Every finding on record at The Guest House Skilled Nursing and Rehabilitation

Based on record review and interview, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day, 7 days a week, for 2 days within FY (Fiscal Year) Quarter 1, 2025 (October 1- December 31). Findings:Review of the facility's payroll summary report provided by S6 Human Resources for the FY Quarter 1 2025 revealed 8 dates with 1 RN (Registered Nurse) coverage. Further review revealed 2 of the 8 dates (10/05/2025 = 6.30 hours and 11/30/2025 = 7.55 hours) indicating RN coverage less than 8 hours. During an interview on 06/04/2026 at 10:00 a.m. S6 Human Resources reviewed and confirmed the facility did not have RN coverage for 8 consecutive hours for 10/05/2025 and 11/30/2025 as required. During an interview on 06/04/2026 at 11:00 a.m. S2 DON (Director of Nursing) reviewed and confirmed there should have been RN coverage for 8 hours per day and was not.

Based on record review and interview, the facility failed to ensure a resident's drug regimen was free of unnecessary medications for 1 (#4) of 5 residents reviewed for unnecessary medications. The facility failed to monitor for edema for a resident receiving a diuretic. Findings:Review of Resident #4's medical record revealed an admission date of 08/30/2024 with diagnoses that included, in part, chronic pulmonary edema, essential (primary) hypertension, and chronic kidney disease stage 3A.Review of Resident #4's physician orders revealed a 04/09/2026 order for Lasix oral tablet 20mg (milligram) (Furosemide) - give 1 tablet by mouth every 8 hours as needed for leg swelling.Review of Resident #4's May 2026 MAR (Medication Administration Record) revealed Lasix oral tablet 20mg was administered on 05/23/2026, 05/25/2026, and 05/28/2026. Further review of Resident #4's May 2026 MAR failed to reveal Resident #4 had been monitored for edema.Review of Resident #4's care plan revealed, in part, resident is on diuretic therapy with interventions that included administer diuretic medications as ordered by physician; document edema: 0=none, 1=trace, 2=+2, 3=+3, 4=pitting; notify Medical Doctor if +3 or greater X3 consecutive days (initiated on 07/09/2025); and observe/document/report any adverse reactions to diuretic therapy.During an interview on 06/03/2026 at 3:30 p.m. S2 DON (Director of Nursing) reported she had reviewed Resident #4's medical record and confirmed there was no evidence monitoring for edema had been conducted in May 2026.

Based on record reviews, observations, and interviews the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards of practice for 3 (#37, #50, and #51) of 3 residents reviewed for respiratory care. The facility failed to ensure:1. O2 (oxygen) tubing was dated when changed for Residents #37, #50, and #51,2. humidification bottle was dated when changed for Resident #37,3. O2 tubing was bagged when not in use for Resident #37,4. nebulizer, Bipap (bi-level positive airway pressure) and Cpap (continuous positive airway pressure) masks were bagged when not in use for Residents #37, #50 and #51 and5. lung sounds were monitored after nebulizer treatment for Resident #50.Findings: Review of the facility's policy Oxygen Use (Respiratory Therapy) - Prevention of Infection revised November 2011 revealed in part:Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff.Steps in the procedure:Infection Control Considerations related to Oxygen Administration 2. Use distilled water for humidification per facility protocol. 3. [NAME] bottle with date and initials upon opening and discard after 7 days. 7. Change the oxygen cannula and tubing every seven (7) days, or as needed. 8. Keep the oxygen cannula tubing used PRN (as needed) in a plastic bag when not in use,Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag or kangaroo pouch between uses . Change plastic bag with the administration set-up every seven (7) days. 9. Discard the administration set-up every seven (7) days. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the respiratory therapy was performed 2. The type of respiratory therapy performed. 4. All assessment data obtained during the treatment. Resident #37Review of Resident #37's medical record revealed an admit date of 09/15/2025 with diagnoses which include in part unspecified dementia, mild, with anxiety, chronic obstructive pulmonary disease, and obstructive sleep apnea. Review of Resident #37's physician orders revealed in part:06/03/2026 Oxygen: change mask, O2 tubing, water bottle and clean concentrator filter every night shift every Wednesday for maintenance.09/15/2025 Oxygen: Cpap q hs (every bedtime) related to obstructive sleep apnea. 09/15/2025 Oxygen: administer oxygen at 2 liter via n/c (nasal cannula) prn for sob (shortness of breath) or sat (saturation) >90% every shift related to immunodeficiency due to conditions classified elsewhere; chronic obstructive pulmonary disease, unspecified. Review of Resident #37's Quarterly MDS (Minimum Data Set) dated 03/18/2026 revealed in part a BIMS (Brief Interview for Mental Status) score of 15 indicating cognitively intact. Observation on 06/01/2026 at 8:35 a.m. revealed Resident #37 had an un-bagged, undated oxygen nasal cannula hanging on the headboard, no date on the oxygen humidification bottle and an un-bagged Cpap mask on the bedside table. During an interview on 06/01/2026 at 8:35 a.m. Resident #37 reported staff have not replaced the oxygen tubing in a really long time or provided a bag for storage for the oxygen tubing or mask when not in use. During an interview on 06/01/2026 at 8:57 a.m. S5 RN (Registered Nurse) confirmed the oxygen tubing and humidification bottle were not dated and the nasal cannula and Cpap mask were not bagged and should have been. Resident #50Review of Resident #50's medical record revealed an admit date of 02/07/2025 with diagnoses which include chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified, and unspecified asthma. Review of Resident #50's physician orders revealed in part:02/07/2025 Oxygen at 2 (two) liters via nasal cannula prn (as needed) for sob or sat <90% O2 sat every shift related to chronic respiratory failure with hypoxia.02/07/2025 Oxygen: Change mask, O2 tubing, water bottle and clean concentrator filter every night shift every Wednesday; change tubing label and date and as needed for contamination. 06/13/2025 Nebulizer: Assess after administering Nebulizer Treatment Document Lung Sounds as 1=Clear 2=Rales 3=Congested 4=Crackles 5=Rhonci 6=Rubs 7=Wheezing 8=Diminished four times a day. Review of Resident #50's Medication Administration Record (MAR) documentation for May 2026 failed to reveal monitoring of lung sounds after nebulizer treatments. Review of Resident #50's Quarterly MDS dated [DATE] revealed in part a brief interview for BIMS of 15 indicating cognitively intact. Special treatments: oxygen therapy, and participates in respiratory therapy. Observation on 06/01/2026 at 9:00 a.m. revealed Resident #50 with oxygen in use via nasal cannula, no date on oxygen cannula tubing, and a nebulizer sitting on the bedside table with the mask not bagged.Observation on 06/02/2026 at 10:00 a.m. revealed Resident #50 sitting up in a wheelchair, oxygen in use via nasal cannula, no date on the oxygen cannula tubing, and a nebulizer sitting on the bedside table with mask not bagged. During an interview on 06/02/2026 at 10:00 a.m. Resident #50 reported staff had not changed the oxygen cannula tubing and never bagged the nebulizer mask or listened to his lungs. During an interview on 06/02/2026 at 11:40 a.m. S3 LPN (Licensed Practical Nurse) confirmed Resident #50's oxygen cannula tubing was not dated and the nebulizer mask was not bagged and should have been. During an interview on 06/03/2026 at 9:42 a.m. S2 DON (Director of Nursing) reviewed Resident #50's medical record and confirmed the lung sounds after nebulizer treatments had not been documented as ordered and should have been.Resident #51Review of Resident #51's medical record revealed an admit date of 09/24/2025 with diagnoses which include in part chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, and heart failure.Review of Resident #51's physician orders revealed in part:09/24/2025 Oxygen: Administer continuous oxygen at 4 Liters per nasal cannula may remove for adls (activities of daily living); keep hob (head of bed) elevated for sob while lying flat every shift related to chronic obstructive pulmonary disease, unspecified; acute and chronic respiratory failure with hypoxia. 09/24/2025 Bipap at 14/6/40% at bedtime 09/24/2025 Oxygen: Change mask, O2 tubing, water bottle and clean concentrator filter every night shift every Wednesday change tubing. Review of Resident #51's Quarterly MDS dated [DATE] revealed in part a BIMS score of 06 indicating severely impaired cognition. Observation on 06/01/2026 at 9:00 a.m. revealed Resident #51 with oxygen in use via nasal cannula with no date on the oxygen tubing, Cpap on bedside table with the hose on the floor, no mask attached and hose un-bagged. Observation on 06/02/2026 at 11:30 a.m. revealed Resident #51 in a wheelchair, oxygen in use via nasal cannula, no date on the oxygen tubing, and a Cpap on bedside table with the hose on the floor, no mask attached and hose un-bagged. During an interview on 06/02/2026 at 11:30 a.m. Resident #51 reported staff have not changed the oxygen tubing in a long time and have not provided a storage bag for the Cpap when not in use. During an interview on 06/02/2026 at 11:40 a.m. with S3 LPN confirmed Resident #51's oxygen was in use via nasal cannula, the oxygen tubing was not dated, cpap hose was on the floor with no mask attached and un-bagged. S3 LPN further confirmed the night shift should have dated the oxygen tubing and bagged the Cpap hose when not in use and did not.

