Every finding on record at St. Anthony Healthcare and Rehabilitation Center

Based on record review, observation, and interview, the facility failed to provide respiratory care in accordance with professional standards for 4 (R #2, R #3, R #5, and R #6) of 4 (R #2, R #3, R #5, and R #6) residents reviewed for respiratory care when the staff failed to:1. Ensure medical orders included the amount of oxygen (a specific flow rate; measurement of the volume of liquid or gas moving per unit of time) and the delivery method (i.e. Nasal canula, simple mask, or non-rebreather mask) for R #6.2. Ensure oxygen tubing included a label with a date indicating when tubing was changed for R #2, R #3, and R #5).These deficient practices are likely to result in residents receiving too much, not enough oxygen, and increase their risk of infection which can lead to worsening of their conditions.The findings are:A. Record review of the facility's Oxygen Concentrator policy, revised on 08/07/23, revealed the following:1. All oxygen components should be labeled and dated.2. The first step to setting up oxygen is to verify orders. R #2B. Record review of R #2's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/14/26, revealed the following:1. R #2 was admitted to the facility on [DATE].2. R #2 had the following diagnoses:-Respiratory failure with hypoxia (a condition where body tissues do not receive enough oxygen to function properly),-Atrial fibrillation (A-Fib; irregular heart rhythm),-Congestive heart failure (CHF; impaired heart function). C. On 06/30/26 at 10:32am, during a random observation, R #2 was sitting in her wheelchair in the activities area. R #2 was wearing a nasal cannula connected to an oxygen tank. The oxygen tubing did not contain a label or a date. D. Record review of R #2's oxygen tubing order, dated 02/22/26, revealed oxygen tubing was to be changed weekly and label each component with date and initials every Sunday night shift. E. On 06/30/26 at 10:33 am, during an interview, the Business Office Manager (BOM) stated the oxygen tubing did not have a label or a date. F. On 07/01/26 at 1:01 p.m., during an interview, the Director of Nursing (DON) stated the lack of labeling on Resident #2's oxygen tubing did not meet her expectations. She stated all oxygen tubing was required to be changed weekly and when visibly soiled. R #3G. Record review of R # 3's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Respiratory failure with hypoxia (a condition where body tissues do not receive enough oxygen to function properly),2. Chronic Obstructive Pulmonary disease (COPD; lung disease),3. Congestive heart failure (CHF; impaired heart function). H. On 06/30/26 at 10:37 am, during an observation, R # 3 was sitting in a wheelchair during physical therapy. R #3 was wearing a nasal cannula connected to oxygen during physical therapy, the oxygen tubing did not have a label or a date on the tubing. I. Record review of R #3's oxygen tubing order, dated 06/26/26, revealed oxygen tubing was to be changed weekly and to label each component with date and initials every Sunday night shift. J. On 06/30/26 at 10:38 am, during an interview, the Occupational Therapy Assistant (OTA) stated the oxygen tubing did not have a label or a date. K. On 07/01/26 at 1:01 p.m., during an interview, the DON stated the lack of labeling on Resident #3's oxygen tubing did not meet her expectations. She stated all oxygen tubing was required to be changed weekly and when visibly soiled. R #5L. Record review of R #5's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/25/26, revealed the following:1. R #5 was admitted to the facility on [DATE].2. R #5 had the following diagnoses:-Respiratory failure with hypoxia (a condition where body tissues do not receive enough oxygen to function properly),-Chronic Obstructive Pulmonary disease (COPD; lung disease). M. On 06/30/26 at 10:39 am, during an observation, R #5 was sitting in a wheelchair outside his room. R #5 had a nasal cannula was connected to oxygen tank, the oxygen tubing did not have a label or a date on the tubing. N. On 06/30/26 at 10:38 am, during an interview, the Certified Medication Aide (CMA) stated the oxygen tubing was not labeled or dated. O. On 07/01/26 at 1:01 p.m., during an interview, the DON stated the lack of labeling on Resident #5's oxygen tubing did not meet her expectations. She stated all oxygen tubing was required to be changed weekly and when visibly soiled. R #6P. Record review of R # 6's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Anemia (not enough healthy red blood cells),2. End stage renal disease (ESRD; chronic irreversible kidney failure),3. Congestive heart failure (CHF; impaired heart function). Q. Record review of R #6's physician order for oxygen, dated 06/26/26, revealed the order did not include a flow rate or an oxygen delivery device [i.e. nasal cannula, simple mask, or non-rebreather mask]. R. On 07/01/26 at 1:01 pm, during an interview, the DON stated oxygen orders should contain appropriate information to ensure residents receive the appropriate amount of oxygen and by which device. She stated this order does not meet her expectations.

Based on interview and record review, the facility failed to ensure timely acquisition and provision of ordered narcotic pain medication for 1 (R #6) of 1(R #6) resident who required post operative pain management. This failure resulted in a delay in receiving prescribed narcotic medication which has the potential to cause the resident unnecessary pain and anguish. The findings are:A. Record review of the facility's Medication Ordering and Receiving From Pharmacy Provider, Ordering and Receiving Controlled Medications policy, dated 01/2023, revealed the Drug Enforcement Agency (DEA) requires a pharmacy must have a valid prescriber signed prescription in order to dispense controlled substances. In emergency situations, verbal authorization may be given by the prescriber to the pharmacist for a new order. B. Record review of R # 6's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Surgical Amputation,2. End stage renal disease (ESRD; chronic irreversible kidney failure),3. Osteomyelitis (inflammation of bone and bone marrow). C. Record review of the electronic health record, revealed R #6 was admitted on [DATE] at 4:06 pm after surgical amputation of left leg above the knee on 06/17/26, left long finger amputation on 06/13/26, and right long finger, ring finger, and small finger amputations on 06/11/26. R #6 complained of 10/10 (pain scale using 0-10, zero being no pain and 10 is the worst it can be) pain. D. Record review of R #6's physician orders for pain revealed the following:1. An order, dated 06/26/26, for celecoxib (anti-inflammatory drug) 200 milligrams (mg), give 1 capsule by mouth one time a day for pain [start 06/27/26 at 8:00 am; end indefinite].2. An order, dated 06/26/26, for gabapentin (anticonvulsant (medication used to prevent control or stop seizures and convulsions) and nerve pain medication) 100 mg, give 1 tablet two times a day for pain [start 06/26/26 at 8:00 pm; end indefinite].3. An order, dated 06/26/26, for hydrocodone-acetaminophen (combination pain medication) 5 mg/325 mg, give 1 tablet by mouth every 4 hours as needed for pain [06/26/26 at 5:45 pm; end indefinite].4. An order, dated 06/26/26, for pregabalin (medication for anticonvulsant and neuropathic pain medication) 75 mg, give 1 capsule by mouth at bedtime for pain [start 06/26/26 at 8:00 pm; end indefinite].5. An order, dated 06/26/26, for capsaicin (topical pain reliever) external cream 0.025%, apply to leg topically every 8 hours as needed for pain up to three times a day [06/26/26 at 5:45 pm; end indefinite].6. An order, dated 06/26/26, for Acetaminophen 325 mg give 2 tablets every four hours as needed for pain [start 6/26/26 at 5:30 pm; end 6/27/26 at 1:45 am].7. An order, dated 06/26/26, for Tylenol 500 mg give 2 tablets every eight hours as needed for pain [start 6/26/26 at 2:00 am; end 6/27/26 at 2:26 am].8. An order, dated 06/26/26, for Tylenol 500 mg give 2 tablets by mouth one time only for pain for 3 days [start 6/27/26 at 10:00 am; end 6/27/26 at 2:26 am].9. An order, dated 06/26/26, for Tylenol 500 mg give 2 tablets every one time only for pain for 3 days [6/27/26 at 11:00 am; end indefinite]. E. Record review of R #6's medication administration record (MAR) revealed the following:1. On 06/26/26 at 5:30 pm, Acetaminophen 650 mg given.2. On 06/26/26, Capsaicin cream was not administered.3. On 06/27/26 at 8:00 pm, Gabapentin 100mg given.4. On 06/26/26 at 9:02 pm, two tablets of Acetaminophen 325 mg were given.5. On 06/26/26, Hydrocodone-Acetaminophen was unavailable from the pharmacy.6. On 06/27/26 at 8:15 am, Hydrocodone-Acetaminophen was given.7. Pregabalin 75 mg was not administered because it was unavailable from the pharmacy. F. Record review of progress notes revealed the following: 1. On 06/26/26 at 4:05 pm, R #6's reported 10/10 pain, distraction techniques utilized, resident position changed, as needed (PRN) medication provided.2. On 06/26/26 at 6:18 pm, the medication was ineffective.3. On 06/26/26 11:07 pm pregabalin was pending pharmacy delivery.4. On 06/26/26 23:39 pm RN #1 documented: a. At 4:19 pm attempt to get narcotic medication filled by pharmacy. b. At 7:26 pm attempt to get narcotic medication filled by pharmacy. c. At 8:39 pm attempt to get narcotic medication filled by pharmacy. d. At 11:14 pm attempt to get narcotic medication filled by pharmacy. G. On 07/01/26 at 12:00 pm, during an interview, Registered Nurse (RN) #2 stated as soon as she had the narcotic prescription signed by the physician, she sent it to the pharmacy. She stated when she was notified the prescription did not go through, she sent it again. She stated that the staff from the facility reached out again later in the evening she sent it again. She stated she did not know the prescription had still not gone through during her last conversation with the facility until the next day. H. On 07/1/26 at 12:11 pm, during an interview, RN #1 stated the resident arrived at approximately 4:00 pm and requested to have the narcotic prescription filled as soon as medication list was received. She stated an emergency kit was accessible only by a code provided by pharmacy once the narcotic prescription was received. She stated the nurse who mediated between the facility and the pharmacy indicated she was sending prescription to pharmacy. She stated she notified the physician multiple times, and the provider allowed only acetaminophen for pain, first 650 mg and then an increased dose of 1000mg. The provider also prescribed capsaicin cream to the area of pain, but stated she could not apply it because the area was a recent surgical incision site and use was contraindicated. She stated she provided the prescribed medications and repositioned the resident as often as possible. I. On 07/01/26 t a1:20 pm, during an interview, the Director of Nursing (DON) stated narcotics were not in the building for new residents until the pharmacy receives the prescription, and the pharmacy would not send narcotics for the resident until the resident was physically in the facility. She stated the process was to request the prescription through an application via phone to the company's providers. She stated the nurse mediator sent the new narcotic prescription to the physician to sign, and once signed, it would be sent to pharmacy to be filled. She stated the pharmacy reported they did not receive this prescription until the next morning. She stated this did not meet her expectations for ensuring narcotic medications were received as soon as possible.

Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring adequate indication of use for medications based off of the residents' diagnosis for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are: R #1A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses:1. Anxiety Disorder (mental health condition characterized by excessive and persistent worry and anxiety that is difficult to control),2. Cognitive Communication Deficit (difficulties in communication arising from impairments in cognitive functions like attention, memory, and executive functions, rather than problems with speech or language itself),3. Dementia (a condition where memory loss, confusion, difficulty with decision-making is present, but the specific underlying cause cannot be identified), Unspecified Severity (there is not enough information to classify its level of impact), without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. B. Record review of R #1's physician's orders revealed the following:1. An order for Ativan (anti-anxiety medication) tablet 0.5 milligrams (mg). Give 1 tablet by mouth every 8 hours as needed for agitated behavior. Start date 08/05/25.2. An order for Trazadone (antidepressant medication) tablet 50 milligrams (mg). Give 1 tablet by mouth at bedtime for insomnia. Start date 09/1/25.3. An order for hydroxyzine tablet (antihistamine medication), 75 milligrams (mg). Give one tablet by mouth at bedtime for agitation. Start date: 08/05/25. C. Record review of R #1's electronic health record (EHR) revealed no diagnosis listed for agitation and insomnia. R #2D. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] with the following diagnoses:1. Dementia in Other Diseases Classified Elsewhere (that occurs as a secondary symptom or complication of other underlying medical conditions), Unspecified Severity (there is not enough information to classify its level of impact), Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety,2. Insomnia (disorder characterized by difficulty falling or staying asleep, resulting in poor sleep quality and daytime fatigue),3. Major depressive disorder (persistent low mood, loss of interest, and other symptoms that significantly interfere with daily functioning). E. Record review of R #2's physician orders revealed an order for 1. Lorazepam (anxiety medication) tablet 0.5 milligrams (mg). Give 1 tablet by mouth every 12 hours as needed for agitation/anxiety. Start date 10/25/25.F. Record review of R #2's electronic health record (EHR) revealed no diagnosis listed for anxiety. R #3G. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses1. Unspecified Dementia (a condition where memory loss, confusion, difficulty with decision-making is present, but the specific underlying cause cannot be identified), unspecified severity (there is not enough information to classify its level of impact), with anxiety (excessive worry, fear, and nervousness that can interfere with daily life),2. Delirium (mental confusion that causes a sudden change in a person's cognitive function, awareness, and behavior),3. Anxiety disorder (excessive worry, fear, and nervousness that can interfere with daily life),4. Major depressive disorder (persistent feelings of sadness, loss of interest, and low energy that significantly interfere with daily life),5. Cognitive communication deficit (difficulties in communication arising from impairments in cognitive functions like attention, memory, and executive functions, rather than problems with speech or language itself). H. Record review of R #3 physician orders revealed an order for Trazadone (antidepressant medication) tablet 50 milligrams (mg). Give 1 tablet by mouth at bedtime for insomnia. Start date 11/1/25.I. Record review of R #3's electronic health record (EHR) revealed no diagnosis listed for insomnia.J. On 11/05/25 at 3:32pm, during an interview with the Director of Nursing (DON), she confirmed the following: 1. R #1 is currently being administered Ativan, Trazadone and Hydroxyzine for the indicated use, 2. R #2 is currently taking Lorazepam for the indicated use,3. R #3 is currently taking Trazadone for the indicated use.

Based on observation and interview, the facility failed to ensure safe medication storage practices by not ensuring the following:1. The medication carts were locked while unattended, 2. The medical supply storage rooms were kept free of expired medications, 3. Supplies and medications were stored according to manufacturer's temperature instructions. These deficient practices have the potential to affect all 61 residents as identified by the census provided by the Activities Coordinator on 08/10/25. If the facility does not ensure safe storage practices, then residents are at risk for unauthorized persons to have access to medications and adverse effects due to improper storage. The findings are: Medication Carts:A. On 08/10/25 at 10:22 am, during an observation of the facility, the medication cart located near the nurse's station was found unlocked and unattended. B. On 08/10/25 at 10:25 am, during an interview with Registered Nurse (RN) #1, he confirmed that the medication cart near nursing station was not locked and should be. C. On 08/11/25 at 8:30 am, during an observation of the facility, the medication cart in main hallway was found unlocked and unattended. D. On 08/11/25 at 8:33 am during an interview with Licensed Practical Nurse (LPN) #2, she confirmed the medication cart was left unlocked while unattended. E. On 08/11/25 at 11:55 am during an observation of the facility, the medication cart in main hallway was found unlocked and unattended. F. On 08/11/25 at 11:57 am, during an interview with LPN #2, she confirmed the medication cart was unlocked while unattended. Medication Storage: G. On 08/13/25 at 12:04 pm, during observation of medication cart by nursing station, a medication named Nitroglycerin issued 06/14/24, had an expiration date of 06/25. H. On 08/13/25 at 12:10 pm, during a medical storage observation revealed the following:1. Three boxes of Influenza vaccines had an expiration date of 06/30/25.2. Two indwelling catheter securement devices named Uro-secure had an expiration date of 09/30/24.3. Two intravenous secondary administration sets had an expiration date of 08/12/25.4. A bottle of Magnesium oxide 400 mg bottle had an expiration date of 07/2025.5. A bottle of Acidophilus with a date opened date of 06/15/25, the bottle indicated it should be refrigerated after opening but was located on the shelf in the medication room, not refrigerated. 6. Ten tubes of Hemorrhoidal cream had an expiration date of 08/25. I. On 08/13/25 at 12:25 pm, during an interview with LPN #1, she confirmed the expired medications should be properly disposed of and the unrefrigerated medication should have been refrigerated.

Based on observation, record review, and interviews, the facility failed to ensure the nutritional needs and preferences were met for all 61 residents listed on the facility census provided by the Administrator (ADM) on 08/10/25, when staff failed to complete the following: 1. Serve food items that were listed on the menu. 2. Provide residents with the opportunity to select their choice from the menu or alternate menu in advance of meal service. These deficient practices are likely to lead to residents experiencing frustration, depression, and weight loss due to not knowing what food is being served or being able to choose what they eat. The findings are: A. Record review of the posted lunch menu for 08/10/25 revealed the following food items listed to be served:1. Main menu had herb crusted roast pork, dinner roll, baked potato, green beans and onions.2. Alternate item for herb crusted roast pork was meatballs. 3. Dessert was cinnamon cheesecake. B. On 08/10/25 at 12:52 pm, observation of the lunch meal revealed turkey and mashed potatoes, or quiche, dinner roll, and tater tots were served as the meal, with no dessert served. C. On 08/10/25 at 1:00 pm, during an interview with the Dietary Manager (DM), she confirmed the lunch meal served did not match the food items listed on the menu. D. On 08/10/25 at 12:50 pm, an interview and observation with R #8 revealed the following: 1. Meal ticket indicated an egg and sausage casserole with white toast, sliced pears, and oven browned potatoes were to be served. 2. Meal served was observed to include eggs with cheese, a white dinner toll, tater tots and peaches. 3. R #8 stated he doesn't even look at the meal tickets or the menus because the facility doesn't follow it.E. On 08/11/25 at 12:38 pm, observation of the lunch menu revealed a burrito, broccoli salad, dinner roll and a mixed fruit cup to be served. The meal that was served included a burrito, peas, bread slices and sliced bananas instead. F. On 08/11/25 at 1:06 pm, during an interview with the DM, she confirmed that the menu is not always followed, stating the staff do their best to make comparable food items.

Based on observation and interview, the facility failed to maintain the kitchen in a sanitary manner when staff failed to complete the following: 1. Maintain the ice machine in a manner to prevent contamination and foodborne pathogens, 2. Maintain the coffee, juice, and tea machines in a clean and sanitary manner, 3. Properly store food items,4. Maintain the kitchen environment in a clean and sanitary manner.These failures have the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illnesses. The findings are: A. On 08/10/25 at 10:00 am, a random observation of the kitchen revealed the following: 1. The ice machine was approximately three quarters of the way full of ice, had dried residue on the inside of the machine and what appeared to be dried food particles and splatters on the outside of the machine. 2. The coffee, juice, and tea machines were visibly dirty with dried spills and splatters on them.3. A sign on the door of the walk-in refrigerator indicates it is out of service. The walk-in refrigerator contained two boxes of molded biscuits, a box of individual portioned packages of whipped butter spread, one box of corn tortillas, one box of hot dog buns, two gallons of water, and one half used gallon of sweet and sour sauce. 4. The floor in its entirety was visibly dirty with trash, food particles, dried fluid spills, and dirt. 5. The walls and backsplash behind the sink and stove were visibly dirty with spills and splatters. 6. The counter tops in the kitchen were visibly soiled with food particles, trash, and dried spills and splatters on them. B. On 08/10/25 at 10:41 am, an interview with the Dietary Manager (DM) confirmed the following: 1. The ice machine, coffee machine, juice machine, and tea machines are visibly dirty. 2. The floors in the kitchen area were visibly dirty. 3. The food items being stored in the walk-in refrigerator are not stored properly and should be.

