Every finding on record at Sunset Villa Post Acute

Based on interview and record review, the facility failed to ensure a resident (Resident 1) who's room was changed, received advance written notice including the reason for the room change, exercised his right to refuse the room change, had the opportunity to sign the room-change notice, and was provided a copy of the notice for one of three sampled residents (Resident 1). This failure resulted in Resident 1 not being given the option to accept or decline the room change and resulted in Resident 1 feeling frustrated, irritated, and disappointed after the room change.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a type of stroke caused by a blockage of blood flow in the brain) affecting the right dominant side. The admission Record indicated Resident 1 was self responsible.During a review of Resident 1's History and Physical (H&P) dated 3/30/2026, the H&P indicated Resident 1 did not have the capacity to make medical decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 4/3/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. During a review of Resident 1's Notice of Room Change, dated 5/29/2026, the Notice of Room Change indicated Resident 1's room change was needed for a new admission, and the room change was not medically necessary, and that Resident 1 preferred to give a verbal consent instead of a signature. The Notice of Room Change indicated staff were to print the form for the resident or resident representative to sign as written notice, and once signed, upload the signed document into the resident's Electronic Health Record.During a review of Resident 1's Progress Notes, dated 5/29/2026, there was no documentation indicating Resident 1 was informed of his right to refuse the room change.During a review of Resident 1's Social Services Notes, dated 5/29/2026, there was no documentation indicating Resident 1 was notified in advance and agreed to the room change. During a telephone interview on 6/18/2026 at 10:28 a.m., with Family Member (FM) 1, FM 1 stated Resident 1 had been in one room, and facility staff had come into his room and informed him he was going to be moved without advance notice. FM 1 stated neither she nor Resident 1 had received advance notice of the room change. FM 1 stated staff had told Resident 1 another resident needed to be in his room so the other resident could be closer to the nursing station. FM 1 stated after the move she noticed a change in Resident 1. FM 1 stated Resident 1 had informed her his previous room allowed him to look out the window at cars and people passing by and staff had been more interactive with him. FM 1 stated Resident 1 had become gloomy and staff in the new room had not understood him as well. FM 1 stated in his previous room he had been more encouraged and had enjoyed watching people and cars outside the window. FM 1 stated the view from the new room only allowed him to see other residents and did not offer the same stimulation. FM 1 stated she met with the Social Services Director (SSD) and Social Services Assistant (SSA) to request another room so Resident 1 could have a front facing window again. FM 1 stated the SSD informed her someone else needed Resident 1's room so the other resident could be closer to the nursing station. FM 1 stated the SSD told her the facility was looking into another room for Resident 1 but could not promise when it would be available. FM 1 stated the room change occurred about three weeks prior and the facility should not have moved Resident 1 abruptly. FM 1 stated Resident 1 had been frustrated because staff had not listened to him and the facility moved him without informing him in advance. FM 1 stated Resident 1 was alert and able to make decisions for himself and stated she was the emergency contact.During a concurrent interview and record review on 6/18/2026 at 11:15 a.m., with Resident 1, Resident 1's Notice of Room Change was reviewed. Resident 1 stated he preferred his previous room because the view was better and nurses had been more attentive in that location. Resident 1 stated he did not want to look at the residents sitting on the patio and wanted to see outside toward the street, where cars and people were passing by, because it reminded him of home. Resident 1 stated, I do not want to look outside and see other residents like me. Resident 1 stated he was not given advance notice of the room change. Resident 1 stated staff came in and woke him up on 5/29/2026 between 8:30 a.m. and 9:30 a.m. and informed him he would be moved to another room. Resident 1 stated he felt disappointed but said okay. Resident 1 stated staff told him the move would occur after lunch but returned within an hour and began moving him. Resident 1 stated he did not receive a written notification. Resident 1 stated he wanted to speak with the social worker regarding the move, but the social worker was not available at the time. Resident 1 stated he felt disappointed of the room change but believed there was nothing he could do. Resident 1 stated he was not provided with a copy of the Notice of Room Change to sign and was not given the option to decline signing the form or to refuse the room change. Resident 1 reviewed the Notice of Room Change form in his medical record and stated he had never seen the form. [JH1.1][BS1.2]Resident 1 stated he did not authorize a verbal consent as the Notice of Room Change form indicated. Resident 1 stated he believed he did not have a choice in the room change. During an interview on 6/18/2026 at 1:13 p.m., with the SSD, the SSD stated she was responsible for notifying residents of room changes. The SSD stated staff were required to obtain consent before moving a resident to another room. The SSD stated Resident 1 had capacity to sign the Notice of Room Change. The SSD stated she should have provided Resident 1 with the Notice of Room Change to sign and should not have documented Resident 1 preferred to give verbal consent instead of a signature. The SSD stated she did not provide Resident 1 with the Notice of Room Change to sign and did not provide Resident 1 with a copy of the Notice of Room Change. The SSD stated Resident 1 should have signed the Notice of Room Change because Resident 1 had capacity to sign. The SSD stated not having Resident 1 sign the Notice of Room Change was an issue because Resident 1 was disputing the room change. The SSD stated she did not complete a progress note regarding Resident 1's room change. The SSD stated she did not document Resident 1 was provided the Notice of Room Change, was offered the opportunity to sign the Notice of Room Change, was informed of his right to refuse the room change or was provided a copy of the Notice of Room Change.During a concurrent interview and record review on 6/18/2026 at 1:41 p.m., with the Director of Nursing (DON), Resident 1's Notice of Room Change dated 5/29/2026, Nursing Progress Notes, and Social Services Notes were reviewed. The DON stated residents had the right to refuse a room change. The DON stated staff should ensure alert residents signed the room-change consent, so it was mutually understood the resident knew about, agreed to, and understood the room change. The DON stated if a resident had capacity to sign, the resident should sign the Notice of Room Change. The DON stated Resident 1 should have been provided with the Notice of Room Change to sign and should have been provided with a copy of the Notice of Room Change. The DON stated there was no documentation in the Nursing Progress Notes or Social Services Notes which indicated Resident 1 was provided with the Notice of Room Change to sign, was informed of his right to refuse the room change or was provided with a copy of the Notice of Room Change.During a review of the facility's policy and procedure titled, Room Change/Roommate Assignment, revised 1/2026, the P&P indicated resident preferences were taken into account when such changes were considered and residents had the right to refuse to move to another room in the facility unless necessary for health or safety reasons. The P&P indicated documentation of a room change was recorded in the resident's medical record. During a review of the facility's P&P, titled, Transfer, Room to Room, revised 1/2026, the P&P indicated staff were to orient the resident to the transfer in a form and manner the resident could understand and provide the resident with information about where the room was located, who the resident's new roommate would be, who would provide the resident's care, that the resident's family and visitors would be informed of the room change, and why the transfer was taking place. The P&P indicated, if possible, staff were to take the resident to see his or her new room before the actual move was made. The P&P indicated documentation recorded in the resident's medical record included the date and time the room transfer was made, the name and title of the individuals who assisted in the move, all assessment data obtained during the move, how the resident tolerated the move, and if the resident refused the move, the reason why and the intervention taken. The P&P indicated staff were to notify the supervisor if the resident refused the move.

Based on interview, and record review, the facility's staff failed to immediately initiate Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of three sampled residents (Resident 1), when Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 1, who were CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), found Resident 1 unresponsive (a person is unconscious and fails to react to any external stimulation), not breathing and without a pulse on [DATE] at 12:21 a.m. In addition, seven of eight staff who were CPR certified (Licensed Vocational Nurse [LVN] 1, LVN 3, LVN 4, LVN 5, Certified Nursing Assistant [CNA] 2, CNA 3, and CNA 4) did not initiate or assist in CPR after a code blue was called for Resident 1. The facility failed to implement its Policy and Procedure (P/P) titled Emergency Procedure-Cardiopulmonary Resuscitation and Basic Life Support ([BLS] a set of emergency medical procedures designed to sustain life by maintain breathing and circulation) that indicated to select and identify a CPR team for each shift in the case of an actual cardiac arrest and to the extent possible, designate a team leader on each shift who is responsible for coordinating and directing other team members during rescue efforts. Staff are trained to follow current American Heart Association (AHA) guidelines and recommendations for the resuscitation. As a result of these deficient practices, there was a delay in providing CPR to Resident 1. Resident 1 was pronounced dead on [DATE] at 12:52 a.m. On [DATE] at 5:02 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM), the Assistant Director of Nursing (ADON), and a Registered Nurse Consultant (RNC) due to the facility's failure to provide BLS to Resident 1, including immediate initiation of CPR, which potentially contributed to Resident 1's death. An IJ Removal Plan (IJRP, a plan to immediately correct the deficient practices) was immediately requested. On [DATE] the facility submitted an acceptable IJ Removal Plan ([IJRP] a plan to immediately correct the deficient practices). After onsite verification of the facility's IJRP implementation through observations interview, and record review the IJ was removed on [DATE] at 4:57 p.m., in the presence of the ADM and the DON. Non-compliance of F678 remained at the scope and severity of D no actual harm with potential for more than minimal harm that is not immediate Jeopardy. The IJRP included the following: 1. On [DATE], the Assistant Director of Nursing (ADON) conducted individualized one-on-one in-service training with RN 1, LVN 2, LVN 3, LVN 4, LVN 5, CNA 1, CNA 2, CNA 3, and CNA 4 regarding the [DATE] Code Blue event and the facility's Emergency Response/Cardiopulmonary Resuscitation policy. The individualized in-services were conducted either in person or by telephone, based on staff availability. For staff members who were unavailable to attend the in person in-service they received the in-service by telephone, a witness was present during the telephone in-service to verify that the education was conducted, the content was reviewed, and the staff member was given the opportunity to ask questions. Any resident found unresponsive and pulseless, who did not have a DNR order, CPR must be initiated immediately, Code Blue must be activated, 911 must be called immediately, and the crash cart must be retrieved without delay. The Code Status Binder located at each nurses' station and inside each crash cart, the binder contains current physician orders, Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) forms, and advance directive documentation. The ADON reviewed each staff member's individual responsibilities during a Code Blue. For staff members who receive the in-service via phone, they will undergo another refresher in-service onsite when they return to work. 2. On [DATE], the ADON reviewed and verified the BLS certification status for RN 1, LVN 2, LVN 3, LVN 4, LVN 5, CNA 1, CNA 2, CNA 3, and CNA 4. Each staff member was confirmed to have an active and current BLS certification card on file. 3. On [DATE], the ADON in collaboration with the Assistant Director of Staff Development (ADSD) conducted a review of all nursing staff CPR/BLS certification records to verify that each staff member had a current and active CPR/BLS certification on file. Any staff member identified without a current and active CPR/BLS certification was immediately removed from resident care assignments and was not permitted to provide direct resident care until current certification was obtained, submitted, reviewed, and verified by the ADON/designee or DSD/designee. 4. On [DATE], the Regional Director of Staff Development (RDSDS) in collaboration with the ADON conducted an audit of all current in-house residents to verify accurate code status. The audit included review of each resident's current POLST/advance directive documentation and medical record to ensure the resident's code status was accurate, clearly documented, and readily identifiable. 5. On [DATE], the ADON in collaboration with the RDSD provided in-service education to licensed nurses and CNAs regarding the designated CPR/Code Blue team, including each team member's assigned role during a Code Blue emergency. The CPR/Code Blue team would be identified for each shift and would be comprised of the RN Supervisor, the Station 1 Charge Nurse(s), the Station 4 Charge Nurse(s), and the CNAs assigned to Run #1 for Station 2 and Station 3. The RN Supervisor will serve as the Code Blue team leader and will be responsible for coordinating the emergency response, directing team members, documenting time of events, ensuring CPR is initiated immediately when indicated, Code Blue is activated, 911 is called, the crash cart is retrieved without delay, and the ADM/DON are notified of code blue before the end of the shift. In the event that a designated CPR/Code Blue team member is on a meal or rest break, the assigned break relief nurse or CNA covering that staff member's assignment will assume the CPR/Code Blue team role until the designated team member returns. The RN Supervisor will ensure coverage is identified before any CPR/Code Blue team member leaves the unit for break. Break coverage and/or alternate CPR/Code Blue team members will be reflected on the shift assignment sheet or break schedule to ensure there is no lapse in emergency response coverage. Regardless of assigned CPR/Code Blue team designation or break status, any CPR/BLS-certified staff member who finds a resident unresponsive and pulseless must immediately initiate CPR when indicated, activate Code Blue, ensure 911 is called, and request the crash cart without delay. The assigned CPR/Code Blue team members and break relief coverage will be clearly documented on each shift assignment sheet to ensure staff are aware of their roles and responsibilities prior to assuming resident care assignments. 6. On [DATE], the DON in collaboration with a CPR-certified instructor, initiated CPR/BLS skills check offs for nursing staff to validate competency and ensure staff can respond appropriately during a Code Blue emergency. The skills check offs included recognition of an unresponsive and pulseless resident, immediate initiation of CPR when indicated, activation of Code Blue, immediate 911 notification, crash cart retrieval, code status verification, role assignment, and use of clear communication during the emergency response. The CPR certified instructor conducted the Train the Trainor with the DON, ADON, Minimum Data Set (MDS) Coordinator, MDS Nurse Assistant, and Infection Prevention Nurse (IPN) and will continue until all licensed nurses and CNAs are trained. Systemic Changes and Education: 1. On [DATE], the facility initiated a systemic corrective action to schedule and conduct Mock Code Blue drills for nursing staff on all shifts. Mock Code Blue drills began on [DATE] during the 3:00 p.m. to 11:00 p.m. shift and included staff transitioning onto the 11:00 p.m. to 7:00 a.m. shift. On [DATE] and [DATE], Mock Code Blue drills were conducted on all three shifts. Mock Code Blue drills will continue on each shift through [DATE], then weekly on random shifts for three months, and monthly on random shifts thereafter. The DON/ADON will conduct a review for every code blue activation the following business day to evaluate success of mock drills. 2. For newly-hired licensed nurses and Certified Nursing Assistants as part of their orientation, staff will be trained regarding the facility's Emergency Procedure - Cardiopulmonary Resuscitation and Basic Life Support policy provided by the ADON. The Social Services Director/designee will conduct daily audits of all current in-house residents' physician orders, POLST and advance directives to ensure each resident's code status is accurate, current, clearly documented, and readily accessible in the Code Status binders, which will be located in each nursing station and inside each crash cart.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing) heart failure, pulmonary hypertension ([HTN] when the blood vessels in your lungs have too much pressure, forcing the right side of your heart to work harder to pump blood through them), acute embolism (when a sudden blood clot travels through your bloodstream and gets stuck blocking blood flow in a vital area like your lung or brain) and thrombosis (when a blood clot that forms inside a blood vessel and gets stuck, blocking normal blood flow like a leg vein of heart artery) of the internal bilateral jugular vein (the two big veins on each side of your neck that carry blood from your brain back to your heart), and acute embolism and thrombosis of unspecified deep veins of left lower extremities. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated [DATE], the MDS indicated Resident 1 had moderate cognitive impairment (a phase of cognitive decline where memory loss and thinking difficulties become consistently noticeable to others and interfere with complex daily tasks). Resident 1 required substantial assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, showering/bathing, dressing, rolling left to right, sit to lying, lying to sitting on side of bed sitting to standing, transferring from chair/bed to chair, toileting transfer, and walking 10 feet. During a review of Resident 1's Physician Orders for Life-Sustaining Treatment ([POLST] a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) dated [DATE], the POLST indicated if Resident 1 was in cardiopulmonary, CPR was required. During a review of Resident 1's Nursing Progress Note, dated [DATE] at 11:33 p.m., the Nursing Progress Note indicated on [DATE] at 11:33 p.m., CNA 5 notified RN 1 that Resident 1 was found (in her room) on the floor mat on her left side, facing the window. Resident 1 reported while sitting on the side of her bed she fell asleep and fell (off the bed). Resident 1 was unsure if she hit her head, but then later denied hitting her head and refused to be transferred to a General Acute Care Hospital (GACH) for further evaluation. During a review of Resident 1's Nursing Progress Note dated [DATE] and timed at 12:21 a.m., the Nursing Progress Note indicated Resident 1 was unresponsive, not responding to verbal or tactile stimuli (any physical inputs or mechanical energy [like touch, pressure, vibration, or texture] applied to the skin that activates the body's sensory receptors), CPR was initiated, 911 was called, paramedics arrived at 12:36 a.m. and took over Resident 1's care. During a review of Resident 1's Nursing Progress Note, dated [DATE] at 1:48 a.m., the Nursing Progress Note indicated Paramedics pronounced Resident 1 deceased at 12:52 a.m. During a review of the Fire Call History, dated [DATE], the Fire Call History indicated on [DATE] the facility called 911 at 12:20 a.m., paramedics were dispatched at 12:21 a.m., and arrived on scene at 12:31 p.m. During a review of Resident 1's Paramedic Run Sheet, dated [DATE], the Paramedic Run Sheet indicated Paramedics arrived at Resident 1's bedside at 12:36 a.m., and found Resident 1 lying supine (lying flat on your back with your face upward) in bed, pulseless and apneic (a state or condition where breathing completely stops), CPR was continued by paramedics. The Paramedic Run Sheet indicated Resident 1's time of death was 12:52 a.m. ([DATE]). During an interview on [DATE], at 9:08 a.m., RN 1 stated on [DATE] at 11:33 p.m., CNA 1 reported to him that Resident 1 was found on the floor. Resident 1 did not know if she hit her head and she refused to go to the GACH. Resident 1 was moved to a room closer to the nursing station, and CNA 1 was assigned to watch her. At approximately 12:21 a.m. ([DATE]), RN 1 stated he found Resident 1 was found unresponsive and without a pulse. RN 1 stated he left the room to call a code blue on the facility's intercom system at Nursing Station 1 (approximately 35 feet away from Resident 1's room ), grabbed the crash cart inside a locked utility room (approximately 50 feet away from Resident 1's room), and took it to Resident 1's room, he then ran back to Nursing Station 1 and called 911. When he returned to Resident 1's room, he saw someone (unsure who) doing chest compressions and someone else (unsure who) using a bag-valve-mask ([BVM] a handheld manual breathing aid used to provide positive pressure when someone is not breathing on their own). He left the room a second time to call 911 because the paramedics were taking a long time. RN 1 stated CNA 1 was in the room when he assessed Resident 1 as unresponsive, not breathing and without a pulse, but he did not think to instruct CNA 1 to call code blue, get the crash cart or call 911, he was not sure why he did not ask for CNA 1's assistance, he should have. During an interview on [DATE] at 12:35 p.m., LVN 2 stated on [DATE] at approximately 12:20 a.m., a code blue was called to Resident 1's room, she ran to Resident 1's room and saw LVN 1 standing in the doorway, then leaving the room. LVN 3, LVN 4, LVN 5, CNA 2, CNA 3, and CNA 4 were in Resident 1's room not doing or saying anything. LVN 2 stated she checked Resident 1's pulse, began chest compressions and asked LVN 5 to get the BVM.During an interview on [DATE] at 10:21 a.m., CNA 1 stated on [DATE] sometime between 11:30 p.m. and 12 a.m., Resident 1 was transferred to a room closer to the nursing station because she had fallen and needed to be monitored, she was assigned as a sitter (a helper who stays in a resident's room to ensure their safety and comfort, especially if they are at risk for falls, wandering or harming themselves) to watch Resident 1. Initially Resident 1 was awake, alert, oriented, and asking for her belongings but approximately 25 minutes after arriving her new room, she (CNA 1) noticed Resident 1's eyes were closed, she tried to arouse her, but Resident 1 did not respond. RN 1 was walking by the room, she reported to him that Resident 1 would not wake up. CNA 1 stated RN 1 tried to arouse Resident 1, but Resident 1 did not respond, he then checked her pulse, left the room, and called a code blue using the facility's intercom system at Nursing Station 1. CNA 1 stated RN 1 did not tell her that Resident 1 had no pulse, and he did not ask her for assistance. CNA 1 stated she was CPR certified, and if Resident 1 had no pulse she or RN 1 should have started compressions while the other one went for help.During an interview on [DATE] at 12:08 p.m., LVN 2 stated she had not received training on the facility's CPR P/P or what to do during a code blue. She was not instructed by the facility regarding a designated team leader or a code team that would operate in an emergency where CPR was warranted. During an interview on [DATE] at 12:15 p.m., the ADON stated CNAs at the facility were CPR certified and were expected to participate in CPR. The ADON stated the facility did not have team leaders or a CPR team designated for each shift. The DON stated CPR codes were run following a chain of command; the RN, LVN, then the CNA. If he found a resident unresponsive, he would yell for help and delegate someone to check the resident's POLST, which was located in their POLST binder, call 911, and activate a code blue. He would stay with the resident, but he would not initiate CPR until the resident's code status was confirmed to ensure the resident's wishes were implemented. The ADON stated he was not familiar with the facility's CPR policies. During a review of facility's P/P titled Emergency Procedure-Cardiopulmonary Resuscitation and Basic Life Support dated 2001, the P/P indicated to select and identify a CPR team for each shift in the case of an actual cardiac arrest and to the extent possible, designate a team leader on each shift who is responsible for coordinating and directing other team members during rescue efforts. And staff are trained to follow the current AHA guidelines and recommendations for the resuscitation. During a review of the AHA Guidelines, dated 2025, the AHA Guidelines indicated for adult basic life support for healthcare professionals the algorithmic steps are:1. Verify scene safety2. Check for responsiveness3. Shout for help nearby4. Activate the emergency response system5. Send someone to get the AED/defibrillator6. Look for breathing and check a pulse simultaneously within 10 seconds\7. If there is no pulse start CPR by performing 30 compressions to 2-breath until an AED/defibrillator arrives8. Once AED arrives check for a shockable rhythm9. If not shockable resume CPR immediately for 2 minutes until prompted by the AED machine and continue until Advanced Life Support (ALS) professionals take over or the person starts to move.https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms

Based on interview, and record review, the facility failed to notify the physician for one of three sampled residents (Resident 1) when Resident 1's renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) scheduled days were changed. As a result, Resident 1's scheduled dialysis days were changed without Resident 1's physician being made aware. This deficient practice placed Resident 1 at risk for worsening symptoms associated with end stage renal disease ([ESRD] irreversible kidney failure).Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including ESRD, and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 5/9/2026, the MDS indicated Resident 1 had moderate cognitive impairment (a phase of cognitive decline where memory loss and thinking difficulties become consistently noticeable to others and interfere with complex daily tasks). Resident 1 required substantial assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, showering/bathing, dressing, rolling left to right, sit to lying, lying to sitting on side of bed sitting to standing, transferring from chair/bed to chair, toileting transfer, and walking 10 feet. During a review of Resident 1's Physician Orders, dated 5/3/2026, the Physician Orders indicated Resident 1 was to receive dialysis at an outside facility every Monday, Wednesday, and Friday. During a review of Resident 1's Nursing Dialysis Communication Record, dated 6/1/2026 and timed at 5:41 p.m., the Nursing Dialysis Communication Record indicated Resident 1 was to have dialysis 6/2/2026 (Tuesday) at 1 p.m., instead of 6/3/2026 (Wednesday). During an interview on 6/11/2026 at 3:57 p.m., Licensed Vocational Nurse (LVN) 5 stated on 6/1/2026 she called the dialysis clinic to find out why Resident 1's dialysis date was changed from 6/3/2026 (Wednesday) to 6/2/2026 (Tuesday). She was told by the dialysis clinic that Resident 1 requested the change in her dialysis schedule because she wanted to attend her son's graduation on 6/3/2026 (Wednesday). LVN 5 stated she did not notify Resident 1's physician about the change in Resident 1's dialysis schedule or obtain an order from the physician because she did not know she needed to do so. During an interview on 6/12/2026 at 4:14 p.m., the Director of Nursing (DON) stated Resident 1 needed an order when her dialysis day was changed from 6/3/2026 (Wednesday) to 6/2/2026 (Tuesday) in order to coordinate care with her physician. The DON stated if it was not ordered by the physician, it should not have been done. During a review of facility's Policy and Procedure (P/P) titled Change in a Resident's Condition or Status dated 2001, the P/P indicated the nurse will notify the resident's physician or physician on call when there has been a need to alter the resident's medical treatment significantly, and specific instructions to notify the physician of changes in the resident's condition. During a review of facility's P/P titled Physician Services dated 2001, the P/P indicated the medical needs of each resident is supervised by a licensed physician which includes supervising the medical care of residents such as participating in the resident's assessment and care planning, and prescribing medications and therapy. The physician will determine relevance of any recommended interventions from other disciplines.

Based on interview, and record review, the facility failed to develop a care plan that addressed the root cause (falling asleep) of Resident 1's previous falls on [DATE] and [DATE] for one of three sampled residents (Resident 1), who was assessed as a high fall risk. This failure resulted in Resident 1's continued falls on [DATE] and [DATE] after her drowsiness/falling asleep was not addressed following falls on [DATE] and again on [DATE], which possibly contributed to her death on [DATE], when approximately 48 minutes after falling asleep and falling from her bed, Resident 1 was found unresponsive and expired on [DATE] at 12:52 a.m.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of idiopathic peripheral autonomic neuropathy (a condition involving damage to the nerves that control involuntary bodily functions, such as heart rate, blood pressure, and digestion. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated [DATE], the MDS indicated Resident 1 had moderate cognitive impairment (a phase of cognitive decline where memory loss and thinking difficulties become consistently noticeable to others and interfere with complex daily tasks). Resident 1 required substantial assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, showering/bathing, dressing, rolling left to right, sit to lying, lying to sitting on side of bed sitting to standing, transferring from chair/bed to chair, toileting transfer, and walking 10 feet. During a review of Resident 1's Fall Risk Observation/Assessment, dated [DATE], the Fall Risk Observation/Assessment indicated Resident 1 was a high risk for falls. During a review of Resident 1's At Risk for Falls Care Plan, dated [DATE], the Care Plan indicated Resident 1 was at high risk for falls due to diagnoses of neuropathy and generalized weakness. The goal of the Care Plan was to minimize Resident 1's risk for falls to the extent possible. The Care Plan's interventions included placing a star identifier on the outside of Resident 1's bedroom, on assistive devices, anticipate Resident 1's needs, educate/remind Resident 1 to call for assistance with all transfers, keep the call light and personal items within reach, supervise Resident 1 as much as possible, and to obtain a rehabilitation (aims to restore, keep, or improve the physical, mental, and cognitive abilities needed for daily life that were lost due to illness, injury, or surgery) consultation. During a review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) dated [DATE] and timed at 12:35 a.m., the SBAR indicated Resident 1 was found on her hands and knees. Resident 1 told staff she had been sleeping and rolled out of bed. During a review of Resident 1's Unwitnessed Fall Care Plan dated [DATE], the Care Plan indicated Resident 1 was at risk for recurring falls, with a goal for Resident 1 to comply with fall interventions, which included bilateral bed bolsters and bilateral floor mats. Continue review of Resident 1's Care Plan indicated the Care Plan did not address Resident 1 falling asleep prior to her rolling out of bed. During a review of the Rehab Status Post Fall Screen, dated [DATE], the Rehab Status-Post-Fall Screen indicated on [DATE] at 3:05 a.m., Resident 1 experienced an unwitnessed fall and reported she fell asleep while sitting in her wheelchair.During a review of Resident 1's Incident Report, dated [DATE] and timed at 3:05 a.m., the Incident Report indicated Resident 1 was found on the floor in front of her wheelchair and reported she fell asleep and fell forward, landing on her knees. During a review of Resident 1's Unwitnessed Fall Care Plan dated [DATE], the Care Plan indicated Resident 1 had an unwitnessed fall on [DATE]. The Care Plan's goal was to minimize the risk for additional falls to the extent possible. The Care Plan's interventions were to anticipate and meet Resident 1's needs, educate/remind Resident 1 to call for assistance, to keep the call light within reach, and to keep personal/frequently used items within reach. Continued review of Resident 1's Care Plan indicated there was no identified trend of Resident 1 falling asleep prior or falls occurring on [DATE] and [DATE]. During a review of Resident 1's Nursing Progress Note, dated [DATE], the Nursing Progress Note indicated on [DATE] at 11:33 p.m., Resident 1 was found (in her room) on a floor mat on her left side, facing the window. Resident 1 reported while sitting on the side of her bed she fell asleep and fell (off the bed). The Nursing Progress Note indicated at 12:21 a.m. ([DATE]), Resident 1 was assessed unresponsive (a person is unconscious and fails to react to any external stimulation), CPR was initiated, 911 was called, and paramedics arrived at 12:36 a.m., and took over patient care. During a review of Resident 1's Nursing Progress Note, dated [DATE], the Nursing Progress Note indicated Paramedics pronounced Resident 1 deceased at 12:52 a.m. ([DATE]). During an interview on [DATE], at 9:08 a.m., RN 1 stated Certified Nursing Assistant (CNA) 1 reported to him ([DATE]) that Resident 1 was lying on the floor. Resident 1 reported she was sitting on the side/edge of her bed, she fell asleep and slipped out of bed. Resident 1 had a previous fall on [DATE] when she fell asleep while sitting in her wheelchair and fell from her wheelchair. RN 1 stated there were no interventions on Resident 1's Care Plan that addressed Resident 1's sleepiness and falls. During an interview on [DATE] at 2:21 p.m., the MDS Nurse (MDSN) stated Resident 1's At Risk for Falls Care Plan dated [DATE] indicated supervise as much as possible meant the resident was placed near the nursing station in a room that was more visible than other rooms. She also stated the phrase supervise as much as possible meant charge nurses and CNAs were informed to keep an eye on Resident 1 as much as possible. The MDS nurse could not explain how the intervention to supervise as much as possible was measurable and could be evaluated for effectiveness. During a interview on [DATE] at 3:57 p.m., Licensed Vocational Nurse (LVN) 5 stated Resident 1 fell three times ([DATE], [DATE] and [DATE]) after falling asleep. During an interview on [DATE] at 3:35 p.m., the Director of Nursing (DON) stated the root cause of Resident 1's falls on [DATE], [DATE], and [DATE] were due to Resident 1 falling asleep. This trend was not addressed in Resident 1's care plans or discussed with the Interdisciplinary Team (a group of people with different specialties who work together toward the same goal. Each person brings their own skills and perspective, and they share information so they can make better decisions as a team) due to an oversight and that addressing it might have prevented Resident 1 from falling on [DATE]. During a review of facility's Policy and Procedure (P/P) titled Care Plans, Comprehensive Person-Centered dated 1/2026, the P/P indicated the purpose of the policy was to include measurable objectives and timetables on the resident care plan to meet their physical, psychosocial, and functional needs for each resident. The care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessment of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change. During a review of facility's P/P titled Fall and Fall Risk, Managing dated 1/2026, the P/P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Risk factors included delirium, cognitive impairment, lower extremity weakness, medication side effects, functional impairments, heart failure, anemia, balance and gait disorders, pain.

Based on observation, interview, and record review, the facility failed to ensure crash carts (a mobile cart stocked with life saving equipment that staff use during emergencies, such as when a patient stops breathing or their heart stops) located at multiple nursing stations were stocked per the Emergency Crash Cart Checklist, the crash carts were easily accessible to staff in the event of an emergent event, and the POLST ([Physician Orders for Life-Sustaining Treatment] a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was easily identifiable. These deficient practices had the potential to delay emergency response, impede the timely initiation of Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop), and negatively affect resident outcomes during a medical emergency.Findings: During a review of the facility's Emergency Crash Cart Checklist, the Emergency Crash Cart Checklist indicated a full tank of oxygen (O2), and sterile water. 1. During an observation on [DATE] at 9 a.m., Crash Cart 1 was observed near Nursing Station 1 inside a locked utility room, the locked utility room required a code for entry. Crash 1 was observed with an empty canister of O2. 2. During an observation on [DATE] at 9:16 a.m., Crash Cart 2 was observed near Nursing Station 2 inside a locked utility room, the locked utility room required a code for entry. Crash Cart 2 was observed with no labels on its drawers, making it difficult to identify and access those items difficult. 3. During an observation on [DATE] at 9:24 a.m., Crash Cart 3 was observed near Nursing Station 3 inside a locked utility room, the locked utility room required a code for entry. Crash Cart 3 was observed without sterile water. During an interview on [DATE] at 9:33 a.m., the Assistant Director of Nursing (ADON) stated it was the night shift Registered Nurse Supervisor's (RNS) responsibility to ensure all crash carts were restocked, supplies were available, and O2 tanks were replaced. The ADON stated storing crash carts in locked utility rooms that required a code to gain entry, Crash Carts with missing items, empty O2 tanks and/or drawers that were not labeled for easy identification/location of items inside the drawers, could waste time and delay emergency response, noting every second counts during a code blue (an announcement used in facilities when a resident is experiencing medical emergency) and that earlier CPR improves resident outcomes. During an interview on [DATE] at 11:36 a.m., and a concurrent observation of a POLST binder located at Nursing Station 1 that was amongst other miscellaneous charts, the POLST binder had no label and was not easily identifiable as the POLST binder. Licensed Vocational Nurse (LVN) 6 looked for the POLST binder and was unable to locate it. During an interview on [DATE] at 9:50 a.m., the DON stated the Crash Carts should be easily accessible at each Nursing Station instead of in a locked utility room. During review of the facility's undated P/P titled Emergency Cart Supplies and Equipment, the P/P indicated the emergency cart must be within easy access of health care workers, and the DON or designee must ensure the cart is stored within easy access, routinely checked for completeness, and that all equipment is in working order. The P/P indicated to ensure the oxygen tank is stocked up, and daily checks of the emergency cart for completeness, and immediate replacement of supplies after use.

Based on observation, interview, and record review, the facility failed to ensure one of seven sampled resident's (Resident 2) call light (device that allows residents to request assistance from nursing staff) was accessible and within reach.This failure resulted in Resident 2 being unable to summon staff for needed assistance and had the potential to result in delayed response, unsafe attempts to self transfer, and falls.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 was admitted to the facility with diagnoses including metabolic encephalopathy (temporary or permanent damage to the brain due to lack of glucose, oxygen, or other metabolic agent, or organ dysfunction), abnormalities of gait and mobility (difficulty walking or moving in a normal, steady, or coordinated way), and dementia (a progressive state of decline in mental abilities) with agitation (restless, upset, or inability to stay calm).During a review of Resident 2's History and Physical (H&P), dated 1/11/2026, the H&P indicated Resident 2 did not have the capacity to make medical decisions.During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 4/13/2026, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and required maximal assistance (helper does more than half the effort) from staff for toileting, bathing, and personal hygiene. The MDS indicated Resident 2 required a wheelchair for mobility and was always incontinent of bowel and bladder (involuntary voiding of urine and stool).During a review of Resident 2's untitled Care Plan dated 1/12/2026, the Care Plan indicated Resident 2 had an alteration in musculoskeletal status related to left wrist pain and edema (swelling), amputated (surgical removal of a body part) third digit, and gout (a form of inflammatory arthritis that develops in some people who have high levels of uric acid in the blood). The Care Plan's interventions indicated anticipating and meeting the needs of Resident 2, ensuring the call light was within reach, and respond promptly to all requests for assistance. During a review of Resident 2's untitled Care Plan dated 1/12/2026, the Care Plan indicated Resident 2 was at risk for an Activities of Daily Living ([ADL] activities such as bathing, dressing and toileting a person performs daily)/Mobility Decline and requires assistance. The Care Plan's interventions indicated encouraging Resident 2 to use the call light for assistance.During a review of Resident 2's untitled Care Plan dated 5/20/2026, the Care Plan indicated Resident 2 had a witnessed fall on 5/19/2026. The Care Plan's interventions indicated to anticipate and meet Resident 2's needs, educate and remind Resident 2 to call for assistance, and keep the call light within reach.During a concurrent observation and interview on 5/26/2026 at 3:37 p.m., with Resident 2, while in Resident 2's room, Resident 2 was observed lying in bed yelling out for help. Resident 2's call light was observed not within reach and was coiled behind his headboard. Resident 2 stated he had to yell out to get assistance. Resident 2 stated it took nursing staff over 30 minutes to respond. Resident 2 stated staff were supposed to help him, but staff did not come all the time. Resident 2 stated he was very aggravated. Resident 2 stated, How can I get to the bathroom if I cannot get up? Resident 2 stated staff did not help him get out of bed and he would have to get up by himself. Resident 2 stated he had trouble with his feet and needed assistance to get up. Resident 2 stated if staff did not come soon, he would have to stand out in the hallway and yell for help.During a concurrent observation and interview on 5/26/2026 at 4:11 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 was incontinent of bowel and bladder and did not always state specific needs. LVN 1 acknowledged and stated Resident 2's call light was out of Resident 2's reach and should not have been behind the headboard. LVN 1 stated Resident 2 needed access to the call light to receive care in a timely manner. LVN 1 stated the call light helped prevent falls because Resident 2 attempted to get up when staff did not respond. LVN 1 stated staff needed to check Resident 2 because he could not always express his needs.During a review of the facility's policy and procedure (P&P) titled Answering the Call, revised January 2026, the P&P indicated the purpose of the call light was to ensure timely responses to residents' requests and needs. The P&P indicated the call light was to be plugged in and functioning at all times. The P&P further indicated staff would ensure the call light was accessible to residents while in their bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review, the facility failed to ensure an outside activity provider, who was contracted by the facility to provide activity's to residents', was monitored by the facility to ensure the activity provider did not videotape six out of sixteen residents (Residents 6, 10, 11, 12 13, and 14) without the resident's and/or their representative's consent and the outside activity provider did not include in their program disparaging (criticizing, belittling, or undervaluing someone, often in a way that shows a lack of respect or aims to diminish their reputation) remarks towards the residents. These deficient practices resulted in Residents 6, 10, 11, 12, 13, and 14, who had different levels of cognitive impairment (a condition when a person has trouble with mental tasks such as memory, learning, concentration or decision making), unknowingly and without permission being videotaped during an activity program while the contracted activity provider teased and mocked the residents and later posted identifiable images of the residents on multiple social media outlets. These deficient practices had the potential for residents loss of privacy and dignity, embarrassment and loss of trust in staff.Findings: a. During a review of Resident 6's admission Record (Face sheet), the Face sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6 had diagnoses that included metabolic encephalopathy (a disease that affects the brain leading to confusion), and dementia (a progressive state of decline in mental abilities). During a review of Resident 6's Minimum Data Set ([MDS] a resident assessment tool) dated 4/14/2026, the MDS indicated Resident 6 was forgetful and was not able to make consistent and reasonable decisions. Resident 6 required a one-person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 6's Skilled Nursing Facility Progress Note dated 1/23/2026, the Skilled Nursing Facility Progress Note indicated Resident 6 was able to make medical decisions with her brother's assistance. b. During a review of Resident 10's admission Record (Face sheet), the Face sheet indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10 had diagnoses including metabolic encephalopathy, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and depression (a mood disorder characterized by persistent sadness that interferes with daily life, work and relationships). During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 was unable to make reasonable and consistent decisions. Resident 10 required a one-person assist to complete his ADLs. c. During a review of Resident 11's admission Record (Face sheet), the Face Sheet indicated Resident 11 was initially admitted to 11/14/2001 and readmitted on [DATE]. Resident 11 had diagnoses including metabolic encephalopathy and dementia. During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 was unable to make decisions that were reasonable and consistent. Resident 11 required a two person assist to complete her ADLs. During a review of Resident 11's History and Physical (H&P) dated 3/20/2026, the H&P indicated Resident 11 had a fluctuating capacity to understand and make decisions. d. During a review of Resident 12's admission Record (Face sheet), the Face sheet indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted om 11/20/2025. Resident 12 had diagnoses including psychosis, and dementia. During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 was forgetful and was not able to make consistent and reasonable decisions. Resident 12 required a one person assist to complete her ADLs. During a review of Resident 12's Physician's Progress Note dated 4/7/2026, the Physician's Progress Note indicated Resident 12 had no capacity for medical decision making due to dementia. e. During a review of Resident 13's admission Record (Face sheet), the Face Sheet indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 13 had diagnoses including anoxic brain damage (when oxygen is cut off completely to the brain), and psychosis. During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 was forgetful and was not able to make consistent and reasonable decisions. Resident 13 required a one person assist to complete his ADLs. During a review of Resident 13's H&P dated 12/9/2025, the H&P indicated Resident 13 did not have a capacity to understand and make decisions. f. During a review of Resident 14's admission Record (Face [NAME]), the Face sheet indicated Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14 had diagnoses including encephalopathy and psychosis. During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 was able to make decisions that were reasonable and consistent. During a review of Resident 14's H&P dated 1/4/2026, the H&P indicated Resident 14 had the capacity to understand and make decisions. During a review of an Instagram ([IG] commonly known as Reel is a short engaging video clip shared through a social media platform designed for quick viewing similar to TikTok) Video dated 3/15/2025, the IG video indicated Resident 10 was sitting in his wheelchair in the presence of the contracted activity provider and eight other unidentified residents. The contracted activity provider was engaged in a conversation with two residents (a female and a male) and was heard saying listen couple, listen hot stuff, you are interrupting my show, it's rude, if you want to take her out, take her outside. The video indicated the male resident told the female resident Shake that pussy! The contracted activity provider laughed and was heard saying he mentioned shake that pussy instead of shake that tushy. Continued review of the IG video showed no indication that staff at the facility intervened during the inappropriate conversation between residents and/or the contracted activity provider. During a review of IG Video dated 3/16/2026, the IG video indicated Resident 10 was sitting in his wheelchair in the presence of eight unidentified residents, when the contracted activity provider was heard rapping hey shake that tushy, eat a cookie, yeah shake it doll, shake it at the mall, shake it doll in the bathroom stall. During a review of an IG Video dated 3/17/2026, the IG video indicated Resident 10 and Resident 11 were sitting in their wheelchairs in the presence of 14 unidentified residents when the contracted activity provider was heard rapping do the finger dance, can't get up that's fine, put your fingers up real high, move it from side to side, yeah [NAME] looking real fly, shake them fingers don't be shy, you got arthritis common just try. The contracted activity provider then pointed to an unidentified male resident and said Oh, my God he's got no finger? Perfect, I love that he's making do. During a review an IG Video dated 3/24/2025, the IG video indicated there were six unidentified residents attending the activity program and the contracted activity personnel was rapping, Gramps in his wheelchair cruising, but the bandage on his head is oozing, call the nurse over here to clean him up, all my walkers in the front row stand up, got a drink in your hand drop that cup, put your hands on the bar you know what's up, for those people who can't get out of bed, put your fingers up you ain't dead. During a review of an IG Video dated 4/29/2026, the IG video indicated Resident 6 was sitting in her wheelchair, in the presence of seven unidentified residents, when the contracted activity provider was heard rapping crockpot, make some chicken stew, throw it all into the crockpot, then it's all cooked boo, hot, hot. After completing the rap song, the contracted activity provider was heard saying, I am so distracted by [NAME]. During a review of an IG Video dated 5/25/2025, the IG Video indicated the contracted activity provider in the presence of Resident 6 and five unidentified residents was heard rapping I stalk my boyfriend it's not a big deal, call me a creep I am just keeping it real, I am just kidding no way, I only stalk during the day. Resident 6 was seen walking to and then holding hands with the contracted activity provider as they danced. During a review of a TikTok Video (a short form of video created, edited and shared through a social media platform designed for a quick entertainment featuring dances, comedy, educational hacks and lip-syncs) dated 7/30/2025, the TikTok video indicated Resident 12 danced while the contracted activity provider was heard rapping, don't need a cane to make you sway, turn this bingo hall into a cabaret, hot like soup like an early bird, making them purr without saying a word, who's having their fourth marriage, where's the [NAME], don't take your diaper off just move it to the side. Resident 10, Resident 11, Resident 13 and Resident 14 were seen in the TikTok video sitting in their wheelchairs along with 12 unidentified residents. During a review of a TikTok Video dated 8/11/2025, the TikTok video showed Resident 12 dancing with the contracted activity provider who was heard rapping, we are all gonna die I am giving you a pass, yeah pass that gas, I ain't judging, you can't remember the date or time, you are like a VHS tape on rewind, so what doll you're losing your mind, let's show these youngins' how we bust and grind, put your hands in the air if you got that gray hair even if it's down in there who cares, embrace your age if you dare, do a wheelie in that wheelchair, we are all gonna die let's dance maybe our last chance. Resident 10, Resident 11, Resident 13 and Resident 14 were seen on the TikTok video sitting in their wheelchairs and Resident 6, was standing by the side of the dining room, waving her hand. The video indicated there were 3 facility staff present (Activity Assistant [AA] 1, 2, and 3) in the dining room during the activity. During a review of a TikTok Video dated 8/13/2025, the TikTok Video indicated a contracted activity provider was heard rapping, she loves the elderly and children because they don't judge and are innocent, their teeth fall out some grow back in and both wear diapers they like to pee in, both get food in their chin- chin, don't touch their happy meal or pill bin, they eat healthy lunch, both are blended because they can only [NAME]. Resident 10 and Resident 11 were seen in the TikTok video sitting in their wheelchairs, while Resident 6 was dancing beside the contracted activity provider. During an interview on 4/21/2026 at 12:43 p.m., Resident 6 stated during the birthday month celebration (cannot remember the dates) there was a lady who performed rapping for the residents. Resident 6 stated there were facility staff (unknown) in the dining/activity room during the performance who were taking videos of her dancing with the lady performer (contracted activity provider). Resident 6 stated no one asked her if it was okay for her to be filmed. During an interview and concurrent record review on 4/21/2026 at 2:03 p.m., Restorative Nurse Assistant (RNA) 1 stated Resident 6, Resident 10, Resident 11, Resident 12, Resident 13 and Resident 14 were amongst the identified residents in the TikTok and IG Videos. RNA 1 stated there were three AAs (AA 1, 2 and 3) in the video on 8/11/2025. RNA 1 stated videotaping of the residents without consent is not allowed in the facility. During an interview on 4/21/2026 at 3:18 p.m., the Activity Director (AD) stated she hired the contracted performers for the residents' activities, but she only discussed the rate of pay with them during a telephone conversation. The AD viewed the TikTok and IG Videos, and stated videotaping of residents should not have happened without consent of the residents and/or their responsible party (RP). The facility's activity staff should have stopped the videotaping and protected the resident's privacy. During an interview on 4/22/2026 at 9:58 a.m., Resident 12 stated the performer (contracted activity provider) and her were dancing in the dining room in front of other residents and staff on different dates during birthday celebrations (dates unknown) and somebody videotaped her and the contracted activity provider dancing. Resident 12 stated she did not feel right about being videotaped because she did not give permission, but she did not stop the videotaping because she saw the residents and the staff were very happy. During an interview on 4/22/2026 at 10:56 a.m., the Director of Staff Development (DSD) stated the activity staff and any other staff present during the contracted activity provider performance should have monitored the residents' and the contracted activity provider to ensure there was no unpermitted videotaping of the residents. The DSD stated this should not have happened because there were AAs present during resident activities at all times. During an interview on 4/22/2026 at 12:06 p.m., the Director of Nursing (DON) stated videotaping of the residents should not have happened at any time because the residents were under the supervision of the facility's activity staff. The DON stated facility staff present during the performance should have protected the residents' and stopped unauthorized photos and videos from being taken. During an interview on 4/22/2026 at 12:52 p.m., the Administrator (ADM) stated the facility should have monitored the contracted activity provider to prevent unauthorized videotaping of the residents and compromise of the residents' privacy and dignity. During a review of the facility's Policy and Procedure (P/P) titled Confidentiality of Information and Personal Privacy revised 1/2026, the P/P indicated the facility shall strive to protect and safeguard the residents' confidentiality and personal privacy during visits, family and resident group meetings and activities. During a review of the facility's P/P titled Dignity revised 1/2026, the P/P indicated the facility residents shall be care for in a manner that promotes and enhances their well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. All residents of the facility shall be treated with dignity and respect at all times. During a review of the facility's P/P titled Email, Internet and Social Media Use revised 1/2026, the P/P indicated the social media platforms will be used only within the legal, ethical and professional boundaries established by the state and federal privacy laws, professional standards of practice, and facility policy.