Based on record review and interviews, the facility failed to ensure a plan of care had been implemented for 1 (#11) of 27 sampled residents whose care plans were reviewed. The facility failed to administer Resident #11's monthly psychotropic medication dose as ordered. Findings: Review of Resident #11's medical record revealed an admission date of 12/31/2025 with diagnoses including in part, paranoid schizophrenia, dementia and generalized anxiety disorder. Review of Resident #11's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately intact cognition. Further review of Resident #11's Quarterly MDS Assessment revealed Resident #11 received antipsychotic medication. Review of Resident #11's comprehensive care plan revealed Resident #11 had a diagnosis of Schizophrenia and was on psychotropic medications with an intervention to administer psychotropic medications as ordered by the physician. Review of Resident #11's physician orders revealed in part, an order dated 01/27/2026 for Invega Sustenna intramuscular suspension prefilled syringe 156 mg (milligram)/ml (milliliter) (Paliperidone Palmitate) (psychotropic); Inject 156 mg intramuscularly one time a day starting on the 28th and ending on the 28th every month related to paranoid schizophrenia. Review of Resident #11's May 2026 Medication Administration Record (MAR) revealed Invega Sustenna intramuscular suspension prefilled syringe 156 mg/ml monthly dose had not been administered. Review of the Pharmacy Manifest dated 05/29/2026 revealed Resident #11's Invega Sustenna 156 mg prefilled syringe was delivered to the facility on [DATE] at 2:51 p.m. and signed by S10 Unit Manager on 05/30/2026 as received. During an interview on 06/02/2026 at 2:00 p.m., S2 Director of Nursing (DON) reviewed Resident #11's May 2026 MAR and acknowledged the monthly dose of Invega Sustenna 156 mg had not been administered. S2 DON reported the facility did not have Resident #11's monthly dosage in stock and she approved the cost of the medication on 05/28/2026 for the pharmacy to fill. S2 DON reported she informed S10 Unit Manager to enter a new order for the May 2026 monthly dose once the medication was received by the pharmacy. During an interview on 06/02/2026 at 2:20 p.m. S10 Unit Manager, reported Resident #11 did not have an available dose of Invega injection for the May 2026 monthly administration. S10 Unit Manager reported he had called the pharmacy a couple of times and was told Resident #11's dose had been delivered to the facility. S10 Unit Manager reported he found Resident #11's Invega prefilled syringe, yesterday, 06/01/2026. S10 Unit Manager reported he notified the Nurse Practitioner yesterday, 06/01/2026, and a one-time verbal order was received to get Resident #11 back on track. S10 Unit Manager stated it slipped my mind and failed to put in the Invega order for May, 2026. During an interview on 06/02/2026 at 2:30 p.m., S2 DON reviewed the Pharmacy Manifest and acknowledged Resident #11's Invega Sustenna156 mg prefilled syringe was delivered to the facility on [DATE] at 2:51 p.m. S2 DON reported Resident #11's medication should have been administered as soon as received on 05/29/2026 and was not.

Based on record review, observation, and interviews, the facility failed to ensure residents' right to a dignified existence in an environment that promotes maintenance and enhancement of quality of life for 1 (#127) of 1 resident reviewed for dignity. The facility failed to provide privacy for Resident #127 while in a community hall shower room.Findings:Review of the facility's policy titled Resident Rights (version 1.2) revealed, in part:Policy StatementEmployees shall treat all residents with kindness, respect and dignity.Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existenceb. be treated with respect, kindness, and dignity .e. self-determination .h. be supported by the facility in exercising his or her rights .Review of Resident #127's medical record revealed an admission date of 01/23/2026 with diagnoses that included cerebral ischemia, hepatic encephalopathy, and depression.Review of Resident #127's 04/30/2026 quarterly MDS (Minimum Data Set) revealed a BIMS (Brief Interview Mental Status) score of 15, indicating intact cognition. During an interview on 06/02/2026 at 12:10 p.m. Resident #127 reported the shower in resident #127's room had no water pressure and had to use the shower in the shower room across the hall. Resident #127 further reported a few days ago Resident #127 went into the shower room and made sure the sign on the outside of the door was changed to in use. While taking a shower, another resident opened the door which made Resident #127 mad and holler, Can't you read the sign?Observation on 06/02/2026 at 12:20 p.m. revealed 2 shower rooms across the hall from Resident #127's room, at the entrance to Hall A. Further observation revealed signage on the outside of each of the doors that could be changed to open or in use. Observation further revealed both of the door signs read in use and no one was in either of the shower rooms. Observation of the inside of each of the shower rooms also revealed each room was an open room with a shower head on the far wall, nothing to block sight between the door and the shower and each of the doors could not be locked from the inside.During an interview on 06/03/2026 at 1:38 p.m. Resident #127 reported entering the shower room around 8:30 a.m., changed the sign outside of the door to in use, went into shower room, put the shower chair in front of the door, and while taking a shower, a staff member barreled into the shower room. Resident #127 reported being furious when staff came in without knocking and continued to hold the door open even though Resident #127 was uncovered.During an interview on 06/02/2026 at 4:24 p.m. S7 CNA (Certified Nursing Assistant) Coordinator observed all community hall shower rooms with this surveyor and confirmed there were 2 shower rooms on Hall A and 1 shower room on Hall B without anything to block residents in the shower from being seen when the door is open.During an interview on 06/20/2026 at 4:30 p.m. S1 Administrator and S8 Corporate Nurse reported there was nothing to block residents from being seen when a resident was in the shower and the entry door was opened for 2 showers on Hall A and 1 shower on Hall B.

Based on record reviews and interviews, the facility failed to ensure an alleged violation of resident to resident physical abuse was reported to the appropriate state agency within 2 hours after the allegations were made for 2 (#11 and #88) of 27 sampled residents. Resident #11 was subject to physical abuse by Resident #88. Findings: Review of the facility's Protocols for Reporting Abuse undated policy revealed in part: Policy Statement: Each facility will ensure that when suspicion or allegations of abuse occur, reporting and investigations are followed per company protocols. Any Facility that has an allegation of Abuse will follow the Protocols below: Administrator and DON (Director of Nursing) will review Algorithms from state agencies and CMS (Centers for Medicare and Medicaid Services) pertaining to abuse reporting when determining abuse and discuss with RVP's (Regional [NAME] President). An investigation must begin in order to have information pertinent to the two (2) hour time frame reporting (Crimes will be reported within two (2) hours). During an interview on 06/03/2026 at 8:50 a.m. S11 LPN (licensed practical nurse) reported she was the nurse assigned to both Resident #11 and Resident #88 on 01/25/2026. S11 LPN reported on 01/25/2026 around 10:00 a.m. she witnessed Resident #88 push Resident #11 down from behind and Resident #11 fell to the ground. S11 LPN reported she and a CNA (Certified Nursing Assistant) separated the two residents and Resident #11 was put into her room and was assessed to have a facial bruise. S11 LPN reported Resident #88 was placed in the common area by the nurse's station and on 01/25/2026 at around 12:30 p.m. S11 LPN reported Resident #88 pushed Resident #11 down to the floor a second time and started dragging Resident #11 by the hair down the hallway towards the exit. S11 LPN reported Resident #88 was sent to a local emergency room due to behaviors. S11 LPN acknowledged she had not documented the second incident of physical abuse to Resident #11 on 01/25/2026 at 12:30 p.m. or an assessment of Resident #11 and should have.During a one on one interview on 06/03/2026 at 11:30 a.m., Resident #11 reported she and her husband (Resident #88) had an altercation while in the facility and Resident #88 hit her in the face. Resident #11 reported she had a black and blue eye and was afraid when this happened. During an interview on 06/03/2026 at 2:20 p.m., S1 Administrator reported he was aware Resident #88 had behaviors upon discussion with family prior to admission but not to the extent of what happened. S1 Administrator reported Resident #88 was confused due to new environment and was sent to the hospital after he struck his wife, Resident #11. During an interview on 06/03/2026 at 3:00 p.m., S2 DON acknowledged an incident report had not been completed on Resident #11 related to the 01/25/2026 incidents of physical abuse. During an interview on 06/03/2026 at 3:15 p.m., S1 Administrator, acknowledged the physical abuse incidents on 01/25/2026 had not been reported to the appropriate State Agency.

Based on record review and interview the facility failed to accurately assess each resident's respiratory status by failing to ensure the Minimum Data Set (MDS) assessment was accurate for 1 (#37) of 27 total sampled residents.Findings:Review of Resident #37's medical record revealed an admit date of 09/15/2025 with diagnoses that include in part: Unspecified dementia, mild, with anxiety, chronic obstructive pulmonary disease, and obstructive sleep apnea. Review of resident #37's physician orders revealed in part:06/03/2026 Oxygen (02): Change Mask, 02 tubing, water bottle and clean concentrator filter every night shift every Wednesday for maintenance.09/15/2025 Oxygen: Cpap (Continuous Positive Airway Pressure) qhs (every night at bedtime) related to obstructive sleep apnea. 09/15/2025 Oxygen: administer oxygen at 2liter via n/c (nasal cannula) prn (as needed) for sob (shortness of breath) or sat (saturation) >90% every shift related to immunodeficiency due to conditions classified elsewhere; chronic obstructive pulmonary disease, unspecified. Review of Resident #37's quarterly MDS (Minimum Data Set) dated 03/18/2026 revealed in part a brief interview for mental status score of 15 indicating cognitively intact. Further reveiw failed to reveal REsidnet #37 required Oygen or respiratory therpay. During an interview on 06/04/2026 at 11:50 a.m. S4 MDS nurse reviewed Resident #37's medical record and confirmed the MDS dated [DATE] had an inaccurate assessment for respiratory and oxygen use. S4 MDS nurse reported the MDS should have been marked yes for oxygen use and respiratory treatment and was not.

Based on observation and interviews, the facility failed to ensure name, address, and telephone numbers of all pertinent State agencies were posted in a manner accessible to residents and resident representatives. The facility failed to post the LDH (Louisiana Department of Health) nursing home complaint phone number. Findings: Observation throughout facility on 06/03/2026 at 12:10 p.m. with S2 DON (Director of Nursing) revealed LDH Nursing Home complaint phone number was not posted in a place accessible to residents and resident representatives.During an interview on 06/03/2026 at 12:40 p.m. S2 DON reported the LDH Nursing home complaint phone number was not posted.During an interview on 06/04/2026 at 7:45 a.m. S1 Administrator confirmed the LDH Nursing Home complaint phone number was not posted.