Based on observation, record review, and interview, the facility failed to develop and implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by not providing the following:Enhanced Barrier (EBP) signs not visible outside of rooms with precautions,Hand Sanitizing,This failed practice has the potential to result in the spread of infectious diseases and residents to be at risk of contracting infections, hospitalization, and death. The findings are:Enhanced BarriersA. On 08/10/25 at 10:22 am, during a random observation of the facility, Personal Protective Equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) were hanging on the doors outside rooms 200, 202, 205, 215, 217, and 222. Enhanced barrier precaution signs for rooms [ROOM NUMBERS] were not visible and were found tucked behind yellow PPE gowns.B. Record review of Infection control policies and procedures dated 07/15/25, indicated to refer to Centers for Disease Control and Prevention (CDC). C. Record review of CDC guidelines from CDC website Enhanced Barrier Precautions (EBP) in Nursing Homes. Centers for Disease Control. https://www.cdc.gov/infection-control /Webinar-EBPinNH-Nov2022-Slides-508.pdf on Slide number 28 Communication - Use appropriate and legible signs for precautions, the CDC recommends that EBP signs be displayed outside the door of the room where EBP is required. The sign should indicate the type of precaution and PPE to be used during high-contact resident care activities.D. On 08/12/25 at 11:35 am during an interview with Administrator/Infection Control, she stated signs should be in place in a way that they are visible and confirmed they are not. Hand SanitizingD. On 08/11/25 at 12:30 pm, an observation of the lunch dining services revealed the following: 1. CNA #5 touched a resident's right arm/shoulder, picked up a cup that was dropped on the floor, opened the kitchen door that leads to the dirty dishes section, placed the cup in the dirty dish container and then served R #35 lunch without sanitizing or washing her hands. 2. CNA #4 touched her head/hair and neck/shoulder demonstrating something while telling a story then served R #47 her lunch without sanitizing or washing her hands. E. On 08/11/25 at 12:56 pm, during an interview with Registered Nurse (RN) #1, he confirmed that staff should be sanitizing or washing their hands after touching dirty surfaces and handling food trays.

Based on record review and interview, the facility failed to maintain documentation related to staff COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccinations (treatment with a vaccine to produce immunity to a particular infections disease or pathogen) for 4 (CNA #1, CNA #2, CNA #3, and CNA #4) of 4 (CNA #1, CNA #2, CNA #3, and CNA #4) staff members reviewed for COVID-19 vaccinations and at a minimum provide the following:1. Staff were given education of the COVID-19 vaccination regarding the benefits and potential risks associated with COVID-19 vaccine,2. Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine. 3. Staff were given opportunity to decline the COVID-19 vaccination.This deficient practice could likely result in staff not having the knowledge or opportunity to get needed vaccinations. The findings are:CNA #1'sA. Record review of CNA #1's personnel file revealed: 1. The record did not contain CNA #1's COVID-19 immunization history.2. The record did not contain documentation that CNA #1 received education about the COVID-19 vaccination.3. The record did not contain documentation of CNA #1 being given the opportunity to refuse or accept the COVID-19 vaccination. CNA #2B. Record review of CNA #2's personnel file revealed: 1. The record did not contain CNA #2's COVID-19 immunization history.2. The record did not contain documentation that CNA #2 received education about the COVID-19 vaccination.3. The record did not contain documentation of CNA #2 being given the opportunity to refuse or accept the COVID-19 vaccination. CNA #3'sC. Record review of CNA #3's personnel file revealed: 1. The record did not contain CNA #3's COVID-19 immunization history.2. The record did not contain documentation that CNA #3 received education about the COVID-19 vaccination.3. The record did not contain documentation of CNA #3 being given the opportunity to refuse or accept the COVID-19 vaccination. CNA #4D. A. Record review of CNA #4's personnel file revealed: 1. The record did not contain CNA #4's COVID-19 immunization history.2. The record did not contain documentation that CNA #4 received education about the COVID-19 vaccination.3. The record did not contain documentation of CNA #4 being given the opportunity to refuse or accept the COVID-19 vaccination.

Based on observation and interview, the facility failed to ensure essential equipment was in safe operating condition by not cleaning, repairing, or replacing the following: 1. The cleaning solution dispenser above the three-compartment sink.2. The walk-in refrigerator. 3. The freezer located in the kitchen. 4. The water heater located in the kitchen. If the facility does not keep essential equipment in the kitchen in safe operating condition, then all 61 residents residing in the facility (according to the facility census that was provided by the administrator (ADM) on 08/10/25) could experience increase in foodborne illnesses and food not being prepared properly. The findings are:A. On 08/10/25 at 10:00 am, a random observation of the kitchen revealed the following: 1. The cleaning solution dispenser above the three-compartment sink had a cloth tied around it with water pouring from it into the sink. 2. A sign on the door of the walk-in refrigerator indicated it was out of service. The walk-in refrigerator contained two boxes of molded biscuits, a box of individual portion packages of whipped butter spread, one box of corn tortillas, one box of hot dog buns, two gallons of water, and one half used gallon of sweet and sour sauce. 3. The bottom vent of the freezer in the kitchen fell off as the freezer door was opened exposing the wires and mechanical parts under the freezer. B. On 08/10/25 at 10:41 am, an interview with the Dietary Manager (DM) she confirmed that the cleaning solution dispenser located above the three-compartment sink was pouring water from the hose and it is not supposed to. The DM stated that the walk-in refrigerator is not working so it is being used for storage. The DM confirmed the walk-in refrigerator contained two boxes of molded biscuits that need to be disposed of. The DM confirmed the food items stored in the walk-in and stated the walk-in refrigerator does not meet her expectations because it is broken and is being used inappropriately to store food items.

Based on record review and interview, the facility failed to report the results of all investigations to the State Survey Agency within five working days of an incident for 2 (R #32 and R #64) of 2 (R #32 and R #64) residents reviewed for abuse or neglect. If the facility is not submitting the summary of the facility's investigation to the State Survey Agency, then the State Survey Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are:R #32A. Record review of the facility's list of reportable incidents revealed an incident for R #32 dated 05/15/25. Review of this incident revealed the facility received an extension to submit the five-day report, making the due date 05/27/25. B. Record review of the facility's five-day report revealed the facility failed to meet the extended due date as it was completed and submitted to the State Survey Agency on 06/09/25.R #64C. Record review of the facility's list of reportable incidents revealed an incident for R #64 dated 05/12/25. Review of this incident revealed the facility received an extension to submit the five-day report, making it due 05/28/25. D. Record review of the facility's five-day report revealed the facility failed to meet the extended due date as it was completed and submitted to the State Survey Agency on 06/02/25.E. On 08/14/25 at 9:17 am, during an interview with the Administrator (ADM), she stated she is the facility's Incident Coordinator, so it is her responsibility to ensure every allegation of abuse and neglect is investigated and to submit the follow-up report to the State Survey Agency within five days. The ADM confirmed that did not happen for the incident regarding R #32 on 05/15/25 and for the incident regarding R #64 on 05/12/25.

Based on observation, interview, and record review, the facility failed to ensure staff revised the care plan for 1 (R #32) of 3 (R #9, R #32, and R #65) residents reviewed when staff failed revise R #34's care plan to include elopement risk and use of a wander guard (wearable technology used to keep residents from wandering or eloping from the facility unattended). This deficient practice is likely to result in residents' care and needs not being addressed. The findings are: A. Record review of R #32's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Other pulmonary embolism (a blood clot that blocks blood flow to an artery in the lungs),2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 3. Schizoaffective disorder (a mental condition that causes both psychosis and mood problems),4. Essential (primary) hypertension (HTN; high blood pressure),B. On 08/10/25 at 11:00 am an observation of R #32 revealed a wander guard located on R #32's wheelchair. C. Record review of R #32's progress note dated 07/01/25 revealed R #32's guardian was contacted and approved of the use of a wander guard due to increased elopement behaviors by R #32. D. Record review of R #32's care plan dated 04/08/25 revealed the care plan did not contain any indication of R #32's elopement risk or use of a wander guard. E. On 08/13/25 at 1:15 pm, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed the following: 1. R #32 does use a wander guard due to an increase in elopement behaviors. 2. R #32's care plan does not include R #32's elopement risk or use of a wander guard.

Based on observation, interview, and record review, the facility failed to keep residents free from physical restraints for 1 (R #4) of 1 (R #4) resident reviewed for restrictions when staff used a wander guard (wearable technology used to keep residents from wandering or eloping from the facility unattended) for a resident that no longer needs a wander guard. This deficient practice could likely result in R #4 being unnecessarily restricted. The findings are: A. Record review of R #4's admission Record revealed R #4 was admitted to the facility on [DATE], with the following diagnoses:1. Dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance (marked by a severe decline in cognitive functions, such as thinking, reasoning, and remembering, to the extent that it interferes with the person's daily life), 2. Thyrotoxicosis, unspecified without thyrotoxic crisis or storm (too much thyroid hormone in your body. Common symptoms include unexplained weight loss, a rapid heart rate and shakiness),3. Gastroesophageal reflux disease (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining),4. Longterm (current) use of insulin (an essential hormone that helps your body turn food into energy and manages your blood sugar levels),5. History of falling,6. Need for assistance with personal care.B. Record review of R #4's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 06/18/25, revealed:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 12 (mildly impaired). 2. Section E-Behavior revealed R #4 is not at risk for wandering.C. Record review of R #4's elopement evaluation dated 07/23/25 revealed R #4 does not have a history of elopement, nor has he attempted to leave the facility without informing staff.D. On 08/13/25 at 1:08 pm observation of R #4 revealed he had a wander guard on his right ankle. E. On 08/13/25 at 1:09 pm during an interview with R #4, he stated he wasn't sure why he had a wander guard on. F. Record review of R #4's current physician orders revealed an order dated 02/10/25 for R #4 to wear a wander guard on his left ankle for poor safety awareness. G. On 08/13/25 at 1:22 pm during an interview with the Administrator (ADM), she stated R #4 does not exhibit any behaviors for a wander guard and should not have one in place. H. On 08/13/25 at 1:23 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated R #4 does not exhibit any signs of wandering and should not have one in place. I. On 08/13/25 at 1:24 pm during an interview with Certified Rehabilitation Counselor (CRC) #1, she stated R #4 does not exhibit any behaviors that would require a wander guard and agreed he should not have one in place.

Based on observation and interview, the facility failed to post nurse staffing data daily, at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Registered nurses. 2. Licensed practical nurses. 3. Certified nurse aides. 4. Resident census. This deficient practice could likely result in residents and visitors not having the staffing information readily available. The findings are:A. On 08/10/25 at 10:00 am, an observation of the main entrance revealed the nurse staffing data sheet was dated 08/08/25. B. On 08/13/25 at 1:22 pm, during an interview with the Administrator, she confirmed the nursing staffing data sheet should be posted daily and it was not.

Based observation, record review, and interviews, the facility failed to ensure residents were free from significant medication errors by not administering medications as ordered for 1 (R #2) of 1 (R #2) resident reviewed for medication administration. This deficient practice could likely lead to severe negative effects on the residents. The findings are: A. Record review of R #2's admission Record revealed she was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease (PVD; poor circulation) and heart failure. B. On 08/13/25 at 11:15 am, an observation and interview with R #2 revealed that she had not received her Lidocaine External Patch and she had no wraps on her legs. C. Record review of R #2's current physician orders revealed the following orders:1. Lidocaine external patch to be applied to her upper back topically in the morning for back pain, end date of 08/31/25.2. An order dated 01/03/25 to wrap R #2's bilateral legs with an ACE bandage daily for edema (swelling caused by excess fluid) and is to be completed daily at 6:00 am.D. Record review of R #2's Medication Administration Record (MAR) for the month of August 2025 revealed Licensed Vocational Nurse (LVN) #4 signed the MAR on 08/13/25 at 10:13 am that indicated the following 1. She applied the Lidocaine external patch on R #2's back. 2. She wrapped R #2's bilateral legs with ACE bandages at 6:00 am. E. On 08/13/25 at 11:23 am during an interview with the Unit Manager (UM) #1, she confirmed R #2 had not received her Lidocaine external patch and that her legs were not wrapped. UM #1 confirmed that LVN #4 signed R #2's MAR indicating that both orders were followed, and they were not. The UM confirmed that LVN #4 not following medical orders and indicated on the MAR that she had, is considered a significant medication error that should not have occurred.

Based on record review and interview, the facility failed to conduct an in-dept investigation, correct the grievance allegations, and notify residents of the outcome of their grievances. These deficient practices have the potential to affect all 62 residents (residents were identified using the census provided by the Administrator on 05/28/25) residing in the facility. If the facility is not investigating, correcting, and notifying residents of their grievance allegations then residents are likely to feel unheard and unimportant. The findings are: A. On 05/28/25 at 10:45 am during an interview with R #1, he stated that he has filed several grievances with the facility regarding the food and has never received an outcome. B. On 05/28/25 at 11:15 am during an interview with R #2, he stated that he has filed several grievances with the facility regarding several issues and has never received an outcome. C. On 05/28/25 at 1:40 pm during an interview with R #6, she stated that she has filed a couple grievances with the facility regarding food and showers and has never received an outcome. D. Record review of the facility's Grievance/Concern policy dated 06/01/22 revealed facility staff are to document all grievances and provide a response to the resident. E. On 05/28/25 at 2:43 pm during an interview with the Administrator (ADM), she stated that she is not able to provide evidence of grievances, the investigations, correction of the allegation or communicating outcomes to residents because the previous Social Services Director took the Grievance binder. The ADM stated that as of 05/01/25 a new binder was started.

Based on observation and interview, the facility failed to secure medications in a medication cart and a treatment cart for all 62 residents living in the facility (residents were identified by the census list provided by the Administrator on 05/28/25). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: A. On 05/28/25 at 1:45 pm, an observation of the facility revealed the medication cart was located by room [ROOM NUMBER] and was unlocked. B. On 05/28/25 at 1:46 pm, during an interview Licensed Practical Nurse (LPN) #1, she confirmed that the medication cart was unlocked. C. On 05/29/25 at 10:11 am, an observation of the facility revealed the treatment cart was in the 200 hall near the nurse's station and was unlocked. D. On 05/29/25 at 10:13 am, during an interview LPN #2, she confirmed that the medication cart was unlocked. E. On 05/29/25 at 11:20 am, during an interview with the Director of Nursing (DON), she stated that all medication carts should be locked when unattended.

Based on record review, interview, and observation, the facility failed to serve food that is palatable, attractive, and at a safe and appetizing temperature. This deficient practice has the potential to affect all 62 residents' ability to eat and enjoy their meals, may decrease their quality of life, and could likely lose weight. The findings are: A. Record review of R #1's admission record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Spinal Stenosis, cervical region, 2. Type 2 diabetes mellitus with hyperglycemia 3. Depression, unspecified, 4. Chronic diastolic (congestive) heart failure. B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/18/24, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. C. On 05/28/25 at 10:45 am, during an interview with R #1, he stated that the food does not taste good, food that is supposed to be hot is served cold, and the facility does not follow the menu. D. Record review of photos that R #1 has taken of meals that he was served and the meal ticket (a facility document that shows information related to a resident's diet recommendations, allergy status, and individual specific menu for that resident's meal) for the meals revealed the following: 1. A meal ticket dated 02/27/25 indicated the breakfast meal to be French toast, but the photo of the meal showed some type of Danish (a type of pastry). 2. A meal ticket dated 02/28/25 indicated oven browned potatoes were to be served with a beef chili and rice casserole but the photo showed potatoes were not served. 3. A meal ticket dated 03/01/25 indicated Toasted O's (dry cereal), scrambled eggs with ham, and wheat toast was to be served for breakfast but the photo showed oatmeal, scrambled eggs without ham, and a biscuit was served. 4. A meal ticket dated 03/01/25 indicated a dinner roll, pan fried potatoes, and herbed green beans were to be served with crunchy buttermilk chicken, but the photo of this meal showed a piece of bread, mixed vegetables, and mashed potatoes were served. 5. A meal ticket dated 03/03/25 indicated Toasted O's, a banana, and French toast was to be served for breakfast, but photo of this meal showed oatmeal, a pancake and eggs were served. 6. A meal ticket dated 03/05/25 indicated Toasted O's and hash browns were to be served with scrambled eggs but the photo of the meal showed oatmeal, scrambled eggs and biscuit with gravy was served. 7. A meal ticket dated 03/05/25 indicated cranberry glazed chicken with a dinner roll, cinnamon apples, Brussel sprouts and stuffing was to be served but the photo of this meal shows what appears to be a casserole, with mixed vegetables, and mashed potatoes was served. 8. Meal ticket dated 03/08/25 indicated a chicken casserole and sliced carrots with a chocolate chip cookie was to be served but the photo of this meal shows what appears to be a casserole, a slice of bread and pinto beans was served. 9. A meal ticket dated 03/09/25 that indicated maple sage turkey was to be served with a dinner roll, homemade pumpkin pie, seasoned peas and cornbread dressing but the photo shows turkey was served with rice, mixed vegetables, a piece of bread, and an oatmeal pie cookie was served for lunch. 10. A meal ticket dated 03/09/25 that indicated beef barley soup, tossed salad, herb crusted chicken, a dinner roll and sliced pears was to be served but the photo of the meal shows spaghetti, a slice of bread, coleslaw and a cup of fruit was served. E. On 05/28/25 at 11:15 am, during an interview with R #2 he stated that the hot food is served cold and the food does not taste good. He stated that he has to buy his own food and keep it in his room, so he has something to eat when the food from the facility is inedible. F. On 05/28/25 at 12:15 pm, an observation of the lunch meal revealed the following: 1. Chicken on a room tray that was served to R #2 had an internal temperature of 109.3 degrees. 2. Pizza (alternative food offered) had an internal temperature of 112.6 degrees. G. On 05/28/25 at 12:15 pm, during an interview with Certified Nursing Assistant (CNA), #1, she confirmed the temperature of the chicken was 109.3 degrees and the temperature of the pizza was 112.6 degrees. H. On 05/28/25 at 12:33 pm during an interview with Dietary Aide (DA), she confirmed that the temperatures taken for the pizza and chicken were not appropriate temperatures for food to be served at.

Based on observation and interviews, the facility failed to provide a comfortable and homelike environment by: 1. Not repairing the peeling and chipped paint, 2. Not repainting areas of repair to match the rest of the wall, 3. Handrails in the 200-hall appeared worn and needed repair/refinishing, 4. Using an overhead paging system to announce phone calls for staff members and to call staff members to the office. These deficient practices could affect everyone that lives in the 200-hall as identified by the Daily Census provided by the Administrator (ADM) on 05/28/25 and will likely cause residents to feel like they are not living in a comfortable home-like environment and make them feel they are not valued. The findings are: A. On 05/29/25 at 9:36 am a random observation of the facility revealed the following: 1. Peeling and chipped paint on the walls throughout the 200-hall. 2. A section of the wall, close to the therapy entrance, approximately two feet wide and one foot tall, where it appears an object once hung on the wall is not repainted to match the rest of the wall. 3. Handrails in the 200-hall appeared worn out and needed repair/refinishing. B. On 05/28/25, random observations of the facility revealed the following announcements using the overhead paging system: 1. 2:53 pm: a staff member had a call on line one. 2. 3:00 pm: a staff member was called to the office. C. On 05/29/25, random observations of the facility revealed the following announcements using the overhead paging system: 1. 9:55 am: maintenance was called to the office 2. 10:00 am: a staff member had a call on line one. 3. 10:17 am: a staff member had a call on line one. 4. 11:21 am: maintenance was called to the office. 5. 11:27 am: a staff member had a call on line one. D. On 05/29/25 at 1:15 pm, during an interview with the Administrator (ADM), she confirmed the facility is not providing an environment that is as comfortable and homelike as she would like.

