entered a progress note indicating that resident 49 at times he can be verbally aggressive, impulsive and manipulative. [Resident 49] has a history of [CONDITION(S)], and was recently hospitalized twice due to having those thoughts. When [resident 49] returned from his last hospital stay he stated that he feels much better. He is being followed by [name of mental health provider] . He is actively taking online collage (sic) courses. Ra offers help and will assist him as needed. Care plans reviewed. [Note: No documentation could be located in resident 49's EMR to indicate he had been seen by his mental health provider since 6/3/21.] On 10/7/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. LCSW Consultant notes for October 2021 were reviewed. No recommendations were documented with regard to resident 49. On 11/8/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. LCSW Consultant notes for November 2021 were reviewed. No recommendations were documented with regard to resident 49. LCSW Consultant notes for December 2021 were reviewed. No recommendations were documented with regard to resident 49. On 12/1/21 at 5:26 PM, a nursing progress note indicated that resident 49 complained to the nurse that he didn't want a roommate. Resident 49 stated he doesn't want to have to share and that there's limited space for the 2 of them to share. res then asked if he doesn't get moved then he will just have to handle him. asked res what he meant by handle him, res refused to say the meaning behind his statement. res encouraged to try to get along with roommate and management team will look for further ability to move either resident into better accommodations, told res to be patient . On 12/6/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 12/8/21, the RA documented that resident 49 can be verbally aggressive, impulsive and manipulative. [Resident 49] has had a few verbal and physical encounters with other residents this quarter. Patient is being followed by [name of mental health provider] and is working on his anger issues and how to deal with situations more appropriately. [Note: No documentation could be located in resident 49's EMR to indicate he had been seen by his mental health provider since 6/3/21.] On 1/6/22, a facility physician evaluated resident 49, after the resident requested a visit related to his anger. States that he has been having a hard time w (with) his temper. Having visual and auditory hallucinations - states is currently clean but used drugs as recently as December 5th. States that voices are telling him to kill himself or others. I really just want to feel like myself again . hallucinations. recent drug use likely contributing. Has had recent psych stays within the last 2 years, last from attempting to drive wheelchair off parking structure. Discussed that I am concerned about his health patient agrees. Sending for acute psych evaluation patient agrees that this is for the best tonight and hopes for help . During conversation tonight, patient revealed 2 knives attached to wheelchair. He voluntarily surrendered them to me. Following this, he continued to express desire to seek help in order to feel like himself and get hallucinations to stop. He agreed to voluntarily be transferred for inpatient psychiatric evaluation. Facility administration notified regarding findings of weapons within the facility. Hospital notes dated 1/6/22 for resident 49 were reviewed. Per the documentation, resident 49 initially presented to a local hospitalER on [DATE], was subsequently evaluated and stayed in the ER until 1/8/22. The ER notes indicated that the resident started feeling more depressed this (sic) just before the holiday, got hit by a car over his left foot just after the holiday resulting in an injury and a fracture which is hurting him. He is not in any sort of splint is wondering if that might help. Will go ahead and provide this for him. With regards to his depression he says like (sic) he is hearing voices and he is not sure whether people that were residence (sic) at the care facility are talking to home (sic) or whether it is voices and they are making him more depressed and want to kill himself. He was found at the home tonight with knives apparently threatening suicide and therefore is transported to our facility. Patient seen evaluated (sic) by crisis. He continues to endorse SI. Recommends admission . A psychiatric evaluation completed on 1/6/22 for resident 49 while at the hospital revealed that the resident had depression, disorganized thought processes, hallucinations and suicidal thoughts. The evaluation also indicated that the degree of incapacity was severe and had been worsening. The documentation also revealed that on 1/8/22 Patient had been in the emergency department for approximately 2 days and was discharged about 1 hour ago. He was originally seen for suicide and possible homicidal ideation at his care facility. He was evaluated by crisis on 2 separate occasions. He was deemed appropriate to be discharged back to his facility . It was reported when he got to the facility that the facility did refuse to let him back in because they were concerned he would be unsafe. Therefore, patient brought back to the emergency department. I did attempt to contact his care facility but was unable to reach anyone. Per the hospital notes, the facility agreed to readmit the resident on 1/11/22. On 1/14/22, the LCSW consultant documented that she completed a thorough review of [resident 49's] chart and revised care plan accordingly. Follow up recommendations made to facility. [Note: The recommendations could not be located in the resident's EMR. In addition, the LCSW consultant notes for the month of January 2022 were reviewed. The LCSW consultant did not document anything in her notes with regard to resident 49.] On 1/16/22 at 1:44 PM, resident 49's Psychosocial Review documented that the resident was sent for a psychiatric evaluation for SI and Homicidal Ideation. The review documented that resident 49 appeared alert and oriented to person, place and situation. Resident 49's short term memory and long term memory appeared intact but resident 49 exhibited impaired decision making skills. Resident 49's mood was documented as agitated with SI/HI and visual and auditory hallucinations. The review documented that resident 49 was refusing his medication. Special Concerns and Recommendations included: to make sure he had access to media and his phone, monitor resident to make sure he did not have anything he could hurt himself with, take one on one time with the resident so he could voice his feelings, and keep administration up to date with any mood changes in resident 49. [Note: This was only one of two psychosocial reviews completed for resident 49 during his 13 month stay, despite ongoing behaviors and increasing suicidality.] LCSW consultant notes for February 2022 documented that I did not provide an audit on social service documentation as there is no resident advocate or social worker in the facility at present. The February notes for the LCSW did not include any recommendations with regard to resident 49. LCSW notes for February 2022 also documented that Upon receiving the PASRR II, it should be uploaded to [the EMR . Social Services should notify DON that it has been received so DON can update current diagnoses. Social Services should ensure that the interdisciplinary team (IDT) and the doctor has reviewed the recommendations and evaluated them. That evaluation should be documented in a social services progress note titled PASRR II review. If the team or doctor disagree with the recommendations, the note should explain why a recommendation is not being followed. The recommendations which will be followed need to be careplanned. Remember that the goal must state what the resident 9 will do and NOT what staff will do. On 2/7/22 at 6:37 AM, a nursing progress note for resident 49 revealed that Resident left the facility at [4:15 PM]. A good samaritan called this writer on the nurse's station to let us know the resident's location. He was at the [gas station]. The resident's powered wheelchair is dead. He reported the resident is cold and he provided him a blanket. He also stated that the resident has 2 knives, bought by resident from [a local store]. Resident was dropped off to the facility by EMS (emergency medical services) at [1:00 AM], EMS reported that he brought out his knives when the EMS was trying to pick him up. EMS reported that he looked upset and seemed did not want to go with them or go back to the facility. Police was called. Police reported that they have a camera footage of the resident being violent and used the knife against his own throat and he also used it to threatened (sic) them. Police confiscated the knife. Police stated that if he might do this again, Administration should take away his [electric wheelchair] and keep him in the facility. On 2/16/22 a nursing progress note documented that PT threatened that he would become violent and told me I didn't know what he was capable of if I didn't give him his pills. I informed patient I have to follow the rules and he is aware that he is not allowed to leave facility grounds w/out being accompanied by somebody. Pt started yelling at staff and then went to the second floor to go smoke. On 2/20/22, a nursing progress note indicated that resident 49 ran his foot into nursing cart forcing the drawer to close as the nurse was working on getting [the morning] meds ready. He was asked to stop and back away or the police would be called as he was being aggressive. He was throwing verbal [NAME] at the nurse to go ahead and call the police RN stepped away to call police and he took the side of his hand and hit the pills knocking them off the cart and scattering them all over the floor. He then left and went back to his room.He has been throwing [NAME] at RN all weekend b/c when he left on Thursday our staff has been instructed to call the police and let him know as our NP has written an order that he is unsafe out in the community. The police called on the phone and talked to him. He declined their help so they closed the case. This has been charted on previously, and how he sent a text to another resident to show RN. He has been rude and throwing verbal [NAME] all weekend. We have attempted to be kind. supervisor has been notified and she has said she will follow up. LCSW Consultant notes were reviewed. In March 2022, the LCSW documented Resident leaves facility without assistance frequently, even goes to shop at [local store]. Is he appropriate for skilled facility placement? We should evaluate him to see if he qualifies to stay. No documentation was located with regard to recommendations for resident 49's behaviors by the LCSW during that month. On 3/23/22 at 6:18 AM, Res was asked to remove himself from another residents room d/t the roommate feeling uncomfortable having him there. Res was non compliant and continued to stay in room. Res was informed that his actions were unacceptable and he needed to leave the room and since the residents of the room were no longer in the room he needed to come out. He became verbally loud and came out yelling shut up [OBSCENITY] ! Res went into his own room and went on his computer. Appropriate staff informed of incident. On 4/7/22, nursing notes indicated that resident 49 was asking administration personnel for his knife from the lockbox. The notes also indicated that the resident became combative and staff wheeled him away before he was able to cause any physical harm. Police were called and arrived promptly to the scene. The situation was resolved without harm to residents or staff. On 4/8/22 at 5:50 PM, nursing notes indicated that resident 49 told the nurse to give him something to sleep or he would cut himself. The resident was subsequently placed on 15 minute checks. On 4/8/22 at 10:17 PM, a facility physician evaluated resident 49 and stated that the resident indicates that he is struggling emotionally. Is amendable/willing (sic) to see a professional via admission to ER for eval. On 4/9/22 at 1:34 AM, nursing notes indicated the following: On 4/8/22 at [10:17 PM] assisted [name of nurse practitioner] with a phone call with the resident. (See NP note.) Pt stated he had [CONDITION(S)] and felt anxious and would like to talk to someone. Resident requested to be sent to the hospital. Informed resident an ambulance would be called and resident stated he would like to remain on the patio so he could smoke before he left. At [10:25 PM] ensured the gate was closed and latched. 2 CNA's were on the patio. Informed one of the CNA's that I needed to notify EMS and coordinate with nursing about the hospital transport. Asked CNA to stay with the resident and watch him until I could return. Notified the floor nurse of the DC (discharge) order and requested they call EMS. [10:34 PM] finished phone call with the NP and immediately returned to the patio to observe the pt. Upon entering the patio it was found that the resident had pushed the gate open with his W/C. All available staff immediately started searching for the resident. Resident last seen at [11:30 PM] Notified Admin who called the police. Several police officers, the administrator and myself searched the surrounding area until [1:20 AM]. At the time of this note pt has not been located.Police still searching for the resident. Resident family and NP notified. Residents phone called several times and goes straight to voicemail. Police have attempted to Ping residents phone without success. On 4/9/22 at 4:50 AM, nursing notes indicated that a local police department contacted the facility to inform them that resident 49 was at a local gas station trying to pour gasoline on himself, then set himself on fire. The police intervened and he was sent to [local hospital]. Hospital notes dated 4/9/22 for resident 49 were reviewed and revealed that resident 49 is a [AGE] year-old male who attempted to kill himself by lighting a stove on fire earlier today. He is wheelchair-bound and has [CONDITION(S)] with a history of depression. He states he was sexually abused by his nursing home administrator [name of ADM] a few months ago, and wanted to burn his groin off due to his experience. He was seen at a gas station pouring gasoline on himself, he was intervened upon before lighting a match but had multiple sources of fire on his person according to the police. He was brought to the emergency department and thoroughly decontaminated for approximately 40 minutes in our showers before being roomed in the ED (emergency department). He endorses severe pain through his abdomen and his groin and feels like they are on fire . On exam he shows significant topical first-degree burn. Patient has significant pain from his topical [CONDITION(S)] especially of his penis and testicles, he was given serial doses of [MEDICATION(S)] and had improvement. The hospital notes also documented that resident 49 was interviewed about the alleged sexual abuse by the ADM and stated that This was not something I had control over . It was abuse. It was abuse caused by a person who is over the house that I am supposed to feel safe at. The notes further stated that Patient reports that he was emotionally, physically, and sexually abused by the person who runs the home that he was staying at. He reports that after 8 months, he has finally been able to get her fired. He reports up until recently, whenever he has called anybody for help, including the police, she calls him a liar. And she reports that the police have called him a liar. He describes himself as having [CONDITION(S)] because of her. He admits to having nightmares as well. He says that whenever he tries t [TRUNCATED]

Based on interview, observation and record review the facility did not notify the physician for 3 of 51 sample residents after the residents experienced a significant change in condition or a need to alter treatment. Specifically, one resident who needed wound care did not see a provider and declined to the point of death, a resident who left the faciity on leave did not have needed medications, and abnormal vital signs were not provided to the physician. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17, 40, and 61. Findings include: HARM 1. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/13/22, resident 61's medical record review was completed. On 12/21/21 at 11:09 AM, resident 61 had discharge orders printed from a regional care facility for wound care. The order for the coccyx wound stated: Bilateral buttocks and coccyx 1. Remove dressing 2. Clean wound with soap and water 3. Apply Santyl [MEDICATION(S)] to the wound bed in a nickel thick consistency. 4. Cut and apply Xeroform or oil emulsion over Santyl. 5. Place large sacral dressing to each buttocks, and silicone bordered foam to coccyx. 6. Please change dressing daily and as needed with hygiene. On 12/21/21 at 6:32 PM, resident 61 was weighed by a mechanical lift, and listed at 430 pounds. Resident 61's care plan did not include wound care. A nutrition care plan revealed that resident 61 was to have supplements to aide in wound healing. A regional hospital Progress Notes for 1/1/22 revealed that resident 61 had . 4. Sacral decubitus ulcer, stage III. Chronic ulcer, present on arrival. Sacral wound itself is unstageable with black eschar and purulent sluff (sic). CT (computerized tomography) showed fat stranding inferior, posterior and right of the midline. Also noted small scattered areas of gas without definitive drainable fluid collection. No signs of [CONDITION(S)]. Plastics was curbsided and agrees with plan for continued wound care. - Continued aggressive wound care. - Patient will need frequent offloading/position changes. On 1/1/22 at 11:04 AM, the regional hospital Discharge Documentation for Discharge Wound Care Instructions were: . coccyx 1. moisten a roll of gauze (kerlix) with Puracyn insert deep into undermining (12 cm toward anus) and depth of wound. On 1/1/22, a regional hospital discharge Progress Notes revealed that resident 61 had a stage 4 pressure ulcer on his coccyx, measuring 5.3 x 3.0 x 0 cm (centimeters) with undermining extending very close to anus. Description of the sacral ulcer revealed, Chronic ulcer, felt to be the cause of above noted bacteremia at his recent hospital stay. Currently, most wounds are looking reasonably clean without any purulence, exudate, or surrounding [CONDITION(S)]. Sacral wound itself is unstageable with black eschar and purulent sluff (sic) . If he is not progressing then we will plan to get a CT abdomen and pelvis with contrast to look for deep wound infection. Wound care consultation requested. Patient will need frequent offloading/position changes. An order in resident 61's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 61's Treatment Administration Record (TAR) revealed that this wound care was completed two times, on 1/2/22 and on 1/9/22. On 1/1/22 at 1:00 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was recorded in the TAR as completed on 1/9/22 at 8:09 PM. On 1/1/22 at 4:22 PM, an Admission Summary revealed, .Skin Status/Interventions: Stage IV pressure ulcer to coccyx; cleansed with NS (normal saline), packed with gauze dressing, noted undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of dressing .Incontinent of bowel and bladder . On 1/1/22 at 6:00 PM, an order was created to monitor the pressure ulcer to the coccyx each shift for signs and symptoms of infection or other complications. Nurses charted no complications on all checks, with the exception on 1/18 and 1/21 in the mornings, when the assessments were not completed. On 1/1/22 at 10:06 PM, a 72 hour charting after admission note revealed that resident 61 was adjusting well to returning to facility; appears to be in low spirits .Mental Status/Behavior: appears depressed and in low spirits; no behaviors noted . On 1/2/22 at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin prep barrier wipe to periwound skin. Pack undermining of wound w/ [MEDICATION(S)] soaked in Puracyn (squeeze out the excess). Apply Venelex to wound bed the apply Xeroform dressing. Secure with ABD (abdominal) pads. To be changed EOD (every other day) & PRN (as needed) if becomes soiled, saturated or accidentally removed one time a day every other day. This order was discontinued on 1/13/22. The TAR revealed that this treatment was completed on 1/2, 1/4, 1/6, 1/8, 1/10, and 1/12/22. On 1/3/22 at 9:56 AM, a skin/wound note revealed: Pressure ulcer to coccyx, undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . A referral was sent to a wound healing company to assess and treat. It was noted that the provider would be at the facility on 1/6/22. On 1/3/22 at 11:50 AM, a physician's note revealed that resident 61 had an admission note created by a physician who performed a telehealth visit. A second note was entered at 8:44 PM. Skin status/interventions: Stage IV pressure ulcer to coccyx, cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100 (left lower side), surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . [Note: No other physician visits occurred during resident 61's stay.] On 1/4/22 at 11:27 PM, a nurses note revealed: Changed dressing to buttocks. Moderate serosanguineous drainage (clear fluid) with odor. Cleansed peri with wound cleanser and dressing with ABD pads and [MEDICATION(S)] tape. On 1/5/22 at 9:35 AM, the resident advocate note revealed that resident 61 was admitted to the facility for [CONDITION(S)].According to resident discharge plan is to return home with home health. He is alert and orientated. He is currently using a wheelchair for locomotion and needs extensive assistance . His moods and behaviors have been cooperative, pleasant, and is compliant with cares since admission. On 1/5/22 at 10:30 AM, a Utilization Review (UR) note revealed that resident 61 .needs wound care (daily and PRN) .goal is to return home with HH (home health) . On 1/6/22 at 9:15 AM, a social services care conference note was started, and was not completed. Status stated In Progress. The note revealed that .wounds have no s/s (signs/symptoms) of infection .pleasant and cooperative with cares . On 1/6/22 at 11:00 AM, resident 61 had blood drawn for laboratory tests. On the results, a note was written that resident 61 needed a BMP (basic metabolic panel) completed in 1 week with a date 1/12/22. Resident 61 had a white blood cell count of 11,300, with high neutrophils and immature granulocytes. [No additional blood tests were completed for resident 61 until 1/23/22.] [The wound clinic provider did not see resident 61 on 1/6/22.] On 1/7/22 at 5:41 PM, resident 61 had a Nutritional Assessment. The assessment revealed that resident 61 had .increased nutritional needs d/t (due