Based on interview and record review the facility failed to provide documented evidence of for 32 out of 32 licensed practitioners, COVID-19 (a highly contagious respiratory disease) vaccination (medications used to prevent diseases usually given by injection or by mouth) status, provision of education on benefits and potential side effects for 32 out of 32 licensed practitioners for the 2025 to 2026 COVID-19 vaccine.This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.Findings:During a concurrent interview and record review on 4/8/2026 at 1:20 p.m., with the Infection Prevention Nurse (IPN), the facility's binders for COVID-19 Staff Vaccination Status were reviewed. The IPN stated there was no documented evidence for licensed practitioners' education on benefits and side effects was provided. The IPN stated COVID-19 vaccination status for licensed practitioners should also be obtained because they have direct access to residents.During an interview on 4/9/2026 at 11 a.m. with the Director of Nursing (DON), the DON stated all staff need to be educated and offered the current COVID-19 vaccine because vaccines minimize sickness and protects residents in the facility.During a review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Staff, revised 1/2026, the P&P indicated staff are educated about the benefits, risks, and potential side effects of the COVID-19 vaccine. The P&P indicates the staff meant individuals who provide any care, treatment, or other services for the facility and/or its residents, regardless of clinical responsibility or resident contact.

Based on observation, interview, and record review, the facility failed to ensure:1. For Residents 24 and Resident 123, manufacturer's specification for dosing diclofenac (for pain relief) topical gel for application was followed. This deficient practice could have resulted in either an overdose or underdose of the topical pain medication diclofenac, potentially leading Resident 24 and Resident 123 to experience adverse reactions (unwanted or harmful effects from a medicine) or inadequate pain relief.2. A Licensed Vocational Nurse (LVN) 9 did not sign the shift change audit (a brief review of medication and documentation at the end of a work shift) and narcotic accountability (records used to track and verify the handling of controlled medications [medications with a high potential for harm, misuse or abuse]) forms in advance, while not in the presence of both the outgoing nurse and the incoming nurse on Station 3.This deficient practice increased the risk for lack of controlled medication accountability. 3. The facility's Cubex Policy and Procedures, for a blind count prior to the removal of a medication was followed. The deficient practice had the potential for inaccuracy of both controlled and noncontrolled medication inventory, by not requiring personnel to physically count items without knowing the expected quantity in the system.Findings:1a. During a review of Resident 24's admission Record, the admission Record indicated the facility admitted Resident 24 on 2/25/2025 with diagnoses including Osteoarthritis (joint disease causing pain and stiffness), Psoriatic Arthritis Mutilans (severe form of joint inflammation that can destroy joints and bones), Prurigo Nodularis (skin condition with itchy, hard lumps), and Acne Keloid (raised, thick scars from acne).During a review of Resident 24's History and Physical (H&P), dated 11/21/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.During a review of Resident 24's Minimum Data Set ([MDS] a resident assessment tool), dated 2/26/2026, the MDS indicated Resident 24's cognitive (thinking and understanding abilities) skills was moderately impairment. The MDS indicated Resident 24 required setup or clean-up assistance for eating, oral hygiene, dressing, toileting, supervision or touch assistance for showering, personal hygiene, and walking.During a review of Resident 24's Order Summary, dated 4/1/2026, the Order Summary indicated Resident 24's orders included the following:Diclofenac Sodium External (Topical) Gel one (1) percent (%), instructions indicated, apply to affected area topically every 6 hours as needed for breast pain and joint pain, apply two (2) grams (gm, unit of mass), order date 3/8/2025Diclofenac Sodium External Gel 1 %, instructions indicated, apply to chest keloids topically two times a day for chronic keloid pain, order date 8/18/2025, with a discontinued date of 4/7/2026 timed at 11:09 AM. During a review of Resident 24's Care Plan, revision date 3/5/2026, the Care Plan focus indicated Resident 24 was at risk for pain or discomfort due to: generalized osteoarthritis.prurigo nodularis.acne keloid. Resident 24's Care Plan goal indicated, pain will be relieved to tolerable level as indicated by resident, using verbal or nonverbal communication.Interventions indicated, administer treatment as ordered.Pain management as indicated. Resident 24's Care plan included a black box warning for Diclofenac, which indicated may cause an increased risk of serious cardiovascular thrombotic events (heart and blood vessel problems caused by blood clots) events and gastrointestinal (stomach and intestines) bleeding.This risk may occur early in treatment and may increase with duration of use.During a record review of Resident 24's Nursing Notes, dated 4/7/2026, timed at 9:02 AM, the Nursing Notes indicated, .resident stated her skin itches when gel is applied.During a concurrent medication pass observation and interview on 4/7/2026 between 9:24 AM to 9:54 AM, with a Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing morning medications for Resident 24 on Station 4 at Medication Cart (MedCart) 4B, that included but was not limited to Diclofenac Sodium Topical Gel. LVN 1 was observed squeezing Diclofenac Sodium Topical Gel from the tube directly into a medication cup. LVN 1 stated Resident 24 was ordered to receive 2 gm of Diclofenac Sodium Topical Gel. Observed inside of the Diclofenac packaging that was labeled for Resident 24 was a medication guide and a measuring dosing card still glued to the inside of the carton, unused. During a concurrent observation and interview on 4/7/2026, at 9:56 AM, with LVN 1 and Resident 24, inside of the resident's room. Resident 24 stated the Diclofenac Gel itches so badly, and it comes off and does not help. LVN 1 stated that Resident 24 does not want the Diclofenac gel, because she is not in pain and the medication causes itching.During a concurrent observation, interview, and review of the manufacturer's labeling for Diclofenac Sodium Topical Gel on 4/7/2026, at 10:13 AM, with LVN 1, LVN 1 stated that more than three-fourths of the Diclofenac Sodium Topical Gel had been used for Resident 24. LVN 1 stated the manufacturer's measuring dosing card was not being used to measure out the 2 gm as ordered. LVN 1 stated that she usually squeeze out an amount from the Diclofenac Sodium Topical Gel medication tube into a medication cup and applies the full amount onto the resident's chest. LVN 1 reviewed the manufacturer's labeling and stated adverse reactions from Diclofenac Topical Gel includes skin redness and irritation. LVN 1 used the manufacturer's medication dosing card and measured out 2 gm of Diclofenac Sodium Topical Gel and placed it into a medication cup and compared the amount to the medication cup that she squeezed out earlier and LVN 1 stated the amount she measured out without using the medication dosing card was over twice as much as prescribed.During a concurrent interview, record review, and review of manufacturer instructions for Diclofenac Sodium Topical Gel on 4/7/2026, at 12:55 PM, with the Assistant Director of Nursing (ADON), the ADON stated the licensed nurses must use the dosing card provided by the manufacturer to measure the correct amount of medicine. The ADON stated it is not acceptable for nurses to estimate the 2 gm dose by putting the gel into a medication cup. The ADON stated if the dosing card is not used the dose for diclofenac could be under or over the required dose. The ADON stated the resident could be under medicated, the pain management would not be as effective or the resident could be over medication. The ADON stated that over medication of Diclofenac Sodium Topical Gel, could lead to side effects, increase systemic absorption, cause skin reactions, particularly in the elderly, gastrointestinal bleeding, ulcers and potentially causing serious cardiovascular reactions. 1b. During a review of Resident 123's admission Record, the admission Record indicated the facility admitted Resident 123 on 5/13/2024 and the resident was readmitted on [DATE] with diagnoses including Osteoarthritis (joint disease that causes pain and stiffness), Right and Left Shoulder and Neuropathy (nerve pain), and Pain due to nervous system prosthetic device, implants.During a review of Resident 123's History and Physical (H&P), dated 3/26/2026, the H&P indicated the patient does not have the capacity for medical decision making due to: chronic encephalopathy (long-lasting brain damage that causes problems with thinking, memory, or understanding) from Cerebrovascular Accident (CVA, or stroke, is a medical emergency caused by a sudden interruption of blood flow to the brain). During a review of Resident 123's MDS, dated [DATE], the MDS indicated Resident 123's cognitive skills was moderately impairment. The MDS indicated Resident 123 required setup or clean-up assistance for eating and oral hygiene, supervision or touch assistance for showering, dressing, and walking, and partial to moderate physical staff assistance with toileting and personal hygiene.During a review of Resident 123's Order Summary, dated 3/1/2026, the Order Summary indicated Resident 123's orders included an order for Diclofenac Sodium External Gel 1%, instructions indicated, apply to both shoulders topically two times a day for pain management, apply two (2) gm, order date 9/17/2025.During a review of Resident 123's Care Plan, dated 11/11/2025, the Care Plan focus indicated Resident 123 has alteration in musculoskeletal status related to pain due to internal orthopedic devices, Osteoarthritis multiple sites: bilateral knees and shoulders. Resident 123's Care Plan goal indicated, the resident will remain free from pain or at a level of discomfort acceptable to the resident through the review date. Interventions included instructions, to give analgesics as ordered by the physician.During a review of Resident 123's Care Plan, dated 2/11/2025, the Care Plan focus indicated Resident 123 has bilateral pain related to diagnosis of osteoarthritis, chronic shoulder pain. Resident 123's Care Plan goal indicated, pain will be relieved to a tolerable level as indicated by resident, using verbal or nonverbal communication to the extent possible. Interventions indicated, administer medications as ordered.Notify physician if resident experiences unmanageable or intolerable pain. Offer nonpharmacological interventions to relieve discomfort or pain.During a record review of Resident 123's Nursing Notes, dated 2/17/2026, the Nursing Note indicated, Obtained clarification of order from Dr. (doctor) to apply 2 gm Diclofenac gel 1 % for bilateral shoulders per pharmacy recommendation. Order noted and carried out.During a concurrent medication cart inspection, interview, and record review, on 4/7/2026, at 3:50 PM with LVN 6 on Station 2 at MedCart 2B, observed in the bottom drawer was a tube of Diclofenac Sodium Topical Gel 1 % labeled for Resident 123. LVN 6 reviewed Resident 123's order and administration detail report and stated the resident was scheduled to be administered Diclofenac Topical Gel twice a day at 9 AM and 9 PM and the resident last dose was administered on 4/7/2026 at 8:23 AM by LVN 2 that works on Station 2 at MedCart 2A. The medication guide and medication dosing card was observed intact glued inside of the Diclofenac Sodium Topical Gel packaging, unused.During a concurrent medication cart inspection, interview, and record review on 4/7/2026, at 4:03 PM with LVN 2, Resident 123's order and administration detail report were reviewed. Resident 123's had an order to have Diclofenac Sodium Topical Gel 1 % applied to both shoulders twice a day for pain management. LVN 2 stated she applied Resident 123 Diclofenac Sodium Topical Gel 1 % this morning, 4/7/2026, for the scheduled 9 AM administration. LVN 2 stated she squeezed into a medication cup the topical gel and then apply to Resident 123 whatever amount she puts into the medication cup to both shoulders of the resident. LVN 2 stated she does not use a medication dosing card to measure out the Diclofenac Sodium Topical Gel. LVN 2 opened the Diclofenac Sodium Topical Gel carton and stated that the dosing card was still taped inside of the medication packaging unused, and that she did not know there was a dosing card inside. LVN 2 stated it is important to give an accurate dose of Diclofenac Sodium Topical Gel to Resident 123 to prevent side effects, not to overdose, and to ensure the effectiveness of the medication. LVN 2 stated that giving too little of the topical gel will not be effective in pain relief and too much could cause Resident 123 to experience adverse effects.During an interview on 4/8/2026 at 1:44 PM, with the Director of Nursing (DON), the DON stated she was made aware of how the facility's nurses were measuring out the Diclofenac Sodium Topical Gel into a medication cup. The DON stated the licensed nurses must use the medication dosing card to measure either 2 gm or 4 gm per physician order to ensure accurate administration to the residents as prescribed.A review of the facility's policy and procedures (P&P) titled, Administering Medications, dated 1/2026, the P&P indicated, Medications are administered in accordance with prescriber ordersA review of the facility's P&P titled, Administration Procedures for All Medications, dated 5/2022, indicated, To administer medications in a safe and effective manner.If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information.A review of the manufacturer's package insert for Diclofenac Sodium Topical Gel, 1 %, User Guide indicated, Before you use Diclofenac Sodium Topical Gel read the Drug Facts Label, which appears on the carton.Remove the dosing card from the inside of the carton. You should always use the dosing card to measure out the correct dose of Diclofenac Sodium topical Gel.Measuring the correct amount using the dosing card.Wash the dosing card with water. Store enclosed dosing card with your Diclofenac Sodium Topical Gel. The dosing card is re-usable.Stop using Diclofenac Sodium Topical Gel and ask a doctor if pain gets worse or lasts more than 21 days.skin irritation occurs.Questions and Answers.Can I apply Diclofenac Sodium Topical Gel without measuring it out on the dosing card first? No. Use the dosing card to make sure you are getting the correct amount of medicine. 2. During a concurrent medication storage area inspection and interview on 4/8/2026 at 10:56 AM of Station 3 MedCart 3B with LVN 9, two different forms for the month of 4/2026 were reviewed, the two forms were titled, Controlled Drugs Count Record and Narcotic Accountability. form. The space for nurses signature on each form that indicated Outgoing from the 7 AM to 3 PM shift on 4/8/2026 was initialed/signed. LVN 9 stated that she accidentally signed the shift change (Controlled Drugs Count Record) and the Narcotic Accountability forms ahead of time before the end of the shift, without a witness or the incoming nurse present. LVN 9 stated that she should have waited and signed together with the incoming nurse to prevent any discrepancies with controlled medications.During an interview and record review on 4/8/2026 at 5:38 PM, with the DON, the April 2026, Controlled Drugs Count Record and Narcotic Accountability. forms, for Station 3, Medcart 3B were reviewed. The DON stated two nurses at the same time must endorse (formally handing over responsibility for) the shift change and narcotic accountability forms together prior to the incoming nurse assuming responsibility of the medication cart. The DON stated the outgoing and incoming nurse are required to review the medication cart and controlled medications together to prevent the risk of controlled drug diversion (misuse or abuse) and enhance the checks and balance system for accountability.A review of the facility's P&P titled, Controlled Substances, dated 1/2026, indicated, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. 3. During a medication area storage inspection on 4/8/2026, at 10:31 AM, with LVN 8, Station 4 medication room's Cubex was reviewed. LVN 8 demonstrated the use of the Cubex, and the available quantity of medication was displayed on the screen. LVN 8 stated the Cubex is not a blind count, and the license nurse can see what quantity of medication is in the Cubex station before the count to verify what was on hand.During an interview on 4/8/2026, at 4:31 PM, with the Director of Nursing (DON), the DON stated the Cubex is used for emergency medication and first dose. The DON stated there is no blind count for the medications inside of the Cubex station for controlled or noncontrolled medications. The DON stated the licensed nurses are supposed to match the available quantity displayed in the Cubex station with the physical count once the Cubex station opens to remove a dose for a resident.During a telephone interview and review of the Cubex policy on 4/9/2026 at 11:14 AM, with the facility's Cubex Pharmacist Manager (Pharm 1), Pharm 1 stated the Cubex station located inside of Station 4 medication room is electronically managed. Pharm 1 stated the Cubex policy and the facility practice do not match. Pharm 1 stated the Cubex policy indicates a blind count prior to removal of medications from the Cubex station. Pharm 1 stated the pharmacy is not doing a blind count, the quantity on hand of medications stored in the Cubex is displayed prior to the nurse removing the medication from the Cubex and the policy would have to be updated.A review of the facility's P&P titled, Cubex Policy and Procedures, dated 9/2023, indicated, Blind Count - Prior to removing a medication, the user will be asked to enter the inventory count of the medication being removed. If the count entered by the nurse and the count kept by the Cubex Station do not match, a discrepancy will be logged by the station and a message electronically sent to the pharmacy. Only authorized individuals have the access to research a discrepancy and correct inventory count. Correcting the inventory count for any medication will create a permanent record and document the individual who adjusted the count, and it will log the date, and time of the inventory adjustment.

Based on observation, interview, and record review, the facility failed to:a. Ensure dietary staff were wearing hair restraints appropriately while working in the kitchen.b. Maintain the ice machine in a sanitary condition to prevent contamination of consumable ice.c. Ensure proper hand hygiene and glove use during food preparation to prevent cross contamination.These failures had the potential to result in contamination of food and ice, placing residents at risk for foodborne illnesses (an illness that comes from eating contaminated food) including Legionella (type of bacteria found in water environments).Findings: a. During a concurrent observation and interview on 4/6/2026 at 8:51 a.m. with the Dietary Supervisor (DS) in the kitchen area, dietary staff were observed working in the kitchen without wearing hair restraints appropriately. The DS stated, [NAME] 1's (CK) 1 hair net did not cover the sides of the head, CK 2's hair net did not cover sides and back of the head, Dietary Aid (DA) 1's hair net did not cover sides and back of the head and DA 2's hair net did not cover sides of the head. b. During a concurrent observation and interview on 4/6/2026 at 9:23 a.m. with the DS in the kitchen area, the ice machine was inspected. The upper interior surface of the ice machine was observed to have brown and pink discoloration. The DS stated the substance was dirt, the ice produced by the machine was used for all residents and staff upon request, and contaminated ice could cause food borne illness.During a concurrent interview and record review on 4/6/2026 at 9:37 a.m. with the Maintenance Supervisor (MS), the MS stated failure to maintain the ice machine in a clean condition could result in bacterial growth, including Legionella and place residents at risk for illness, as the ice is consumed facility wide.c. During a concurrent observation and interview on 4/7/2026 at 10:28 a.m. with the DS in the kitchen, food preparation area, CK1 was observed wearing gloves while preparing sandwiches. CK 1 placed 4 slices of bread and added ham. [NAME] 1 then turned to refrigerator B, touched the handle, opened the refrigerator, and retrieved a container of margarine placing it next to the bread. [NAME] 1 then continued preparing the sandwiches by placing the bread over the ham without changing gloves or performing hand hygiene. The DS stated [NAME] 1 should change gloves and perform hand hygiene after touching non-food contact surfaces, and this failure to do so could result in foodborne illness, as the food may become contaminated when handled the surface not clean. During an interview on 4/9/2026 at 3:27 p.m. with the Registered Dietitian (RD), the RD stated dietary staff should wear hair restraint properly while working in the kitchen to prevent the hair from contaminating food. The RD stated the ice machine should be cleaned and maintained in a sanitary condition to prevent the buildup of bacteria and mold. The DS stated dietary staff should perform hand hygiene and change gloves during food preparation to prevent cross contamination. The RD stated these practices could result in foodborne illness.During a review of the facility's policy and procedure (P&P) titled, Dress Code, dated 2023, the P&P indicated staff should dress properly hair net for hair, if hair is long cover the ears or longer. During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated 14. Ice which is used in connection with food or drink shall be from sanitary sources.During a review of the facility's P&P titled, Hand Washing Procedure, dated 2023, the P&P indicated when hands need to be washed: before and after handling foods with the hands (cutting, peeling, missing, etc.)During a review of the facility's P&P titled, Food Handling, dated 2023, the P&P indicated food will be prepared and served in a safe and sanitary manner:All food and nutrition services personnel will wash their hands prior to handing all food.Food & Nutrition services personnel should never use bare hand contact with any food, ready to eat or otherwise.This includes food preparation. Gloves should be changed before handling washed food items.

Based on interview and record review the facility failed to ensure proper catheter management for three of three sampled residents (Resident 10, 50, and 184) with an indwelling catheter (flexible tube inserted into the bladder to drain urine) by failing to: a. Clean the catheter, assess urine for signs and symptoms of infection, and monitor the urine output for Resident 10 and 184. b. Ensure Resident 50 had an order for a suprapubic catheter (a tube inserted through the lower abdomen directly into the bladder to drain urine) and monitoring for a urinary tract infection ([UTI]- an infection in the bladder/urinary tract) were in place.These deficient practices had the potential for the residents to develop an UTI and result in fever, pain or blood in the urine.Findings: a. During a review of Resident 10's admission record, the admission record indicated Resident 10 was admitted to the facility on [DATE] with a diagnoses including hydronephrosis (swelling of one or both kidneys) with ureteropelvic junction obstruction (blockage where the kidney meets the ureter, disrupting urine flow), obstructive and reflux uropathy (conditions that block or reverse the normal flow of urine), benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms, presence of urogenital implants (prosthetic devices used to treat urinary incontinence), and urinary retention. During a review of Resident 10's Minimum Data Set ([MDS] a resident assessment tool), dated 3/28/2026, the MDS indicated Resident 10's cognitive (thinking) skills indicated moderate cognitive impairment. The MDS indicated Resident 10 required partial assistance (helper does less than half the effort to complete the task) with eating, oral hygiene, substantial assistance (helper does more than half the effort to complete the task) with showering and toileting hygiene. During a review of Resident 10's Order Summary dated 3/3/2026, the order summary indicated an order for an Indwelling Urinary Catheter for Obstructive Uropathy. During a review of Resident 184's admission record, the admission record indicated Resident 184 was admitted to the facility on [DATE] with a diagnosis including Neuromuscular dysfunction of bladder (bladder control problems caused by nerve or muscle damage), infection and inflammatory reaction (the immune system's non-specific, immediate response to tissue injury) due to indwelling urethral (hollow tube that lets urine, a waste product, leave your body) catheter, and benign prostatic hyperplasia with lower urinary tract symptoms. During a review of Resident 184's MDS, dated [DATE], the MDS indicated Resident 184's cognitive skills indicated moderate cognitive impairment. The MDS indicated Resident 184 required partial assistance with eating, substantial assistance with oral hygiene, and resident was dependent on staff with showering and toileting hygiene. During a review of Resident 184's Order Summary dated 4/1/2026, the order summary indicated starting 4/1/2026, an order for an Indwelling Urinary Catheter for a neurogenic bladder (dysfunction caused by nerve damage). During a concurrent interview and record review on 4/7/2026 at 1:31 p.m., with the Infection Prevention Nurse (IPN), Resident 10 and184's medical records were reviewed. The IPN stated that there was no documentation of urinary care administered to Resident 10 and 184. The IPN stated there was no documented evidence of monitoring the urine output in the indwelling catheter for signs and symptoms of infection. During an interview on 4/9/2026 at 11 a.m. with the Director of Nursing (DON), the DON stated residents with an indwelling catheter need to receive indwelling catheter care, assessed for signs and symptoms of infection and need to monitor urine output to prevent an UTI. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised 1/2026, the P&P indicated the facility need to prevent urinary catheter-associated complications including UTIs. The P&P indicated to observe residents' urine for unusual appearance, bleeding, complaints of burning, tenderness, or pain in urethral area. The P&P indicated to provide routine perineal hygiene. The P&P indicated to document all care rendered and assessment of characteristic of urine, any problems and assessment data. b. During a record review of Resident 50's admission Records, the admission Records indicated Resident 50 was originally admitted to the facility on [DATE] with a readmission date on 1/30/2026 with diagnoses including dementia (a progressive state of decline in mental abilities), diabetes mellitus ([DM],a disorder characterized by difficulty in blood sugar control and poor wound healing), and Guillain-Barre Syndrome ([GBS], a serious autoimmune disorder where immune system attacks the body). During a review of Resident 50's history and physical (H&P), dated 1/31/2026, the H&P indicated Resident 50 had the capacity to understand and make decisions. During a record review of Resident 50's MDS dated [DATE], the MDS indicated Resident 50 had intact cognitive (ability to think, understand, learn, and remember) status. The MDS indicated Resident 50 required setup assistance (helper sets up or cleans up but resident can complete the activity) for self-care abilities such as eating, and oral hygiene and was dependent (helper does all the effort) for hygiene, shower, and dressing. The MDS indicated Resident 50 was maximal assistance for mobility such as rolling left to right, sitting to lying position and dependent on transfers. The MDS indicated Resident 50 had a neurogenic bladder (a dysfunction of the bladder caused by nerve damage leading to an inability to empty the bladder) and indwelling catheter was in place. During a record review of Resident 50's Order Summary Report dated 7/6/2025, the Order Summary Report indicated to cleanse of the suprapubic catheter site daily. There was no order for the suprapubic catheter with the indication of use, and no monitoring in place to ensure suprapubic catheter was in place and Resident 50 was being monitored for UTI. During a concurrent interview and record review on 4/9/2026 at 10:14 a.m. with MDS Nurse (MDSN) 1, the Order Summary Report dated 7/6/2025 and MDS dated [DATE] were reviewed. MDSN 1 stated there were no orders for the suprapubic catheter but there should have been an order for it. MDSN 1 stated if the facility staff did not have orders before interventions were done for the residents, the facility staff were practicing medicine, and it was not within their scope of practice. MDSN 1 stated Resident 50 had a suprapubic catheter for neurogenic bladder and there should be monitoring in place for the suprapubic catheter use. MDSN 1 stated the importance of having a physician order for the suprapubic catheter was for facility staff to be aware that Resident 50 had the indwelling catheter and to monitor the resident with the suprapubic catheter, to make sure staff are monitoring for infection, bleeding, leaking, sediments. MDSN 1 stated there should be a physician order to monitor the Resident 50 for signs and symptoms of infection to reduce the risk of resident getting recurrent infections such as UTI. During an interview on 4/9/2026 at 1:03 p.m. with the Director of Nursing (DON), the DON stated there should have been a physician order for any type of indwelling catheter use with indication and monitoring in place for any residents with indwelling catheter. The DON stated if there was a physician order for the suprapubic catheter, the staff could monitor the residents to make sure the use of the indwelling catheter was appropriate and the indwelling catheter was monitored and cleaned as ordered. The DON stated the orders to monitor the residents for indwelling catheter was to ensure the residents do not develop infections and to monitor for clarity of the indwelling catheter and urine for foul smelling, bleeding, leaking, which could indicate that something was wrong with the indwelling catheter or resident and to notify the physician right away. During a review of the facility's policy and procedures (P&P) titled Catheter Care, Urinary, revised January 2026, indicated, the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. review and document the clinical indications for catheter use prior to inserting. nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place using a standardized tool for documenting clinical indications for catheter use. the following information should be recorded in the resident's medical record such as all assessment data obtained when giving catheter care, character of urine such as color (straw-colored, dark, or red), clarity ( cloudy, solid particles, or blood), and odor, any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain, any problems or complaints made by the resident related to the procedure.

Based on observation, interview and record review, the facility failed to provide three of three hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents (Resident 1, 6, and 103) with dialysis care and services consistent with standards of practice when the facility failed to:a. Ensure a blood pressure (measures the force in arteries when heart beats and rests) reading was not obtained on Resident 6 and 103's left upper extremity where the arteriovenous (AV) shunt (a direct connection between an artery and a vein, bypassing the capillary network, which can be natural or surgically created for medical access) was located. b. Notify the physician on 2/17/2026 and 2/19/2026, educate Resident 6 regarding risk for missing HD, call the Dialysis center to reschedule the dialysis, and monitor Resident 6 for complications after Resident 6 missed HD.c. Ensure Resident 1's AV shunt on the right upper extremity was assessed, monitored, cared for and that the blood pressure was not obtained on Residents 1's right arm.These deficient practices had the potential to result in complications including fluid overload (excessive fluid buildup in the body), access site clotting (process that prevents excessive bleeding when a blood vessel is injured), bleeding or inaccurate blood pressure readings.Findings: a) and b) During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD]irreversible kidney failure) and dependence on hemodialysis. During a review of Resident 6's Minimum Data Set ([MDS] a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 6's cognition (ability to think) was moderately impaired. The MDS indicated Resident 6 needed supervision with eating, partial assistance (helper does less than half the effort to complete the task) with oral hygiene, substantial assistance (helper does more than half the effort) with toileting hygiene, showering, and dependent (helper does all the effort) on staff with personal hygiene. During a review of Resident 6's Order Detail dated 5/20/2026, the order detail indicated: Do not take blood pressure on left upper extremity with AV shunt and on 10/25/2025 to start Dialysis- three days a week every Tuesday, Thursday, and Saturday. During a review of Resident 6's care plan titled Needs dialysis (hemodialysis) r/t renal failure, revised 12/30/2024, the care plan's intervention indicated not to take blood pressure in the arm with the graft. During a review of Resident 6's Weight and Vitals Summary, dated from 3/3/2026 to 4/9/2026, the summary indicated staff documented blood pressure measurements taken from the resident's left arm on following dates:3/3/2026 at 8:30 a.m., 3/5/2026 at 8:46 a.m., 3/6/2026 at 9:53 p.m., 3/7/2026 at 8:31 a.m., 3/10/2026 at 8:26 a.m., 3/12/2026 at 8:05 a.m., 3/13/2026 at 3:07 a.m., 3/14/2026 at 8:40 a.m., 3/17/2026 at 8:49 a.m., 3/21/2026 at 7:40 a.m., 3/24/2026 8:25 a.m., 3/26/2026 8:37 a.m., 3/28/2026 at 7:35 a.m., 3/31/2026 at 8:21 a.m., 4/2/2026 at 8:31 a.m., 4/4/2026 at 8:35 a.m., and 4/7/2026 at 8:48 a.m. (17 times). During a review of Resident 103's admission Record, the admission Record indicated Resident 103 was admitted to the facility on [DATE] with diagnoses including ESRD and dependence on hemodialysis. During a review of Resident 103's MDS dated [DATE], the MDS indicated Resident 103's cognition was severely impaired. The MDS indicated Resident 103 needed partial assistance when eating, substantial assistance with oral hygiene, showering, and dependent on staff with toileting hygiene. During a review of Resident 103's Order Detail, dated 3/17/2026, the order indicated: Do not take blood pressure on left upper extremity with AV shunt. During a concurrent interview and record review on 4/7/2026 at 2 p.m. with the Infection Prevention Nurse (IPN), Resident 103's blood pressure readings, 3/17/2026 to 4/7/2026, were reviewed and the IPN confirmed and stated Resident 103's blood pressure was taken in the left upper arm on several occasions. The IPN stated Resident 103's blood pressure should not be taken from the left upper arm. During a concurrent interview and record review on 4/8/2026 at 1:04 p.m. with Licensed Vocational Nurse (LVN) 5, Resident 6's blood pressure readings, dated from 5/24/2026 to 4/7/2026, were reviewed. LVN 5 stated Resident 6's blood pressure was taken in the left upper arm on several occasions. LVN 5 stated Resident 6's blood pressure should not be taken from the left upper arm with the AV shunt, as doing so could damage the access site. During a concurrent interview and record review on 4/8/2026 at 3:58 p.m. with the Assistant Director of Nursing (ADON), Resident 6's medical records were reviewed. The ADON confirmed Resident 6 did not attend scheduled dialysis treatment on 2/17/2026 and 2/19/2026. The ADON stated a Change of Condition (COC) assessment was not completed following the missed dialysis treatments including notifying the physician, assessing the resident for risks related to missed hemodialysis, contacting the dialysis center to reschedule, and monitoring the resident for potential complications after missing dialysis on the identified dates. The ADON stated missed dialysis placed the resident at risk for fluid overload, congestion, and other complications, and that failure to intervene was not safe. During an interview on 4/9/2026 at 11 a.m. with the Director of Nursing (DON), the DON stated blood pressure should not be taken from the arm with the AV shunt because it could cause bleeding. The DON stated when residents miss HD days the staff needed to do a COC; The staff need to notify the physician/ responsible party, assess, educate the resident regarding risk for missing HD, call the Dialysis center to reschedule the dialysis, and monitor the resident for complications. The DON stated resident with missed HD was at risk for fluid overload. During a review of the facility's policy and procedure (P&P) titled, End-Stage Renal Disease, Care of a Resident with revised 1/2026, the P&P indicated Residents with ESRD will be cared for according to currently recognized standards of care and standards. c. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/25/2019 and was re-admitted on [DATE] with diagnoses including end stage renal disease (ESRD -irreversible kidney failure) and dependence on renal dialysis (life-sustaining treatment for kidney failure that filters waste, salt, and excess water from the blood, acting as an artificial kidney). During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 1's cognition (ability to think) was severely impaired. The MDS indicated Resident 1 needed partial assistance (helper does less than half the effort to complete the task) when eating, substantial assistance (helper does more than half effort) with oral hygiene, and dependent on staff with toileting hygiene, showering, and personal hygiene. During a review of Resident 1's General Acute Care Hospital (GACH) record titled, History and Physical (H&P) Notes, dated 2/12/2026 at 11:48 a.m., the H&P indicated Resident 1 had an AV shunt in the right upper arm which was inserted on 12/31/2024, a second AV shunt in the right upper arm was inserted on 1/2/2026, and a central line (flexible tube inserted into a large vein) in the left internal jugular (large vein in side of neck) was inserted on 12/31/2024. During a concurrent observation, interview and record review on 4/8/2026 at 11:00 a.m. with LVN 3, stated Resident 1 had an old AV shunt on his right arm and the dialysis site currently used is the perma catheter (tunneled, cuffed central venous catheter designed for long-term vascular access, primary used for hemodialysis) on his left upper chest. LVN 3 while reviewing the GACH record, stated the resident had an AV shunt on right upper arm placed on 12/24/2024 and a second AV shunt on right upper arm placed on 1/2/2026. At bedside, LVN 3 verified two different AV shunt on the resident's right upper arm. LVN 3stated he was not aware of the second AV shunt. Resident 1's blood pressure readings from 3/30/2026 to 4/8/2026, were reviewed. LVN 3 stated Resident 1's blood pressure was taken in the right arm on several occasions during from 3/30/2026 through 4/8/2026. LVN 3 stated resident's blood pressure should be taken on the leg because there was a doctor's order to not be taking blood pressure on the left arm. LVN 3 stated if blood pressure was taken on the right arm there is potential for the shunt to burst and cause the AV shunt to stop working, preventing an access site for dialysis. During a concurrent interview and record review on 4/8/2026 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated there was no documentation for the second AV shunt. LVN 4 stated assessments should include skin assessments acknowledging the presence of the second AV shunt. LVN 4 stated even if Resident 1 had an old AV shunt, care such as monitoring and assessing signs of bleeding should still be documented. During an interview on 4/9/2026 at 11:53 a.m. with the Director of Nursing (DON), the DON stated she was not aware Resident 1 had two AV shunts. The DON stated blood pressure should not be taken from the arm with the AV shunt because taking the blood pressure over an AV shunt site can cause a malfunction. The DON stated ensuring the AV shunt was assessed is important to ensure it the AV shunt was working, operational for dialysis, and to ensure the right care was being provided. During a review of the facility's policy and procedure (P&P) titled Care of arteriovenous fistula (AVF – connection between an artery and a vein created surgically for dialysis access to allow for rapid, long-term hemodialysis) and arteriovenous grafts (AVG – surgical connection between an artery and a vein using a synthetic tube to provide vascular access for hemodialysis), revised 1/2026, the P&P indicated After placement of the fistula or graft, the site cannot be accessed until it matures. Care involved the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). Do not use the access arm to take blood pressure. Check patency of the site at regular intervals.