Based on interview, the facility failed to have evidence that all allegations of abuse, neglect, exploitation or mistreatment were thoroughly investigated to prevent further incidents from occurring. This deficient practice could likely affect all 62 residents residing in the facility according to the census provided by the Administrator (ADM) on 05/28/25. If the facility is not thoroughly investigating and maintaining evidence of the investigations then residents are at a higher risk of being abused, neglected, exploited, or mistreated. The findings are: A. On 05/28/25 at 2:43 pm during an interview with the Administrator, she stated that she does not have evidence of any investigations conducted since 01/01/25 due to the previous Social Services Director taking the Reportable Binder (a binder the facility uses to keep all documentation and evidence of investigations) when she left. The ADM confirmed that she had to start a new binder as of 05/01/25.

Based on interviews and record reviews, the facility failed to ensure the comprehensive care plan was accurate for 2 (R #1 and R #7) of 2 (R #1 and R #7) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the residents. The findings are: R #1 A. Record review of R #1's admission record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Spinal Stenosis, cervical region (narrowing of one or more spaces within the spinal canal), 2. Type 2 diabetes mellitus with hyperglycemia (blood sugar levels rise significantly), 3. Depression, unspecified, 4. Chronic diastolic (congestive) heart failure. B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/18/24, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. C. Record review of R #1's care plan dated 12/05/24 revealed that R #1 has an advance directive of (do not resuscitate) DNR; lifesaving measures are not desired) code status in place. D. Record review of R #1's New Mexico Orders for Scope and Treatment (MOST) form dated 07/30/24 revealed that R #1 has an advance directive of attempt resuscitation code status in place. E. On 05/29/25 at 12:20 pm during an interview with the Director of Nursing (DON), she confirmed that the facility failed to revise the care plan for R #1 after returning from the hospital. R #7 F. Record review of R #7's admission record revealed R #7 was originally admitted to the facility on [DATE] with the following diagnoses: 1. Acute respiratory failure with Hypoxia (not enough oxygen or too much carbon dioxide in the body), 2. Essential hypertension (HTN; high blood pressure), 3. Diverticulosis of Intestine, Part Unspecified, without perforation (inflammation/infection of somewhere in the intestine, without a hole in the intestine), or without Abscess without Bleeding, 4. Type 2 Diabetes Mellitus without Complications (too much sugar in the blood) 5. Muscle Weakness. G. Record review of R #7's care plan, dated 12/04/24, revealed the following: 1. Intervention for R #7 to have the choice between bed baths or showers twice per week. 2. Bathing Preference Sheet was updated to bathing once a week. 3. The facility failed to revise the care plan to reflect the change in bathing and showering. H. Record review of R #7's MOST form dated 02/28/25 revealed R #7 has an attempt resuscitation code status in place. I. Record review of R #7's care plan dated 02/28/25 revealed R #7 has a do not resuscitate code status in place. J. On 05/29/25 at 12:20 pm during an interview with the DON, she confirmed R #7 should have had a care plan for refusals of care and she does not. The DON confirmed that R #7's care plan should have been revised to match the most current MOST form, and it was not.

Based on record review and interview, the facility failed to provide pain relief for 8 hours since admission to the facility for 1 (R #1) of 3 (R #1, R #5, and R #8) residents reviewed for pain. This deficient practice likely resulted in R #1 experiencing significant pain which led to her calling 911 for relief and discharging from the facility against medical advice. The findings are: A. Record review of R #1's Admission Record revealed the resident was admitted on [DATE] following hip surgery on 10/22/24. B. Record review of R #1's physician's order, dated 10/25/2024 at 4:15 pm, revealed the following orders: - Gabapentin (nerve pain medication and anticonvulsant), 400 milligram (mg), oral tablet three times a day for neuropathic pain, as needed (PRN), - Norco (hydrocodone-acetaminophen; opioid pain medication), 7.5-325 mg, every six hours for pain, - Ibuprofen (anti-inflammatory and pain medication), 800 mg, every eight hours PRN. - The record did not contain an order for Tylenol (acetaminophen; pain medication) 500 mg. C. Record review of R #1's progress note, dated 10/26/24 at 7:45 am (progress note indicated the time of occurrence was at 9:00 pm on 10/25/24, but note was written the next morning as per timestamp) and written by LPN #1, revealed the nurse walked into R #1's room on 10/25/24 at 9:00 pm to conduct a new resident assessment and to ask if R #1 needed anything. Resident told the nurse she needed gabapentin and hydrocodone (Norco). The nurse told R #1 that she could administer two Tylenol 500 mg to the resident while they waited for the pharmacy delivery, which was normally by 10:00 pm to 10:30 pm. D. Record review of R #1's nursing progress note, dated 10/25/24 at 6:35 pm, revealed the resident complained of pain at a level eight (pain scale 0-10, 10 was the worst pain.) The non-medication interventions did not provide relief and PRN pain medication was provided. E. Record review of R #1's Medication Administration Record (MAR), dated 10/25/24, revealed staff did not administer any medications to R #1 during her stay. Further review of the MAR revealed it did not contain an order for Tylenol, 500 mg. F. On 01/02/25 at 5:42 PM, during an interview with R #1's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care), she stated her sister arrived at the facility on 10/25/25 around 1:00 pm. She stated her sister called her around 8:30 pm or 9:00 pm, and her sister was screaming that she had not gotten anything for pain . since she got there. The POA stated she called 911 so they could take her back to the emergency room (ER) to be assessed and to given pain medications. The POA stated R #1 discharged at approximately 9:30 pm. G. Record review of R #1's Discharge Against Medical Advice (AMA) form (used when a resident wants to leave the facility against medical advice), dated 10/25/24 at 9:30 pm and signed by LPN #1, revealed R #1 refused to sign the form and left the facility AMA. The form indicated resident called EMS (Emergency Medical Services) to pick her up, because facility could not provide her with pain medication. Resident extremely upset and she could not stay. Res [resident] using profanity while on the phone with her sister. H. On 01/02/2025 at 5:15 PM, during an interview with the Director of Nursing (DON), she stated narcotic pain medications should be available through the facility's Nexus (a medication dispensing machine containing a variety of medications for residents) and an E-Kit (emergency medication lock box that contains various controlled medications) found in the medication room. She stated residents should not have to wait for pain medication to arrive from the pharmacy if the resident experienced pain. I. On 01/02/2025 at 5:11 PM, during an interview, the Assistant Director of Nursing (ADON) stated pain medications were available for new residents before their medications arrived from the pharmacy by accessing the Nexus.

Based on observation, interview, record review, and facility policy review, the facility failed to: 1. Ensure the environment was free of accident hazards when water temperatures were not maintained at a safe temperature level for six of 20 residents (Resident (R) 31, R23, R43, R22, R18, and R41) residing on the dementia care unit. 0n 07/19/24, water temperatures at the hand washing sinks on the dementia care unit were recorded to be 123.4 degrees Fahrenheit (F). Water temperatures were adjusted but no monitoring occurred. On 07/24/24, water temperatures in two resident bathrooms were noted to be 122 degrees F and 125 degrees F. The water temperatures were not adjusted after water was measured to be in excess of 120-degree F. The failure to maintain water temperatures at a safe level had the potential to cause serious burns or injuries for the residents, and 2. Provide supervision to prevent accidents related to falls for one of three residents (R42) reviewed for falls out of total sample of 23. The facility failed to assess R42 after falls and failed to attempt to identify and implement interventions to prevent future falls and/or injury. This had the potential to cause R42 to sustain additional falls and injury. The facility's failure to ensure the environment was free of accident hazards by not maintaining safe water temperatures placed residents at continued risk of serious injury, harm, or impairment. Immediate Jeopardy at S483.25(d) - Accidents, at a Scope and Severity of a J, was identified on 07/24/24 and was determined to exist on 07/19/24 when hot water temperatures in excess of 120-degree F were first noted on the dementia care unit, and resident rooms were not monitored for safe water temperatures. The Administrator and Director of Nursing (DON) were informed on 07/25/24 at 4:28 PM. The facility provided an acceptable removal plan on 07/25/24 at 8:15 PM. The survey team validated implementation of the removal plan through observations of water temperatures, review of education documentation, and by interview with staff and the professional plumber. Immediate Jeopardy was removed on 07/26/24 at 3:17 PM. After removal of the Immediate Jeopardy, the deficiency remained at an E scope and severity for a pattern of potential harm. Findings include: 1. Water Temperatures a. Review of R31's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/24 and located under the MDS tab of the electronic medical record (EMR) revealed R31 was admitted to the facility on [DATE] and had severely impaired cognition. It was recorded R31was able to walk independently. Review of R31's Diagnosis tab of the EMR revealed R31 had diagnoses that included diabetes mellitus, dementia, and depression. R31 resided on the dementia care unit. Review of R28's quarterly MDS, with an ARD of 03/21/24 and located under the MDS tab of the EMR, revealed R28 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated he was moderately cognitively impaired. It was recorded R28 utilized a wheelchair for mobility. Review of R31's Diagnosis tab of the EMR revealed R28 had diagnoses that included hemiplegia and depression. R28 resided on the dementia care unit. During an observation on 07/24/24 at 1:15 PM, the water temperature at the bathroom sink utilized by R31 and R28 was checked with the Maintenance (MD) using his thermometer. The water temperature was 122 degrees F. On 07/24/24 at 3:10 PM, Certified Nurse Aide (CNA) 1 stated R31 could turn the water on independently and R28 needed assistance with turning the water on. b. Review of R43's quarterly MDS, with an ARD of 05/27/24 and located under the MDS tab of the EMR, revealed R43 was admitted to the facility on [DATE] and was severely impaired in cognitive skills for daily decision making and was independent with walking. Review of R43's Diagnosis tab of the EMR revealed R43 had diagnoses that included schizophrenia, dementia with other behavioral disturbances, and cognitive communication deficit. Review of R22's significant change MDS, with an ARD of 06/14/24 and located under the MDS tab of the EMR, revealed R22 was readmitted to the facility on [DATE] and had a BIMS score of six out of 15, which indicated R22 was severely cognitively impaired. It was recorded R22required supervision with walking. Review of R22's Diagnosis tab of the EMR revealed R22 had diagnoses that included post-traumatic stress disorder, major depressive disorder, psychosis, anxiety disorder, and dementia. R22 was observed ambulating independently on 07/23/24 and 07/24/24. Review of R18's annual MDS, with an ARD of 04/06/24 and located under the MDS tab of the EMR, revealed R18 was admitted to the facility on [DATE] and was severely impaired in cognitive skills for daily decision making. It was recorded R18 walked independently. Review of R18's Diagnosis tab of the EMR revealed R18 had diagnoses that included Alzheimer's disease and depression. Review of R41's quarterly MDS, with an ARD of 05/16/24 and located under the MDS tab of the EMR, revealed R41 was admitted to the facility on [DATE] and was severely impaired in cognitive skills for daily decision making. It was recorded R41 was unable to walk. Review of R41's Diagnosis tab of the EMR revealed R41 had diagnoses that included Alzheimer's disease and dementia. During an observation on 07/24/24 at 1:23 PM, the water temperature at the bathroom sink used by R43, R22, R18 and R41 was checked with the MD using the facility thermometer, and it was noted to be 125 degrees F. On 07/24/24 at 3:10 PM CNA1 stated R43 could turn the water on independently, and she felt the resident could ensure the water was not too hot. CNA1 stated R22 could only turn the water on with help. She stated R18 and R41 did not turn the water on independently but potentially could. c. Review of temperature monitoring logs, provided by the facility, revealed water temperatures were taken on 10 days during the previous three months. There was no documentation that water temperatures were taken in any resident room. It was recorded that on 07/19/24, the hot water temperatures in the North Hall Sink and South Hall Sink were 123.4 F. There was no documentation that water temperatures were tested in any resident rooms after the water was noted to be 123.4 F on 07/19/24 or that any monitoring occurred. During an interview on 07/25/24 at 8:25 AM, the MD stated he could not find a policy related to hot water temperatures, but he had been informed the water temperatures should be maintained between 110 F and 120 F. The MD stated on 07/19/24, he did adjust the hot water temperature and checked the temperature at the sinks in residents' bathrooms close to the North and South Hall sinks, but he did not document those results. The MD confirmed he did not check the hot water temperature in resident rooms unless the hot water temperatures at the hand sinks on the North and/or South halls exceeded 120 F. The MD stated that he had not monitored the resident room water temperatures after 07/19/24 until checking with the surveyor on 07/24/24. On 07/25/24 at 10:51 AM, the MD was asked to recheck the water temperatures at the bathroom sinks for R32, R28, R43, R22, R18, and R41. The MD obtained the water tempertures and reported they were 119 degrees F. He stated he did not adjust the hot water temperatures on 07/24/24 after the temperatures obtained were more than 120 F. The MD stated he adjusted the hot water on this date, 07/25/24, right after he learned of the surveyor's request to recheck them. During an interview on 07/26/24 at 3:17 PM, the plumber who came to service the water heaters stated the hot water heater servicing the dementia care unit needed a new mixing valve. He stated the hot water temperatures were steady at 110 degrees F for now. Review of the facility's policy titled, Preventive Maintenance Policies and Procedures PM202 Hot Water Temperatures: Inspection, with a revision date of 01/08/24, revealed the policy was to test water temperatures daily. The policy recorded, . Conduct test in at least three locations . These locations should be the closest, median, and farthest points from the source . If the temperature does not meet State or Local regulations, the facility will investigate and adjust the mixing valve . 2.Falls Review of R42's significant change MDS, with an ARD of 06/30/24 and located in the MDS tab of the EMR, revealed R42 was admitted to the facility on [DATE] and had a BIMS score of five out of 15, which indicated he had severe cognitive impairment. It was recorded R42 had inattention and disorganized thinking; had functional limitation in range of motion to both lower extremities; required substantial/maximal assistance with dressing, personal hygiene, lying down, and transfers; did not walk; and was always incontinent. It was recorded R42 had falls with injuries since the prior assessment. Review of R42's Diagnosis tab of the EMR revealed R42 had diagnoses that included alcoholic cirrhosis of the liver, encephalopathy, vascular dementia with agitation, major depressive disorder, hepatic encephalopathy, post-traumatic stress disorder, chronic migraine, paranoid schizophrenia, cognitive communication deficit, muscle weakness, abnormalities of gait and mobility, and a history of falling. Review of R42's Care Plan, dated 05/05/23 and located under the Care Plan tab of the EMR, revealed a problem related to being at risk for falls due to cognitive loss, lack of safety awareness, history of falling, bilateral primary osteoarthritis of knee, and sleep apnea. Interventions included a bed in low position and fall mats with a created date of 07/02/24; to provide safe place for the resident to lie on the floor with a created date of 07/02/24; to assist to organize belongings for a clutter-free environment in resident's room; and to encourage to attend activities. Review of R42's Progress Notes tab of the EMR and/or Incident Reports, provided by the facility revealed the following: A progress note, dated 06/05/24 and timed 3:08 PM, recorded the writer heard a loud noise then R42 called out, I fell down. Upon entering the room, R42 was sitting on the floor at the side of his bed. According to the note, the resident was not injured. A paper Fall incident report, dated 06/08/24 and timed 11:36 PM, recorded two nurse aides found the resident on the floor. The note recorded the fall had not been witnessed. R42 stated he needed to use the toilet, was walking across the room, and when he was in the doorway, he lost his balance and fell beside his toilet. According to the report, R42 had no visual injuries but stated he hit his head. A progress note, dated 06/09/24 and timed 2:17 AM, recorded two nurse aides found the resident on the floor. The note recorded the incident was not witnessed, and the resident claimed he hit his head and denied pain. A social service progress note, dated 06/20/24 and timed 11:24 PM, recorded the Social Service Director (SSD) was visiting another resident in the dementia care unit when the SSD heard R42 calling from his room. The SSD observed R42 lying on the floor outside of his bathroom. According to the note, the resident stated it was because he had a migraine. The SSD wrote she informed the south nurse and the nurse aide regarding the resident being on the floor. Review of the EMR revealed there was no nursing documentation related to this fall. A nursing note, dated 06/29/24 and timed 10:33 AM, recorded while the nurse was assisting with care, she noted a very large bruise to the left buttocks. The nurse wrote, . the bruise covers left buttocks and smaller bruise noted to left hip .Also, small spot noted to top of head with a small amount of blood noted . A nursing note, dated 06/29/24 and timed 5:46 PM, recorded clarification to the previous note and stated the area on the top of R42's head was soft, but the resident would not allow the nurse to touch it. The medical record was reviewed in its entirety and was silent for an investigation into how the injuries occurred or any additional interventions to prevent further injuries. A nursing progress note, dated 6/29/24 and timed 9:15 PM, recorded the resident fell on the floor in his room and hit his head. His pants and briefs were around his ankles. R42 stated he needed to use the bathroom. The note recorded he had a recent change in condition and was no longer aware of safety risks and the decline in physical abilities to do things. R42's EMR was reviewed in its entirety and was silent for further assessment of this fall or of additional interventions put in place to prevent further falls or injuries. A progress note, dated 07/13/24 and timed 8:14 PM, recorded the nurse aides reported that R42 had a small bruise and hematoma to the left side of his head. It was recorded that the writer had noted a large bruise on R42's forehead and the top of his head when she arrived on shift. She wrote there was no documentation of the bruise on the right side of the forehead and the top of his head. She wrote, . not sure how this resident ended up with these bruises. He was on the floor crawling around most of the night but stated he thinks he must have hit his head on the floor when he climbed out of bed but is not totally sure. The EMR was reviewed in its entirety and was silent for an assessment of how R42 could have obtained the hematoma and bruises. A nursing progress note, dated 07/20/24 and timed 6:31 AM, recorded upon receiving report from the night nurse, the night shift CNAs voiced to this nurse that R42 had a lot of bruising to right side of face. The nurse wrote upon entering the room, bruising was noted to the right side of his face, nose, eye, forehead, cheek, and the top of his head. It was recorded, . The bruising is red and purple in color. Resident is unable to tell me what happened at this time. Bruising also noted to bilateral knees and bilateral arms . The fall incident report, dated 07/20/24 and timed 6:31 AM, stated upon arriving to the evening shift it was noted the resident had swelling around the right eye and forehead. The note recorded the day nurse said he had been on the floor throughout the day but did not know what happened. The note recorded the swelling and bruising became extremely worse. The EMR was reviewed in its entirety and was silent for an assessment of how he potentially obtained the hematoma and bruises. A nursing note, dated 07/21/24 and timed 5:00 PM, recorded the resident was found lying on floor mat with his feet facing towards this bed and his head towards the roommates' bed near the wall. It was recorded R42 already had bruising to the right side of his face, and he stated he was trying to pull the call light out of the wall so it could call 911 because he had a migraine headache. During an observation on 07/23/24 at 10:32 AM, R42 was seen sitting on the floor in his room, holding onto the wall close to the bathroom and across the room from his bed. Staff were immediately notified and Licensed Practical Nurse (LPN) 2 and Certified Nurse Aide (CNA) 2 came down to the room with the gait belt. They lifted him up into the wheelchair with the gait belt and asked him if he wanted to go to the common area or to bed or in room and he stated no to all the questions. CNA2 stated he had been in bed prior to finding him on the floor. The bed was low, and the fall mat was beside the bed; however, the call light was not in reach as it was clipped to the wall and not within reach of his bed. LPN2 verified the call light was not in reach. LPN2 and CNA2 stated R42 typically did not use the call light by his bed and would attempt to go into the bathroom to pull the bathroom call light. They left the room leaving the resident in his room in a wheelchair by the window. CNA2 and LPN2 both stated R42 frequently got out of bed and attempted to walk or crawl around on the floor. R42 was noted to have fading bruise to his right eye, right side of his face, and the top of his forehead. During an interview on 07/25/24 at 2:30 PM, the DON was interviewed about R42's incidents. When ask if R42 had any interventions added to his care plan after the falls, the DON stated he was moved from the 200 unit to the last room on the dementia care unit, furthest way from the nursing station; had floor mats and low bed put in place on 06/04/24; and had some blood draws/laboratory completed on 06/12/24. Continuing with the interview on 07/25/24 at 2:30 PM, the nursing progress notes dated 06/20/24 and timed 11:24 PM; 06/29/24 and timed 9:15 PM; 06/29/14 and timed 10:33 AM; 07/13/24 and timed 8:14 PM; 07/20/24 and timed 6:31 AM; 07/21/24 and timed 5:00 PM were reviewed with the DON. The DON was unable to provide any additional documentation to show assessments were completed to determine the cause of R42's bruising or that any additional interventions were put in place to prevent further falls and/or injuries. The DON stated that she and her staff discussed moving him to a private room closer to the nursing station earlier that week; however, they had not moved him. During an interview on 07/26/24 at 10:58 AM, the Social Worker from R42's hospice company stated she had been providing services for the resident since he was admitted to hospice on 06/24/24. She stated she was very concerned about the bruising the resident had. She stated the staff tell her he crawls around on the floor. She stated that on 07/02/24 at 3:00 PM she had a meeting with the facility social worker and a Registered Nurse, and during the meeting they discussed the falls and injuries. The hospice social worker stated she was told they would move R42 to a room closer to the nursing station.