Based on record reviews and interview the facility failed to provide documentation regarding the existence of any written advance directives for 2 (#4, #20) of 2 residents reviewed for Advanced Directives.Findings:Review of the facility's policy titled Advance Directives (revised May 31, 2023) revealed:Policy StatementAdvance directives will be respected in accordance with state law and facility policy.Policy Interpretation and Implementation1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Resident #4Review of Resident #4's medical record revealed an admission date of 08/30/2024 with diagnoses that included, in part, chronic pulmonary edema, diabetes mellitus, unstable angina, myocardial infarction, atherosclerotic heart disease of native coronary artery without angina pectoris, and essential (primary) hypertension.Review of Resident #4's Advanced Medical Directives Form dated 09/01/2024 revealed a section of the form which read: Please note whether an Advanced Directive has been executed: was incomplete with no box checked to indicate whether or not an Advanced Directive had been executed. Resident #20Review of Resident #20's medical record revealed an admission date of 10/06/2025 with diagnoses that included, in part, chronic obstructive disease pulmonary disease unspecified, type 2 diabetes mellitus, dementia in other diseases classified elsewhere mild with agitation, and atherosclerotic heart disease of native coronary artery without angina pectoris.Review of Resident #20's Advanced Medical Directives Form signed on 10/06/2025 revealed a section of form which read: Please note whether an Advanced Directive has been executed: was incomplete with no box checked to indicate whether or not an Advanced Directive had been executed.During an interview on 06/02/2026 at 3:53 p.m. S1 Administrator and S8 Corporate Nurse reviewed Resident #4 and Resident #20's Advanced Medical Directives Forms and confirmed the section which had unchecked boxes to indicate whether or not an Advanced Directive had been executed should have been completed and was not.

Based on record reviews, observations, and interviews, the facility failed to ensure that each resident receives necessary respiratory care and services in accordance with professional standards of practice and the resident's plan of care for 2 (#54, #116) of 4 (#54, #75, #89, #116) residents reviewed for respiratory care. The facility failed to change the oxygen tubing and humidification bottle, change the nebulizer mask or provide a cover for the oxygen tubing and nebulizer mask when not in use for Resident #54 and Resident #116, Findings: Review of the facility policy for Oxygen Administration revised 02/2025, revealed in part: Preparation: 5. Oxygen cannula and tubing will be changed within 7-10 days or if visibly soiled/ Store in a covered device (i.e. plastic bag, kangaroo pouch) between uses. Infection Control Considerations and Maintenance related to Medication Nebulizers 6. Nebulizer Tubing will be changed within 7-10 days, or if visibly soiled. 7. Store nebulizer equipment in a covered device (i.e. plastic bag, kangaroo pouch) between uses. Resident #54 Review of Resident #54's medical record revealed an admitted [DATE] with diagnoses that included in part: heart failure, cardiomyopathy, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease with (acute) exacerbation. Review of Resident #54's physician orders revealed in part orders dated: 01/29/2025 Albuterol-Budesonide Inhalation Aerosol 90-80 mcg/act (micrograms/actuation) (Albuterol-Budesonide) 1 inhalation inhale orally every 6 hours as needed for wheezing related to chronic obstructive pulmonary disease with (acute) exacerbation. 01/29/2025 Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligram/milliliter) 1 vial inhale orally every 6 hours as needed for wheezing. Observation on 04/07/2025 at 6:20 a.m. of Resident #54's oxygen tubing and humidification tubing failed to reveal a date. Further observation revealed Resident #54's nasal cannula and nebulizer mask was not stored in a covered device. During an interview on 04/07/2025 at 6:50 a.m. Resident #54 reported the nurses change the tubing about once a month or so but he did not have a bag to store the oxygen tube or nebulizer mask. During an interview on 04/07/2025 at 6:55 a.m. S8 Unit Manager confirmed the oxygen tubing, humidification bottle and the nebulizer mask should have been dated, and bagged when not in use and were not. Resident #116 Review of Resident #116's medical record revealed in part an admitted [DATE] with diagnoses that include in part type 2 diabetes mellitus, chronic respiratory failure with hypoxia and essential (primary) hypertension. Review of Resident #116's physician orders revealed in part orders dated: 03/05/2025 Ventolin HFA (hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for SOB (shortness of breath). 03/05/2025 Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally three times a day for COPD (chronic obstructive pulmonary disease) 02/07/2025 Breztri Aerosphere Inhalation Aerosol 160-9-4.8 MCG/ACT (Budesonide-Glycopyrrolate-Formoterol Fumarate) Breztri Aerosphere Inhalation Aerosol 160-9-4.8 MCG/ACT (Budesonide-Glycopyrrolate-Formoterol Fumarate) 02/07/2025 Oxygen: Change Mask, 02 (oxygen) tubing, water bottle and clean concentrator filter every night shift every Wednesday change tubing label and date and as needed for contamination. 02/07/2025 02 2L Nasal Cannula as needed Observation on 04/07/2025 at 6:20 a.m. revealed Resident #116's oxygen concentrator at bedside with undated, un-bagged nasal cannula draped over the concentrator, and humidification bottle dated 03/13/2025. Further observation revealed Resident #116's nebulizer sitting on bedside table, undated and not stored in a covered device. Observation on 04/07/2025 at 7:00 a.m. S8 Unit Manager verified oxygen concentrator at bedside with undated, un-bagged nasal cannula draped over the concentrator, and humidification bottle dated 03/13/2025. Further observation revealed Resident #116's nebulizer sitting on bedside table, undated and not stored in a covered device. During an interview on 04/07/2025 at 7:00 a.m. S8 Unit Manager reported Resident #116's tubing should have been changed every week and stored in covered device when not in use. 39897

Based on record reviews and interviews, the facility failed to develop and implement residents comprehensive care plan for 2 (#116, #225) out of 40 total sampled residents reviewed. The facility failed to: 1. develop Resident #116's plan of care to include diabetes with insulin use, diuretic use and oxygen use, and 2. monitor Resident #225's urinary catheter for urine color and consistency. Findings: Resident #116 Review of Resident #116's medical record revealed in part an admitted [DATE] with diagnoses that include in part: type 2 diabetes mellitus, chronic respiratory failure with hypoxia and essential (primary) hypertension. Review of Resident #116's physician's orders revealed in part orders dated: 02/07/2025 O2 (oxygen) at 2 Liters via N/C (nasal cannula) PRN (as needed) for SOB (shortness of breath) or Sat (saturation) < (less than) 90% O2 sat Q (every) shift. 04/01/2024 Valsartan-hydrochlorothiazide oral tablet 160-25 mg (milligram) (valsartan-hydrochlorothiazide) give 1 tablet by mouth one time a day for hypertension hold for blood pressure under 110/60. 02/14/2025 Humalog Subcutaneous solution cartridge 100 unit/ml (milliliter) (insulin Lispro) inject as per sliding scale: if 150-200=2 units; 201-250 =4 units; 251-300=6 units; 301-350 =8 units; 351-400=10 units; [PHONE NUMBER]=12 units, subcutaneously before meals and at bedtime for DM2 (type 2 diabetes mellitus). Review of Resident #116's comprehensive care plan failed to reveal Resident #116 had been care planned with appropriate interventions for type 2 diabetes mellitus and the use of insulin, diuretic use, and oxygen. During an interview on 04/09/2025 at 8:00 a.m. S9 Assistant Administrator reported Resident 116's comprehensive care plan did not include appropriate interventions for type 2 diabetes mellitus and the use of insulin, diuretic use, and oxygen and should have. During an interview on 04/09/2025 at 8:15 a.m. S11 MDS (Minimum Data Set) Coordinator reviewed and confirmed Resident #116 was not care planned for type 2 diabetes mellitus and the use of insulin, diuretic use, and oxygen and should have been. Resident #225 Review of facility's Catheter Care, Urinary Policy (revised January 3, 2023) revealed in part: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Documentation - The following information should be recorded in the resident's medical record: 4. character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood). Review of Resident #225's medical record revealed an admitted [DATE] with the following diagnoses, including in part: urinary tract infection/site not specified, other chronic cystitis without hematuria, retention of urine, unspecified and other obstructive and reflux uropathy. Review of Resident #225's comprehensive care plan revealed: .urinary catheter monitor urine color, 1 = yellow, 2 = bloody, 3 = dark, if not = 1 notify MD (Medical Director) every shift; urinary catheter monitor urine consistency, 1 = clear, 2 = cloudy, 3 = mucus every shift. Review of Resident #225's medical record failed to reveal urine color and consistency were monitored. During an interview on 04/09/2025 at 11:00 a.m. S7 LPN (Licensed Practical Nurse) acknowledged Resident #225's urine color and consistency were not monitored. During an interview on 04/09/2025 S8 Unit Manager acknowledged Resident #225's urine color and consistency were not monitored. Resident #75 39897 40193