Based on observation, interview, and record review, the facility failed to ensure two out of eight sampled residents (Resident 29 and 76) were treated with respect and dignity by failing to:a. Cover Resident 29's back during ambulation.b. Provide scheduled showers for Resident 76.These deficient practices had the potential to have a negative impact on the psychosocial well-being of the residents and affect their self-worth and self-esteem.Findings:a. During an observation on 4/7/2026 at 8:07 a.m., Resident 29 was observed walking in front of Nursing Station 3 with the back of his gown open, exposing his back and adult brief. There were multiple staff in and around Nursing Station 3 that observed Resident 29's back and adult brief exposed.During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was originally admitted to the facility on [DATE] and was admitted on [DATE] with diagnoses including encephalopathy (any damage or disease that affects the brain), generalized muscle weakness, and cognitive communication deficit.During a review of Resident 29's history and physical (H&P) dated 11/17/2025, the H&P indicated Resident 29 has fluctuating capacity to make medical decisions.During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 3/23/2026, the MDS indicated Resident 29 had mild cognitive impairment. The MDS indicated Resident 29 required supervision for all aspects of activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 29 had no impairments both sides of the upper (arms/shoulders) and lower (hips/legs) extremities and utilized a walker and wheelchair.During an interview on 4/7/2026 at 8:08 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she saw Resident 29's gown open in the back and indicated it was not acceptable for his back to be exposed.During an interview on 4/7/2026 at 8:27 a.m. with CNA 2, CNA 2 stated she saw Resident 29 walking in the hallway with his back exposed and indicated she saw other staff that witnessed the back exposure. CNA 2 stated the staff should cover his back immediately and bring him back to his room to protect his privacy.During an interview on 4/9/2026 at 12:29 p.m. with the DON, the DON stated it is not acceptable for residents to be walking in the hallway with their back exposed as their dignity would not be protected and should always be covered.b. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was originally admitted to the facility on [DATE] and was admitted to the facility on [DATE] with diagnoses including a history of healed traumatic fracture (break in a bone caused by a high-energy incident, such as a fall, car accident, or direct blow, resulting in significant force), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) on left knee, and abnormalities of gait and mobility.During a review of Resident 76's H&P dated 2/9/2026, the H&P indicated Resident 76 has the capacity to understand and make decisions.During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76 had mild cognitive impairment. The MDS indicated Resident 76 required substantial assistance (Helper does more than half the effort) for oral hygiene, toileting hygiene, bathing, upper body (waist above) and lower body (waist below) dressing, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toileting transfer, shower transfer, and required supervision for eating. The MDS indicated Resident 76 had an impairment on one side of the lower extremity. The MDS indicated Resident 76's preference for customary routine and activities indicated it is very important for Resident 76 to be able to choose between a tub bath, shower, bed bath, or sponge bath.During a review of the Resident Shower Schedule, the resident shower schedule indicated Resident 76's shower days are Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift.During an interview on 4/6/2026 at 10:03 a.m. with Resident 76, Resident 76 stated she has a hard time getting showers and indicated she is supposed to get showers on Monday and Thursdays and today 4/6/2026 was her shower day. Resident 76 stated last Monday 3/30/2026 was her last shower day. Resident 76 indicated the staff brings her a basin so that she can clean herself and indicated she used to take showers when she used to live at home and would like to shower.During a review of Resident 76's Documentation survey Report dated Apr-26, the bathing task indicated the following:4/2/2026 (Thursday): Bed bathDuring a review of Resident 76's Documentation survey Report dated MAR-26, the bathing task indicated the following:3/26/2026 (Thursday): Bed bath3/23/2026 (Monday): Bed bath3/12/2026 (Thursday): Bed bath3/9/2026 (Monday): Bed bath3/2/2026 (Monday): Bed bathDuring a review of Resident 76's Documentation survey Report dated FEB-26, the bathing task indicated the following:2/26/2026 (Thursday): Bed bath2/23/2026 (Monday): Bed bath2/16/2026 (Monday): Bed bathDuring a concurrent interview and record review o 4/8/2026 at 4:27 p.m. with CNA 6, CNA 6 stated Resident 76 required assistance with her ADLs. CNA 6 stated Resident 76 is scheduled to get showers on Monday and Thursday and indicated it is the residents' right to get their showers. CNA 6 stated that despite the residents getting a shower on their non-shower days, they would still be able to get their shower on their scheduled shower days. CNA 6 stated bed baths count as shower days if the resident refuses the shower. CNA 6 stated Resident 76's Documentation survey Report dated MAR-26 task sheet indicated on 3/9/2026, it does not indicate Resident 76 refused her shower day. CNA 6 stated Resident 76 had gotten a bed bath on 3/9/2026, 3/12/2026, 3/23/2026, 3/26/2026, and 4/2/2026 with no showers. CNA 6 stated it is important for residents to receive showers to eliminate skin issues. CNA 6 stated if residents did not receive their shower, it would not make them feel good and they would be upset.During a concurrent interview and record review on 4/9/2026 at 12:26 p.m. with the Director of Nursing (DON), the DON stated showers are important as it is body hygiene and residents can still get showers outside of their shower days. The DON stated if the residents do not get their showers, they would be frustrated and upset. The DON stated a bed bath is not the same as showers and indicated on Resident 76's Documentation survey Report dated MAR-26, Resident 76 received a bed bath on 3/2/2026 and 3/9/2026.During a review of the facility's policy and procedure (P&P) titled, Dignity, revised January 2026, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues through the resident's facility stay. When assisting with care, residents are supported in exercising their rights. For example, residents are allowed to choose when to sleep, eat and conduct activities of daily living. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents.During a review of the facility's P&P titled, Resident Rights, revised January 2026, the P&P indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, be supported by the facility in exercising his or her rights, and privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to ensure ongoing assessment and evaluation for the continued use of a sensor pad alarm (a device designed to detect moisture or movement, alerting someone immediately) for one of one sample resident (Resident 142).This failure has the potential to result in restricting the residents' movement, loss of dignity, sleep disturbance due to the sound of alarm, confusion, fear, agitation, and anxiety or irritation.Findings:During a review of Resident 142's admission Record, the admission Record indicated the facility admitted Resident 142 on 11/7/2024, and readmitted on [DATE] with diagnoses including anoxic brain damage (occurs when the brain is totally cut off from oxygen, causing brain cells to die within minutes), cognitive communication deficit (difficulties with communication that arise from underlying problems with thinking skills, rather than primary language or speech disorders), and abnormalities of gait and mobility (an abnormal working pattern).During a review of Resident 142's History and Physical (H&P), dated 12/9/2025, the H&P indicated, Resident 142 did not have the ability to understand and make decisions.During a review of Resident 142's Minimum Data Set (MDS- a resident assessment tool), dated 2/3/2026, the MDS indicated Resident 142' cognitive (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired. The MDS indicated Resident 142 required moderate assistance (helper does less than half the effort to complete the task) with personal hygiene, supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, toileting hygiene, showering, lying to sitting on side of bed, sitting to stand, chair/bed-to chair transferring, toilet transferring and walking.During a review of Resident 142's Order Summary Report, dated 4/6/2026, the Order Summary Report indicated starting 1/8/2026, Resident 142 may have a sensor pad alarm in bed and wheelchair to alert staff when Resident 142 tries to get up unassisted.During a review of Resident 142's Fall Risk Observation/Assessment, dated 12/21/2025 and 1/4/2026, and 2/3/2026 the assessments indicated Resident 142 wasa high risk for falls.During a review of Resident 142's Restraint- physical (initial Evaluation), dated 1/4/2026, the evaluation indicated the facility placed the sensor pad alarm to alert staff when resident tries to get up unassisted. The evaluation did not indicate alternatives attempted to reduce risk of harm to the resident or others prior to the application of the sensor pad alarm.During a concurrent observation and interview on 4/6/2026 at 12:33 p.m. in Resident 142's room with Certified Nurse Assistant (CNA) 7, a sensor pad alarm with blue light on under the resident's mattress and another alarm with light off in the wheelchair were observed. CNA 7 stated Resident 142 needed the sensor pad alarm because he was at high risk for fall and the resident got out of bed without requesting assistance to go to the restroom.During an interview on 4/9/2026 at 10:15 a.m. with CNA 8, CNA 8 stated Resident 142 a sensor pad alarm that was loud enough to be heard anywhere in the nursing station and the alarm sound could startle or upset Resident 142.During a concurrent interview and record review on 4/9/2026 at 10:41 a.m. with Registered Nurse Supervisor (RNS) 2, Resident 142's Restraint- physical (initial Evaluation), dated 1/4/2026 was reviewed. RNS 2 stated the facility should evaluate more than once to assess the psychological effect of a bed alarm and determine whether it limits the Resident 142's free movement. RNS 2 stated a one-time assessment is not sufficient to determine that a bed alarm does not have a psychological or restrictive effect.During a concurrent interview and record review on 4/9/2026 at 12:21 p.m. with the Assistant Directive of Nursing (ADON), Resident 142's Restraint- physical (initial Evaluation), dated 1/4/2026 was reviewed. The ADON stated he assessed the Resident 142 on 1/4/2026 approximately for 30 minutes, and the facility identified the bed alarm as a safety device not a restraint. The ADON stated the facility did not implement a consent and restraint -related requirements including attempting alternatives to reduce risk of harm to the resident or others prior to the application of the sensor pad. The ADON stated, the determination was based on a single observation, indicating the resident continued attempting to get out of bed. The ADON stated there was no further evaluation to assess the potential psychological impact or restrictive effect over time, including whether the alarm limited the resident's voluntary movement.During a review of the facility's P&P titled Sensor Alarms/Tab Alarms/Pad Alarms, dated January 2026, the P&P indicated1. Assess residents for appropriateness of using position change alarm, either in bed and/or in the wheelchair. Select residents may be appropriate for a position change alarm for limited use aimed at assisting staff to assess patterns and routines of the resident.2. Staff will consider the negative potential outcomes which could result from position change alarm use when determining necessity:-Loss of dignity-Decreased mobility-Bowel and bladder incontinence-Sleep disturbances due to the sound of alarm or because afraid to move-Confusion, fear, agitation, anxiety or irritation in response to the sound of alarm. During a review of the facility's policy and procedures (P&P) titled Use of Restraints, dated January 2026, the P&P indicated: -Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted. -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. -The following safety guidelines shall be implemented and documented while a resident is in restraints: A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 14) was free of unnecessary psychotropic medications (any drug that affects brain activity related to mental processes and behavior) by failing to:1.Ensure Resident 14's Lexapro (a prescription medication that helps keep more serotonin available in the brain which helps improve mood, anxiety (constantly feeling worried and nervous), and emotional stability) order had the correct indication for anxiety as indicated by the physician.This failure had the potential to place Resident 14 at risk for unnecessary exposure to psychotropic medications and adverse drug reactions (a harmful or unwanted effect caused by a medication when taken normally and correctly), which could result in impairment or decline in the residents' physical and functional condition, and mental and psychosocial status.Findings:During a review of Resident 14's admission Record, the admission Record indicated the facility admitted Resident 14 on 3/30/2018 and was readmitted on [DATE] with diagnoses including bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) and anxiety disorder.During a review of Resident 14's History and Physical (H&P) dated 3/27/2025, the H&P indicated Resident 14 had the capacity to understand and make decisions. The H&P did not indicate a diagnosis of depression (a mental health condition where someone feels very sad, empty, or loses interest in things for a long time).During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool) dated 7/14/2025, the MDS indicated Resident 14 had an intact cognition (ability to think or make decisions). The MDS indicated Resident 14 needed setup or clean-up assistance (helper assists only prior to or following the activity) with eating, moderate assistance (helper does less than half the effort to complete the activity) with oral and toileting hygiene, upper body dressing, and personal hygiene, and maximum assistance (helper does more than half the effort to complete the activity) with showering, lower body dressing, and putting on or taking off footwear. The MDS indicated Resident 14 had active diagnosis of bipolar and schizophrenia (a mental illness that is characterized by disturbances in thought). The MDS did not indicate Resident 14 had an active diagnosis of depression. The MDS indicated Resident 14 was taking antipsychotic [a drug that helps reduce symptoms of hallucinations (seeing, hearing, or feeling something that is not actually there), delusions (strong beliefs that are not true) or severe confusion] and antidepressant (a drug that helps with the feeling of sadness and improves an individual's mood) medications.During a review of Resident 14's Order Summary Report dated 4/9/2026, the order summary report included the following physician orders:-Lexapro Oral Tablet 5 mg (milligrams - metric unit of measurement) one tablet by mouth one time a day for Depression manifested by (m/b) episodes of tearfulness order dated 5/20/2025, with a start date of 5/21/2025.During a concurrent interview and record review on 4/9/2026 at 8:21 a.m. with the Assistant Director of Nursing (ADON), Resident 14's diagnosis information in the admission record, order summary report, and psychiatry follow-up note dated 5/20/2025 were reviewed. The ADON stated Resident 14's diagnosis list did not indicate Resident 14 had a diagnosis of anxiety. The ADON stated the order summary report indicated Lexapro oral tablet 5 mg give 1 tablet by mouth one time a day for depression m/b episodes of tearfulness ordered on 5/20/2025 and was started on 5/21/2025. The ADON stated the psychiatry follow-up notes dated 5/20/2025 indicated a plan to start Resident 14 on Lexapro 5 mg by mouth in the morning for generalized anxiety disorder manifested by inability to relax and continue the remaining psychiatric regimen. The ADON stated the psychiatry follow-up note did not indicate a diagnosis of depression. The ADON stated the importance of making sure the indication for the medication matched the psychiatrist plan was to ensure the resident was monitored and treated for correct signs and symptoms of anxiety. The ADON stated if the medication did not have the correct indication as indicated by the psychiatrist, there would be increased risk for Resident 14 to receive medications that was not needed.During an interview on 4/2026 at 12:07 p.m. with the Director of Nursing (DON), the DON stated nurses should clarify the correct indication for the medication with the psychiatrist. The DON stated the importance of making sure the medication had the accurate indication was to ensure Resident 14 received the correct treatment plan. The DON stated if the medication did not have the correct indication as indicated by the psychiatrist, Resident 14 would be at risk for unnecessary use of psychotropic medication for non-diagnosed depression.During a review of the facility's policy and procedures (P&P) titled Psychotropic Medication Use dated 2001, the P&P indicated Adequate indication for use, refers to the identified, documented clinical rationale for administering medications that is based on: a. an assessment of the residents' condition and therapeutic goals. The P&P did not indicate procedures regarding clarification of orders psychotropic medications.During a review of the facility's policy and procedures (P&P) titled Unnecessary Medications revised 1/2026, the P&P indicated .1. The facility will ensure to conduct regular medication reviews for all residents and to assess the appropriateness of each medication prescribed. The review will consider the resident's medical condition, goal of care, potential drug interaction, and adverse effects.

Based on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a resident assessment tool) for two of four sampled residents (Resident 17 and Resident 40) when:a. Resident 17 was taking an anti-anxiety medication (medication to treat symptoms such as feelings of fear, dread, uneasiness, and muscle tightness) for anxiety (constantly feeling worried and nervous).b. Resident 40 was taking an anti-coagulant medication (medications that prevent harmful blood clots from forming) for diagnosis of atrial fibrillation (irregular heart rate that can cause poor blood flow).This deficient practice had the potential to result in inaccurate assessment and services for the residents due to the inaccurate MDS assessment and care screening tool practices.Findings:a. During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety disorder (constantly feeling worried and nervous), and dementia (a progressive state of decline in mental abilities).During a review of Resident 17's history and physical (H&P), dated 9/2/2025, the H&P indicated Resident 17 had fluctuating capacity to understand and make decisions. During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 was moderately impaired in cognitive (thought process) functioning for daily decision making. The MDS indicated Resident 17 required supervision (helper provides verbal cues as resident completes the task) to maximal assistance (helper does more than half the effort to complete the task) with self-care abilities such as eating, hygiene and dressing. The MDS indicated Resident 17 was not taking an anti-anxiety medication. During a review of Resident 17's Order Summary Report, dated 10/22/2025, the Order Summary Report indicated Buspirone (medication used for anxiety) 15 milligrams ([mg] metric unit of measurement) by mouth three times a day for anxiety manifested by verbalizing feeling anxious.During a concurrent interview and record review on 4/8/2026 at 1:04 p.m. with the MDS Nurse (MDSN) 1, the MDS dated [DATE] and Order Summary Report dated 10/22/2025 were reviewed. The MDS indicated that Resident 17 was not taking an anti-anxiety medication, but the Order Summary Report indicated Resident 17 was taking an anti-anxiety medication since 10/22/2025. MDSN 1 stated the MDS assessment for medication use should have been coded that Resident 17 was taking an anti-anxiety medication. MDSN 1 stated the importance of having an accurate MDS assessment was to have an impact on the overall care for the residents, the medications the residents are taking, and the treatments and services being provided to the residents in the facility.b. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including DM, atrial fibrillation and dementia.During a review of Resident 40's MDS dated [DATE], the MDS indicated Resident 40 was moderately impaired in cognitive functioning for daily decision making. The MDS indicated Resident 40 required supervision assistance with self-care abilities such as eating, and hygiene. The MDS indicated Resident 40 was taking anticoagulant, but no active diagnosis indicated for the anticoagulant. During a review of Resident 40's Order Summary Report dated 7/9/2023, the Order Summary Report indicated Eliquis (anticoagulant medication) 2.5 mg, two times a day for atrial fibrillation. During a concurrent interview and record review on 4/9/2026 at 9:58 a.m. with MDSN 1, the MDS dated [DATE] and Order Summary Report dated 7/9/2023 were reviewed. MDSN 1 stated the MDS assessment should have indicated the diagnosis of atrial fibrillation because the MDS assessment showed what the resident has and the care the staff are providing for the residents. MDSN 1 stated Resident 40 was taking anti-coagulant medication for the diagnosis of atrial fibrillation. MDSN 1 stated the MDS assessment gets transmitted to CMS, and CMS would need to see the reason Resident 40 was taking anti-coagulant for the diagnosis of atrial fibrillation. MDSN 1 stated that the medication could be deemed an unnecessary medication if no diagnosis indicated the reason for the medication use. MDSN 1 stated the importance of accurate MDS was because it was a comprehensive assessment of the residents, their cognitive functioning, medical status, mobility and the diagnosis of atrial fibrillation should have been on the list of active diagnosis. During an interview on 4/9/2026 at 12:32 p.m. with the Director of Nursing (DON), the DON stated the MDS assessment was an overall assessment of the resident, and the MDS assessment indicates what the resident has from diagnosis, cognitive functioning, medications and treatments. The DON stated the importance of accurate MDS assessment was so there would be proper interventions and care planning in place for the residents based on what the MDS assessment indicators are. The DON stated the staff would not be able to monitor the residents accordingly if the assessment was not done correctly. During a review of the facility's policy and procedure (P&P) titled Resident Assessments, revised January 2026, indicated, a comprehensive assessment of each resident is completed as required. the resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments.all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.During a review of the facility's policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessment revised November 2019, indicated, any person completing a portion of the Minimum Data Set/MOS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. any person who completes any portion of the MOS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. the MDS Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the MDS Coordinator, who is a registered nurse.

The facility failed to ensure adequate supervision to prevent one of one sampled resident (Resident 27) from accessing and consuming food from another resident (Resident 25).This failure had the potential to result in choking, allergic reaction, consumption of food inconsistent with the resident's prescribed diet and exposure to contaminated food.Findings:During a review of Resident 27's admission Record, the admission Record indicated the facility admitted Resident 27 on 12/9/2024 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain), dysphagia (difficulty swallowing) and respiratory failure (any condition that affects breathing function and results in lungs not functioning properly).During a review of Resident 27's History and Physical (H&P), dated 3/13/2026, the H&P indicated, Resident 27 did not have ability for medical decision making. During a review of Resident 27's Minimum Data Set (MDS- a resident assessment tool), dated 3/17/2026, the MDS indicated Resident 27's cognition (ability to think) was moderately impaired. The MDS indicated Resident 27 required moderate assistance (helper does less than half the effort to complete the task) with eating, oral hygiene, dependent (helper does all the effort) with toileting hygiene, showering and personal hygiene. During an observation on 4/6/2026 at 2:46 p.m. in Resident 27's room, Resident 27 was observed sitting on the bed and eating a sandwich. The food container was labeled for Resident 25.During a concurrent observation and interview on 4/6/2026 at 2:48 p.m. in Resident 27's room with Licensed Vocational Nurse (LVN) 10, LVN 10 assessed the name on the food container. LVN 10 confirmed and stated the food was intended for Resident 25. LVN 10 stated the food had already been distributed to Resident 25 and may have been contaminated. LVN 10 stated Resident 27 could choke when consuming food not ordered for him.During a concurrent interview and record review on 4/6/2026 at 2:55 p.m. with LVN 10, Resident 25 and 27's diet order, as of 4/6/2026 were reviewed. LVN 10 stated Resident 27's diet order was soft and bite-sized, while Resident 25's diet order was regular. LVN 10 confirmed there was no care plan in place to address Resident 27's behavior of taking other residents' food. During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised January 2026, the P&P indicated:1. When accident hazards are identified, the QAPl/safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.2. Employees shall be trained on potential accident hazards and demonstrate competence in how to identify and report accident hazards and try to prevent avoidable accidents.3. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.4. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.5. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on interview and record review, the facility failed to ensure a person-centered care plan was implemented for two of four sampled residents (Resident 17 and Resident 1) when:a. Resident 17 who was receiving a psychotropic medication (a medication that alters chemical levels in the brain, affecting mood, perception, thoughts, and behavior). b. addressing Resident 1's arteriovenous (AV) (connection or interaction between arteries and veins) shunt (a direct connection between an artery and a vein, bypassing the capillary network, which can be natural or surgically created for medical access).These deficient practices had the potential to negatively affect the quality of life and wellbeing for Resident 17 and Resident 1 to prevent them from achieving their highest practical well-being. Findings: a. During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety disorder (constantly feeling worried and nervous), and dementia (a progressive state of decline in mental abilities). During a review of Resident 17's history and physical (H&P), dated 9/2/2025, the H&P indicated Resident 17 had fluctuating capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set ([MDS], a resident assessment tool) dated 1/2/2026, the MDS indicated Resident 17 was moderately impaired in cognitive (thought process) functioning for daily decision making. The MDS indicated Resident 17 required supervision (helper provides verbal cues as resident completes the task) to maximal assistance (helper does more than half the effort to complete the task) with self-care abilities such as eating, hygiene and dressing. The MDS indicated Resident 17 was maximal assistance to dependent (helper does all the effort) for mobility such as rolling, sitting, standing and transfers. During a review of Resident 17's Order Summary Report dated 10/22/2025, the Order Summary Report indicated Buspirone (medication used for anxiety) 15 milligrams ([mg] metric unit of measurement) by mouth three times a day for anxiety manifested by verbalizing feeling anxious. During a review of Resident 17's person centered care plan, dated 8/8/2025, the person-centered care plan indicated a focus that Resident 17 required anti-anxiety medication related to anxiety disorder manifested by verbalizing feeling anxious. The care plan goals indicated the medication use will result in the maintenance of the resident's functional status with interventions to administer the medication as ordered by the doctor, but no other interventions to monitor or maintain the effectiveness of the medication or no person-centered interventions were in place. During a concurrent interview and record review on 4/8/20265 at 1:04 p.m. with MDS Nurse (MDSN) 1, the person-centered care plan dated 8/8/2025 was reviewed. MDSN 1 stated a care plan was a plan of care for residents and how the staff would care for the residents in the facility based on their needs. MDSN 1 stated there was no person-centered care plan interventions for the anti-anxiety medication Resident 17 was taking. MDSN 1 stated there was a care plan for anti-anxiety medication, but the interventions were not person centered and did not have monitoring in place to monitor the behaviors Resident 17 had and the effectiveness of the medication Resident 17 was taking for the targeted behaviors. During an interview on 4/9/2026 at 12:49 p.m. with the Director of Nursing (DON), the DON stated a care plan was an overall individualized patient centered plan of care for residents. The DON stated the importance of residents having a person-centered care plan was that each resident has different needs, treatment and services and so the care plan should be individualized to their needs and reflect the care the staff are providing to the residents. During a review of the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered revised on January 2026, indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. b. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 9/25/2019 and was re-admitted on [DATE] with diagnoses including end stage renal disease (ESRD -irreversible kidney failure) and dependence on renal dialysis (life-sustaining treatment for kidney failure that filters waste, salt, and excess water from the blood, acting as an artificial kidney). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognition (ability to think) was severely impaired. The MDS indicated Resident 1 needed partial assistance (helper does less than half the effort to complete the task) when eating, substantial assistance (helper does more than half effort) with oral hygiene, and dependent on staff with toileting hygiene, showering, and personal hygiene. During a concurrent interview and record review on 4/8/2026 at 12:15 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated there was no care plan for Resident 1's AV shunt. LVN 4 stated a care plan for the AV shunt should be included because a care plan reflects the care that is provided to the resident. LVN 4 stated if there is no care plan they are not providing the individualized care the resident needs. During an interview on 4/9/2026 at 11:53 a.m. with the Director of Nursing (DON), the DON stated care plans need to be individualized to meet resident needs. During a review of the P&P titled, Care Plans, Comprehensive Person-Centered, revised 1/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to ensure that one (1) expired medication, fluticasone furoate Ellipta (a once-daily inhaled corticosteroid used for long-term maintenance treatment of asthma, which lowers swelling and helps the body fight inflammation) oral inhaler was not stored in one out of four (4) sampled medication carts (Medcart) 2A on Station 2 and administered to a resident (Resident 79) two times after expiration on [DATE] and [DATE]. These deficient practices had the potential for loss of potency of the medication and for Resident 79 to receive ineffective medication necessary to help maintain and/or improve the resident's breathing.Findings:During a review of Resident 79's admission Record, the admission Record indicated the facility admitted Resident 79 on [DATE] and readmitted on [DATE] with diagnoses including Asthma (a chronic condition where the airways become inflamed and narrow, making it hard to breathe), Chronic Obstructive Pulmonary Disease (COPD, a long-term lung disease that blocks airflow and makes breathing difficult), interstitial pulmonary disease (a group of disorders causing scarring of lung tissue, which affects oxygen flow), and acute respiratory failure with hypoxia (sudden inability of the lungs to provide enough oxygen to the blood).During a review of Resident 79's History and Physical (H&P), dated [DATE], the H&P indicated that Resident 79 has the capacity to understand and make decisions.During a review of Resident 79's Order Summary Report, dated [DATE], the Order Summary included an active order for Fluticasone Furoate Inhalation Aerosol Powder Breath Activated 50 micrograms (mcg, unit of mass) per actuation (medication per inhalation), ordered to inhale one (1) puff orally one time a day for shortness of breath, with an order date of [DATE]. During a concurrent observation and interview on [DATE] at 4:17 p.m. with a Licensed Vocational Nurse (LVN) 2 on Nursing Station 2, MedCart 2A was inspected, and one oral inhaler, fluticasone furoate Ellipta 50 mcg was observed inside of MedCart 2A with an open date of [DATE]. LVN 2 reviewed the manufacturer labeling for fluticasone furoate Ellipta inhaler 50 mcg and stated the inhaler for Resident 79 expires six (6) weeks after opening. LVN 2 stated Resident 79's inhaler expired on [DATE]. LVN 2 stated that she administered a dose of fluticasone furoate Ellipta inhaler 50 mcg to Resident 79 today, [DATE]. LVN 2 stated the fluticasone furoate Ellipta inhaler 50 mcg expired on [DATE] and a new inhaler was ordered but has not arrived yet.During an interview on [DATE] at 4:36 p.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 79's fluticasone furoate Ellipta inhaler 50 mcg expired on [DATE] and would have to be replaced. During a concurrent interview and record review on [DATE] at 1:55 p.m., with the Director of Nursing, Resident 79's Medication Administration Record (MAR, a permanent record that shows which medicine was given, how much, when, and by whom), Administration Detail Reports (a record that lists what was administered, the amount, the time, and by whom) were reviewed for 4/2026, and the fluticasone furoate Ellipta inhaler 50 mcg medication labeled for Resident 79, manufacturer's label was reviewed. The DON stated Resident 79's inhaler was marked as first opened on [DATE] and expired on [DATE]. The DON stated Resident 79 was documented in the MAR and Administration Detail Report to have been administered two doses of the inhaler after the expiration date, on [DATE] and [DATE].A review of the manufacturer's labeling for Fluticasone Furoate Ellipta, revised 3/2025, indicated, Fluticasone Furoate ELLIPTA should be stored inside the unopened moisture-protective foil tray and only removed from the tray immediately before initial use. Discard Fluticasone Furoate ELLIPTA 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first.A review of the facility's policy and procedures (P&P), titled, Administering Medications, dated 1/2026, the P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.A review of the facility's P&P titled, Medication Labeling and Storage, dated1/2026, indicated, To administer medication in a safe and effective manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on interview and record review, the facility failed to ensure two of five sampled residents (Residents 14 and Resident 19) Preadmission Screening and Resident Review (PASARR- a federal assessment requirement to help ensure that individuals who have a mental disorder -MD- are placed in facilities that can provide the appropriate care) were reassessed appropriately by:1.Failing to ensure a PASARR level 1 resident review screening was resubmitted for Resident 14's and Resident 19's new mental health diagnosis and medications.This deficient practice placed Resident 14 and Resident 19 at risk of not receiving necessary care and services needed for mental illness or developmental disability. Findings:During a review of Resident 14's admission Record, the admission Record indicated the facility admitted Resident 14 on 3/30/2018 and was readmitted on [DATE] with diagnoses including bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional high) and anxiety disorder (constantly feeling worried and nervous).During a review of Resident 14's History and Physical (H&P) dated 3/27/2025, the H&P indicated Resident 14 had the capacity to understand and make decisions. The H&P did not indicate a diagnosis of depression (a mental health condition where someone feels very sad, empty).During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool) dated 7/14/2025, the MDS indicated Resident 14 had an intact cognition (ability to think or make decisions). The MDS indicated Resident 14 needed setup or clean-up assistance (helper assists only prior to or following the activity) with eating, moderate assistance (helper does less than half the effort to complete the activity) with oral and toileting hygiene, upper body dressing, and personal hygiene, and maximum assistance (helper does more than half the effort to complete the activity) with showering, lower body dressing, and putting on or taking off footwear. The MDS indicated Resident 14 had active diagnosis of bipolar and schizophrenia (a mental illness that is characterized by disturbances in thought). The MDS did not indicate Resident 14 had an active diagnosis of depression. The MDS indicated Resident 14 was taking antipsychotic (a drug that helps reduce symptoms of hallucinations [seeing, hearing, or feeling something that is not actually there]), delusions (strong beliefs that are not true) or severe confusion] and antidepressant (medication that helps with the feeling of sadness and improves an individual's mood) medications.During a review of Resident 14's Order Summary Report dated 4/9/2026, the order summary report included the following physician orders:1. Lexapro Oral Tablet 5 MG [milligrams - metric unit of measurement), one time a day for depression manifested by (m/b) episodes of tearfulness.During a concurrent review and interview on 4/8/2026 at 11:07 a.m. with the Assistant Director of Nursing (ADON), Resident 14's PASRR dated 3/19/2025 and 3/24/2025 were reviewed. The ADON stated Resident 14's PASRR level 1 screening dated 3/19/2025 did not indicate mental illness diagnoses or medications. The ADON stated Resident 14's PASARR level 1 resident review screening dated 3/24/2025 indicated diagnoses including paranoid schizophrenia (a mental illness that affects how a person thinks and understands what is real), bipolar disorder and anxiety disorder. The ADON stated Resident 14 did not have another PASARR level 1 screening submitted after the resident started treatment with Lexapro (antidepressant medication) for depression. The ADON stated it was important to submit another PASARR level 1 screening when Resident 14 had a new diagnosis or was prescribed a new medication for a mental illness diagnosis to ensure the resident would be evaluated and provided the appropriate treatment plan. The ADON stated there would be potential for Resident 14 not to receive the proper guidance for treatment and care.During a review of Resident 19's admission Record, the admission Record indicated the facility admitted Resident 19 on 11/14/2001 and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) bipolar disorder, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder.During a review of Resident 19's H&P dated 1/23/2026, the H&P indicated Resident 19 does not have the capacity to understand and make decisions.During a review of Resident 19's MDS dated [DATE], the MDS indicated Resident 19 had severe cognitive impairment. The MDS indicated Resident 19 needed moderate assistance (helper does less than half the effort to complete the activity) with eating, maximal assistance (helper does more than half the effort to complete the activity) with oral hygiene and upper body dressing, and was dependent on staff with toileting hygiene, showering, lower body dressing, and putting on or taking off footwear. The MDS indicated Resident 19 had active diagnoses of anxiety disorder, depression, and bipolar disorder.During a concurrent interview and record review on 4/8/2026 at 10:48 a.m. with the ADON, Resident 19's PASARR level 1 screening dated 1/23/2026 was reviewed. The ADON stated Resident 19's PASARR level 1 screening indicated the mental illness diagnosis of bipolar disorder and dementia. The ADON stated Resident 19's PASARR level 1 screening did not indicate mental illness diagnosis of depressive disorder, mood disorder, or anxiety disorder. The ADON stated he should have included the diagnoses of depressive disorder, mood disorder, and anxiety disorder upon submission of the PASARR level 1 screening dated 1/23/2026. The ADON stated it was important to include the mental illness diagnoses to ensure the facility was able to provide the services Resident 19 needed. The ADON stated if the PASARR level 1 screening did not include the mental health diagnoses, Resident 19 would lack the appropriate care and treatment.During an interview on 4/9/2026 at 11:55 a.m. with the Director of Nursing (DON), the DON stated it was important to submit another PASARR level 1 screening upon start of a new medication for a new mental illness diagnosis to ensure residents were evaluated to develop a plan of care. The DON stated if a PASARR level 1 screening was not resubmitted, there would be potential for the residents not to receive the appropriate plan of care and not be able to follow through any recommendations indicated during the evaluation.During a review of the facility's policy and procedures (P&P) titled PASARR dated 1/2026, the P&P did not indicate procedures regarding resubmission of a PASRR level 1 resident review screening when the resident had a new mental illness diagnosis or prescribed a new medication to treat a new mental illness diagnosis.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had an unwitnessed fall, did not experience extreme pain for over two hours after she was found on the floor, before care and treatment were rendered, when: 1. Licensed Vocational Nurse 1 (LVN 1) failed to report to Resident 1 ' s physician, that Resident 1 had an unwitnessed fall, so that care instructions including an order for pain medication could be prescribed and administered. 2. LVN 1 failed to conduct a post-fall assessment of Resident 1 to determine if an injury occurred or to determine Resident 1 ' s pain level. 3. LVN 1 failed to report to Resident 1 ' s physician when the Physical Therapist (PT 1) reported to her, following PT 1 ' s evaluation of Resident 1, that Resident 1 was screaming and guarding (involuntary reaction to protect an area of pain) her left hip on evaluation. 4. LVN 1 failed to report to RNS 1 that Resident 1 had an unwitnessed fall when Resident 1 ' s RP visited the resident and reported that Resident 1 was in excruciating pain. These deficient practices resulted in Resident 1 experiencing unrelieved pain for over two hours following an unwitnessed fall, a delay in evaluation, treatment, and transfer to the GACH. Resident 1 was subsequently transferred to a GACH on 10/7/2024, where she was assessed with a comminuted left intertrochanteric fracture (a broken hip where the bone is broken into multiple pieces) and underwent a surgical procedure to repair the fracture. This deficient practice had the potential for Resident 1 ' s pain to continue to go unmanaged if Resident 1 ' s RP had not intervened and reported Resident 1 ' s pain. Findings: During a review of Resident 1 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis including a history of falls and a subdural hemorrhage (a buildup of blood on the surface of the brain). During a review of Resident 1 ' s Nursing Admission assessment dated [DATE], the Nursing Admission Assessment indicated Resident 1 was alert, oriented to self and nonverbal. The Nursing Admission Assessment indicated Resident 1 required transfer assistance and assistance with activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1 ' s Change of Condition (COC) dated 10/7/2024 and timed at 2:21 p.m., the COC indicated Resident 1 was found on the floor by facility staff (Certified Nursing Assistant 1 [CNA 1]). The COC indicated Resident 1 was unable to explain how the fall happened, did not complaint of pain, and no swelling or redness was noted on Resident 1. During a review of Resident 1 ' s Joint Mobility Screen dated 10/7/2024 and timed at 8:59 a.m., the Joint Mobility Screen indicated Resident 1 was screaming, guarding, and holding her left leg upon movement. During a review of Resident 1 ' s Transfer Form dated 10/7/2024 and timed at 11:45 a.m., the Transfer Form indicated Resident 1 was transferred to a GACH due to uncontrolled pain on the back of her left iliac crest (the curved part at the top of the hip bone). The Transfer Form indicated Resident 1 had a pain level of 9 out of 10, on an 11 eleven-point scale (0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, and 7-10 = severe pain, and 10 = worst imaginable pain). During a review of the Paramedic ' s Report, dated 10/7/2024, the Paramedic ' s Report indicated they were dispatched to the facility at 11:13 a.m., arrived at the facility at 11:19 a.m., left the facility at 11:47 a.m., and arrived at the GACH at 11:49 a.m. The Paramedic ' s Report indicated Resident 1 complained of hip pain, without any traumatic events or reported falls and was in significant pain. The Paramedic ' s Report indicated Resident 1 was administered 50 micrograms ([mcg] a unit of measurement) of intravenous ([IV] directly into the blood stream via a vein) Fentanyl at 11:36 a.m., and 50 mcg of IV Fentanyl at 11:41. During a review of Resident 1 ' s GACH ' s Admission record, the Admission record indicated Resident 1 was admitted to the GACH on 10/7/2024. During a review of Resident 1 ' s GACH Radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) report dated 10/7/2024, the Radiology report indicated Resident 1 had a comminuted left intertrochanteric fracture. During a review of Resident 1 ' s GACH Post-Operative Note dated 10/9/2024, the Post-Operative Note indicated Resident 1 had surgery to repair the left hip fracture. During an interview on 10/9/2024 at 11:30 a.m., with Resident 1 ' s RP, the RP stated he visited Resident 1 on 10/7/2024 at 10:30 a.m. and found Resident 1 in excruciating (unbearable) pain. The RP stated Resident 1 was screaming and wailing as if she had been hit by a car, she was grabbing her left hip, and grabbing his (the RP ' s) arm, trying to say something to him (the RP). The RP stated he informed one of the facility staff that Resident 1 was in pain and how she was acting differently than her normal self. The RP stated facility staff tried to give Resident 1 pain medication and he could hear her yelling bloody murder, which was when he asked the facility to call 911. The RP stated when the paramedics arrived, they attempted to move Resident 1 to a gurney to transfer her to the GACH, and Resident 1 screamed in pure pain and the Paramedics administered Fentanyl (a very strong pain medication used to treat patients with severe pain) to Resident 1 prior to moving her to the gurney. During an interview on 10/9/2024 at 2:30 p.m., with Certified Nursing Assistant 1 (CNA 1 ), CNA 1 stated on 10/7/2024, between 7 a.m. and 9:30 a.m., she found Resident 1 in her room on the floor, on her left side. CNA 1 stated she asked Resident 1 if she was okay, but Resident 1 was agitated and did not respond. CNA 1 stated she called CNA 2 and LVN 1 to Resident 1 ' s room. CNA 1 stated she, LVN 1, and CNA 2 transferred Resident 1 back to bed. During an interview on 10/9/2024 at 3:10 p.m., with LVN 1, LVN 1 stated on 10/7/2024 around 9:20 a.m., she was called to Resident 1 ' s room by CNA 1, when she entered Resident 1 ' s room she observed Resident 1 on the floor lying on her left side in a fetal position (when a person curls up on their side with their arms and legs drawn up toward their chest and their head bowed forward) facing the restroom. LVN 1 stated Resident 1 was non-verbal and could not say she was in pain but was combative, held on to the linen, would not let go of staff ' s hands, and she (LVN 1) could not tell if Resident 1 was experiencing pain. LVN 1 stated on 10/7/2024 at 10:30 a.m., Resident 1 ' s RP came to visit Resident 1 and informed her that Resident was in pain. LVN 1 stated the RP requested that Resident 1 be transferred to the GACH, via 911. During an interview on 10/10/2024 at 9:15 a.m., with RNS 1, RNS 1 stated on 10/7/2024 around 10:40 a.m., LVN 1 notified her that Resident 1 ' s RP was very agitated and requested pain medication for Resident 1. RNS 1 stated she asked LVN 1 if Resident 1 was in pain and LVN 1 told her that Resident 1 had a baseline behavior of screaming and was not experiencing anything different from her baseline behavior. RNS 1 stated when she assessed Resident 1, Resident 1 moved her (RNS 1) hands away to prevent her from touching or assessing her (Resident 1). RNS 1 stated Resident 1 screamed when she (RNS 1) barely touched her gown, guarded her left hip, and grimaced (facial expression of pain or disgust). RNS 1 stated Resident 1 was combative and uncooperative when LVN 1 attempted to give her pain medication and was subsequently given intravenous ([IV] directly into the blood stream) pain medication (Fentanyl), by the paramedics, just before she was transferred to the gurney when the paramedics arrived. RNS 1 stated LVN 1 should have notified her and Resident 1 ' s physician when she (LVN 1) observed Resident 1 on the floor, so that resident 1 ' s physician could be notified to obtain an order for pain medication. RNS 1 stated LVN 1 should have assessed Resident 1 ' s mentation (mental activity), neurological status (brain and nervous system functioning), skin condition, range of motion ([ROM] the amount of movement that a particular joint or series of joints can achieve in a specific direction) to her extremities, and her vital signs ([v/s] measurements of the body ' s most basic functions including the body temperature [BT], blood pressure [BP], heart rate [HR] and respiratory rate [RR]). During an interview on 10/10/2024 at 10:51 a.m., with PT 1, PT 1 stated on 10/7/2024 around 9:30 - 9:45 a.m., he assessed Resident 1 because Resident 1 ' s physician ordered PT to complete an initial assessment and evaluation on Resident 1. PT 1 stated when he tried to assess Resident 1 ' s mobility, she guarded her left leg and screamed when he moved her left leg. PT 1 stated he reported to LVN 1 that Resident 1 was guarding her left leg and in pain during her evaluation. PT 1 stated he was unaware Resident 1 had an unwitnessed fall that morning. During an interview on 10/10/2024 at 6:44 p.m., with LVN 1, LVN 1 stated PT 1 reported to her that Resident 1 was guarding her left hip during PT 1 ' s evaluation. LVN 1 stated she did not have time to report PT 1 ' s findings to Resident 1 ' s physician or RNS 1 because on 10/7/2024, at 10:30 a.m., Resident 1 ' s RP came to the facility and reported Resident 1 was in pain and 911 was called. During an interview on 10/10/2024 at 5:06 p.m., the Director of Nursing (DON) stated LVN 1 should have notified himself (DON), Resident 1 ' s physician, RNS 1 and the Resident 1 ' s RP following Resident 1 ' s unwitnessed fall. The DON stated if RNS 1 had been notified of Resident 1 ' s unwitnessed fall, RNS 1 could have assessed Resident 1 immediately when Resident 1 was found on the floor. The DON stated, if Resident 1 was in pain, staff should have given her pain medication. The DON stated Resident 1 was transferred to a GACH because Resident 1 ' s pain was uncontrollable. During a review of the facility ' s Policy and Procedure (P/P), titled Pain-Clinical Protocol dated 2001, the P/P indicated the nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and where there is onset or new pain or worsening existing. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident ' s cognitive level. During a review of the facility ' s P/P titled Change in a Resident ' s Condition or Status dated 9/2015, the P/P indicated the nurse supervisor or charge nurse will notify the resident ' s physician when there has been an accident or incident involving the resident and if there is a significant change in the resident ' s physical/emotional/mental conditions.