Based on record review, observations, and interviews, the facility failed to prevent accidents by not ensuring 1 (R #1) of 14 (R #'s 1-14) residents reviewed for therapeutic diets, were receiving the proper therapeutic diet (diet consistency to meet resident ability to consume it) and failed to implement corrective measures to ensure residents receive their order therapeutic diets following the choking incident. This failure likely resulted in R #1 to have a choking episode and loss of consciousness (ability to be aware) requiring medical intervention. The findings are: A. On 12/20/22 at 12:54 pm, during an interview the Complainant stated that during a visit on 12/14/22 to the facility she was told of an incident (12/13/22) where a resident (R #1) had suffered a choking incident, and that he was receiving the wrong texture diet from the kitchen. The Complainant stated that she spoke to R #1 who had stated that he was ok, but that it was scary. B. Record review of facility face sheet for R #1 revealed he was admitted on [DATE] with diagnosis which included: Cellulitis Of Left Lower Limb (skin infection in left leg), Seizures (uncontrolled muscle spasms), Traumatic Brain Injury (brain damage), Major Depressive Disorder (feeling of sadness), Bipolar Disorder (mood swings), Dysphagia (difficulty swallowing), Hypertension (high blood pressure), Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side (partial paralysis after a stroke), Gastro-Esophageal Reflux Disease (acid reflux), Cognitive Communication Deficit (difficulty communicating), Long Term Use Of Opiate Analgesic (long use of high risk medication), Acute Respiratory Failure With Hypoxia (stopped breathing with loss of oxygen to the brain), Need For Assistance With Personal Care (help with care), Vascular Dementia with Behavioral Disturbance (memory loss with behaviors). C. Record review of current swallowing care plan, dated 12/15/22, for R #1, revealed the following: Focus: R #1 is at risk for impaired swallowing related to dysphagia; Resident choked on dinner and was sent to hospital and admitted on [DATE]. R #1 choked on ham during breakfast, Heimlich was performed and resident sent to ER (emergency room ) for further evaluation on 12/13/22. D. Record review of dietary orders dated 09/19/22 for R #1 revealed a therapeutic diet of dysphasia - advanced (chopped meat/mechanical soft pieces no bigger than 1/2 inch). E. Record review of Complaint NM-00063366 revealed that R #1 had received an incorrect meal consistency (whole meats) during the breakfast meal on 12/13/22, in which he tried to consume full size portion of breakfast meat causing a choking episode with loss of consciousness. F. Record review of Complaint NM-00063365 (related facility self report) revealed that the Heimlich Maneuver was initiated on R #1 by the charge nurse and RA (Restorative Aide) #1 during the choking episode. G. Record review of nursing progress notes for R #1 Revealed the following: 12/13/2022 at 12:00 pm, General Note: Staff alerted this nurse that resident was given wrong diet consistency for breakfast and had noticed he had some food in his mouth. This nurse brought plate into kitchen to get a new plate with correct consistency. Staff alerted this nurse that resident started to choke on food, and yelled for help. This nurse and Restorative Aide attempted to get resident to cough up food. Back thrusts were administered, no success. CNA (Certified Nurse Assistant), Restorative Aide and this Nurse lowered resident to floor and continued back thrusts with knee and chest thrusts simultaneously. Additional staff brought crash cart down for oxygen and suction as needed. Resident turned blue in face during these attempts. Additional nurse assisted was able to get resident to vomit and food was released. Color returned to resident's face and was able to get some words out and gestured to his throat that there was another piece. High flow O2 (Oxygen) applied to via face mask when EMS (Emergency Medical Services) arrived and took over. Attempted to call (name), POA (Power of Attorney). Unable to reach and left a voicemail. PCP (Primary Care Physician) was also notified. H. On 12/20/22 at 1:35 pm, during an interview the Administrator/Center Executive Director (ADM/CED) stated that he did remember the incident of resident (R #1) choking. He stated that he had been the ADM/CED since August 2022 for the building. He stated that the Dietary Manager (DM #1) was the one on during that time, and DM #1 had been hired on 12/01/22. He stated that a triple check of the meal was being conducted to help with ensuring that meals were served correctly, since the incident occurred with R #1. When asked what was different from the original plan, he admitted that it was still a triple check and nothing was changed in that sense. He stated that R #1 had received a regular texture tray (12/13/22 instead of prescribed dysphasia-advanced). Restorative Aide (RA) #1 had noticed that it was the wrong texture diet (whole meats) and returned it to the kitchen. He stated that the kitchen staff, Dietary Manager in Training (DMIT), had brought the same type of meal (whole meats) back out to the resident (R #1). So, R #1 was served the wrong type of meal texture (whole meats) twice. He stated that the resident (R #1) started choking on the food and that the Heimlich maneuver had to be performed to clear his airway by the charge nurse and RA #1. He stated that R #1 was transported to the hospital for observation and treatment if necessary following that incident. He stated that meal texture for residents are prescribed by the physician and evaluated by the Speech Therapist upon a residents arrival. The ADM stated that R #1 was supposed to be receiving a Dysphasia - Advanced diet (chopped meat/mechanical soft pieces no bigger than 1/2 ) at the time of the incident and was downgraded to a Dysphasia - Puree diet (blended) after the incident. I. On 12/20/22 at 3:30 pm, during an interview R #1 stated that he was supposed to be getting a ground (meat) diet, but received a regular diet. He stated that it (the breakfast meat/ham) tasted good and so he was shoveling it in. He stated that he remembered that he did not chew up the meat (ham) and a piece got stuck in his throat. He stated that he started to choke and did not remember much after that. He said that he remembered being very tired after the incident. He stated that he was scared to eat much after that for a few days and that I'm still scared to eat things like bread and such. He stated that he has not been served a different meal texture other than puree since that day. J. Record review of the follow-up plan in the facility's report of incident submitted (12/21/22) in response to the choking episode endured by R #1 on 12/13/22, revealed that a supervisor would be placed in the kitchen during meal service to oversee that the correct meal texture was being placed on plate for residents and a schedule would be in place to show who was assigned. Those supervisors would also be conducting audits of the service to determine that errors were minimized/eliminated and results of audits would be brought to QAPI (Quality Assurance Performance Improvement) committee meetings. K. On 12/20/22 at 4:40 pm, an observation of the dinner meal service revealed the following: 1. The posted schedule for Supervisors to audit the service line had not been updated to reflect a change in the scheduled supervisor for that meal, making it unclear who watched for compliance. 2. During entry to kitchen to watch service line, there was no supervisor in place. 3. Food had been plated from the line and sitting on the transportation cart ready for delivery as room trays (north hall), and no supervisor was present to validate meal consistency. L. On 12/20/22 at 5:00 pm, during an interview DM #1 stated that she was not quite sure what happened during the process of the resident (R #1) receiving his tray on the day of the incident (12/13/2022). She stated that RA #1 brought a plate back for R #1 and that it was the wrong diet texture (whole meats). She had went to chop the meat (into 1/2 pieces) and that during that time DMIT had taken another tray out to R #1. When asked what new process was being done in the kitchen to eliminate residents receiving wrong texture diets, she was unsure. When she was asked where the schedule was for who was supposed to be monitoring the service line, she stated that she did not know what schedule the surveyor was talking about, and had not received one. M. Record review of supervisor audit forms to show compliance with follow-up plan, dated 12/13/22 to 12/20/22, against the scheduled/assigned staff revealed several uncorrected changes in the supervisor who was supposed to be monitoring the meal. The audit forms showed that meals were still coming out of the kitchen that were not meeting the proper texture. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J (an isolated of jeopardy to resident health and safety) being identified on 12/21/22 at 11:55 am with the facility Administrator (ADM), Director of Nursing (DON), Senior Administrator, and Regional Nurse On 12/21/22 at 11:55 am, the Administrator, Director of Nursing (DON), Senior Administrator, and Regional Nurse were notified of an Immediate Jeopardy (IJ) in the following area: Free of Accident Hazards. The survey team identified that measures put in place to correct/prevent improper food consistency being served to the residents were not being followed as outlined by the facility's self report follow up investigation and corrective actions (triple check) dated 12/13/22. A Plan of Removal was received and accepted on 12/22/22 at 3:00 PM. The removal plan included: 1. In-service trainings to explain diet texture and requirements for ordered diet, 2. That meal service will not begin to be plated until a supervisor is present to ensure correct ordered diet was plated per printed meal ticket, 3. A schedule for supervisors assigned to oversee plating with notation if changed, 4. Meal audits by supervisors, and 5. Results of amassed information taken to QAPI (Quality Assurance and Performance Improvement) committee. The survey team interviewed facility staff, observed meal practices, and reviewed staff training for practices. The survey team verified all elements of the facility's IJ Removal Plan.

Based on record review, observation, and interview, the following was identified: 1. A resident on the dementia unit (R #1) known to have prior medication hoarding behaviors was found to have a total of 29 medications inside her purse, including [MEDICATION(S)] (antipsychotic), Buproprion HCL ([MEDICATION(S)]) ER (extended release) (antianxiety), [MEDICATION(S)] (antianginal), [MEDICATION(S)] (blood pressure) and [MEDICATION(S)] (diuretic) [3 days of medication], and was in possession of Gabapentine (nerve pain) medication in a cup not ordered for this resident by physician. The resident had in her purse 3 days of medications not taken, including blood pressure medication. On 01/09/22, the resident experienced a hypertensive episode and was transferred to the hospital for higher care. 2. Photographs taken on a family member's phone were submitted with the complaint of abuse/neglect revealed 29 medication doses found in R #1's purse including blood pressure medications, and a photograph of a single dose of medication found in R #1 and R #2's room that neither resident was prescribed/issued. 3. Staff providing medication administration failed to supervise the residents to ensure that the residents took the medications and were not able to hoard medications or be in possession of a medication not ordered for them. These deficient practices resulted in an Immediate Jeopardy (IJ) being called on 02/09/22 at 12:45 pm. The facility Center Executive Director (CED), Unit Manager (UM), and Senior Center Executive Director (SCED) were notified at this time. . A Plan of Removal was received on 02/10/22 at 9:30 am and was accepted at 10:30 am. Implementation of the Plan of Removal was validated onsite. The scope and severity was reduced from Level 4, K to level 2, E. The Plan of Removal Included: 1. The resident identified (R #1) was no longer residing at the facility: 2. A search of the rooms of the 17 residents that lived on the secured memory unit was conducted with three (3) additional residents (R # 5, R #6, and R #7) being identified for having unsecured medications. 3. The Unit Manager (UM) will ensure center staff complete training in responsibilities of being aware of surroundings, act if unsecured medications are discovered, and medication administration competencies by 09/12/22, or prior to their next scheduled shift. 4. Newly hired staff will also be required to complete the trainings during the orientation period. 5. The Center Executive Director (CED)/Designee will complete an audit of resident rooms on the secured unit for unsecured medications daily for two (2) weeks, then three (3) times weekly for 2 weeks, then weekly ongoing. 6. The Center Nursing Executive (CNE)/Designee will complete a weekly audit of licensed nurses on each shift observing a random sample of residents to ensure medications are administered according to and the resident does not have an opportunity to keep/divert medications or obtain non-prescribed medications daily for two (2) weeks, then three (3) times weekly for Two (2) weeks, then weekly ongoing. 7. The CED/Designee and CNE/Designee will bring the results of the audits to the Quality Assurance and Performance Improvement (QAPI) committee for tracking and trending and further recommendations for three (3) months. Based on record review, observation, and interview, the facility failed to adequately monitor the administration of medications to ensure that the resident(s) were unable to accumulate/store/hoard physician prescribed medication at the time of administration for 6 (R #1, R #5, R #6, R #7, R #8 and R #9) of 9 (R#s 1 thru 9) residents reviewed for unnecessary medication. This deficient practice likely contributed to R #1's accumulation of 30 medication doses, and likely contributed to R #5, R #6, and R #7 being in possession of medications which should have been taken at the time of administration. The findings are: A. Record review of the facility Medication Administration: General, policies and procedures revealed the following: . 8. Administer medication 8.1 Assist patient as needed. 8.2 Remain with patient until administration is complete. Do not leave medications at the patient's bedside. 9. If medication is refused by patient, discard medication and attempt to administer again at a later time. 10. Monitor patient for adverse reactions and effectiveness of medication. B. Record review of Clinical Competency Validation; Medication Administration: Oral, form revealed the following: . 12. Stays with patient until the drug has been swallowed. Asks patient to open mouth if uncertain whether medication has been swallowed. Resident #1 C. Record review of facility face sheet for R #1 revealed that she was admitted on [DATE] to the Alzheimer/Dementia care unit. admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Record review of progress notes for R #1 revealed the following: 01/9/22 17:21 (5:21 pm) Alert Note Text: Nurse and CNA (Certified Nurses Assistant) (name) were alerted by voice of resident yelling in distress. Entered resident noted resident standing in doorway of bathroom out of breath and anxious swaying back and forth resident was assisted to a safe seated position at bed side. Oxygen was placed VS (Vital Signs) are as follows 215/123 95P 98.0T responding to commands and follows orders. Describes chest pain and impending feeling of [NAME] she began to have emesis (vomiting) and have pallor (being pale). Nitro given x2 (times 2) with no improvement resident was sent out via 911 MD (medical director) notified (name) and POA (POA name) were made aware 12/28/2021 at 1:24 pm General Note: Resident's daughter called and spoke with this RN (Registered Nurse) notifying me that she found a medication cup with a pill in it on the roommate's dresser . 12/24/21. States she looked it up and it's a 300 mg [MEDICATION(S)]. 12/27/2021 at 3:00 pm Social Service Late Entry: Note: (Social Services Director) SSD was approached by residents daughter/POA (Power of Attorney), (name). (name of POA) stated that sometime last week she found a pill that was left on her mothers dresser that was not for her mother. (name of POA) stated that she could let writer know of the time and date at a later time. SSD notified DON (Director Of Nursing). DON stated that this has already been reported to her and she is aware. E. Record review of submitted photographs taken by a family members phone as evidence for R #1 revealed the following: 1. Photo A - 29 doses of medications that were removed from the purse of R #1, of which 23 doses were able to be identified and that the resident was prescribed at the time. 2. Photo B - 1 dose of medication that was not prescribed to R #1 or roommate (R #2), identified as [MEDICATION(S)] (medication for nerve pain) 300 mg (milligrams), found in room [ROOM NUMBER] on 12/24/21. F. Record review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 100 mg ([MEDICATION(S)]) - antianxiety . 2. Buproprion HCL ([MEDICATION(S)]) ER (extended release) 150 mg - antidepressant 3. Cloidogrel Bisulfate 75 mg - blood thinner. 4. [MEDICATION(S)] ER 500 mg - [CONDITION(S)]. 5. [MEDICATION(S)] 100 mg - high blood pressure 6. [MEDICATION(S)] 20 mg ([MEDICATION(S)]) - hypertension. 7. Ezetimbe 10 mg - high cholesterol. G. On 02/07/22 at 1:00 pm, during an interview the SCED (Senior Center Executive Director) and the ADON helped to identify 23 of the 29 medications shown in the photograph submitted (Photo A) medications were: 1. One (1) round yellow pill with Q indicated on it - [MEDICATION(S)], used as an antipsychotic. 2. Seven (7) round white pills with A101 indicated on them - Buproprion HCL ER, used as an antianxiety. 3. Three (3) round pink pills with CL 75 indicated on them - [MEDICATION(S)] bisulfate, used as a blood thinner. 4. Two (2) oval dark pink pill with 319 indicated on them - [MEDICATION(S)], used as an antiangina. 5. Three (3) round blue pills with M47 indicated on them - [MEDICATION(S)], used as a beta blocker for high blood pressure. 6. Four (4) white oval pills with 3107 indicated on them - [MEDICATION(S)], used as a diuretic. 7. One (2) white oval pills with K31 indicated on them - [MEDICATION(S)], used for high cholesterol. 8. One (1) oval cream/pink pill with RZ1 indicated on it - [MEDICATION(S)], used as an antiagina. 9. Six (6) unidentifiable medications. 10. Photo B was of one (1) [MEDICATION(S)] 300 mg in a medication cup. H. On 02/07/22 at 1:00 pm, during an interview the SCED (Senior Center Executive Director) and the ADON both stated that the Gabepentin 300 mg, was not prescribed for either resident R #1 or R #2 according to the Electronic Medical Record (EMR). I. On 02/07/22 at 2:30 pm, during an interview LPN (Licensed Practical Nurse) # 1 stated that the photograph (Photo A) displaying 29 medications was concerning. He stated that the resident was known to be a hoarder of medications previously. He continued, stating that she should not be in possession of medications like that and in that quantity, especially in the dementia unit. J. On 02/08/22 at 3:35 pm, during an interview ADON, he stated that the photograph (Photo A) displaying 29 medications was concerning, and concurred that the medication in Photo B was of [MEDICATION(S)] 300 mg. He stated that based on the amount of medication doses that were within the bag that it would have been from several administrations. He stated that the protocols for administration would have been to identify the resident, confirm medications to be dispensed, dispense the medication from the packs (blister) into a cup and administer the medications to the resident and then give them some water while ensuring that they swallow them. K. On 02/08/22 at 4:05 pm, during an interview with CED, he stated that the photograph (Photo A) displaying 29 medications and (Photo B) displaying 1 medication was concerning. He stated that a resident should not be in possession of that amount of medication, and stated that there would have to be a breakdown in the system (for medication administration) based on what he saw. L. On 02/09/22 between 8:45 am and 9:55 am, Interviews with LPN's #2, #3, and #4 and RN (Registered Nurse) #1 regarding the discovered medications revealed that the medications were of concern and the residents should not have had them. They all described the process for medication administration per their policy, but were unable to give an explanation as to how R #1 would have accumulated that many medications unless the process was broken somewhere. Resident #2 M. Record review of facility face sheet for R #2 revealed she was admitted on [DATE] to the Alzheimer/Dementia care unit. admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . N. Record review of progress notes for the month of December 2021 for R #2 revealed no mention in the progress notes regarding the discovery of medication ([MEDICATION(S)] 300 mg) found in room [ROOM NUMBER], as seen in the photograph taken on 12/24/21. O. Record review of progress notes following the Immediate jeopardy for R #2 revealed the following: 02/09/2022 at 1:50 pm, General Note: (Name of Guardian) approved to search room/belonging Resident #5 P. Record review of facility face sheet for R #5 revealed that she was admitted on [DATE] to the Alzheimer/Dementia care unit. admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Q. Record review of facility communication sheet following the Immediate jeopardy dated 02/10/22 revealed that a search of R #5's room lead to the discovery of one (1) dose of [MEDICATION(S)] [[CONDITION(S)] medication, found on R #5 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R. Record review of progress notes for R #5 following the Immediate Jeopardy revealed the following: 02/09/2022 at 1:28 pm General Note: left voicemail with POA 02/09/2022 at 6:03 pm General Note: There (were) pills found in resident's room by staff while doing a room safety check. Resident had no change in status. Notified (h)er provider. Resident #6 S. Record review of facility face sheet for R #6 revealed that she was admitted on [DATE] to the Alzheimer/Dementia care unit. admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . T. Record review of facility communication sheet following the Immediate Jeopardy dated 02/10/22 revealed that a search of R #6's room lead to the discovery of two (2) unknown white tablets unsecured in her room. U. Record review of progress notes for R #6 following the Immediate Jeopardy revealed the following: 02/09/2022 1:48 pm, General Note: Residents POA gave permission for residents room and belongings to be searched. 02/09/2022 at 6:00 pm General Note: There (were) pills found in resident's room by staff while doing a room safety check. Resident had no change in status. Notified (h)er provider. Resident #7 V. Record review of facility face sheet for R #7 revealed that she was admitted on [DATE] to the Alzheimer/Dementia care unit. admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . W. Record review of facility communication sheet following the Immediate Jeopardy, dated 02/10/2022, revealed that a search of R #7's room lead to the discovery of one (1) medication dose of [MEDICATION(S)] [[CONDITION(S)] medication, found on R #7 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . X. Record review of progress notes for R #7 following the Immediate Jeopardy revealed the following: 02/09/2022 at 6:03 pm, General Note: There (were) pills found in resident's room by staff while doing a room safety check. Resident had no change in status. Notified (h)er provider. 02/10/2022 at 8:29 am, General Note: Medical Director and POA notified of occurrence on 02/09/2022. 02/10/2022 at 2:27 pm, General Note: Residents daughter gave consent for residents belongings to be searched. Resident was also in agreement. Y. On 02/09/22 at 6:35 am, during an observation of the medication administration by LPN #1 the following was noted: 1. Administration at 6:53 am, For R #8, LPN #1 took medications in dispensing cup and water to the resident, while walking over to resident another staff member asked if he was going to put something different on the TV for the residents. He stated that he would. He handed the resident the pills, picked up the remote control for the TV from the table, turned away from the resident, and then proceeded to change the channel. The resident was waving hand at LPN #1 and finally tapped him on the arm and he then gave her the water. 2. Administration at 7:18 am, For R #9, LPN #1 took medications and water to the resident, handed the resident the medication, turned to see what was on the television for few moments, turned back and gave the resident the water. Z. On 02/10/22 at 10:00 am, during an interview SCED stated that there was a search completed of the residents rooms on the Alzheimer/dementia unit the night of 02/09/22. The results of that search were that three (3) residents were found to have four (4) doses of medications in their possession. R #5 - 1 medication; R #6 - 2 medications; R #7 - 1 medication. SCED was unable to determine how the residents were able to possess those medications unless there was a breakdown in the system.