Based on record reviews and interviews the facility failed to consider the views of residents' grievances voiced during Resident Council Meeting. The facility failed to act promptly upon 1 (#79) of 1(#79) resident's grievances concerning issues of resident care and life in the facility. Findings: Review of the facility's Resident Grievance/Complaints, Recording and Investigating Policy (revised November 2023) revealed in part: Policy Statement: All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance (s). Policy Interpretation and Implementation: 1. Administrator has assigned the responsibility of investigating grievances and complaints to the Grievance Officer. 2. Upon receiving a grievance and complaint report, the Grievance Officer will begin an investigation into the allegations. 3. The department director (s) of any named employee (s) will be notified of the nature of the complaint and that an investigation is underway. 4. The investigation and report will include, as applicable: g. Accounts of any other individuals involved (i.e. employee's supervisor, etc.; 5. The Grievance Officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: a. the date of the grievance/complaint was received. B. the name and room number of the resident filing the grievance/complaint (if available). D. the date the alleged incident took place. E. the name of the person (S) investigating the incident. F. the date the resident, or interested party, was informed of the findings. G. the disposition of the grievance (i.e., resolved, dispute, etc.). 6. The resident Grievance/Complaint Form will be filed with the Administrator within five (5) working days of the incident. 7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within five (5) working days of the filing of the grievance or complaint. 9. Copies of reports will be made available to the resident or resident representative acting on behalf of the resident upon request. Review of #79's medical record revealed an admitted [DATE] with the following diagnoses, including in part: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle wasting and atrophy/not elsewhere classified/multiple sites , other reduced mobility and contracture of muscle left hand. Review of #79's MDS (Minimal Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 15 (cognitively intact). Further review revealed a functional status of: extensive assistance with one person assist for bed mobility, transfer, and toilet use. Review of the facility's Resident Council Minutes dated 03/20/2025 revealed: Grievances or Complaints (can be anonymous) - .S4 CNA (Certified Nursing Assistant) does not tend to Resident #79 as much for example not tending to him, made him late for the meeting. When S4 CNA has an attitude and acts like it's not his job. Review of the facility's Grievance Log failed to reveal Resident #79's grievance from the 03/20/2025 Resident Council Meeting. Further review failed to reveal a Grievance/Complaint Form filled out concerninging Resident #79's grievance about S4 CNA. During the Resident Council Meeting on 04/07/2025 at 1:30 p.m. Resident #79 reported he had not heard anything about his grievance concerning S4 CNA. Resident #79 further reported S4 CNA was lazy and did not help him or the other residents; especially those who cannot do for themselves. During an interview on 04/09/2025 at 8:25 a.m. S5 Activities Director reported she typed up Resident #79's grievance regarding S4 CNA and turned it in to S1 Administrator. During an interview on 04/09/2025 at 10:50 a.m. S1 Administrator reported he was aware of Resident #79's grievance regarding S4 CNA. S1 Administrator acknowledged the facility's policy reads, in part, complaint findings are to be discussed with the complainant within five working days of receiving the grievance. S1 Administrator further acknowledged the grievance was not on the grievance log, a grievance form was not completed, and he had not followed up with Resident #79 of the findings.

Based on record reviews, observation, and interviews the facility failed to ensure it was clinically appropriate for a resident to self-administer medications for 1 (Resident #54) of 41 Sampled Residents. Findings: Review of the facility's Administering Medications policy dated as revised April 2019 revealed in part: Policy Interpretation and Implementation 23. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of resident #54's Physician Orders revealed in part orders dated: 1. 01/29/2025 Albuterol-Budesonide Inhalation Aerosol 90-80 mcg/act (microgram/actuation) (Albuterol-Budesonide) 1 inhalation inhale orally every 6 hours as needed for wheezing related to chronic obstructive pulmonary disease . 2. 01/29/2025 Ipratropium-Albuterol Solution 0.5-2.5 (3) mg(milligram) /3 ml (milliliter) 1 vial inhale orally every 6 hours as needed for wheezing. Review of March/April 2025 Medication Administration Record documentation failed to reveal Albuterol inhalation medications had been administered. Observation on 04/07/2025 at 6:50 a.m. with S8 Unit Manager revealed Resident #54 was sitting on his bedside self-administering nebulizer treatment. A large shoe-box sized box full of empty Albuterol respiratory treatment vials was observed on the floor. During an interview on 04/07/2025 at 6:50 a.m. Resident #54 reported the nurses left treatment vials in the nebulizer and he administered the treatments when he needed them. Resident #54 further reported he just threw the empty vials in the box on the floor and the nurse's did not check, he just administered the treatments himself when he needed them. During an interview on 04/07/2025 at 6:55 a.m. S8 Unit Manager reported the nurses should be administering the nebulizer treatments, and Resident #54 should not be giving himself the treatments. During an interview on 04/08/2025 at 2:20 p.m. S8 Unit Manager verified Resident #54 did not have an order, a consent, or assessment for self administration of medication and should have.

Based on record reviews and interviews, the facility failed to ensure appropriate care and services were provide for 1 (#52) of 1 (#52) resident reviewed for dialysis. The facility failed ensure Resident #52s dialysis shunt was accurately assessed and monitored. Findings: Review of the facilitys policy for End-Stage Renal Disease Care of a resident (revised September 2010) revealed in part: 2. b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. 3. The resident's comprehensive care plan will reflect the resident's needs related to ESRD (end stage renal disease) Dialysis care. Review of Resident #52's medical record revealed an admitted [DATE] and diagnoses that include in part type 2 diabetes mellitus with other diabetic kidney complications, benign prostatic hyperplasia without lower urinary tract symptoms and dependence on renal dialysis. Review of Resident #52's comprehensive care plan revealed resident #52 was care planned for dialysis with approaches that included, may have dialysis Monday, Wednesday and Friday, observe for signs and symptoms of bleeding, hemorrhage, bacteremia. Review of Resident #52's medical record failed to reveal Resident #52's dialysis shunt was accurately assessed and monitored During an interview on 04/08/2025 at 2:30 p.m. Resident #52 reported he received dialysis Mondays, Wednesdays and Fridays and indicated the facility nurse did not assess and monitor his dialysis shunt. During an interview on 04/08/2025 at 1:20 p.m. S16 Unit Manager confirmed Resident #52 received dialysis. S16 Unit Manager reviewed Resident #52's medical record failed to reveal documentation Resident #52s dialysis shunt was accurately assessed and monitored.

Based on record reviews, observations, and interviews the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to installation and use for 2 (#43, #80) of 2 residents reviewed for accident hazards. Findings: Review of the facility's Proper Use of Side Rails policy dated as revised August 2024 revealed in part: General Guidelines 3. Upon admission, readmission, with routine quarterly or significant change MDS (Minimum Data Set) and PRN (as needed), therapy/designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation, When used for mobility or transfer, the assessment will include a review of the resident's: c. Risk of entrapment from the use of side rails; and 5. The resident's care plan will reflect the use of side rails and updated as necessary. Resident #43 Review of Resident #43's medical record revealed Resident #43 was admitted on [DATE] with diagnoses that included, in part, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, lack of coordination, difficulty in walking, Parkinson's disease with dyskinesia, and generalized muscle weakness. Review of Resident #43's April 2025 Physician Orders revealed an order dated 09/18/2024 for bilateral assist rails to promote independence in bed mobility, check for placement and functioning every shift. Review of Resident #43's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. Further review of the MDS revealed Resident #43 required extensive one person assistance for bed mobility, transfers, and toilet use. During the survey dates of 04/07/2025 to 04/10/2025 observations revealed Resident #43 had bilateral bed assist rails in use. Review of Resident #43's medical record failed to reveal documentation of an assessment for risk of entrapment from bed rails prior to installation and use. Resident #80 Review of Resident #80's medical record revealed diagnoses that included, in part, right femur fracture, generalized osteoarthritis, cognitive communication deficit, lack of coordination, and repeated falls. Review of Resident #80's April 2025 Physicians Orders revealed an order dated 08/06/2024 for bilateral assist rails to promote independence and bed mobility, check for placement and functioning every shift. Review of Resident #80's MDS assessment dated [DATE] revealed Resident #80 had a BIMS of 3 which indicated severely impaired cognition. Further review of the MDS revealed Resident #80 required extensive one person assistance for bed mobility, transfers, and toilet use. During the survey dates of 04/07/2025 to 04/10/2025 observations revealed Resident #80 had bilateral bed assist rails in use. Review of Resident #80's medical record failed to reveal documentation of an assessment for risk of entrapment from bed rails prior to installation and use. During an interview on 04/08/2025 at 1:27 p.m. S2 Director of Nursing reviewed Resident #43 and Resident #80's medical records and acknowledged there was not documentation of an assessment for risk of entrapment from bed rails prior to installation and use. 36665

Based on record reviews and interviews the facility failed to complete a significant change assessment for 1 (#75) of 3 (#14, #75, #84) residents reviewed for hospitalization . The facility failed to complete a significant change assessment after Resident #75 was diagnosed with a cerebral vascular infarction resulting in right dominant side hemiplegia. Findings: Review of Resident #75's medical record revealed an initial admitted [DATE] and a readmitted [DATE] with a new diagnosis hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Review of Resident #75's Nurse Practitioner's progress note dated 03/10/2025 revealed Resident #75 had been admitted to the hospital from 02/22/2025 to 03/04/2025 and treated for weakness, confusion, and bilateral ptosis. An MRI (magnetic resonance imaging) on 02/26/2025 revealed Resident #75 had experienced a new cerebral vascular accident. Resident #75 was readmitted to the facility on [DATE] with a new diagnosis of a CVA (cerebral vascular accident) with hemiplegia affecting the right dominant side. Review of Resident #75's Quarterly MDS (minimum data set) assessment dated [DATE] revealed Resident #75 was assessed to have a BIMS (brief interview mental status) of 13 indicating intact cognition and to have a new diagnosis of hemiplegia affecting Resident #75's right dominant side. Further review failed to reveal a significant change assessment had been completed in connection with Resident #75's new diagnosis of CVAwith hemiplegia affecting the right dominant side on 03/04/2025. During an interview on 04/09/2025 at 10:00 a.m. S11 MDS Coordinator confirmed a significant change assessment should have been completed after Resident #75's readmission to the facility on [DATE] with a new diagnosis of CVA with hemiplegia and dysphagia. During an interview on 04/09/2025 at 10:30 a.m. S2 DON (Director of Nurses) confirmed a significant change MDS should have been completed after Resident #75's readmission to the facility on [DATE] with a new diagnosis of CVA with hemiplegia and dysphagia.