Based on observation, interview, and record review, the facility failed to prevent unplanned weight loss (a weight loss greater than 5 % in one month) of 24.3 pounds ([lbs.] 18.2 % percent {%}) in 40 days from 3/11/2024 to 4/20/2024 for one of three sampled residents (Resident 1). The facility failed to ensure: a. Staff identified Resident 1's decrease in oral intake (amount of food and water consumed) from 3/16/2024 to 3/27/2024 (a total of 11 days). b. The nursing staff reported a decrease in Resident 1's oral intake to Resident 1's physician (MD 1), when Resident 1 began refusing meals from 3/16/2024 to 4/1/2024 (MD 1 was notified 16 days later). c. Nursing staff followed the facility's P&P titled, Nutrition (Impaired)/ Unplanned Weight Loss- Clinical Protocol and immediately notified physician of any abrupt or persistent change from baseline appetite or food intake. d. Staff followed the Registered Dietician's (RD 2) recommendations dated 3/29/2023 which indicated to monitor Resident 1's weight and oral intake. e. Follow Resident 1's care plan titled Nutritional Risk; Resident has the potential for altered nutrition which indicated to notify physician and RD if Resident 1 refused meals and had a significant weight loss. These failures resulted in Resident 1's severe weight loss of 18.2 % in 40 days and requiring the insertion of a gastrostomy tube (G-tube- a tube inserted through the belly for food and medication administration) on 5/6/2024. These failures placed Resident 1 at risk for malnutrition (lack of proper nutrition, caused by not eating enough), dehydration (dangerous loss of body fluid), and skin break down. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (damage or disease that affects the brain) chronic obstructive pulmonary disease (COPD-progressive disease that makes it hard to breath), type II diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly ), presence of right artificial hip joint (onset date, 3/14/2024), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life). During a review of Resident 1's Care Plan titled At risk for adverse reaction (undesirable outcome) related to polypharmacy (multiple medications used by the resident) initiated on 1/23/2024, the care plan's goal indicated Resident 1 will be free from adverse drug reactions. The care plan interventions included to monitor Resident 1 for possible signs and symptoms of adverse drug reactions such as weight loss ., and poor appetite. During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 1/29/2024, the MDS indicated Resident 1 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 1 had no episodes of refusing care. The MDS indicated Resident 1 weighed 133 lbs and did not have any weight loss during the review period. The MDS indicated Resident 1 did not have a G-tube. During a review of Resident 1's Care Plan titled Nutritional Risk; Resident has the potential for altered nutrition initiated on 2/9/2024, had a goal to maintain adequate nutritional status as evidenced by stable weight. (goal maintenance of 133 lbs. plus (+) or minus (-) five percent [%]). The care plan interventions included to observe for signs or symptoms of malnutrition as evidenced by emaciation (abnormally thin or weak, because of illness or lack of food), refusing meals, significant weight loss, signs and symptoms of dehydration, report to physician as needed, and RD to reassess as indicated. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 was discharged for a short term stay at general acute care hospital (GACH) due to a right hip fracture (broken bone). The MDS indicated Resident 1 did not have a G-tube and weighed 139 lbs. The MDS indicated Resident 1 did not have any episodes of refusing care and only needed assistance setting up her tray during meals. During a review of Resident 1's Weights and Vitals Summary, the summary, indicated the following: On 1/23/2024 Resident 1 weigh 133.0 lbs. (mechanical lift) On 2/25/2024 138.8 lbs. (mechanical lift) On 3/11/2024 133.8 lbs. (mechanical lift) On 4/20/2024 109.5 lbs. (mechanical lift) reflecting a severe weight loss of 24.3 lbs. since 3/11/2024 (a total of 18.2% weight loss in 40 days). During a review of Resident 1's Certified Nursing Assistant (CNA) documentation titled Documentation Survey Report under the interventions and tasks line, titled Amount Eaten for the month of March 2024 the Amount Eaten indicated prior to Resident 1's hospitalization on [DATE], Resident 1 was eating between 51-100% for most meals (out of 27 opportunities of meal percentages documented. Resident 1 had 17 meals where she ate 76-100%, 5 meals in which she ate 51-75%, 3 meals where she ate 26-50%, 1 meal she ate 0-25%, and Resident 1 refused 1 meal prior to hospitalization ). After readmission on 3/15/2024 the Amount Eaten, indicated Resident 1 refused 5 meals, consumed 0-50% for 10 meals, and consumed 51-100% for 8 meals (out of 23 opportunities of meal percentages documented). During a review of Resident 1's Nursing Progress Notes from 3/2024 through 4/1/2024, there were no documentations addressing Resident 1's poor oral meal intake. During a review of Resident 1's History and Physical (H&P) dated 3/17/2024, MD 1 indicated Resident 1 was readmitted from the GACH, status post (after) right hip hemiarthroplasty (right hip replacement due to fracture). During a review of Resident 1's Interdisciplinary Team (IDT-team members from different departments working together with a common purpose to set goals and make decisions that ensure the resident received the best care) Conference Summary dated 3/27/2024, the IDT indicated Resident 1 was compliant with her treatment and not refusing any treatments. The IDT conference summary indicated Resident 1 had no significant weight loss, weighed 133.8 lbs. (weight taken 3/11/2024, 16 days prior) and was not receiving tube feeding. The IDT conference summary indicated a progress note from RD 2 indicated Resident 1's diet was constant carbohydrate (CCHO- diet with the same amount of carbohydrates every day to maintain good blood sugar) diet, regular texture, thin liquids, with bedtime snacks. RD 2's progress notes also indicated Resident 1's oral intake was variable (not consistent), and the average oral intake was about 60% during the last 7 days and had refused three meals. During a review of Resident 1's Nutritional Risk assessment dated [DATE] completed by RD 2, the Nutritional Risk Assessment indicated Resident 1 was readmitted from the GACH on 3/14/2024 and had no significant weight changes at that time. RD 2 recommended to add bedtime snacks and a health shake three times a day due to variable oral intake for Resident 1. The Nutritional Risk Assessment indicated to monitor Resident 1's weight and variable oral intake as needed. During a review of Resident 1's H&P dated 3/29/2024, MD 1 indicated Resident 1 was readmitted from the GACH (second admission) for right hip dislocation (hip joint out of place), and Resident 1 required a revision (second surgery) of the first right hip surgery. The H&P did not indicate Resident 1 had weight loss. During a review of Resident 1's Physician Order Summary Report, dated 4/1/2024, the Physician Order Summary report indicated an order for bedtime snacks and Health Shake NSA (a nutritional shake) three times a day (which was 5 days after RD 2 made recommendations, due to variable intake for Resident 1). During a review of Resident 1's Nursing Progress Note dated 4/20/2024, the Nursing Progress Note indicated Resident 1 was monitored for poor oral intake. The note indicated Resident 1 was not eating her breakfast, snacks, lunch, or dinner. The Nursing Progress Note indicated Megace (physician order: Megestrol Acetate (a medication used to increase appetite) 20 milligram (mg- a unit of measurement) one tablet three times a day for appetite stimulation, ordered 4/18/2024 for three weeks) and Boost Nutritional drink very high calorie (530 Calories) three times a day (ordered 4/20/2024) were newly started. During a review of Resident 1's IDT Conference Summary dated 4/22/2024, the IDT Conference Summary indicated Resident 1 had a severe weight loss and weighed 109.5 lbs. (weight taken 4/20/2024). The IDT Conference Summary indicated Resident 1 had poor oral intake with a history of refusing meals and preferred to drink liquids. The IDT indicated an appetite stimulant (Megace) was started on 4/19/2024 and Resident 1's family was to visit Resident 1 to bring food from outside and see if her meal preferences could be updated. During a review of Resident 1's GACH Physician H&P dated 5/6/2024, the H&P indicated Resident 1 was admitted to the GACH for failure to thrive failure (to grow or to gain or maintain weight) and had a G-tube placement. The H&P indicated the resident was hospitalized because the condition posed a danger to Resident 1. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had a significant change in status and was readmitted from the GACH on 5/10/2024. The MDS indicated Resident 1 was moderately cognitively intact. The MDS indicated Resident 1 now had a G-tube and was receiving her nutrition via the G-tube. The MDS indicated Resident 1 was now dependent (staff did all the effort to complete the activity) on staff to complete the following activities: toileting, bathing, dressing, and personal hygiene. During a concurrent observation and interview on 7/29/2024 at 10:20 a.m., with Resident 1, in Resident 1's room, Resident 1 was lying in bed with a G-tube connected to the G-tube pump (machine that administers feeding). Resident 1 stated they feed me through my naval (belly button) and pointed towards the G-tube machine. During a concurrent interview and record review on 7/30/2024 at 2:36 p.m., with the Quality Assurance nurse (QA), Resident 1's Documentation Survey Report under Interventions and Tasks Amount Eaten for 3/2024 was reviewed. The QA nurse stated the significant change in Resident 1's weight was identified on 4/20/2024 when she (Resident 1) went from 133.8 lbs on 3/11/2024 to 109.5 lbs on 4/20/2024. The QA nurse stated prior to Resident 1's hospitalization on [DATE], Resident 1 was consistently eating 76-100% and after she was readmitted on [DATE] she was eating less, about 0-50% on most days. The QA nurse stated there was a decrease in Resident 1's oral intake. The QA nurse stated a decrease in oral intake should be reported to the physician right away so interventions could be implemented to prevent weight loss. The QA nurse stated a change of condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) report was not done, and should have been done for the decrease in Resident 1's oral intake so the resident could be closely monitored by the RD and nursing staff. The QA stated there was no COC report done until 4/20/2024. The QA nurse stated interventions such as nutritional shakes were placed on 4/1/2024, after the recommendation from RD 2 on 3/29/2024, but a COC was not completed for monitoring. The QA nurse stated, there was no documentation to indicate the RD or MD were notified of Resident 1's weight loss or refusal to eat before 3/27/2024. The QA nurse stated Resident 1 ended up with a G-tube because of her severe weight loss, poor oral intake and refusing to eat. The QA nurse stated the facility did not follow Resident 1's care plan to inform the physician when Resident 1 was refusing meals and having poor oral intake. During a concurrent interview and record review on 7/30/2024 at 3:29 p.m., with the Director of Nursing (DON), Resident 1's Documentation Survey Report under Interventions and Tasks Amount Eaten dated 3/2024 was reviewed. The DON stated per the report, Resident 1's oral intake was decreased after her readmission on 3/14/2024. The DON stated, when Resident 1 began refusing food and consuming less during meals, the physician should have been notified. The DON stated a 24 lbs weight loss in one month was considered severe weight loss. The DON stated the potential outcome for residents with poor oral intake or refusing meals was severe weight loss and in the case for Resident 1, poor oral intake led to her needing G-tube placement. The DON stated the importance of informing the physician of meal refusals and poor oral intake was, the physician could put new orders for interventions to try and prevent weight loss and increase appetite. During an interview on 7/31/2024 at 12:30 p.m., with RD 1, RD 1 stated hospitalization and fractures (broken bone) in the elderly were risk factors for weight loss, so any resident readmitted from the hospital should be closely monitored for weight loss. The RD 1 stated decreased oral intake and meal refusals were considered a change of condition, and the RD and physician should have been notified right away so the resident could be closely monitored, and interventions could be started promptly. During an interview on 8/2/2024 at 2:05 p.m., with MD 1, MD 1 stated when Resident 1 was initially admitted to the facility on [DATE], she did not have a G-tube, but during her stay she ended up requiring G-tube placement due to failure to thrive. MD 1 stated he was not notified by the facility when Resident 1 was refusing to eat and had poor oral intake from 3/16/2024 to 3/31/2024. During a review of the facility's policy and procedure (P&P) Nutrition (Impaired)/ Unplanned Weight Loss- Clinical Protocol dated 9/2012, the P&P indicated the nursing staff was to monitor and document the weight and dietary intake of residents. The P&P indicated the staff was to report to the physician any abrupt or persistent change from baseline appetite or food intake. During a review of the facility's P&P titled Requesting, Refusing, and/or Discontinuing Care or Treatment dated 2/2021, the P/P indicated Treatment referred to the medical care, nursing care, and interventions provided to maintain or restore the resident's health or well-being. The P&P indicated the healthcare provider needed to be notified of the refusals of treatment, in a time frame determined by the resident's condition and potential serious consequences. The P&P indicated documentation was needed in the resident's chart of the time and date the healthcare provider was notified and the practitioners response. During a review of the facility's P&P titled Change in a Resident's Condition or Status dated 2/2021, the P&P indicated the staff was to inform the resident's attending physician when there was a refusal of treatment, or a significant change (a major decline in the resident's status that will not normally resolve itself or requires interdisciplinary review and revision of the care plan) in the resident's condition. The P&P indicated such situations needed to be reported to the physician within 24 hours.

Based on interview and record review, the facility failed to ensure that during the facility ' s pharmaceutical services transition to a new pharmacy provider the residents continued to receive medications as order by the physician without missing any doses and would be free from significant mediation errors for three of six sampled residents (Resident 1, 2 and 3). The facility failed to: 1. Ensure Resident 1, who was prescribed Clonazepam (a control medication in schedule IV [group of medicines has been associated with abuse, misuse and diversion] used to treat anxiety, panic attacks and seizures) 1.0 milligram ([mg] a unit of measurement) for anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness) manifested by severe panic and agitation that interfered with care, did not miss 23 doses of Clonazepam 1 mg from 3/28/2024 through 4/14/2024. 2. Ensure Resident 2 did not miss four doses of Risperdal (a medication used to treat schizophrenia, and bipolar disorder) as ordered from 4/3/2024 through 4/8/2024. 3. Ensure Resident 3 did not miss five doses of Seroquel (a medication used to treat schizophrenia, bipolar disorder, and depression) from 4/9/2024 through 4/11/2024. 4. Notify the physicians for Residents 1, 2, and 3 and/or the facility ' s Medical Director that Resident 1 did not receive 23 doses of Clonazepam 1 mg from 3/28/2024 through 4/14/2024, that Resident 2 did not receive four doses of Risperdal from 4/3/2024 through 4/8/2024 and that Resident 3 did not receive five doses of Seroquel from 4/9/2024 through 4/1102024. These deficient practices resulted in Residents 1, 2 and 3, not receiving prescribed medications and the facility ' s inability to ascertain the extent to which medications were not available to all residents residing at the facility. These deficient practices placed Residents 1, 2 and 3 at risk for symptoms of medication withdrawal (the unpleasant physical reaction that accompanies the process of ceasing to take an addictive drug) including anxiety, insomnia, restlessness, agitation, irritability, difficulty concentrating, poor memory, muscle tension, muscle aches, depression, and death, as a result of the sudden discontinuance of prescribed medications. On 4/24/2024 at 4:50 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility ' s Administrator (ADM) and the Assistant Director of Nursing (ADON) due to the facility ' s failure to ensure Resident 1 was free from a significant medication error when Clonazepam was not administered to Resident 1, as prescribed the physician. On 4/27/2024 the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility ' s IJRP ' s implementation through observation, interview, and record review, the IJ was removed on 4/27/2024 at 5:38 p.m., in the presence of the facility ' s the ADON and Quality Assurance Nurse Consultant. The facility ' s IJPR included the following immediate actions: 1. An in-service was conducted on 4/24/2024 and 4/26/2024 to licensed nurses by the facility ' s Regional Nurse Consultants, Director of Staff Development (DSD) and the ADON to ensure licensed nurses were knowledgeable regarding the new pharmacy provider ' s overall pharmacy services such as ordering and reordering medications, cut-off times for ordering medication, delivery process and times, policy and procedure on medication administration, documenting the administration of medication to residents only if the medication was actually administered, medication storage, medication quality controls, protocol to follow when a medication is not available, policy and procedure on narcotic reconciliation, understanding the process of reporting any medication discrepancies/errors, and ensuring the attending physicians will respond back to facility in a timely manner. For licensed nurses who were unable to attend the scheduled in-services on medication administration, acquisition, storage, control, documentation, and the process for reporting discrepancies, they will receive this training before the start of their next scheduled shift. If the nurse does not receive a response from the primary physician within 30 minutes of paging, calling, or texting through the HIPAA compliant phone, they should then reach out to the Medical Director, as well as the Administrator and ADON to obtain any possible orders for the residents. 2. On 4/24/2024 investigation and risk management were initiated by the Administrator regarding Resident 1 ' s Clonazepam mismanagement and unexpected death. The Administrator and ADON notified Resident 1 ' s physician regarding missed Clonazepam doses. Receipts and manifests from the old pharmacy provider and new pharmacy provider were obtained and reviewed. Also, an internal investigation was initiated. On 4/24/2024, licensed staff interviews were obtained by the ADON and the Regional Nurse Consultant to gather details and create a timeline of events. The Pharmacy Consultant and Medical Director were notified of incident. Findings from the investigation were immediately addressed on 4/24/2024 to licensed nurses via in-services which discussed the following: ordering and reordering medications, cut-off times for ordering medication, delivery process and times, policy and procedure on medication administration, documenting the administration of medication to residents only if the medication was actually administered, medication storage, medication quality controls, protocol to follow when a medication is not available, policy and procedure on narcotic reconciliation, understanding the process of reporting any medication discrepancies/errors, and ensuring the attending physicians will respond back to facility in a timely manner. For licensed nurses who were unable to attend the scheduled in-services on medication administration, acquisition, storage, control, documentation, and the process for reporting discrepancies, they will receive this training before the start of their next scheduled shift. 3. On 4/18/2024, in-service was conducted to licensed nurses regarding narcotic reconciliation, steps to follow and the reporting process when narcotics are missing and/or not available. For licensed nurses who were unable to attend the scheduled in-services, they will receive this training before the start of their next scheduled shift. 4. A three-way audit of eight medication carts was initiated by the new and the old pharmacy provider and facility staff to ensure medications were available as prescribed, medications that were not available were communicated to the attending physician or the medical director via phone or text message, and licensed nurses were documenting medications administered appropriately. Any medication identified from the three-way audit as not being administered were immediately investigated, clarified, and corrected. Change of Conditions (COC) will be completed immediately to ensure residents with missed medications are followed-up and the attending physicians will be made aware. 5. A second three-way audit is scheduled to be completed by the new pharmacy provider on 4/27/2024 to ensure medications are available as prescribed, medications that are not available are communicated to attending physician or medical director via phone or text message, and licensed nurses are following proper procedure on medication administration and documenting appropriately. Issues identified will be communicated to the Administrator, ADON and Regional Clinical Nurse Consultant immediately after audit is completed. 6. Licensed nurses will undergo an evaluation both annually and at the time of hiring to assess their proficiency in key competencies. These include medication administration, the proper storage and labeling of medications, narcotic reconciliation, administration of medication, and pharmacy procedures related to ordering and reordering of medications. 7. On 4/25/2024, the Regional Clinical Nurse Consultant ascertained the findings of the new Pharmacy Provider ' s audit conducted on 4/21/2024. Per the new Pharmacy Provider representative, a three-way medication cart audit was not completed on 4/21/2024. The Representative instead focused on the organization of the medication carts, internal and external medications not mixed together, liquid bottle needs to be wiped down, cleanliness of the cart, paying attention to expiration dates and to removing expired medications as well as removing medications from cart when a resident is discharged . Results of visit from 4/16/2024 and 4/21/2024 were reviewed by Assistant Director of Nursing (ADON), Administrator, and Regional Consultants on 4/25/2024. 8. In-services were initiated on 4/24/2024 to all licensed nurses regarding gaps on control logs, proper storage of medications, discharge meds still inside med carts, medications missing, and by ADON and Regional Nurse Consultant. Licensed nurses who could not attend the scheduled in-services on medication administration, acquisition, storage, control, documentation, and the process for reporting discrepancies will receive this training before the start of their next scheduled shift until all licensed nurses receive such in-service. 9. A COC was completed for Resident 2 on 4/24/2024 related to four doses of Risperdal missed. Attending physician and the resident ' s Responsible Party (RP) were notified. No new orders were received from physician. Resident 2 ' s vital signs were within normal limits; Resident 2 was not in any form of emotional distress. In-services were conducted with all licensed nurses on ordering and reordering process, and protocol when medication not available. Licensed nurses unable to attend in-services will receive this training before the start of their next scheduled shift until all licensed nurses receive such in-service. 10. A COC was completed for Resident 3 on 4/25/2024 related to five doses of Seroquel missed. Resident 3 ' s attending physician and RP were notified. There were no new orders. Resident 3 ' s vital signs were within normal limits and Resident 3 was not in any form of emotional distress. In-services were conducted with all licensed nurses on ordering and reordering process, and protocol when medication not available. Licensed nurses not able to attend in-services will receive this training before the start of their next scheduled shift until all licensed nurses receive such in-service. 11. Issues identified were communicated to the Administrator, ADON and Regional Clinical Nurse Consultant immediately after the audit was completed. The Regional Consultant, Administrator, and ADON investigated, made corrections, made clarifications, and provided additional training to licensed nurses on findings from audit. Weekly medication cart audit findings will be monitored closely by the Regional Consultant in collaboration with Owl Pharmacy Consultant to ensure substantial compliance. QA&A Committee will discuss findings for further recommendations as needed during monthly QAPI meetings. 12. The Administrator confirmed a meeting was held on 4/25/2024 with the new Pharmacy Provider ' s Director, Director of Nursing (DON), Administrator, Medical Director, and Regional Nurse Consultants to review contracts and systems to ensure the new Pharmacy Provider and facility are in mutual agreement. Necessary changes in processes and systems were specified in the revised contract. The contract was revised on 4/25/2024. Both parties agree on necessary changes of processes and systems. Systemic Changes and Education: 1. An in-service was scheduled on 4/30/2024 to licensed nursing staff by the new pharmacy provider ' s consultants to ensure licensed nurses are knowledgeable about medication administration, acquisition, storage, control, documentation, and they understand the process of reporting any medication discrepancies. For licensed nurses who were unable to attend the scheduled in-services on medication administration, acquisition, storage, control, documentation, and the process for reporting discrepancies, they will receive this training before the start of their next scheduled shift. 2. Moving forward, the Administrator will get approval from Regional Nurse Consultant before the decision is made to switch pharmacy providers. The Regional Nurse Consultant will provide oversight following the new pharmacy ' s integration to ensure resident ' s medication regimen is not interrupted and medications are received as prescribed. 3. For any plan of switching pharmacy providers, the Regional [NAME] President of Operations (RVPO) will ensure approval from the DON and Regional Nurse Consultant is in place to ensure oversight and smoother transition will occur. The new pharmacy provider will conduct a three-way audit on all medication carts within a week prior to transition and a second three-way audit will be completed a week after the start of new pharmacy services. Results of three-way audits will be communicated to Administrator and DON for immediate resolution. 4. A weekly three-way audit of all 8 medication carts for the next 3 months will be performed by facility and/or the new pharmacy provider staff to ensure medications are in place and facility ' s contracted pharmacy provider is meeting the pharmaceutical needs of the residents. Three-way audits will reflect that medications are available as prescribed, medications that are not available are communicated to attending physician immediately or the medical director via phone or /text message, and that licensed nurses are documenting medications administered appropriately. 5. Medical Records will print the daily missed medications report before 9:00 a.m., Monday - Friday. The RN Supervisor/designee will review and ensure the facility ' s policy is followed for missed medications. The ADON/designee will ensure that findings are immediately addressed. Results of daily RN reviews will be discussed for further resolution during daily stand-up meetings Monday - Friday. 6. The Pharmacy Consultant or DSD will conduct weekly random Medication Pass Observations to five licensed nurses for the next three months to ensure policy and procedure for Medication Administration is followed. Findings which include medication error and medication not available thus not administered will be reported immediately to RN supervisor. The RN supervisor will assist with investigation, correction, clarification, or initiating a COC as needed immediately. Weekly Medication Pass Observation findings will be monitored closely by the Regional Consultant in collaboration with the new Pharmacy Provider Consultant to ensure substantial compliance. QA&A Committee will discuss findings for further recommendations as needed during monthly QAPI meetings. 7. For medications documented not available, RN Supervisor/designee will review daily Medication Administration Records (MAR) for the next 3 months to ensure issues identified will have immediate resolution. Results of the MAR reviews will be discussed for further resolution during daily stand-up meetings Monday - Friday. Licensed nurses continuing to have deficient practices will undergo performance improvement plan and/or progressive discipline. 8. On April 25, 2024, the facility Administrator and the ADON reviewed the preferred methods of contact for the facility's physicians. Following this review, the ADON initiated an in-service for the licensed nurses, instructing them on the specific contact preferences for each physician. A list of each physicians ' preferred contact preference will be located at each nurse ' s station, the list of preferred physicians' communication method will be updated during the monthly QA&A. 9. On April 25, 2024, the licensed nurses were in-serviced and instructed that if a response from the primary physician is not received within 30 minutes of paging, calling, or texting through the HIPAA compliant phone, the Medical Director, should be contacted as well as the Administrator and ADON to obtain any possible orders for the residents. Monitoring: 1. The Administrator will monitor compliance of the plan of action during the monthly QA&A meetings by reviewing results and corrections of the 3-way audits, results and corrections of medication administration observations, results and corrections completed due to the audits of the MARS when medication is unavailable. 2. Summarized findings from scheduled audits/reviews/observations and corrections will be presented by the DON during the monthly QA&A Committee meeting. Trends and patterns identified will be discussed for further recommendations to ensure compliance for the next 3 months. Findings 1. During a review of Resident 1 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses including anxiety disorder. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 3/7/2024, the MDS indicated Resident 1 ' s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were severely impaired. The MDS indicated Resident 1 had an active diagnosis of anxiety disorder. During a review of Resident 1 ' s Physician ' s Order dated 10/26/2023, the Physician ' s Order indicated Resident 1 was to receive Clonazepam 1 mg two times a day for anxiety manifested by severe panic and agitation that interferes with needed care. During a review of the Pharmacy Provider ' s Delivery Sheet dated 2/27/2024 and timed at 7:45 p.m., the Delivery Sheet indicated 60 tablets of Clonazepam 1 mg was delivered to the facility for Resident 1 on 2/27/2024, to provide Resident 1 with medication as order from 2/27/24 through 3/27/2024 During a review of Resident MAR dated 3/24/2024, the MAR indicated Resident 1 received Clonazepam 1 mg on the following days when Clonazepam was Not available in the facility: a. On 3/28/2024 at 9 a.m. and 5 p.m. b. On 3/29/2024 at 9 a.m. and 5 p.m. c. On 3/30/2024 at 9 a.m. and 5 p.m. d. On 3/31/2024 at 9 a.m. and 5 p.m. During a review of the Pharmacy Provider ' s Delivery Sheet dated 4/7/2024 and timed at 7:38 p.m., the Delivery Sheet indicated 60 tablets of Clonazepam 1 mg were delivered to the facility on [DATE]. During a review of Resident 1 ' s MAR dated 4/2024, the MAR indicated Resident 1 did Not receive Clonazepam 1 mg on the following days: a. On 4/3/2024 at 9 a.m. b. On 4/4/2024 at 9 a.m. c. On 4/5/2024 at 9 a.m. and 5 p.m. d. On 4/7/2024 at 9 a.m. and 5 p.m. During a review of Resident 1 ' s MAR dated 4/2024, the MAR indicated Resident 1 did not receive Clonazepam 1 mg on the following dates, when the medication was available at the facility since 4/7/2024: a. On 4/9/2024 at 9 a.m. and 5 p.m. b. On 4/11/2024 at 9 a.m. and 5 p.m. c. On 4/12/2024 at 9 a.m. and 5 p.m. d. On 4/13/2024 at 9 a.m. and 5 p.m. e. On 4/14/2024 at 9 a.m. During a review of Resident 1 ' s MAR note dated 4/3/2024 and timed at 2:14 p.m., the MAR note indicated Clonazepam 1 mg was not available and the facility and the nurses were waiting on medication delivery from the pharmacy. During a review of Resident 1 ' s MAR note dated 4/5/2024 and timed at 9:13 a.m., and a subsequent MAR note on the same day, timed at 6:31 p.m., the MAR notes indicated Clonazepam 1 mg was not available for administration. During a review of Resident 1 ' s MAR note dated 4/9/2024 and timed at 2:12 p.m., and a subsequent MAR note on the same day, timed at 5:38 p.m., the MAR notes indicated Clonazepam 1 mg was pending pharmacy delivery and the estimated time of delivery was 24 to 48 hours with an estimated arrival time in the evening (4/9/2024). During a review of Resident 1 ' s MAR note dated 4/12/2024 and timed at 1:50 p.m., the MAR note indicated the pharmacy was waiting for Resident 1 ' s physician ' s authorization for Clonazepam 1mg. During a review of Resident 1 ' s MAR note dated 4/13/2024 and timed at 9:41 a.m., the MAR note indicated the pharmacy was waiting on Resident 1 ' s physician ' s authorization for the Clonazepam 1 mg. A subsequent MAR note on the same day, timed at 9:04 p.m., indicated the Clonazepam 1 mg was not available. During a review of Resident 1 ' s MAR note dated 4/14/2024 and timed at 9:59 a.m., the MAR note indicated the pharmacy was waiting on Resident 1 ' s physician ' s authorization for the Clonazepam 1mg. A subsequent MAR note on the same day, timed at 5:36 p.m., and 8:15 p.m., indicated Clonazepam was not available and a refill was being sent by the pharmacy. During an interview on 4/18/2024 at 2:31 p.m., the Licensed Vocational Nurse (LVN 1) stated on 4/12/2024 she contacted Resident 1 ' s physician to notify him that Resident 1 was more socially withdrawn but she did not notify him that Resident 1 had missed multiple doses of Clonazepam 1 mg. LVN 1 stated Clonazepam was not available on 4/13/2024 and 4/14/2024 because a physician ' s authorization was required and the pharmacy had not sent the medication to the facility. LVN 1 stated she did not inform the Registered Nurse Supervisor 3 (RNS 3) or the ADON regarding Resident 1 ' s missed doses of Clonazepam 1 mg and she did not notify the Medical Director because Resident 1 was not showing any signs of restlessness or aggressive behaviors. LVN 1 stated antipsychotic medication should be slowly tapered off and not stopped abruptly because the resident could show aggressive behaviors, restlessness, or agitation. During an interview on 4/19/2024 at 4:27 a.m. and a subsequent interview on 4/22/2024 at 11:13 a.m., the facility ' s Clinical Consultant stated if a medication was not available the licensed nurse should investigate, call the pharmacy to check and verify if the medication was delivered to the facility. The Clinical Consultant stated the licensed nurse should notify the DON and Administrator (ADM) when medication was unavailable so they could follow up. The Clinical Consultant stated the physician should be notified when the residents miss a dose of their medication, a COC should be created and if the licensed nurse was unable to reach the resident ' s physician, the medical director should be contacted. The Clinical Consultant stated if a resident does not get the antipsychotic medication over time, there could be an escalation of an unwanted behavior. During an interview on 4/22/2024 at 11:38 a.m., Resident 1 ' s physician stated he was not informed that Resident 1 missed multiple doses of Clonazepam. Resident 1 ' s physician stated if a resident stops taking the antipsychotic medication, the resident may become combative, confused, depressed and aggressive. During an interview on 4/23/2024 at 8:36 a.m., and subsequent interviews on the same day at 10:14 a.m. and 1:15 p.m., the ADON stated she was unaware that Resident 1 had not received multiple doses of Clonazepam. The ADON stated according to the delivery receipts from the facility ' s pharmacy provider, the staff were documenting medication was administered to Resident 1 when the medication was not available in the facility. The ADON after reviewing Resident 1 ' s MAR stated licensed nurses documented the number nine on Resident 1 ' s MAR indicating to see the nurse ' s notes but when she reviewed the nurse ' s notes there was no documentation indicating why Resident 1 ' s medication was not available for administration to Resident 1. The ADON stated if antipsychotic medication is not administered according to physician ' s order it can lead to residents ' exhibiting aggressive behaviors or mood swings which can jeopardize the safety of the residents and facility staff. 2. During a review of Resident 2 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health condition characterized primarily by symptoms of hallucinations or delusions) and bipolar disorder (a mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function). During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decision making was intact. During a review of Resident 2 ' s Physician ' s Order dated 3/1/2024, the Physician ' s Order indicated Resident 2 was to receive Risperdal 2 mg at bedtime for schizoaffective disorder manifested by aggression that may interfere with needed care. During a review of the facility ' s Pharmacy Providers Delivery sheet, the Delivery sheet indicated on 3/2/2024, 30 tablets of Risperdal 2 mg were delivered to the facility, to provide Resident 2 with medication as order until 4/1/2024. During a review of Resident 2 ' s MAR dated 4/2024, the MAR indicated Resident 2 received Risperdal on 4/2/2024 through 4/4/2024 and 4/6/2024 through 4/8/2024 when Risperdal was no longer available in the facility. During a review of Resident 2 ' s MAR dated 4/2024, the MAR indicated Resident 2 did not receive Risperdal on 4/5/2024 and 4/9/2024. During a review of the facility ' s Pharmacy Providers Delivery Sheet, the Delivery sheet indicated on 4/10/2024, 14 tablets of Risperdal 2 mg were delivered to the facility, to provide Resident 2 with medication as order until 4/24/2024. During an interview on 4/23/2024 at 8:36 a.m., and subsequent interviews on the same day at 10:14 a.m., and 1:15 p.m., the ADON stated for Resident 2, according to the delivery receipts, the facility would have no supply of the medication after 4/2/2024 but facility staff were still documenting medication was administered 4/3/2024 and 4/4/2024. 3. During a review of Resident 3 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognition was severely impaired. During a review of Resident 3 ' s Physician ' s Orders dated 12/28/2024, the Physician ' s Orders indicated Resident 3 was to receive the following Medications: a. Seroquel 100 mg by mouth once a day for aggression which causes interference with needed care. b. Seroquel 150 mg by mouth at bedtime for aggression which causes interference with needed care. During a review of the facility ' s Pharmacy Providers Delivery sheet, the Delivery sheet indicated on 3/26/2024, 14 tablets of Seroquel 100 mg was delivered to the facility, to provide Resident 3 with medication as order through 4/9/2024. During a review of Resident 3 ' s MAR dated 4/2024, the MAR indicated Resident 3 did not receive Seroquel on 4/2/2024 at 9 a.m., 4/9/2024 at 9 a.m., when Seroquel should have been available for administration to Resident 3. The MAR indicated Resident 3 did not receive Seroquel 4/10/2024 at 9 a.m. During a review of the facility ' s Pharmacy Providers Delivery sheet, the Delivery sheet indicated on 4/11/2024, 54 tablets of Seroquel 100 mg was delivered to the facility. During a review of facility ' s Pharmacy Providers Delivery sheet, the Delivery sheet indicated on 4/12/2024, 27 tablets of Seroquel 50 mg was delivered to the facility. During a review of Resident 3 ' s MAR note dated 4/11/2024, the MAR note indicated Seroquel was not available and it was pending delivery from the pharmacy. During a review of Resident 3 ' s COC note dated 4/11/2024, the COC indicated the facility was waiting for pharmacy to deliver the Seroquel and Resident 3 ' s physician was notified regarding missed dose since 4/9/2024. During an interview on 4/19/2024 at 12:26 p.m., LVN 3 stated she did not administer Seroquel to Resident 3 on 4/2/2024 and 4/9/2024 (it was available, see above) because it was pending delivery from the pharmacy and not available in the facility. LVN 3 stated on 4/11/2024, Resident 3 did not receive a dose of Seroquel because it was not available and she notified pharmacy, the physician, and initiated a COC. LVN 3 stated a COC should be started when a resident does not receive their medication for three days. During an interview on 4/19/2024 at 4:27 a.m. and a subsequent interview on 4/22/2024 at 11:13 a.m., the Clinical Consultant stated if a medication was not available the licensed nurse should investigate, call the pharmacy to check and verify if it was delivered to the facility. The Clinical Consultant stated the licensed nurse should notify the DON and ADM so they are aware and can follow up. During an interview on 4/22/2024 at 1:43 p.m., the facility ' s new Pharmacy Provider stated the transition to the new pharmacy occurred on 4/1/2024 and the new cycle date (start date of new medication administration packages for the month )for the facility started 4/8/2024. The Pharmacy Provider they were working with the ADON during the transition between pharmacies, but the facility was large, the ADON was new and it seemed the transition was too much for the ADON to handle. During an interview on 4/22/2024 at 9:26 a.m., and subsequent interviews on the same day at 11:08 a.m., and on 4/23/2024 at 10:14 a.m., the ADM stated their DON resigned unexpectedly from the facility on 4/1/12024, the same day the transition between pharmacies occurred, the DON ' s resignation left everyone at the facility scrambling. The ADM stated the previous DON handled most of the communication between the two pharmacy providers in preparation for the transition. The ADM stated he did not assign anyone to oversee the pharmacy transition after the DON resigned on 4/1/2024 because he thought the transition between pharmacies was complete, nor did he follow up to ensure residents ' medications were properly reconciled after the transition. The ADM stated no audits of the medication carts were conducted after the transition between pharmacies because he trusted the licensed nurses to report any medication issues, he was not made aware that there were any problems. During an interview on 4/23/2024 at 8:36 a.m., and subsequent interviews on the same day at 10:14 a.m., and 1:15 p.m., the ADON stated for Resident 3, she was unsure why Resident 3 ' s medication would be reordered on 4/2/2024 and 4/9/2024, when the delivery receipt indicated one delivery on 4/11/2024. The ADON stated if antipsychotics are not administered according to physician ' s order it could lead to the residents exhibiting aggressive behaviors or mood swings which could affect other residents and facility staff. During a review of the facility ' s Job Description for the Licensed Vocational Nurse (LVN) dated 11/2018, the job description indicated the LVN ' s job duties included preparing and administering medications as ordered by the physician, ordering prescribed medications in accordance with established policies, and to notify the nurse supervisor of all drug discrepancies noted on the LVN ' s shift. During a review of the facility ' s policy and procedure (P/P) titled Pharmacy Services Overview, dated 4/2019, the P/P indicated residents should have sufficient supply of their prescribed medications and receive (routine, emergency or as needed) medications in a timely manner. The P/P indicated nursing staff are responsible for contacting the pharmacy if a resident ' s medication is not available for administration. During a review of the facility ' s P/P titled Administering Medications, dated 4/2019, the P/P indicated medications are administered in accordance with prescriber orders.

Based on observation, interview, and record review, the facility failed to ensure, a resident, who was receiving nutrition through a gastrostomy tube ([GT] a soft tube surgically inserted through the belly to provide nutrition, hydration and administer medications) did not have severe weight loss of 10.3 percent (%) in a little over one month (42 days) for one of eight sampled residents (Resident 41). The facility failed to: 1.Ensure Resident 41's care plan interventions to provide adequate nutrition were implemented. 2.Ensure the Interdisciplinary Team ([IDT] resident's health care team consisting of various specialties) meetings were held regularly in accordance with the facility policy and procedure (P&P) titled Weight Committee to make recommendations to prevent Resident 41's weight loss. 3.Ensure the Registered Dietitian ([RD] a health professional who has special training in diet and nutrition) made recommendations to provide Resident 41 with the enteral (form of nutrition that is delivered into the digestive system as liquid) feeding formula to provide Resident 41 nutritional adequacy including sufficient amount of calories and nutrients to prevent the resident's weight loss in accordance with the facility's P&P titled Nutritional Assessment. 4.Implement facility's P&P titled Weight Assessment and Intervention to immediately notify the RD in writing of any Resident 41's weight change of 5% or more since the last weight assessment on 2/11/2024. 5.Ensure RD had estimated Resident 41's caloric, protein, nutrient and fluids needs, and documented in accordance with the facility's P&P titled, Nutritional Assessment. These deficient practices resulted in Resident 41 having severe weight loss (severe weight loss greater than 5 % in one month, greater than 7.5 % in three months and greater than 10 % in 6 months) of 10.3% in a little over one month and placed Resident 41 at risk for malnutrition, dehydration, skin breakdown, having feelings of depression and hopelessness. Findings: During the initial tour observation on 3/19/2023 at 9:45 a.m., Resident 41 was observed lying in bed with an abdominal binder (fabric compression device) around his stomach and a GT in place. During a review of Resident 41's Admission Record (Face Sheet) dated 8/29/2023, the Face Sheet indicated Resident 41 was admitted to the facility with diagnoses including dysphagia (difficulty in swallowing), aphasia (disorder that affects how you communicate), schizophrenia (mental illness that affects how a person thinks, feels and behaves) and hemiplegia (severe weakness that affects only one side of the body) of the right side of the body. Resident 41's admission weight was 181 pounds. During a review of Resident 41's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 2/20/2024, the MDS indicated Resident 41 had severely impaired cognitively (ability to learn, remember, understand, and make decisions) skills for daily decision making. The MDS indicated Resident 41 had lost 10% or more weight in the last six months and was not on a physician prescribed weight-loss regimen. During a review of Resident 41's Weight Variance (changes) IDT meeting dated 2/1/2024, the IDT meeting indicated Resident 41's previous weight was 170 pounds on 1/8/2024. There were no other IDT Weight Variance meetings documented in Resident 41's medical record from 2/2/2024 to 3/26/2024. During a review of Resident 41's physician's order (PO) dated 2/11/2024, the PO indicated for Resident 41 to receive Jevity (high protein [an important ingredient for normal body function] fiber fortified nutritional supplement) 1.2 calories (a unit of energy the body consumes to function) one can three times a day through his newly inserted GT. According to the manufacturer's label three cans of Jevity 1.2 provided Resident 41 with 750 calories per day (one can provided 250 calories). During a review of Resident 41's untitled care plan initiated on 2/12/2024, the care plan indicated Resident 41 had a significant weight loss and weighed 141 lbs. The care plan goal was to maintain Resident 41's adequate nutritional status as evidenced by maintaining weight within 5% of 150 pounds and have no signs and symptoms of malnutrition. The care plan interventions included to monitor, record, and report to the physician signs and symptoms of malnutrition, muscle wasting, and significant weight loss of 5% in one month, 7.5% in three months and 10% in 6 months. During a review for Resident 41's care plan titled, Enteral Nutrition (form of nutrition that is delivered into the digestive system as liquid) initiated on 2/26/2024, the care plan indicated Resident 41 was at risk for enteral nutrition complications including weight loss and dehydration. The care plan goal for Resident 41 was to maintain adequate nutritional and hydration status as evidenced by stable weight, the resident will have no unplanned significant weight change related to enteral feedings and will receive adequate caloric and nutritional requirements. The care plan interventions included to refer to the Registered Dietician ([RD] a health professional who has special training in diet and nutrition) as needed and monitor the resident's weight. During a review of the PO dated 3/11/2024, the PO indicated to administer Jevity 1.2 Calorie oral liquid 237 milliliters ([ml] a unit of measure of volume), 250 calories per can, every 4 hours through GT. This offered Resident 41, 1500 calories per 24 hours. During a review of Resident 41's Weight Summary dated from 2/11/2024 to 3/24/2024, the Weight Summary indicated the following weights for Resident 41: 1. On 2/11/2024-154 pounds. 2. On 2/18/2024-147.4 pounds 3. On 2/25/2024-140.6 pounds 4. On 3/3/2024-142.6 pounds 5. On 3/11/2024-140.5 pounds (8.8% weight loss) 6. On 3/12/2024-141.5 pounds (8.1% weight loss) 7. On 3/17/2024-141.3 pounds (8.2% weight loss) 8. On 3/24/2024-138 pounds (10.3% weight loss) During a review of Resident 41's Change of Condition (COC) form dated 2/13/2024, the COC indicated Resident 41 had signs and symptoms of weight loss of 16 pounds in one month, from 2/11/2024 to 3/24/2024. During a review of Resident 41's Nutritional Risk Assessment (NRA) dated 2/21/2024, the NRA indicated Resident 41's usual body weight was 180 pounds and his most recent weight on 2/18/2024 was 147.4 pounds. During a review of Resident 41's medical record a document titled, At Risk for Malnutrition Form dated 2/29/2024 and completed by the RD, the Risk for Malnutrition Form indicated Resident 41 had enteral feedings, with significant weight loss of 14 pounds (8.7%) times one month from 2/11/2024-2/25/2024. It stated Resident 41 was at risk for malnutrition. The physician plan of care was to continue with current orders and for the dietician to continue to follow (monitor) the resident. During a concurrent interview with the RD and record review of Resident 41's medical record on 3/26/2024 at 1:01 p.m., the RD confirmed she did not documented Resident 41's estimation of caloric needs and stated Resident 41 was losing weight. Resident 41's medical record indicated Resident 41's weight on 2/11/2024 was 154 pounds and his current weight on 3/24/2024 was 138 pounds, a total of 16 pounds weight loss. The RD stated 16 pounds was weight loss was equal to a 10.3% severe weight loss during that timeframe. The RD stated Resident 41 had one IDT meeting for weight loss on 2/1/2024 and no other weight loss meetings were held for this resident. The RD stated, if a resident was losing weight the nursing team and RD meet once a month to make recommendations and prevent further weight loss. The RD stated once a month is a long time to wait to have a meeting if a resident was continuously losing weight. During a concurrent interview with the RD and record review of Resident 41's medical record on 3/26/2024 at 1:05 p.m., the RD stated there were no licensed nurses' progress notes found in Resident 41's medical record regarding weight loss. The RD stated Resident 41 was started on GT feedings on 2/11/2024 and was receiving one can of Jevity 1.2 three times a day for a total of 750 calories per day (24 hours). The RD stated that was not enough calories as Resident 41 was receiving half of the calories he needed to sustain his weight of 170 pounds from 1/8/2024. The RD stated that Resident 41 needed a total of 1706 calories per day to sustain his weight of 170 lbs. This prescribed diet left Resident 41 with a deficit of 956 calories per day to maintain his weight of 170 lbs. During a concurrent interview with the RD and record review of Resident 41's medical record on 3/26/2024 at 1:15 p.m., the RD stated the GT feeding was increased to five cans per day, which provided the resident with 1250 calories per day from 3/1/2024 to 3/3/2024 and still that was not enough calories per day to prevent weight loss. The RD stated Resident 41 needed 1706 calories per day to prevent weight loss and sustain his caloric intake daily. The RD stated, if Resident 41 continued to lose weight he would be malnourished (lack of significant nutrients [substance used in the body to function] in the body leading to physical decline), have a functional decline, develop wounds, or become dehydrated. The RD stated she takes full responsibility for the IDT weight meetings not being held and for not mitigating (having the effect of making something bad less severe, serious, or painful) the weight loss for Resident 41. During a concurrent interview with the RD and record review of Resident 41's medical record on 3/26/2024 at 1:21 p.m., the RD stated she wanted to change Resident 41's GT feeding to Jevity 1.5 Cal (according to the manufacturer Jevity 1.5. Cal is a calorically dense, high-protein, fiber fortified formula providing complete, balanced nutrition for people who require an increase in caloric and protein density) to increase Resident 41 caloric intake, but the facility does not have that formula available at the present time. The RD stated, Jevity 1.2 does not provide enough calories for Resident 41 to prevent further weight loss. The RD stated for the month of February 2024, there were no recommendations to mitigate (correct) weight loss for Resident 41 when his weight loss was greater than 10%. During an interview on 3/26/2024 at 5:36 p.m. the Director of Nurses (DON) stated, he was aware Resident 41 was losing weight. The DON stated the IDT weight loss meetings are done weekly but the facility did not have the meetings. The DON stated, if a resident is losing weight a COC should be done, the care plan updated, and have a weekly IDT meeting. The DON stated it was the responsibility of nursing and the RD to make sure the IDT meetings were done. The DON stated he was aware Resident 41 had a severe weight loss of a 10% in little over a month. During a review of the facility's policy and procedure (P&P) titled Weight Protocol revised 1/2013, the P&P indicated all significant weight changes or 5 pounds weight changes in a resident who weights greater or equal to 100 pounds are assessed and charted, plan of care is updated in the medical record. The P&P indicated the assessment is to include, but not limited to: Reason for weight change 1. If the weight change is an expected or desired outcome 2. If the weight change is avoidable or unavoidable 3. If the diet order is appropriate to meet the goal 4. If the intake of the resident will be sufficient to meet needs or goals. 5. Goal for the future, wt. maintenance, wt. gain, or wt. loss and how that goal is to be reach. During a review of the P&P titled Weight Committee revised 1/2013, the P&P indicated an Interdisciplinary Team (IDT) meets regularly to review residents identified to be at nutritional risk due to weight changes of 5% in 30 days, 7.5% in 90 days or insidious (develops gradually without being noticed) weight change over 3 months or more. The P&P indicated as necessary; each discipline is responsible for documenting the results of the meeting in the appropriate section of the medical record. The P&P indicated identified residents are reviewed by the IDT to determine the reason for weight variance, plan interventions to prevent further weight change and improve weight status. During a review of the facility P&P titled Weight Assessment and Intervention revised 3/2022, the P&P indicated Resident weights are monitored for undesirable or unintended weight loss or gain. The P&P indicated any weight change of 5% or more since the last weight assessment, nursing will immediately notify the dietician in writing. During a review of the facility P&P titled Nutritional Assessment revised 10/2017, the P&P indicated the dietician in conjunction with the nursing staff and healthcare practitioners will conduct a nutritional assess for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The P&P indicated the nutrition care plan shall indicate the route of administration and the resident's requirements for nutrient intake. The P&P indicated the dietician monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. During a review of the revised 11/2018, the P&P indicated the dietician, with input from the provider and nurse: 1. Estimates calorie, protein, nutrient and fluids needs. 2. Determines whether the resident's current intake is adequate to meet his or her nutritional needs. 3. Recommends special food formulations. 4. Calculates fluids to be provided (beyond free fluids in formula). During a review of the Job Description titled Registered Dietician (RD) dated 9/2017, the job description indicated the RD completes nutritional initial, quarterly, annual, and significant change reviews on residents according to federal and state guidelines. The job description indicated the RD completes nutritional reviews monthly on high risk residents (significant weight loss/gain, pressure ulcer, hemodialysis and tube feedings).