Based on record review and interview, the following was identified: 1. A resident to resident altercation between R #7 and R #9 resulted in R #7 pushing R #9 resulting in a [CONDITION(S)]. 2. A resident (R #7) with known behaviors (hitting and pushing) pushed another resident (R #9) to the floor causing a hip fracture, this same resident (R #7) exhibited continued behaviors after medication adjustments and monitoring interventions were placed in care plan. No new interventions were implemented after 3 additional instances of abusive behaviors towards other dementia residents, on 08/09/21 of verbal abuse towards R #15, 09/07/21 throwing of roommate's items around room, and 10/12/21 striking resident R #15. 3. The facility failed to ensure training was completed and maintained for nursing staff on specialized dementia care (memory loss/care) training and how to treat those behaviors. (see F741) These deficient practices resulted in an Immediate Jeopardy (IJ) being called on 10/14/21 at 6:45 pm. The facility Center Executive Director (CED) and Center Nursing Executive (CNE) were notified at this time. A first Plan of Removal was received on 10/15/21 at 8:30 am and was rejected. A second Plan of Removal was received and accepted on 10/15/21 at 9:00 am. Implementation of the Plan of Removal was validated onsite. The scope and severity was reduced from Level 4, K to Level 4, H. The Plan of Removal Included: 1. The resident identified as the aggressor (R #7) and been involved in the resident-to-resident events that pushed/hit other secured dementia residents causing injury on: 1. 04/26/20 - R #7 attempted to strike and grazed (a glancing blow) R #17. 2. 05/25/20 - R #7 struck R #17. 3. 05/26/20 - R #7 struck R #17 - struck resident in chest. 4. 07/25/20 - R #7 struck R #17 - struck in face. 5. 01/14/21 - R #7 struck nurse on hand. 6. 04/21/21 - R #7 attempted to hit another resident. 7. 07/16/21 - R #7 grabbed R #9 by the arm? 8. 07/23/21 - R #7 pushed down R #9 causing [CONDITION(S)] 9. 07/27/21 - R # 7 shows signs of aggression with clinching fists and rocking back and forth in wheel chair. 10. 08/09/21 - R #7 was verbally abusive to R #15. 11. 09/07/21 - R #7 was throwing roommate's items around room. 12. 10/12/21 - R #7 stuck R #15 in face with an open hand. R #7 was transferred on 10/15/21 to a behavioral health hospital for observation and treatment with a plan for return to the facility. 2. The 19 residents that lived on the secured memory unit were reviewed for behaviors with 3 additional residents (R # 2, R #10, and R #16) being identified for aggressive behaviors and their care plans were updated to reflect those changes. 3. The Center Nursing Executive (CNE) will ensure Center staff complete training in the vital learn system (facility training program) for Dementia Care and Everyday Compassion: Communication through Behavioral expressions by 10/16/21, or prior to their next scheduled shift. 4. Newly hired staff will also be required to complete Dementia Care and Everyday Compassion: Communication through Behavioral expressions during the orientation period. 5. The Center Nursing Executive (CNE) will discuss resident to resident events with the interdisciplinary team (team of staff and family/friends that make decisions to help the resident) and use root cause analysis (determining where issue resulted from originally) to determine action for staff and residents. New actions will be care planned for those residents and staff will be educated on the new plan. 6. The Center Nursing Executive (CNE) will complete a weekly audit to ensure compliance with plan and for the CNE/Center Executive Director (CED) to give actions to take to ensure the safety of the residents during the investigation of the event. Staff will complete Resident Management System (RMS) information entry on both aggressor and victim. 7. The CNE will bring the results of the weekly audits to the Quality Assurance and Performance Improvement (QAPI) committee for tracking and trending and further recommendations. Based on record review and interview, the facility failed to prevent abuse and neglect for 4 (R #7, R #9, R #15, and R #17) of 4 (R #7, R #9, R #15 and R #17) residents reviewed for resident to resident altercations in the Memory Care/Locked Unit by: 1. Not protecting R #9 and R #15 from physical abuse by R #7. 2. Not appropriately treating R #7's aggressive behaviors and distress. 3. Not ensuring that staff on the dementia unit received the appropriate training to manage dementia behaviors/symptoms. This deficient practice likely resulted in the residents not feeling safe, suffering injury, and/or exacerbate (make worse) other resident behaviors. The findings are: A. Record review of facility face sheet for R #7 revealed admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of progress notes for R #7 revealed the following: 1. 07/16/2021 17:04 (5:04 pm) General Note: Resident yelling at another resident (R #9), when SN (shift nurse) got into dining area, resident (R #7) had another resident by the arm (R #9), SN was able to redirect away from the other female resident (R #9). Resident ( R #7) got angry and went to room. When staff entered room to make sure, roommate was not present, resident (R #7) threw shoe at staff. Roommate was not in the room. C. Record review of progress notes for R #9 revealed the following: 1. 07/16/2021 17:23 (5:23 pm) General Note: Resident (R #9) was in dining area when she got up to follow another resident (R #3), a female resident (R #7) grabbed resident (R #9) by the right upper arm causing a scratch mark. SN (shift nurse) was able to separate residents. Resident (R #9) does not exhibit any s/sx (sign/symptoms) of pain. ADON (Assistant Director of Nursing) notified, spouse notified, physician (Medical Director) notified. D. Record review of progress notes for R #9 revealed the following: 1. 07/23/2021 17:56 (5:56 pm) General Note: Resident (R #9) observed falling to floor at 1641 (4:41 pm) onto Right hip. No immediate complaint of pain. No pain verbalized when asked. Resident unable to tolerate weight bearing.1717 (5:17 pm) EMS left with resident via ambulance. E. Record review of progress notes for R #7 revealed the following: 1. 07/23/2021 17:32 (5:32 pm) General Late Entry: Note: Resident (R #7) admitted verbally to pushing another resident (R #9) to the floor. Resident (R #7) laughed afterwards. Educated by another nurse to notify staff of complications. Resident did not show any other behaviors. F. Record review of progress notes for R #7 revealed the following: 1. 07/24/2021 17:31 (5:31 pm) General Note: Resident (R #7) observed trying to hit another resident (R #15). Provided redirection. No further behavior observed. 2. 07/27/2021 19:41 (7:41 pm) eINTERACT SBAR Summary for Providers Situation: The Change In Condition/s reported on this (CIC) Evaluation are/were: Behavioral symptoms (e.g. agitation, [CONDITION(S)]) . Outcomes of Physical Assessment: . Behavioral Status Evaluation: Physical aggression Danger to self or others Other behavioral symptoms; . Nursing observations, evaluation, and recommendations are: Resident continues to rock back in forth in wheelchair . Clenched fists noted and redirected with socialization. Recommendations to collaborate with MD, refer to (mental health counseling service) for evaluation and possible treatment, . Primary Care Provider responded with the following feedback: A. Recommendations: Dr. (medical director); . C. New Intervention Orders: - New or Change in Medications Other; - psychological services 3. 07/27/2021 20:41 (8:41 pm) General Note: Spoke with Dr. (medical director) about possible interventions for (R #7), to avoid future altercations with other residents. Notified Dr. about her BIMS score (brief interview for mental status) of 1, and her inability to be educated or retain information for behavior modification, etc. New order received for [MEDICATION(S)] (antipsychotic/antimanic agent) 0.5 mg (milligram)one by mouth twice daily for [CONDITION(S)] with features of agitation and aggression . 4. 07/28/2021 22:42 (8:42 pm) General Late Entry: Note: MD (medical director) gave verbal order to start [MEDICATION(S)] 0.5 mg bid (twice a day), po (by mouth). (mental health counseling service) recommended to dc (discontinue) [MEDICATION(S)] and start [MEDICATION(S)] (antipsychotic) 12.5 mg PO, BID Left voicemail with legal guardian for consent. G. Record review of progress notes for R #9 revealed the following: 1. 07/28/2021 17:25 (5:25 pm) Nursing Documentation Note General: Patient was admitted /readmitted for the following reason(s): . Wound Care fracture . Post-Op (after operation) . Pain Management skilled care status post [MEDICAL RECORD OR PHYSICIAN ORDER] . H. Record review of progress notes for R #7 revealed the following: 1. 07/29/2021 11:44 (am) General Late Entry: Note: Collaborated with MD regarding history of physical behaviors and of current aggression. Dr. declined recommendation of [MEDICATION(S)] and to start [MEDICATION(S)] (antipsychotics/antimanic agent) 1 mg PO BID. Left voicemail for legal guardian to return call. 2. 07/29/2021 19:56 (7:56 pm) General Note: Verbal order from MD (medical director) to start [MEDICATION(S)] 1 mg PO BID. Legal guardian gave consent to start medication. Legal guardian stated that she wants to wait and monitor med change, monitor for increased behaviors, and hold off on sending her to (mental/behavioral health facility). 3. 07/29/2021 22:35 (10:35 pm) General Note: (R #7) attempted to push another resident [unidentified resident]. I. Record review of progress note for R #9 revealed the following: 1. 07/29/2021 12:16 (pm) General Note: SN (shift nurse) spoke with husband, (name), in regard to residents status, SN informed resident (POA) she was in her old room, Resident (POA) got highly upset stating you put my wife back in that same place with the b*&^# that hurt her. Spouse stated he spoke to someone on 07/28/21 and they said she would be going to north hall and he was not sure why she was placed back over here (memory care/locked unit). SN redirected resident (POA) that SN would speak with administrator in regards to changing rooms.; Resident was moved to north hall and husband was notified of move. J. Record review of progress notes for R #7 revealed the following: 1. 08/9/2021 17:20 (5:20 pm) General Note: . new order of [MEDICATION(S)], resident continues with seeking companionship with a specific male resident (R #3) resident yelled at another resident (R #15) when the other resident was attempting to get the male resident (R #3) from the dining room door. Resident was redirected to notify staff of any concerns. 2. 09/07/2021 20:52 (8:52 pm) General Note: (R #7) was reported by her roommate to be throwing the roommate's possessions around the room, and the roommate stated she was tired of (R #7)s' behaviors. Notified Dr. new order received to increase [MEDICATION(S)] (antipsychotic/antimanic agent) to 1.5 mg twice daily for [CONDITION(S)] with features of physical aggression. Notified (name), legal guardian, she voiced understanding and gave consent for medication increase. Order put into PCC (point click care/electronic medical record), roommate was moved out of room, (R #7) will continue to be monitored for behaviors and physical aggression. 3. 10/12/2021 18:11 (6:11 pm) General Late Entry: Note: Resident was self-propelling in wheelchair towards dining area when she saw resident (R #15) sitting at the same table and sharing a snack with (R #3). Resident (R #7) approached (R #15) quickly, open- handed swung at her and made contact with her right cheek on her face. (R #15) then grabbed (R #7)'s arm and pushed her away. CNA (Certified Nursing Aide) notified this nurse of the incident. Both residents were separated from each other. Reported to DON. POA notified. K. Record review of progress notes for R #15 revealed that the resident to resident altercation between R #7 and R #15 was not documented in R #15's record. L. On 10/14/21 at 2:40 pm, during an interview CNA #15 when asked if there were known aggressive behaviors (verbally abusive/physically abusive) residents in the memory care/loss unit she stated that R #7 was very particular about who was able to be near R #3 or she would become aggressive. She stated that R #7 was very possessive of R #3 and would become very jealous of others being around R #3. CNA #15 stated that staff would mostly watch/monitor other residents around R #7. M. On 10/14/21 at 2:50 pm, during an interview RN (Registered Nurse) #1 when asked if there were known aggressive behaviors residents in the memory care/loss unit he stated that this was only the second time he was working both sides (memory care/locked unit and North hall). He stated that R #7 had been aggressive the other night (10/12/21) and hit/struck another resident (R #15). N. On 10/14/21 at 2:55 pm, during an interview CNA #6 when asked if there were known aggressive behaviors residents in the memory care/loss unit she stated that R #7 can have aggressive behaviors with staff. She stated that she did have an affection towards R #3. O. Record review of behaviors care plan for R #7 revealed the following: Focus: (R #7) exhibits, or has the potential to exhibit physical behaviors related to: Dementia and History of harm to others: (R #7) has had numerous altercations with resident (R #17). 1. (R #7) had a resident to resident altercation with (R #17) on 5/25/20. Date Initiated: 05/28/2020 2. (R #7) had a resident to resident altercation with (R #17) on 07/25/20. 3. Resident (R #7) had a resident to resident altercation with (R #9) on 7/13/21. 4. Resident (R #7) had a resident to resident with (R #9) on 7/23/21. (major injury); ; Revision on: 07/27/2021 Goal(s): (R #7) will demonstrate less than one resident to resident altercation through next review Intervention(s): 1. Monitor resident while in common area/dining room; Date Initiated: 07/27/2021 2. When (R #7) is in common area, Staff will redirect residents from (R #7)'s personal space.; Date Initiated: 06/27/2020 3. Evaluate the nature of the circumstance of physical behavior towards female residents; Date Initiated: 05/28/2020 4. Evaluate need for Psych/Behavioral Health consult; Date Initiated: 05/28/2020 5. Encourage resident/patient to seek staff support for distressed mood.; Date Initiated: 05/28/2020 6. Observe for non-verbal signs of physical aggression, e.g., rigid body position, clenched fists, etc such as rocking back and forth in the wheelchair; Date Initiated: 05/28/2020 7. Remove resident/patient from environment, if needed. Gently guide the resident from the environment while speaking in a calm, reassuring voice.; Date Initiated: 05/28/2020 8. Provide resident/patient with opportunities for choice during care/activities to provide a sense of control.; Date Initiated: 07/27/2021 9. Social Service visits to provide support, as needed and/or requested resident/patient.; Date Initiated: 05/28/2020 10. Divert resident/patient by giving alternative objects or activities; Date Initiated: 05/28/2020 P. Record review of current behavioral care plan for R #7 revealed that there were no new interventions documented after 07/27/21 showing an attempt for resident safety or well-being (mental state). Resident R #7 continued to have behaviors on 08/09/21 of verbal abuse towards R #15, 09/07/21 throwing roommate's items around room, and 10/12/21 striking resident R #15. Q. On 10/13/21 at 2:45 pm, during an interview the Center Nursing Executive (CNE), when asked what new interventions were in place for R #7 after 07/27/21, stated that there were no new documented interventions in the care plan. R. On 10/14/21 at 9:15 am, during an interview the Center Nursing Executive (CNE) was asked if the behavioral care plan for R #7 should have been completed to include the incidents on 08/09/21, 09/07/21 and 10/12/21 along with any newly initiated interventions. She stated that the care plan was ugly and that it should have been updated with incidents and new interventions. S. Cross reference F741.