Based on record reviews, observations, and interview, the facility failed to accommodate the needs of 3 (#26, #30, #325) of 41 sampled residents. The facility failed to ensure the resident's call lights remained in reach. Findings: Review of the facility's Resident Call Light System Policy revealed the following: Purpose: A call light system (audible or visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and or bathing and toileting facilities. General Guidelines 4. Ensure that the call light is easily reachable by the resident. Resident #26 Review of Resident #26's MDS (Minimum Data Set) assessment dated [DATE] revealed severe cognitive impairment and functional limitations requiring one person assistance for bed mobility, transfer, and toilet use. Observation on 04/07/2025 at 6:15 a.m. revealed Resident #26 was sitting in a chair at the bedside, with the call light on the other side of the bed, behind the bedside dresser out of Resident #26's reach. Observation on 04/07/2025 at 6:40 a.m. with S8 Unit Manager revealed Resident #26's the call light was on the other side of the bed, behind the bedside dresser, and out of Resident #26's reach. During an interview on 04/07/2025 at 6:40 a.m. S8 Unit Manager verified Resident #26's call light was not in reach. Resident #30 Review of Resident #30's MDS assessment dated [DATE] revealed Resident #30 had a BIMS (brief interview mental status) score of 3 indicating severe impaired cognition and required extensive one person assistance with bed mobility, limited one person physical assistance with transfers, and extensive one person assistance with toilet use. Observation on 04/07/2025 at 6:00 a.m. with S15 LPN (Licensed Practical Nurse) revealed Resident #30's call light was lying on the floor out of Resident #30's reach. During an interview on 04/07/2025 at 6:00 a.m. S15 LPN confirmed Resident #30's call light should have been pinned to her bed linen within her reach. Resident #325 Review of Resident #325's MDS assessement dated 03/10/2025 revealed moderate cognitive impairment and functional limitations requiring extensive one person assistance for bed mobility and toilet use and extensive two person assistance for transfers. Observation on 04/07/2025 at 6:20 a.m. revealed Resident #325 was lying in bed, with the call light on the floor behind bedside dresser, out of Resident #325's reach. Observation on 04/07/2025 at 6:40 a.m. with S8 Unit Manager revealed Resident #325's call light was on the floor behind bedside dresser and out of Resident #235's reach. During an interview on 04/07/2025 at 6:40 a.m. S8 Unit Manager verified Resident #325's call light was not in reach. 39897

Based on record reviews and interviews, the facility failed to ensure residents were free from unnecessary medications for 3 (#46, #52, #54) out of 8 (#10, #23, #46, #50, #52, #54, #90, #115, #117) residents review for unnecesary medications . The facility failed to monitor Resident #46, Resident #52, and Resident #54 for edema while receiving a diuretic. Findings: Resident #46 Review of Resident #46's medical records revealed an admitted [DATE] with the following diagnoses, including in part: localized edema and hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Review of Resident #46's Physician's Orders revealed an order dated 04/01/2025 for Furosemide Oral Tablet 20 mg (milligram) give 0.5 tablet by mouth one time a day for edema. Review of Resident #46's March and April 2025 Medication Administration Records and Treatment Administration Records failed to reveal monitoring for edema while receiving a diuretic. During an interview on 04/09/2025 at 2:15 p.m. S8 Unit Manager acknowledged Resident #46 was not monitored for edema while receiving a diuretic and should have been. Resident #52 Review of Resident #52's medical record revealed an admitted [DATE] with diagnoses that include in part chronic diastolic (congestive) heart failure, shortness of breath, benign prostatic hyperplasia without lower urinary tract symptoms, obesity, edema, type 2 diabetes mellitus with other diabetic kidney complication, and essential (primary) hypertension. Review of Resident #52's Physician's Orders revealed and order dated 2/15/2025 for Furosemide Tablet 80 mg give 1 tablet by mouth one time a day for edema. Review of Resident #52's March and April 2025 Medication Administration Records and Treatment Administration Records failed to reveal monitoring for edema while receiving a diuretic. During an interview on 04/08/2025 at 1:20 p.m. S8 Unit Manager verified Resident #52 was not being monitored for edema and stated, I know if it's not documented, it's not done. and should have been. Resident #54 Review of Resident #54's medical record revealed an admitted [DATE] with diagnoses that include in part heart failure, cardiomyopathy, and chronic obstructive pulmonary disease. Review of Resident #54's Physician Orders revealed in part an order dated 1/30/2025 Furosemide Tablet 40 mg give 1 tablet by mouth one time a day related to heart failure. Review of Resident #52's March and April 2025 Medication Administration Records and Treatment Administration Records failed to reveal monitoring for edema while receiving a diuretic. During an interview on 04/09/2025 at 1:35 p.m. S9 Assistant Administrator and S2 Director of Nursing reviewed Resident #54's medical record and verified there was no documentation that Resident #54 was being monitored for edema and should have been. 40193

Based on record reviews and interviews the facility failed to ensure resident drug regimens were free of unnecessary medications for 1 (#117) of 5 (#10, #23, #90, #115, #117) residents reviewed for unnecessary medications. The facility failed to ensure monitoring of side effects and behaviors had been conducted on Resident #117 who received psychotropic medications. Findings: Review of Resident #117's medical record revealed Resident #117 was admitted on [DATE] with diagnoses that included, in part, malignant neoplasm of rectum and depression. Review of Resident #117's April 2025 Physician Orders revealed the following: An order dated 02/18/2025 for Amitriptyline HCL (hydrochloride) 25 mg (milligram) tablet give 1 tablet by mouth once daily. An order dated 02/19/2025 for Buspirone HCL 10 mg tablet give 1 tablet by mouth 3 times a day. An order dated 04/03/2025 for Lorazepam tablet 0.5 mg give 1 tablet by mouth every 6 hours as needed for anxiety. Review of Resident #117's March and April 2025 Medication Administration Records failed to reveal documentation that monitoring of side effects and behaviors had been conducted for Resident #117 who was receiving antidepressant and antianxiety medications. During an interview on 04/09/2025 at 3:30 p.m. S2 Director of Nursing reviewed Resident #117's medical record and confirmed Resident #117 received antidepressant and antianxiety medications and there was no documentation that monitoring of side effects and behaviors had been conducted.

Based on record reviews, observations and interviews, the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. The facility failed to ensure 1 out of 4 medication carts and 1 out of 3 medication rooms contained unexpired medications. Findings: Review of the facility's Storage of Medications policy dated as revised April 2019 revealed in part: Policy Statement - The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 23. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Observation of Medication Room A on 04/09/2025 at 3:25 p.m. revealed following expired and discontinued medications: 1. Resident #5- blister pack - Sumatriptan Succinate (milligram) 1 tablet as needed - expiration date of 02/2025. 2. Resident #59 - discontinued blister pack - Metoprolol Tartrate 25 mg 1 tablet by mouth twice a day with an expiration date of 11/20/2024. 3. Resident #85 - discontinued blister pack - Ondansetron HCL (hydrochloride) 4 mg 1 tablet every 4 hours as needed for nausea/vomiting with an expiration date of 11/20/2024. 4. Resident #25 - discontinued blister pack - Ondansetron HCL 4 mg 1 tablet every 6 hours as needed with an expiration date of 02/08/2025. During an interview on 04/09/2025 at 3:25 p.m. S6 LPN (Licensed Practical Nurse) acknowledged Resident #5's medication Sumatriptan Succinate 1 tablet as needed had an expiration date of 02/2025, Resident #59's blister pack of Metoprolol Tartrate 25 mg 1 tablet by mouth twice a day had an expiration date of 11/20/2024, Resident #85's blister pack of Ondansetron HCL 4 mg 1 tablet every 4 hours as needed for nausea/vomiting had an expiration date of 11/20/2024, and Resident #25 - discontinued blister pack - Ondansetron HCL 4 mg 1 tablet every 6 hours as needed had an expiration date of 02/08/2025. S6 LPN further acknowledged the expired medications should not be in the medication room. Observaton of Medication Cart B on 04/10/2025 at 11:30 a.m revealed the following expired medications: 1. Acetaminophen 500 mg tablets with an expiration date of 10/2024 for general stock. 2. Resident #72's blister pack for Keppra 500 mg 1 tablet by mouth 2 times a day with an expiration date of 02/28/2025. During an interview on 04/10/2025 at 11:30 a.m. S7 LPN acknowledged Acetaminophen 500 mg tablets had an expiration date of 10/2024 and Resident #72's blister pack for Keppra 500 mg 1 tablet by mouth 2 times a day had an expiration date of 02/28/2025.