to) skin impairment to coccyx . Recommend adding . Juven BID (twice daily) and liquid protein . to support healing. Will monitor weight, intake, wound healing and will adjust nutritional interventions as needed. [No orders for Juven or liquid protein were initiated for resident 61.] On 1/7/22, a Mini Nutritional Assessment was completed. Resident 61 was At risk of malnutrition. [Note: No further nutrition assessments were completed.] Resident 61 had a nutritional care plan created on 1/7/22. An intervention was to Provide supplements to promote wound healing. Resident 61 did not have a wound care plan included in his care plans. On 1/8/22, resident 61 was assessed in the Minimum Data Set (MDS) as requiring rehabilitation, urinary incontinence, fluid maintenance, fall risk, pain management, nutritional status management and pressure ulcer management. On 1/8/22, resident's [MEDICATION(S)] tablet order was not provided due to being out of supply, not in med cart. On 1/9/22 at 8:09 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/10/22 at 9:32 AM, a Minimum Data Set (MDS) skin conditions evaluation revealed resident 61 had 1 stage 4 pressure ulcer. Resident 61 had a pressure reducing device for the bed. Nutrition or hydration intervention to manage skin problems were noted as being in place. On 1/12/22 at 5:33 PM, a nurses note revealed that labs drawn 1/6/22 rec'd (received) w/ (with) noted abnormalities .NP (Nurse Practitioner) reviewed w/ N/O (new order) for BMP recheck in 1 week. [This lab was not redrawn.] On 1/12/22 at 3:25 PM, a Utilization Review (UR) note revealed that resident 61 .needs skilled wound care (daily and PRN) .goal is to return home with HH (home health) . On 1/13/22 at 4:30 PM, a skin/wound note revealed: Residents wound remains with deep 2 o'clock tunneling. with 5 X 6 (centimeters) opening. Wound has foul odor. Peri wound has improved. New order to fill wound bed with calcium alginate rope cover with bordered foam. Resident tolerated well . Resident 61 reported the following pain scores (out of 10) without reporting effective pain control: a. On 1/15/22 at 10:26 AM, 9 b. On 1/15/22 at 1:06 PM, 8 c. On 1/15/22 at 1:11 PM, 7 d. On 1/15/22 at 9:15 PM, 8 e. On 1/21/22 at 5:06 PM, 7 f. On 1/21/22 at 9:58 PM, 7 [No new interventions were noted.] On 1/16/22 at 8:37 PM, a skin/wound note revealed: Change resident dressing daily. Wound is 6 cm X 6.5 cm X 8.5 cm tunnel at 2 o'clock. Lots of blood drainage. Wound nurse's are following dressing change order from the hospital On 1/19/22 at 1:57 PM, a Utilization Review (UR) meeting revealed that resident 61's plan of care was to work with therapy and to return home with home health. The nursing update included .skilled wound care (daily and PRN), . On 1/20/22 at 6:28 AM, a nursing note revealed that resident 61's Wound remains open with foul odor. Wound is 6 cm X 5.5 CM x 2 CM. It tunnels at 2 o'clock 8 cm. Wound has necrotic tissue coming out of the tunnel area. Dressing change daily. Dakins soak 30 min. then Calcium alginate rope to tunnel with calcium alginate in wound bed. Cover with ABD pad and foam cover . On 1/21/22 at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR revealed that this order was completed on 1/22/22 and 1/23/22. On 1/21/22, a Skilled Daily Review was performed for resident 61. Skilled need was wound to coccyx with tunneling at 2:00 position per wound care nurse. Pain mgmt (management). Assist with ADLs (activities of daily living). Resident 61 was incontinent of urine and bowel movements, and wore briefs with peri care provided with each brief change. [Note: There is no documentation about wound care changes with brief changes.] On 12/21/22 at 3:17 PM, resident complained of sacral pain for which PRN medication was provided. On 1/22/22 at 11:33 PM, a weekly skin review revealed no new skin integrity problems. The sacral pressure injury was noted. On 1/23/22 at 9:43 AM, a nurses note revealed that the nurse had received report of resident 61 having increased confusion with shaking, high blood pressure, resident looking to the left to respond to the nurse who was on the left side of the bed, and confusion about how to drink water. Nurse contacted physician who ordered STAT blood and urine tests along with a chest X-ray to rule out infection. Resident was given 1 liter of normal saline over 5 hours. On 1/23/22, blood pressure obtained was 139/127, followed by 155/60. On 1/23/22 at 10:36 AM, a nurses notes revealed that resident 61 had an IV (intravenous access line) placed in the right hand for blood draw. On 1/23/22 at 1:59 PM, a higher-than-normal respiratory rate was noted at 22 breaths per minute and heart rate was 124 beats per minute, irregular, and was identified as a new finding. [There was no documentation that a physician was contacted.] On 1/23/22, resident 61's lab results were faxed to the facility at 4:43 PM. Resident 61's white blood cell count was 25,100, with segmented neutrophils. RN 1 noted the results on 1/23/22. [There was no documentation that this report was forwarded to a medical provider until the following day.] On 1/23/22 at 7:37 PM, an order was initiated for resident 61 to assess resident 61's pressure ulcer and notify the physician if any complications. On 1/24/22 at 3:55 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was noted as done by previous shift. [No documentation of providing the results to the physician was noted.] On 1/24/22 at 4:44 AM, a nursing note revealed a blood pressure of 98/50, heart rate of 99 beats per minute, and oxygen saturation at 93% on a Continuous Positive Airway Pressure ([CONDITION(S)]) device. The nursing note stated no changes res (resident's) health status from yesterday. Asked res if he would like to go to the hospital for checkup but he refused it. Encouraged res to increase fluid intake. PRN (as needed) pain med was given for pain on both knees. will continue to monitor. On 1/24/22, on the final lab results report, a note written at the bottom of the report revealed that one of the medical providers made an order to send resident 61 to the Emergency Department. On 1/24/22 at 11:41 PM, an order was entered/discontinued for a wound care company to eval and tx (treatment) r/t pressure wounds to coccyx and bilateral buttocks. On 1/24/22 at 12:36 PM, a nursing not revealed that resident 61 was sent to the hospital. On 1/24/22 at 1:32 PM, a regional hospital Emergency Documentation was initiated for resident 61. The documentation revealed that resident 61 had chief complaints of: a. altered level of consciousness b. high heart rate c. not looking to the right . He apparently was acting abnormally this morning according to rehab facility staff but what that means is a little bit unclear. He was transported and there was no mention of increased work of breathing or [CONDITION(S)] I was called to the room because of high heart rate and tachypnea (rapid breathing). Looks like he is in [CONDITION(S)] with RVR (rapid ventricular rate of response) but does not endorse any chest pain at all. He is noted to be with a right-sided neglect. No known vomiting. Given patient status no other history was obtained. Stroke 1 is called. Meds ordered for his high heart rate. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. initiation of end-of-life care b. septic shock c. [CONDITION(S)] d. respiratory failure e. acidosis f. superobesity g. diabetes h. strokelike syndrome i. [CONDITION(S)]/[CONDITION(S)] .Medical decision making/differential Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . He presented with [CONDITION(S)], some altered mental status, rapid heart rate with what looked like new onset [CONDITION(S)] (fluttering atria of the heart). He is also quite tacypneic. He already had leuckocytosis yesterday at 26,000. Today it climbed to 32,000. I think this clinical picture was strongly suggestive of septic shock and overwhelming [CONDITION(S)]. His sacral area wound showed a large area of ecchymosis and [CONDITION(S)] and some purulent drainage from the central portion of the ulcer. He seemed to medically stabilize early on but then after resuscitative efforts were towards the tail and the patient actually worsened in status. Long discussion was held with numerous family members .he became medically unstable and worse over time despite antibiotics fluids respiratory support no other [CONDITION(S)] treatment measures. I did not see any obvious reasons to counter patient and family wishes and initiating end-of-life care. The massive area of skin and soft tissue infection with ulceration was the likely source of his infection and massive debridement would be necessary . The course of treatment in the Emergency Department included . Required supplemental oxygen. [CONDITION(S)] protocol enrollment with treatment provided. In addition neurology consultation was required early on given concerns for potential stroke. [A neurologist] did not feel that the patient was under going a stroke syndrome Thereafter [CONDITION(S)] treatment was the focus We evaluated the wound on his backside and it was massive encompassing a large territory of the entire lower lumbar and sacral region with a draining wound and a lot of surrounding necrotic tissue with [CONDITION(S)] extending down to the perineum without obvious drainable abscess. Shortly after evaluating this wound the patient became diaphoretic and more short of breath but remained lucid. Additional oxygen was provided. We had discussed at this point in time about focus of treatment and goals of treatment . An arterial blood gas (ABG) was obtained and resident 61 had worsening acidosis Patient progress towards severe illness and end of life pretty quickly at around 5:30 PM, resident was noted to have agonal respirations and confirmed at this time if we do not act patient will certainly die soon. Again there was consensus with family members present to proceed with comfort measures and monitors were turned off and high flow oxygen was turned off along with vasopressors. Family gathered at the bedside and said their goodbyes and time of death was estimated to be at 6:10 PM. On 3/24/22 at 11:31 AM, a former Director of Nursing (DON), DON 2, was interviewed. DON 2 stated that resident 61 had a pretty serious tunneling wound that no doctor had examined while resident 61 was in the facility. DON 2 stated that she spoke with a medical provider in the facility and determined that he was not following resident 61. DON 2 stated that the wound clinic was unable to treat resident 61 because of his insurance, so resident 61 was not seen by prescribing provider. DON 2 stated that resident 61 had insurance that would provide wound care to their clients in their wound clinic, but resident 61 was not sent out. DON 2 stated that resident did not have orders provided by any clinician, that wound care orders were generated by the wound nurse (now the ADON). DON 2 stated that resident 61 never went to wound clinic. He went to the hospital, went septic, and started crashing. On 3/29/22 at 10:10 AM, the ADON was interviewed. The ADON stated that typically, residents have wound care provided in the facility, depending on their insurance. The ADON stated that resident 61 had an insurance that required him to go out to a specific wound clinic, but resident 61 was not able to be sent out to the clinic. The ADON stated that DON 1 was working on obtaining a different insurance for resident 61 so their providers could follow his wound. The ADON stated that she did not have the authority to send resident 61 out to the clinic when she was the wound nurse. The ADON stated that no physician consulted for resident 61, and all new orders for his wound care were generated by her. The ADON stated that no physician ever laid eyes on resident 61's wound. The ADON stated that I was just doing the best I could as the wound nurse. The ADON stated that the providers wouldn't give an order without seeing resident 61. The ADON stated that resident 61's wound was not getting any better, but he weighed almost 600 pounds so it was difficult to get an ambulance to take him out. The ADON stated that she ordered Dakins solution because the wound had such an odor. The ADON stated that she wanted to order a silver alginate to keep infection away. The ADON stated that she was not aware of resident 61 being discussed in the interdisciplinary team (IDT) meetings. The ADON stated that the order she initiated was for wound care to be performed every other day, but it should have been done daily if possible. The ADON stated that the wound care was possibly done more often than what was charted. The ADON stated that there was so much agency in the building, there were a lot of things they didn't get around to. The ADON stated that the bloody drainage on the 16th was good, because it meant that the wound was healing. The ADON stated that resident 61's bowel movements would get all over the dressings. The ADON stated that she was not wound care certified, and staging a wound was beyond her scope of practice. The ADON stated that on 1/20/22, there was a foul odor, and she wanted the doctors to provide an antibiotic. The ADON stated that she changed resident 61's wounds, but did not do anything else for him. The ADON stated that resident 61 was not taken out until he went to the hospital on 1/24/22 with [CONDITION(S)]. The ADON stated that there was no way to determine what wound care was done, that if a nurse signed that they completed the wound care, she would have to believe they did it. On 3/29/22 at 12:42 PM, the Corporate Resource Nurse (CRN) 1 was interviewed. CRN 1 stated that the wound nurse was responsible for communication with the wound care providers and physicians. CRN 1 stated that the wound nurse (now the ADON) would look at wounds and show them to the physicians. CRN 1 stated that the ADON requested orders from physicians, and would enter orders in the computerized record and request physicians to sign the orders. CRN 1 stated that she was not aware if physicians created the orders or signed the orders after the fact. On 3/29/22 at 1:32 PM, the Administrator (ADM) was interviewed. The ADM stated that the former DON (DON 1) was working on resident 61's insurance. The ADM stated that she assumed that a doctor was following resident 61's wounds, and that the wound nurse would take care of that. The ADM stated that an analysis of preventing resident 61's hospitalization was no completed. The ADM stated that she was not aware of discussing resident 61 in the morning stand-up meetings. The ADM stated that when a resident had a change of condition, staff would discuss what to do, what tests were required and determine if the resident needed to go to the hospital. The ADM stated that she did not believe that resident 61 had a change of condition before he was sent out. On 3/30/22 at 12:26 PM, an interview was conducted with Medical Provider (MP) 1. MP 1 stated that resident 61 had insurance that required him to have his wound care provided at the insurance company's provider. MP 1 stated that the wound nurse had approached him for cares, and he informed her that resident 61 needed surgical debridement. On 4/4/22 at 12:10 PM, the Administrator was re-interviewed. The ADM stated that she had assumed the physician would check on resident 61. The ADM stated that when resident 61 went to the hospital with [CONDITION(S)], she did not complete an analysis of what staff might have done to prevent the hospitalization . The ADM stated that she had not completed an analysis of identifying residents' change of condition timely. The ADM stated that staff were not always very talkative during morning meetings, and she was not clinical, so sometimes she didn't know what was happening with the residents. On 4/11/22 at 12:20 PM, the ADON was re-interviewed. The ADON stated that prior to the last two weeks, she was acting as the wound care nurse in the building. The ADON stated that her responsibilities as the wound nurse (WN) was to assist the provider on Thursdays with wounds, new orders, and at times, she was also fulfilling the role as a floor nurse. The ADON stated that she was responsible for wound care in the building four days each week, and the floor nurses were responsible the other three days. The ADON stated that she entered the wound care orders for the residents into the computer for the floor nurses to follow. The ADON stated that the wound physician would complete the measurements and staging of the wounds. The ADON stated that when a resident was admitted to the facility, she would create a temporary order for wound care. The ADON stated that she would tell the physician's group Nurse Practitioner what she was going to do for a resident. The ADON stated that she put the order in as a verbal order from the medical director. The ADON stated that she noticed that some wound care treatments had not been completed by the nurses. The ADON stated that It took me an hour to go through the whole building. The ADON stated that she was unsure why the nurses weren't doing their wounds. The ADON stated that for resident 61, she felt like I was screaming into a void on that one. I was very concerned about him and I couldn't get anyone to listen to me. The ADON stated that the Nurse Practitioner told her to get him into a wound clinic to have the wound debrided surgically, but she could not get him into the other clinic because he weighed about 600 pounds. POTENTIAL FOR HARM 2. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/2/22 at 11:26 AM, an observation was made of resident 17 at the nurse's station on the 2nd floor with a visitor. The visitor was heard informing Registered Nurse (RN) 4 that he was taking resident 17 home over the weekend and that he would need to obtain the resident's medications. RN 4 stated that she had not been informed of this in report from the previous shift and she would need to speak with the Corporate Resource Nurse (CRN) for guidance. On 4/2/22 at 11:31 AM, an interview was conducted with RN 4. RN 4 stated that she did not know what the process was for a resident who was going home for the weekend. RN 4 stated she would ask the Assistant Director of Nursing (ADON), but that usually the nurse would pass that information off in report. The ADON was heard instructing RN 4 to give the family member enough medications for tonight and tomorrow morning. RN 4 was observed to dispense the medication into individual medication packs and the packs were labeled with the medication name and dosage. RN 4 stated that the resident 17 was out of the medication Sevelamer. RN 4 stated that resident 17 had refused all her medication this morning. RN 4 stated that resident 17 was supposed to have the Sevelamer medication before every meal and they did not have them in the medication cart to send with the family. The RN was observed to provide the family member with all the medication and a list of the medication with instructions. Resident 17 was observed to leave the facility with the visitor. Review of resident 17's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was scheduled for administration times of 8:00 AM, 12:00 PM, and 5:00 PM. On 4/2/22 at 12:08 PM, resident 17's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 4 documented for the 12:00 PM administration time that the medication was administered and RN 4 also documented for the future administration time at 5:00 PM that the medication was refused by resident 17. An immediate interview was conducted with RN 4. RN 4 stated that she did not send the Sevelamer medication with resident 17. RN 4 stated that the other documentation for the 12:00 PM and 5:00 PM administration times was an error and she would correct the mistake. RN 4 stated that she did not know what to do with the medication for the family member, and no one gave her instructions. On 4/2/22 at 3:23 PM, resident 17's order administration note documented that the medication Sevelamer was not available. The note did not document that the physician was notified of resident 17's missed medications. On 3/19/22 at 4:23 PM, resident 17's order administration note documented that the medication Sevelamer was not available, and a request was sent to the pharmacy. The note did not document that the physician was notified of resident 17's missed medications. On 3/13/22 at 3:59 PM, resident 17's order administration note documented that the medication Sevelamer was out of stock. The note did not document that the physician was notified of resident 17's missed medications. On 3/6/22 at 1:40 PM, resident 17's order administration note documented that the medication Sevelamer was unavailable. The note did not document that the physician was notified of resident 17's missed medications. On 3/6/22 at 10:35 AM, resident 17's order administration note documented that the medication Sevelamer was out of stock. The note did not document that the physician was notified of resident 17's missed medications. On 3/5/22 at 9:35 AM, resident 17's order administration note documented that the medication Sevelamer was not available to administer. The note did not document that the physician was notified of resident 17's missed medications. Review of resident 17's progress notes revealed the following: a. On 7/15/21 at 4:21 AM, the note documented that resident 17's right below the knee amputation was red and worm (sic). The Nurse Practitioner (NP) and DON were notified. b. On 7/15/21 at 12:37 PM, the note documented, Pt [patient] continues to be lethargic. She has had 3 bowel movements this shift. No diarrhea, stool is soft semi-formed. Pt BP [blood pressure] is low 90/47. She did take her AM [morning] meds after changing brief around approx 0930 [9:30 AM]. Before that she was very lethargic and would not wake up for them. After changing brief she was more alert, able to take pills but did choke on bigger ones. She gagged and spit up scant amount of white mucous. When asked if pt was in pain she said no. c. On 7/15/21 at 3:43 PM, the note documented, Pt continues to be lethargic this shift. She has been drowsy, she will respond to her name after calling and rubbing her chest. O2 [oxygen] sats [saturations] are difficult to obtain, on R [right] hand she read low 80's, cap [capillary] refill is greater than 3 seconds. L [left] hand sats will read 90%.Pt has not eaten all day, she has refused all beverages. The only fluid she has had is small sips with medications. CNA reports that she has not had a wet brief. d. On 7/15/21 at 4:30 PM, .NP came to facility. Requested new set of vitals. BP was 70/40, taken twice on both wrist. No manual BP cuff found in facil [TRUNCATED]