Based on record review and interview, the following was identified: 1. A resident to resident altercation between R #7 and R #9 resulted in R #7 pushing R #9 resulting in a [CONDITION(S)]. 2. A resident (R #7) with known behaviors (hitting and pushing) pushed another resident (R #9) to the floor causing a hip fracture, this same resident (R #7) exhibited continued behaviors after medication adjustments and monitoring interventions were placed in care plan. No new interventions were implemented after 3 additional instances of abusive behaviors towards other dementia residents, on 08/09/21 of verbal abuse towards R #15, 09/07/21 throwing of roommate's items around room, and 10/12/21 striking resident R #15 3. The facility failed to ensure training was completed and maintained for nursing staff on specialized dementia care (memory loss/care) training and how to treat those behaviors. (F741) These deficient practices resulted in an Immediate Jeopardy (IJ) being called on 10/14/21 at 6:45 pm. The facility Center Executive Director (CED) and Center Nursing Executive (CNE) were notified at this time. A first Plan of Removal was received on 10/15/21 at 8:30 am and was rejected. A second Plan of Removal was received and accepted on 10/15/21 at 9:00 am. Implementation of the Plan of Removal was validated onsite. The scope and severity was reduced from Level 4, K to Level 4, H. The Plan of Removal Included: 1. The resident identified as the aggressor (R #7) and been involved in the resident-to-resident events that pushed/hit other secured dementia residents causing injury on: 1. 04/26/20 - R #7 attempted to strike and grazed (a glancing blow) R #17. 2. 05/25/20 - R #7 struck R #17. 3. 05/26/20 - R #7 struck R #17 - struck resident in chest. 4. 07/25/20 - R #7 struck R #17 - struck in face. 5. 01/14/21 - R #7 struck nurse on hand. 6. 04/21/21 - R #7 attempted to hit another resident. 7. 07/16/21 - R #7 grabbed R #9 by the arm 8. 07/23/21 - R #7 pushed down R #9 causing [CONDITION(S)] 9. 07/27/21 - R # 7 shows signs of aggression with clinching fists and rocking back and forth in wheel chair. 10. 08/09/21 - R #7 was verbally abusive to R #15. 11. 09/07/21 - R #7 was throwing roommate's items around room. 12. 10/12/21 - R #7 stuck R #15 in face with an open hand. R #7 was transferred on 10/15/21 to a behavioral health hospital for observation and treatment with a plan for return to the facility. 2. The 19 residents that lived on the secured memory unit were reviewed for behaviors with 3 additional residents (R # 2, R #10, and R #16) being identified for aggressive behaviors and their care plans were updated. 3. The Center Nursing Executive (CNE) will ensure Center staff complete training in the vital learn system (facility training program) for Dementia Care and Everyday Compassion: Communication through Behavioral expressions by 10/16/21, or prior to their next scheduled shift. 4. Newly hired staff will also be required to complete Dementia Care and Everyday Compassion: Communication through Behavioral expressions during the orientation period. 5. The Center Nursing Executive (CNE) will discuss resident to resident events with the interdisciplinary team (team of staff and family/friends that make decisions to help the resident) and use root cause analysis (determining where issue resulted from originally) to determine action for staff and residents. New actions will be care planned for those residents and staff will be educated on the new plan. 6. The Center Nursing Executive (CNE) will complete a weekly audit to ensure compliance with plan and for the CNE/Center Executive Director (CED) to give actions to take to ensure the safety of the residents during the investigation of the event. Staff will complete Resident Management System (RMS) information entry on both aggressor and victim. 7. The CNE will bring the results of the weekly audits to the Quality Assurance and Performance Improvement (QAPI) committee for tracking and trending and further recommendations. Based on record review and interview, the facility failed to ensure the memory care/locked unit had a sufficient amount of staff and that those staff had completed specialized trainings (trainings to meet the needs of the residents on the memory care unit; eg Dementia Care) before they worked with the residents. This deficient practice could likely affect the 19 residents in the memory care/locked unit by affecting the staffing levels and resident care. The findings are: A. Record review of facility CNA (Certified Nursing Aide) personnel files for CNA #1, #3, #4 and #14 revealed that they did not receive an annual Employee Performance Review/Assessment. (evaluation provided to staff to show where they are achieving expectations of the administration and where they may need to concentrate efforts for improvement) B. Record review of facility training records for CNA #1, #2, #3, #4, #6 #14 and #16 revealed that they were not up-to-date with assigned training hours to meet their required 12 hours per year. 1. CNA #1 - unknown as no duration was provided in order to tally hours. 2. CNA #2 - 2.75 hours. 3. CNA #3 - 5.75 hours. 4. CNA #4 - 7 hours 35 minutes. 5. CNA #6 - 5.75 hours. 6. CNA #14 - 9.5 hours. 7. CNA #16 - 3.5 hours. 8. No record was requested/provided for CNA's #5 (new hire), #7- #13, and #15. C. Record review of Dementia Care Basics Communications trainings for the employed CNA's revealed that 9 (CNA #'s 2, #3, #7, #8, #10, #11, #12, #13, and #14) of the 16 (CNA's #1 - #16) had not completed the mandatory trainings prior to the due date of 09/29/21. D. Record review of facility nursing schedules for October 13, 2021 revealed that Licensed Practical Nurse (LPN) #1 had not completed the mandatory specialized dementia care trainings scheduled for completion on 09/29/21, and was working in the memory care/locked unit with residents. F. Record review of facility healthcare center sign-in sheets dated 10/14/21 to 10/17/21 revealed that there was only one (1) staff member scheduled during the evening/night shift (6 pm to 6 am) and those scheduled/posted positions were not updated to indicate who worked that shift. Failing to update the sign-in sheet with who worked on the memory care/locked would not allow the facility to track who worked in the memory care/locked unit and if they were up-to-date with their specialized trainings. G. Record review of facility healthcare center sign-in sheets dated 10/18/21 revealed that there was no (0) staff member scheduled during the evening/night shift (6 pm to 6 am) and those scheduled/posted positions were not updated to reflect who worked that shift. Failing to update the sign-in sheet with who worked on the memory care/locked would not allow the facility to track who worked in the memory care/locked unit and if they were up-to-date with their specialized trainings. H. On 10/20/21 at 10:15 am, during an interview the Center Nursing Executive (CNE) stated that she was unable to answer for why the prior CNE had not completed evaluations and monitored trainings, as she had only taken over the CNE position at the end of September 2021. When asked if she should have reviewed the employee training and personnel files for completeness and to see who might need to have evaluations completed upon her taking over that position at the end of September 2021, she stated that she probably should have.

Based on record review, interview, and observation the facility failed to prevent an avoidable pressure ulcer (injury to the skin or tissue over a bony area of the body) from developing for one (#44) of one (R#44) residents reviewed for pressure ulcer care. The facility failed to conduct skin assessments according to R #44's plan of care and did not discover the pressure ulcer until it was unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured) and was covered with eschar (a thick crust of dead tissue). The findings are: A. Record review of R #44's face sheet indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. B. Record review of nursing progress notes for R #44 indicated the following: 1. 02/12/2018 at 9:20 pm Assessment Note: A skin check was performed. No skin injury/wound(s) were noted. 2. 03/10/2018 at 6:59 pm General Note: Certified Nursing Assistant (CNA) reported to writer a sore to the left lateral (side) leg of (name of R#44) caused by wheelchair leg rest, orders obtained and provided wound care. Measures 6 centimeters (cm) by (x) 4 cm and has eschar to wound bed and some redness to periwound (skin tissue surrounding the wound). 3. 03/22/2018 at 05:14 pm General Note: Resident refused to let this nurse measure his wounds, he stated it hurts too much. 4. 03/25/2018 at 11:28 General Note: 0920 am - PRN (as needed) [MEDICATION NAME] 5/325 (a brand name for the combination prescription drug [MEDICATION NAME]/[MEDICATION NAME]. It's used to treat moderate to severe pain) given PO (by mouth) per resident (name of R#44) request for leg cramps. 5. 03/26/2018 at 23:55 (10:55 pm) General Note: Medicated (name of R#44) per prn orders for complaints of pain 6. 04/10/2018 at 09:47 am General Note: Wound care performed per treatment administration record (TAR) on resident's left lower extremity. Wound unstageable, Serosanguineous (yellowish fluid with small amounts of blood) drainage. Surrounding tissue inflamed. C. Record review of R #44's care plan dated 03/30/18 indicated the resident was at risk for skin breakdown as evidenced limited mobility. Three interventions on the care plan for this risk were: 1. Evaluate for skin risk factors per protocol 2. Monitor skin for sign/symptoms of skin breakdown i.e. redness, cracking, blistering, and decreased sensation. 3. Observe skin condition with activities of daily living (ADL) care daily and report abnormalities. D. On 04/05/18 at 2:14 pm during an interview with the Director of Nursing (DON), Facility Administrator and Corporate Regional Registered Nurse (RN), they stated there were no weekly skin integrity sheets filled out on R #44 from 02/12/18 until 03/10/18 when the pressure ulcer was discovered. The DON stated R #44 had received a new leg rest during this time period and they believed that is what caused the pressure ulcer. When ask of R #44's care plan had been updated after the discovery of R #44's pressure ulcer and the leg rest indicated as a possible cause, she stated no. E. On 04/10/18 at 10:00 am during observation and interview of wound care to R #44's pressure ulcer indicated a 5 X 4 cm wound with 2/3 of wound with slough and the other 1/3, beefy red tissue. The surrounding area was red and inflamed. R #44 stated the treatment to the pressure ulcer hurt, his leg hurt, and that he couldn't stand it. Licensed Practical Nurse (LPN) #2 indicated a wound specialist had been to the facility the week before after the surveyor began questioning R#44's pressure ulcer. LPN #2 stated the wound specialist had recommended a new treatment for [REDACTED].

Based on record review and interview, the facility failed to protect from neglect Resident #67 by not following Physician order [REDACTED]. The resident did not have the opportunity to potentially be revived, and died . This failure could likely cause additional resident's to not have CPR preformed if their heart and respirations stopped. This was evidenced by: 1. On [DATE], at 9:00 am, Resident #67 fell by the nurses station with no visual injury. The resident was not checked again by the nurse. 2. The resident was found on [DATE] at 12:15 pm without a pulse or respirations. The resident, who was a full code, did not have Cardio [MEDICAL CONDITION] Resuscitation (CPR) started by the nurse. Resident #67 had Physician order [REDACTED]. This resulted in an immediate jeopardy at a scope and severity of level J. An immediate jeopardy was called on [DATE] at 12:27 pm. At that time, the Administrator (ADM), Director of Nursing (DON), and Regional Manager (RM) were informed. The facility provided an acceptable Plan of Removal on [DATE] at 3:25 pm. Acceptance of the Plan of Removal lowered the scope and severity level to a level G, with the IJ lifted, and included the following interventions: Immediate Plan: 1. An audit of the code status of all residents in the facility will be confirmed by the physician orders, the code status will be placed on color coded paper in the front of the clinical record, and at the room doors, where the resident's name is written, the name will be written on the same color coded paper. 2. A licensed staff member who is CPR certified will be in the facility 24 hours a day. 3. Immediate and on-going in-servicing of current licensed staff has been initiated. Education Plan: 1. An in-service of current licensed staff has been initiated and will continue in regards to following physician orders, code status, and fall protocol. A list of current residents with full code status will be addressed. This in-servicing will be completed by [DATE], and will be completed prior to anyone working their next shift. Based on record review and interview, the facility failed to protect from neglect 1 (Resident #67) of 1 (Resident #67) resident reviewed for death in a closed record review. Resident #67 was a full code requiring CPR. When found without a heartbeat and respirations, CPR was not started. The resident did not have the opportunity to potentially be revived, and died . This failure could likely cause additional resident's to not have CPR preformed if their heart and respirations stopped. The findings are: A. Record review of Resident #67's Long Term Care admission orders Code Status: Full Code" was checked. B. The Directive for CPR-Cardiopulmonary Resuscitation "FULL CODE" revealed, "In the event of [MEDICAL CONDITION] (heart stoppage), I wish CPR to be administered immediately. I understand the possible outcomes and the possible complications of this procedure." This directive was signed on [DATE] by telephone consent by the Power of Attorney (POA). C. Nursing Policies and Procedures, no date, "Cardiopulmonary Resuscitation," provided by the facility revealed: 1. "Policy: 1. Cardiopulmonary resuscitation is instituted on all residents except those designated of "no Code"/no CPR. 2. Only individuals certified in basic CPR, perform cardiopulmonary resuscitation. 3. All licensed nursing personnel are required to have a certification for basic CPR." 2. "Procedures: 1. In cases of a cardiac and or [MEDICAL CONDITION] arrest, CPR is instituted immediately. 2. CPR is continued until medical emergency personnel are available to take over the procedure." 3. "CPR may be discontinued a. If the victim responds, or b. If a physician orders [REDACTED]. D. Review of the Daily Shift Charting (Nurses Notes) for Resident #67 dated [DATE] (no time), revealed, " ... At 9:00 (am) Resident was walking from dining room toward NS (nursing station), fell , slipping down to bottom then laid head down. Nurse observed. No obvious injuries noted. VS (Vital Signs) ,[DATE] (blood pressure) R (respirations) 20 T (temperature) 97.6 P (pulse) 72. ... " E. Record review of Resident #67's medical record revealed the following: 1. Nurses Notes dated [DATE] at 12:15 pm, revealed, "Aide (Certified Nursing Assistant) called nurse to room. Resident not responsive. Unable to feel pulse, no lung sounds heard. Body temp cool to touch." Called nurse on call (name of LPN {Licensed Practical Nurse} #4) 12:20 approximately. Administrator called this nurse after being contacted, informed of procedure. RN (Registered Nurse) to be contacted for pronouncement. Awaiting response." 2. Nurses Notes dated [DATE] (no time), "Aide reported Resident at 10:15 responsive at that time." 3. Licensed Nurses Notes dated [DATE] at 12:50 pm revealed, "Resident pronounced at this time. Pupils fixed bilaterally, no resp (respiration) no pulses and resident cold to touch, no heart beat noted. Resident did have fall and fx (fracture) to humerus - [DATE] fall and sent to hospital on [DATE] and fx found." F. On [DATE] at 10:40 am, an interview was conducted with Licensed Practical Nurse (LPN) #4 concerning the incident with Resident #67. LPN #4 stated that she was on call that weekend and was contacted by LPN #3 about the incident. LPN #4 stated that LPN #3 called her about the incident because LPN #3 had been unable to contact the Administrator (ADM). When asked about the timeframe of the incident and the phone call, LPN #4 stated that it was approximately 30 minutes after LPN #3 found the body. LPN #4 asked LPN #3 what the Code status of the resident was and was told that the resident was full code. LPN #4 asked LPN #3 if she had initiated CPR. LPN #3 told LPN #4, "No, she was cold to the touch." LPN #4 stated that she told LPN #3, CPR should have been initiated. LPN #4 stated she then contacted the Administrator about the incident. G. On [DATE] at 11:20 am, an interview was conducted with the Administrator (ADM). When asked if she talked to LPN #3, the ADM stated that she had talked to her, but LPN #3 was not a Registered Nurse, so she talked to LPN #4 and to get an RN into the building to pronounce. When the ADM was asked if she had inquired of the code status of the resident, the ADM stated that she did not. H. On [DATE] at 12:25 pm, an interview was conducted with the Regional Director (RD) and the Director of Nurses (DON) of the facility. When asked if a full code procedure should have been initiated, they both stated, "The LPN should have initiated CPR." I. On [DATE] at 2:30 pm, LPN #3 was interviewed. LPN #3 was asked to describe the events leading to the time Resident #67 was found without vital signs, and the facility response. LPN #3 stated, "After breakfast, I witnessed her fall by the nurses station. She did not hit her head or appear to be injured. We got her up and she sat in the dining room for a while. About 9:20 to 9:30 am, the aide took her to the bathroom and then put her to bed to rest. The aide waited to get her up because she had the 2 falls and we were letting her rest. A little after 12:00 (noon), the aide called to me from the room and when I got there, she (Resident #67) was not breathing, had no pulse, she was pale, did not respond, and her mouth was open. She was cool to touch with no signs of life, 'she was gone.' I called (name of LPN #4) who was on call. She asked me what the code status was and I went to look it up. I told her the resident was a full code. LPN #4 told me a Registered Nurse (RN) would be located to pronounce. I did tell (name of LPN #4) the resident was gone and nothing could have been done. I then finished my med (medication) pass and looked for the black facility book that had contact phone numbers for staff and physicians in it. There was only one in the facility and it was on the other unit. The Administrator called me, and said an RN was contacted to pronounce and, we were told to contact the Office of the Medical Investigator (OMI). No one ever suggested to call 911." When LPN #3 was asked if she knew CPR, LPN #3 stated, "Yes, I am CPR certified." When LPN #3 was asked if the signed code status was a physician order, LPN #3 stated, "Yes, now I do know that. I know a lot more than I did on that day. I did not follow that physician order [REDACTED]. J. On [DATE] at 8:50 am, Certified Nurse Aide (CNA) #5 was interviewed. CNA #5 stated that when Resident #67 got dressed and up for breakfast she was acting weak and unstable so CNA #5 got another aide to assist her to walk Resident #67 to the dining room. I was in a resident room when I heard the nurse call that she needed help. Resident #67 was laying on the floor by the nurses station. The nurse said she saw her fall and she did not hit her head. The two of us got her (Resident #67) up and sat her in a chair in the dining room. The nurse took her vitals and everything seemed to be ok. After about 20 to 30 minutes, I took Resident #67 to her room to lay down because she seemed to be tired. I toileted her and laid her down about 10:00 to 10:15 am. I did not check on her until about 12:00 when I went in to get her changed and dressed for lunch. That is when I noticed she was not breathing.... I left the room and got the nurse. (Name of LPN #3) and I went into the room. She assessed Resident #67 and said she was not breathing and there was no pulse. The nurse left the room, I think to get a nurse from the other side, and I stayed in the room with the resident. I did not see any other nurse until (Name of RN #1) came about 12:45 pm." When CNA #5 was asked to describe the condition of Resident #67 when she found her, CNA #5 stated, "She was not cold but cool, and she was not stiff like some I have seen before. Her back was still warm. When you looked at her, you could tell she had passed." K. On [DATE] at 8:50 am, the Regional Director (RD) of the facility was interviewed. When asked if the failure to administer CPR to a full code resident was neglect, the RD agreed that it was neglect.