Based on record review, video review, an interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently by failing to have an adequate system in place to ensure 3 (#1, #5, #6) of 6 (#1, #2, #3, #4, #5, #6) sampled residents who were at risk for elopement were adequately supervised to prevent elopement from the facility. The lack of administrative oversight resulted in an Immediate Jeopardy on 04/07/2024 at 2:50 a.m. when Resident #1, a moderately cognitively impaired resident who ambulated with a walker, was unsupervised and eloped from the facility. Resident #1 crawled out of the window in her room and exited the facility. Staff did not realize Resident #1 eloped from the facility until staff received a phone call from S9 Responsible Party, reporting the Resident #1 was found at a gas station. Resident #1 was located at a gas station approximately one mile from the facility, Resident #1 walked down a dark single lane highway and a 4 lane divided highway during the night. Resident #1 was returned to the facility on [DATE] at approximately 3:30 a.m. by S9 Responsible Party. Resident #1 was assessed on 04/04/2024 as at risk for elopement and protective measures had not been put into place related to Resident #1's recent documented history of exit seeking behaviors. Review of facility video surveillance from 09/19/2024 from 11:18 p.m. until 5:18 a.m. revealed staff were not performing visual checks on remaining residents (Resident #5 and Resident #6) who resided on Hall A and were identified at risk for elopement. The facility's system to adequately supervise residents every two hours according to the facility's routine resident checks policy is deficient. S3 Assistant Administrator and S2 Corporate Nurse were notified of the Immediate Jeopardy on 09/24/2024 at 5:20 p.m. This deficient practice had the likelihood to cause more than minimal harm to the remaining ten residents at risk for elopement residing in the facility. The Immediate Jeopardy was removed on 09/25/2024 at 10:18 a.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit. Findings: Cross Reference F689 Review of facility's Wandering and Elopements Policy and Procedure (revised November 15, 2023) revealed in part: Policy: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measures to help guard against a resident wandering from the facility. Review of facility's Routine Resident Checks Policy Statement (09/23/2024) revealed in part: Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretation and Implementation: 1. to ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each resident at least four times per each 8-hour shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs. During a review on 09/24/2024 at 11:55 a.m. of the facility's video surveillance on the Hall A dated 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift with S2 Corporate Nurse and S3 Assistant Administrator revealed staff failed to perform visual checks every 2 hours on residents. Resident #5 and Resident #6 resided on Hall A and were identified at risk for elopement. During an interview on 09/24/2024 at 12:25 p.m. S2 Corporate Nurse acknowledged video surveillance of the Hall A on 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift revealed rounding was not completed every 2 hours and should have been done. S2 Corporate Nurse further acknowledged the nurse on duty did not enter the rooms to perform visual checks on the residents every 2 hours according to facility policy. S2 Corporate Nurse acknowledged the lack of supervision had the potential to adversely affect the remaining ten residents identified at risk for elopement. S2 Corporate Nurse acknowledged the facility failed to ensure nurses were performing visual checks and CNAs were rounding every two hours. S2 Corporate Nurse reported administration should be monitoring the night shifts to ensure monitoring every two hours is being completed. During an interview on 09/24/2024 at 12:25 p.m. S3 Assistant Administrator acknowledged video surveillance of the Hall A on 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift revealed rounding was not completed every 2 hours and should have been done. S3 Assistant Administrator further acknowledged the nurse on duty did not enter the rooms to perform visual checks on the residents.

Based on record reviews, video review, and interviews the facility failed to supervise cognitively impaired residents who were high risk for elopement. Resident #1 exited the facility and Residents #5 and #6 remained at high risk for elopement, 3 (#1, #5, #6) of 6 (#1, #2, #3, #4, #5, #6) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy (IJ) on 04/07/2024 at 2:50 a.m. when Resident #1, a moderately cognitively impaired resident who ambulated with a walker, was unsupervised and eloped from the facility. Resident #1 crawled out of the window in her room and exited the facility. Staff did not realize Resident #1 eloped from the facility until staff received a phone call from the S9 Responsible, reporting the Resident #1 was found at a gas station approximately one mile from the facility. Resident #1 walked down a dark single lane highway and a 4 lane divided highway during the night. Resident #1 was returned to the facility on [DATE] at approximately 3:30 a.m. by S9 Responsible Party. The IJ continued as a review of facility video surveillance from 09/19/2024 from 11:18 p.m. until 5:18 a.m. revealed staff were not performing visual checks on remaining residents (Resident #5 and Resident #6) who resided on Hall A and were identified at risk for elopement. The facility's system to adequately supervise residents every two hours according to the facility's routine resident checks policy is deficient. S3 Assistant Administrator and S2 Corporate Nurse were notified of the Immediate Jeopardy on 09/24/2024 at 5:20 p.m. This deficient practice had the likelihood to cause more than minimal harm to the remaining ten residents at risk for elopement residing in the facility. The Immediate Jeopardy was removed on 09/25/2024 at 10:18 a.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit. Findings: Review of facility's Wandering and Elopements Policy and Procedure (revised November 15, 2023) revealed in part: Policy: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measures to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. Identifying residents at risk: 2. if identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Wandering and elopement protocols: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or Director of Nursing (DON). 2.Instruct another staff member to inform charge nurse or DON that a resident has left the premises. 3. When the resident returns to the facility, the DON or charge nurse shall: examine the resident for injuries, notify the attending physician and report findings .complete and file report of incident/accident, document the event in the resident's medical record and notify regulatory agencies per state guidelines as indicated. Review of facility's Routine Resident Checks Policy Statement (no date) revealed in part: Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretation and Implementation: 1. to ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each resident at least four times per each 8-hour shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs. Review of the Resident #1's medical record revealed an admitted [DATE] with diagnoses including but not limited to: chronic obstructive pulmonary disease/unspecified, heart failure/unspecified, chronic kidney disease/unspecified, depression/unspecified, insomnia/unspecified, problems related to living alone, at risk for elopement and history of falling. Review of Resident #1's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #1 had a BIMS score of 10, indicating moderate cognitive impairment. Review of Resident #1's Elopement assessment dated [DATE] revealed an elopement score of 3.0 indicating resident is at risk. (Score > = 1 = At Risk for Elopement). Review of an internet mapping site revealed Resident #1 was located approximately 1 mile from the facility and had to walk down a single lane highway and a 4 lane divided highway at night. Review of Resident #1's Physician's orders revealed an order dated 04/04/2024 to perform visual census checks, resident at risk for wandering, exit seeking behaviors, and elopement every 2 hours for elopement risk. Review of Resident #1's progress notes revealed an entry on 04/04/2024 at 5:53 p.m. read in part, Resident #1 sitting near front door crying with bags packed. When asked what was wrong, resident stated she wants to go home, she is not going back to her room . Will notify all staff to monitor res closely. Further review revealed a late entry on 04/07/2024 at 3:18 a.m. read in part, at approximately 2:50 a.m. staff nurse received a phone call from Resident #1's S9 Responsible Party, stating Resident #1 was found at a gas station. Staff on shift had previously observed resident or what appeared to be the resident asleep in the bed. Upon further inspection, it was noted by staff that the bed was stuffed with pillows and blankets to resemble a body asleep in bed. Upon searching by staff, resident was not found anywhere in the building. The window in Resident #1's room was observed by staff to be raised open, which leads to the outside of the building area. At approximately 3:30 a.m. resident was returned to the facility via S9 Responsible Party . Will continue to monitor and maintain safety measures while on shift. During a telephone interview on 09/19/2024 at 3:50 p.m. S9 Responsible Party of Resident #1, reported resident has dementia and was transferred to a memory care unit. S9 Responsible Party further reported she thought staff were supposed to be doing checks every 2 hours on the residents. S9 Responsible Party confirmed on 04/07/2024 at approximately 3:00 a.m. a gas station clerk notified her Resident #1 was wandering in the parking lot. S9 Responsible Party reported on 04/07/2024 she picked up Resident #1 from the gas station and returned her to the facility at approximately 3:30 a.m. S9 Responsible Party further reported on the way back to the facility she contacted the facility and requested staff check on Resident #1. S9 Responsible Party reported staff confirmed Resident #1 was not in her room. During an interview on 09/23/2024 at 10:10 a.m. S5 Receptionist reported she had witnessed Resident #1 following visitors and/staff out of the locked double doors to the front entrance of the facility prior to 04/07/2024. S5 Receptionist further reported she witnessed Resident #1 during the week of 04/01/2024 walking out behind someone and noticed her walking down the street not realizing she was a resident. S5 Receptionist reported staff was notified and Resident #1 was brought back to the facility. During a telephone interview on 09/23/2024 at 11:45 a.m. S8 Licensed Practical Nurse (LPN) confirmed she worked on 04/07/2024 when Resident #1 eloped. S8 LPN confirmed the night of 04/07/2024 Resident #1's S9 Responsible Party called and told staff she was on her way to pick up Resident #1 at the gas station. S8 LPN reported Resident #1 left out the window in her room. During an interview on 09/23/2024 at 12:15 p.m. S10 Business Office reported Resident #1 would see her put her purse on and follow her to the front door, wanting to leave. During a telephone interview on 09/23/2024 at 11:38 a.m. S6 Former Assistant Director of Nursing (ADON) reported Resident #1 had behaviors of wanting to leave the facility. During an interview on 09/23/2024 at 1:20 p.m. S4 DON reported Resident #1 always had her bag packed and had exhibited exit seeking behaviors. During an interview on 09/23/2024 at 2:20 p.m. S2 Corporate Nurse reported Resident #1 had been exhibiting exit seeking behaviors. S2 Corporate Nurse further reported Resident #1 would carry her bags around wanting to go home. During a review on 09/24/2024 at 11:55 a.m. of the facility's video surveillance of Hall A dated 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift with S2 Corporate Nurse and S3 Assistant Administrator revealed staff failed to perform visual checks every 2 hours on residents. Resident #5 and Resident #6 resided on Hall A and were identified at risk for elopement. Review of Resident #5's medical records revealed an admitted [DATE] with diagnoses including but not limited to: cognitive communication deficit, dementia in other diseases classified elsewhere/moderate with anxiety, insomnia/unspecified, schizoaffective disorder/bipolar type, and major depressive disorder/recurrent/moderate. Review of Resident #5's MDS assessment dated [DATE] revealed a BIMS score of 1 (severely cognitively impaired). Review of Resident #5's Elopement Risk Evaluation dated 09/23/2024 revealed a score of 1.0 (Score > = 1 = At Risk for Elopement) indicating at risk for elopement. Review of Resident #5's Physician's orders revealed an order dated 08/23/2024 to perform visual census checks, resident at risk for wandering, exit seeking behaviors, elopement every 2 hours. Review of Resident #6's medical records revealed an admitted [DATE] with diagnoses including but not limited to: unspecified dementia/unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #6's MDS assessment dated [DATE] revealed a BIMS score of 00 (severely cognitively impaired). Review of Resident #6's Elopement Risk Evaluation dated 09/23/2024 revealed a score of 1.0 (Score > = 1 = At Risk for Elopement) indicating at risk for elopement. Review of Resident #6's Physician's orders revealed an order dated 08/23/2024 to perform visual census checks, resident at risk for wandering, exit seeking behaviors, elopement every 2 hours. During an interview on 09/24/2024 at 12:25 p.m. S2 Corporate Nurse acknowledged video surveillance of the Hall A on 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift revealed rounding was not completed every 2 hours and should have been done. S2 Corporate Nurse further acknowledged the nurse on duty did not enter the rooms to perform visual checks on the residents, including Resident #5 and Resident #6 identified at risk for elopement, every 2 hours according to facility policy. S2 Corporate Nurse acknowledged the lack of supervision had the potential to adversely affect the remaining ten residents identified at risk for elopement. During an interview on 09/24/2024 at 12:25 p.m. S3 Assistant Administrator acknowledged video surveillance of Hall A on 09/19/2024 from 11:18 p.m. until 5:18 a.m. during the night shift revealed rounding was not completed every 2 hours and should have been done. S3 Assistant Administrator further acknowledged the nurse on duty did not enter the rooms to perform visual checks on the residents. Observation on 09/24/2024 at 9:20 a.m. revealed Resident #5 walking around nursing station and staff were redirecting her. Observation on 09/24/2024 at 9:20 a.m. revealed Resident #6 self-propelling her wheelchair down the hallway. Observation on 09/25/2024 at 9:45 a.m. revealed Resident #5 pushing her wheelchair in the hallway being redirected by staff.