Based on observation, interview and record review, the facility failed to ensure the resident, who was complaining of a right hip pain after sustaining a fall with the right hip fracture, had the pain under control for one of eight sampled residents (Resident 153). The facility failed to: 1.Ensure Resident 153 was accurately assesses for pain level, documented, and re-assessed the resident's pain level after administration of pain medication to evaluate medication effectiveness in relieving pain. 2.Notify the physician Resident 153 did not have a pain relief from Tylenol (medication for mild pain relief) 325 milligrams ([mg] a unit of measurement) two tablets. 3.Ensure the facility's licensed nurses implemented Resident 153's care plan and notified the physician of Resident 153 experiencing unmanageable and intolerable pain. 4.Ensure staff followed the facility's policy and procedure (P&P) titled Pain Assessment and Management and assess Resident 153's pain level every 30 to 60 minutes after the onset and reassess as indicated for acute pain until the resident's pain is relieved. These deficient practices resulted in Resident 153 experiencing excruciating unrelieved pain rated 10/10 on a pain rating scale (an assessment tool that measures pain levels, 0-no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) for almost 24 hours, from the first time she complained of pain on 3/8/2024 at 11:37 p.m., until she was transferred to a general acute care hospital (GACH) on 3/9/2024 at 10:24 p.m. Resident 153's uncontrolled pain placed the resident at risk for a delay in physical therapy (a type of therapy that can help improve ability to stand and walk) improvement in ambulation, recovery from right hip surgery and development of depression. Findings: During a concurrent observation and interview on 3/19/2024 at 11:32 a.m., Resident 153 was observed in bed lying on her left side and yelling for help. Resident 153 stated she was in pain rating it 7/10. Resident 153 was observed to have an uncovered right hip surgical incision with 23 staples without a dressing over the incision. Resident 153 stated she had fallen and broke her hip. Resident 153 stated she had Tylenol 325 mg two tablets for pain that morning, but it was not relieving her pain. During a concurrent observation and interview with Resident 153 on 3/20/2024 at 10:15 a.m., Resident 153 was observed lying in bed on her left side, not in proper alignment (body positioning to lessen pain) for post operative right hip arthroplasty surgery. Resident 153 stated, she was in the worst pain of her life. Resident 153 stated, the nurse gave her Tylenol for pain that morning, but it was not working. During a concurrent observation and interview with Resident 153 on 3/21/2024 at 8:51 a.m., Resident 153 stated, she has been in pain since she fell on [DATE], and the pain medication was given was not helping her pain. During a review of Resident 153's Admission Record (Face Sheet) dated 1/22/2024, the Admission Record indicated Resident 153 was admitted to the facility with diagnoses including major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities), muscle weakness and hypertension (high blood pressure). During a review of Resident 153's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/29/2024, the MDS indicated Resident 153 had severe impairment in cognitive (problems remembering things, solving problems, or making decisions) skills for daily decision making. The MDS indicated Resident 153 had no impairment (ability to perform an activity without restriction) of the upper or lower extremities (arms and legs). During a review of Resident 153's Change of Condition (COC) form dated 3/8/2024 at 11:37 p.m., the Change of Condition form indicated Resident 153 complained of the right hip pain, without bruising and swelling, skin intact upon assessment. The COC indicated Resident 153 needed assistance with positioning in bed due to pain, and an x-ray (imaging of internal organs and bones) of the right hip was ordered. During a review of Resident 153's Physician's Order dated 3/8/2024 and timed at 12:45 a.m., the Physician's Order indicated an order for X-ray due to the resident's right hip pain. During a review of Resident 153's X-ray report of the right hip dated 3/9/2024 at 12:59 p.m., the X-ray report indicated Resident 153 had a right sub-capital (neck of the thighbone) fracture with moderate displacement (when ball of the hip joint is pushed out of the socket) of the right hip. During a review of Resident 153's Progress Notes dated 3/9/2024 at 10:24 p.m., the Progress Notes indicated Resident 153 was picked up by transportation and taken to the general acute care hospital (GACH) over 10 hours after the X-ray report indicated a right hip fracture. The X-ray report result was sent to the facility on [DATE] at 12:59 p.m. During a review of Resident 153's COC form dated 3/8/2024 at 11:37 p.m., the COC form indicated Resident 153 had a decline in ambulation (ability to walk) and mobility (movement from place to place) and required a pain assessment due to the change of condition reported and occasional moaning and groaning. The COC form indicated Resident 153's body language was tense, distressed and fidgeting (physical reaction to relieve pain). During a review of Resident 153's Medication Administration Record (MAR) dated 3/8/2024 (the date Resident 153 fractured her hip), the MAR did not indicate Resident 153 was assessed and medicated for pain. During a review of Resident 153's physician's orders (PO) dated 3/9/2024, the PO indicated an order for Tylenol 325 mg two tablets for mild pain level of 1/10 to 3/10 (reference range 1-3 mild pain, 4-7 moderate pain, 8-10 severe pain). During a review of Resident 153's GACH's record dated 3/12/2024, the GACH's record indicated Resident 153 had a right hip arthroplasty (removal of a broken bone and/or cartilage and replaced with prosthetic components). During a review of Resident 153' s Progress Notes dated 3/9/2024 at 2:56 p.m., the Progress Notes indicated Resident 153 was transferred back to the facility from GACH. The Progress Notes indicated Resident 153 was unable to walk due to her right hip fracture. During a review of Resident 153's PO dated from 3/14/2024 to 3/19/2024, the PO indicated Resident 153 only had Tylenol 325 mg two tablets ordered after arthroplasty surgery for a broken right hip on 3/12/2024. During a review of Resident 153's care plan revised on 3/15/2024, the care plan indicated Resident 153 was at Risk for Pain or Discomfort due to status post (after) right hip arthroplasty. The care plan goals for Resident 153 were to have pain relieved to a tolerable level as indicated by the resident, using verbal or non-verbal communication and to express pain relief after administration of medication. The care plan interventions were to administer medication as ordered, assess pain every shift and as indicated, and notify physician if resident experiences unmanageable or intolerable pain. During a review of Resident 153's Physical Therapy (PT) evaluation dated 3/15/2024, the PT evaluation indicated Resident 153 had a pain level rated 7 out of 10 upon movement of the right hip, aching (pain that occurs continuously in a localized area) in intensity and intermittent (pain that comes and goes) in frequency. The PT evaluation indicated the pain limited Resident 153's right leg movement, bed mobility, and transfers out of bed. During a review of Resident 153's PT progress note dated 3/18/2024, the PT progress note indicated Resident 153 was screaming out and physically combative, hitting the therapist due to pain. The PT progress note indicated the charge nurse (unspecified) came into the room and stated Resident 153 was already given pain medication. During a review of Resident 153's MAR dated 3/18/2024, the MAR indicated Resident 153's pain levels were documented as 0/10 for the day, evening, and night shifts. During a review of Resident 153's PT progress note dated 3/19/2024, the PT progress note indicated Resident 153's pain level with movement was 7/10. The PT progress note indicated when Resident 153 was repositioned, she started screaming out because of pain despite Resident 153 being medicated prior to treatment. During a review of Resident 153's physician orders (PO) dated 3/14/2024-3/28/2024, the PO indicated Resident 153 had an order for Tylenol 325 mg two tablets every four hours as needed for mild pain levels of 1-3. During a review of Resident 153's MAR dated 3/19/2024 at 11:32 a.m., the MAR indicated Resident 153 had a pain level of 4/10 and was given Tylenol 325 mg two tablets (ordered for mild pain levels of 1-3). During a review of Resident 153's physician orders (PO) dated 3/19/2024-3/20/2024, the PO indicated Resident 153 had an order for Tramadol (medication used to help relieve moderate to moderately severe pain. Tramadol belongs to a class of drugs known as opioid [narcotic] analgesics [medication that relieve pain]) 50 mg every eight hours as needed for pain. The PO did not indicate a criteria for pain level to administer the Tramadol. Tramadol was order 5 days after Resident's 153 experience lack of pain relief from two tablets of Tylenol 325 mg. During a review of Resident 153's MAR dated 3/19/2024 at 2:42 p.m., the MAR indicated Resident 153 had a pain level of 10/10, and was given Tramadol 50 mg. During a review of Resident 153's PT Progress Notes dated 3/20/2024, the PT Progress Notes indicated Resident 153's pain level with movement was 7/10. The PT Progress Notes indicated Resident 153 was very guarded (protective from movement that causes pain) with gentle passive range of motion ([PROM] someone physically moves or stretches a part of your body) and started screaming out in pain despite being medicated prior to PT therapy. During an interview on 3/21/2024 at 8:48 a.m., Resident 153 stated after she fell on [DATE] she told staff member but does not remember who, that she was in excruciating pain rated 10/10. Resident 153 stated she was given pain medication that morning, but it did not relieve her pain. During an interview on 3/21/2024 at 10:37 a.m., Physical Therapist ([PT 1] a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery), stated he saw Resident 153 for ROM therapy on 3/9/2024 and she was in pain. PT 1 stated Resident 153 was not able to walk, and he did not ask the resident what happened to her. PT 1 stated he reported Resident 153 was having pain to the Licensed Vocational Nurse (LVN 2) but she stated she was already aware. PT 1 stated, Resident 153 was moaning in pain, and he stopped the treatment. During an interview on 3/22/2024 at 3:35 p.m., LVN 7 stated Resident 153 had a fall on 3/8/2024 after 3 p.m. LVN 7 stated Resident 153 was in too much pain the morning of 3/9/2024 and could not work with physical therapy. During an interview on 3/26/2024 at 2:45 p.m., CNA 6 stated her coworkers (unable to identify coworker) reported to her that Resident 153 had a fall on 3/8/2024 and broke her hip. CNA 7 stated Resident 153 was ambulatory (able and strong enough to walk; not confined to a bed) before the fall and able to take care of herself. CNA 7 stated Resident 153 was very depressed after the fall. CNA 6 stated it was hard to move Resident 153 because she was in a lot of pain. During a review of the facility policy and procedure (P&P) titled Pain Assessment and Management revised 10/2022, the P&P indicated the purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The P&P indicated the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The P&P indicated Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. The P&P indicated cognitive, cultural, familial, or gender-specific influences on the residents' ability or willingness to verbalize pain are considered when assessing and treating pain. The P&P indicated comprehensive pain assessments are conducted upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The P&P indicated acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.

Based on observation, interview, and record review, the facility failed to prevent physical abuse for one of three sampled residents (Resident 2). The facility failed to: 1. Ensure staff monitored Resident 1's aggressive and physically assaulting behavior due to history of these behavior to prevent Resident 1 to push Resident 2 on the floor. 2. Ensure a plan of care (PC) was developed and implemented for Resident 1's history of aggressive behavior with interventions to prevent Resident 1 from being physically assaultive and push Resident 2 on the floor. 3. Ensure staff followed facility's policy and procedure titled, Resident Supervision and Monitoring by providing intense supervision Resident 1 who had an aggressive and physically assaultive behavior history placing other residents at risk for harm. These deficient practices resulted in Resident 2 sustain skin tears (traumatic wounds that may result from a variety of mechanical forces such as falls) on both arms after Resident 1 pushed Resident 2 to the to the floor. Resident 2 was fearful and physically shaken up after this incident. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] from a general acute care hospital (GACH 1_ with diagnoses including schizophrenia and bipolar disorder (a mental illness that causes extreme shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had severely impaired cognitive (thinking, reasoning, or remembering) skills for daily decision making and never or rarely made decisions. During a review of Resident 1's GACH 1 record sent to the facility prior to the resident's admission, including the psychiatric (relating to mental illness or its treatment) consult (PC) dated 9/28/2023, the PC indicated Resident 1 was admitted to GACH 1 for acute psychiatric inpatient treatment due to aggressive behavior. Resident 1 was residing at another skilled nursing facility (SNF) when he became physically assaultive, aggressive, and agitated and was sent out to GACH 1 for evaluation. The PC indicated Resident 1 was impulsive, confused, and disorganized and was threatening GACH 1 staff. During a review of Resident 2's Admission record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility 4/14/2023 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and schizophrenia (involves delusions [false beliefs] hallucinations [hearing or seeing things that don't exist], unusual physical behavior, disorganized (abnormal thought process, thinking or speech). During a review of Resident 2's history and physical (H&P) report dated 5/10/2023, the H&P indicated Resident 2 did not have the capacity to make decisions. During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 8/10/2023, the MDS indicated Resident 2 had the ability to make herself understood and was able to understand others. The MDS indicated Resident 2's required limited assistance with one person assistance with bed mobility, transfer, walk in the room and in the corridor, locomotion on unit (how resident moves between locations in her room and adjacent corridor), toilet use and personal hygiene. The MDS indicated Resident 2 needed extensive assistance with dressing. During a review of Resident 2's change of condition ([COC] - a sudden change from the Resident's baseline) note dated 10/9/2023, the COC indicated Resident 2 reported Resident 1 was sitting in her (Resident 2's) personal chair, so she asked Resident 1 to get up from her chair. Resident 1 became agitated and pushed Resident 2 onto the floor. The COC indicated Resident 2 was found sitting on the floor in a sitting position and was complaining of headache. Resident 2 was found to have a skin tear on both arms. During a review of Resident 2's Physician's Order Summary Report (OSR) the OSR indicated new orders were placed on 10/9/2023 for the following treatment: 1. Left and right forearm skin tears to cleanse with Normal Saline ([NS] a solution mixture of salt and water), pat dry and cover with Xeroform (a wound dressing) gauze then with an Island (multi-layer sterile wound dressing) dressing for 14 days, then reassess. 2. Left upper arm skin tear to cleanse with NS, pat dry and cover with Xeroform gauze then with an Island dressing for 14 days, then reassess. 3. Monitor crown area (very top of skull) for presence of bump, notify physician for any significant changes. During a review of Resident 2's the Social Services Consultant Note (SSN) dated 10/13/2023 the SSN indicated Resident 2 was referred to the Social Services Consultant (SSC) for crisis intervention. The SSN indicated Resident 2 was referred to SSC for urgent assessment following an incident and concerns for possible deterioration of Resident 2's mental health. The SSN indicated Resident 2 expressed concerns about her safety and was feeling scared following the incident. The SSN indicated Resident 2 presented with anxious mood and frustration about a recent incident involving Resident 1. The SSN indicated Resident 2 reported being pushed by Resident 1. During an observation on 10/18/2023 at 11:35 a.m., Resident 2 pulled up both of her sleeves revealing two clean wound dressing, one on each forearm. During an interview on 10/18/2023 at 11:55 a.m., the licensed vocational nurse (LVN 2) stated that on 10/9/2023, she finished her morning medication pass and sat down at the nurse's station to do charting and heard Resident 2 yelling. LVN 2 stated she stood up and saw Resident 1 sitting on Resident 2's personal chair and Resident 2 was on the floor. LVN 2 stated Resident 2 informed her, Resident 1 pushed her (Resident 2) to the floor. LVN 2 stated upon assessing Resident 2, she (LVN 2) found the resident sustained a skin tear on both arm and Resident 2 was complaining of a headache. LVN 2 stated Resident 2's favorite thing is coffee so after the incident they brought a cup of coffee to her to help her relax because she was physically shaken up. LVN 2 stated Resident 1 was recently admitted , and she was not made aware Resident 1 had a history of aggressive behavior. LVN 2 stated that the incident happened in front of Resident's 2 room. During an interview and concurrent record review on 10/18/2023 at 2 p.m., the Assistant Director of Nursing (ADON) stated when receiving a new admission, it was important to inquire from the GACH to see if the aggression had been addressed and what kind of supervision the resident would need. The ADON stated when a new resident was admitted the facility needed to create a baseline care plan for behaviors if the resident had history of behavior issues in the past. The ADON stated base line care plans for behaviors was a form of communication for the staff, so they know what to look out for. The GACH 1 admission inquiry paperwork (documents sent to the facility for review prior to admission regarding residents' hospital stay) was reviewed with the ADON and the ADON stated due to Resident 1's history, a baseline care plan should have been created for behaviors including physically assaultive behavior, aggression, and agitation. The ADON confirmed Resident 1 did not have a care plan regarding his history of behavior until 10/9/2023 when the altercation occurred with Resident 2. The ADON stated to have a care plan for Resident 1's behavior was important in order to communicate with staff that Resident 1 had a history of aggressive and physically assaultive behavior and staff could keep a closer eye on him. During an interview and concurrent record review on 10/18/2023 at 3:09 p.m., the registered nurse supervisor (RNS 1) stated she was the admitting nurse for Resident 1. RNS 1 stated, when preparing for a new admission she reviews the inquiry packet sent by the GACH. RNS 1 stated she skimmed through the packet to review important things like current medications and the reason the resident was sent to the GACH. RNS 1 stated when they receive new admissions with history of aggressive behavior, they ensure they put it on the communication board so the nurses from incoming shift will be aware and monitor the resident for aggressive behavior. The GACH 1 Admission Inquiry packet was reviewed with RNS 1, and she stated, unfortunately she skimmed (go over quickly) through the information and missed the information regarding Resident 1's aggressive and physically assaultive behavior, but confirmed the packet indicated Resident 1 was admitted to GACH 1 for evaluation of his aggression. During an interview on 10/18/2023 at 3:20 p.m. RNS 1 stated if she had not missed Resident 1's history of aggressive behavior, she would have made a note in the admission assessment, but she did not. RNS 1 stated if she was aware of Resident 1's aggressive behavior, she would have asked the GACH 1 nurse during report (spoken information about the resident and the hospital stay) if Resident 1 was still having episodes of aggression, but she did not ask. RNS 1 stated she believed the incident that occurred between Resident 1 and Resident 2 could have been avoided if Resident 1's past aggressive behavior had been addressed with a care plan and necessary interventions to prevent physical altercation, and close monitoring. RNS 1 stated if Resident 1's past aggression had been identified upon the resident's admission, they could have added interventions into Resident 1's care plan and asked the physician for an order to monitor Resident 1 behavior past the initial 72-hour new-admission monitoring. RNS 1 stated the behavior monitoring was important so the physician could evaluate whether the plan of care was effective or not and if any changes needed to be made to the resident's medications. During a review of the facility's policy and procedure (P/P) titled Resident Supervision and Monitoring dated 4/2017, the P/P indicated facility residents were provided with intense supervision when they presented with conditions that may place other residents at risk for harm. During a review of the facility's P/P titled Abuse Prohibition & Prevention Policy and Procedure dated 8/2022, the P/P indicated the facility residents had the right to be free from abuse and residents must not be subjected to abuse by anyone including other residents.

Based on interview and record review, the facility failed to ensure a four-wheel walker (a device with three or four large wheels, a handlebar and a built-in seat used for assistance with walking) was maintained in a safe operating condition for one of three sampled residents (Resident 1). The facility failed to: 1.Ensure the facility staff followed the facility's policy and procedure (P/P) facility's policy and procedure (P/P), titled Personal Equipment, Caring For, to maintain Resident 1's four-wheel walker functional integrity. Resident 1 was ambulating independently while using the walker when one of the walker's front wheels fell off and Resident 1 fell on to the floor. This deficient practice resulted in Resident 1 sustaining a right collar bone fracture (a partial or complete break in a bone, that can cause severe pain and swelling) and functional decline in moving independently. Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including right knee osteoarthritis (wearing down of protective tissue at the ends of bones that occurs gradually and worsens over time), and tremors (rhythmic shaking movement in one or more parts of the body). During a review of Resident 1's Minimum Data Set ([MDS]), a standardized assessment and care planning tool), dated 8/12/2022, the MDS indicated Resident 1's cognitive (process of acquiring knowledge and understanding thought, experience, and the senses) skills for daily decision-making were intact. The MDS indicated Resident 1 required supervision (oversight, encouragement, or cueing) to walk in her room, in the corridor and locomotion on and off the unit. The MDS indicated Resident 1 was not steady when walking or turning around but was able to stabilize herself without staff assistance and used a walker for mobility. The MDS indicated Resident 1 had no functional limitations in range of motion ([ROM] the distance and direction a joint can move to its full potential). During a review of Resident 1's Progress Notes (PN), dated 9/6/2022 timed at 12:08 p.m., and at 12:48 p.m., the PN indicated Resident 1 was pushing her walker in the dining room when one of the rollers on the walker broke, the walker tilted, and Resident 1 fell to the floor with her right shoulder landing on top of her walker. The PN indicated Resident 1 complained of ongoing pain to her right shoulder. The PN indicated the physician's order was obtained for an x-ray (a medical test that produces images of structures such as bones, inside the body) and to transfer Resident 1 to the General Acute Care Hospital (GACH) for evaluation. During a review of Resident 1's Physician's Order, dated 9/6/2022, the Physician's Order indicated to transfer Resident 1 to a GACH due to fall with pain to the right shoulder. During a review of the GACH admission records (face sheet), the face sheet indicated Resident 1 was admitted to the GACH on 9/6/2022 due to a fall and complaints of a shoulder pain. During a review of the GACH's Radiology (X-ray) report, dated 9/6/2022, the X-ray report indicated Resident 1 had an acute displaced (bones moved out of alignment) fracture of the distal clavicle (shoulder bone and upper arm bone area) and mild widening of the AC ([Acromioclavicular] is formed by the cap of the shoulder [acromion] and the collar bone [clavicle]) joint. During a review of the GACH's Emergency Department Course (EDC) form dated 9/6/2022, the EDC form indicated Resident 1's right arm was placed in a sling and swath (a device used to hold the arm and shoulder close to the body, after an injury) for right shoulder immobilization. During an interview on 9/21/2022, at 1:53 p.m., Resident 1 stated the day she fell (9/6/2022) she was walking in the dining room when suddenly, one of the wheels fell off the front of her walker, she lost her balance and fell on the floor. Resident 1 stated she was in a lot of pain and was sent to the hospital (GACH) where a sling was applied to her right arm to use because her collar bone was broken. Resident 1 stated she hated using the sling because it was so hard to move around with one arm especially when she had to get out of the bed to use the restroom. Resident 1 stated she was frustrated because she had to call for help now when before she was used to doing things on her own. During an interview with Certified Nursing Assistant (CNA) 1 on 10/14/2022 at 1:27 p.m., CNA 1 stated Resident 1 had always been very independent with activities of daily living, such as using the restroom, and getting dressed. CNA 1 stated Resident 1 did require more assistance since she had the accident. During an interview on 9/21/2022, at 2:59 p.m., with the Director of Maintenance (DM), the DM stated, Resident 1's four-wheel-walker had never been inspected or maintained prior to Resident 1's fall. The DM stated We (the facility) were aware Resident 1 had a rollator walker, but we never checked the safety of the personal walkers. During an interview on 9/21/2022, at 3:12 p.m., with the Rehabilitation Technician (RT), the RT stated, Resident 1 was participating in Restorative Nursing Services ([RNA] person-centered nursing care designed to improve or maintain the functional ability of residents) prior to her fall with fracture, but because of her fracture, Resident 1's RNA participation was on hold until her fracture healed. During a concurrent interview and record review on 9/21/2022, at 4:20 p.m., with the Maintenance Supervisor (MS), a document titled, Maintenance Instructions for Rollators (a brand name) and four-wheel walkers, dated 6/2017 was reviewed. The instructions indicated a visual inspection and functional check must be done at least once per year and shorter time intervals between maintenance may be necessary when the frequency of use or the condition of the product exists due to safety reasons. The MS stated it is the facility's responsibility to ensure the four wheels walker was safe to use. The MS stated they were not aware of how to maintain the safety of those walkers before Resident 1's fall. The MS stated the facility does not have a policy on maintenance of four wheels walkers. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 required limited (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) one-person physical assist for transfers and extensive (resident involved in activity staff provide weight bearing support) one-person physical assist for dressing and toilet use. Indicating a lower level of independence from her previous MDS dated [DATE]. During an interview on 10/14/2022, at 1:35 p.m., a certified nursing assistant (CNA 1) stated since Resident 1's fall (9/6/2022) and subsequent fracture, Resident 1 needed a lot of assistance from staff that she did not need before her fall. CNA 1 stated Resident 1 was unable to put weight on her right arm, which was her dominant arm/hand, so Resident 1 must use her left hand/arm to eat and clean herself after she used the restroom. CNA 1 stated Resident 1 now used a four-point cane with her left arm since her right arm was in a sling. CNA 1 stated staff must help Resident 1 get out of bed to use the restroom, help her to dress, bath and set up her meal trays so she can eat. During an interview and concurrent record review with PT, Resident 1's Physical Therapy Treatment Encounter Notes (PTTEN), dated 10/14/2022 and timed at 2:06 p.m., was reviewed. The PTTEN indicated Resident 1's occupational therapy (therapy to help the resident achieve the highest level of independence in performing activities of daily living) evaluation and plan of treatment dated 10/10/2022, indicated Resident 1 required moderate assistance with transfers and minimal to moderate assistance from sitting to standing. The PT stated prior to Resident 1's fracture (9/6/2022) Resident 1 was independent during ambulation, transfers and with bed mobility, but stated since fracturing her clavicle, Resident 1 does approximately 75% to 80% of tasks independently and requires staff assistance with the remaining percentage of her task. The PT stated, since Resident 1's fracture, Resident 1 was no longer able to use her walker and was now using a four-point cane for mobility. The PT stated per Resident 1's orthopedic (medical specialty treating issues with muscles and bones) consult recommendations on 10/4/2022, Resident 1 must refrain from weight bearing activities on her right arm and she could not use her four-wheel walker due to her clavicle fracture. The PT stated, Resident 1 experienced a decline and was restricted with activities because of her fracture and stated if Resident 1 had not fallen and fractured her clavicle, she would not have had this decline. During a review of the facility's policy and procedure (P/P), titled Personal Equipment, Caring For, revised 11/2012, the P/P indicated residents' personal equipment is cared for to maintain functioning and device integrity.

Based on interview and record review, the facility failed to provide supervision to ensure the resident, who had a history of elopement (leaving unnoticed without permission) and a diagnosis of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) did not leave the facility out on pass (OOP) with two family members (FM 2 and FM 3) who were not listed as the resident's responsible [(RP) a person who may act alone without the other agent or join to make medical decisions; authorized to make all health care decisions) for one of one resident (Resident 1). The facility failed to: 1. Ensure the facility's staff followed a physician's order for Resident 1 to go OOP with a responsible party. 2. Ensure the facility's staff verified and/or contacted Resident 1's listed responsible party RP 1 and RP 2 to verify if FM 2 and FM 3 were a part of the Resident 1's representatives and responsible parties. 3. Ensure the facility's staff adhere to its policy titled, Leave of Absence by ensuring Resident 1 was signed OOP by her responsible party or those persons who were designated by responsible party. These failures resulted in Resident 1 not returning to the facility for two weeks, being displaced from the facility without receiving adequate care and treatment by FM 2 and FM 3, including not receiving daily significant medications for two weeks. On 10/22/2022, while out of the facility with FM 2 and FM 3, Resident 1 was admitted to the general acute hospital (GACH) due to urinary tract infection ([UTI] an infection in any part of the urinary system), excess agitation (exacerbation [worsen] of dementia), abnormal laboratory results, and needed placement. Resident 1 was admitted to the GACH for six days. Findings: During a review of Resident 1's Admission Record (AR), dated 11/1/2022 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), chronic diastolic heart failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly), hypothyroidism (the thyroid gland [a butterfly-shaped organ located in the base of the neck; releases hormones that control metabolism {the way the body uses energy}] does not make enough thyroid hormones to meet the body's needs) and anxiety disorder (involves persistent and excessive worry that interferes with daily activities). The AR indicated Resident 1's family members RP 1 and RP 2 were listed as the responsible parties. During a review of Resident 1's Advance Health Care Directive ([AHCD] legal documents used one's decisions about end-of-life care ahead of time), dated 7/2/2022, the AHCD indicated Resident 1's family members RP 1 and RP 2 were listed as Resident 1's responsible parties and had a durable power of attorney ([DPOA] an appointment of an agent if one becomes disabled or incapacitated - [no longer have the ability, due to illness or injury, to make decisions for oneself]) over Resident 1. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 9/3/2022, the MDS indicated Resident 1 had clear speech but difficulty in communicating some words or finishing thoughts, but was usually understood. The MDS indicated Resident 1 required an extensive assistance with walking, dressing, and using the toilet. During a review of Resident 1's History and Physical (H/P), dated 9/7/2022, the H/P indicated Resident 1 had unspecified dementia with confusion, cognition (thought process) impairment and memory loss with behavior problems of wanting to leave the facility, which required frequent redirection and close monitoring. The H/P assessment indicated the plan was to keep Resident 1 in the memory unit (with doors locked to prevent residents from leaving the facility) of the facility due to safety concerns and the resident risk for elopement. During a review of Resident 1's Physician Progress Note (PPN), dated 9/20/2022 and untimed, the PPN indicated Resident 1 had dementia with an altered level of consciousness (a state of reduced alertness or inability to arouse due to low awareness of the environment), and encephalopathy (damage or disease of the brain that affects and alters the brain function or structure). During a review of Resident 1's physician's orders, dated 9/26/2022, the physician orders indicated Resident 1 was receiving Albuterol inhaler (used to prevent and treat wheezing [shrill, coarse whistling or rattling sound the breath makes when the airway is partially blocked] and shortness of breath caused by breathing problems) two puffs (act of inhaling [to breathe in]) as needed every 4 hours for shortness of breath, ordered on 8/23/2022, Aricept 5 milligram ([mg] unit of measurement) tablet (used to treat confusion [dementia]) at bedtime for dementia, ordered 8/25/2022, Aspirin 81 mg daily for prevention of cerebral vascular accident ([CVA/stroke occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts) ordered 8/25/2022, Buspirone 5 mg tablet every day for agitation related to anxiety disorder, ordered 9/1/2022, Famotidine 20 mg (used to decrease the amount of acid in the stomach) twice a day, ordered on 8/31/2022, Lipitor 40 mg (used to treat high cholesterol; to lower the risk of stroke, heart attack), one tablet at bedtime for hyperlipidemia (used to treat high cholesterol [fats], and to lower the risk of stroke, heart attack), ordered on 8/25/2022, and Lasix 20 mg every day for edema (swelling, due to trapped fluid), ordered on 8/25/2022. During a review of Resident 1's physician order dated 9/26/2022, the physician's order indicated an order dated 8/25/2022 and timed at 8:08 p.m. that Resident 1 may go OOP with the responsible party, if not in conflict with treatment plan. During a review of the facility's Release of Responsibility for Leave of Absence (RORFLA) for Resident 1, dated 10/8/2022 and timed at 12:31 p.m., the RORFLA required a signature of the person accepting responsibility for Resident 1 to go OOP. However, the person who signed Resident 1 OOP was not listed as Resident 1's RP on Resident 1's AR face sheet. During a review of Resident 1's Nursing Progress Note (NPN), dated 10/8/2022 and timed at 4:47 p.m., the NPN indicated Resident 1 went OOP earlier on the morning shift (7 a.m., to 3 p.m.). At 4 p.m., the same day, the NPN indicated Resident 1's FM 2 and FM 3 came to the facility demanding Resident 1's medical records, stating they have a new Power of Attorney (POA) for Resident 1. The family member (FM 2) stated, I'm not bringing the resident (Resident 1) back to the facility. The NPN indicated the police were called and before the police arrived the family members (FM 2 and FM 3) left the facility. The NPN indicated Resident 1's listed RP 1 RP 2 were informed of the situation and RP 2 stated they were going to call the police to report the incident as a kidnapping (action of abducting someone and holding them captive). During a telephone interview on 11/14/2022 at 3:30 p.m., RP 2 stated FM 2 and FM 3, who took Resident 1 OOP on 10/8/2022, were other family members to Resident 1. RP 2 stated the facility failed to notify RP 1 and RP 2 of the other family members visiting and taking Resident 1 OOP. RP 2 stated FM 2 and 3 did not have permission to take Resident 1 out of the facility, but the facility allowed them to take the resident OOP. RP 2 stated FM 2 and 3 abducted Resident 1 on 10/8/2022 and took the resident somewhere and obtained another DPOA which indicated FM 2 and FM 3 were listed as Resident 1's responsible parties. RP 2 stated FM 2 and FM 3 returned to the facility the same day without the resident and informed the facility they now had DPOA. RP 2 stated FM 2 and FM 3 kept Resident 1 for two weeks and when they could no longer care for Resident 1, FM 2 and FM 3 took Resident 1 to the hospital. During a review of Resident 1's GACH discharge note, dated 10/29/2022, the discharge note indicated Resident 1 was admitted to the GACH on 10/22/2022 with a UTI, low levels of thyroid hormones, possibly due to not taking her medications for two weeks, increased aggressive behavior, including threats to leave and to kill herself. The GACH discharge note indicated Resident 1 was residing in a nursing home, and three weeks prior the resident's family members (FM 2 and FM 3), who states they now have the DPOA decided to take the resident out of the nursing home because they were unhappy with the care. During a review of the GACH's social worker (SW) note, dated 10/25/2022 and timed at 5:02 p.m., titled, 'Suspected Dependent Adult/Elder Abuse,' the note indicated the SW was consulted due to family concerns, as it was unclear who had DPOA of Resident 1. The note indicated FM 2 and FM 3 had a recent DPOA, dated 10/8/2022. The SW note indicated she spoke to Resident 1's RP 1 and was told he and RP 2 had DPOA of Resident 1 since 7/2/2022 and provided a verified copy of the DPOA. The SW note indicated RP 1 and RP 2 stated FM 2 and FM 3 took Resident 1 from the facility without permission and had a DPOA done that day (10/8/2022). Due to safety concerns, the SW's note indicated she contacted the facility and was informed FM 2 and FM 3 took Resident 1 OOP on 10/8/2022 and did not return the resident to the facility. The SW note indicated the facility called the police and filed a report for Resident 1's abduction (the act of taking someone away by force or cunning; kidnapping). During an interview on 11/17/2022 at 2:15 p.m., the Administrator (ADM) stated Resident 1's abduction was not recognized as a reportable event and so he did not report it to the Department. The ADM stated Resident 1 had a physician order to go OOP with RP 1 and RP 2. The ADM stated it was the first time an event of abduction has occurred in the facility. The ADM stated the resident's physician was notified and gave an order for the resident to be discharged against medical advice (AMA). The ADM stated the AMA documentation indicated Resident 1 acknowledging the discharge against medical advice and the risk and benefits were explained. The AMA documentation was not provided when requested from the ADM. During a telephone interview on 11/28/2022 at 3:05 p.m., with Resident 1's attending physician (Physician 1), Physician 1 stated the responsible party was the person listed on Resident 1's AR Face Sheet. Physician 1 stated the social worker should have investigated the family dynamics and informed him. Physician 1 stated he was not made aware Resident 1 was going OOP with a person other than a responsible person, as per his order. Physician 1 stated since the resident was not returned to the facility it was not AMA because Resident 1 was not present in the facility to explain the risk of AMA and/or sign acknowledging she (Resident 1) was informed. During a review of the facility's policy and procedure (P/P) titled, 'Leave of Absence' (LOA) dated 11/2012, the LOA policy indicated all residents leaving the premises must be signed out and signed from/to the facility and have clearance from resident's physician to go out on passes. Each resident leaving the premises must be signed out in the sign-out register-by the resident if he/she is his/her own responsible party; or responsible party/legal guardian; or those persons designated by responsible party or legal guardian. During a review of the facility's P/P titled, 'Physician's Orders, Accepting, Transcribing and Implementing,' with a revised date of 11/2012, the P/P indicated licensed nursing personnel will ensure that the physicians' telephone and verbal orders be recorded and implemented. During a review of the facility's P/P titled, 'Resident Supervision and Monitoring,' last revised in 4/2017, the P/P indicated residents were provided with intense supervision when they present with conditions that may place other residents and/or themselves at risk for harm.

Based on observation, interview, and record review, the facility failed to provide care, treatment, and services to maintain or improve the ability to perform activities of daily living ([ADLs], daily skills like eating, toileting, bed mobility, grooming, transferring, and walking), for one of 32 sampled residents (Resident 127). The facility failed to: 1. Notify Rehabilitation Services, including Physical Therapy [(PT), a profession aimed in the restoration, maintenance, and promotion of optimal physical function], Occupational Therapy [(OT), a profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)], and Speech Therapy [(ST), a profession aimed in the prevention, assessment, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Provide Rehabilitation Services intervention to maintain or improve Resident 127's ADL status after the resident's Change of Condition (COC) on 2/14/2022. 3. Follow facility's policy and procedure (P/P) titled Restorative Nursing Documentation ensuring the interdisciplinary team ([IDT] a group of health care professionals with various areas of expertise who work together toward the resident's goals) provided the appropriate treatment to maintain or improve Resident 127's abilities to perform ADLs. 4. To adhere to Resident 127's plan of care titled, ADL Self Care Performance Deficit revised on 2/15/2022, which indicated the resident had a decline in ADLs with interventions to have an occupational therapy and physical therapy evaluation and treatment (PT/OT) per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 127's assessment indicated the resident required only supervision for walking, toileting, and eating on 11/9/2021. On 2/14/2022, Resident 127 experienced a significant change of condition with eating, toileting, and walking and was not provided with rehabilitative intervention to maintain or improve abilities to perform activities of daily living as per the resident's plan of care and physician order. These deficient practices resulted in a delay in care and services for Resident 127's change of condition and a decline with the resident becoming dependent on staff and requiring extensive assistance from staff for eating, toileting, bed mobility, transfers, and walking. Findings: During a review of Resident 127's Admission Record (AR), the AR indicated the resident was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 127's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 127's Minimum Data Set (MDS), an assessment and care-screening tool, dated 11/9/2021, the MDS indicated Resident 127's cognition (thought process) was moderately impaired. The MDS indicated Resident 127 required supervision for eating, bed mobility, transfers between surfaces, and walking. During a review of the facility's census records (record of residents' hospitalization s, room changes, and payer source changes), the records indicated Resident 127 was transferred to the hospital on 12/20/2021 at 4 PM and returned to the facility the same day (12/20/2021) at 8:57 PM. During a review of Resident 127's Change of Condition Evaluation (COC Evaluation), dated 2/14/2022, the COC Evaluation indicated the resident had a decline in ADL which started on 2/14/2022. The COC Evaluation indicated Resident 127's change of condition included requiring more assistance with ADLs and decreased mobility. The COC Evaluation indicated the physician and responsible party were notified and blood tests were ordered. There was no other intervention indicated for Resident 127's decline in ADLs and decreased mobility. A review of Resident 127's quarterly Interdisciplinary Team (IDT) conference note, dated 2/9/2022 and signed on 2/14/2022, indicated the following departments attended the meeting: nursing (registered nurse/licensed vocational nurse), dietary, social worker, and the rehab department. The IDT conference note, under Evaluations/Goals section, indicated Resident 127 required assistance to complete ADLs and to continue the plan of care. There were no evaluations or goals indicated under the Rehab Services and Restorative Summary sections of the conference note. A review of Resident 127's MDS, dated [DATE], the MDS indicated Resident 127 was severely impaired for cognitive skills for daily decision-making. The MDS indicated Resident 127 required extensive assistance for eating and bed mobility. The MDS indicated transfers between surfaces and walking did not occur since the activity was not performed by the resident or staff at all over the entire seven-day evaluation period (2/7/2022-2/14/2022). During a review of Resident 127's care plan for ADL Self Care Performance Deficit, revised on 2/15/2022, the care plan indicated Resident 127 required extensive assistance with toilet use, transfers, bed mobility, personal hygiene, dressing and eating. The care plan indicated, under staff interventions, for the resident to have an occupational therapy and physical therapy evaluation and treatment (PT/OT) per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 127's Order Summary Report (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/6/2022 at 9:39 AM, during a concurrent interview and review of Resident 127's electronic health records (EHR), PT, and OT documented evaluations, the Licensed Vocational Nurse (LVN 5) stated there was no documentation in the Resident 127's EHR, PT, and OT evaluations that treatment was done before. LVN 5 stated she spoke to the Director of Rehab (DOR) on 5/6/2022 regarding the resident's order for OT/PT back on 5/25/2020 and the DOR told her Resident 127 did not require an evaluation at that time because the resident was walking. A review of Resident 127's most current MDS, dated [DATE], the MDS indicated Resident 127 had severely impaired cognitive skills for daily decision-making. The MDS indicated Resident 127 required an extensive assistance with eating and bed mobility. Resident 127's MDS indicated transfers between surfaces and walking did not occur since the activity was not performed by the resident or staff at all over the entire seven-day evaluation period (3/25/2022-3/31/2022). During a concurrent observation and interview on 5/3/2022 at 12:44 PM, while in Resident 127's room, a Certified Nursing Assistant 12 (CNA 12) was observed assisting Resident 127 with lunch. LVN 2 stated Resident 127 used to be independent with activities of daily living, but lately there has been a decrease in Resident 127's strength. LVN 2 stated Resident 127 required physical assistance to go to the restroom. During an interview on 5/5/2022 at 12:38 PM, CNA 3 stated Resident 127 did not need assistance with eating, toileting, or walking a couple of months ago. During an observation on 5/5/2022 at 12:53 PM, Resident 127 was sitting in a wheelchair with other residents watching and observing the staff. During an interview on 5/5/2022 at 12:54 PM, LVN 2 stated Resident 127 had a COC, including a decline in activities of daily living on 2/14/2022. LVN 2 stated the physician was notified, and orders were received (for laboratory blood test to be done) regarding Resident 127's change of condition. During a review of Resident 127's Order Summary Report, dated 5/6/2022, there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/6/2022 at 12:56 PM, the Physical Therapist (PT 3) confirmed receiving an order on 5/6/2022 to perform a PT evaluation for Resident 127 related to Resident 127's COC. PT 3 stated the nursing staff informed PT 3 that Resident 127 experienced a decline in mobility and gait (walking). PT 3 stated Resident 127 had not received any therapy services since Resident 127 could walk. During a concurrent review of Resident 127's COC Evaluation, dated 2/14/2022, the COC Evaluation indicated Resident 127 had a decline in ADLs. PT 3 stated PT and OT should have been ordered once a resident's COC was identified. PT 3 stated Resident 127 had a decline in function and did not know PT and OT were not notified of Resident 127's COC sooner. During an interview on 5/6/2022 at 1:40 PM, LVN 3 stated a PT evaluation was ordered on 5/6/2022, after the staff was questioned about Resident 127's decline in ADLs with a COC that was identified on 2/14/2022. During an interview on 5/6/2022 at 2:30 PM the DOR stated Resident 127 had only received speech therapy from 4/6/2022 to 4/12/2022. The DOR stated no other therapy services, such as PT and/or OT, were provided to address Resident 127's decline in ADLs in 2/2022. The DOR stated rehabilitation screenings (brief assessments of a resident's mobility and function) were completed for the residents quarterly, on admission, and when there was a COC. During an interview on 5/9/2022 at 10:44 AM, the Assistant Director of Nursing (ADON) stated a rehabilitation screening should have been completed for Resident 127's COC. The ADON stated the DOR was not notified of Resident 127's COC which should have been communicated in the electronic documentation and/or discussed at the daily meeting. The ADON stated if it was discussed with the DOR or discussed at the meeting, then there would have been a rehabilitation screening completed. During a subsequent interview on 5/9/2022 at 11:46 AM, the DOR stated nursing staff should put communication in the electronic documentation for rehabilitation services to perform evaluations. The DOR stated there was no other way to be notified of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DOR stated she reviews the electronic documentation communications about two to three times a day, looking for updates. The DOR stated she did not remember any communication regarding Resident 127's COC, because once alerted of a COC, a rehabilitation screening would be initiated to determine if therapy services are necessary. During an interview on 5/9/2022 at 2 p.m., the Director of Nursing (DON) and the DOR both agreed and stated there was a delay in initiation of therapy services for Resident 127 after the COC was identified on 2/14/2022. Both the DON and DOR stated the PT evaluation was not ordered until 5/6/2022 (3 months later). The DON stated the process with identification of COCs included the nursing staff entering the information regarding a resident's COC into the electronic record communications which would have alerted the therapy department. The DON reviewed the Resident 127's electronic record communications and did not find any information related to Resident 127's COC. The DON confirmed COCs were also supposed to be discussed during daily meeting but Resident 127's COC was not. The DOR stated Resident 127's COC was missed and somehow fell through the cracks. During a review of the facility's policy and procedure (P/P) titled, Routine Resident Care revised on 11/2012, the P/P indicated it was the responsibility of all nursing staff to maintain the care standards of the facility and assist the residents to attain or maintain their highest practicable level of functioning. During a review of the facility's P/P titled, Restorative Nursing Documentation dated 11/2017, the P/P indicated the interdisciplinary team would provide the appropriate treatment to maintain or improve the resident's abilities to perform their activities of daily living . which will not deteriorate unless the deterioration is unavoidable.