Based on record review and interview, the facility failed to implement and follow their policies for abuse and neglect by not investigating a sudden death and neglect where CPR was not preformed. The resident did not have the opportunity to potentially be revived, and died . This failure to investigate could likely cause additional resident's to not have CPR preformed if their heart and respirations stopped. The facility also failed to report the neglect to the state agency for 1 (#67) of 1 (#67) resident reviewed for death in a closed record review. The neglect was evidenced by: 1. On [DATE], at 9:00 am, Resident #67 fell by the nurses station with no visual injury. The resident was not checked again by the nurse. 2. The resident was found at [DATE] at 12:15 pm without a pulse or respirations. The resident, who was a full code, did not have Cardio [MEDICAL CONDITION] Resuscitation (CPR) started by the nurse. Resident #67 had Physician order [REDACTED]. This resulted in an immediate jeopardy at a scope and severity of level J. An immediate jeopardy was called on [DATE] at 12:27 pm. At that time, the Administrator (ADM), Director of Nursing (DON), and Regional Director (RD) were informed. The facility provided an acceptable Plan of Removal on [DATE] at 3:25 pm. Acceptance of the Plan of Removal lowered the scope and severity level to a level G, with the IJ lifted, and included the following interventions: Immediate Plan: 1. An audit of the code status of all residents in the facility will be confirmed by the physician orders, the code status will be placed on color coded paper in the front of the clinical record, and at the room doors, where the resident's name is written, the name will be written on the same color coded paper. 2. A licensed staff member who is CPR certified will be in the facility 24 hours a day. 3. Immediate and on-going in-servicing of current licensed staff has been initiated. Education Plan: 1. An in-service of current licensed staff has been initiated and will continue in regards to following physician orders, code status, and fall protocol. A list of current residents with full code status will be addressed. This in-servicing will be completed by [DATE], and will be completed prior to anyone working their next shift. Based on record review and interview, the facility failed to follow their policies for abuse and neglect by not investigating a sudden death and neglect where CPR was not preformed. The facility also failed to follow their policies by not reporting the neglect to the state agency for 1 (#67) of 1 (#67) resident reviewed for death in a closed record review. The neglect was evidenced by: 1. On [DATE], at 9:00 am, Resident #67 fell by the nurses station with no visual injury. The resident was not checked again by the nurse. 2. The resident was found at [DATE] at 12:15 pm without a pulse or respirations. The resident, who was a full code, did not have Cardio [MEDICAL CONDITION] Resuscitation (CPR) started by the nurse. Resident #67 had Physician order [REDACTED]. The resident did not have the opportunity to potentially be revived, and died . This failure to investigate the neglect could likely cause additional resident's to not have CPR preformed if their heart and respirations stopped. A. Record review of the Facility's policy titled "Abuse Prevention" dated [DATE], revised [DATE], revealed, "Investigation: A. The administrator is responsible for coordinating and completing the investigation,...C. Investigation to include identifying the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities....D. Investigation results will be recorded and organized to include actual statements of witnesses versus summaries, medical record information related to the investigation, analysis and plan of correction, and any disciplinary action taken...Reporting 2. Alleged violations and substantiated incidents will be reported to the state agency immediately and to all other agencies as required and in accordance with state and federal law..." B. Record review of Resident #67's Long Term Care admission orders Code Status: Full Code" was checked. C. The Directive for CPR-Cardiopulmonary Resuscitation "FULL CODE" revealed, "In the event of [MEDICAL CONDITION] (heart stoppage), I wish CPR to be administered immediately. I understand the possible outcomes and the possible complications of this procedure." This directive was signed on [DATE] by telephone consent by the Power of Attorney (POA). D. Nursing Policies and Procedures, no date, "Cardiopulmonary Resuscitation," provided by the facility revealed: 1. "Policy: 1. Cardiopulmonary resuscitation is instituted on all residents except those designated of "no Code"/no CPR. 2. Only individuals certified in basic CPR, perform cardiopulmonary resuscitation. 3. All licensed nursing personnel are required to have a certification for basic CPR." 2. "Procedures: 1. In cases of a cardiac and or [MEDICAL CONDITION] arrest, CPR is instituted immediately. 2. CPR is continued until medical emergency personnel are available to take over the procedure." 3. "CPR may be discontinued a. If the victim responds, or b. If a physician orders [REDACTED]. E. Review of the Daily Shift Charting (Nurses Notes) dated [DATE] (no time), revealed, " ... At 9:00 (am) Resident was walking from dining room toward NS (nursing station), fell , slipping down to bottom then laid head down. Nurse observed. No obvious injuries noted. VS (Vital Signs) ,[DATE] (blood pressure) R (respirations) 20 T (temperature) 97.6 P (pulse) 72. ... " 1. Nurses Notes dated [DATE] at 12:15 pm, revealed, "Aide (Certified Nursing Assistant) called nurse to room. Resident not responsive. Unable to feel pulse, no lung sounds heard. Body temp cool to touch. Called nurse on call (name of LPN #4) 12:20 approximately. Administrator called this nurse after being contacted, informed of procedure. RN (Registered Nurse) to be contacted for pronouncement. Awaiting response." 2. Nurses Notes dated [DATE] (no time) revealed, "Aide reported Resident at 10:15 responsive at that time." 3. Licensed Nurses Notes dated [DATE] at 12:50 pm revealed, "Resident pronounced at this time. Pupils fixed bilaterally, no resp (respiration) no pulses and resident cold to touch, no heart beat noted. Resident did have fall and fx (fracture) to humerus - [DATE] fall and sent to hospital on [DATE] and fx found." F. On [DATE] at 10:40 am, an interview was conducted with Licensed Practical Nurse (LPN) #4 concerning the incident with Resident #67. LPN #4 stated that she was on call that weekend and was contacted by LPN #3 about the incident. LPN #4 stated that LPN #3 called her about the incident because LPN #3 had been unable to contact the Administrator (ADM). When asked about the timeframe of the incident and the phone call, LPN #4 stated that it was approximately 30 minutes after LPN #3 found the body. LPN #4 asked LPN #3 what the Code status of the resident was and was told that the resident was full code. LPN #4 asked LPN #3 if she had initiated CPR. LPN #3 told LPN #4, "No, she was cold to the touch." LPN #4 stated that she told LPN #3, CPR should have been initiated. LPN #4 stated she then contacted the Administrator about the incident. 1. On [DATE] at 11:20 am, an interview was conducted with the Administrator (ADM). When asked if she talked to LPN #3, the ADM stated that she had talked to her, but LPN #3 was not a Registered Nurse, so she talked to LPN #4 and to get an RN into the building to pronounce. When the ADM was asked if she had inquired of the code status of the resident, the ADM stated that she did not. 2. On [DATE] at 12:25 pm, an interview was conducted with the Regional Director (RD) and the Director of Nurses (DON) of the facility. When asked if a full code procedure should have been initiated, they both stated, "The LPN should have initiated CPR." 3. On [DATE] at 2:30 pm, LPN #3 was interviewed. LPN #3 was asked to describe the events leading to the time Resident #67 was found without vital signs, and the facility response. LPN #3 stated, "After breakfast, I witnessed her fall by the nurses station. She did not hit her head or appear to be injured. We got her up and she sat in the dining room for a while. About 9:20 to 9:30 am, the aid took her to the bathroom and then put her to bed to rest. The aides waited to get her up because she had the 2 falls and we were letting her rest. A little after 12:00 (noon), the aide called to me from the room and when I got there, she (Resident #67) was not breathing, had no pulse, she was pale, did not respond, and her mouth was open. She was cool to touch with no signs of life, 'she was gone.' I called (name of LPN #4) who was on call. She asked me what the code status was and I went to look it up. I told her the resident was a full code. LPN #4 told me a Registered Nurse (RN) would be located to pronounce. I did tell (name of LPN #4) the resident was gone and nothing could have been done. I then finished my med (medication) pass and looked for the black facility book that had contact phone numbers for staff and physicians in it. There was only one in the facility and it was on the other unit. The Administrator called me, and said an RN was contacted to pronounce and, and we were told to contact the Office Of Medical Investigator (OMI). No one ever suggested to call 911." When LPN #3 was asked if she knew CPR, LPN #3 stated, "Yes, I am CPR certified." When LPN #3 was asked if the signed code status was a physician order, LPN #3 stated, "Yes, now I do know that. I know a lot more than I did on that day. I did not follow that physician order [REDACTED]. 4. On [DATE] at 8:50 am, Certified Nurse Aide (CNA) # 5 was interviewed. CNA #5 stated that when Resident #67 got dressed and up for breakfast she was acting weak and unstable so CNA #5 got another aide to assist her to walk Resident #67 to the dining room. I was in a resident room when I head the nurse call that she needed help. Resident #67 was laying on the floor by the nurses station. The nurse said she saw her fall and she did not hit her head. The 2 of us got her (Resident #67) up and sat her in a chair in the dining room. The nurse took her vitals and everything seemed to be ok. After about 20 to 30 minutes, I took Resident #67 to her room to lay down because she seemed to be tired. I toileted her and laid her down about 10:00 to 10:15 am. I did not check on her until about 12:00 when I went in to get her changed and dressed for lunch. That is when I noticed she was not breathing...I left the room and got the nurse. (Name of LPN #3) and I went into the room. She assessed Resident #67 and said she was not breathing and there was no pulse. The nurse left the room I think to get a nurse from the other side, and I stayed in the room with the resident. I did not see any other nurse until (Name of RN #1) came about 12:45 pm. When CNA #5 was asked to describe the condition of Resident #67 when she found her, CNA #5 stated, "She was not cold but cool, and she was not stiff like some I have seen before. Her back was still warm. When you looked at her, you could tell she had passed." G. Record review of abuse and neglect reporting by the facility revealed no investigation was completed for Resident #67's death without CPR being done. There was no report to the state agency concerning Resident #67. H. On [DATE] at 8:50 am, the RD of the facility was interviewed. When asked if the failure to administer CPR to a full code resident was neglect, the RD agreed that it was neglect. When the RD was asked if the facility reported the neglect the State, the RD stated that there was no report sent to the State Agency because she did not know about the incident. I. On [DATE] at 8:55 am, the Administrator (ADM) was asked if a report had been sent to the State about the incident with Resident #67. The ADM stated that she did not send a report to the State Agency.

Based on record review and interview, the facility failed to follow the resident's care plan and physician orders [REDACTED].#67) resident reviewed for death in a closed record review. Resident #67 was a full code. In the event of heart stoppage, CPR was to be started. When found without a heartbeat or respirations, CPR was not started. The resident did not have the opportunity to potentially be revived, and died . This failure could likely cause additional resident's to not have CPR preformed if their heart and respirations stopped. This caused neglect of the Resident. This was evidenced by: 1. Resident #67 was found at [DATE] at 12:15 pm without a pulse or respirations. The resident, who was a full code, did not have Cardio [MEDICAL CONDITION] Resuscitation (CPR) started by the nurse. Resident #67 had Physician order [REDACTED]. This resulted in an immediate jeopardy at a scope and severity of level J. An immediate jeopardy was called on [DATE] at 12:27 pm. At that time, the Administrator (ADM), Director of Nursing (DON), and Regional Manager (RM) were informed. The facility provided an acceptable Plan of Removal on [DATE] at 3:25 pm. Acceptance of the Plan of Removal lowered the scope and severity level to a level G, with the IJ lifted, and included the following interventions: Immediate Plan: 1. An audit of the code status of all residents in the facility will be confirmed by the physician orders, the code status will be placed on color coded paper in the front of the clinical record, and at the room doors, where the resident's name is written, the name will be written on the same color coded paper. 2. A licensed staff member who is CPR certified will be in the facility 24 hours a day. 3. Immediate and on-going in-servicing of current licensed staff has been initiated. Education Plan: 1. An in-service of current licensed staff has been initiated and will continue in regards to following physician orders, code status, and fall protocol. A list of current residents with full code status will be addressed. This in-servicing will be completed by [DATE], and will be completed prior to anyone working their next shift. Based on record review and interview, the facility failed to follow the resident's care plan and physician orders [REDACTED].#67) resident reviewed for death in a closed record review. Resident #67 was a full code. In the event of heart stoppage, CPR was to be started. When found without a heartbeat or respirations, CPR was not started. The resident did not have the opportunity to potentially be revived, and died . This failure could likely cause additional resident's to not have CPR preformed if their heart and respirations stopped. This caused neglect of the Resident. The findings are: A. Record review of Resident #67's Long Term Care admission orders Code Status: Full Code" was checked. B. The Directive for CPR-Cardiopulmonary Resuscitation "FULL CODE" revealed, "In the event of [MEDICAL CONDITION] (heart stoppage), I wish CPR to be administered immediately. I understand the possible outcomes and the possible complications of this procedure." This directive was signed on [DATE] by telephone consent by the Power of Attorney (POA). C. Nursing Policies and Procedures, no date, "Cardiopulmonary Resuscitation," provided by the facility revealed: 1. "Policy: 1. Cardiopulmonary resuscitation is instituted on all residents except those designated of "no Code"/no CPR. 2. Only individuals certified in basic CPR, perform cardiopulmonary resuscitation. 3. All licensed nursing personnel are required to have a certification for basic CPR." 2. "Procedures: 1. In cases of a cardiac and or [MEDICAL CONDITION] arrest, CPR is instituted immediately. 2. CPR is continued until medical emergency personnel are available to take over the procedure." 3. "CPR may be discontinued a. If the victim responds, or b, If a physician orders [REDACTED]. D. Review of the Daily Shift Charting (Nurses Notes) dated [DATE] (no time), revealed, " ... At 9:00 (am) Resident was walking from dining room toward NS (nursing station), fell , slipping down to bottom then laid head down. Nurse observed. No obvious injuries noted. VS (Vital Signs) ,[DATE] (blood pressure) R (respirations) 20 T (temperature) 97.6 P (pulse) 72. ... " 1. Nurses Notes dated [DATE] at 12:15 pm, revealed, "Aide (Certified Nursing Assistant) called nurse to room. Resident not responsive. Unable to feel pulse, no lung sounds heard. Body temp cool to touch." Called nurse on call (name of LPN #4) 12:20 (pm) approximately. Administrator called this nurse after being contacted, informed of procedure. RN (Registered Nurse) to be contacted for pronouncement. Awaiting response." 2. Nurses Notes dated [DATE] (no time), "Aide reported Resident at 10:15 (am) responsive at that time." 3. Licensed Nurses Notes dated [DATE] at 12:50 pm revealed, "Resident pronounced at this time. Pupils fixed bilaterally, no resp (respiration) no pulses and resident cold to touch, no heart beat noted. Resident did have fall and fx (fracture) to humerus - [DATE] fall and sent to hospital on [DATE] and fx found." E. On [DATE] at 10:40 am, an interview was conducted with Licensed Practical Nurse (LPN) #4 concerning the incident with Resident #67. LPN #4 stated that she was on call that weekend and was contacted by LPN #3 about the incident. LPN #4 stated that LPN #3 called her about the incident because LPN #3 had been unable to contact the Administrator (ADM). When asked about the timeframe of the incident and the phone call, LPN #4 stated that it was approximately 30 minutes after LPN #3 found the body. LPN #4 asked LPN #3 what the Code status of the resident was and was told that the resident was full code. LPN #4 asked LPN #3 if she had initiated CPR. LPN #3 told LPN #4, "No, she was cold to the touch." LPN #4 stated that she told LPN #3, CPR should have been initiated. LPN #4 stated she then contacted the Administrator about the incident. 1. On [DATE] at 11:20 am, an interview was conducted with the Administrator (ADM). When asked if she talked to LPN #3, the ADM stated that she had talked to her, but LPN #3 was not a Registered Nurse, so she talked to LPN #4 and to get an RN into the building to pronounce. When the ADM was asked if she had inquired of the code status of the resident, the ADM stated that she did not. 2. On [DATE] at 12:25 pm, an interview was conducted with the Regional Director (RD) and the Director of Nurses (DON) of the facility. When asked if a full code procedure should have been initiated, they both stated, "The LPN should have initiated CPR." 3. On [DATE] at 2:30 pm, LPN #3 was interviewed. LPN #3 was asked to describe the events leading to the time Resident #67 was found without vital signs, and the facility response. LPN #3 stated, "After breakfast, I witnessed her fall by the nurses station. She did not hit her head or appear to be injured. We got her up and she sat in the dining room for a while. About 9:20 to 9:30 am, the aide took her to the bathroom and then put her to bed to rest. The aides waited to get her up because she had the 2 falls and we were letting her rest. A little after 12:00 (noon), the aid called to me from the room and when I got there, she (Resident #67) was not breathing, had no pulse, she was pale, did not respond, and her mouth was open. She was cool to touch with no signs of life, 'she was gone.' I called (name of LPN #4) who was on call. She asked me what the code status was and I went to look it up. I told her the resident was a full code. LPN #4 told me a Registered Nurse (RN) would be located to pronounce. I did tell (name of LPN #4) the resident was gone and nothing could have been done. I then finished my med (medication) pass and looked for the black facility book that had contact phone numbers for staff and physicians in it. There was only one in the facility and it was on the other unit. The Administrator called me, and said an RN was contacted to pronounce and, and we were told to contact the Office Of Medical Investigator (OMI). No one ever suggested to call 911." When LPN #3 was asked if she knew CPR, LPN #3 stated, "Yes, I am CPR certified." When LPN #3 was asked if the signed code status was a physician order, LPN #3 stated, "Yes, now I do know that. I know a lot more than I did on that day. I did not follow that physician order [REDACTED]. 4. On [DATE] at 8:50 am, Certified Nurse Aide (CNA) # 5 was interviewed. CNA #5 stated, '... I toileted her (Resident #67) and laid her down about 10:00 to 10:15 am. I did not check on her until about 12:00 when I went in to get her changed and dressed for lunch. That is when I noticed she was not breathing. ... I left the room and got the nurse. (Name of LPN #3) and I went into the room. She assessed Resident #67 and said she was not breathing and there was no pulse. The nurse left the room I think to get a nurse from the other side, and I stayed in the room with the resident. I did not see any other nurse until (Name of RN #1) came about 12:45 pm. When CNA #5 was asked to describe the condition of Resident #67 when she found her, CNA #5 stated, "She was not cold but cool, and she was not stiff like some I have seen before. Her back was still warm. When you looked at her, you could tell she had passed." 5. On [DATE] at 8:50 am, the RD of the facility was interviewed. When asked if the failure to administer CPR to a full code resident was neglect, the RD agreed that it was neglect.

Based on record review and interview, the facility failed to provide the necessary care and services, Cardiopulmonary Resuscitation (CPR), for 1 (#67) of 1 (#67) Residents reviewed for death in closed record review. In the event of heart stoppage, CPR was to be started. When found without a heartbeat or respirations, CPR was not started. This caused neglect of the Resident. The resident did not have the opportunity to potentially be revived, and died . This failure could likely cause additional resident's to not have CPR preformed if their heart and respirations stopped This was evidenced by: 1. Resident #67 was found at [DATE] at 12:15 pm without a pulse or respirations. The resident, who was a full code, did not have Cardio [MEDICAL CONDITION] Resuscitation (CPR) started by the nurse. Resident #67 had Physician order [REDACTED]. This resulted in an immediate jeopardy at a scope and severity of level J. An immediate jeopardy was called on [DATE] at 12:27 pm. At that time, the Administrator (ADM), Director of Nursing (DON), and Regional Manager (RM) were informed. The facility provided an acceptable Plan of Removal on [DATE] at 3:25 pm. Acceptance of the Plan of Removal lowered the scope and severity level to a level G, with the IJ lifted, and included the following interventions: Immediate Plan: 1. An audit of the code status of all residents in the facility will be confirmed by the physician orders, the code status will be placed on color coded paper in the front of the clinical record, and at the room doors, where the resident's name is written, the name will be written on the same color coded paper. 2. A licensed staff member who is CPR certified will be in the facility 24 hours a day. 3. Immediate and on-going in-servicing of current licensed staff has been initiated. Education Plan: 1. An in-service of current licensed staff has been initiated and will continue in regards to following physician orders, code status, and fall protocol. A list of current residents with full code status will be addressed. This in-servicing will be completed by [DATE], and will be completed prior to anyone working their next shift. Based on record review and interview, the facility failed to provide the necessary care and services for 1 (#67) of 1 (#67) Resident who required Cardiopulmonary Resuscitation (CPR). Resident #67 was a full code. In the event of heart stoppage, CPR was to be started. When found without a heartbeat or respirations, CPR was not started. This caused neglect of the Resident. The resident did not have the opportunity to potentially be revived, and died . This failure could likely cause additional resident's to not have CPR preformed if their heart and respirations stopped. The findings are: A. Record review of Resident #67's Long Term Care admission orders Code Status: Full Code" was checked. B. The Directive for CPR-Cardiopulmonary Resuscitation "FULL CODE" revealed, "In the event of [MEDICAL CONDITION] (heart stoppage), I wish CPR to be administered immediately. I understand the possible outcomes and the possible complications of this procedure." This directive was signed on [DATE] by telephone consent by the Power of Attorney (POA). C. Nursing Policies and Procedures, no date, "Cardiopulmonary Resuscitation," provided by the facility revealed: 1. "Policy: 1. Cardiopulmonary resuscitation is instituted on all residents except those designated of "no Code"/no CPR. 2. Only individuals certified in basic CPR, perform cardiopulmonary resuscitation. 3. All licensed nursing personnel are required to have a certification for basic CPR." 2. "Procedures: 1. In cases of a cardiac and or [MEDICAL CONDITION] arrest, CPR is instituted immediately. 2. CPR is continued until medical emergency personnel are available to take over the procedure." 3. "CPR may be discontinued a. If the victim responds, or b, If a physician orders [REDACTED]. D. Review of the Daily and Q Shift Charting (Nurses Notes) dated [DATE] (no time), revealed, " ... At 9:00 (am) Resident was walking from dining room toward NS (nursing station), fell , slipping down to bottom then laid head down. Nurse observed. No obvious injuries noted. VS (Vital Signs) ,[DATE] (blood pressure) R (respirations) 20 T (temperature) 97.6 P (pulse) 72. ... " 1. Nurses Notes dated [DATE] at 12:15 pm, revealed, "Aide (Certified Nursing Assistant) called nurse to room. Resident not responsive. Unable to feel pulse, no lung sounds heard. Body temp cool to touch." Called nurse on call (name of LPN #4) 12:20 approximately. Administrator called this nurse after being contacted, informed of procedure. RN (Registered Nurse) to be contacted for pronouncement. Awaiting response." 2. Nurses Notes dated [DATE] (no time), "Aide reported Resident at 10:15 responsive at that time." 3. Licensed Nurses Notes dated [DATE] at 12:50 pm revealed, "Resident pronounced at this time. Pupils fixed bilaterally, no resp (respiration) no pulses and resident cold to touch, no heart beat noted. Resident did have fall and fx (fracture) to humerus - [DATE] fall and sent to hospital on [DATE] and fx found." E. On [DATE] at 10:40 am, an interview was conducted with Licensed Practical Nurse (LPN) #4 concerning the incident with Resident #67. LPN #4 stated that she was on call that weekend and was contacted by LPN #3 about the incident. LPN #4 stated that LPN #3 called her about the incident because LPN #3 had been unable to contact the Administrator (ADM). When asked about the timeframe of the incident and the phone call, LPN #4 stated that it was approximately 30 minutes after LPN #3 found the body. LPN #4 asked LPN #3 what the Code status of the resident was and was told that the resident was full code. LPN #4 asked LPN #3 if she had initiated CPR. LPN #3 told LPN #4, "No, she was cold to the touch." LPN #4 stated that she told LPN #3, CPR should have been initiated. LPN #4 stated she then contacted the Administrator about the incident. 1. On [DATE] at 11:20 am, an interview was conducted with the Administrator (ADM). When asked if she talked to LPN #3, the ADM stated that she had talked to her, but LPN #3 was not a Registered Nurse, so she talked to LPN #4 and to get an RN into the building to pronounce. When the ADM was asked if she had inquired of the code status of the resident, the ADM stated that she did not. 2. On [DATE] at 12:25 pm, an interview was conducted with the Regional Director (RD) and the Director of Nurses (DON) of the facility. When asked if a full code procedure should have been initiated, they both stated, "The LPN should have initiated CPR." 3. On [DATE] at 2:30 pm, LPN #3 was interviewed. LPN #3 was asked to describe the events leading to the time Resident #67 was found without vital signs, and the facility response. LPN #3 stated, "After breakfast, I witnessed her fall by the nurses station. She did not hit her head or appear to be injured. We got her up and she sat in the dining room for a while. About 9:20 to 9:30 am, the aide took her to the bathroom and then put her to bed to rest. The aides waited to get her up because she had the 2 falls and we were letting her rest. A little after 12:00 (noon), the aide called to me from the room and when I got there, she (Resident #67) was not breathing, had no pulse, she was pale, did not respond, and her mouth was open. She was cool to touch with no signs of life, 'she was gone.' I called (name of LPN #4) who was on call. She asked me what the code status was and I went to look it up. I told her the resident was a full code. LPN #4 told me a Registered Nurse (RN) would be located to pronounce. I did tell (name of LPN #4) the resident was gone and nothing could have been done. I then finished my med (medication) pass and looked for the black facility book that had contact phone numbers for staff and physicians in it. There was only one in the facility and it was on the other unit. The Administrator called me, and said an RN was contacted to pronounce and, and we were told to contact the Office Of Medical Investigator (OMI). No one ever suggested to call 911." When LPN #3 was asked if she knew CPR, LPN #3 stated, "Yes, I am CPR certified." When LPN #3 was asked if the signed code status was a physician order, LPN #3 stated, "Yes, now I do know that. I know a lot more than I did on that day. I did not follow that physician order [REDACTED]. 4. On [DATE] at 8:50 am, Certified Nurse Aide (CNA) # 5 was interviewed. CNA #5 stated, '... I toileted her (Resident #67) and laid her down about 10:00 to 10:15 am. I did not check on her until about 12:00 when I went in to get her changed and dressed for lunch. That is when I noticed she was not breathing. ... I left the room and got the nurse. (Name of LPN #3) and I went into the room. She assessed Resident #67 and said she was not breathing and there was no pulse. The nurse left the room I think to get a nurse from the other side, and I stayed in the room with the resident. I did not see any other nurse until (Name of RN #1) came about 12:45 pm. When CNA #5 was asked to describe the condition of Resident #67 when she found her, CNA #5 stated, "She was not cold but cool, and she was not stiff like some I have seen before. Her back was still warm. When you looked at her, you could tell she had passed." 5. On [DATE] at 8:50 am, the RD of the facility was interviewed. When asked if the failure to administer CPR to a full code resident was neglect, the RD agreed that it was neglect.