Based on observations, record review, and interviews, the facility failed to protect the resident's right to be free from sexual and mental abuse by a staff member resulting in psychosocial harm for 1 (Resident #64) of 1 resident reviewed for abuse. This deficient practice resulted in sexual and mental abuse causing actual psychosocial harm for Resident #64 when on 02/02/2024 S11CNA (certified nursing assistant) touched her right breast, asked her for oral sex, and took her hand and placed it on his penis. Resident #64 reported feeling scared and afraid of being alone after the incident occurred. She became tearful when explaining how this incident with S11CNA brought back feelings of anxiousness and fear from a sexual assault in her past. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Abuse and Neglect-Clinical Protocol (Revised October 15, 2022) revealed the following, in part: Policy Statement- The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Staff to Resident Abuse of any Types: Deals with diverse populations including residents with dementia, mental disorders, intellectual disabilities, ethnic/cultural differences, speech/language challenges, and generational differences. The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident. Definitions: Sexual abuse is defined as non-consensual sexual contact of any type with a resident . Review of Resident #64's medical record included diagnoses of multiple sclerosis and chronic pain. Record review of Resident #64's MDS (minimum data set) dated 12/14/2023 revealed a BIMS (brief interview for mental status) of 15, which would indicate Resident #64 was cognitively intact. Wheelchair was used for mobility. Record review of Resident #64's Care Plan included, in part: Psychosocial at risk for mood/behaviors: 02/09/2024 - Resident to be monitored for possible PTSD (Post Traumatic Stress Disorder) s/sx (signs/symptoms) from inappropriate actions from CNA. During an interview on 03/11/2024 at 1:50 p.m., Resident # 64 reported on 02/02/2024 S11CNA came in her room to fix her over bed light. Resident #64 confirmed when S11CNA came into her room he sat down on her bed next to her, hugged her and started feeling on her breast. Record review of Resident #64's incident investigation report revealed the following, in part: Occurred date was 02/02/2024 at 4:38 p.m., discovered on 02/03/2024 at 5:00 p.m. Victim was Resident #64 and accused was S11CNA. Timeline of video camera footage: At 3:51 p.m. Resident #64 entered her room, door shut. At 4:34 p.m. Resident #64's roommate entered her room, door shut. At 4:38 p.m. Resident #64's roommate leaves her room, door shut. At 4:38 p.m. S11CNA enters Resident #64's room, door shut. At 4:41 p.m. Resident #64's roommate re-enters her room, door shut. At 4:43 p.m. S11CNA leaves Resident #64's room, door shut. During an interview on 03/12/2024 at 12:05 p.m., S1Administrator reported an investigation was completed for Resident # 64's allegations of S11CNA touching her breast. S1Administrator further indicated the facility suspended S11CNA pending the investigation and ultimately terminated S11CNA. During an interview on 03/13/2024 at 7:45 a.m., Resident # 64 reported she was very nervous about telling staff what happened with S11CNA, but it kept wearing on her. She finally told S4LPN (licensed practical nurse) on the morning of 02/03/2024 and also told S13LPN later around 5:00 p.m. of the non-consensual sexual contact. Resident #64 said S11CNA told her they need to get together sometime. When Resident #64 informed him that she was married, he told her, that's okay. Resident #64 reported when S11CNA left her room she was scared, and she didn't want her roommate to leave and get ice because she was scared of S11CNA coming back in her room. Resident #64 further indicated she was not afraid of S11CNA before the incident but after S11CNA touched her inappropriately she was very afraid and shocked. Resident #64 acknowledged she started blaming herself because she had started wearing makeup again. During an interview on 03/13/2024 at 3:20 p.m. Resident #64 confirmed on 02/02/2024 S11CNA came into her room when she was alone and touched her right breast. Resident #64 reported S11CNA asked her to perform oral sex on him and took her hand and placed it on his penis. Resident #64 stated she froze and was shocked by S11CNA's behavior and S11CNA stopped when he heard the door to her room open. Resident #64 reported feeling like S11CNA did this to her because she was in a wheelchair and he looked down on her because of her limitations. Surveyor observed Resident #64 become tearful when she stated she was sexually assaulted in the past and this incident brought back all of the fear and anxiety from that event. During a telephone interview on 03/13/2024 at 9:12 a.m. S12 Psych (Psychiatric) Nurse Practitioner (NP) indicated he was consulted by facility's NP to make a visit after the incident occurred. S12 Psych NP confirmed when he visited with Resident #64 she was alert and oriented. S12 Psych NP indicated Resident #64 was oriented to reality. S12 Psych NP indicated no uncontrolled moods were observed. S12 Psych NP confirmed Resident #64 had been compliant with her medications. Phone interviews were attempted with S11CNA during the survey with no success on 03/12/2024 at 1:17 p.m. and on 03/12/2024 at 3:02 p.m. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice. The facility's QAPI (Quality Assurance/Performance Improvement) Sexual Abuse Allegation 02/05/2024 report, provided by S3CorporateNurse, revealed the following as a result of the allegation of sexual abuse by Resident #64: Introduction: A recent event occurred in the facility in which a resident accused a male staff member of grabbing her breast and solicited her for oral sex . The CNA was suspended pending investigation .Police were notified. Did the facility, once notified, take immediate action to protect the resident from further harm? The facility did ensure that the resident was protected, when notified of the allegation. The resident had a head to toe assessment completed and assured that she was safe. The nurse practitioner was notified and the responsible party was notified. The accused staff member was immediately placed on suspension and has not been present in the facility since notification of the allegation. QAPI Committee plan based on investigation and review: 1. The facility will ensure that resident remains feeling safe in the facility. 2. The facility will reach out to psychiatric services for follow up on resident which did occur on 02/06/2024. 3. Any male staff members entering the room will keep the door open and be escorted by a female staff member for resident comfort. 4. Safe surveys of residents within the facility will occur randomly throughout the building three times a week for the next four weeks to ensure that residents do not feel unsafe. Any adverse findings or concerns will be brought to the administrator immediately and addressed. 5. The accused staff member will be terminated at this time pending police investigation because the facility cannot determine if the incident did or did not occur. The facility only wants the resident of incident to feel safe. 6. The administrative staff will in-service all staff on abuse, neglect and reporting. This started on 02/03/2024 with all staff on duty. All other staff in-service will be completed by 02/09/2024. 7. The facility will also conduct in-service/training on professionalism and burnout of staff. 8. Quality Improvement Nurse or Regional [NAME] President will check in with Administrator and/or Director of Nursing are completing safe surveys. 9. Each week for four weeks the Quality Assurance/Performance Improvement committee will review all findings and make any changes as necessary.