Based on observations, interviews, and record review it was determined that the facility did not ensure a 3 of 51 sample resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease in range of motion. Specifically, a resident who arrived to the facility with the ability to walk was not provided with treatment and services to increase their range of motion or to prevent further decrease in range of motion and the facility did not provide a restorative nurse assistant (RNA) to residents. This finding resulted in a harm deficiency for resident 29. Resident identifiers: 29, 30, and 55. Findings include: HARM 1. Resident 29 was initially admitted to the facility on [DATE] and again on 1/24/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 29's medical record was reviewed on 4/7/22. 1. Admissions Minimum Data Set (MDS) from 10/14/21 A. Section G (functional status) of resident 29's admissions MDS from 10/14/21 revealed that resident 29 required supervision with setup help only when walking in his room and walking in the corridor and toilet use. Resident 29 required supervision with one persons physical assist for dressing. Section G0400 revealed that resident 29 had impairment on one side of his lower extremities. B. Section GG (functional abilities and goal) of the admission MDS revealed that resident 29 was able to walk 50 feet with two turns with supervision or touching assistance. Section GG also revealed that resident 29 required supervision or touching assistance with the following: a. Roll left and right b. Sit to lying c. Lying to sitting on side of bed d. Sit to stand e. Chair/bed-to chair transfer f. Toilet transfer 2. Most recent quarterly MDS from 1/28/22 A. Section G of resident 29's most recent quarterly MDS from 1/28/22 revealed that resident 29 required extensive two plus persons physical assist with bed mobility. Activity did not occur was marked for walking in his room and walking in the corridor. Section G revealed that resident 29 required extensive one persons physical assist for dressing, eating, toilet use, and personal hygiene. Section G0400 revealed that resident 29 had impairment on both sides of his lower extremities. B. Section GG of resident 29's most recent quarterly MDS from 1/28/22 revealed that the activity of walking 50 feet with two turns was not attempted due to a medical condition or safety concerns. Section GG revealed that resident 29 now required partial/moderate assistance with the following: a. Sit to lying b. Lying to sitting on side of bed c. Sit to stand d. Chair/bed-to-chair transfer e. Toilet transfer A progress note from 1/12/22 revealed that a catheter was placed on 1/12/22. On 4/11/22 at 12:20 PM an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that resident 29 now had a catheter. The ADON stated that the reason why resident 29 had a catheter was due to resident 29 frequently urinating and staff were attempting to keep the wound on his coccyx dry. On 4/12/22 an interview with resident 29's family member (Power of Attorney) was conducted. Resident 29's family member stated that she was told resident 29 needed a catheter to keep the wound on his coccyx dry and that it would eliminate resident 29 from needing to go to the bathroom. The family member stated that resident 29 had not walked since he got the catheter. Resident 29's family member stated that the facility was not assisting resident 29 with leg exercises and resident 29 lost muscle mass in his legs due to not moving out of bed. Resident 29's family member stated that she was told by resident 29's nurse practitioner that resident 29 most likely would not be able to walk again. Resident 29's family member stated that since he has been admitted to the facility, he had developed a pressure sore, his wounds on his legs had progressively gotten worse, and he was no longer able to walk. Resident 29's family member stated that the facility was letting him waste away and she felt like resident 29's life was shortened due to the neglect he received at the facility. POTENTIAL FOR HARM 2. Resident 55 was admitted to the facility on [DATE], and was readmitted on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/13/22 at 10:00 AM a contracture of the left hand and arm of resident 55 was observed. On 4/13/22 a review of residents orders was conducted. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment will focus on therapeutic exercise, therapeutic activities, neuromuscular reeducation, self care retraining and community reintegration. According to the Care Plan dated 12/3/21, staff were to encourage and provide treatment with Activities of Daily Living (ADL's) as per physicians orders. 3. Resident 30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 30's medical record was reviewed between 3/23/22 and 4/13/22. Resident 30's quarterly MDS assessment dated [DATE], indicated that resident 30 required supervision with one person assistance for bed mobility, transfer, toilet use, personal hygiene, and walking. The MDS also indicated that resident 30 required extensive one person assistance with dressing. On 9/16/20, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/25/22 an interview with Employee 12 was conducted. When asked about the RNA program, she stated that the facility really needed an RNA. Employee 12 stated that the last RNA was first pulled to help the CNA's with weights, then they pulled the RNA to help with showers, then they pulled the RNA to help the CNA's with other duties until the RNA program just ended. Employee 12 stated that there are so many residents that would benefit with an RNA program. Employee 12 stated that a RNA is essential to make sure residents continually progress. On 3/28/22 an interview was conducted with Employee 1. Employee 1 stated that the RNA program had been dissolved at the facility, and that it was needed. On 4/13/22 at 10:36 AM an interview was conducted with the facility Occupational Therapist (OT). The OT confirmed that she had been working with resident 55. The OT stated that a carrot was given to resident to aid with resident 55's hand contracture, and that range of motion exercises were performed during these therapy sessions. The OT stated that the resident would benefit from a Restorative Nursing Assistant (RNA) program. On 4/11/22 at 12:19 PM, an interview was conducted with the ADON. The ADON stated she did not know if RNA program in place or if it was occurring. On 4/13/22 at 10:50 AM, an interview with Certified Nurses Assistant (CNA) 3 was conducted. CNA 3 stated that frequently they were lucky to get baths done, and rarely had time to do range of motion exercises with the residents. On 3/29/22 at 10:38 AM, an interview with the Administrator was conducted. During this interview, the Administrator stated that there was no RNA program in the facility, nor had there been since she had started employment at the facility in September 2022. The Administrator stated that she used to have one, but the RNA was being pulled to assist the Certified Nursing Assistant's (CNA) with their duties until the RNA did not have time to do RNA activities and was just helping the CNA's. The ADM stated that she had the perfect person in mind to get it back going again but hasnt had time to fully implement it yet.

Based on interview and record review, the facility did not ensure that for 2 of 51 sample residents, the medical care was supervised by a physician. Specifically, appropriate oversight for wound care was not provided, and resident 61 subsequently passed away. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 17 and 61. Findings include: HARM 1. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/13/22, resident 61's medical record review was completed. On 12/21/21 at 11:09 AM, resident 61 had discharge orders printed from a regional care facility for wound care. The order for the coccyx wound stated: Bilateral buttocks and coccyx 1. Remove dressing 2. Clean wound with soap and water 3. Apply Santyl [MEDICATION(S)] to the wound bed in a nickel thick consistency. 4. Cut and apply Xeroform or oil emulsion over Santyl. 5. Place large sacral dressing to each buttocks, and silicone bordered foam to coccyx. 6. Please change dressing daily and as needed with hygiene. On 12/21/21 at 6:32 PM, resident 61 was weight by a mechanical lift at 430 pounds. Resident 61's care plan did not include wound care. A nutrition care plan revealed that resident 61 was to have supplements to aide in wound healing. A regional hospital Progress Notes for 1/1/22 revealed that resident 61 had 4. Sacral decubitus ulcer, stage III. Chronic ulcer, present on arrival. Sacral wound itself is unstageable with black eschar and purulent sluff. CT showed fat stranding inferior, posterior and right of the midline. Also noted small scattered areas of gas without definitive drainable fluid collection. No signs of [CONDITION(S)]. Plastics was curbsided and agrees with plan for continued wound care. - Continued aggressive wound care. - Patient will need frequent offloading/position changes. On 1/1/22 at 11:04 AM, the regional hospital Discharge Documentation for Discharge Wound Care Instructions were: coccyx 1. moisten a roll of gauze (kerlix) with Puracyn insert deep into undermining (12 cm toward anus) and depth of wound. On 1/1/22, a regional hospital discharge Progress Notes revealed that resident 61 had a stage 4 pressure ulcer on his coccyx, measuring 5.3 x 3.0 x 0 cm (centimeters) with undermining extending very close to anus. Description of the sacral ulcer revealed, Chronic ulcer, felt to be the cause of above noted bacteremia at his recent hospital stay. Currently, most wounds are looking reasonably clean without any purulence, exudate, or surrounding [CONDITION(S)]. Sacral wound itself is unstageable with black eschar and purulent sluff . If he is not progressing then we will plan to get a CT (computerized tomography) abdomen and pelvis with contrast to look for deep wound infection. Wound care consultation requested. Patient will need frequent offloading/position changes. An order in resident 61's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 61's Treatment Administration Record (TAR) revealed that this wound care was completed two times, on 1/2/22 and on 1/9/22. On 1/1/22 at 1:00 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was recorded in the TAR as completed on 1/9/22 at 8:09 PM. On 1/1/22 at 4:22 PM, an Admission Summary revealed, .Skin Status/Interventions: Stage IV pressure ulcer to coccyx; cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of dressing .Incontinent of bowel and bladder . On 1/1/22 at 6:00 PM, an order was created to monitor the pressure ulcer to the coccyx each shift for signs and symptoms of infection or other complications. Nurses charted no complications on all checks, with the exception on 1/18 and 1/21 in the mornings, when the assessments were not completed. On 1/1/22 at 10:06 PM, a 72 hour charting after admission note revealed that resident 61 was adjusting well to returning to facility; appears to be in low spirits .Mental Status/Behavior: appears depressed and in low spirits; no behaviors noted . On 1/2/22 at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin prep barrier wipe to periwound skin. Pack undermining of wound w/ [MEDICATION(S)] soaked in Puracyn (squeeze out the excess). Apply Venelex to wound bed the apply Xeroform dressing. Secure with ABD (abdominal) pads. To be changed EOD (every other day) & PRN (as needed) if becomes soiled, saturated or accidentally removed one time a day every other day. This order was discontinued on 1/13/22. The TAR revealed that this treatment was completed on 1/2, 1/4, 1/6, 1/8, 1/10, and 1/12/22. On 1/3/22 at 9:56 AM, a skin/wound note revealed: Pressure ulcer to coccyx, undermining from 1600 to 2100, surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . A referral was sent to a wound healing company to assess and treat. It was noted that the provider would be at the facility on 1/6/22. On 1/3/22 at 11:50 AM, a physician's note revealed that resident 61 had an admission note created by a physician who performed a telehealth visit. A second note was entered at 8:44 PM. Skin status/interventions: Stage IV pressure ulcer to coccyx, cleansed with NS, packed with gauze dressing, noted undermining from 1600 to 2100 (left lower side), surrounding skin macerated, red, open areas, foul odor from wound, Venelex applied to maceration, moderate amount of drainage . No other physician visits occurred during resident 61's stay. On 1/4/22 at 11:27 PM, a nurses note revealed: Changed dressing to buttocks. Moderate serosanguineous drainage (clear fluid) with odor. Cleansed peri with wound cleanser and dressing with ABD pads and [MEDICATION(S)] tape. On 1/5/22 at 9:35 AM, the resident advocate note revealed that resident 61 was admitted to the facility for [CONDITION(S)].According to resident discharge plan is to return home with home health. He is alert and orientated. He is currently using a wheelchair for locomotion and needs extensive assistance . His moods and behaviors have been cooperative, pleasant, and is compliant with cares since admission. On 1/5/22 at 10:30 AM, a Utilization Review (UR) note revealed that resident 61 .needs wound care (daily and PRN) .goal is to return home with HH (home health) . On 1/6/22 at 9:15 AM, a social services care conference note was started, and was not completed. Status stated In Progress. The note revealed that .wounds have no s/s (signs/symptoms) of infection .pleasant and cooperative with cares . On 1/6/22 at 11:00 AM, resident 61 had blood drawn for laboratory tests. On the results, a note was written that resident 61 needed a BMP (basic metabolic panel) completed in 1 week with a date 1/12/22. Resident 61 had a white blood cell count of 11,300, with high neutrophils and immature granulocytes. [No additional blood tests were completed for resident 61 until 1/23/22.] [Wound physician did not see resident 61 on 1/6/22.] On 1/7/22 at 5:41 PM, resident 61 had a Nutritional Assessment. The assessment revealed that resident 61 had .increased nutritional needs d/t (due to) skin impairment to coccyx . Recommend adding . Juven BID (twice daily) and liquid protein . to support healing. Will monitor weight, intake, wound healing and will adjust nutritional interventions as needed. [No orders for Juven or liquid protein were initiated for resident 61.] On 1/7/22, a Mini Nutritional Assessment was completed. Resident 61 was At risk of malnutrition. [Note: No further nutrition assessments were completed.] Resident 61 had a nutritional care plan created on 1/7/22. An intervention was to Provide supplements to promote wound healing. Resident 61 did not have a wound care plan included in his care plans. On 1/8/22, resident 61 was assessed in the Minimum Data Set (MDS) as requiring rehabilitation, urinary incontinence, fluid maintenance, fall risk, pain management, nutritional status management and pressure ulcer management. On 1/8/22, resident's [MEDICATION(S)] tablet order was not provided due to being out of supply, not in med cart. On 1/9/22 at 8:09 PM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/10/22 at 9:32 AM, a MDS skin conditions evaluation that revealed resident 61 had 1 stage 4 pressure ulcer. Resident 61 had a pressure reducing device for the bed. Nutrition or hydration intervention to manage skin problems were noted as being in place. On 1/12/22 at 5:33 PM, a nurses note revealed that labs drawn 1/6/22 rec'd (received) w/ (with) noted abnormalities .NP (Nurse Practitioner) reviewed w/ N/O (new order) for BMP recheck in 1 week. [This lab was not redrawn.] On 1/12/22 at 3:25 PM, a Utilization Review (UR) note revealed that resident 61 .needs skilled wound care (daily and PRN) .goal is to return home with HH (home health) . On 1/13/22 at 4:30 PM, a skin/wound note revealed: Residents wound remains with deep 2 o'clock tunneling. with 5 X 6 (centimeters) opening. Wound has foul odor. Peri wound has improved. New order to fill wound bed with calcium alginate rope cover with bordered foam. Resident tolerated well . Resident 61 reported the following pain scores (out of 10) without reporting effective pain control: a. On 1/15/22 at 10:26 AM, 9 b. On 1/15/22 at 1:06 PM, 8 c. On 1/15/22 at 1:11 PM, 7 d. On 1/15/22 at 9:15 PM, 8 e. On 1/21/22 at 5:06 PM, 7 f. On 1/21/22 at 9:58 PM, 7 [No new interventions were noted.] On 1/16/22 at 8:37 PM, a skin/wound note revealed: Change resident dressing daily. Wound is 6 cm X 6.5 cm X 8.5 cm tunnel at 2 o'clock. Lots of blood drainage. Wound nurse's are following dressing change order from the hospital On 1/19/22 at 1:57 PM, a Utilization Review (UR) meeting revealed that resident 61's plan of care was to work with therapy and to return home with home health. The nursing update included .skilled wound care (daily and PRN), . On 1/20/22 at 6:28 AM, a nursing note revealed that resident 61's Wound remains open with foul odor. Wound is 6 cm X 5.5 CM x 2 CM. It tunnels at 2 o'clock 8 cm. Wound has necrotic tissue coming out of the tunnel area. Dressing change daily. Dakins soak 30 min. then Calcium alginate rope to tunnel with calcium alginate in wound bed. Cover with ABD pad and foam cover . On 1/21/22 at 6:00 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR revealed that this order was completed on 1/22/22 and 1/23/22. On 1/21/22, a Skilled Daily Review was performed for resident 61. Skilled need was wound to coccyx with tunneling at 2:00 position per wound care nurse. Pain mgmt (management). Assist with ADLs (activities of daily living). Resident 61 was incontinent of urine and bowel movements, and wore briefs with peri care provided with each brief change. [Note: There is no documentation about wound care changes with brief changes.] On 12/21/22 at 3:17 PM, resident complained of sacral pain for which PRN medication was provided. On 1/22/22 at 11:33 PM, a weekly skin review revealed no new skin integrity problems. The sacral pressure injury was noted. On 1/23/22 at 9:43 AM, a nurses note revealed that the nurse had received report of resident 61 having increased confusion with shaking, high blood pressure, resident looking to the left to respond to the nurse who was on the left side of the bed, and confusion about how to drink water. Nurse contacted physician who ordered STAT blood and urine tests along with a chest X-ray to rule out infection. Resident was given 1 liter of normal saline over 5 hours. On 1/23/22, blood pressure obtained was 139/127, followed by 155/60. On 1/23/22 at 10:36 AM, a nurses notes revealed that resident 61 had an IV (intravenous access line) placed in the right hand for blood draw. On 1/23/22 at 1:59 PM, a higher-than-normal respiratory rate was noted at 22 breaths per minute and heart rate was 124 beats per minute, irregular, and was identified as a new finding. [There was no documentation that a physician was contacted.] On 1/23/22, resident 61's lab results were faxed to the facility at 4:43 PM. Resident 61's white blood cell count was 25,100, with segmented neutrophils. RN 1 noted the results on 1/23/22. [There was no documentation that this report was forwarded to a medical provider until the following day.] On 1/23/22 at 7:37 PM, an order was initiated for resident 61 to assess resident 61's pressure ulcer and notify the physician if any complications. On 1/24/22 at 3:55 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was noted as done by previous shift. [No documentation of providing the results to the physician was noted.] On 1/24/22 at 4:44 AM, a nursing note revealed a blood pressure of 98/50, heart rate of 99 beats per minute, and oxygen saturation at 93% on a Continuous Positive Airway Pressure ([CONDITION(S)]) device. The nursing note stated no changes res (resident's) health status from yesterday. Asked res if he would like to go to the hospital for checkup but he refused it. Encouraged res to increase fluid intake. PRN (as needed) pain med was given for pain on both knees. will continue to monitor. On 1/24/22, on the final lab results report, a note written at the bottom of the report revealed that one of the medical providers made an order to send resident 61 to the Emergency Department. On 1/24/22 at 11:41 PM, an order was entered/discontinued for a wound care company to eval and tx (treatment) r/t pressure wounds to coccyx and bilateral buttocks. On 1/24/22 at 12:36 PM, a nursing not revealed that resident 61 was sent to the hospital. On 1/24/22 at 1:32 PM, a regional hospital Emergency Documentation was initiated for resident 61. The documentation revealed that resident 61 had chief complaints of: a. altered level of consciousness b. high heart rate c. not looking to the right He apparently was acting abnormally this morning according to rehab facility staff but what that means is a little bit unclear. He was transported and there was no mention of increased work of breathing or [CONDITION(S)] I was called to the room because of high heart rate and tachypnea (rapid breathing). Looks like he is in [CONDITION(S)] with RVR (rapid ventricular rate of response) but does not endorse any chest pain at all. He is noted to be with a right-sided neglect. No known vomiting. Given patient status no other history was obtained. Stroke 1 is called. Meds ordered for his high heart rate. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. initiation of end-of-life care b. septic shock c. [CONDITION(S)] d. respiratory failure e. acidosis f. superobesity g. diabetes h. strokelike syndrome i. [CONDITION(S)]/[CONDITION(S)] Medical decision making/differential Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . He presented with [CONDITION(S)], some altered mental status, rapid heart rate with what looked like new onset [CONDITION(S)] (fluttering atria of the heart). He is also quite tacypneic. He already had leuckocytosis yesterday at 26,000. Today it climbed to 32,000. I think this clinical picture was strongly suggestive of septic shock and overwhelming [CONDITION(S)]. His sacral area wound showed a large area of ecchymosis and [CONDITION(S)] and some purulent drainage from the central portion of the ulcer. He seemed to medically stabilize early on but then after resuscitative efforts were towards the tail and the patient actually worsened in status. Long discussion was held with numerous family members .he became medically unstable and worse over time despite antibiotics fluids respiratory support no other [CONDITION(S)] treatment measures. I did not see any obvious reasons to counter patient and family wishes and initiating end-of-life care. The massive area of skin and soft tissue infection with ulceration was the likely source of his infection and massive debridement would be necessary . The course of treatment in the Emergency Department included . Required supplemental oxygen. [CONDITION(S)] protocol enrollment with treatment provided. In addition neurology consultation was required early on given concerns for potential stroke. [A neurologist] did not feel that the patient was under going a stroke syndrome Thereafter [CONDITION(S)] treatment was the focus We evaluated the wound on his backside and it was massive encompassing a large territory of the entire lower lumbar and sacral region with a draining wound and a lot of surrounding necrotic tissue with [CONDITION(S)] extending down to the perineum without obvious drainable abscess. Shortly after evaluating this wound the patient became diaphoretic and more short of breath but remained lucid. Additional oxygen was provided. We had discussed at this point in time about focus of treatment and goals of treatment . An arterial blood gas (ABG) was obtained and resident 61 had worsening acidosis Patient progress towards severe illness and end of life pretty quickly at around 5:30 PM, resident was noted to have agonal respirations and confirmed at this time if we do not act patient will certainly die soon. Again there was consensus with family members present to proceed with comfort measures and monitors were turned off and high flow oxygen was turned off along with vasopressors. Family gathered at the bedside and said their goodbyes and time of death was estimated to be at 6:10 PM. On 3/24/22 at 11:31 AM, a former DON, DON 2, was interviewed. DON 2 stated that resident 61 had a pretty serious tunneling wound that no doctor had examined while resident 61 was in the facility. DON 2 stated that she spoke with a medical provider in the facility and determined that he was not following resident 61. DON 2 stated that the wound clinic was unable to treat resident 61 because of his insurance, so resident 61 was not seen by prescribing provider. DON 2 stated that resident 61 had insurance that would provide wound care to their clients in their wound clinic, but resident 61 was not sent out. DON 2 stated that resident did not have orders provided by any clinician, that wound care orders were generated by the wound nurse (now the ADON). DON 2 stated that resident 61 never went to wound clinic. He went to the hospital, went septic, and started crashing. On 3/29/22 at 10:10 AM, the ADON was interviewed. The ADON stated that typically, residents have wound care provided in the facility, depending on their insurance. The ADON stated that resident 61 had an insurance that required him to go out to a specific wound clinic, but resident 61 was not able to be sent out to the clinic. The ADON stated that DON 1 was working on obtaining a different insurance for resident 61 so their providers could follow his wound. The ADON stated that she did not have the authority to send resident 61 out to the clinic when she was the wound nurse. The ADON stated that no physician consulted for resident 61, and all new orders for his wound care were generated by her. The ADON stated that no physician ever laid eyes on resident 61's wound. The ADON stated that I was just doing the best I could as the wound nurse. The ADON stated that the providers wouldn't give an order without seeing resident 61. The ADON stated that resident 61's wound was not getting any better, but he weighed almost 600 pounds so it was difficult to get an ambulance to take him out. The ADON stated that she ordered Dakins solution because the wound had such an odor. The ADON stated that she wanted to order a silver alginate to keep infection away. The ADON stated that she was not aware of resident 61 being discussed in the interdisciplinary team (IDT) meetings. The ADON stated that the order she initiated was for wound care to be performed every other day, but it should have been done daily if possible. The ADON stated that the wound care was possibly done more often than what was charted. The ADON stated that there was so much agency in the building, there were a lot of things they didn't get around to. The ADON stated that the bloody drainage on the 16th was good, because it meant that the wound was healing. The ADON stated that resident 61's bowel movements would get all over the dressings. The ADON stated that she was not wound care certified, and staging a wound was beyond her scope of practice. The ADON stated that on 1/20/22, there was a foul odor, and she wanted the doctors to provide an antibiotic. The ADON stated that she changed resident 61's wounds, but did not do anything else for him. The ADON stated that resident 61 was not taken out until he went to the hospital on 1/24/22 with [CONDITION(S)]. The ADON stated that there was no way to determine what wound care was done, that if a nurse signed that they completed the wound care, she would have to believe they did it. On 3/29/22 at 12:42 PM, the Corporate Resource Nurse (CRN 1) was interviewed. CRN 1 stated that the wound nurse was responsible for communication with the wound care providers and physicians. CRN 1 stated that the wound nurse (now the ADON) would look at wounds and show them to the physicians. CRN 1 stated that the ADON requested orders from physicians, and would enter orders in the computerized record and request physicians to sign the orders. CRN 1 stated that she was not aware if physicians created the orders or signed the orders after the fact. On 3/29/22 at 1:32 PM, the Administrator (ADM) was interviewed. The ADM stated that the former DON (DON 1) was working on resident 61's insurance. The ADM stated that she assumed that a doctor was following resident 61's wounds, and that the wound nurse would take care of that. The ADM stated that an analysis of preventing resident 61's hospitalization was no completed. The ADM stated that she was not aware of discussing resident 61 in the morning stand-up meetings. The ADM stated that when a resident had a change of condition, staff would discuss what to do, what tests were required and determine if the resident needed to go to the hospital. The ADM stated that she did not believe that resident 61 had a change of condition before he was sent out. On 3/30/22 at 12:26 PM, an interview was conducted with Medical Provider (MP) 1. MP 1 stated that resident 61 had insurance that required him to have his wound care provided at the insurance company's provider. MP 1 stated that the wound nurse had approached him for cares, and he informed her that resident 61 needed surgical debridement. On 04/4/22 at 12:10 PM, the Administrator was re-interviewed. The ADM stated that she had assumed the physician would check on resident 61. The ADM stated that when resident 61 went to the hospital with [CONDITION(S)], she did not complete an analysis of what staff might have done to prevent the hospitalization . The ADM stated that she had not completed an analysis of identifying residents' change of condition timely. The ADM stated that staff were not always very talkative during morning meetings, and she was not clinical, so sometimes she didn't know what was happening with the residents. On 4/11/22 at 12:20 PM, the ADON was re-interviewed. The ADON stated that prior to the last two weeks, she was acting as the wound care nurse in the building. The ADON stated that her responsibilities as the wound nurse (WN) was to assist the provider on Thursdays with wounds, new orders, and at times, she was also fulfilling the role as a floor nurse. The ADON stated that she was responsible for wound care in the building four days each week, and the floor nurses were responsible the other three days. The ADON stated that she entered the wound care orders for the residents into the computer for the floor nurses to follow. The ADON stated that the wound physician would complete the measurements and staging of the wounds. The ADON stated that when a resident was admitted to the facility, she would create a temporary order for wound care. The ADON stated that she would tell the physician's group Nurse Practitioner what she was going to do for a resident. The ADON stated that she put the order in as a verbal order from the medical director. The ADON stated that she noticed that some wound care treatments had not been completed by the nurses. The ADON stated that It took me an hour to go through the whole building. The ADON stated that she was unsure why the nurses weren't doing their wounds. The ADON stated that for resident 61, she felt like I was screaming into a void on that one. I was very concerned about him and I couldn't get anyone to listen to me. The ADON stated that the Nurse Practitioner told her to get him into a wound clinic to have the wound debrided surgically, but she could not get him into the other clinic because he weighed about 600 pounds. [Cross-refer F686] POTENTIAL FOR HARM 2. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/2/22 resident 17's medical records were reviewed. On 7/16/21, an Admission Minimum Data Set (MDS) Assessment documented that resident 17 had one unhealed pressure ulcers (PU)/injuries, and it was an unstageable PU due to the coverage of slough or eschar. The assessment documented that the resident had a pressure reducing device for the bed but did not indicate what that device was. The Care Area Assessment Summary indicated that a care plan was triggered for Pressure Ulcer/Injury. The assessment documented that resident 17 was a one-person extensive physical assist for bed mobility, dressing, and personal hygiene. The assessment documented that resident 17 was a two-person extensive physical assist for transfers, locomotion on and off the unit, and toilet use. The assessment documented a limitation in range of motion for resident 17's lower extremity with impairments noted on one side. The assessment documented that resident 17 utilized a wheelchair as a mobility device. It should be noted that the care plan for skin integrity issues and pressure injury (PI) was not developed until 1/18/22. Review of resident 17's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Wound to outer aspect of left malleolus/ankle area. Clean, apply skin prep to peri wound, apply calcium alginate, and cover with bordered foam dressing. Change every day (QD) and as needed (PRN). The order was initiated on 3/24/22. b. Wound to outer aspect of left malleolus/ankle area. Clean, apply skin prep to peri wound, apply calcium alginate, and cover with bordered foam dressing. Change 3 times (x) week and PRN, one time a day every Tuesday, Thursday, and Saturday. The order was initiated on 2/22/22 and discontinued on 3/23/22. c. Wound to medial top great toe. Clean with wound cleaner or normal saline (NS) and pat dry. Apply oil emulsion gauze cut to fit and a small bordered foam dressing, and cover with her sock. Monitor and change dressing daily (QD) and PRN one time a day for wound care. The order was initiated on 1/15/22 and was discontinued on 4/6/22. d. Gently clean left great outer toe with wound cleaner and gauze. Check for blanching around the wound. Gauze dressings are keeping moisture in and increased risk for infection. Please apply an adhesive strip (band aide) and report any signs and symptoms (s/sx) of infection, two times a day for preventing infection. The order was initiated on 1/21/22 and was discontinued on 2/19/22. e. Left Buttocks wound, clean and apply zinc-based cream two times a day for wound care. The order was initiated on 1/29/22. f. Weekly Skin checks on Thursday day shift. The order was initiated on 7/15/21. Review of resident 17's progress notes revealed the following: a. On 7/9/21 at 5:49 PM, the admission note documented that resident 17 was admitted with [CONDITION(S)] and a right below the knee amputation (R BKA) and Left posterior heel has pressure ulcer that is almost healed. b. On 7/15/21 at 4:21 AM, the note documented, redressed R BKA skin is red and worm (sic) on the right side of wound surrounding stitched notified NP [Nurse Practitioner] and DON [Director of Nursing]. c. On 10/4/2021 at 9:19 PM, the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Tablet 1 MG [milligram] -Nephro Vitamins Tablet 0.8 MG (B Complex-C-[MEDICATION(S)]) -[MEDICATION(S)] [[MEDICATION(S)]] Tablet 100 MG -Vitamin D3 Tablet ([MEDICATION(S)]) d. On 11/3/2021 at 1:01 AM, the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Tablet 1 MG -Nephro Vitamins Tablet 0.8 MG (B Complex-C-[MEDICATION(S)]) -[MEDICATION(S)] Tablet 100 MG -Vitamin D3 Tablet ([MEDICATION(S)]) e On 12/27/2021 at 11:47 AM, the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . f. On 1/15/2022 at 6:39 AM, the note documented, . left big toe appeared to have an abrasion which she received during the transport to the SNF [Skilled Nursing Facility]. The wound is addressed and dressing is applied. g. On 1/15/2022 at 12:26 PM, the note documented, Wound to left great toe, resident had this wound on arrival from [name of receiving facility]. They claimed they hit her toe in transfer. Wound is Approximately 2.5 CM [centimeters] X [by] 1 CM X 0.0 CM. it is on the left Great toe medial top side. It looks bubbled and red in color. Clean carefully, apply oil emulsion gauze and covered with bordered foam. Will Monitor daily. h. On 1/29/2022 at 11:46 AM, the note documented, New pressure injury wound to left buttocks. Red, Warm, and painful 10 cm x 8cm. Non Blanchable. Applied zinc based cream. i. On 2/19/2022 at 4:15 PM, the note documented, New wound on resident, Left Outer aspect of malleolus/ankle area. Wound is firm, No drainage. Red center with brown peri wound. 2 cm [centimeter] x 1.4 cm. Cleaned wound, applied Calcium Alginate, Covered with bordered foam dressing. Management ordering a air mattress for pressure wound. Dressing to be changed 3 x week and prn [as needed]. j. On 2/22/2022 at 5:42 AM, the note documented, Res [resident] refused airbed x10 by aides and nurse. Son was called and notified to help translate. Son stated he had translated earlier and to continue trying. Multiple attempts until son spoke to nurse once again and stated to place mom on regular mattress. He stated Res did not feel safe on air mattress and feels as thou [TRUNCATED]

Based on interview, observation and record review, the facility did not ensure that 2 of 51 sample residents who displayed or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident expressing [CONDITION(S)] was not treated appropriately. This finding was determined to have occurred at a harm level. In addition, one resident was not assisted in making an appointment with a mental health provider, despite multiple requests. Resident identifiers: 43 and 49. Findings include: HARM 1. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 49 was discharged from the facility on 4/10/22. Resident medical record was reviewed between 3/23/22 and 4/13/22. Resident 49's care plan was reviewed. On 3/2/21, after the resident's admission, the facility developed a care plan with regard to the resident becoming anxious. The care plan history revealed that this care plan was not revised throughout resident 49's stay at the facility. On 3/2/21, the facility also developed a care plan with regard to the resident feeling down or depressed. The care plan for depression indicated that the goal was to name at least one positive strength or ability each week. This goal was in place throughout the resident's stay at the facility, although no other documentation could be located to indicate this goal was being accomplished. In addition, interventions for the depression care plan were not revised throughout resident 49's stay at the facility. On 3/25/21, the facility developed a care plan resident 49 with regard to the resident having a PASRR Level II. The goal in place was to have the resident's mental health needs met by facility staff following PASRR II recommendations. In addition, interventions for the PASRR II care plan were not revised throughout resident 49's stay at the facility. A PASRR level II was completed for resident 49 on 3/22/21. The PASRR documented that resident 49 has a history of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . He also endorsed symptoms of [CONDITION(S)] (Post Traumatic Stress Disorder) that he reports are causing him significant disruption at this time. The PASRR indicated that resident 49 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASRR indicated that in September 2020, resident 49 was residing at a long term care facility and tried to strangle himself, which led to an inpatient psychiatric hospitalization . The PASRR continues He has also experienced excessive anxiety and worry, difficulty managing feelings of worry, restlessness/fatigue d/t (due to) excessive worry, irritability, tension, and trouble sleeping d/t anxiety. He has been diagnosed with [CONDITION(S)] in the past, but it appears that his symptoms are more consistent with borderline traits vs (versus) true manic sxs (signs and symptoms). he described very rapid mood swings but struggled to identify manic sxs. He has experienced and reported chronic fears of abandonment, a long standing pattern of dysfunctional interpersonal relationships and devaluation/elevations of others in relationships, impulsivity in multiple areas in his life . recurring and often impulsive suicidal gestures or threats (he purchased a knife on the Internet and had it delivered to his prior SNF (skilled nursing facility) in a suicidal gesture and later tried to strangle himself), anger/irritability w/o (without) provocation, and affective instability/emotional reactivity vs true [CONDITION(S)] (he describes going from depressed to angery (sic) very rapidly . ). He has also been diagnosed with antisocial personality disorder given his history of disregard for the rules (smoking marijuana in the SNF setting), being disrespectful to police w/o provocation, irritability and verbal aggression with staff, and reckless disregard for his own safety with his impulsivity and failure to plan ahead. He has taken flights impulsively to various places in the United States where he has no support, unable to provide for himself or without funds to pay for food and shelter. He has left multiple nursing homes AMA (against medical advice) without adequate planning for his needs, resulting in poor outcomes. He has often been deceptive/overreported symptoms in medication seeking behaviors (pain meds (medications) or benzos (benzodiazepenes)). He has also snuck friends into the SNF or has snuck out of SNF's in the past, violating COVID-19 protocols. He has feigned helplessness to get help or sympathy from staff. He has been physically assaulted on multiple occasions, including once being beaten up and left for dead in an abandoned house. Due to this incident among his other altercations he reports sxs of [CONDITION(S)] including recurring nightmares/intrusive memories (The nightmares don't stop and they haunt me), avoidant behaviors, feelings of distrust of others/detachment from others, persistent negative emotions, irritability/anger out of the blue (I don't know why I just get pissed and I want to fight or punch a wall or something), reckless/self-destructive behaviors, and difficulty sleeping d/t his nightmares. The PASRR also stated that Pt stated that he is willing to get a referral for mental health but that it can be difficult to re-establish rapport and trust with new mental health providers. Pt did state that he wants to have someone who can help him in his decision making, such as a guardian or POA (power of attorney) . He recognized that he needs help in his decision making, and stated I have walked away from too many places over nothing, and it is getting to the point where people are going to start saying we can't have him come here. I'm going to be in a lot worse place than where I'm at now If I don't get help. The SNF Resident Advocate was made aware of pt's wishes. Pt is on multiple [CONDITION(S)] medications and he has been compliant in taking them. He reported that he has been depressed ever since leaving his prior SNF and that he hit bottom when he left there. He did not endorse SI ([CONDITION(S)]) at this time; however given his history of impulsivity and multiple suicide attempts (and hospitalization d/t a suicide attempt in 2020) he should be closely monitored for any lethal means/means for self-harm that would be accessible to him. Given his online purchase of a knife in 2020 every package that might come to pt should be opened with staff present to ensure pt's safety. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. He should be referred for outpatient mental health treatment as well to him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. A second PASRR level II was completed for resident 49 on 3/22/21, that indicated resident 49 has profound motor deficits and has little assistive technology to help him. He would benefit greatly from assistive computer technology and an assistive communication device. He would also benefit from recreational activities that are geared to his age and interests. No indication could be located in the resident's EMR that these recommendations had been put into place. On 3/26/21, facility staff documented that Reported to administrator that resident confided in another resident that he was contemplating suicide. Nursing to monitor resident for behaviors/self harm and/or suicidal verbalizations. On 4/7/21, approximately 12 days later, the facility Licensed Clinical Social Worker (LCSW) Consultant documented the following in resident 49's progress notes: Special concerns and recommendations: 1:1, PRN (as needed), to address any concerns or issues. Provide support and validation. Encourage resident to participate in activities of his preference. Encourage and support family involvement. Remind resident of socially appropriate behavior. Praise resident when he deals with difficulties appropriately. Redirect resident to a quiet place to calm when aggressive or anxious. Encourage and help resident to participate in mental health therapy. Monitor resident closely for any means for self-harm given his multiple suicide attempts while in his prior SNF. On 5/6/21, the Resident Advocate (RA) documented that resident 49 was having some hallucinations, and was talking to someone that wasn't there. He stated that a CNA (Certified Nursing Assistant) asked who he was talking to and [resident 49] stated another patients name, and CNA said there's no one here. RA informed DON and [mental health provider]. On 5/6/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 5/11/21 resident 49 attended a session with a local mental health provider. The provider documented that the resident reported feeling bored and lonelily (sic). We talked about activities to do in the room. On 5/27/21, a nursing note entry documented that resident reported to me that 3 weeks after his admit he had swallowed a razor and then threw it up. He states this was a razor that had been ordered [online] to cut his hair. He reported to me that he did not tell anyone at the time but he is now because he is worried that it may be a concerning factor to his recent sx and not feeling well. He denies having any [CONDITION(S)] at this time. This was reported to the DON who stated pt has been having a lot of behaviors lately due to d/c (discharge) of pt's friend and that the bloodwork ordered this shift will be suffice (sic) indication to need for further eval (evaluation) and that she would visit with resident tomorrow. On 6/3/21, the RA entered a note documenting that resident 49 at times he can be verbally aggressive, impulsive and manipulative. [resident 49] has a history of [CONDITION(S)], but has not reported any recently. He is being followed by [name of mental health provider], and participates in visits. [Resident 49] was also recently in trouble with the law, and is ordered to take anger management classes. He is actively working on setting up those classes, along with taking online collage (sic) courses. Ra offers help and will assist him when needed. [Note: Per review of the EMR, resident 49 had only seen his mental health provider on 4/9/21, 5/11/21, and 6/3/21. In addition, no evidence of the anger management courses could be located in resident 49's EMR.] On 7/7/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 7/14/21 at 1:08 AM, a nursing progress note indicated that at 8:00 PM on 7/13/21, Aide was unable to enter Res room d/t it being blocked from the inside. Writer knocked on door and heard Res say wait, writer waited and asked him to open the door. Res did not open the door and writer walked through the bathroom door into his room. Res was hovering over a tissue. When writer lifted tissue a white substance was found and when asked Res what it was he stated it was salt I notified him that I was removing it from his room and that I would have it verified. Non emergency number was called to get a confirmation of the substance as well as disposal. MD/NP and Proper administration notified per facility protocol. Administration notified family. All meds were placed on hold per MD/NP. It was confirmed that it was illicit drugs. [at 8:15 PM] 7/13/21 Res went to the smoking area. [at 8:18 PM] Another Resident came to notify writer that he left facility through the back gate. Two aides went out to look for him but were unable to find him. [at 11:05 PM] Police were notified of Res not returning to facility. Police located him . in the entrance of a complex. He stated his chair had no battery and he had told police he was high and hallucinating. On 7/14/21, a physician note documented that she saw the resident for a follow up visit due to resident 49's history of leaving the premises. The physician documented that resident 49 was not very talkative, does not want to have conversation about his drug use Drug use- pt used party ball with meth, heroin and potentially other substances as well - briefly discussed, pt states he had none to bring back here and has not used any since his was out . does not appear in any imminent danger to himself or others. On 7/15/21, a nursing progress note was entered indicating that resident 49 was intentionally banging head against wall and trying to throw himself on the floor. Nursing wrned (sic) him of risk of self injury, wctm (will continue to monitor). On 8/12/21 at 12:47 AM, a nursing progress note indicated that the nurse was called by a local deputy office around 9 pm. Patient was found in field, with knife in his possession, had fallen out of his wheelchair and been on the ground for an unknown amount of time. They admitted [name of resident] for 24 hrs with a pink slip to the local . hospital, noting he was a danger to himself. I was contacted later by the social worker, .[the social worker] called back and stated [resident 49] had been medically cleared and that we had to readmit him to the facility tonight. They didn't run a tox (toxicology) screen on him. Our administrator states he is evicted and can no longer return. Social worker states we have to take him back and I referred her to our administrator to clarify that we would not accept him back. If social worker calls back, please refer them to our Administrator and do not take patient back. Social worker called again and stated we have to take him back. I told her they would need to contact us in the morning and that we cannot take him tonight. She will tell us we have to take him back. [Note: No hospital documentation was included in resident 49's EMR to indicate what the hospital's findings and/or recommendations were upon discharge.] On 8/12/21 at 5:27 PM, a nursing progress note indicated that resident was admitted back in today with a 30 day eviction noticed (sic). PT was found in . in a field stuck with a knife. He was sent to the hospital and pinked slipped for suicidal ideation. He was cleared with a clean bill of health. Labs were good and his drug screens came back negative. So they sent him back. His assessment was good nothing abnormal was found. everything was with in range. On 8/16/21, a facility physician evaluated resident 49 and stated that the resident reportedly left the facility, purchased a knife and attempted to stab himself. Resident 49 denied the suicide attempt to the physician, stating that he bought the knife to go fishing. On 8/18/21, a facility physician evaluated resident 49 and stated that the resident refuses psychiatric outpatient care. On 8/27/21, a History and Physical was completed by a hospital physician for resident 49. The hospital notes indicated that on 8/20/21, resident 49 was pink sheeted to the hospital because he eloped from the nursing home and his electric scooter and drove up to the ninth floor of a parking structure where he was attempting to throw himself off in a suicide attempt. Police intervened and brought him to the hospital. Per the report, pt was combative with police who were pulling him away from the edge of the building . Pt reports feeling acutely suicidal for the past few weeks and that tonight is his 2nd suicide attempt this month. Pt states he 'planned every second' of the attempt and made sure no one at his care center knew. Pt states I had it. and they took it away from me, meaning, he was almost successful in ending his life and the police took that peace away from him. Pt reports feeling frustrated about his quality of life and that he has no reason to live. Pt is frustrated his plan was interrupted and still wishes to die. Pt will require IP (inpatient) psychiatric admission for stabilization. The resident was subsequently hospitalized and then transferred to a behavioral health bed at a different hospital for further assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes documented that when another provider at the hospital saw resident 49, he states he has been having suicidal ideation for the last few weeks and this is his second attempt to kill himself in the last month. Evidently he left the care facility and was headed towards a lake in order to drowned (sic) himself before and was seen in the ER (emergency room ) and then sent back to the care facility. the patient endorses depressed mood, low interest, loss of pleasure, feeling hopeless and worthless, isolative behavior, and has suicidal but no homicidal ideation. The hospital notes indicated that the resident had been scheduled for an involuntary commitment hearing. The hospital notes indicated that The nursing facility also said they are going to increase his supervision where he will not have any opportunity to go out on his own for instance. [Note: There were no notes entered into the resident's EMR regarding this event. The resident was readmitted to the facility on [DATE].] Per review of the care plan, when the resident returned on 9/1/21, the exact same interventions were included in the anxiety, depression and PASRR Level II care plans for resident 49 that had been in place prior to the resident's hospitalization . On 9/3/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 9/6/21, facility staff completed a Psychosocial Review for resident 49. The review indicated that the resident had experienced [CONDITION(S)] in the past and could be manipulative. The review also documented that the resident had been verbally aggressive and treatening (sic) towards staff. The Special Concerns and Recommendations included: make sure resident had access to media and his phone, staff would help with redirection and validation, and staff would monitor the resident's mood while keeping administration updated. [Note: This was only one of two psychosocial reviews completed for resident 49 during his 13 month stay, despite ongoing behaviors and increasing suicidality.] On 9/8/21, resident 49 had an updated PASRR level II completed. The updated PASRR indicated due to the resident's recent suicide attempt and hospitalization , a significant change PASRR evaluation was completed. The PASRR documented, When asked about why he left the care center and went to the parking structure in his suicide attempt . He stated that he got to the point where he felt that 'I had no choice but to try and kill myself' as dying by natural causes would 'take too long'. he feels he would benefit from increased frequency of counseling and maybe a [CONDITION(S)] medications review as he's not sure how much his [CONDITION(S)] medications are helping. He reports poor sleep . he only eats one meal a day . He tends to isolate in his room . he stated he tried to go to SNF activities but didn't fond them enjoyable. The PASRR listed the following recommendations for mental health treatment: He should be monitored closely for any means for self-harm given his multiple suicide attempts. He should be referred for increased mental health services from his outpatient mental health treatment providers at [name of mental health provider]. This can hopefully help him him learn better coping skills. He was getting treatment from [name of mental health provider] at his prior SNF. On 9/14/21, the facility RA entered a progress note indicating that resident 49 at times he can be verbally aggressive, impulsive and manipulative. [Resident 49] has a history of [CONDITION(S)], and was recently hospitalized twice due to having those thoughts. When [resident 49] returned from his last hospital stay he stated that he feels much better. He is being followed by [name of mental health provider] . He is actively taking online collage (sic) courses. Ra offers help and will assist him as needed. Care plans reviewed. [Note: No documentation could be located in resident 49's EMR to indicate he had been seen by his mental health provider since 6/3/21.] On 10/7/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. LCSW Consultant notes for October 2021 were reviewed. No recommendations were documented with regard to resident 49. On 11/8/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. LCSW Consultant notes for November 2021 were reviewed. No recommendations were documented with regard to resident 49. LCSW Consultant notes for December 2021 were reviewed. No recommendations were documented with regard to resident 49. On 12/1/21 at 5:26 PM, a nursing progress note indicated that resident 49 complained to the nurse that he didn't want a roommate. Resident 49 stated he doesn't want to have to share and that there's limited space for the 2 of them to share. res then asked if he doesn't get moved then he will just have to handle him. asked res what he meant by handle him, res refused to say the meaning behind his statement. res encouraged to try to get along with roommate and management team will look for further ability to move either resident into better accommodations, told res to be patient . On 12/6/21, the LCSW Consultant entered a progress note indicating that she had reviewed social service documentation. The note did not indicate what, if any, recommendations she had for the resident's mental health needs. On 12/8/21, the RA documented that resident 49 can be verbally aggressive, impulsive and manipulative. [Resident 49] has had a few verbal and physical encounters with other residents this quarter. Patient is being followed by [name of mental health provider] and is working on his anger issues and how to deal with situations more appropriately. [Note: No documentation could be located in resident 49's EMR to indicate he had been seen by his mental health provider since 6/3/21.] On 1/6/22, a facility physician evaluated resident 49, after the resident requested a visit related to his anger. States that he has been having a hard time w (with) his temper. Having visual and auditory hallucinations - states is currently clean but used drugs as recently as December 5th. States that voices are telling him to kill himself or others. I really just want to feel like myself again . hallucinations. recent drug use likely contributing. Has had recent psych stays within the last 2 years, last from attempting to drive wheelchair off parking structure. Discussed that I am concerned about his health patient agrees. Sending for acute psych evaluation patient agrees that this is for the best tonight and hopes for help . During conversation tonight, patient revealed 2 knives attached to wheelchair. He voluntarily surrendered them to me. Following this, he continued to express desire to seek help in order to feel like himself and get hallucinations to stop. He agreed to voluntarily be transferred for inpatient psychiatric evaluation. Facility administration notified regarding findings of weapons within the facility. Hospital notes dated 1/6/22 for resident 49 were reviewed. Per the documentation, resident 49 initially presented to a local hospitalER on [DATE], was subsequently evaluated and stayed in the ER until 1/8/22. The ER notes indicated that the resident started feeling more depressed this (sic) just before the holiday, got hit by a car over his left foot just after the holiday resulting in an injury and a fracture which is hurting him. He is not in any sort of splint is wondering if that might help. Will go ahead and provide this for him. With regards to his depression he says like (sic) he is hearing voices and he is not sure whether people that were residence (sic) at the care facility are talking to home (sic) or whether it is voices and they are making him more depressed and want to kill himself. He was found at the home tonight with knives apparently threatening suicide and therefore is transported to our facility. Patient seen evaluated (sic) by crisis. He continues to endorse SI. Recommends admission . A psychiatric evaluation completed on 1/6/22 for resident 49 while at the hospital revealed that the resident had depression, disorganized thought processes, hallucinations and suicidal thoughts. The evaluation also indicated that the degree of incapacity was severe and had been worsening. The documentation also revealed that on 1/8/22 Patient had been in the emergency department for approximately 2 days and was discharged about 1 hour ago. He was originally seen for suicide and possible homicidal ideation at his care facility. He was evaluated by crisis on 2 separate occasions. He was deemed appropriate to be discharged back to his facility . It was reported when he got to the facility that the facility did refuse to let him back in because they were concerned he would be unsafe. Therefore, patient brought back to the emergency department. I did attempt to contact his care facility but was unable to reach anyone. Per the hospital notes, the facility agreed to readmit the resident on 1/11/22. On 1/14/22, the LCSW consultant documented that she completed a thorough review of [resident 49's] chart and revised care plan accordingly. Follow up recommendations made to facility. [Note: The recommendations could not be located in the resident's EMR. In addition, the LCSW consultant notes for the month of January 2022 were reviewed. The LCSW consultant did not document anything in her notes with regard to resident 49.] On 1/16/22 at 1:44 PM, resident 49's Psychosocial Review documented that the resident was sent for a psychiatric evaluation for SI and Homicidal Ideation. The review documented that resident 49 appeared alert and oriented to person, place and situation. Resident 49's short term memory and long term memory appeared intact but resident 49 exhibited impaired decision making skills. Resident 49's mood was documented as agitated with SI/HI and visual and auditory hallucinations. The review documented that resident 49 was refusing his medication. Special Concerns and Recommendations included: to make sure he had access to media and his phone, monitor resident to make sure he did not have anything he could hurt himself with, take one on one time with the residents he could voice his feelings, and keep administration up to date with any mood changes in resident 49. [Note: This was only one of two psychosocial reviews completed for resident 49 during his 13 month stay, despite ongoing behaviors and increasing suicidality.] LCSW consultant notes for February 2022 documented that I did not provide an audit on social service documentation as there is no resident advocate or social worker in the facility at present. The February notes for the LCSW did not include any recommendations with regard to resident 49. On 2/7/22 at 6:37 AM, a nursing progress note for resident 49 revealed that Resident left the facility at [4:15 PM]. A good samaritan called this writer on the nurse's station to let us know the resident's location. He was at the [gas station]. The resident's powered wheelchair is dead. He reported the resident is cold and he provided him a blanket. He also stated that the resident has 2 knives, bought by resident from [a local store]. Resident was dropped off to the facility by EMS (emergency medical services) at [1:00 AM], EMS reported that he brought out his knives when the EMS was trying to pick him up. EMS reported that he looked upset and seemed did not want to go with them or go back to the facility. Police was called. Police reported that they have a camera footage of the resident being violent and used the knife against his own throat and he also used it to threatened (sic) them. Police confiscated the knife. Police stated that if he might do this again, Administration should take away his [electric wheelchair] and keep him in the facility. On 2/16/22 a nursing progress note documented that PT threatened that he would become violent and told me I didn't know what he was capable of if I didn't give him his pills. I informed patient I have to follow the rules and he is aware that he is not allowed to leave facility grounds w/out being accompanied by somebody. Pt started yelling at staff and then went to the second floor to go smoke. On 2/20/22, nursing notes indicated that the resident left the facility without notifying staff. As of 5:30 AM on 2/21/22, the resident had not returned to the facility. There is no documentation indicating when resident 49 returned to the facility. LCSW Consultant notes were reviewed. In March 2022, the LCSW documented Resident leaves facility without assistance frequently, even goes to shop at [local store]. Is he appropriate for skilled facility placement? We should evaluate him to see if he qualifies to stay. No documentation was located with regard to recommendations for resident 49's behaviors by the LCSW during that month. On 3/23/22 at 6:18 AM, Res was asked to remove himself from another residents room d/t the roommate feeling uncomfortable having him there. Res was non compliant and continued to stay in room. Res was informed that his actions were unacceptable and he needed to leave the room and since the residents of the room were no longer in the room he needed to come out. He became verbally loud and came out yelling shut up [OBSCENITY] ! Res went into his own room and went on his computer. Appropriate staff informed of incident. On 4/7/22, nursing notes indicated that resident 49 was asking administration personnel for his knife from the lockbox. The notes also indicated that the resident became combative and staff wheeled him away before he was able to cause any physical harm. Police were called and arrived promptly to the scene. The situation was resolved without harm to residents or staff. On 4/8/22 at 5:50 PM, nursing notes indicated that resident 49 told the nurse to give him something to sleep or he would cut himself. The resident was subsequently placed on 15 minute checks. On 4/8/22 at 10:17 PM, a facility physician evaluated resident 49 and stated that the resident indicates that he is struggling emotionally. Is amendable/willing (sic) to see a professional via admission to ER for eval. On 4/9/22 at 1:34 AM, nursing notes indicated the following: On 4/8/22 at [10:17 PM] assisted [name of nurse practitioner] with a phone call with the resident. (See NP note.) Pt stated he had [CONDITION(S)] and felt anxious and would like to talk to someone. Resident requested to be sent to the hospital. Informed resident an ambulance would be called and resident stated he would like to remain on the patio so he could smoke before he left. At [10:25 PM] ensured the gate was closed and latched. 2 CNA's were on the patio. Informed one of the CNA's that I needed to notify EMS and coordinate wit [TRUNCATED]