Based on record review and interview, the facility failed to report and investigate neglect when Cardio [MEDICAL CONDITION] Resuscitation (CPR) was not provided to 1 (#67) of 1 (#67) resident reviewed for death in a closed record review. Resident #67 had Physician order [REDACTED]. Resident #67 was found without pulse or respirations, and the facility failed to begin CPR. The resident did not have the opportunity to potentially be revived, and died . This failure to investigate could likely cause additional resident's to not have CPR preformed if their heart and respirations stopped. The findings are: A. Review of the facility Abuse Prevention Policy dated [DATE], Section VII Reporting revealed, "A. Reporting of incidents, investigations, and facility responses related to the results of investigation to include: 1. All staff will be trained to report incidents immediately to the Administrator or designee to include: mistreatment, neglect, abuse,... . 2. Alleged violations and substantiated incidents will be reported to the state agency immediately and to all other agencies as required and in accordance with state and federal law. ... 5. The Administrator shall notify the following persons of the allegation of abuse and that as investigation is underway. a. Incident Report will be faxed to the Department of Health, ...immediately within 24 hours of incident ..." B. Record review of Resident #67's Long Term Care admission orders 6. Code Status: Full Code" was checked. C. The Directive for CPR-Cardiopulmonary Resuscitation "FULL CODE" revealed, "In the event of [MEDICAL CONDITION] (heart stoppage), I wish CPR to be administered immediately. I understand the possible outcomes and the possible complications of this procedure." This directive was signed on [DATE] by telephone consent by the Power of Attorney (POA). D. Nursing Policies and Procedures, no date, "Cardiopulmonary Resuscitation," provided by the facility revealed: 1. "Policy: 1. Cardiopulmonary resuscitation is instituted on all residents except those designated of "no Code"/"no CPR. 2. Only individuals certified in basic CPR, perform cardiopulmonary resuscitation. 3. All licensed nursing personnel are required to have a certification for basic CPR. 2. Procedures: 1. In cases of a cardiac and or [MEDICAL CONDITION] arrest, CPR is instituted immediately. 2. CPR is continued until medical emergency personnel are available to take over the procedure. 3. CPR may be discontinued a. If the victim responds, or b. If a physician orders [REDACTED]. E. Nurses Notes dated [DATE] at 12:15 pm, revealed, "Aide (Certified Nursing Assistant) called nurse to room. Resident not responsive. Unable to feel pulse, no lung sounds heard. Body temp cool to touch. Called nurse on call (name of Licensed Practical Nurse {LPN} #4) 12:20 approximately. Administrator called this nurse after being contacted, informed of procedure. RN (Registered Nurse) to be contacted for pronouncement. Awaiting response." F. Licensed Nurses Notes dated [DATE] at 12:50 pm, revealed, "Resident pronounced at this time. Pupils fixed bilaterally, no resp (respiration) no pulses and resident cold to touch, no heart beat noted. ..." G. On [DATE] at 10:40 am, an interview was conducted with LPN #4 concerning the incident with Resident #67. LPN #4 stated that she was on call that weekend and was contacted by LPN #3 about the incident. LPN #4 stated that LPN #3 called her about the incident because LPN #3 had been unable to contact the Administrator (ADM).. When asked about the timeframe of the incident and the phone call, LPN #4 stated that it was approximately 30 minutes after LPN #3 found the body. LPN #4 asked LPN #3 what the Code status of the resident was. LPN #3 told LPN #4 that the resident was full code. LPN #4 asked LPN #3 if she had initiated CPR. LPN #3 told LPN #4, "No, she was cold to the touch." LPN #4 stated that she told LPN #3, CPR should have been initiated. LPN #4 stated she then contacted the Administrator about the incident. H. On [DATE] at 12:25 pm, an interview was conducted with the Regional Director (RD) of the facility. When asked if a full code procedure should have been initiated, the RD stated, "The LPN should have initiated CPR." I. On [DATE] at 2:30 pm, Licensed Practical Nurse (LPN) #3 was interviewed. When LPN #3 was asked to describe the events when Resident #67 was found without vital signs, LPN #3 stated, "A little after 12:00, the aide (certified nursing assistant) called to me from the room and when I got there, she (Resident #67) was not breathing, had no pulse, she was pale, did not respond, and her mouth was open. She was cool to touch with no signs of life, 'she was gone.' I called (name of LPN #4) who was on call. She asked me what the code status was and I went to look it up. I told her the resident was a full code. LPN #4 told me a Registered Nurse (RN) would be located to come to pronounce. The Administrator (ADM) called me, and said an RN was contacted to pronounce and, and we were told to contact the Office of the Medical Investigator (OMI). No one ever suggested to call 911." When LPN #3 was asked if she knew CPR, LPN #3 stated, "Yes, I am CPR certified." When LPN #3 was asked if the signed code status was a physician order, LPN #3 stated, "Now I do, I know a lot more than I did on that day. I did not follow that physician order [REDACTED]. J. On [DATE] at 8:50 am, Certified Nurse Aide (CNA) # 5 was interviewed. CNA #5 stated that when Resident #67 got dressed and up for breakfast she was acting weak and unstable so CNA #5 got another aide to assist her to walk Resident #67 to the dining room. Later, I toileted her and laid her down about 10:00 to 10:15 am. I did not check on her until about 12:00 (pm), when I went in to get her changed and dressed for lunch. That is when I noticed she was not breathing. ...I left the room and got the nurse. (Name of LPN #3) and I went into the room. LPN #3 assessed Resident #67 and said she was not breathing and there was no pulse. The nurse left room I think to get nurse from other side and I stayed in the room with the resident. I did not see any other nurse until (Name of RN #1) RN came about 12:45 pm. When CNA #5 was asked to describe the condition of Resident #67 when she found her, CNA #5 stated, "She was not cold but cool, and she was not stiff like some I have seen before. Her back was still warm. When you looked at her, you could tell she had passed." K. Record review of abuse and neglect reporting by the facility revealed no investigation was completed for Resident #67's death without CPR being done. There was no report to the state agency concerning Resident #67. L. On [DATE] at 8:50 am, the RD of the facility was interviewed. When asked if the failure to administer CPR to a full code resident was neglect, the RD agreed that it was neglect. When the RD was asked if the facility reported the neglect to the State Agency, the RD stated that there was no report sent to State because she did not know about the incident. M. On [DATE] at 8:55 am, the Administrator (ADM) was asked if a report had been sent to the State about the incident with Resident #67. The ADM stated that she did not send a report to the State Agency.

Based on record review, observations and interview, the facility failed to revise the plan of care for falls for 1 (#31) of 3 (#31, 13, 30) residents reviewed for falls. This was evidenced by: 1. Resident #31 fell and hit his head on the bed side dresser on 12/14/11. The bedside stand was not moved, an environment review was not done concerning the bed side stand, and no new interventions were implemented. 2. Resident #31 fell on [DATE] and hit the bed side stand, received a laceration which required staples to the head. This caused actual harm for the resident. No new interventions were implemented. The findings are: A. Record review of Resident #31's medical record revealed the following: 1. Fall Care Plan was initiated on 11/01/11 after the resident had a fall on 10/28/11. The Fall Care Plan revealed, "10/28/11 resident had a fall in room during self transfers, abrasion to left eye." An intervention dated 11/01/11 revealed, "fall mat next to bed and PT/OT (physical therapy/occupational therapy) per orders." 2. Licensed Nurses Notes (LNN) dated 12/14/11 at 6 am, revealed, "Resident alert, very confused, resident stood up from w/c (wheelchair) feet slipped out causing resident to hit bedside table no injury noted, denies pain ..." 3. Interdisciplinary Team Notes (IDT) dated 12/15/11 revealed, "IDT review for fall on 12/14/11. Resident stated he stood up and w/c moved no injury landed on fall mat. Does not use call light for assistance. Will continue to use fall mat for safety." There were no changes to interventions on the fall care plan for the 12/14/11 fall. B. Review of Resident #31's records concerning a fall on 01/03/12 revealed: 1. LNN dated 01/03/12 at 6:00 am, revealed, "Resident was noted on floor in room appears to have attempted to transfer self out of bed unassisted and hit head against night stand received a laceration to left side of head new order to send to local hospital emergency room for evaluation as indicated. Transported ..." 2. LNN dated 01/03/12 at 6 pm, revealed, "Returned from (Name of local hospital) emergency room approximately 3 centimeter laceration to left side of head, 3 staples intact..." 3. A 01/03/12 Transfer Form to the local hospital revealed, "Resident attempted to transfer self unassisted appears to have hit head against night stand. Laceration noted to left side of head." 4. The 01/03/12 Discharge Instructions from the local hospital revealed, "Laceration Scalp...Staples need to be removed in 7 days." 5. Review of Resident #31's Fall Care Plan dated 11/01/11 revealed no revision or new interventions to prevent further falls or minimize injury from falls from the 01/03/12 fall. 6. Review of the 01/04/12 IDT review for the fall revealed, "...Continue to use fall mat. Does not use call light for assistance..." No new interventions were implemented. C. Observation of Resident #31on 03/14/12 at 11:00 am, revealed that Resident #31 was in his room in a wheelchair, a fall mat was beside the bed. The bedside stand was beside the bed. The resident was confused. D. The Care Plan Coordinator (CPC) was interviewed on 03/15/12 at 4:15 pm concerning Resident #31's falls. After reviewing the falls and the care plans, the CPC agreed that there were no revisions or new interventions on the 12/14/11 and 01/03/12 falls to try and prevent additional falls or minimize injury. Based on record review and interview, the facility failed to revise the Patient Care Plan for 1 (#57) of 3 residents (#32,43,57) reviewed for the use of [MEDICAL CONDITION] medications. The resident had behaviors and had to have the medications increased. Behavioral interventions were not revised. This failure had the likelihood for staff not to know the current goals and approaches for the resident receiving antipsychotic medications. The findings are: A. Review of Resident #57's physician's orders [REDACTED]. 1. The Long Term Care admission orders [REDACTED].(milligram) QHS (every hour of sleep), [MEDICATION NAME] 20 mg. after breakfast, [MEDICATION NAME] 40 mg. QHS. 2. On 08/25/11 a Physician order [REDACTED]. Resident refuses 8 pm medication [MEDICATION NAME] 100 mg. 1 tab PO (by mouth) and [MEDICATION NAME] 40 mg. 1 tab PO. 2. Will take medication with meal. [MEDICATION NAME] 100 mg 1 tab PO 6 pm [MEDICATION NAME] 40 mg. 1 tab PO Q 6 P (pm)." 3. On 08/25/11, a Physician order [REDACTED]." 4. On 10/27/11, a Physician order [REDACTED]. BID (2 times a day). 5. On 11/23/11, a Physician order [REDACTED]. 1 PO PRN anxiety/agitation" and, "Increase [MEDICATION NAME] to 150 mg. PO, QHS [MEDICAL CONDITION] ..." 6. On 01/11/12, a Physician order [REDACTED]. [MEDICATION NAME] 60 mg. 1 PO BID, DX (diagnosis) Depression with F/O (features of ) Aggression; 2. [MEDICATION NAME] 0.5 1/2 tab PO Q 8 hrs PRN, Dx Anxiety with F/O verbal aggression, physical aggression; 3. [MEDICATION NAME] 0.5 mg. 1 PO Q 8 hrs PRN, Dx: Anxiety with F/O sleeplessness, Isolation, Refusal of care." B. Review of Resident #57's Licensed Nurses Notes (LNN) revealed the following: 1. LNN dated 08/19/11 at 5:45 am revealed, "While trying to give resident TB ([MEDICAL CONDITION]) injection resident hit this writer in the mouth and yelled... " 2. LNN dated 08/20/11, no time, revealed, " ...Attempted to give 8 PM meds, refused them states ... pushed them away...attempted to take vital signs, resident stood up and pushed me away... " 3. LNN dated 08/22/11, no time, revealed, "...uncooperative with care. Refused meds..." 4. LNN dated 08/26/11, no time, revealed, "refused care..." 5. LNN dated 09/02/11, no time, revealed, "Raised his voice and has become agitated with CNA's (Certified Nursing Assistants)." 6. LNN dated 10/27/11, no time, revealed, "Increase in agitation." C. Review of Resident #57's Patient Care Plan dated 08/31/11 revealed the following: 1. A [DIAGNOSES REDACTED]. 2. Goals included, "Minimal side effects, Verbalize feelings, Interact peacefully in social situations, and be able to complete an assigned task." A date of 12/01/11 and 05/23/12 was written in the Goal area but no changes were made to interventions. A sticker for the Medications contained,"[MEDICATION NAME] (an antipsychotic medication) Side Effects and Special Attention instructions; Anti-Anxiety Medication [MEDICATION NAME]/[MEDICATION NAME], Side effects and Nursing Alert; Antipsychotic Medication [MEDICATION NAME], Side effects and Nursing Alert" was attached to the Care Plan. 3. The Approaches/Needs or Preferences included, "Evaluate effectiveness/side effects of medications, Medications as ordered, ... Observe conversational content, change in mental status, and cognitive ability..." When the Care Plan was reviewed on 12/01/11, no changes were made to the approaches for specific behaviors that were exhibited by Resident #57. D. On 03/16/12 at 1:20 pm, the Regional Director (RD) was interviewed. When asked if there were revisions made to the Patient Care Plan for [MEDICAL CONDITION], the RD stated, "No there were no changes made, and there should have been with his behaviors and the changes that were made in the medications."

Based on record review, observation, and interview, the facility failed to prevent accident hazards for 1 (#31) of 3 (#31,13, 30) residents reviewed for falls. The facility failed to implement new interventions to try and prevent additional falls. This was evidenced by: 1. Resident #31 fell and hit his head on the bed side dresser on 12/14/11. The bedside stand was not moved, an environment review was not done concerning the bed side stand, and no new interventions were implemented. 2. Resident #31 fell on [DATE] and hit the bed side stand, received a laceration which required staples to the head. This caused actual harm for the resident. No new interventions were implemented. The findings are: A. Record review of Resident #31's medical record revealed the following: 1. Fall Care Plan was initiated on 11/01/11 after the resident had a fall on 10/28/11. The Fall Care Plan revealed, "10/28/11 resident had a fall in room during self transfers, abrasion to left eye." An intervention dated 11/01/11 revealed, "fall mat next to bed and PT/OT (physical therapy/occupational therapy) per orders." 2. Licensed Nurses Notes (LNN) dated 12/14/11 at 6 am, revealed, "Resident alert, very confused, resident stood up from w/c (wheelchair) feet slipped out causing resident to hit bedside table no injury noted, denies pain ..." 3. Interdisciplinary Team Notes (IDT) dated 12/15/11 revealed, "IDT review for fall on 12/14/11. Resident stated he stood up and w/c moved no injury landed on fall mat. Does not use call light for assistance. Will continue to use fall mat for safety." There were no changes to interventions on the fall care plan for the 12/14/11 fall. B.. Review of Resident #31's records concerning a fall on 01/03/12 revealed: 1. LNN dated 01/03/12 at 6:00 am, revealed, "Resident was noted on floor in room appears to have attempted to transfer self out of bed unassisted and hit head against night stand received a laceration to left side of head new order to send to local hospital emergency room for evaluation as indicated. Transported ..." 2. LNN dated 01/03/12 at 6 pm, revealed, "Returned from (Name of local hospital) emergency room approximately 3 centimeter laceration to left side of head, 3 staples intact..." 3. A 01/03/12 Transfer Form to the local hospital revealed, "Resident attempted to transfer self unassisted appears to have hit head against night stand. Laceration noted to left side of head." 4. The 01/03/12 Discharge Instructions from the local hospital revealed, "Laceration Scalp...Staples need to be removed in 7 days." 5. Review of Resident #31's Fall Care Plan dated 11/01/11 revealed no revision or new interventions to prevent further falls or minimize injury from falls from the 01/03/12 fall. 6. Review of the 01/04/12 IDT review for the fall revealed, "...Continue to use fall mat. Does not use call light for assistance..." No new interventions were implemented. C. Observation of Resident #31on 03/14/12 at 11:00 am, revealed that Resident #31 was in his room in a wheelchair, a fall mat was beside the bed. The bedside stand was beside the bed. The resident was confused. D. The Care Plan Coordinator (CPC) was interviewed on 03/15/12 at 4:15 pm concerning Resident #31's falls. After reviewing the falls and the care plans, the CPC agreed that there were no revisions or new interventions on the 12/14/11 and 01/03/12 falls to try and prevent additional falls or minimize injury.