Based on observation, interview, and record review, the facility failed to ensure four of eight sampled residents (Residents 106, 55, 23, and 152) received appropriate services to prevent further a decline in range of motion ([ROM], full movement potential of a joint) and mobility by failing to: 1a. Provide passive range of motion ([PROM], movement of a joint through the ROM with no effort from resident) to Resident 106's both legs in accordance with the Physical Therapy ([PT], profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge recommendation on 1/28/2021. As a result of this failure, Resident 106 developed contractures (chronic loss of joint motion associated with deformity and joint stiffness) to both knees and both ankles, requiring a PT evaluation on 3/19/2021. Resident 106 was discharged from PT on 5/31/2021 with recommendations for both knee and both ankle splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and or increase range of motion). 1b. Provide Resident 106 with PROM to both legs to prevent further decline in range of motion from 5/31/2021 to 5/5/2022 (approximately one year). As a result of this failure, Resident 106 developed contractures to both hips and worsening contractures to both knees. 1c. Provide appropriate monitoring of Resident 106's range of motion on a quarterly basis to determine any changes in ROM in accordance with the facility's policy. These multiple failures from 1/28/2021 to 5/5/2022 resulted in Resident 106 experiencing a significant decline in range of motion to both legs, including the development of irreversible contractures (not able to be undone or altered) of both hips, knees, and ankles, and requiring an increase in care (from extensive assistance to total assistance) for activities of daily living. 2. For Resident 55, the facility failed to provide intervention to maintain the distance of 150-200 feet of ambulation (walking) after discharge from Physical Therapy on 10/13/2021. This deficient practice had the potential for Resident 55 to have a decline in functional mobility. 3. For Residents 152 and 23, the facility failed to provide appropriate monitoring of range of motion in both arms and legs on a quarterly basis to determine any changes in ROM in accordance with the facility's policy. This deficient practice had the potential for Residents 152 and 23 to experience an undetectable decline in range of motion. Findings: a. During a review of Resident 106's Admission Record (AR), the AR indicated Resident 106 was admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 106's AR indicated dated 3/19/2021 indicated the resident had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 106's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/18/2020, the MDS indicated Resident 106 was severely impaired in cognitive (ability to think, understand, learn, and remember) skills for daily decision-making. The MDS indicated Resident 106 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, was totally dependent on staff for transfers, and required extensive assistance from staff for dressing, eating, and personal hygiene. The MDS indicated Resident 106 had no functional limitations in ROM to both legs. During a review of the Physical Therapy (PT) Evaluation and Plan of Treatment, dated 12/14/2020, the PT Evaluation indicated Resident 106's prior level of function was independent with bed mobility, independent with transfers, and stand-by assist for walking 300 feet. The PT Evaluation indicated Resident 106 required, at the time of the evaluation on 12/14/2020, total assistance for bed mobility and transferring from a lying down position to a seated position. The PT Evaluation indicated the ROM in both of Resident 106's legs were within functional limits ([WFL], sufficient joint movement to functionally complete daily routines). A review of Resident 106's PT Discharge Summary, dated 1/28/2021, indicated Resident 106 required maximum assistance (required 51-75% assistance to complete the task) with a two persons physical assistance for bed mobility, total assistance for transfers, maximum assistance to maintain standing, and was unable to walk. The PT discharge summary recommendations for Resident 106 included to perform PROM exercises to both legs in all planes ([planes of motion], all the movements possible at a given joint) to maintain the current level of performance and in order to prevent decline. During a review of Resident 106's physician's orders, there were no physician's orders for Resident 106 to receive PROM to both legs as PT recommended on 1/28/2021. A review of Resident 106's MDS, dated [DATE], indicated Resident 106 required extensive assistance for bed mobility, transfers, dressing, and eating, and was totally dependent on staff for personal hygiene. The MDS indicated Resident 106 had no functional limitations in ROM to both legs. During a review of the PT Evaluation and Plan of Treatment, dated 3/19/2021, the PT Evaluation indicated Resident 106 was refer to PT for decreased ROM in both legs placing the resident at risk for contracture(s), decreased skin integrity, pressure sores (damage to skin due to prolong pressure), further decline in function and increased dependency on caregivers. The PT Evaluation indicated Resident 106 developed contractures to both knees and both ankles with an onset date of 3/19/2021. The PT Evaluation indicated Resident 106 had ROM impairments in both legs at the hip, knee, and ankle joints with the following assessments: 1. Left hip flexion (movement at hip with the leg moving upward toward the head): 10-125 (115 degrees of motion, [normal is 0-120]). 2. Left hip abduction (movement at hip with the leg moving away from midline): 0-10 degrees (10 degrees of motion, [normal is 0-45 degrees]). 3. Left knee flexion (knee bent): 30-130 degrees (100 degrees of motion, [normal is 0-135 degrees]). 4. Left ankle plantar flexion (ankle bent away from body): 20-50 degrees (30 degrees of motion, [normal is 0-45 degrees]). 5. Right hip abduction: 0-5 degrees (5 degrees of motion). 6. Right knee flexion: 20-130 degrees (110 degrees of motion). 7. Right ankle plantar flexion: 20-50 degrees (30 degrees of motion). A review of Resident 106's MDS, dated [DATE], indicated Resident 106 required extensive assistance for bed mobility, transfers, dressing and eating, and totally dependent for personal hygiene. During a review of the PT Discharge Summary, dated 5/31/2021, the PT Discharge Summary indicated Resident 106 tolerated both knee splints for four hours and both ankle splints for four (4) hours. The PT discharge recommendations included to wear both knee extension splints and both ankle splints for up to four hours to maintain joint integrity and inhibit abnormal positions. The PT Discharge Summary indicated Resident 106's ROM in both legs was as follows on 5/31/2021: 1. Left hip abduction: 0-15 degrees (15 degrees of motion). 2. Left knee flexion: 15-115 (100 degrees of motion). 3. Left ankle plantar flexion: 20-50 degrees (30 degrees of motion). 4. Right hip abduction: 0-10 degrees (10 degrees of motion). 5. Right knee flexion: 10-115 degrees (105 degrees of motion). 6. Right ankle plantar flexion: 20-50 degrees (30 degrees of motion). During a review of Resident 106's physician's order, dated 6/1/2021, the physician order indicated for the Restorative Nursing Aide ([RNA], nursing aide program that helps residents to maintain their function and joint mobility) to apply both knee extension and foot drop (ankle) splints for 4-6 hours daily, four times per week or as tolerated. Further review of Resident 106 physician's orders, dated 6/3/2021, indicated for the RNA to provide PROM exercises to Resident 106 both arms daily, four times per week and as tolerated. There were no physician's orders for Resident 106 to receive ROM exercises to both legs. During a review of Resident 106's monthly RNA documentation, from 6/2021 to 5/2022, the RNA documentation indicated an RNA provided PROM exercises to Resident 106's both arms four times per week and applied both knee extension and foot drop splints for 4-6 hours, four times per week. There was no documentation the RNA provided ROM exercises to Resident 106's legs. During a review of Resident 106's Rehab Screening records, Resident 106 received multiple Rehab Screenings on the following days: 6/13/2021, 8/3/2021, 11/3/2021, 12/28/2021, and 3/28/2022. Resident 106's Rehab Screenings did not indicate any assessment or monitoring of ROM in both arms and both legs. Each Rehab Screening for Resident 106 had identical information, which included the following: 1. Reason for screening: Quarterly review. 2. Observation/Findings: Blank. 3. Evaluations indicated: No evaluation required. 4. Comments: RNA program PROM exercises to BUE (bilateral upper extremities, both arms) daily 4x (four times) week or as tolerated. RNA to apply bilateral (both) knee extension and foot drop splints (ankle splints) 4-6 hours daily 4x week or as tolerated. A review of Resident 106's MDS, dated [DATE], the MDS indicated Resident 106 was totally dependent on staff for bed mobility, transfers, dressing, eating, and personal hygiene. The MDS indicated Resident 106 had functional range of motion impairments to both legs. During an observation on 5/4/2022, at 10:51 AM, while in Resident 106's room, the resident was observed sleeping flat in the bed with a blanket covering both legs. Certified Nursing Assistant (CNA 1) uncovered Resident 106's legs. Resident 106 was observed to have splints on to both knees and both ankles. There was a pillow observed placed between the legs. During an interview on 5/5/2022, at 9:15 AM, CNA 1 stated Resident 106 required a total assistance for care due to the inability to move both arms and legs. CNA 1 stated the contractures in both arms and legs prevented Resident 106 from moving to assist with care. During a concurrent observation and interview on 5/8/2022 at 9:36 AM while in Resident 106's room, CNA 1 stated the resident used to walk but had declined in function. CNA 1, RNA 1, and RNA 2, had to use a mechanical lift (used to transfer immobile residents) to transfer Resident 106 from the bed to a Geri-chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported). CNA 1 stated Resident 106 used to require only a two persons physical assist with a mechanical lift transfer but now required three persons. CNA 1 stated Resident 106 could only sit in a Geri-chair for safety because both hips tend to slide forward in the wheelchair. During a concurrent interview and review of Resident 106's MDS on 5/9/2022, at 10:03 AM, the MDS nurse (MDS 1) stated Resident 106 walked and did not have any impairments to both legs prior to hospitalization on [DATE] for COVID-19 ([Coronavirus-19], a new highly contagious virus that can affect lungs and airways). During an interview and record review on 5/9/2022, at 10:28 AM, the Director of Rehabilitation (DOR) and Physical Therapist 3 (PT 3) stated Resident 106 returned to the facility on [DATE] after being hospitalized for COVID-19 and received a PT Evaluation on 12/14/2020. The DOR confirmed Resident 106's ROM to both legs were within functional limits prior to discharge from PT on 1/28/2021. The DOR confirmed the PT discharge recommendations to provide ROM exercises to both legs were not done and stated, We missed it. The DOR stated Resident 106 did not receive ROM exercises to both legs from 1/28/2021 to 3/19/2021 and developed contractures to both knees and both ankles. The DOR stated Resident 106 received another PT Evaluation on 3/19/2021 due to reports from nursing of decreased ROM in both legs. During a concurrent interview and review of Resident 106's PT assessments on 5/5/2022, at 3:23 PM, the DOR and PT 1 confirmed PT 1 performed the PT Evaluation for Resident 106 on 3/19/2021 and discharged Resident 106 on 5/31/2021. PT 1 stated the application of both knee and both ankle splints were recommended to maintain ROM in Resident 106's legs. PT 1 and the DOR stated Resident 106 should have but did not receive ROM exercises to both legs from 5/31/2021 to 5/5/2022 (approximately one year). PT 1 and the DOR stated Resident 106 received quarterly Rehab Screens, but both stated these Rehab Screens did not monitor whether Resident 106's ROM was getting better or worse. PT 1 and the DOR stated the therapists relied on communication from the nursing staff to determine changes in Resident 106's ROM. During a concurrent interview and review of Resident 106's RNA documentation on 5/5/2022, at 4:24 PM, the Assistant Director of Nursing (ADON) stated the provision of ROM exercises were important to prevent contractures. The ADON reviewed Resident 106's clinical record and confirmed there was no documented evidence Resident 106 was provided with ROM exercises to both legs since 5/31/2021. During a concurrent observation and interview on 5/5/2022, at 4:34 PM, while in Resident 106's room, PT 1 stated Resident 106 developed worsening contractures to both hips and knees. PT 1 re-assessed Resident 106's ROM to both legs as followed: 1. Left hip flexion: 0-40 degrees (40 degrees of motion). 2. Left hip abduction: 0-5 degrees (5 degrees of motion). 3. Left knee flexion: 20-80 degrees (60 degrees of motion). 4. Left ankle plantar flexion: 10-50 degrees (40 degrees of motion). 5. Right hip flexion: 0-58 degrees (58 degrees of motion). 6. Right hip abduction: 0-10 degrees (10 degrees of motion). 7. Right knee flexion: 20-100 degrees (80 degrees of motion). 8. Right ankle plantar flexion: 10-40 degrees (30 degrees of motion). During a concurrent interview and review of Resident 106's MDS assessments, PT assessments, and Rehab Screenings on 5/6/2022, at 3:29 PM, the ADON, DOR, PT 1, and Director of Nursing (DON) reviewed Resident 106's MDS assessments from 5/6/2021 to 3/28/2022. The ADON, DOR, PT 1, and the DON agreed Resident 106's range of motion loss to both legs were a contributing factor to the resident's decline in function. The DOR stated Resident 106 should have, but did not, receive ROM exercises to both legs after discharge from PT on 5/31/2021. The DON stated Resident 106's ROM loss in both legs were avoidable since the resident did not receive ROM exercises and the Rehab Screens did not monitor Resident 106's ROM. A review of the facility's policy and procedure (P/P) titled, Assessment, Joint Mobility, revised on 11/2012, the P/P indicated, all residents will be assessed for joint mobility limitations upon admission and at a minimum of every three months thereafter. According to the P/P, the Physical Therapist and Licensed nurse will assess each joint for range of motion and document findings, date it; for each joint and indicate the degree of mobility. The P/P also indicated the staff should update reassessment and changes, which will show progress of lack of progress. During a concurrent interview, review of Resident 106's PT assessments, and the facility's P/P on 5/9/2022, at 2:09 PM, with the ADON, the ADON stated contractures cannot be reversed. The ADON confirmed Resident 106's ROM in both legs were within functional limits when discharged from PT on 1/28/2021. The ADON confirmed Resident 106 did not receive any ROM exercises to both legs in accordance with the PT discharge recommendation from 1/28/2021 to 3/19/2021. The ADON confirmed PT re-evaluated Resident 106 on 3/19/2021 due to the development of contractures in both knees and ankles. The ADON confirmed Resident 106 was discharged from PT on 5/31/2021 and had not received any ROM exercises to both legs from 5/31/2021 to 5/5/2022 to prevent worsening contractures. The ADON stated the facility's Rehab Screen repeated the RNA order and did not monitor the resident's ROM. The ADON stated the facility did not perform the joint mobility assessment for all residents in the facility in accordance to the policy. The ADON stated Resident 106 worsening ROM in both legs, could have been detected if the facility had monitored the resident's joints in accordance with the facility's policy. During a review of the facility's P/P titled, Contracture Management, revised on 11/2012, the P/P indicated, Residents will be assisted to maintain normal joint mobility, prevent complications associated with joint deformity and prevent worsening of existing contractures, unless the resident's cognitive, physical or medical condition is such that contracture formation of decline is unavoidable. b. During a review of Resident 55's Admission Record (AR), the AR indicated the facility readmitted Resident 55 on 7/6/2021. According to the AR, Resident 55's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 55's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 3/14/2022, the MDS indicated Resident 55 was moderately impaired for cognition (ability to think, understand, learn, and remember), had clear speech, expressed wants clearly, and understood clearly. According to the MDS, Resident 55 was required supervision for bed mobility and transfers and required limited assistance for walking. During review of Resident 55's Physical Therapy ([PT], professional aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge Summary, dated 10/13/2021, the PT Discharge Summary indicated Resident 55 walked 200 feet with contact guard assistance (occasional physical contact provided to maintain balance or stability). The PT discharge recommendations included a referral to the restorative nursing program (nursing program that uses restorative nursing aides [RNA] to help residents maintain their function and joint mobility) for ambulation (walking). A review of Resident 55's physician's orders, dated 10/13/2021, the physician orders indicated for the Restorative Nursing Aide ([RNA], nursing aide program that helps residents to maintain their function and joint mobility) to provide ambulation exercises daily four times per week or as tolerated with right hip precautions (restrictions placed on hip movement after surgery). A review of the Interdisciplinary Team (IDT) Progress Notes - Restorative Nursing (IDT RNA Progress Notes), dated 10/22/2021, indicated the Assistant Director of Nursing (ADON), the RNA (unnamed), the Director of Staff Development (DSD), and the Director of Rehabilitation (DOR) were present for the IDT meeting to discuss Resident 55's RNA services. The IDT RNA Progress Notes, dated 10/22/2021, indicated Resident 55 ambulated 50-100 feet with a front wheeled walker ([FWW], assistive device with two front wheels used for stability when walking). During a concurrent interview and review of Resident 55's PT assessments and IDT RNA Progress Notes, on 5/5/2022, at 3:23 PM, Physical Therapist 1 (PT 1) stated PT 1 usually wrote the distance for the RNA to walk with the resident to maintain the resident's functional mobility after a resident's discharge from PT services. PT 1 confirmed Resident 55 walked 150-200 feet when discharged from PT services. The ADON stated the RNAs only walked 50 feet with Resident 55 upon Resident 55's discharge from PT's services. The ADON stated this was significantly less distance than when Resident 55 was discharged from PT. During a concurrent interview and review of Resident 55's PT assessments and RNA physician's orders, on 5/9/2022, at 11:16 AM, the ADON stated Resident 55's physician's order for RNA should have included the level of assistance required for walking, the distance to walk, and the assistive device needed for walking. A review of the facility's policy and procedure (P/P) titled, Restorative Nursing Documentation, dated 11/2017, the P/P indicated the interdisciplinary team shall provide residents with the appropriate treatment, and attention to maintain or improve his/her abilities and that the resident's activities of daily living (ADL), and range of motion (ROM), will not deteriorate unless the deterioration was unavoidable. c. A review of Resident 152's AR, the AR indicated the facility readmitted Resident 152 on 7/26/2021. Resident 152's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 152's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 4/13/2022, the MDS indicated Resident 152 was severely impaired for daily decision-making, required extensive assistance for bed mobility, dressing, and eating, and was totally dependent for transfers and personal hygiene. The MDS also indicated Resident 152 had functional range of motion ([ROM], full movement potential of a joint) impairments to both arms and both legs. A review of Resident 152's physician's orders, dated 8/26/2021, the orders indicated for the Restorative Nursing Aide ([RNA], nursing aide program that helps residents to maintain their function and joint mobility) to provide both leg Passive Range of Motion ([PROM], movement of a joint through the ROM with no effort from the resident) exercises daily four times per week or as tolerated. Another physician's order for Resident 152, dated 10/19/2021, the order indicated for RNA to provide both arm Active Assistive Range of Motion ([AAROM], use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) exercises everyday four times per week. During a review of Resident 152's Rehab Screening record, dated 9/16/2021, Resident 152's Rehab Screen did not indicate any assessment or monitoring of ROM in both arms and both legs. Resident 152's Rehab Screen included the following: - Reason for screening: Quarterly review - Observation/Findings: Blank - Evaluations indicated: No evaluation required - Comments: RNA to provide both leg PROM exercises daily four times per week or as tolerated. During a review of Resident 152's Rehab Screening record, dated 12/23/2021 and 3/31/2022, Resident 152's Rehab Screen did not include any assessment or monitoring of ROM in both arms and both legs. Resident 152's Rehab Screen on 12/23/2021 included the following: - Reason for screening: Quarterly review - Observation/Findings: Blank - Evaluations indicated: No evaluation required - Comments: RNA to provide AAROM to both arms exercises everyday four times per week. RNA to provide both leg PROM exercises daily four times per week or as tolerated. During an interview and review of Resident 152's Rehab Screen records on 5/5/2022, at 3:23 PM, the Director of Rehabilitation (DOR) and Physical Therapist 1 (PT 1) stated Resident 152's Rehab Screen did not monitor whether Resident 152's ROM was getting better or worse. PT 1 and the DOR stated the therapists relied on communication from the nursing staff to determine changes in ROM. During a review of the facility's policy and procedure (P/P) titled, Assessment, Joint Mobility, revised on 11/2012, the P/P indicated, all residents will be assessed for joint mobility limitations upon admission and at a minimum of every three months thereafter. According to the P/P, the Physical Therapist and Licensed nurse will assess each joint for range of motion and document findings .For each joint and indicate the degree of mobility. The P/P also indicated the staff should date, and then update reassessment and changes, which will show progress of lack of progress. During a concurrent interview and review of Resident 152's Rehab Screen records and the facility's P/P on 5/9/2022, at 2:09 PM, the Assistant Director of Nursing (ADON) stated Resident 152's Rehab Screens did not monitor Resident 152's ROM. The ADON stated the facility did not monitor Resident 152's ROM according to their policy. d. A review of Resident 23's Admission Record (AR), the AR indicated the facility readmitted Resident 23 on 1/20/2022. According to the AR, Resident 23's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 23's Minimum Data Set (MDS), a comprehensive assessment used as a care-screening tool, dated 2/19/2022, the MDS indicated Resident 23 was severely impaired for cognition (ability to think, understand, learn, and remember) and was totally dependent for bed mobility, transfers, eating, personal hygiene, dressing, and bathing. The MDS indicated Resident 23 had functional range of motion ([ROM], full movement potential of a joint) impairments to one arm and both legs. A review of Resident 23's physician's orders, dated 1/24/2022, the orders indicated for the Restorative Nursing Aide ([RNA], nursing aide program that helps residents to maintain their function and joint mobility) to apply the left resting hand splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for 4-6 hours or as tolerated daily four times per week or as tolerated. Resident 23's physician's order, dated 4/4/2022, also included the following: - RNA to apply left knee splint and bilateral (both) PRAFO/Foot drop splints (Passive Range Ankle Foot Orthosis, material placed to foot to prevent the ankle from bending away from the body) for 4-6 hours or as tolerated every day, seven times a week or as tolerated. - RNA to provide Passive Range of Motion ([PROM], movement of a joint through the ROM with no effort from the resident) exercises to both arms daily four times per week or as tolerated. - RNA to provide PROM exercises to both legs daily four times per week or as tolerated. During a review of Resident 23's Rehab Screening record, dated 2/18/2022, Resident 23's Rehab Screen did not indicate any assessment or monitoring of ROM in both arms and both legs. Resident 23's Rehab Screen included the following: - Reason for screening: Quarterly review - Observation/Findings: Blank - Evaluations indicated: No evaluation required - Comments: RNA to provide PROM exercises to both arms and left leg daily four times per week or as tolerated. RNA to apply the left resting hand splint for 4-6 hours daily four times per week or as tolerated. RNA to apply the left knee and both foot drop (ankle) splints for 4-6 hours or as tolerated four times per week. During an interview and review of Resident 23's Rehab Screen record on 5/5/2022, at 3:23 PM, the Director of Rehabilitation (DOR) and Physical Therapist 1 (PT 1) stated Resident 23's Rehab Screen did not monitor whether Resident 23's ROM was getting better or worse. PT 1 and the DOR stated the therapists relied on communication from the nursing staff to determine changes in ROM. During a review of the facility's policy and procedure (P/P) titled, Assessment, Joint Mobility, revised on 11/2012, the P/P indicated, all residents will be assessed for joint mobility limitations upon admission and at a minimum of every three months thereafter. According to the P/P, the Physical Therapist and Licensed nurse will assess each joint for range of motion and document findings .For each joint and indicate the degree of mobility. The P/P also indicated the staff should date, and then update reassessment and changes, which will show progress of lack of progress. During a concurrent interview and review of Resident 23's Rehab Screen and the facility's P/P on 5/9/2022, at 2:09 PM, the Assistant Director of Nursing (ADON) stated Resident 23's Rehab Screen did not monitor Resident 23's ROM. The ADON stated the facility did not monitor Resident 23's ROM according to their policy.

Based on observation, interview, and record review, the facility's failed to ensure one of one sampled resident (Resident A), who had a history of a suicide attempt by wrapping a telephone cord around his neck, was provided an environment free of cords to prevent Resident A from utilizing cords as a tool to attempt suicide. The facility failed to: 1. Ensure Resident A, who had a recent suicide attempt by wrapping a telephone cord around his neck, was not left alone in a room with multiple cords accessible to the resident with the door closed. 2. Have interventions in place to address Resident A's safety monitoring and removal of objects Resident A used previously to attempt suicide, including telephone cords, call light cords, and other objects Resident A could use to harm himself. 3. Ensure the Interdisciplinary Team (IDT) assessed and monitored Resident A upon re-admission to the facility on [DATE] for the symptoms of recurrence of [CONDITION(S)], behavioral attempts, or any signs and/or symptoms of acute depression due to the history of Resident A's previous suicidal attempt (3/1/2022) by completing from PHQ9 (nine question form used to screen depression and monitor changes in signs/symptoms of depression) per the facility's policy and procedure titled Suicide Prevention. 4. Ensure Certified Nursing Assistant 1 (CNA 1), who was assigned to monitor Resident A, was informed of the resident's previous suicide attempt to ensure CNA 1 had knowledge for what behavior to monitor Resident A. 5. Develop a care plan for Resident A's past suicidal attempt with interventions to prevent any potential future attempts. This deficient practice had a high potential for Resident A to use available cords in his room as a tool to attempt suicide as he previously attempted (3/1/2022) to commit suicide by wrapping a telephone cord around his neck on. On 3/1/2022 Resident A attempted suicide by wrapping a telephone cord around his neck. On the same day, Resident A was transferred to a general acute care hospital (GACH) for evaluation and treatment, and on 3/7/2022 the resident was transferred back to the facility. On 3/20/2022, while at the facility, Resident A tested positive for COVID-19 (a highly contagious [CONDITION(S)] infection) and was relocated to a room with four beds, located on the facility's red zone (a designated area where COVID -19 positive residents were cohorted) where Resident A was the sole resident in the room. On 3/27/2022 at 4:47 p.m., Resident A was observed behind closed doors alone in a room with three unoccupied beds. On each unoccupied bed was a call light cord measuring approximately three feet in length on top of the bare mattress. On the bed directly across from Resident A, in addition to a call light cord was a telephone with an attached cord measuring approximately three feet in length at the foot of the bed. Two of three beds had cords attached to the light fixtures located behind the beds. The call light cords, telephone cords, and light fixtures cords were in full view of Resident A and accessible to him. Resident A was observed to be agitated and according to him was experiencing high levels of anxiety. On 3/27/2022 at 8:54 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called via a telephone conference in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) due to the facility's failure to ensure Resident A, who had a history of a previous suicide attempt by wrapping a telephone cord around his neck, was not left alone in a room with multiple cords accessible to him. On 3/30/2022 at 2 p.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After onsite verification of IJPR implementation through observation, interview, and record review, the ADM was notified that IJ situation was removed. The facility's IJRP included the following actions: 1. On 3/27/2022 at 8:50 p.m., the call light cords were removed from Resident A's room. 2. On 3/27/2022, at 9:10 p.m., two registered nurse supervisors (RN) assessed Resident A for the risk of suicide. 3. On 3/27/2022 a certified nursing assistant (CNA) continued to be dedicated to the red zone on all shifts. The CNA was assigned to provide care and monitor Resident A every 30 minutes while he is on isolation precautions. 4. On 3/27/2022 the Director of Staff Development (DSD) conducted an in-service to staff regarding suicide prevention and environmental hazard monitoring. This in-service will be conducted monthly for 3 months and quarterly thereafter. 5. On 3/27/2022 the DON and designee conducted an in-service regarding the facility's protocol on development of a comprehensive care plan. This in-service will be conducted for 3 monthly and quarterly thereafter. 6. On 3/27/2022 the DON updated the care plans for Resident A's history of attempted suicide indicating new nursing interventions such as every two-hour monitoring by the licensed nurses and every 30 minutes monitoring by the CNA assigned to Resident A every shift until the isolation has been completed in the red zone. Findings: During a review, Resident A's Admission Records indicated Resident A was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including COVID-19, recurrent major depressive disorder ([MDD] a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep feeling of guilt or inadequacy and suicidal thoughts), [CONDITION(S)] disorder of [CONDITION(S)] type (a combination of symptom of [CONDITION(S)] [a mental disorder often characterized by abnormal social behavior and failure to recognize what is real], a mood disorder [a health that broadly describes all types of depression]), anxiety (extreme worry or fear) and [CONDITION(S)] (difficulty sleeping and/or remaining asleep) During a review, Resident A's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/12/2022, indicated Resident A's cognitive skills for daily decision-making were moderately impaired. The MDS Mood section indicated Resident A felt bad about himself or felt as though he was a failure or that he let himself or his family down 2 to 6 days during a seven-day week. The MDS indicated Resident A required extensive one-person physical assist for bed mobility, with locomotion on and off the unit, and required extensive two plus person physical assist with transfer (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). According to the MDS Resident A had a functional limitation in range of motion ([ROM] the distance and direction a joint can move to its full potential) to one of his upper extremities. During a review, of Situation Background Assessment Recommendation (SBAR) communication form (a form of communication between members of a health care team), dated 3/1/2022, the SBAR indicated Resident A attempted to loosely wrap a telephone cord around his neck and staff immediately intercepted. Resident A was placed on one-on-one monitoring for suicidal watch/precautions and the resident's physician, psychiatrist and the social worker were notified of the incident. During a review of Physician's Order dated 3/1/2022 and timed at 7:03 p.m., the Physician's Order indicated there was an order to transfer Resident A to a GACH emergency room (ER) for behavioral management and medication review. During a review of Physician's Order dated 3/7/2022 the Physician's Order indicated Resident A was readmitted to the facility. During a review, a COVID test dated 3/20/2022, indicated Resident A tested positive for COVID-19. During a review of Interdisciplinary Team (IDT) Progress Note, dated 3/21/2022 and timed at 4:12 p.m., the IDT Progress Notes indicated Resident A was placed in the red zone. The IDT notes indicated there was no documentation to demonstrate the IDT assessed and monitored Resident A upon re-admission to the facility on [DATE] for the symptoms of recurrence of [CONDITION(S)], behavioral attempts, or any signs and/or symptoms of acute depression due to the history of Resident A's previous suicidal attempt (3/1/2022) by completing form PHQ9 (nine question form used to screen depression and monitor changes in signs/symptoms of depression) per the facility's policy and procedure titled Suicide Prevention. A review of Resident A's all care plans indicated there was no written documentation a care plan for the resident's past suicidal attempt with interventions to prevent any potential future attempts was developed. There was not documented evidence the interventions to remove all cords and other objects from Resident A's room that could be potentially used to harm himself and to frequently monitor the resident for signs and symptoms of depression and behavior of harmful activity were care planned to ensure the Resident A's safety. A review of Resident A's clinical record indicated there was no written documentation to indicate Resident A was being monitored to determine if he displayed any harmful behaviors. During an observation and concurrent interview on 3/27/2022 at 4:57 p.m., Resident A was noted to be in a four-beds room alone with the door closed. Resident A was observed in bed awake and stated he was very anxious and had asked the nurses for medication earlier and the nurses were taking a long time to give it to him. Resident A stated it was difficult for him to sleep and the medication was helping to rest his mind. During a telephone interview on 3/27/2022 at 4:21p.m., the DON stated Resident A was admitted to the facility at the end of February but was discharged about a week after admission because of a suicide attempt on 3/1/2022. The DON stated Resident A was readmitted on [DATE] and was placed in the yellow zone (an area where residents are placed for a designated time while they are monitored for COVID symptoms) where he was monitored for symptoms of COVID -19 and when the resident tested negative, he was moved to the green zone (an area where COVID-19 free residents are cared for). The DON stated Resident A was tested during their routine COVID-19 testing on 3/20/2022 and the results on 3/21/2022 indicated Resident A was positive for COVID-19 Resident A was moved to the red zone on the same day where he was the only resident. The DON stated CNA 1 was designated to the red zone and Resident A's care. The DON stated CNA 1 sat outside of Resident A's room and checked on the resident's care needs frequently. The DON stated Resident A was provided a bell to alert staff when he needed assistance. The DON stated the telephone and call lights were removed from Resident A's room and the only cord left in his room was the resident's bed control cord which was not that long. The DON stated there was a care plan developed but they did not document when Resident A was monitored. During an interview on 3/27/2022, at 4:49 p.m., and a subsequent interview on 4/6/2022 at 4:05 p.m., Registered Nurse Supervisor 1 (RN 1) stated she was doing rounds on 3/1/2022 when she heard Resident A call out for a nurse. RN 1 stated she went to Resident A's room and found him with a telephone cord wrapped one time loosely around his neck. RN 1 stated she removed the telephone cord from Resident A's neck, placed the resident on one-to-one observation (continuous observation of one resident by one nurse) and called the resident's physician (MD) who ordered Resident A's transfer to a GACH. RN 1 stated Resident A was cleared (had no [CONDITION(S)]) by the psychiatrist (a physician specializing in the diagnosis and treatment of mental illness) at the GACH prior to the resident's readmission to the facility. RN 1 reviewed Resident A's care plan and confirmed the care plan did not include interventions to monitor Resident A and remove the cords from his room. During an interview on 3/27/2022, at 5:05 p.m., and a subsequent interview on 3/30/2022 at 12:35 p.m., CNA 1 stated she usually works part-time, and this was her first time caring for Resident A. CNA 1 stated on 3/27/2022 she came to work a little late and the nurses from the previous shift were already gone so no one gave her report. CNA 1 stated she asked the CNAs, who were sitting at the nursing station, if they knew anything about Resident A. CNA 1 stated the nurses told her Resident A gets anxious, was a fall risk, and could not move his left side but they never reported he was a suicide risk. CNA 1 stated Resident A received a phone call but there was only one phone in his room connected to Bed A which was directly across from Resident A. CNA 1 stated she tried to connect the telephone to a phone port near Resident A so he could talk but the call disconnected. CNA 1 stated Resident A began to get stressed out when she told him about the person on the phone would call him back tomorrow. CNA 1 stated Resident A kept asking over and over when they were going to call back. During an interview on 3/28/2022 at 2:30 p.m., the DON and ADM stated the Resident A could not transfer himself or walk without assistance so neither of them believed the cords on the other beds were a threat. The DON stated the cords were removed from Resident A's surrounding area and his call light was replaced with a bell that he was able to ring when he needed assistance. During an observation and concurrent interview on 3/30/2022, at 11:48 a.m., the Occupational Therapist ([OT] licensed health care professionals who help people develop, recover, improve, and maintain skills need to do daily activities) stated initially when Resident A began occupational therapy the resident was dependent and could not perform many of the task, however today Resident A has made great improvements in his ability to follow direction and to complete movements. During an observation Resident A was assisted by the OT to sit on the right side of his bed and was able to scoot to the edge of the bed when the OT instructed Resident A to do so. Resident A was observed following the OT's instructions and was able to perform exercises with his right arm and right leg which had little to no functional limitation. Resident A was able to perform some of the same exercises with his left arm and leg although his left arm required more active assistance from the OT and Resident A who at times would move his left arm with his right arm. Resident A was observed kicking and moving his left leg around with little to no difficulty. The OT was observed assisting Resident A to lie down on the bed and instructed the resident to grab the handrail with his right arm to pull himself over without difficulty. The OT was observed again assisting Resident A to sit up on the right side of his bed, scoot to the edge of the bed and placing a gait belt (a device place around a resident's waist used to aid the resident in the safe movement from a sitting to standing position) around Resident A's waist. Resident A was then assisted by the OT to a standing position where he was able to stand on his own for a short time. The OT then verbally instructed Resident A and physically assisted him to sit in his wheelchair. Resident A was then provided his lunch tray and after the CNA set up the resident's tray Resident A was observed eating his meal unassisted using his right hand. During a review, a facility policy and procedure (P/P), titled Suicide Prevention and dated 11/2022, indicated the IDT will continually monitor residents for indicators of acute depression associated with suicidality and provide immediate intervention. Any resident with a history of suicidal ideation, behavioral attempts, or any signs and/or symptoms of acute depression will be monitored for the recurrence of such signs and symptoms. Residents will be assessed upon admission, quarterly, or when significant changes occur using the PHQ9. A room search will be conducted following facility room search policies, to remove potentially dangerous objects. Items such as sharps, glass, call light electrical cords, belts, shoelaces, ties, combs, portable mirrors, shaving cream, and food and beverage items may need to be removed or temporarily confiscated for the resident's safety. Other personal items may be temporarily confiscated as clinically appropriate for the resident's protections.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program by not adhering to its policy and procedure for having bimonthly pest control maintenance service to eradicate (destroy) and prevent cockroach (the presence of an unusually large number of cockroaches [roach-a small insect that can be carriers and spread infectious diseases]) rodent (mouse/rat) infestation. There were more than eight (8) live adult German cockroaches at different stages of life cycle (a small species of cockroach) throughout the facility's kitchen serving 163 residents. This deficient practice placed 163 residents at risk for serious diseases caused by contaminating human food with germs (small living things/cells, especially one which cause diseases) that cockroaches pick up in the toilets and garbage dumps, which can cause gastroenteritis (an intestinal [the intestine a long tube from the stomach to the anus] infection marked by watery diarrhea [feces or stool], stomach cramps, and nausea and vomiting (act of ejecting matter from the stomach through the mouth). This deficient practice resulted in the facility's kitchen being closed by Environmental Health Department (EHD) County Department that assesses environmental conditions and reduces exposures to health risks) on 10/14/2021 for more than ten days due to the cockroach infestation. On 10/15/2021 at 12:20 p.m., an Immediate Jeopardy (IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident), was called in the presence of the Administrator (ADM). The administrator provided an acceptable plan of action (POA) on 10/15/2021 at 4:55 p.m. to correct the deficient practice. POA included the following actions: 1. The pest control company provided the facility with interior treatment in the residents' rooms and the kitchen. A follow-up treatment was made on 10/14/2021 and 10/15/2021. Treatment will continue until no pest activities are noted. 2. The dietary service employees and the maintenance team will conduct a thorough cleaning project in the kitchen and will be followed by a pest control treatment application. This project will be completed on Sunday, 10/18/2021. 3. The facility will implement its food service contingency plan immediately. The facility will provide pre-packaged meals and drinks to all residents until the kitchen is reopened. 4. In-service training will be provided to all dietary staff members regarding the policy on kitchen sanitation. Daily cleaning schedule will be established and implemented. 5. The facility will implement its food service contingency plan. The plan will continue until the kitchen has been reinspected and reopened. The sister facility will prepare puree and mechanical diets for the residents and prepackaged food and drinks will be provided to the residents on regular diets. 6. The Dietary manager or designee will conduct daily inspections of the kitchen for two weeks and weekly inspection thereafter. 7. The Registered Dietician will conduct kitchen sanitation audits weekly for four weeks then monthly thereafter. The findings will be reported to the quality assurance (QA) committee. 8. The maintenance director or designee will conduct a daily inspection of the kitchen for two weeks and monthly thereafter. 9. The facility will continue weekly pest control treatment and frequency of the termination treatment will be reviewed per recommendations based on findings. 10. To ensure compliance, the administrator will be provided with weekly kitchen sanitation audits by the dietary manager and the maintenance director and findings will be shared during the stand up and QA meetings. On 10/24/2021 at 5:45 p.m., the IJ was removed in the presence of the ADM after the implementation of POA was verified and confirmed while onsite through observation, interview, and record review. Findings: On 10/13/2021 during an inspection and a concurrent interview of the facility's kitchen with dietary supervisor (DS) the following was observed: a. At 2:18 p.m., one (1) live adult cockroach was observed in the kitchen's dry food storage room. b. At 2:19 p.m., more than 10 rodent's droppings and wooden shavings (indicative of live rodent activity) were observed on the floor of the dry storage room. c. At 2:28 p.m., one (1) live adult cockroach was observed at the cook's preparation line table behind the bulk food storage bin. The DS confirmed the finding of one live adult cockroach, rodent's droppings, and wooden shavings. During a telephone call on 10/13/2021 at 2:45 p.m. to the Environmental Health Department (EHD) was notified of the facility's cockroach infestation in the kitchen. During an interview on 10/13/2021 at 3:09 p.m., the housekeeping supervisor stated he has seen gnats (a small two-winged fly that resembles a mosquito) and cockroaches in the facility. During a review of the Environmental Health Specialist ([REHS] a health inspector who inspects various facilities and properties to determine conformance with California Health and Safety Code and Title 8 and Title 11) report, the report indicated an inspection of the kitchen was conducted on 10/14/2021 at 9:30 a.m. from a complaint investigation the following was observed: a. Two live adult cockroaches on the floor between the cook's line and the food steam table. b. One live nymph ([baby cockroach] an immature form of an insect that does not change greatly as it grows) at the bottom of the steam table. c. Approximately 11 egg casings (a cover or shell that houses and protects multiple cockroach eggs) were at the bottom of the food steam table. d. Cockroach fecal (stool) spotting (indicative of live cockroach activity) around the electric panel and the unapproved and deteriorated piece of wood below the steam table e. Live adult cockroaches behind the electric panel of the steam table. f. Two live adult cockroaches on the floor below the dish machine. g. One live adult cockroach in the empty space between/below the drain board of the dish machine and wall. h. One live adult cockroach on the ceiling above the preparation area between the preparation sinks. i. Two live adult cockroaches on the floors below the preparation sink. A review of the EHD report, the report indicated the REHS informed the administrator on 10/14/2021 at 10:30 a.m. that the kitchen would be closed until the cockroach activity and evidence of infestation have been eliminated. During a review on 10/15/2021 of the facility's census, the census indicated there were 163 residents residing in the facility. During an observation tour with the maintenance supervisor (MS) on 10/15/2021, at 9:36 a.m., one (1) live cockroach was observed near the entrance of the kitchen and one (1) dead cockroach was observed by the dry food storage room in the kitchen. A review on 10/15/2021, of the facility's pest control service invoice, dated 10/15/021 at 11 a.m., indicated there was cockroach activity in the dishwashing area and behind the six-burner stove in the kitchen. During an interview on 10/15/2021 at 11:10 a.m., the administrator stated the facility did not have a pest control contract with an outside vendor. The administrator stated the pest control vendor was called to come to the facility for treatment once a month. During the facility's closure of the kitchen operation, the Health Facilities Inspection Division (HFID) was monitoring the facility daily from 10/16/2021 to 10/24/2021 to ensure the facility was working towards achieving overall compliance and the residents were receiving their prescribed diets and nourishments. The facility remained to be in non-compliance with cockroach activity in the kitchen as following: a. On 10/16/2021 at 9:30 a.m., one dead cockroach was observed under the three- compartment sink in the kitchen, one dead cockroach was observed under the oven in the kitchen and two dead cockroaches were observed in the dry food storage room in the kitchen. b. On 10/20/2021 at 4 p.m., one egg casing and one dead cockroach was near the walk-in cooler door in the kitchen. c. On 10/20/2021 at 4:05 p.m., one live adult cockroach inside the chemical closet and one live adult cockroach at the three-compartment sink. d. On 10/22/2021 at 3:41 p.m., one live cockroach was near the food steam table. e. On 10/23/2021 at 9 a.m., one dead cockroach was observed the mechanical dishwasher machine in the kitchen and one dead cockroach was observed under the cooking equipment. During an interview on 10/22/2021 at 3:45 p.m., the administrator and the MS stated they suspected the location of the rodent entry was from the sliding doors into the dining area, just outside of the kitchen. They stated weather strips (attachments that are added to decrease the size of the gap below the doors) were added below the doors for rodent proofing (preventing rodent entry). The MS stated the kitchen was cleaned of rodent droppings (feces). During a review of an updated article from the Los Angeles County Department of Public Health titled, Effective Management of Cockroach Infestation, the article indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. The article indicated when cockroaches come into contact with human excrement [feces or stool] in the sewer or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. http://publichealth.lacounty.gov/eh/docs/specialized/vector_management/cockroachmgmt.pdf During a review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/2019, the guidelines indicated recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). During a review of the facility's policy and procedure (P/P), titled Pest Control with a revised date of 11/2012, the P/P indicated if pests are sighted, staff should communicate with the maintenance supervisor (MS) detailing the location pests were seen, type of pests, and quantity. The MS is to relay the information to the pest control technician(s) and schedule service to mitigate the problem. The P/P also indicated the pest control vendor was contracted to complete visits consisting of observing the property grounds twice a month. The treatment should cover the interior and exterior of the facility including the patios and the kitchen, with the purpose intended to maintain a pest-free environment or mitigate the presence of any pests from the facility.