Based on interview and record review it was determined for 4 of 51 sample residents that the facility did not obtain laboratory services to meet the needs of its residents. Specifically, resident had orders to obtain lab draws that were not completed. The findings for resident 61 were determined to have occurred at a harm level. Resident identifiers: 2, 17, 30, and 61. Findings include: HARM 1. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/13/22, resident 61's medical record review was completed. On 1/6/22 at 11:00 AM, resident 61 had blood drawn for laboratory tests. On the results, a note was written that resident 61 needed a follow up BMP (basic metabolic panel) completed in 1 week with a noted date of 1/12/22. Resident 61 had a white blood cell count of 11,300, with high neutrophils and immature granulocytes. Resident 61's alkaline phosphatase (Alk Phos) level was high at 169 (normal 40-120) and additional abnormal levels were low sodium, low chloride, high glucose, high BUN (blood urea nitrogen), low [MEDICATION(S)], and high AST (liver enzyme). Nursing notes did not demonstrate that resident 61 had this laboratory work completed. Additional documents for resident 61 did not reveal laboratory results between 1/6/22 and 1/23/22. Laboratory results were obtained through a STAT (immediate) order on 1/23/22 after resident 61 declined. Results were faxed to the facility on [DATE] and were not reported to the physician. Resident 61's results were reported to the physician on 1/24/22 and resident 61 was taken to the emergency roiagnom on [DATE]. On 1/24/22 at 1:32 PM, a regional hospital Emergency Documentation was initiated for resident 61. The documentation revealed that resident 61 had chief complaints of: a. altered level of consciousness b. high heart rate c. not looking to the right He apparently was acting abnormally this morning according to rehab facility staff but what that means is a little bit unclear. He was transported and there was no mention of increased work of breathing or [CONDITION(S)] I was called to the room because of high heart rate and tachypnea (rapid breathing). Looks like he is in [CONDITION(S)] with RVR (rapid ventricular rate of response) but does not endorse any chest pain at all. He is noted to be with a right-sided neglect. No known vomiting. Given patient status no other history was obtained. Stroke 1 is called. Meds ordered for his high heart rate. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. initiation of end-of-life care b. septic shock c. [CONDITION(S)] d. [CONDITION(S)] e. acidosis f. superobesity g. diabetes h. strokelike syndrome i. [CONDITION(S)]/[CONDITION(S)] Medical decision making/differential Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . He presented with [CONDITION(S)], some altered mental status, rapid heart rate with what looked like new onset [CONDITION(S)] (fluttering atria of the heart). He is also quite tacypneic. He already had leuckocytosis yesterday at 26,000. Today it climbed to 32,000. I think this clinical picture was strongly suggestive of septic shock and overwhelming [CONDITION(S)]. His sacral area wound showed a large area of ecchymosis and [CONDITION(S)] and some purulent drainage from the central portion of the ulcer. He seemed to medically stabilize early on but then after resuscitative efforts were towards the tail and the patient actually worsened in status. Long discussion was held with numerous family members .he became medically unstable and worse over time despite antibiotics fluids respiratory support no other [CONDITION(S)] treatment measures. I did not see any obvious reasons to counter patient and family wishes and initiating end-of-life care. The massive area of skin and soft tissue infection with ulceration was the likely source of his infection and massive debridement would be necessary . The course of treatment in the Emergency Department included . Required supplemental oxygen. [CONDITION(S)] protocol enrollment with treatment provided. In addition neurology consultation was required early on given concerns for potential stroke. [A neurologist] did not feel that the patient was under going a stroke syndrome Thereafter [CONDITION(S)] treatment was the focus We evaluated the wound on his backside and it was massive encompassing a large territory of the entire lower lumbar and sacral region with a draining wound and a lot of surrounding necrotic tissue with [CONDITION(S)] extending down to the perineum without obvious drainable abscess. Shortly after evaluating this wound the patient became diaphoretic and more short of breath but remained lucid. Additional oxygen was provided. We had discussed at this point in time about focus of treatment and goals of treatment . An arterial blood gas (ABG) was obtained and resident 61 had worsening acidosis Patient progress towards severe illness and end of life pretty quickly at around 5:30 PM, resident was noted to have agonal respirations and confirmed at this time if we do not act patient will certainly die soon. Again there was consensus with family members present to proceed with comfort measures and monitors were turned off and high flow oxygen was turned off along with vasopressors. Family gathered at the bedside and said their goodbyes and time of death was estimated to be at 6:10 PM. On 3/24/22 at 11:31 AM, a former DON, DON 2, was interviewed. DON 2 stated that resident 61 had a pretty serious tunneling wound that no doctor had examined while resident 61 was in the facility. DON 2 stated that resident did not have orders provided by any clinician, and that wound care orders were generated by the wound nurse (now the ADON). DON 2 stated that resident 61 did not have laboratory tests drawn and wound care was not provided as needed. DON 2 stated that resident 61 never went to wound clinic. He went to the hospital, went septic, and started crashing. On 3/29/22 at 10:10 AM, the ADON was interviewed. The ADON stated that resident 61 had an insurance that required him to go out to a specific wound clinic, but resident 61 was not able to be sent out to the clinic. The ADON stated that no physician followed resident 61's wound. The ADON stated that she did not know why the laboratory orders were not entered in the computer, and therefore nurses did not draw the labs. The ADON stated that I was just doing the best I could as the wound nurse. The ADON stated that the providers wouldn't give an order without seeing resident 61. The ADON stated that there was so much agency in the building, there were a lot of things they didn't get around to doing. On 3/29/22 at 12:42 PM, the Corporate Resource Nurse (CRN 1) was interviewed. CRN 1 stated that the wound nurse was responsible for communication with the wound care providers and physicians. CRN 1 stated that the wound nurse (now the ADON) would look at wounds and show them to the physicians. CRN 1 stated that the ADON requested orders from physicians, and would enter orders in the computerized record. CRN 1 stated that sometimes the orders were not transcribed into the computerized system, and therefore were missed. CRN 1 stated that she was not aware if physicians created the orders or signed the orders after the fact. CRN 1 stated that there was no evidence that the laboratory order for resident 61 on 1/12/22 was completed. On 3/29/22 at 1:32 PM, the Administrator (ADM) was interviewed. The ADM stated that the former DON (DON 1) was working on resident 61's insurance. The ADM stated that she assumed that a doctor was following resident 61's wounds, and that the wound nurse would take care of that. The ADM stated that she was not aware of required laboratory tests, and had to rely on the nurses for those. The ADM stated that when staff determined that resident 61 had a change of condition, he was sent out. On 3/30/22 at 12:26 PM, an interview was conducted with Medical Provider (MP) 1. MP 1 stated that resident 61 did not have the ordered tests drawn by the facility. MP 1 stated that when the physician's group was notified of the results, resident 61 was sent out immediately to the hospital, but it was too late. On 04/4/22 at 12:10 PM, the Administrator was re-interviewed. The ADM stated that she had assumed the physician would check on resident 61. The ADM stated that when resident 61 went to the hospital with [CONDITION(S)], she did not complete an analysis of what staff might have done to prevent the hospitalization . The ADM stated that she had not completed an analysis of identifying residents' change of condition timely. The ADM stated that staff were not always very talkative during morning meetings, and she was not clinical, so sometimes she didn't know what was happening with the residents. On 4/11/22 at 12:20 PM, the ADON was re-interviewed. The ADON stated that prior to the last two weeks, she was acting as the wound care nurse in the building. The ADON stated that her responsibilities as the wound nurse (WN) was to assist the provider on Thursdays with wounds, new orders, and at times, she was also fulfilling the role as a floor nurse. POTENTIAL FOR HARM 2. Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's medical record was reviewed between 3/23/22 and 4/13/22. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. 10/6/21 - CBC, CMP and ammonia level. Review of the EMR revealed that the CBC and CMP were not drawn as ordered. b. 11/9/21 - CBC and CMP. Review of the EMR revealed that the physician signed to indicate he had review the labs, and indicated that the labs were to be rechecked in two weeks. However, the facility staff did not recheck the CBC. c. 2/1/22 - CBC and CMP. Review of the EMR revealed that the labs were not drawn as ordered. d. 2/9/22 - STAT CBC, CMP, erythrocyte sedimentation rate (ESR), and C-Reactive Protein (CRP). Review of the EMR revealed that the labs were not drawn as ordered. e. 3/10/22 - CBC, CMP, and ammonia level. Review of the EMR revealed that the labs were not drawn as ordered. In addition, a physician note on 3/10/22 documented check CBC, CMP in AM - not completed at last visit - please complete today. [Note: No order had been entered to check the CBC and CMP between 2/9/22 and 3/10/22.] f. 3/16/22 - CBC, CMP and ammonia level. Review of the EMR revealed that the ammonia level was not drawn as ordered. 3. Resident 30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 30's medical record was reviewed between 3/23/22 and 4/13/22. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. 1/18/21 - Hemoglobin A1c every 6 months. Review of the EMR revealed that the lab had not been drawn since 7/19/21. b. 1/18/21 - Lipid panel every year. Review of the EMR revealed that the lab had not been drawn since 2019. On 3/30/22 at 1:00 PM, an interview was conducted with Medical Provider (MP) 3. When asked about the process for obtaining labs, MP 3 stated that she would complete her rounds, and then check in with the floor nurse and go through any new orders for residents. MP 3 stated that the nurse would write those on a paper and then enter them into the EMR. MP 3 stated that uncertainty of whether a lab was going to be completed as ordered directly impacted her decisions about which medications a resident was prescribed. MP 3 stated that she had identified a concern with labs not being completed as ordered. MP 3 stated that over the fall and winter, there were many times when the order for a lab was not entered into the EMR. On 3/29/22 at 11:10 AM, an interview was conducted with the ADON. When asked about staffing levels, the ADON stated Theres so much agency, that we have to go back and do the assessments that the agency nurses did not know how to complete. The ADON stated that because of that, labs were being performed as ordered sometimes as well. 4. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/2/22 resident 17's medical records were reviewed. On 12/2/21 at 6:40 PM, the nurse documented that the Nurse Practitioner (NP) gave new orders for a Complete Blood Count (CBC), a Basic Metabolic Panel (BMP), and a Urinalysis (UA). No documentation could be found in resident 17's medical records of the laboratory results for the UA that was ordered on 12/2/21. On 4/11/22 at 10:08 AM, an interview was conducted with Certified Nurse Assistant (CNA) 11. CNA 11 stated that she was familiar with resident 17 and had provided her with care previously. CNA 11 stated that resident 17 was incontinent of bowel and bladder and wore briefs. CNA 11 stated that resident 17 produced regular amounts of urine output. On 4/11/22 at 1:21 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the process for obtaining labs was that the floor nurse would put the order requisition into the electronic medical records and if it was a stat order the nurse would obtain them immediately. The ADON stated that when the results were obtained from the laboratory, she would take a picture of it and send it to the doctor, or the provider could access the results through the laboratory portal. The ADON stated that the provider would confirm that they received the results, either verbally or by secure message, and then she would note the date and time. The ADON stated that the results would then go to medical records to be scanned into the resident's chart. The ADON stated that for any abnormal lab values the doctor should be notified immediately. The ADON stated that if the laboratory called with a critical lab value, then they notified the doctor right away. I notify of any preliminary lab results also. The ADON stated that the licensed nurse should chart that they notified the doctor of the labs in the progress notes.

Based on interview, observation, and record review it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible. Specifically, hot water temperatures in 8 resident rooms throughout the facility were observed to range in temperatures from 137 degrees to 150 degrees Fahrenheit. The deficient practice identified, in regards to the hot water, was found to have occurred at an Immediate Jeopardy level due to the potential risk of scalding and 3rd degree burns to the residents residing within the facility. Additionally, chemicals were observed to be left unattended and unsecured in the facilty beauty shop. The deficient practice identifed, in regards to the chemicals, was found to have occurred at a potential for harm and will not be included in the Immediate Jeopardy. Resident identifier: 98. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on 7/31/13 at 3:00 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to hot water temperatures. PLAN: On 8/5/13 at 1:50 PM, the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated August 5, 2013 stated the following: "State of Utah Department of Health 288 North 1460 West P.O. Box 3 Salt Lake City, UT Amendment of Abatement Request RE: Immediate Jeopardy Spring Creek To Whom It May Concern: On July 31st Spring Creek Healthcare Center was placed in an Immediate Jeopardy situation due to elevated water temperatures that were found within the facility. By 6:30pm on July 31st the facility had taken the necessary actions to correct the unsafe water temperatures in the building and a process had been implemented to monitor and ensure water temperatures remained safe for all of our residents. Thus we are requesting the IJ (Immediate Jeopardy) be abated as per our initial request dated July 31 at 6:30 PM. In summary, the facility completed the following tasks in order to correct newly found high water temperature findings: ? Facility has maintained water temperatures at a safe temperature < (less than) 120 degrees since original finding and has monitored water temperatures in order to ensure safe temperatures are present. All temperatures have been found at safe levels. ? Facility has in-serviced employees on proper water temperature and proper reporting should temperatures appear to be hotter than normal. ? Facility replaced tempermatic control valve, which regulates water temperature. This took place at about 4:30pm on the 31st of July. ? Recalibration of tempermatic valve is necessary to obtain required safe water temperatures and has been adjusted as per need requires. ? In an effort to be proactive and ensure facility did not have any additional concerns; H&H Boiler Services was called on Thursday, 8/1/2013, to provide preventive maintenance to the boiler to prevent the system from short cycling. Routine cleaning was performed on the boiler system and found to be in working order. Note: in order to complete routine maintenance the boiler system was shut down from 2:30 PM to 4:40 PM. Please feel free to contact Sean at H&H Boiler Company at (801) [PHONE NUMBER] to confirm that they were called to provide preventative maintenance to our system.) No work was provided on the tempermatic control valve at that time. ? Water temps continued to be monitored every hour throughout the night of Thursday, 8/1/13 and every 4 hours or as needed throughout Friday, 8/2/13, Saturday, 8/3/2013 and Sunday, 8/4/2013. As with any new equipment, adjustments were being done accordingly with any water temp fluctuations. While adjustments were being made, water temps were never found to be at an unsafe level. ? Maintenance department and facility staff will continue to monitor as needed and will report findings to the QA (Quality Assurance) committee for further review and recommendations if needed. We appreciate the opportunity to ensure that we provide a safe environment for each of our residents and feel the above indicates that we are doing this appropriately." Prior to leaving the facility on 8/5/13, the surveyors confirmed the components outlined above in the written plan of action had been implemented. During the survey on 8/5/13 the surveyors confirmed removal of the Immediate Jeopardy situation as of July 31, 2013. Deficient practice with the potential for more than minimal harm remained for the risk of injury. Findings include: Immediate Jeopardy: A. On 7/31/13 at 12:15 PM to 12:45 PM, hot water temperatures were checked in resident rooms. The following water temperatures (all temperatures are listed in degrees Fahrenheit) were observed: 1. Room 320 - 145 degrees 2. Room 309 - 137 degrees 3. Room 307 - 145.6 degrees 4. Room 306 - 147.3 degrees 5. Room 207 - 150 degrees 6. Room 202 - 148.9 degrees 7. Room 212 - 149.3 degrees 8. Room 215 - 142 degrees The above listed temperatures were taken with both a digital and analog thermometer in the presence of two surveyors. On 7/31/13 at 12:50 PM, the facility Maintenance Assistant (MA) was interviewed. The MA stated that the facility Maintenance Supervisor (MS) had been spending one week in the facility and another week at a different building that was being remodeled. The MA stated that the water temperatures in resident rooms were checked on a weekly basis. The MA stated that the facility water heater temperatures had not been checked for the last two weeks. The MA further stated that the water heater temperatures should be 120 degress and the water in resident rooms should be 115 degrees. On 7/31/13 at 1:00 PM, observations were made of the facility water heaters. Observations revealed that storage tank #2 (water heater for the 2nd floor) read 150.8 degrees and storage tank #1 (water heater for the 3rd floor) read 149.3 degrees. Additionally, a sticker with the following information was observed on the water heater: "Caution, water above 120 degrees can cause scalding and 3rd degree burns in children and the elderly." The MA was interviewed directly after the water heaters were observed. The MA stated that he did not know why the storage tanks were measuring that high or how the water temperature got that high. The MA further stated that there was not a thermometer past the mixing valve. The MA stated that in order to adjust the water in the mixing valve a valve labeled "hot" or "cold" was turned to adjust the temperature. On 7/31/13 at 1:10 PM, the following temperatures, in resident rooms, were taken with the MA's digital thermometer, in the presence of the MA: 1. Room 207 - 150.5 degrees 2. Room 202 - 144.1 degrees 3. Room 212 - 142.2 degrees 4. Room 306 - 143.6 degrees 5. Room 307 - 137.9 degrees 6. Room 309 - 138.2 degrees After the temperatures had been taken in the resident rooms, the MA stated that he was not sure why the water was getting "so hot". The MA further stated that he would need to go turn down the temperature on the water heaters. On 7/31/13 at 2:40 PM, a Maintenance Supervisor (MS 2), who came to the facility at the request of facility staff, was interviewed. MS 2 stated that there was a thermometer after the mixing valve. MS 2 stated that when he got to the facility he had checked the temperature on the mixing valve and the temperature had been 120 degrees. MS 2 stated that the temperature on the thermometer was taken after the MA had turned the temperature down on the water heaters. On 7/31/12 the Maintenance temperature logs were requested for review. Review of the temperature logs revealed that the water temperatures for resident rooms, shower rooms, and the water heaters labeled "Storage Tank # 1" and "Storage Tank # 2" were checked on 7/12/13, 6/24/13, and 5/15/13. No other documentation could be found to show that the water temperatures had been checked more frequently or weekly as stated by the MA. No documentation could be found to show that facility staff were checking the temperature on the thermometer above the mixing valve. On 7/31/13 at 12:30 PM, resident 98 was interviewed. Resident 98 resided in room 307. Resident 98 stated that the water in the bathroom was hot. Resident 98 stated that he had to turn the cold on because the water would get too hot. On 7/31/13 at 12:14 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that the cold water had to be mixed with the hot water or the residents in the facility would get burned. RN 1 stated that there were several residents who could wash their hands independently and not know to turn the cold water on with the hot water. On 7/31/13 at 1:09 PM, Certified Nursing Assistant (CNA) 4 was interviewed. CNA 4 stated that the hot and cold water had to be mixed in the shower room. CNA 4 stated that if the water was turned all the way to hot, the water was too hot and the water could not be touched. On 7/31/13 at 1:02 PM, CNA 6 stated the facility water had been hot since March. CNA 6 stated that the staff could not just leave the hot water on or "It's extremely hot." On 7/31/13 at 5:00 PM, the facility Maintenance Supervisor (MS 1) was interviewed. MS 1 stated that he only checked water temperatures once monthly because the facility had never had an issue with hot water. The MS 1 stated that the mixing valve could go out at anytime but he had not had any indication that there was a problem. The MS 1 stated that the last time the water temperatures were checked was two weeks prior. Potential for more the Minimal Harm: B. On 8/6/13 at 8:55 AM, an observation was made of the unlocked beauty shop. Sitting on top of the shampoo sink countertop were 2 glass cylindrical containers. A blue colored substance and combs were observed in the glass cylindrical containers. The containers were labeled with (product name), a "fungicide" and "virucide", or a chemical used for disinfecting salon tools such as combs and brushes. Additionally, a cabinet under the shampoo sink was observed to be unlocked. The cabinet contained the following items: 1. A 16 oz. (ounce) bottle which was 1/3 full of a liquid substance. The label on the product revealed it was a neuralizer used follwoing permanent wave solution. 2. A 64 oz. bottle labeled (product name) a "fungicide" and virucide" or chemical used for disinfecting salon tools. The bottle appeared to be approximately 1/3 filled. 3. A 32 oz. plastic bottle of (name of product) a cleaner and disinfectant. The label on the cleaner revealed "keep out of the reach of children." A note was observed to be posted on the wall of the beauty shop, by the light switch. The note revealed, "Attention: Lock the door." At 9:05 AM, an interview was held with CNA 4. CNA 4 stated the door to the beauty shop should be closed and locked. At approximately 9:15 AM, an interview was conducted with the ADON (Assistant Director of Nursing). The ADON stated the door for the beauty shop should be kept closed and locked.

Based on interview and record review it was determined, for one sample resident, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care. Specifically, facility staff did not coordinate pain medication dosages with the different physicians the resident was being seen by, and the facility did not give the resident her prescribed pain medication resulting in the resident having increased pain. Resident identifier: 61. Findings include: Resident 61 was admitted to the facility on [DATE] and discharged on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/11/12 resident 61's medical record was reviewed. Review of the medical record revealed an admission Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed resident 61 as having high cognition with a Brief Interview for Mental Status score of 14, resident 61 had pain "constantly" making it hard to sleep and resident 61's pain score was 8. No documentation could be found to show facility staff completed a pain assessment upon admission to the facility. Facility staff did not complete a pain assessment for resident 61 until 1/5/12. Review of the medical record revealed a care plan for pain dated 11/2/11. Facility staff documented that resident 61 had pain related to "neuropathies, a history of neutropenic fever, [MEDICAL CONDITIONS], chronic pain and wounds." Facility staff documented on the care plan that the goals of the care plan were for resident 61's pain to be relieved 30 to 45 minutes after medication was administered, resident 61 would be comfortable using non-pharmaceutical methods to control pain daily, resident 61 would demonstrate effective coping strategies daily, resident 61 would participate in ADLs (Activities of Daily Living) daily, and resident 61 would not experience any adverse side effects from medications daily for 3 months. It was documented on the care plan that resident 61 was to accomplish the goals by facility staff, "administering medication as ordered and observing for side effects and effectiveness of medication" and facility staff were to, "evaluate verbal and nonverbal cues of resident to assess degree and severity of pain." Review of the physician's orders [REDACTED]. On 12/22/11 facility staff received a physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. On 1/11/12, the December 2011 Medication Administration Record (MAR) and Controlled Drug Record for [MEDICATION NAME]es were reviewed for resident 61. The MAR indicated resident 61 received a 100 mcg [MEDICATION NAME] on 12/22/11. On 12/25/11 [MEDICATION NAME] 100 mcg was initialed and circled. No documentation could be found to show if facility staff administered the [MEDICATION NAME] to resident 61. No documentation could be found on the Controlled Drug Record to indicate the [MEDICATION NAME] was administered to resident 61. On 1/12/12 the facility Director of Nursing (DON) reviewed the MAR and Controlled Drug Record. The DON confirmed that the documentation on 12/25/11 did not indicate that the [MEDICATION NAME] had been administered. On 1/12/12 the DON was interviewed. The DON stated that the 100 mcg patch ordered by the physician was not available so the facility administered a 75 mcg patch to resident 61 on 12/28/11. (Note: Resident 61 went 3 days, 12/25/11, 12/26/11, and 12/27/11 without the [MEDICATION NAME] for pain control.) The DON further stated that the 100 mcg patch was ordered by the physician but the order had not been signed and the facility was waiting for the Nurse Practitioner to sign the order. The DON further stated that the same issue had occurred in January of 2012 and the facility had gotten the prescription from a nearby pharmacy. The DON stated that if the nurse had informed her of the facility not having the 100 mcg patches she would have instructed the nurse to get the prescription from the nearby pharmacy. On 1/9/12 resident 61 was interviewed. Resident 61 stated that between 12/25/11 and 12/31/11 the facility did not have the right dose of [MEDICATION NAME] for her. Resident 61 stated that when she did not receive the correct dose of medication she would hurt more and her body would go into spasms. Resident 61 stated she had muscle pain and [MEDICATION NAME] did not work for muscle pain. On 1/12/12 at 9:54 AM, resident 61 was again interviewed. Resident 61 stated that she had pain 24 hours a day, 7 days a week. Resident 61 stated that when it took 5 days to change the [MEDICATION NAME] orders in December 2011, "it about killed me, my pain is in my joints and [MEDICATION NAME] doesn't help with muscle pain." Reveiw of facility Progress Notes revealed the following entries: 1.) 12/20/11 2:14 PM "(Recorded as Late Entry on 12/21/2011 at 9:18 PM) Pt returned from appointment with these notes:" Pt received platelet transfusion as scheduled. . . (Resident) was discharged on [MEDICATION NAME]/[MEDICATION NAME] 125 mg (sic) patch. She is on a lower dose now, I am not sure why. She will see pain management MD tomorrow. 12/27/11 with (one doctor), 12/20/11 with (another doctor)." 2.) 12/20/2011 3:53 AM ". . . . PRN (as needed) pain meds, [MEDICATION NAME] and ambian (sic) administered. . . . Pt has appointment with a pain specialist in the morning to discuss increasing her [MEDICATION NAME] prescription. It was 125 mcg prior to (Facility name). Current order is for 75 mcg. . . . " 3.) 12/25/11 3:34 AM ". . . pt c/o (complains of ) pain this shift. Pt given [MEDICATION NAME] 10 mg. Pt. sleeping well at this time. . . " 4.) 12/28/11 09:13 AM " Pt was gone to her appointment at (hospital) from 0700 to 1900 (7:00 AM to 7:00 PM). She was emotional and agitated upon return. Stated she was upset she had not received her am meds prior to leaving facility. She also had not received her [MEDICATION NAME] as we do not have her 100 mcg from pharmacy. Ok from (facility MD) to write one-time order for 75 mcg [MEDICATION NAME] the pt was previously using. . . Pt requested PRN pain meds throughout night. She rated her pain 10/10 in her back and legs. Applied [MEDICATION NAME] creme (sic) to legs and offered heating pad." Review of the medical record revealed the following hospital consultation note, dated 1/3/12, titled Supportive Oncology/Pain Medicine and Pallative Care-inpatient: " Impression: 1. Nociceptive somatic, neuropathic, and myofascial pain associated with a history of [MEDICAL CONDITION] type pain with diffuse joint pain exacerbated by onset of [MEDICAL CONDITIONS] and its treatment. 2. Exacerbation of her pain with admission and significant reduction in her baseline and breakthrough opioid medication as well the necessary decrease in her neuropathic pain medication. . . 3. Recent alteration in mental status is likely multifactoral. . . mental status has cleared considerably, but her pain has also increased significantly. . . 6. Sleep disturbance associated with symptom burden, responds to [MEDICATION NAME] at bedtime." "Integrated Supportive Oncology and Palliative Care Plan: Medical Symptom Management 1. Re-titrate the [MEDICATION NAME] and [MEDICATION NAME] to her baseline levels to promote her physical functioning and return to active rehabilitation efforts. Be sure to change the [MEDICATION NAME] every 48 hours as she has documented end-of- dose failure with 72 hours patch changes. . . . "

Based on interview and medical record review it was determined, for two sample residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, a known diabetic resident experienced continual low and high blood sugars which resulted in the resident receiving medication to correct the out of normal range blood sugars. In addition, facility staff were withholding insulin or giving the wrong dose of insulin and not notifying the physician of the changes, thus not allowing the physician to make changes to the insulin regimen. Resident identifiers: 4 and 30. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/11/12 resident 4's medical record was reviewed. Review of the physician's orders [REDACTED]. a.) "Humalog (insulin [MEDICATION NAME])Solution; 100 unit/mL (milliter); Subcutaneous Special Instructions: Dx (diagnosis): DM (Diabetes Mellitus); BS (Blood Sugar) < (less than) 50 give D50W (50% [MEDICATION NAME] in Water) & (and) call MD (Medical Doctor)." 150-209=1 unit 210-269=2 units 270-329=3 units 330-389=4 units 390-449=5 units >450=6 units and call MD dated 10/5/11. The sliding scale [MEDICATION NAME] was to be administered 5 times daily after Blood Glucose checks were completed at 2:00 AM, 8:00 AM, 12:00 PM, 5:00 PM, and 8:00 PM. (Note: A normal blood sugar or glucose level should be 70 - 120 mg/dL (milligrams per deciliter)). b.) "[MEDICATION NAME] 50% in water (D50W)Syringe; -; amt: 25 ml (milliters); Intravenous Special Instructions: for BS <70 Once a Day - PRN (as needed)" dated 10/30/11. The following entries were facility Progress Note entries: 1.) 01/09/2012 16:20 (4:20 PM) "A & D ointment applied to right heel, foot and lower leg per orders. Split in heel present with no bleeding or exudate found. Pt (patient) BS (blood sugar)169 at 0700 (7:00 AM) and 24 at 1000 (10:00 AM). Pt diaphoretic and non responsive to verbal commands. Pt given PRN (as needed) 50% [MEDICATION NAME] per orders with BS increasing to 125 at 1030 (10:30 AM) with pt alert and oriented at that time. Pt encouraged to consume all meals and not to skip. Pt refused breakfast stating that she was too tired. Pt up out of bed during the remainder of the shift and at lunch." No documentation could be found to show facility staff notified the physician of the decreased blood sugar or the need for the D50W. 2.) 01/08/2012 09:45 (9:45 AM) "Pt BS prior to breakfast was 215. Insulin held. Right heel very dry. Pt continues to put lotion on heel. Will continue to monitor." (Note: Resident 4 should have received 2 units of insulin based on the physician's orders [REDACTED]. No documentation could be found to show that the physician was notified that resident 4's scheduled insulin was held. 3.) 01/05/2012 02:54 (2:54 AM) "pt is a/o (alert and oriented) x3 (person, place and time). pt is independent - 1x (person) assist with adl's (activities of daily living), toileting, transfers, and eating. BS was 430 at 2000 (8:00 PM). 5 units was ordered but administered 2.5 due to rapid decrease. Pt's BS was 36 @ (at) 0200 (2:00 AM) D50W (50% [MEDICATION NAME] in water) given via LUE (Left upper extremity) PICC (Peripherally Inserted Central Catheter) line. BS rechecked and was 259. Pt was given graham crakers (sic) to eat. Pt is compliant with all cares and follows diet. PT denied any episode of emesis during shift. call light visible and wihtin (sic) reach. WCTM (Will Continue To Monitor)." No documentation could be found to show that the physician was notified of the decreased amount of insulin administered nor that resident 4 had a low blood sugar and required D50W. 4.) 01/04/2012 21:01 (9:01 PM) "Pt difficult to arouse in the AM. BS 51 at 0800. Pt given juice and cookies which brought up BS to 110. [MEDICATION NAME] given per orders. Pt encouraged to consume breakfast but was LOA (Leave of Absence) for lunch. BS at dinner was elevated with (?) but insulin held r/t (related to) rapid decrease in BS levels during the night. Pt with room change and encouraged to wear protective footwear when ambulating in room or hall. Clutter removed from floors in pt room. Pt with no c/o (complaints of) pain or discomfort." No documentation could be found to show that the physician was notified of resident 4's insulin being held. 5.) 01/02/2012 02:44 (2:44 AM) "Pt has had no episodes of emesis or diarrhea this shift, Pt was found during 2000 (8:00 PM) med pass with BS of 26, glucose was given via PICC line, PICC line is patent, dressing is clean, dry and intact, weekly skin assessment completed with no new skin issues noted, will continue to monitor." No documentation could be found to show that the physician was notified of the low blood sugar and the need for D50W. 6.) 01/01/2012 16:51 (4:51 PM) (Recorded as Late Entry on 01/03/2012 02:55)"Pt had no vomiting or diarrhea. Her morning BS was WNL (Within Normal Limits). Pt left facility before lunch and returned at 1630 (4:30 PM). Her blood sugar was 599. Administered 6 units per orders and notified Dr. Walsh. No further action was advised." 7.) 01/01/2012 03:28 (3:28 AM) "Pt. feeling tired and c/o fatigued. BS in 300s. Insulin held d/t (due to) no snack. Pt BS 2300 (11:00 PM) 500. 4 units administered. BS at 0200 (2:00 AM) was 124. Pt asleep, alert and oriented. Compliant with medications. Call light within reach. Will continue to monitor." ( Note: Resident 4 should have received 6 units of insulin for the blood sugar of 500, in addition there was not a physician's orders [REDACTED]. No documentation could be found to show facility staff notified the physician regarding the insulin being held or the increased blood sugar at 11:00 PM. 8.) 12/30/2011 08:04 (8:04 AM) "Pt is A/O x 3. Pt had multiple low BS during the night. at 2200 (10:00 PM) last night pt had a BS of 26. Pt immediately given glucose via Picc. Pt BS elevated to 130. Pt BS then declined to 46 at 0200 (2:00 AM) in the morning. Pt given snacks and juice. Pt's BS stayed around 65 while eating small snacks the rest of the night. Pt is up and eating breakfast at this time. Pt appears in good spirts. Pt ambulates with walker. Pt denies pain and nausea at this time. No emesis from pt.. Pt is compliant with all cares and medications. Pt requires supervision only with transfers. Pt is independent with bed mobility and toileting. Will CTM (Contine To Monitor)." No documentation could be found to show facility staff notified physician regarding the multiple low blood sugars and the need for the D50W. 9.) 12/29/2011 15:58 (3:58 PM) "Resident BS 34 at 0730 (7:30 AM). Resident able to open her eyes but was unable to dring/swallow (sic), she just lick med pass 2.0, juice (sic). Order for peripheral IV (intravenous) PRN for 50% [MEDICATION NAME] IV attempted x 3 but unable to start IV.Resident become totaly unresponsive . Order received to call transport for ED (Emergency Department) and (ambulance company) notified. While in transit she became responsive and drank 240 cc (cubic centimeters) of orange juice increasing BS to 50 within 15 min (minutes) and 15 min after that BS was 93. (Ambulance Company) canceled,resident monitoring ,PIC line nurse called for line insertion,panding (sic) respond." 10.) 12/26/2011 04:51 (4:51 AM) "BS 40 MD and DON (Director of Nursing) notified, [MEDICATION NAME] given from ekit (emergency medication kit), a glass of milk and a soda pop, BS 57, then 103, a sandwich was given, Pt vomiting, DON notified." 11.) 12/24/2011 04:05 (4:05 AM) "Pt. BS at HS 241. No insulin given. BS at 0200 (2:00 AM) is 115. No changes in LOC (Level of Consciousness). No snack had before bed. Pleasant with staff. Alert and oriented. No c/o pain at this time. Pt. requires supervisory care. Pt. compliant with treatments and cares. Continent to B/B (bowel and bladder). Call light within reach. Will continue to monitor." ( Note: Resident 4 should have received 2 units of insulin for the blood sugar of 241). No documentation could be found to show that facility staff notified the physician of the insulin being held. 12.) 12/23/2011 04:33 (4:33 AM) "Pt. has BS in lower 400s HS (hour of sleep). Pt given 4 units of insuling (sic). Pt has BS of 51 at 0200 (2:00 AM). Pt drank capri sun and part of soda. Pt BS at 0330 (1:30 PM) 150s. Pt oriented and alert all throughout the night. Able to walk to restroom without any problems noted. Call light within reach. Will continue to monitor." (Note: Resident 4 should have received 5 untis of insulin for the blood sugar in the low 400's). No documentation could be found to show that facility staff notified the physician regarding the misdosing of insulin nor the low blood sugar. 13.) 12/21/2011 14:15 (2:15 PM) "Pt. alert and oriented x 3. Independent with ADL's, transfers, bed mobility and toileting. Eats meals in dining room with good appetite. B.S. at 0200 (2:00 AM) was 68, at 0800 (8:00 AM) it was 53 and I.V. dextrsoe (sic) given. Doctor . . notified. At 1200 (12:00 PM) it was 256 and schedueld (sic) insulin was given. PICC line dressing is clean, dry and intact. No drainage or redness to insertion site. Flushes well with no resistance. Pt. takes all medications whole without difficulty. Compliant with medication and treatments. Skin tear on left pinky toe is healing and dressing is clean, dry and intact. Will check upon her arrival. Will continue to monitor." 14.) 12/20/2011 15:55 (3:55 PM) "Pt. alert and oriented x 3. Independent with ADL's, transfers, bed mobility and toileting. Requires set up assistance for meals. Eats meals in dining room with good appetite. Pt. sometimes skips meals. This morning pt. skipped breakfast. Checked b/s at noon and it was 28. Pt. was hard to wake up, pale, and clammy. IV [MEDICATION NAME] given via PICC line as per order to bring blood sugar up. Re-check blood sugar 1 hour later and it was up to 157. Encouraged pt. to eat a snack and eat a good lunch. Continuing to educate pt. on diet and importance of meals and healthy snacks. PICC line dressing is clean, dry and intact. No drainage or redness to insertion site. Flushes well with no resistance. Pt. takes all medications whole without difficulty. Pleasant and cooperative with cares and meds. Unable to assess pinky toe at this time because pt. is LOA with a friend. Will check upon her arrival. Will continue to monitor." No documentation could be found to show that facility staff notified the physician regarding resident 4's low blood sugar and the need for the D50W. 15.) 