Based on interview, record review and an observation of the facility's video surveillance camera, the facility failed to provide supervision and follow a resident's plan of care, which indicated that facility staff would monitor and keep a close watch on resident every shift and ensure the resident had a wander guard bracelet (a monitoring device that can be worn around the wrist or ankle, which triggers alarms when the resident tries to leave out an alarmed door) on at all times for one of three sampled residents (Resident 1). Resident 1, who had a history of wandering, eloped (leaving without permission) from the facility and whereabouts were not located until 3/12/19, 19 days later. This deficient practice resulted in Resident 1 leaving the facility unsupervised and was picked up by emergency medical services (EMS). The EMS took Resident 1 to a general acute care hospital (GACH) emergency room (ER) where he was treated for [CONDITION(S)] (the body's response to an infection), dehydration (a condition caused by the loss of too much fluid from the body), alcohol withdrawal (a condition that occurs when alcohol was not consumed after a period of heavy drinking), [CONDITION(S)] (low blood pressure), urinary tract infection ([[CONDITION(S)]] an infection of any part of the urinary system - kidneys, ureters, bladder and urethra) and vomiting or throwing up (a forceful discharge of stomach contents). Resident 1 required treatment in the hospital for 43 days. Findings: A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included high blood pressure, [CONDITION(S)] ([DVT] a blood clot in the deep veins) and [CONDITION(S)] (a persistent feeling of sadness). A review of Resident 1's Minimum Data Set (MDS), a comprehensive resident assessment and care-screening tool, dated 2/5/2020 indicated Resident 1 had the ability to make his needs known. A review of Resident 1's history and physical (H/P), dated 5/6/19 indicated Resident 1 had the capacity to make decisions. A review of Resident 1's Wandering Risk Assessment Scale, dated 2/5/2020 indicated Resident 1 had a score of 7 (without parameters listed) and was categorized as a moderate risk for wandering. A review of Resident 1's Nursing Care Plan, with initiation date of 5/18/19 and revision date of 2/24/2020 indicated Resident 1 was at risk for wandering and had impairment with safety awareness. The facility interventions included to monitor and keep a close watch on Resident 1 every shift and to ensure Resident 1 have a wander guard bracelet on always. A review of a Wander Guard Log for the month of February 2020 indicated the staff checked and tested Resident 1's wander guard daily for placement and the ability to function. The last recorded date was 2/21/2020. A review of Resident 1's nursing progress note dated 2/22/2020 and timed at 10:57 p.m., the licensed nurse documented Resident 1 was missing. On 2/25/2020 at 1:05 p.m., during an interview, the Administrator stated Resident 1's elopement was captured on the facility's video surveillance camera. The Administrator stated Resident 1 left the facility through the front door on 2/22/2020 while the receptionist was with four visitors that had walked into the facility at the same time. On 2/25/2020 at 4:38 p.m., the surveillance video was watched with the Administrator and the Director of Nursing (DON) and revealed the following on 2/22/2020: At 2:51 p.m., Resident 1 was seen sitting in a chair in the front lobby and his wheelchair was in front of him. The facility's receptionist (Receptionist 1) was seen sitting behind the counter in the lobby. At 2:53 p.m., four visitors walked into the front lobby, three visitors were standing in front of the counter talking to Receptionist 1. Resident 1 was observed getting up, while pushing his wheelchair in front of him and walked out of the facility's front door (no alarm was heard). The video was not showing that resident 1 had the wonder guard on. On 2/25/2020 at 2:05 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she gave Resident 1 his afternoon medications at 1:30 p.m. on 2/22/2020 and later saw Resident 1 wheeling his wheelchair at about 2:20 p.m. in the hallway. On 2/25/2020 at 2:30 p.m., during an interview, Certified Nursing Assistance 1 (CNA 1) stated on 2/22/2020 at about 3;10 pm, Resident 1 was sitting on one of the couches in the dining room and she told Resident 1 to be good, so he would not fall as she was clocking out for the day. On 2/25/2020 at 4:02 p.m., during an interview, Receptionist 1 stated Resident 1 was sitting on one of the chairs in the front lobby on the afternoon of 2/22/2020. Receptionist 1 stated she did not see Resident 1 walk out of the facility because she was assisting three visitors and the front door did not alarm. On 2/26/2020 at 10 a.m., during an interview, the DON stated Resident 1 had attempted to leave the facility in the past on 5/18/2019. The DON stated Resident 1 wandered briefly outside the facility on 5/18/19 and was brought back by the staff. The DON stated a Code alert bracelet ([wander guard bracelet] used to alert the staff of a resident attempting to leave the building) was placed on the resident's left wrist after that elopement and was to alert the staff any time the resident gets close to the exit doors. DON stated that Resident 1's code alert bracelet was checked daily for placement and function and is documented in the log. Each time any resident with code alert gets close to the exit doors the alarm will peep loud and staff will respond to the alarm. On 3/12/2020 at 3 p.m., the Administrator called the Department stating Resident 1 had been located (19 days after eloping from the facility) that he was notified by the Long Beach Detective that resident 1 is currently admitted in a GACH. A review of Resident 1's GACH ER records, dated 2/25/2020 indicated Resident 1 was picked up on the street and brought to ER by Emergency Medical Services (EMS). Resident 1 presented to the ER with alcohol intoxication (drinking too much alcohol in a short amount of time, it affects the body temperature, breathing, heart rate and gag reflex [reflex action in which the muscles of the throat contract]), low blood pressure of 74/40 mg/Hg (milligram per mercury [unit of measurement]) normal reference range [NRR] is 90/60-139/79. According to the ER note, Resident 1 was tachypneic (abnormal breathing rapid and shallow), skin was mottled (patchy and irregular colors and cool to touch). According to the ER record, Resident 1 was covered in vomitus (matters that has been vomited) and had purulent (thick and yellowish in color) discharge from his eyes. The ER note indicated Resident 1 was very ill and the EMS had to give the resident intravenous ([IV] into the vein) fluid of normal saline (salt water) bolus (giving a large amount of fluid in a short time) before arriving to the ER. A review of Resident 1's GACH Discharge Summary, dated 4/8/2020 Resident 1 spent 43 days in the GACH before being transferred to a different skilled nursing facility. A review of the facility' policy and procedure (P/P) titled, Elopement Prevention with revised date of 11/2012 indicated the facility would provide a safe and secure environment and ensure the safety of any resident attempting to elope from the facility. A review of facility's P/P titled, Resident Supervision and Monitoring, with revised date of 4/2017 indicated the facility would provide residents with intense supervision when they present with conditions that may place other residents and or themselves at risk for harm.

Based on interview, and record review, the facility failed to follow its policy regarding restraints and abuse to ensure one of three residents, (Resident 1) was not restrained for convenience and was free from abuse. Resident 1 was found restrained in bed and soiled with feces (bowel movement) and urine. This deficient practice violated Resident 1's rights and resulted in disrespect, neglect, and abuse. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/1/17, indicated Resident 1 had cognitive (thought process) problems, impaired decision-making, and was unable to make needs known and unable to understand others. According to the MDS, the resident was assessed as being totally dependent with bed mobility, transferring, locomotion on and off the unit, totally dependent with eating and personal hygiene. A review of Resident 1's care plan initiated on 10/10/16, identified a problem with [DIAGNOSES REDACTED] with [DIAGNOSES REDACTED] (inability to perform purposive actions, as a result of brain damage), advanced dementia, impaired language fluency, and severe cognitive impairment. The goal indicated that the resident would be able to make basic needs known on a daily basis through the review date. The staff interventions were to encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express. Ensure to provide a safe environment, call light in reach, bed in lowest position, and wheels locked. Avoid isolation. Monitor and document for physical, nonverbal indicators of discomfort or distress, and follow up as needed. A review of a Licensed Nurses progress note, dated 12/21/17 and timed at 6:47 a.m., indicated at 12:30 a.m., on 12/21/17 a Certified Nursing Assistant 1 (CNA 1) observed the resident (Resident 1) with the sheet tied onto the mattress side belts on both sides of the mattress across the resident's upper chest. According to the Licensed nurse's progress note, the sheet was untied immediately, skin assessment completed with no redness, discoloration, swelling or [MEDICAL CONDITION] observed noted. The resident had no pain or discomfort noted. No facial grimacing, moaning, or restlessness noted. Resident asleep most of the night. Informed physician. A review of physicians' orders indicated Resident 1 had no order to be physically restrained. A review of a Police Report dated 12/22/17 and timed at 1:47 p.m., indicated a battery (the act of intentionally placing a person in apprehension of a harmful or offensive contact) allegation was reported by Resident 1's family member (FM 1) regarding abuse related to Resident 1 being tied to the bed in facility. During an interview on 12/29/17 at 5:16 a.m., CNA 1 stated, A red blanket was spread neatly on top of the resident (Resident 1) and I pulled it back to check his diaper. I saw a white sheet tied in knots onto the handles of the resident' mattress. The charge nurse (LVN 1) was right behind me and saw the sheet tied onto the mattress too. We immediately untied the sheet. I felt so bad for the resident being tied down because he cannot speak for himself. He was soaked with urine and feces when I removed the sheet. I do not know who the assigned CNA was on the shift before mine. On 12/29/17 at 12:25 p.m., during a telephone interview FM 1 stated while crying, I was told he (Resident 1) constantly moves and he (Resident 1) was tied down to keep the sheet in place, he cannot move his arms or press the call light for help. He does not speak and he keeps his hands clinched at all times. They did not contact the police, I did. I do not think having him tied down will stop him from moving, he cannot walk or yell for help at all. During a telephone interview on 1/3/18 at 10:04 a.m., Licensed Vocational Nurse 1 (LVN 1) stated, The CNA (CNA 1) called me to the resident's room, and I saw the sheet tied in knots on the side of the mattress to the handles. I immediately told her to untie the knots because it is a restraint. The resident was assessed and I did not see any injuries, and he was not in pain or distress. During an interview on 1/3/18 at 4:42 p.m., CNA 2 stated, The resident (Resident 1) stays in bed, and he kicks his legs constantly, but I did not tie a sheet on him. I changed his gown and brief after a bowel movement. A review of the facility's policy titled, Restraints dated 11/28/17, indicated it was the policy of the facility that patients are assessed prior to application of restrictive devices to determine medical symptoms that may require the use of a restraint, to determine how the use of restraints would treat the medical symptom, protect the patient's safety, and assist the patient in attaining or maintaining highest practicable level of physical and psychosocial well-being. If considering initiating a restraint, attempt alternative methods prior to restraining devices and document effectiveness. Obtain patient and/or family signature on the consent form, consent of physical restraint use. A review of the facility's policy titled, Abuse prevention and prohibition program revised 4/2017 indicated to ensure that residents' rights are protected by providing a method for the prevention of any type of abuse. Abuse, neglect, exploitation, of residents and property, abandonment, isolation, financial abuse, will not be tolerated in this facility at any time. It is presumed that instances of abuse for all residents, even those in a coma, cause physical harm, pain, or mental anguish.

Based on observation, interview, and record review, the facility failed to follow infection control standards for indwelling catheter care, develop and implement a indwelling catheter care policy, develop and implement a care plan for the care of indwelling catheters and to provide and ensure the necessary care and services of the use of indwelling catheters (tube which is inserted into the bladder and left in place to drain urine) for one of five sampled residents (Resident 1). This deficient practice resulted in Resident 1 having a urinary tract infection ([MEDICAL CONDITION] an infection of any part of the urinary system),[MEDICAL CONDITION] (a severe infection of the body), requiring a blood transfusion and a transfer to a General Acute Care Hospital (GACH) for five days for further evaluation and treatment. Findings: A review of Resident 1's Admission Record, indicated the resident was initially admitted to the facility on (MONTH) 14, 2013 and was last readmitted on (MONTH) 17, (YEAR). The resident's [DIAGNOSES REDACTED]. or hear things that are not there). A review of Resident 1's History and Physical, dated (MONTH) 30, (YEAR), indicated the resident did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated (MONTH) 23, (YEAR), indicated the resident had moderate problems with memory and cognition (thought process). The MDS indicated Resident 1 had difficulty focusing attention and had behavioral symptoms not directed towards others on a daily basis. According to the MDS, Resident 1 always had urine and bowel incontinence. A review of Resident 1's Nurse's Progress Note, dated (MONTH) 29, (YEAR) and timed at 10 a.m., indicated the Resident had blood in the catheter urine. On (MONTH) 29, (YEAR) at 11:10 a.m., during a concurrent observation and interview, Resident 1 was observed positioned on the back (supine position) in bed. Red urine with sediment (small particles present in urine) was observed in the resident's indwelling catheter bag and tubing. The tubing was unanchored (without a clamp to prevent injury and allow proper urine flow) and unsecured (without a securement device that keeps the catheter securely in place) and under the resident's feet. The Assistant Director of Nursing (ADON) moved the tubing and stated that the tubing was now draining the urine into the bag. The ADON stated that when the tubing was under the resident's feet, it could not flow and that could cause urine backflow that could lead to a UTI. On (MONTH) 29, (YEAR) at 12 p.m., during a concurrent observation and interview, Resident 1's indwelling catheter bag was observed unsecured and unanchored and on the floor near the bed. Licensed Vocational Nurse (LVN 1) stated the bag should not be on the floor because it could cause a UTI. The LVN stated the catheter should be secured to the resident and if left unsecured, it could cause the resident pain, bleeding, and it could dislodge. A review of Resident 1's Physician orders, dated (MONTH) 29, (YEAR), indicated an order for [REDACTED].>On (MONTH) 6, (YEAR) at 8:30 a.m., during a concurrent observation and interview, Resident 1 was observed in bed, the resident's indwelling catheter bag was observed on the floor and the tubing was unanchored and unsecured. The resident's indwelling catheter bag was observed on the floor. LVN 2 stated the resident's indwelling catheter bag was on the floor and to prevent infection, the catheter bag should be kept off of the floor. The LVN stated that the catheter tubing was not positioned to properly flow and should be secured to the resident. A review of Resident 1's (MONTH) Treatment Administration Record (TAR) indicated there was no documentation of indwelling catheter monitoring or catheter care provided to the resident on (MONTH) 1, (YEAR) (day shift), (MONTH) 6, (YEAR) (evening shift) and (MONTH) 7, (YEAR) (evening shift). A review of Resident 1's Nurse's Progress Note, dated (MONTH) 10, (YEAR) and timed at 3 p.m., indicated the Resident had blood and sediment (solid matter in the urine) in the urine and complained of pain. The note indicated the resident sometimes pulled at the indwelling catheter and had been instructed several times not to pull on or tug on the indwelling catheter. A review of Resident 1's Nurse's Progress Note, dated (MONTH) 10, (YEAR) and timed at 7:52 p.m., indicated the resident had had an indwelling catheter with yellow, clear urine. A review of Resident 1's Nurse's Progress Note, dated (MONTH) 11, (YEAR) and timed at 12:20 a.m., indicated the resident had some blood and sediments in the urine. A review of Resident 1's Nurse's Progress Note, dated (MONTH) 12, (YEAR) and timed at 6:11 p.m., indicated the resident continued to have blood and sediments in the urine. The note indicated the resident had facial grimacing and moaning and was administered pain medication. A review of Resident 1's Nurse's Progress Note, dated (MONTH) 12, (YEAR) and timed at 6:11 p.m., indicated the resident was started on antibiotics due to abnormal urine lab results. A review of Resident 1's Nurse's Progress Note, dated (MONTH) 30, (YEAR) and timed at 3:35 p.m., indicated the resident was being monitored for a positive urine culture (lab test that checks for the growth of bacteria in the urine) and had cloudy, amber colored urine. A review of Resident 1's Nurse's Progress Note, dated (MONTH) 5, (YEAR) and timed at 9:01 a.m., indicated the resident had an elevated body temperature of 104.4 Fahrenheit (F) (Normal Reference Range (NRR) is 97-99 F) and a pulse of 117 (NRR 60-100). A review of Resident 1's Nurse's Progress Note, dated (MONTH) 5, (YEAR) and timed at 3:14 p.m., indicated the resident was transferred via ambulance to a GACH for further evaluation of the resident's elevated temperature. A review of the GACH medical records indicated the following: 1. The GACH problem list indicated Resident 1 was admitted on (MONTH) 5, (YEAR). The Resident was diagnosed with [REDACTED]. 2. The GACH labs and imaging notes dated (MONTH) 5, (YEAR) indicated Resident 1's White Blood Cells (WBC) were elevated at 16.40 (NRR 3.8-10.8) and the resident's hemoglobin was identified low at 8.2 (NRR 12-16 female, 13.5-18 male). The resident's urinalysis lab results indicated the following results: yellow hazy urine, with trace amounts of blood, 3+ Leukocyte Esterase (indicative of presence of white blood cells), WBC 6-15 and bacteria 1-9. 3. The GACH recent medication administrations dated (MONTH) 5, (YEAR), indicated Resident 1 was treated for [REDACTED]. 4. The GACH physician order [REDACTED]. A review of Resident 1's Nurse's Progress Notes, dated (MONTH) 10, (YEAR) and timed at 10:16 p.m., indicated the resident was readmitted to the facility from the GACH. On (MONTH) 18, (YEAR) at 8:45 a.m., during an observation in the presence of CNA 1, Resident 1 was observed positioned on the back with knees bent and facing the left side. The resident's catheter tubing was unsecured, unanchored and under the resident's left leg. On (MONTH) 18, (YEAR) at 9:08 a.m., during an interview, LVN 3 was unsure if Resident 1 had any wounds, pressure sores, tubing or lines. The LVN stated it was her first week working with Resident 1. According to the LVN, during nurse report, the previous LVN only stated that the residents were okay did not provide report on any wounds, lines or tubing. On (MONTH) 18, (YEAR) at 11:30 a.m., during a wound care observation in the presence of LVN 4 and RN 2, Resident 1 was observed in bed. The resident's catheter tubing was unsecured, unanchored and looped around the resident's left foot. LVN 4 lifted Resident 1's foot and removed the catheter tubing. The Medical Records Director (MRD) and the DON were unable to locate any current or previous care plans for Resident 1's indwelling catheter. The DON was asked for a policy and procedure for indwelling catheter care, but was unable to locate one. A review of the facility's policy and procedure titled, Female Catheterization, revised (MONTH) 2012, indicated the catheter would be secured to the resident with a leg band and the catheter tubing would be secured to the bed sheet with a clip. A review of the facility's policy and procedure titled, Baseline and Comprehensive Care Plans, revised (MONTH) (YEAR), indicated a comprehensive person centered care plan, based on physician and admission orders [REDACTED]. According to the policy, the care plan would describe the services that were to be furnished to maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to follow its infection control policy in providing wound care, develop and implement a policy on the care of wounds and to provide treatment and services as prescribed by the physician to prevent further development of wounds and pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) for one of five of sampled residents (Resident 1). These deficient practices resulted in Resident 1 developing an unstageable pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), 25 wounds and being recommended for a left leg amputation. Findings: A review of Resident 1's Admission Record, indicated the resident was initially admitted to the facility on (MONTH) 14, 2013 and was last readmitted on (MONTH) 17, (YEAR). The resident's [DIAGNOSES REDACTED]. not there). A review of Resident 1's History and Physical, dated (MONTH) 30, (YEAR), indicated the resident did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated (MONTH) 23, (YEAR), indicated the resident had moderate problems with memory and cognition (thought process). The MDS indicated Resident 1 had difficulty focusing attention and had behavioral symptoms not directed towards others daily. According to the MDS, Resident 1 required an extensive two person physical assist with bed mobility. A review of Resident 1's Care Plan, dated (MONTH) 18, (YEAR), indicated the following: 1. Resident 1 had potential for alteration in comfort due to pain and would verbalize adequate relief of pain. The staff's interventions included administering [MEDICATION NAME] (strong narcotic pain medication) half an hour before treatments or care and monitoring the resident for any non-verbal signs of pain. 2. Resident 1 had impaired behavior manifested by screaming, yelling, spitting, scratching, hitting staff, resistance to care and agitation. The care plan indicated the resident would allow staff assistance without aggressive behavior, and would cooperate with caregivers. Interventions included administering medication as ordered. A review of Resident 1's Care Plan, dated (MONTH) 20, (YEAR), indicated the resident had right and left heel blanchable redness (redness that disappears when pressed) and would be compliant with the treatment plan as well as show signs of healing. The staff's interventions included elevating the resident's heels. A review of Resident 1's Physician order, dated (MONTH) 17, (YEAR), indicated an order for [REDACTED]. On (MONTH) 29, (YEAR) at 11:10 a.m., during a concurrent observation and interview, Resident 1 was observed positioned on the back and in bed. The resident's heels were in direct contact with the mattress. A review of Resident 1's laboratory (lab) results, dated (MONTH) 5, (YEAR), indicated the resident had a low [MEDICATION NAME] (a protein found in the blood) level of 2.6 (NRR 3.5-5.7) and a low pre [MEDICATION NAME] level of 14 (NRR 17-34). The lab results indicated no new orders from the physician. A review of an online article titled, NPUAP Pressure Injury Stages, by The National Pressure Ulcer Advisory Panel - NPUAP, dated 8/28/12, indicated the importance of maintaining nutrition, especially protein levels in the prevention of pressure ulcers development. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ A review of Resident 1's Nurse's Progress Note, dated (MONTH) 12, (YEAR) and timed at 2 p.m., indicated the resident was being monitored for left inner heel and mid foot blanchable redness and had a purple discoloration to the left heel. A review of Resident 1's Wound Consult notes, dated (MONTH) 2, (YEAR), indicated the resident had the following wounds and would require continued offloading (elevating the heels to relieve pressure and prevent pressure ulcer development or worsening) and turning: 1. Left heel pressure injury measuring three centimeters (cm) in length, three cm in width. The note indicated the wound was 100% eschar (dead tissue, usually brown or black in color) and had increased in size. 2. Left foot pressure injury measuring one cm in length, 1.6 cm in width. The note indicated the wound was 100% necrotic (dead) tissue. 3. Right heel pressure injury measuring 1 cm in length, 0.9 cm in width. The note indicated the wound was 100% necrotic (dead) tissue. A review of Resident 1's Wound Consult note, dated (MONTH) 23, (YEAR), indicated the resident had the following wounds and would require continued offloading and turning: 1. Left heel pressure injury measuring 3.8 centimeters (cm) in length, 4.4 cm in width. The note indicated the wound was 100% eschar (dead tissue, usually brown or black in color) and had increased in size. 2. Left lateral foot pressure injury measuring 1.7 cm in length, two cm in width. The note indicated the wound was 100% eschar tissue. 3. Right heel pressure injury measuring 4.7 cm in length, 3.7 cm in width. The note indicated the wound was 100% necrotic (dead) tissue and had increased in size. 4. Right lateral malleolus (outer ankle area) pressure injury measuring two cm in length, 2.5 cm in width. The note indicated the wound was 100% necrotic (dead) tissue and had increased in size. 5. Left lateral malleolus (outer ankle area) pressure injury measuring 2.1 cm in length, two cm in width and .1 cm in depth. The note indicated the wound was 100% eschar tissue. 6. Left lateral shin pressure injury measuring 5.8 cm in length, 2.5 cm in width. The note indicated the wound was 100% necrotic (dead) tissue. 7. Right medial foot pressure injury measuring four cm in length, 3.1 cm in width. The note indicated the wound was 100% necrotic (dead) tissue and had increased in size. 8. Right lateral malleolus (inner ankle area) pressure injury measuring 2.4 cm in length, 1.8 cm in width. The note indicated the wound was 100% necrotic (dead) tissue. A review of Resident 1's wound assessment, dated (MONTH) 11, (YEAR), indicated the resident had a left lateral calf arterial wound measuring 13.6 cm in length and 3.4 cm in width. The note indicated the resident's wounds had been reclassified from pressure ulcers to vascular wounds. A review of Resident 1's (MONTH) Treatment Administration Record (TAR) indicated the following: 1. Resident 1 refused wound care treatment for [REDACTED]. 2. There was no documentation of Resident 1's wound care provided on (MONTH) 1, (YEAR) for the following sites: right lateral malleolus, left lateral malleolus, right medial first metatarsal, right medial mid foot, right medial malleolus, left outer mid foot and the left heel. 3. Resident 1 refused wound care on (MONTH) 13, (YEAR) for the following sites: right heel, right malleolus, right lateral foot, left outer mid foot and the left heel. 4. There was no documentation of wound care provided on (MONTH) 26, (YEAR) for the following sites: right first metatarsal and right medial malleolus. 5. There was no documentation of wound care provided to Resident 1's right medial mid foot from (MONTH) 14-29, (YEAR). 6. There was no documentation of wound care for Resident 1's Moisture Associated Skin Damage ((MASD) damage that occurs when the skin is exposed to moisture for extended periods of time) of the coccyx provided on (MONTH) 1, (YEAR) (day shift), (MONTH) 6, (YEAR) (evening shift) and (MONTH) 7, (YEAR) (evening shift). A review of Resident 1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of Resident 1's Nurse's Progress Note, dated (MONTH) 23, (YEAR) and timed at 7:23 p.m., indicated the resident was on monitoring for redness to the left lower leg. A review of Resident 1's Nurse's Progress Note, dated (MONTH) 5, (YEAR) and timed at 9:01 a.m., indicated the resident had an elevated temperature of 104.4 Fahrenheit (F) (Normal Reference Range (NRR) is 97-99F) and an elevated pulse of 117 (NRR 60-100). A review of Resident 1's Nurse's Progress Note, dated (MONTH) 5, (YEAR) and timed at 3:14 p.m., indicated the resident was transferred to a General Acute Care Hospital (GACH) for further evaluation of the resident's elevated temperature. A review of the GACH medical records indicated the following: 1. The GACH problem list indicated Resident 1 was admitted on (MONTH) 5, (YEAR). 2. The GACH history and physical dated (MONTH) 7, (YEAR), indicated the resident had a contracture (a permanent shortening of a muscle or joint) of the right knee, a pressure sore (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on the sacrum (tailbone) and gangrenous wounds (dead body tissue caused by either a lack of blood flow or a serious bacterial infection) on the left and right lower extremities. The physician recommended an above the knee amputation of the left lower extremity. 3. The GACH physician order [REDACTED]. A review of a physician order, dated (MONTH) 11, (YEAR), indicated an order for [REDACTED]. A review of Resident 1's skin/wound note, dated (MONTH) 11, (YEAR) and timed 7:12 p.m., indicated the resident's legs were cool to touch, swollen and did not have pedal (foot) pulses. The note indicated the resident had the following wounds: 1. Left lower leg vascular wound measuring 14.5 cm in length, four cm in width with 100% dry eschar. 2. Left outer malleolus vascular wound measuring 3.5 cm in length, three cm in width with 100% dry eschar. 3. Left lateral mid foot vascular wound measuring two cm in length, two cm in width. The note indicated the wound was intact with dark purplish discoloration. 4. Left fifth metatarsal (toe) head vascular wound measuring one cm in length, two cm in width with 100% dry eschar. 5. Left heel vascular wound measuring seven cm in length, eight cm in width and .1 cm in depth with 100% eschar tissue. 6. Left dorsal aspect of foot vascular wound measuring four cm in length, five cm in width with 100% dry eschar. 7. Left inner ankle vascular wound measuring two cm in length, 2.5 cm in width with 100% dry eschar. 8. Left inner lower leg vascular wound measuring seven cm in length, three cm in width with intact purplish discoloration. 9. Right anterior ankle vascular wound with intact blood blister measuring three cm in length, one cm in width with 100% dry eschar. 10. Right dorsal mid foot vascular wound with intact blood blister measuring 1.5 cm in length, 1.5 cm. 11. Right fifth metatarsal vascular wound measuring three cm in length, three cm in width with intact dark purple discoloration. 12. Right heel vascular wound with dark purple discoloration. 13. Sacrum unstageable wound measuring three cm in length, three cm in width and 80% yellow slough and 20% reddish pink tissue. 14. Right outer back unstageable wound measuring five cm in length, four cm in width with purplish discoloration. 15. Left outer back partial thickness skin loss measuring 0.8 cm length and 0.8 cm width. 16. Right outer ear unstageable wound measuring 1.5 cm length and 1 cm in width 50% slough, 30% pink and 20% dark red tissue. 17. Right first metatarsal head vascular wound measuring 3.5 cm in length, 3.5 cm in width with 100% dry eschar. 18. Right inner foot Site 1 (proximal to heel) vascular wound with 100% dry eschar. 19. Right inner foot Site 2 (distal to heel) vascular wound with 100% dry eschar. 20. Right inner ankle vascular wound with 100% dry eschar. 21. Right outer ankle vascular wound measuring 3.5 cm in length, three cm in width with 20% yellow, 20%dark red, 20% red and 40% dry eschar tissue. A review of Resident 1's (MONTH) (YEAR) TAR indicated the following: 1. There was documentation on (MONTH) 12, (YEAR) that the resident refused treatment for [REDACTED]. 2. There was no documentation of Santyl ointment being applied to Resident 1's sacrum unstageable wound, as prescribed by the physician. A review of Resident 1's (MONTH) MAR indicated [REDACTED]. The resident received [MEDICATION NAME] (a medication used to treat anxiety) 0.5 mg via gastric (stomach) tube once on (MONTH) 22, (YEAR) at 9:06 a.m. On (MONTH) 18, (YEAR) at 8:45 a.m., during an observation and concurrent interview Certified Nursing Assistant (CNA 1), Resident 1 was observed positioned on the back with knees bent and facing the left side. The resident's feet and heels were resting on top of the mattress. CNA 1 stated the Resident 1 could not move her legs and required repositioning every two hours. CNA 1 stated Resident 1 was currently positioned on the left side and had been on that side since she came in around 6:30 a.m. CNA 1 stated the resident had not been turned. On (MONTH) 18, (YEAR) at 9:08 a.m., during an interview, Licensed Vocational Nurse (LVN 3) was unsure if Resident 1 had any wounds, pressure sores, and/or tubing or lines. LVN 3 stated it was her first week working with Resident 1. According LVN 3, during her report, the previous LVN only stated that Resident 1 was okay did not provide report regarding wounds, lines or tubing. On (MONTH) 18, (YEAR) at 9:15 a.m., during an observation in the presence of RN 2, Resident 1 was observed positioned on the back with knees bent and facing the left side. A dried scab was observed on the resident's right ear with a misplaced wound dressing and stuck to Resident 1's matted hair (hair tangled into a thick and dense mass). On (MONTH) 18, (YEAR) at 11:13 a.m., during an interview, LVN 4 stated Resident 1 had already been given pain medication and was ready for wound care. LVN 4 stated the resident had vascular wounds, which were wounds not located on a bony prominence. LVN 4 stated Resident 1 had vascular wounds on the heels and the resident's heels required offloading to prevent the wounds from worsening. LVN 4 stated the heel of the foot was a bony prominence. LVN 4 was unsure of the difference between vascular wounds and pressure ulcers located on the heel. LVN 4 stated that he was not the usual treatment nurse and was still learning. On (MONTH) 18, (YEAR) at 11:30 a.m., during a concurrent observation and interview, LVN 4 stated Resident 1's treatment order for the unstageable pressure ulcer on the sacrum included applying Santyl ointment. LVN 4 stated there was no Santyl ointment currently available for Resident 1 and an order would need to be placed with the pharmacy. LVN 4 stated he would just apply a dry gauze Resident 1's sacrum pressure ulcer until the order for Santyl was received. The following was observed during the wound care in the presence of LVN 4 and RN 2: 1. Resident 1 was observed in bed positioned on the back with the heels on top of the mattress. 2. During the left leg dressing change, LVN 4 failed to change gloves or perform hand hygiene after removing the dirty dressing and cleaning the wound. 3. LVN 4 did not remove change gloves or perform hand hygiene after completing wound care for one site and moving to the next wound site. 4. The wounds located on Resident 1's left leg were all covered with 100% black brown eschar. 5. After completion of treatment for [REDACTED]. LVN 4 asked the resident if it was okay to continue. The resident was quiet and did not respond. RN 2 attempted to reposition the resident and the resident yelled out and attempted to spit at and hit the staff. 6. LVN 4 stated the resident was refusing treatment and they would not be able to continue any further. The LVN completed wound care treatment for [REDACTED]. The resident's other wounds were not treated. 7. A review of the (MONTH) MAR indicated [REDACTED]. The DON was asked for a non-pressure ulcer wound care policy procedure, but was unable to locate one. A review of the facility's policy and procedure, titled Pressure Ulcer Risk Assessment, revised (MONTH) 2012 indicated pressure sores were made worse by continual pressure on the site and if not treated when discovered, pressure sores could quickly get larger and very painful for residents. A review of the facility's policy and procedure, titled Non Sterile Dressings, revised (MONTH) 2012 indicated after removing the old dressing and observing the wound, staff was to remove used gloves and wash hands thoroughly. All dressing were to be opened and cleaning solutions prepared as ordered. Gloves were to be applied and the wound cleaned. Gloves were to then be discarded and a new pair of gloves applied. Ointments and dressings were to be applied as ordered.

Based on observation, interview, and record review, the facility failed to follow its policy and ensure the environment was free of accident hazards and residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1). Resident 1 was receiving narcotic (any of a class of substances that [MEDICATION NAME] the senses) while being allowed to go out of pass daily and consume alcohol while receiving narcotic pain medication (crossed referenced to F757). These failures resulted in Resident 1 leaving the facility daily unsupervised after the staff were aware the resident was consuming alcohol, in addition to receiving narcotic pain medication which resulted in falls, sustaining injuries, that required transfers to the general acute care hospital (GACH). The facility's failure of not providing supervision had the potential to result in more injuries and possibly death to Resident 1. On 1/31/18 at 4:41 p.m., an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared under F757 and F689. The facility's Administrator and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 2/2/18 at 12:14 p.m., the IJ was lifted after the team confirmed that the facility's POA was implemented. The Administrator was informed of the removal of the IJ. The facility submitted a Plan of Action (POA) for the correction of the IJ which included the following: 1. An order was written on 2/1/18 to discontinue the out on pass order for Resident 1. In addition, the physician gave an order to [MEDICATION NAME](sedative to treat [MEDICAL CONDITION]) and [MEDICATION NAME] (Narcotic to treat moderate to severe pain) for 24 hours for any suspicion of intoxication or drug use. 2. An order was obtained for Resident 1 to be discharged to a lower level of care and sober living options were to be researched and presented to Resident 1. 3. On 2/1/18, an interdisciplinary meeting was conducted, including the attending physician, with Resident 1. The physician's new orders were discussed, as well as the resident's behavior toward the staff. Resident 1 agreed with the orders and to treat the staff with respect. 4. The Director of Nursing (DON) initiated in-services on 1/31/18, to Licensed Nurses on evaluation regarding residents returning from out on pass for signs of intoxication. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 11/15/17 indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was interviewable (8-15= interviewable). According to the MDS, the resident was assessed as requiring no help or staff oversight at any time with bed mobility, transferring, locomotion on and off the unit, as well as no help or oversight from staff with eating or with personal hygiene. A review of a physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. 1.[MEDICATION NAME](([MEDICATION NAME]) a sedative, used to treat [MEDICAL CONDITION] (sleeplessness)) five (5) (mg) give one tablet by mouth as needed for sleeplessness at bedtime. 2. [MEDICATION NAME] (([MEDICATION NAME]) a medication used to treat anxiety) one (1) mg by mouth every eight (8) hours as needed for anxiety and restlessness. 3. [MEDICATION NAME] tablet give one tablet by mouth every 8 hours as needed for pain. A review of Resident 1's care plan initiated on 12/14/17 identified a problem with the resident Exhibiting Unusual Behavior. Smells of alcohol after going out on pass. He (Resident 1) comes and goes as he chooses, does not sign out when he leaves the facility. He goes to the liquor store and brings back a paper bag. The goal indicated that the resident will behave or comply in a manner that was within the policy and procedure of the facility upon next review date of 3/15/18. The staff's interventions were to continue to educate the resident on the risks of going outside and getting drunk. Explain risks of consuming alcohol that can cause changes in loss of consciousness, falls, behavior, aggressiveness, and intervene accordingly. Remind him to inform staff of what items he brings in to the facility, for prompt follow through. A care plan initiated on 12/14/17 for an Unwitnessed Fall, indicated the resident was found sitting on the floor next to the bed without injuries related to alcohol consumption, two bottles of vodka was found in the resident's room. Resident 1's goal was to resume usual activities without further incident through the review date of 3/15/18. The staff's interventions were to monitor, document, report as needed to the primary physician for signs and symptoms of pain, bruises, change in mental status, new onset confusion, sleeplessness, inability to maintain posture and agitation. A review of Resident 1's care plan, initiated 12/14/17 identified a black box warning for the use of [MEDICATION NAME]. The goal was the resident will not experience interactions or side effect from the use of [MEDICATION NAME]. A review of the controlled narcotic record, dated 12/23/17 and timed at 4:30 p.m., indicated Resident 1 was administered [MEDICATION NAME] 10-325 milligrams (mg). A review of the Medication Administration Record [REDACTED]. A review of the MAR, for the month of 12/2017, dated 12/23/17 and timed at 8 p.m., indicated Resident 1 was administered [MEDICATION NAME] 1 mg. A review of the nurses' progress note, dated 12/23/17 and timed at 9:05 p.m., an hour after receiving the second [MEDICATION NAME] 1 mg, indicated a Certified Nursing Assistant (CNA) reported that Resident 1 appeared intoxicated. The CNA stated the resident was accusing nurses of not giving him his sleeping medication. Resident 1 was verbally threatening the staff and physically throwing items around in his room. A review of the controlled narcotic record, dated 1/3/18 and timed at 7 a.m. indicated Resident 1 was administered [MEDICATION NAME] 10-325 mg and two hours later received [MEDICATION NAME] 1 mg at 9 a.m. A review of the Social Service note, dated 1/3/18 and timed at 11:09 a.m. indicated Resident 1 appeared intoxicated. A review of the nurses' progress note, dated 1/3/18 and timed at 2:05 p.m. indicated Resident 1 was found sitting on the floor at 12:15 p.m., close to the bathroom with his left posterior index and pinky finger observed bleeding. The resident stated he fell on the floor after his leg gave out. According to the note, the resident was offered to be sent to the hospital for evaluation, but the resident refused. According to the nurses' progress note, dated 1/3/18 and timed at 6:20 p.m., six hours after the previous fall and two hours after receiving [MEDICATION NAME]. Resident 1 was found on the floor intoxicated face down, with blood on the floor. The resident had slurred speech and was unable to follow instructions. The note indicated the resident was bleeding profusely from the right side of the forehead while he remained on the floor. Three nurses assisted the resident to turn over face up, and ice and pressure were applied to the resident's facial injuries. The nurses were unable to control the bleeding and 911 and police were called. Three empty bottles of vodka were found in the resident's drawer. The resident was transferred to GACH's emergency room (ER). A review of the GACH's records, dated 1/3/18 and timed at 7:06 p.m., indicated Resident 1 was treated for [REDACTED]. The GACH's records indicated Resident 1 admitted to drinking vodka, and per the medical emergency medical technician (EMT). The resident was found with two pints of vodka. A review of the ER notes, dated 1/3/18 timed at 8:41 p.m., indicated Resident 1 sustained a head injury with a right eyebrow laceration due to a mechanical fall after intoxication of alcohol. Resident 1's wound required six sutures (a stitch holding together the edges of a wound) to close the wound with a length of 3.0 centimeter (cm). A review of Resident 1's GACH laboratory results for [MEDICATION NAME] (alcohol) level in blood indicated a value of 394 mg/ deciliter (dl), (normal reference range (NRR) 0 < 50 mg/dl. According to an undated online Mayo Clinic Laboratories results, titled [MEDICATION NAME] Blood (alcohol in the blood) potentially Lethal Concentration >400 mg/dl, 0.4g/dl. A review of Resident 1's controlled narcotic records indicated Resident 1 was administered the following: [MEDICATION NAME] October (YEAR) 79 tablets November (YEAR) 113 tablets December (YEAR) 28 tablets from 12/2/17 to 12/11/17. January 82 tablets 1/3/18-1/31/18 Ambien 14 tablets from 12/17-1/18/18 12 tablets from 1/19/18 to 1/30/18 [MEDICATION NAME] 30 tablets 12/25/17- 1/5/18 A review of the nurses' progress note, dated 1/14/18 and timed at 2:45 a.m., indicated Resident 1 arrived back from the hospital with stitches on the right eyebrow with swelling and purplish discoloration around the area. The note indicated there were scratches on the Resident 1's left cheek with discoloration on the left upper arm, and left index finger with an abrasion (superficial cut). The resident was complaining of generalized body pain and medication was given. A review of the Social Services note, dated 1/4/18 and timed at 3:14 p.m., indicated Resident 1 appeared intoxicated, stumbling, and incoherently ( unclear; muddled) yelling at the staff. The SSD attempted to speak with the resident but the resident became upset and refused to talk. According to the SSD note, the resident refused to go out for an appointment and stated, I am too unsteady to go. The SSD note indicated the resident continued to leave the facility several times a day out on pass, but refused to sign in/out on the log. A review of the facility's policy, revised 11/2012, titled Leave of Absence, indicated all residents leaving the premise must be signed out to/from and have clearance from the physician to go out on pass. The policy also indicated that staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify the supervisor at once. A review of the nurses progress notes dated 1/4/18 and timed at 7:44 p.m. indicated Resident 1 cursed at facility's staff, and left the facility without notifying staff or signing out on log. A review of MAR for the month of 1/2018 timed at 8 p.m. indicated the resident was administered [MEDICATION NAME] 10-325 mg [MEDICATION NAME] mg. A review of the nurses' progress note, dated 1/4/18 and timed at 8:05 p.m. indicated Resident 1 was verbally aggressive towards the staff, expressing derogatory remarks and threatening the facility staff. The note further stated that Resident 1 smelled of liquor (after receiving [MEDICATION NAME] and Ambien). On 1/31/18 at 1:50 p.m., during an interview, CNA 1 stated, The resident (Resident 1) goes out on pass and drinks alcohol every day and comes back wasted. He is a big guy and most of the nurses are afraid of him. He rarely brings the alcohol back to the facility, but I know that another CNA found some alcohol in his room before. The charge nurse knows he gets drunk and so does the Director of Nursing (DON). On 1/31/18 at 2:04 p.m., during an interview, Resident 1 stated, I have this black eye because I fell coming out of the bathroom. I had a few stitches on my right eye, but I am fine now. I am an alcoholic; I drink a lot, especially the last couple of months, because my doctor refuses to give me my medication. I leave and walk to the store; I do not bring any alcohol back here. On 1/31/18 at 3:21 p.m., during an interview the SSD stated, The resident (Resident 1) goes out on pass, sometimes a few times in one day. There has been alcohol found in his room by the staff. He leaves and does not sign out on log. At times, he yells and threatens the staff. I have tried to talk with him, but he will not listen to me. On 1/31/18 during an observation at 5:16 p.m., Resident 1 was observed throwing a dinner tray and yelling profanity at the facility's staff. Resident 1 stated, This place always gives me a problem! On 1/31/18 at 5:21 p.m., during an interview CNA 2 stated, The resident gets drunk all the time, he gets very aggressive. If he does not get his medication he threatens the nurses, I have seen him drunk at least 4 to 5 times a week. On 1/31/18 at 6:16 p.m., during an interview CNA 3 stated, He (Resident 1) gets drunk almost every day. I found two vodka bottles in his room a few weeks ago, and empty beer cans. I told the charge nurse when I found the vodka bottles in his room. On 2/2/18 at 10:31 a.m., during an interview RN 2 stated, The resident fell in the bathroom and was found face down by the CNA. He had blood gushing from his eye and it did not stop. I know he was intoxicated because he had slurred speech and could not follow directions. He had bottles of vodka that was found in his drawer. He has been known to be intoxicated at times. A review of the facility's policy, revised on 4/2017, titled Resident Supervision and Monitoring, indicated residents are provided with intense supervision when they present with conditions that may place other residents and/or themselves at risk for harm.