12/18/2011 04:22 (4:22 AM) "Pt BS at HS in high 400s. MD notified. 6 units of insulin administered. BS at midnight 108. BS at 0200 (2:00 AM) 88. Pt. alert and orienteded. No s/s (signs or symptoms) of distress. Pt asleep. No c/o pain . Pt compliant with medications. Continent to B/B. Requires supervisory care. No c/o pain at this time. Call light within reach. Will continue to monitor." 16.) 12/17/2011 03:08 (3:08 AM) "Pt. BS at HS 500. MD notified. 6 units administered to pt. Midnight BS 426. 3 units of insulin administered. 0200 BS 220 (2:00 AM). Pt. denies snack before bed. Pt. alert and oriented. Pt pleasant and cooperative with cares and medications. PICC line flushed and patent. Call light with in reach. Will continue to monitor" (Note: According to the physician ordered sliding scale insulin, resident 4 should have received 5 units of insulin for the blood sugar of 426 and 2 units of insulin for the blood sugar of 220). No documentation could be found to show facility staff received an order to administer the additional insulin at midnight. 17.) 12/16/2011 03:52 (3:52 AM) "Pt. sleepy during shift. Easy to awake but still groggy. No bumps or problems noted d/t hitting head previous shift while in room. BS at 0200 (2:00 AM) at 500. MD notified. Four units given and brought down 45 minutes later to 446. Two more units given and dropped down to 289. Pt compliant with cares and medications. Pt. denies snack before bed. Pt. continent to B/B. Pt requires superviosry assistance. IV flushed and locked. Call light within reach. Will continue to monitor" No documentation could be found to show facility staff received a physician's orders [REDACTED]. 18.) 12/12/2011 02:02 (2:02 AM) "Checked B.S. at 2300 (11:00 PM) was 43. PRN I.V. [MEDICATION NAME] 50 ml was given via Right PICC line. She also drank a capri sun. Dr. . . notified of blood sugar level. At 2347 (11:47 PM) B.S. was 222. Patient was alert and oriented with the low B.S. level. She was able to respond and answer questions appropriately. Will check B.S. again at 0200 (2:00 AM) as ordered. Patient returned to facility around 1900 (7:00 PM) with significant other. Requested to put cinnamin (sic) waffles and gogurts in the freeer (sic) and creamer in the fridge. Patient continent of B/B. No complaints of pain during shift. Will continue to monitor" (Note: Facility staff administered 50 ml (milliters) of [MEDICATION NAME] instead of the 25 ml that was ordered.) 19.) 12/11/2011 15:05 (3:05 PM) "Pt is awake and alert and oriented x4. Pt was difficult to rouse this am and could not identify the day or the LN (Licensed Nurse) present despite having known who it is in the past. Pt am glucose was 42. [MEDICATION NAME] was given per orders and blood sugar re-checked was 49 after 1 hr. Pt was woken again and given apple juice to drink. Recheck 1 hr after was 88. Pt was given 2 cookies. Pt left LOA without informing LN or staff before lunch so medications were held. Pt continues to be non-compliant with diet while out on LOA and frequently brings back leftover meals from restauraunts (sic). Pt skin tear is OTA (open to air) and appears to be resolved. WCTM." No documentation could be found to show that facility staff notified the physician regarding the low blood sugar or the administration of the [MEDICATION NAME]. 20.) 12/10/2011 02:05 (2:05 AM) "Pt. had blood sugar of 308 HS. Pt. had snack with 1 unit of insulin administered. BS at 0200 (2:00 AM) 77. Pt given oreos to eat. Pt. stated frustration about meeting today and was worried about living arrangements. Pt. wanted to know about being able to move up stairs d/t lack of sleep down on 2nd from noise of other residents. Pt. under supervisory care. Pleasant, alert, and cooperative with cares. Call light within reach. Will continue to monitor." (Note: Resident 4 should have received 3 units of insulin for the blood sugar of 308). No documentation could be found to show that facility staff notified the physician regarding the incorrect doseage of insulin administered. 21.) 12/09/2011 03:52 (3:52 AM) "Pt. asleep. Alert and oriented. Compliant with cares and medications. Had snack before bed. BS HS 330. Insulin administered. BS at 0200 (2:00 AM) 60. Pt. oriented and alert. Half bottle of [MEDICATION NAME] administrered. BS at 0300 (3:00 AM) 149. Will continue to monitor." No documentation could be found to show that facility staff notified the physician regarding the low blood sugar and the administration of the [MEDICATION NAME]. 22.) 12/05/2011 05:52 (5:52 AM) "Check BS at 0411 (4:11 AM) and was 33. She was shaky and not fully aware of her surroundings. I asked if she was okay and she responded with a "uh-huh." She would not respond to anything else. She had a blank stare on her face. I had her drink a glass of orange juice and capri sun before leaving the room. After, I administered 50 ml of [MEDICATION NAME] via right PICC line. I re-checked BS at 0421 (4:21 AM) and BS was 224. Patient was very alert and oriented at this time. Doctor . . . notified of BS." (Note: Facility staff administered 50 ml of [MEDICATION NAME] instead of the physician ordered 25 ml). 23.) 12/03/2011 02:28 (2:28 AM) "DRSG (dressing) covering right great toe is dry and intact. Pt with no s/s infection at site of skin tear. Pt with low BS (22) at 1200 (12:00 PM) on 12/2/11 and unresponsive to verbal cues. Pt given 25 ml 50% [MEDICATION NAME] via PICC with no response within 15 minutes. Pt given additional 25 mg 50% [MEDICATION NAME] via PICC and became responsive within 5 minutes of admin (administration). Pt became more alert and ate all of her lunch. BS's have been above when checked during this shift. Pt alert and oriented x 3. (Note: Facility staff administered an additional 25 ml of [MEDICATION NAME] with no evidence of a physician's orders [REDACTED]. No documentation could be found to show facility staff notified the physician regarding the additional dose of [MEDICATION NAME] administered. 24.) 11/30/2011 17:50 (5:50 PM) "BS at 1700 (5:00 PM) was 549. Dr. Notified and administed sliding scale of insulin." No documentation could be found to show that facility staff inquired to find out if resident 4 administered any insulin to herself while at home, based on the physician's orders [REDACTED]. 25.) 11/30/2011 14:41 (2:41 PM) "Pt. Alert and Oriented X3. Requires one person minimal assist with ADL's. No complaints of pain. Patient is mobile. Eats majority of meals in dining room and has adeqaute intake. Continent of bowel and bladder. Compliant of medications and treatments. Blood sugar at 0800 (8:00 AM) was 254 and insulin was administered. She was leaving to go home at 1045 (10:45 AM) with significant other and checked blood sugar before she left. Reading was "high". Doctor was sitting at nursing station and was notified of the reading. He stated to have pt take her insulin when she went home for sliding scale of over 400. Did not order to administer any insulin before she left facility. Will continue to monitor when she returns." No documentation could be found to show facility staff educated resident 4 regarding dosing herself with the sliding scale insulin upon reaching her home. 26.) 11/28/2011 02:18 (2:18 AM) "Pt. is alert and oriented. BS was 337 HS. 2 units of insulin administered. At 0200 (2:00 AM) BS was 147. No further action required. PICC flushed with saline and [MEDICATION NAME]. Dressing on great toe of right foot dry, clean and intact. Pt. is compliant with medications and cares. Pt. requires supervision with ADLs. No c/o pain at this time. Pt. is continent to B/B. Pt. not compliant with diabetic diet. Pt pleasant with staff and other residents. Call light within reach. Will continue to monitor." (Note: Facility staff should have administered 4 units of sliding scale insulin for the blood sugar of 337). No documenation could be found to show facility staff notified the physician of the incorrect dosage of insulin administered. 27.) 11/27/2011 02:39 (2:39 AM) "Pt. had BS of 158 after dinner. No insulin given. Pt. had snack before bed. Glucose level 256 at 0200 (2:00 AM). no insulin given. Pt. alert and oriented. Is compliant with cares and medications. Minimal drainage on bandage on right great toe. No c/o pain at this time. Is pleasant with staff. Is continent to B/B. Requires supervision for ADLs. Call light within reach. Will continue to monitor." (Note: Resident 4 should have received 1 unit of insulin for the blood sugar of 158 and 2 units of insulin for the blood sugar of 256). No documentation could be found to show facility staff notified the physician of the insulin being held after dinner and at 2:00 AM. 28.) 11/26/2011 04:40 (4:40 AM) "Pt. had BS of 250 at 2200 (10:00 PM). Insulin not given. BS at 0200 (2:00 AM) 359. Pt. denies eating a snack. 2 units of insulin given, pt. BS 289 at 0300 (3:00 AM). 1 unit of insulin given. Pt. is responsive, alert and oriented. Skin dry and warm to touch. Pt. compliant with cares and medications, not compliant with diet. PT. has no c/p (complaints of) pain. Pt. pleasant with staff. No statements that signify depression made. Call light within reach. Will continue to monitor." (Note: Resident 4 should have received 2 units of insulin for the 250 blood sugar at 10:00 PM, 4 units of insulin for the blood sugar of 359 at 2:00 AM and no additional insulin at 3:00 AM). No documentation could be found to show facility staff notified the physician regarding the incorrect dosage of insuliln administered at 10:00 PM and 2:00 AM nor could a physician's orders [REDACTED]. 29.) 11/21/2011 03:52 (3:52 AM) "Pt. no compliant with diet. Pt. doesn't continually have snacks given before bed to assist in keeping BS at normal value. BS at 200 (10:00 PM) 224. No insulin given. BS at 0200 (2:00 AM) was 35. [MEDICATION NAME] given. At 0310 (3:10 AM) BS was 131 with full 50 mL of [MEDICATION NAME] given. Pt. reported to have denied snack last night. Pt. compliant with cares and medications. Pt. has no c/o pain. Pt. is continent to B/B. Pt. is under supervisory care. Call light within reach. Will continue to monitor." (Note: Resident 4 should have received 2 units of insulin for the blood sugar of 224 at 10:00 PM). No documentaion could be found to show facility staff notified the physician regarding the insulin not being administered nor of the low blood sugar requiring the use of [MEDICATION NAME]. 30.) 11/13/2011 18:05 (6:05 PM) "Pt left on LOA before lunch. Returned at appx 1600 (4:00 PM). Reported a b.s. prior to eating lunch of 394. Gave insulin per sliding scaled based on that number. Checked at 1700 (5:00 PM) and was 253 so I gave insulin again per sliding scale because pt was leaving on LOA again for dinner and reported that she would not return for a couple of hours. Pt educated about proper diabetic diet and blood sugar checks. Also noted that her gait appeared to be unstable when walking and that she ocasionally needed to brace against a surface of a wall or other object. Pt continues to be noncompliant with meals and b.s. checks. Will continue to re-educate and teach pt." (Note: Facility staff administered insulin to resident 4 four hours after the scheduled time frame and one hour before the scheduled time frame). 31.) 11/12/2011 23:13 (11:13 PM) 'Pt has had positive outlook tonight, BS monitored and insulin given per MD orders, Pt made no remarks regarding feeling depressed this shift, Pt in bed sleeping, call light is within reach will continue to monitor." 32.) 11/11/2011 04:59 (4:59 AM) "Weekly Skin Assessment completed. 2+ [MEDICAL CONDITION] bilaterally on lower legs. PICC line flushed and patent. Dressing dry, clean and intact. FBS 0200 (2:00 AM) 34. [MEDICATION NAME] given. BS improved to 103. Pt. has no c/o pain or discomfort. Was alert and oriented. Pt pleasant with staff but frustrated at BS level at 0200 (2:00 AM). Will continue to monitor." 33.) 11/10/2011 16:39 (4:39 PM) Order received from diabetic center to decrease [MEDICATION NAME] to 15 units SQ every AM. 34.) 11/09/2011 09:59 (9:59 AM) 'Pt states she gets depressed mostly because she requires the [MEDICATION NAME] so often and it is really hard on her body when she has to have it. She is encouraged to see the diabetic specialist tomorrow. She was glad she has started and anti-depressant and is looking forward to getting control of her disease process. Pt has very good outlook today with positive attitude." Review of the medical record revealed that on 12/29/11 resident 4 had a HgBA1C (Glycosylated Hemoglobin) performed. This test was performed as an indication of how well the blood sugar was being controlled and or managed over a 90 day period. Resident 4's level was 8.9. According to the lab documenation the acceptable range was 4.4-5.6. Documentation on the lab sheet indicated that 4.1-5.6% was desireable, 5.7-6.4% was an impaired glucose tolerance and >= (greater than or equal to) 6.5% indicated provisional diabetes. On 1/11/12 at 12:45 PM, the medical director was interviewed. The medical director stated that he was not able to treat resident 4's diabetes due to her depression. The medical director stated that when resident 4's depression was under control he would then treat her diabetes and manage the disease. The medical director further stated that resident 4 was not interested in managing her own disease. The medical director stated that he was notified 15 times from 12/10/11 to current about high and low blood sugars. The medical director stated that he was not aware that the nurses were not following the sliding scale insulin orders. The medical director stated that he had just found out about the nurses not notifying him about the sliding scale or about the [MEDICATION NAME] being given. The medical director stated that the DON was educating the staff now so he would be notified all the time if resident 4's blood sugar was below 70 or increased over 400. Facility staff did not notify resident 4's attending physician as directed by physician orders. Cross refer to F-157. Facility staff did not ensure that resident 4 was free of significant medication errors relative to insulin administration. Cross refer to F-333. 2. Resident 30 was admitted to the facility on [DATE] with admit [DIAGNOSES REDACTED]. On 1/12/12 a medical record review was conducted for resident 30. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No indication for use and dosing instructions such as a correct dose and time frame in which to give the drug was noted. Further review of the MAR indicated [REDACTED]. A review of the minutes for the [MEDICAL CONDITION] meeting review on 12/7/11 revealed that the pharmacist, DON and the Social Services Worker Consultant (SSWC) determined that the [MEDICATION NAME] ordered for resident 30 should be discontinued. The medical director signed the form and agreed with the recommendation. The facility staff did not follow through with the recommendation. On 1/12/12 at 8:30 AM, an interview was conducted with licensed practical nurse (LPN) 1. LPN stated that [MEDICATION NAME] was a medication that hospice ordered. LPN 1 stated that she did not know the reason why resident 30 had an order for [REDACTED]. On 1/12/12 at 8:35 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that [MEDICATION NAME] was a hospice medication that was given for anxiety. RN 2 stated that he was unaware that resident 30 had anxiety and needed the medication. On 1/12/12 at 8:40 AM, an interview was conducted with the DON. The DON stated each medication that was ordered for a resident must have an indication for use and instructions for administration such a time frame and dose. The DON stated the physician would enter the information necessary into the computer when they prescribed the medication. If the order was a telephone order then the RN would enter the information and the physician would electronically sign the order. When asked about the [MEDICATION NAME] order for resident 30, the DON stated that she did not know what had happened for this medication and why the indciation for use, time frame for medication to be given and dosage were not written. The DON further stated that [MEDICATION NAME] was a medication that hospice ordered for increased anxiety. The DON stated that anxiety was not an approved indication for the use of [MEDICATION NAME] but hospice used it anyway. On 1/12/12 at 9:45 AM, a second interview was conducted with the DON. The DON stated the facility had recommended the drug [MEDICATION NAME] to be discontinued during the monthly [MEDICAL CONDITION] medication review meeting on 12/7/11. The facility realized resident 30 was on hospice and had decided that the hospice agency needed to be contacted prior to discontinuing the medication. When the DON was asked if the hospice agency had been contacted, the DON stated that the facility hadn't gotten around to it yet.