Based on observation, interview, and record review, the facility failed to ensure unnecessary medications were not given, in the presence of adverse consequences for one of three sampled residents (Resident 1). Resident 1 was receiving large amounts of narcotic (any of a class of substances that [MEDICATION NAME] the senses, as [MEDICATION NAME], and alcohol, that in large quantities produce euphoria, stupor, or coma, that when used constantly can cause habituation or addiction, and that are used in medicine to relieve pain, cause sedation, and induce sleep), without indications for its usage in the presence of a potential adverse consequences of consuming alcohol while out on pass for over five months (crossed referenced to F689). These failures resulted in Resident 1 falling three times, twice in one day (1/3/18), at the facility, sustaining an injury to the left index (pointer finger), left pinky finger (baby finger), a periorbital hematoma (bruising around the eye due to injury) and laceration to the right eyebrow, which required a transfer to the general acute care hospital (GACH) and placement of six stitches. The failures also had the potential for the resident to become addicted to the narcotics, in addition, result in more injuries and possibly death. On 1/31/18 at 4:41 p.m., an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared under F757 and F689. The facility's Administrator and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 2/2/18 at 12:14 p.m., the IJ was lifted after the team confirmed that the facility's POA was implemented. The Administrator was informed of the removal of the IJ. The facility submitted a Plan of Action (POA) for the correction of the IJ which included the following: 1. An order was written on 2/1/18 to discontinue the out on pass order for Resident 1. In addition, the physician gave an order to [MEDICATION NAME](sedative to treat [MEDICAL CONDITION]) and [MEDICATION NAME] (Narcotic to treat moderate to severe pain) for 24 hours for any suspicion of intoxication or drug use. 2. An order was obtained for Resident 1 to be discharged to a lower level of care and sober living options were to be researched and presented to Resident 1. 3. On 2/1/18, an interdisciplinary (IDT) meeting was conducted, including the attending physician, with Resident 1. The physician's new orders were discussed, as well as the resident's behavior toward the staff. Resident 1 agreed with the orders and to treat the staff with respect. 4. The Director of Nursing (DON) initiated in-services on 1/31/18 to the Licensed Nurses on evaluation regarding residents returning from out on pass for signs of intoxication. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 11/15/17 indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was interviewable (8-15= interviewable). According to the MDS, the resident was assessed as requiring no help or staff oversight at any time with bed mobility, transferring, locomotion on and off the unit, as well as no help or oversight from staff with eating or with personal hygiene. A review of a physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. 1.[MEDICATION NAME](([MEDICATION NAME]) a sedative, used to treat [MEDICAL CONDITION] (sleeplessness)) five (5) (mg) give one tablet by mouth as needed for sleeplessness at bedtime. 2. [MEDICATION NAME] (([MEDICATION NAME]) a medication used to treat anxiety) one (1) mg by mouth every eight (8) hours as needed for anxiety and restlessness. 3. [MEDICATION NAME] tablet give one tablet by mouth every 8 hours as needed for pain. According to Lexicomp, an online pharmacy site, [MEDICATION NAME] is an extremely strong opioid pain killer ([MEDICATION NAME]), which causes CNS depression ((central nervous system)refers to physiological depression of the CNS that can result in decreased rate of breathing, decreased heart rate, and loss of consciousness possibly leading to coma or death), which may impair physical or mental abilities; respiratory depression: (US Boxed Warning): with serious, life-threatening, or fatal (death) respiratory depression may occur. Hepatic impairment: Use with caution in patients with hepatic (liver) problems; Abuse/misuse/diversion: (US Boxed Warning): Use with caution in patients with a history of drug abuse or acute alcoholism; potential for drug dependency exists and can result in overdose and death. A review of Resident 1's care plan initiated on 12/14/17 identified a problem with the resident Exhibiting Unusual Behavior. Smells of alcohol after going out on pass. He (Resident 1) comes and goes as he chooses, does not sign out when he leaves the facility. He goes to the liquor store and brings back a paper bag. The goal indicated that the resident will behave or comply in a manner that was within the policy and procedure of the facility upon next review date of 3/15/18. The staff's interventions were to continue to educate the resident on the risks of going outside and getting drunk. Explain risks of consuming alcohol that can cause changes in loss of consciousness, falls, behavior, aggressiveness, and intervene accordingly. Remind him to inform staff of what items he brings in to the facility, for prompt follow through. A care plan initiated on 12/14/17 for an Unwitnessed Fall, indicated the resident was found sitting on the floor next to the bed without injuries related to alcohol consumption, two bottles of vodka was found in the resident's room. Resident 1's goal was to resume usual activities without further incident through the review date of 3/15/18. The staff's interventions were to monitor, document, report as needed to the primary physician for signs and symptoms of pain, bruises, change in mental status, new onset confusion, sleeplessness, inability to maintain posture and agitation. A review of Resident 1's care plan, initiated 12/14/17 identified a black box warning for the use of [MEDICATION NAME]. The goal was the resident will not experience interactions or side effect from the use of [MEDICATION NAME]. The staff's interventions indicate a warning for addiction, abuse and misuse of [MEDICATION NAME]. A review of the controlled narcotic record, dated 12/23/17 and timed at 4:30 p.m., indicated Resident 1 was administered [MEDICATION NAME] 10-325 milligrams (mg). A review of the Medication Administration Record [REDACTED]. A review of the MAR, for the month of 12/2017, dated 12/23/17 and timed at 8 p.m., indicated Resident 1 was administered [MEDICATION NAME] 1 mg. A review of the nurses' progress note, dated 12/23/17 and timed at 9:05 p.m., an hour after receiving the second [MEDICATION NAME] 1 mg, indicated a Certified Nursing Assistant (CNA) reported that Resident 1 appeared intoxicated. The CNA stated the resident was accusing nurses of not giving him his sleeping medication. Resident 1 was verbally threatening the staff and physically throwing items around in his room. A review of the controlled narcotic record, dated 1/3/18 and timed at 7 a.m. indicated Resident 1 was administered [MEDICATION NAME] 10-325 mg and two hours later received [MEDICATION NAME] 1 mg at 9 a.m. A review of the Social Service note, dated 1/3/18 and timed at 11:09 a.m. indicated Resident 1 received a notice of an appeal hearing and brought information to resident. The social worker indicated the resident appeared intoxicated and dropped the appeal paper on the floor. A review of the nurses' progress note, dated 1/3/18 and timed at 2:05 p.m. indicated Resident 1 was found sitting on the floor at 12:15 p.m., close to the bathroom with his left posterior index and pinky finger observed bleeding. The resident stated he fell on the floor after his leg gave out. According to the note, the resident was offered to be sent to the hospital for evaluation, but the resident refused. After the fall on 1/3/18, according to the controlled narcotic record, dated 1/3/18 and timed at 4:26 p.m., Resident 1 was administered [MEDICATION NAME] 10-325 mg. According to the narcotic record, Resident 1 received [MEDICATION NAME] at 7 a.m. that morning, as well as [MEDICATION NAME] 1 mg at 9 a.m. According to the nurses' progress note, dated 1/3/18 and timed at 6:20 p.m., six hours after the previous fall and two hours after receiving [MEDICATION NAME]. Resident 1 was found on the floor intoxicated face down, with blood on the floor. The resident had slurred speech and was unable to follow instructions. The note indicated the resident was bleeding profusely from the right side of the forehead while he remained on the floor. Three nurses assisted the resident to turn over face up, and ice and pressure were applied to the resident's facial injuries. The nurses were unable to control the bleeding and 911 and police were called. Three empty bottles of vodka were found in the resident's drawer. The resident was transferred to GACH's emergency room (ER). A review of the GACH's records, dated 1/3/18 and timed at 7:06 p.m., indicated Resident 1 was treated for [REDACTED]. The GACH's records indicated Resident 1 admitted to drinking vodka, and per the medical emergency medical technician (EMT). The resident was found with two pints of vodka. A review of the ER notes, dated 1/3/18 timed at 8:41 p.m., indicated Resident 1 sustained a head injury with a right eyebrow laceration due to a mechanical fall after intoxication of alcohol. Resident 1's wound required six sutures (a stitch holding together the edges of a wound) to close the wound with a length of 3.0 centimeter (cm). A review of Resident 1's GACH laboratory results for [MEDICATION NAME] (alcohol) level in blood indicated a value of 394 mg/ 0.3 g/dl deciliter (dl), (normal reference range (NRR) 0 < 50mg/dl. According to an undated online Mayo Clinic Laboratories results, titled [MEDICATION NAME] Blood (alcohol in the blood) potentially Lethal Concentration >400 mg/dl, 0.4g/dl., which was 3.75 times the legal blood alcohol concentration (BAC) level of intoxication of 0.08 g/dl. According to the article, as BAC increases, so does the impairment that included, but not limited to the following: 0.0-0.05 g/dl=mild impairment of speech, meomory, attention, coordination and balance. 0.31-0.45 g/dl- 0.45=severe impairment of judgement, decision making, and vomiting. A review of the GACH records, dated 1/4/18 and timed at 2:18 a.m., indicated Resident 1 became somewhat agitated and was walking around the ER yelling at the hospital's staff. Resident 1 was discharged back to nursing home. A review of Resident 1's controlled narcotic records indicated Resident 1 was administered the following: [MEDICATION NAME] October (YEAR)= 79 tablets November (YEAR) =113 tablets December (YEAR) =28 tablets (12/2/17 to 12/11/17). January 1/3/18-1/31/18= 82 tablets Ambien 14 tablets from 12/17-1/18/18 12 tablets from 1/19/18 to 1/30/18 [MEDICATION NAME] 30 tablets 12/25/17- 1/5/18 A review of the nurses' progress note, dated 1/14/18 and timed at 2:45 a.m., indicated Resident 1 arrived back from the hospital with stitches on the right eyebrow with swelling and purplish discoloration around the area. The note indicated there were scratches on the Resident 1's left cheek with discoloration on the left upper arm, and left index finger with an abrasion (superficial cut). The resident was complaining of generalized body pain and medication was given. A review of Resident 1's MAR for the month of 1/2018, dated 1/4/18 and timed at 2:45 a.m., indicated Resident 1 was administered [MEDICATION NAME] 10-325 mg and an hour later at 3:45 a.m., Resident 1 was administered [MEDICATION NAME] 1mg . A review of Resident 1's controlled narcotic record, dated 1/4/18 and timed at 10:45 a.m., indicated the resident was administered [MEDICATION NAME] 10-325 mg. A review of the Social Services note, dated 1/4/18 and timed at 3:14 p.m., indicated Resident 1 appeared intoxicated, stumbling, and incoherently ( unclear; muddled) yelling at the staff. The SSD attempted to speak with the resident but the resident became upset and refused to talk. According to the SSD note, the resident refused to go out for an appointment and stated, I am too unsteady to go. The SSD note indicated the resident continued to leave the facility several times a day out on pass, but refused to sign in/out on the log. A review of the nurses progress notes dated 1/4/18 and timed at 7:44 p.m. indicated Resident 1 cursed at facility's staff, and left the facility without notifying staff or signing out on log. A review of MAR for the month of 1/2018 timed at 8 p.m. indicated the resident was administered [MEDICATION NAME] 10-325 mg [MEDICATION NAME] mg. According to DailyMed [MEDICATION NAME] (an opioid medication for severe pain) has a black box warning (BBW) - the strongest warning that the Food and Drug Administration (FDA) requires which indicated, under Warning: addiction, abuse, and misuse; life-threatening respiratory depression; and risks from concomitant use with benzodiazepines (e.g. [MEDICATION NAME] and [MEDICATION NAME]) or other CNS depressants (e.g.[MEDICATION NAME]), including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of [MEDICATION NAME] and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation. The monograph for [MEDICATION NAME] indicated a BBW with similar side effects for opioid addition, abuse, and misuse, which can lead to overdose and death, and cautioned against concomitant prescribing of [MEDICATION NAME] and benzodiazepine or other CNS depressants. A review of the nurses' progress note, dated 1/4/18 and timed at 8:05 p.m. indicated Resident 1 was verbally aggressive towards the staff, expressing derogatory remarks and threatening the facility staff. The note further stated that Resident 1 smelled of liquor (after receiving [MEDICATION NAME] and Ambien). On 1/31/18 at 1:50 p.m., during an interview, CNA1 stated, The resident goes out on pass and drinks alcohol every day and comes back wasted. He is a big guy and most of the nurses are afraid of him. He rarely brings the alcohol back to the facility. I know that another CNA found some alcohol in his room before. The charge nurse knows he gets drunk and so does the Director of Nursing (DON). On 1/31/18 at 2:04 p.m., during an interview, Resident 1 stated, I have this black eye because I fell coming out of the bathroom. I had a few stitches on my right eye, but I am fine now. I am an alcoholic; I drink a lot, especially the last couple of months, because my doctor refuses to give me my medication. I leave and walk to the store; I do not bring any alcohol back here. On 1/31/18 at 3:21 p.m., during an interview the SSD stated, The resident (Resident 1) goes out on pass, sometimes a few times in one day. There has been alcohol found in his room by the staff. He leaves and does not sign out on log. At times, he yells and threatens the staff. I have tried to talk with him, but he will not listen to me. On 1/31/18 during an observation at 5:16 p.m., Resident 1 was observed throwing a dinner tray and yelling profanity at the facility's staff. Resident 1 stated, This place always gives me a problem! On 1/31/18 at 5:21 p.m., during an interview CNA 2 stated, The resident gets drunk all the time, he gets very aggressive. If he does not get his medication he threatens the nurses, I have seen him drunk at least 4 to 5 times a week. On 1/31/18 at 6:16 p.m., during an interview CNA 3 stated, He (Resident 1) gets drunk almost every day. I found two vodka bottles in his room a few weeks ago, and empty beer cans. I told the charge nurse when I found the vodka bottles in his room. On 2/1/18 at 8:49 a.m., during an interview, Resident 1 stated, They told me I cannot go out on pass any more, I am very upset. They are trying to punish me. I do not need to go rehab either, I would leave if they get me an apartment and pay for it. On 2/1/18 at 11:29 a.m., in the presence of the DON and Administrator, Resident 1's primary physician stated, This resident (Resident 1) is eligible for a lower level care, he is manipulative. The fall where he sustained stitches he brought on himself, if we cut off the narcotic then we may be accused of not treating the problem. His pain and anxiety is very real. The physician stated he prescribed the [MEDICATION NAME] to the resident for his leg [MEDICAL CONDITION] (a bacterial infection of the skin and tissues beneath the skin). On 2/2/18 at 10:12 a.m., during an interview, Registered Nurse 1 (RN 1) stated, The day he (Resident 1) fell I assessed him and told the next shift that he fell . On 2/2/18 at 10:31 a.m., during an interview RN 2 stated, The resident fell in the bathroom and was found face down by the CNA. He had blood gushing from his eye and it did not stop. I know he was intoxicated because he had slurred speech and could not follow directions. He had bottles of vodka that was found in his drawer. He has been known to be intoxicated at times.

Based on interview and record review, the facility failed to adhere to its policy and the resident's plan of care in prevention of falls for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls with a history of falls with injuries, had no floor mats and/or bed alarms used, as indicated in the resident's care plan, Fall Investigation plan and the facility's policy and procedure. These deficient practices, resulted in Resident 1 falling and being transferred to the general acute care hospital (GACH). Resident 1 was admitted to the intensive care unit (ICU) with a scalp laceration (deep cut), internal brain hemorrhage (bleeding inside the skull around or within the brain), subarachnoid hemorrhage (blood leaks into the space between two of the membranes surrounding the brain), and fractures of the cheek bone, nose, and eye socket. Resident 1 was hospitalized for [REDACTED]. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H&P), dated 6/16/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 11/16/17 , indicated Resident 1 had memory problems, impaired decision-making, was unable to make needs known and understand others. According to the MDS, Resident 1 was assessed as requiring extensive assistance with bed mobility, transferring, locomotion on and off the unit, as well extensive assistance with eating and personal hygiene. A review of Resident 1's Fall Assessment, dated 10/29/17, indicated Resident 1 had a score of 23 ( total score above 10 represents high risk for falls). According to the Fall Risk Assessment, indicated Resident 1 had a history of [REDACTED]. A review of Resident 1's care plan titled, At risk for Falls and Injuries, related to general weakness, impaired mobility, poor safety awareness, unsteady gait and use of [MEDICAL CONDITION] medication (mind altering) with a history of falls. The staff's interventions included to anticipate and meet the resident's needs, apply non-skid mat on top of resident's wheelchair to prevent from sliding, continue with a low bed and concave mattress (elevated sides for fall prevention), provide a safe environment such as floors free from spills and/or clutter, adequate glare free light, a working reachable call light, and to ensure personal items were within reach. A review of the facility's Fall Scene Investigation, indicated on 10/29/17, Resident 1 had an unwitnessed fall and was found lying on her back with her head facing the foot of the bed. The investigation report indicated Resident 1 did not have an alarm being used at the time of the fall and the root cause of the fall was due to confusion and the resident getting up and losing her balance. The interventions to prevent future falls included to use bed sensor and a pad alarm. Another Fall scene investigation, dated 11/20/17, indicated Resident 1 had a second unwitnessed fall on 11/20/17, and was found lying on the floor to the right side of the bed. Upon assessment, Resident 1 had a skin cut to the right eye with moderate amount of bleeding. First aid was rendered and 911 was called by the registered nurse supervisor. The report indicated that an alarm was not being used on Resident 1 at the time, as per the resident's interventions on the previous fall investigation on 10/29/17 . The report indicated that the initial interventions to prevent future falls included to provide increased supervision almost one to one at times. A review of the Licensed Personnel Progress Note, dated 11/20/17 and timed at 8:45 p.m., indicated Registered Nurse 1 (RN 1), while sitting at the nurses' station, heard a thud sound coming from the resident's (Resident 1) room. Certified Nursing Assistant 1 (CNA 1) had just come out of the resident's room approximately five to 10 minutes prior, after care was provided, and the resident gone to sleep. RN 1 went into the room and found the resident lying on the floor on the right side next of the low bed. Licensed Vocational Nurse 1 (LVN 1) and CNA 1 went to the room immediately. LVN 1 and RN Supervisor (RN 1) assessed the resident and observed the resident to have a laceration to the right eye with moderate amount of blood. Resident 1 was able to move all extremities and there was no signs and symptoms of pain or discomfort at the time. The note indicate d the physician and responsible party was notified. A review of the Paramedics' Report, dated 11/20/17, indicated Resident 1's blood pressure was 162/98 (normal reference range (NRR) is 120/70-80), pulse of 120 (NRR 60-100), respirations 20 (breaths per minute (bpm) NRR 12-20), and the oxygen saturation was 96 percent (%) (NRR 95-100 %). A review of the GACH's Emergency department (ED) report, dated 11/20/17 and timed at 11:55 p.m., indicated Resident 1 had multiple [MEDICAL CONDITION], fracture to the right orbital floor, and fracture to the lateral and anterior wall of the right maxillary sinuses. The ED's report indicated Resident 1's medical condition placed her at an increased risk of decompensation (showing signs of deterioration regarding daily functioning) and death. On 12/11/17 at 1:49 p.m., the facility's administrator (ADM) stated, This is the second fall within a month for this resident. On 12/11/17 at 2:26 p.m., during an interview, the assistant director of nursing (ADON) stated, For this resident (Resident 1) there are no floor pads, because she is ambulatory (able to walk) and there is a risk for tripping over the pads. The resident is able to walk with assistance from someone. At 3:50 p.m., on 12/13/17, during an interview, CNA 1 stated, The resident is energetic and likes to walk. I was caring for another resident in another room during the resident's fall. The two upper side rails were up; the resident is at risk for falls. I do not remember if there were floor mats next to the bed. The resident does not use her call light; we do frequent visual checks on her. There is no bed alarm. Usually the physical therapist ambulates with the resident. On 12/13/17 at 4:08 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated, I was called to the resident room, and saw the resident (Resident 1) on the floor close to the bathroom. The resident had a laceration on the side of her eye. I am unsure if there was a mat next to the bed. We do not use bed alarms here. On 1/8/18 at 11:20 a.m., the ADON stated, We do not have any bed alarms that are in use for fall risks. I am not sure why it was documented that there would be an alarm used for the resident (Resident 1). I will follow-up with the nurse who documented that. On 1/8/18 at 12:15 p.m., during an interview, the physical therapist (PT 1) stated, The resident has poor safety awareness, and has difficulty following commands. Physical therapy would assist with bed mobility and transfers, but her knees would buckle. I do not recall a floor mat next to the bed, but the resident needs a lot of hand held assistance. On 1/10/18 at 10:06 a.m., during a telephone interview, RN 1 stated, I was in the nursing station and heard a thud and the resident was found face down next to her bed. She had a cut to her right eye that was swollen and bleeding. The CNA and LVN helped me get her into bed and I called 911. There is no mat next to her bed because we do not want her to trip on it. She is not on 1 to 1 monitoring because her room is right next to the nursing station. A review of the facility policy titled, Falls management, dated 11/2012 indicated, residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls. Licensed nurses will monitor the residents' status and revise care plans as needed during their weekly progress notes. Recent falls would be reviewed daily by a designated facility fall team, to evaluate cause, determine additional strategies as needed to prevent recurrence for each resident and further revise the care plan if needed.

Based on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 1) was not tied up in a wheelchair with a cloth-sheet for staff convenience. As a result, Resident 1 reported an increase in anxiety and fear that required the routine administration of anti-anxiety medication. Findings: On 3/24/16, at 11:46 a.m., an unannounced visit was conducted at the facility to investigate an entity reported incident that Resident 1 was inappropriately restrained in a wheelchair by certified nursing assistant, (CNA 1) for staff convenience. A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].<http://www.webmd.com/lung/lung-diseases-overview> that makes it hard to breathe). A review of the Minimum Data Set (MDS, an assessment care and screening tool), dated 1/14/16, indicated Resident 1 had unclear speech, able to make self-understood and had the ability to understand others. The resident's cognitive skills for daily decision-making were severely impaired and had signs and symptoms of [MEDICAL CONDITION] (a state of mental confusion that develops quickly and usually fluctuates in intensity) and disorganized thinking. The MDS indicated the resident required extensive assistance from the staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. On 3/24/16, at 12:18 p.m., Resident 1 was observed asleep in front of the nurse's station. Resident 1 was sitting on a wheelchair with a self-release belt (A belt prescribed by the doctor to prevent sliding and getting up unassisted), around her waist. During an interview on 5/18/16, at 12:40 p.m., Resident 1 stated words repeatedly and tensed up as she tried to respond to questions. Resident 1 was offered a pen and paper which she used to communicate. Resident 1 was unable to elaborate on what had occurred on 3/10/16, which was the alleged day when CNA 1 restrained her to a wheelchair. When asked if CNA 1 applied a blanket over her chest to keep her in the wheelchair, Resident 1 stated Yes, and indicated that it made her feel like a prisoner. On 5/18/16, at 1:35 p.m., during an interview, Resident 2 stated she witnessed CNA 1 tie Resident 1 to a wheelchair. According to Resident 2, she saw CNA 1 place what looked like a long towel under Resident 1's breasts, wrapped it around the wheelchair and tied her (Resident 1) to a dinner chair. Resident 2 stated the dinner chair was heavy and Resident 1 could not get up. Resident 2 stated the incident happened in March 2016 and she recalled the incident clearly because she just got admitted to the facility at that time. Resident 2 stated she could not help Resident 1 because she was scared that CNA 1 might hit her. Resident 2 stated that after CNA 1 left their room, she stopped the head nurse in the hallway and showed her where Resident 1 was. During a telephone interview with CNA 1 on 5/19/16, at 8:51 a.m., she stated that at around 7:00 p.m., on 3/10/16, she used the bed sheet to tie Resident 1 in her wheelchair. CNA 1 stated Resident 1 kept getting up from the wheelchair. CNA 1 acknowledged that she should not have tied the resident in her wheelchair. CNA 1 stated, I should have looked for somebody to help or I should have stayed with her. In a telephone interview with registered nurse 1 (RN 1) on 5/18/16, at 2:54 p.m., she stated that at around 7:00 p.m., on 3/10/16, Resident 2 called her attention and indicated that Resident 1 was tied in a wheelchair inside their room. RN 1 stated that Resident 1 and 2 were roommates. RN 1 stated that she saw Resident 1 tied to a wheelchair when she went in the residents' room. RN 1 stated she asked one of the CNAs to untie Resident 1. RN 1 stated she investigated the incident immediately, and found out that CNA 1 tied Resident 1 to the wheelchair, and CNA 1 was escorted out of the facility. A review of the Psychological Services Progress Notes, dated 3/11/16, indicated that Resident 1 stated she has had increased anxiety and fear since the incident. The documentation indicated that Resident 1 has had nightmares since the incident, and would like to have a medical evaluation as her current medication was not effective and would like to address her increased anxiety. A review of the Progress Notes written by the assistant director of nursing (ADON) dated 3/11/16, at 8:55 a.m., indicated that the psychiatrist was called regarding Resident 1's continued restlessness behavior. On 3/11/16 at 11:02 a.m., the psychiatrist called back and changed Resident 1 ' s [MEDICATION NAME] medication (A medication used to treat anxiety) from one (1) milligram every 12 hours as needed (PRN) to 0.5 mg every 6 hours routinely. A review of the Progress Notes written by the social worker dated 3/11/16 at 2:44 p.m., indicated that the social worker asked Resident 1 how she was doing, and the resident stated I'm afraid. The documentation indicated when Resident 1was asked what she was afraid of, she stated that she was afraid that she was going to be tied up again. A review of the 2/2014, facility's policy and procedure titled, Care of Resident with Dementia & Behavior Assessment Policy indicated that the physician and the staff will review situations requiring restraint use to ensure that they are beneficial to the individual and are not causing complications or disabling the individual.

Based on interview and record review, the facility failed to provide adequate supervision for one of five sampled residents (Resident A). Resident A, who had dementia (loss of brain function, as evidenced by memory loss, impaired judgment, behavior changes, learning difficulties, and communication problems), was known by the facility staff to exhibit aggressive behavior of striking out at caregivers, wandering into other residents' rooms, and touching other residents ' personal belongings without permission. Resident A was able to enter Resident B's room (an alert female resident's room) on 8/30/14, as he had done before, and swung his fist towards Resident B, grazing her left breast. On 9/4/14, the staff was alerted after hearing Resident B screaming for the nurse. Resident A was seen sitting outside of Resident B's door. Resident A was moved away from Resident B's room and was re-oriented that it was not his room. On 9/10/14, Resident B cried and stated she did not feel safe in the presence of Resident A. Resident C and D, alert female residents who were roommates, also stated Resident A had entered their room (date undetermined) and they felt scared of Resident A because they had seen him yell loudly and hit staff. Resident B, C, and D were unable to defend themselves. There was no documented evidence in Resident A's clinical record that the facility implemented interventions to supervise Resident A and manage his wandering behavior into other resident's rooms. This deficient practice resulted in psychological harm to the female residents (Resident B, C, and D) and had the potential to result in physical harm to Resident A and the other residents. On 9/10/14 at 2:30 p.m., the Director of Nurses (DON) and the Administrator were both notified of the Immediate Jeopardy situation. On 9/10/14 at 5:30 p.m., the facility provided an acceptable credible Allegation of Compliance and the Immediate Jeopardy was lifted. The facility's plan of corrections included: 1. Initiating a one to one care since 10:15 a.m., in order to monitor Resident A's behavior and whereabouts. 2. Obtaining a psychiatric consult for medication review, behavior management, and or further interventions as needed. 3. Changing Resident A's room to Station 3 (Secure Unit) for smaller area of confinement to minimize wandering and intrusive behavior to the degree possible. 4. Applying a pole to the back of the wheelchair seat, with anti-tippers in front and back as a trial basis to prevent the resident from entering other resident's rooms. 5. Identifying past hobbies, likes, dislikes by the Activity Director to keep the resident occupied, to minimize the wandering and intrusive behavior to the degree possible. 6. Escorting Resident A by the Activity staff to appropriate activity program offered. Findings: On 9/1014 at 7 a.m., an investigation of facility's self-reported incident was initiated regarding an allegation of resident-to-resident abuse between Resident A and B on 8/30/14. A review of Resident A's clinical records indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the interview record form, dated 7/19/14, indicated a self-reported incident involving resident-to-resident altercation involving Resident A and E. The form indicated Resident A grabbed Resident E's cane, Resident E immediately stood up and got closer to Resident A, Resident E grabbed his cane back from Resident A, and Resident E hit Resident A on the right side of his head, resulting in a small tear on his ear. An undated letter to the Department indicated Resident A was treated for [REDACTED]. A review of the physician's orders [REDACTED]. The Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/14/14, indicated Resident A sometimes had the ability to understand and be understood by others, had short-term and long-term memory problems, was severely impaired in cognitive skills for daily decision making, had disorganized thinking, and was short tempered and easily annoyed. The MDS assessment also indicated Resident A at times rejected the care, had wandering behavior that placed the resident at significant risk of getting in to a potentially dangerous place, his wandering significantly intruded on the privacy or activities of others, he needed extensive assistance (resident involved in activity, staff provide weight-bearing support) for activities of daily living (ADLs), and he used his wheelchair as a mobility device. The care area assessment (CAA), which was triggered by the MDS item responses that indicated the need for additional assessment based on the problem identification worksheet compiled by the Social Services Designee (SSD), dated 8/31/14, did not identify Resident A's behavior of being short tempered, easily annoyed, and wandering, which significantly intruded on the privacy or activities of others as a possible threat to other residents. On 9/10/14 at 7:35 a.m., during an interview, Resident B, an alert female resident, stated that on 8/30/14 at 11:40 a.m., Resident A entered her room against her will, as he (Resident A) always did. According to Resident B, she used her cell phone to call the front desk for assistance and when no one came, she started yelling for help. Resident B stated Resident A attempted to take her bedside table away, but she held on to the table. Resident B stated she tried to shoo Resident A away with her "reacher-device" but Resident A became hostile and started swinging at her, striking her left breast. During the interview, Resident B stated she informed the facility she was scared when a male resident comes in her room. Resident B started crying and stated she did not feel safe being in the facility with Resident A, because she could not get away. Resident B stated she had also told the facility staff that Resident A went in her room, and she was fearful of him. Resident B stated the facility would not address her concerns about Resident A, but wanted her to see a psychiatrist. A review of the Resident Care Conference (a meeting discussing the care of the resident) Review form, dated 4/25/14, indicated prior to the incident with Resident A, Resident B voiced her fear to the facility staff about a male resident (unknown) entering her room. The interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) met with Resident B, discussed her fear, and encouraged the resident to vent about her feelings. The interventions were to have a Registered Nurse (RN) supervisor check on Resident B every shift, ensure the sliding door was locked at all times, ensure that no male residents would be allowed in her room, and to have a psychologist see Resident B to discuss her fears. On 9/10/14 at 9:50 a.m., in an interview with Certified Nursing Assistant (CNA) 1, she stated Resident A exhibited anger, strike out at the care givers, and exhibited a behavior of entering other resident's rooms. She stated Resident A had been seen entering Resident B's room, and Resident B always screamed for help. When asked why Resident B screamed for help, CNA 1 stated because she was scared of Resident A. When asked if Resident A's behavior was reported to the charge nurses, CNA 1 stated yes. CNA 1 further stated she had also witnessed the charge nurses remove Resident A from other residents' rooms. On 9/10/14 at 10:20 a.m., in an interview with CNA 2, she described Resident A as angry, very loud, and cursed showing his fist saying, "If you don't get out of my way I will hit you." CNA 2 described Resident A as having tendencies to touch other resident's personal belongings without permission. During the interview, CNA 2 stated on 8/30/14, she heard Resident B screamed for help several times and saw Resident A at Resident B's doorway. CNA 2 stated she removed Resident A and took him to the patio. When asked if she reported the incident to the charge nurse, CNA 2 stated, "No, because everyone knows," about Resident A's behavior of going inside female residents' rooms. A review of the Interdisciplinary (IDT) Progress Notes, dated 9/4/14 at 4:48 p.m., indicated Resident B allegedly accused Resident A on 9/3/14 of slapping her on the left upper breast, and that someone escorted Resident A out of the room. The notes indicated Resident A was interviewed and did not recall the incident. A review of the Health Status Note (a progress note), dated 9/4/14 at 9:11 p.m., indicated the staff was alerted after hearing Resident B screaming for the nurse. The notes indicated Resident A was seen sitting outside of Resident B's door. Resident A was moved away from Resident B's room and was re-oriented that it was not his room. On 9/10/14 at 9:30 a.m., in an interview with Resident C, she stated Resident A had entered her room (she could not recall the exact date) while she was sitting in her wheelchair talking to her mother (Resident D), who was her roommate and also a resident of the facility. Resident C told Resident A to leave the room because he was in a female room. Resident A told Resident C, he was there to check her out. Resident C stated she was very scared of Resident A because she had witnessed him yelling very loudly and hitting staff members. Resident C stated she was afraid of Resident A because she was unable to defend herself if Resident A became physically aggressive. On 9/10/14 at 10:40 a.m., during an interview with Resident D as she was sitting in a wheelchair, wearing a neck/back brace (to immobilize the neck and the back bones), she stated she just had a surgery and was not able to move without staff's assistance. Resident D stated Resident A entered their room (Resident C and D's shared room), and Resident A told her daughter (Resident C) he was there (inside their room) to check her (Resident C) out. Resident D stated she was very scared because she had seen Resident A hit staff members. Resident D also stated she was not able to stand up on her own in order to leave the room when she felt threatened by Resident A. On 9/10/14 at 3:10 p.m., during an interview with Registered Nurse (RN) 1, she confirmed that prior to the incident on 8/30/14, she had seen Resident A enter other residents' rooms. However, during a record review, RN 1 could not find any documentation and/or care plans specifically addressing Resident A's wandering behavior into other residents' rooms. RN 1 could not find documentation indicating how Resident A and/or other residents were going to be protected from Resident A's behavior of wandering into other residents' rooms. A review of Resident B's clinical records indicated the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. A review of Resident B's Minimum Data Set (MDS) a standardized assessment and care planning tool dated 3/5/14, indicated Resident B was alert and oriented, required extensive assistance with bed mobility, and was totally dependent on staff for transferring. A review of the clinical records indicated Resident C was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated Resident C was alert and oriented, needing extensive assistance with bed mobility, transferring, and walking. A review of the clinical records indicated Resident D was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated the resident was alert and oriented, and needed extensive assistance for bed mobility, transferring, and walking A review of clinical records indicated Resident E was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated Resident E usually understand or is understood, was alert and oriented, and needed supervision with walking using a cane/crutch.

Based on interview and record review, the facility failed to identify the risk factors for the types of behaviors which might lead to conflict and thoroughly investigate an allegation of abuse to ensure four of five sampled residents (Residents A, B, C, and D) were free from physical and mental abuse in accordance with the facility's policy and procedure. Resident A, who had dementia (loss of brain function, as evidenced by memory loss, impaired judgment, behavior changes, learning difficulties, and communication problems), was known by the facility staff to exhibit aggressive behavior of striking out at caregivers, wandering into other residents' rooms, and touching other residents' personal belongings without permission, which placed Resident A and other residents at increased risk for harm. On 8/30/14, Resident A entered Resident B's room (an alert female resident's room), as he had done before, and swung his fist towards Resident B, grazing her left breast. On 9/4/14 at 9:11 p.m., the staff was alerted after hearing Resident B screaming for the nurse. Resident A was seen sitting outside of Resident B's door. Resident A was moved away from Resident B's room and was re-oriented that it was not his room. On 9/10/14, Resident B cried and stated she did not feel safe in the presence of Resident A. Resident C and D, alert female residents who were roommates, also stated Resident A had entered their room and they felt scared of Resident A because they had seen him yell loudly and hit staff. Resident B, C, and D were unable to defend themselves. There was no documented evidence in Resident A's clinical record that the facility: 1. Identified the risk factors of the aggressive and wandering behaviors exhibited by Resident A which could lead to altercations/conflict with other residents; 2. Thoroughly investigated the allegation of abuse against Resident A made by Resident B by failing to interview other residents and family members to identify if they had been affected by Resident A's aggressive and wandering behavior; and 3. Implemented effective, preventive measures to protect other residents from Resident A's aggressive behavior and to prevent the re-occurrence of Resident A's wandering behavior inside other residents' rooms. This deficient practice resulted in psychological harm to the female residents (Resident B, C, and D) and had the potential to result in physical harm to Resident A and the other residents. On 9/10/14 at 2:30 p.m., the Director of Nurses (DON) and the Administrator were notified of the Immediate Jeopardy situation. At 5:30 p.m., the facility provided an acceptable credible Allegation of Compliance and the Immediate Jeopardy was lifted. The facility's plan of corrections included the following: 1. Social Services Designee (SSD) will continue to interview all interviewable residents in all stations. The SSD will provide emotional support as needed. 2. Facility will continue with staff interviews to determine any concerns about allegation of abuse. Any allegations of abuse identified will be followed up by the Administrator to ensure that any allegations have been thoroughly investigated. 3. Initiate Resident Council meeting on 9/11/14. 4. All staff education on Abuse Policy, prevention, and reporting was initiated on 9/10/14, to ensure thorough investigation of accident and incidents, and provide increased supervision, as determined by conclusion of the investigation identified through resident interviews. 5. Facility will review allegations of abuse in the last 90 days to ensure thorough and complete investigation and follow through has occurred to include each resident's level of supervision has been evaluated. Findings: On 9/10/14 at 7 a.m., an investigation of the facility's self-reported incident, dated 9/3/14, was initiated regarding an allegation of resident-to-resident abuse between Resident A and B on 8/30/14. A review of Resident A's clinical records indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the interview record form, dated 7/19/14, indicated a self-reported incident involving resident-to-resident altercation involving Resident A and E. The form indicated Resident A grabbed Resident E's cane, Resident E immediately stood up and got closer to Resident A, Resident E grabbed his cane back from Resident A, and Resident E hit Resident A on the right side of his head, resulting in a small tear on his ear. An undated letter to the Department indicated Resident A was treated for [REDACTED]. A review of the physician's orders [REDACTED]. The Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/14/14, indicated Resident A sometimes had the ability to understand and be understood by others, had short-term and long-term memory problems, was severely impaired in cognitive skills for daily decision making, had disorganized thinking, and was short tempered and easily annoyed. The MDS assessment also indicated Resident A at times rejected the care, had wandering behavior which placed the resident at significant risk of getting into a potentially dangerous place, his wandering significantly intruded on the privacy or activities of others, he needed extensive assistance (resident involved in activity, staff provide weight-bearing support) for activities of daily living (ADLs), and he used his wheelchair as a mobility device. The care area assessment (CAA), which was triggered by the MDS item responses that indicated the need for additional assessment based on the problem identification worksheet compiled by the SSD, dated 8/31/14, did not identify Resident A's behavior of being short tempered, easily annoyed, and wandering, which significantly intruded on the privacy or activities of others, as a possible threat to other residents. On 9/10/14 at 7:35 a.m., during an interview, Resident B, an alert female resident, stated on 8/30/14 at 11:40 a.m., Resident A entered her room against her will, as he always did. According to Resident B, she used her cell phone to call the front desk for assistance and when no one came, she started yelling for help. Resident B stated Resident A attempted to take her bedside table away, but she held on to the table. Resident B stated she tried to shoo Resident A away with her "reacher-device," but Resident A became hostile and started swinging at her, striking her left breast. During the interview, Resident B stated she informed the facility she was scared when a male resident comes in her room. Resident B started crying and stated she did not feel safe being in the facility with Resident A, because she could not get away. Resident B stated she had also told the facility staff that Resident A went in her room, and she was fearful of him. Resident B stated the facility would not address her concerns about Resident A, but wanted her to see a psychiatrist. On 9/10/14 at 10:20 a.m., during an interview, Certified Nursing Assistant (CNA) 2 stated on 8/30/14, she heard Resident B scream for help several times and saw Resident A at Resident B's doorway. CNA 2 stated she removed Resident A and took him to the patio. When asked if she reported the incident to the charge nurse, CNA 2 stated, "No, because everyone knows," about Resident A's behavior of going inside female residents' rooms. A review of the Interdisciplinary (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) Progress Notes, dated 9/4/14 at 4:48 p.m., indicated Resident B allegedly accused Resident A on 9/3/14, of slapping her on the left upper breast, and that someone escorted Resident A out of the room. The notes indicated Resident A was interviewed and did not recall the incident. A review of the Health Status Note (a progress note), dated 9/4/14 at 9:11 p.m., indicated the staff was alerted after hearing Resident B screaming for the nurse. The notes indicated Resident A was seen sitting outside of Resident B's door. Resident A was moved away from Resident B's room and was re-oriented that it was not his room. On 9/10/14 at 9:30 a.m., in an interview with Resident C, she stated Resident A had entered her room (she could not recall the exact date) while she was sitting in her wheelchair talking to her mother (Resident D), who was her roommate and also a resident of the facility. Resident C told Resident A to leave the room because he was in a female room. Resident A told Resident C, he was there to check her out. Resident C stated she was very scared of Resident A because she had witnessed him yelling very loudly and hitting staff members. Resident C stated she was afraid of Resident A because she was unable to defend herself if Resident A became physically aggressive. On 9/10/14 at 10:40 a.m., during an interview with Resident D, as she was sitting in a wheelchair, wearing a neck/back brace (to immobilize the neck and the back bones), she stated she just had a surgery and was not able to move without staff's assistance. Resident D stated Resident A entered their room (Resident C and D's shared room), and Resident A told her daughter (Resident C) he was there (inside their room) to check her (Resident C) out. Resident D stated she was very scared because she had seen Resident A hit staff members. Resident D also stated she was not able to stand up on her own in order to leave the room when she felt threatened by Resident A. On 9/10/14 at 10:10 a.m., in an interview with the director of nursing (DON), while reading the facility's investigation, she stated after interviewing the staff, and Resident A and B, the allegation was unsubstantiated. However, a review of the facility's interviews, dated 9/3/14, indicated there were no interviews with other residents and family members in order to ensure a thorough investigation. The investigation interview with CNA 3 on 9/3/14 at 11:45 a.m., indicated at 2 p.m. (on 8/30/14), Resident A was seen wheeling into a room, but the staff was able to redirect him before he entered that room. The investigation interview with CNA 4 on 9/3/14 at 12 noon, indicated on 8/30/14, Resident B was crying because a man was in her room and he was trying to get in the bed with her, so she reported it to the charge nurse. The DON could not ensure the residents were being protected from their fear of Resident A when he enters their rooms. The DON also could not ensure a way of protecting Resident A from the consequences of his aggressive and wandering behavior. On 9/10/14 at 3:10 p.m., during an interview and record review with Registered Nurse (RN) 1, she confirmed that prior to the incident on 8/30/14, she had seen Resident A enter other residents' rooms. However, RN 1 could not find any documentation and/or care plans specifically addressing Resident A's wandering behavior into other residents' rooms. RN 1 could not find documentation indicating how Resident A and/or other residents were going to be protected from Resident A's behavior of wandering into other residents' rooms. A review of the facility's policy and procedures titled "Abuse Prevention, Investigation and Reporting," revised 3/13, indicated "the facility will ensure the resident's rights are protected by providing a method for prevention of any type of resident abuse ...All incidents of suspected or alleged abuse will be investigated by the assigned staff and continue the investigation process. The investigation and report shall include ...d) Names of the witnesses and their account when applicable ...g) Accounts of any other individuals involved ...The licensed nurse shall document the objective data in the medical record and initiate a care plan to reflect the resident's condition and measures to be taken to prevent recurrence." A review of Resident B's clinical records indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident B's MDS, dated [DATE], indicated Resident B was alert and oriented, required extensive assistance with bed mobility, and was totally dependent on staff for transferring. A review of Resident C's clinical records indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated Resident C was alert and oriented, needing extensive assistance with bed mobility, transferring, and walking. A review of Resident D's clinical records indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated Resident D was alert and oriented, and needed extensive assistance for bed mobility, transferring, and walking. A review of clinical records indicated Resident E was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated Resident E usually understand or is understood, was alert and oriented, and needed supervision with walking using a cane/crutch.