Based on interviews, record reviews, and observations the facility failed to provide adequate supervision for 2 (#1, #2) of 4 (#1, #2, #3, #4) sampled residents reviewed for impaired cognition and/or a diagnosis that may increase their risk of elopement. The deficient practice resulted in Immediate Jeopardy for Resident #1 and Resident #2 on 09/05/2023 at 1:54 p.m. when Resident #1 pushed Resident #2 in her wheelchair and exited through the Hall A door of the facility. At 2:33 p.m. on 09/05/2023, Resident #1 and Resident #2 were seen in the median of a four lane public road and observed crossing over the last two lanes into a grocery store parking lot by S3 Physical Therapist. Physical Therapist called and notified facility of residents being out of the building and at 2:35 p.m. on 09/05/2023 staff members, including S1 Administrator, exited the facility. On 09/05/2023 at 2:46 p.m. Resident #1 and Resident #2 returned to facility assisted by S4 Medical Records and S5 RN (Registered Nurse). Resident #1 and Resident #2 were assessed with no injuries noted and placed on every 2 hour monitoring. The Immediate Jeopardy continued for 2 other (#3, #4) residents at risk for elopement until 09/05/2023 at 2:46 p.m. when S6 Unit Manager closed the Hall A exit door. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility's Wandering and Elopements Policy with revision date of March 2019 revealed in part: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measure to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. Resident #1 Review of Resident #1's medical record revealed an admitted [DATE] and diagnoses including but not limited to: Alzheimer's disease and bipolar disorder with psych features. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 06/22/2023 revealed in part, Resident #1 had a BIMS (Brief Interview Mental Status) score of 5 indicating severe cognitive impairment, wandering behavior occurred 0 days during 7 day look back period, and Resident #1 received antipsychotic medication for 4 of the 7 day look back period. Review of Resident #1's physician orders prior to incident on 09/05/2023 revealed in part: Zoloft 100mg (milligrams) 1 by mouth every day. Seroquel XR 400mg 1 by mouth every day at 5 pm Monitor resident for behaviors every shift for use of psychotropics. Monitor resident for side effects of antipsychotic medication every shift. Review of Resident #1's Comprehensive Care Plan 08/05/2023 revealed Resident #1 was care planned for risk of elopement with interventions including place resident's picture at exits to identify not to let resident out, note which exits resident favors for elopement and alert staff working near those areas. Further review of Resident #1's care plan did not reveal an intervention for monitoring resident's whereabouts. Review of Resident #1's Elopement Risk assessment dated [DATE] revealed Resident #1 was found to be at risk for elopement. Review of Resident #1's September 2023 progress notes revealed in part: 09/06/2023 late entry for 09/05/2023 by S7 RN- [NAME] clerk notified S5 RN of someone had called facility and stated 2 residents were outside facility grounds. S5 RN then told writer Residents were last seen between 1:30-1:40 p.m. by writer. Noted Hall A outside door was propped open by plumber working in building on Hall A. Hall A door closed and plumber notified to keep door closed at all times for safety. No apparent injuries to resident when arrived back to facility. Family notified by S6 Unit Manager. 09/08/2023 at 11:11 a.m. late entry for 9/5/2023 by S6 Unit Manager. Resident #1 head to toe assessment completed when back inside facility from elopement incident - skin intact, Resident #1 alert. No distress noted. Blood pressure 128/76, pulse 70, Respirations 18, Temperature. 98.2. Resident #1's whereabouts to be monitored every 2 hours. Resident #2 Review of Resident #2's medical record revealed a readmitted [DATE] and diagnoses including but not limited to: Hemiplegia following CVA (cerebral vascular accident) affecting right dominant side, dementia, and anxiety. Review of Resident #2's Quarterly MDS dated [DATE] revealed in part, Resident #2 had a BIMS score of 7 indicating severe cognitive impairment, wandering behavior occurred 0 days during 7 day look back period, and Resident #1 received antianxiety medication for 7 of the 7 day look back period. Review of Resident #2's physician orders prior to incident on 09/05/2023 revealed in part: Lorazepam 0.5mg 1 by mouth every 12 hours Monitor for behaviors every shift for use of psychotropic medication. Monitor for medication side effects every shift. Review of Resident #2's Comprehensive Care Plan 08/07/2023 revealed Resident #2 was not care planned for risk of elopement until after elopement incident on 09/05/2023. Review of Resident #2's Elopement Risk assessment dated [DATE] revealed Resident #2 was found not to be at risk for elopement. Review of Resident #2's September 2023 progress notes revealed in part: 09/08/2023 at 11:24 p.m. late entry for 09/05/2023 by S6 Unit Manager- Resident #2 was pushed in wheelchair by another resident (Resident #1) outside and off facility grounds. Resident #2 was brought back to facility by nurse. Head to toe assessment done, no skin breakdown or bruising noted. Resident #2 at normal self. NP (Nurse Practitioner) and family notified. 09/08/2023 at 1:02 p.m. by S6 Unit Manager- Follow up from incident on 09/05/2023, Resident #2 up in dining room, no complaint of pain or distress at this time. Blood pressure 128/76, Pulse 79, Respirations 18, Temperature 98.2. During an observation on 09/19/2023 at 3:30 p.m. of facility surveillance video from 09/05/2023 at 1:54 p.m. revealed Resident #1 pushing Resident #2 in wheelchair on Hall A when Resident #1 reached fire doors at end of Hall A, Resident #1 pushed door open and Resident #1 walked through doors pushing Resident #2 in her wheelchair. Resident #1 and Resident #2 were not seen again on video until 2:46 p.m. when Resident #1 and Resident #2 were brought back to the facility by facility staff members. During an interview on 09/19/2023 at 3:30 p.m. S1 Administrator confirmed Resident #1 and Resident #2 were found off facility property in a local grocery store parking lot on 09/05/2023 after being notified by S3 Physical Therapist residents were out of the facility, and residents should not have been out of facility unsupervised. During an interview on 09/19/2023 at 4:10 p.m. S1 Administrator confirmed Hall A door had been propped open and no facility door should be propped open. During an interview on 09/18/2023 at 2:40 p.m.S3 Physical Therapist reported on 09/05/2023 she was taking a late lunch and had left the facility to go pick up her food when she saw Resident #1 and Resident #2 in the median that separates a public 4 lane road. S3 Physical Therapist reported she got into a turn lane so she could follow the residents and at same time called the facility to notify them of the two residents being out of the facility. S3 Physical Therapist reported she was able to observe the two residents as they crossed over the last 2 lanes of the public 4 lane road into a local grocery store parking lot. S3 Physical Therapist further reported facility staff arrived at the local grocery store parking lot and were able to get residents into a vehicle and take residents back to the facility. S3 Physical Therapist reported she could no longer remember the exact time this incident happened, but stated it was around 2:30 p.m. to 2:45 p.m. During an observation on 09/18/2023 at 4:50 p.m. surveyor observed the local grocery store parking lot in which Resident #1 and Resident #2 were found on 09/05/2023. Surveyor was also able to observe the public 2 lane service road and the public 4 lane road in which residents had to cross to get to the local grocery store parking lot. Surveyor was able to determine the local grocery store parking lot was two tenths of a mile from the facility. During an interview on 09/19/2023 at 1:15 p.m. S5 RN reported on 09/05/2023 she was told by a ward clerk that a phone call had been received informing facility of two residents being out in a local grocery store parking lot. S5 RN reported she got in her car and drove over to the local grocery store parking lot and was able to get Resident #1 and Resident #2 into the car and back to the facility. S5 RN further reported she was not sure of the exact time the incident happened but thought it was sometime around 2:30 p.m. - 2:45 p.m. During an interview on 09/19/2023 at 1:20 p.m. S4 Medical Records reported on 09/05/2023 the ward clerk told her she had received a call reporting two residents were in a local grocery store parking lot. S4 Medical Records reported she rode with S5 RN to the local grocery store parking lot and assisted with bringing residents back to the facility. S4 Medical Records reported she was unsure of the incident time but believed it was around 2:30 p.m. Attempted to contact S9 [NAME] Clerk via telephone on 09/19/2023 at 3:20 p.m. S9 [NAME] Clerk did not answer the phone and by end of survey had not returned phone call. Attempted to contact S10 CNA via telephone on 09/20/2023 at 8:05 a.m. and again on 09/20/2023 at 12:30 p.m. without success. During an interview on 09/19/2023 at 11:00 a.m. S7 RN reported on 09/05/2023, the day of the elopement incident, she was working on Hall A, Hall B, and part of Hall C. S7 RN reported she had seen S8 Housekeeping and another man working down near the last rooms of the Hall A on 09/05/2023. S7 RN reported Resident #1 and Resident #2 were sitting in common area across from Nurse Station II and the last time she saw the residents prior to the elopement incident was at about 1:40 p.m. S7 RN reported after hearing two residents were out of the building she and S6 Unit Manager found the exit door at the end of the Hall A propped open with a broom stick and S6 Unit Manager closed and secured the door. S7 RN reported she was unsure of time the Hall A exit door was closed but stated it was before Resident #1 and Resident #2 returned to the facility. S7 RN reported once Resident #1 and Resident #2 were returned to the facility she assessed Resident #1 for injuries and no injuries were found. During an interview on 09/19/2023 at 11:10 a.m. S6 Unit Manager reported prior to Resident #1 and Resident #2 being returned to the facility, she went down the Hall A through the fire doors where a plumber was working and found the Hall A exit door propped open. S6 Unit Manager reported she closed the Hall A exit door so no one else could get out. S6 Unit Manager reported she assessed Resident #2 after the elopement incident on 09/05/2023 and Resident #2 was assessed to have no injuries. During an interview on 09/19/2023 at 11:25 a.m. S8 Housekeeping reported when plumber arrived at the facility he took the plumber to the Hall A and showed the plumber what work needed to be done. S8 Housekeeping reported he unlocked the exit door on the Hall A for the plumber, and left him to do his work. S8 Housekeeping reported the plumber must have propped the door open once he left. S8 Housekeeping further reported once he heard residents had gotten out, he went to the Hall A exit door to shut it, but it was already closed. Resident #3 Review of Resident #3's medical record revealed a diagnosis of Dementia and major depressive disorder, MDS dated [DATE] revealed BIMS score of 9 indicating moderate cognitive impairment and no wandering during 7 day look back period. Review of Resident #3's Elopement Risk assessment dated [DATE] revealed Resident #3 was found to be at risk for elopement. Review of Resident #3's Comprehensive Care Plan dated 09/04/2023 revealed Resident #3 was care planned for risk of elopement with interventions including place resident's picture at exits to identify not to let resident out, note which exits resident favors for elopement and alert staff working near those areas. Visualize resident every shift for risk of elopement. Resident #4 Review of Resident #4's medical record revealed a diagnosis of Schizoaffective disorder, bipolar type and depression, MDS dated [DATE] revealed BIMS score of 5 indicating severe cognitive impairment, and no wandering during 7 day look back period. Review of Resident #4's Comprehensive Care Plan dated 07/11/2023 revealed Resident #4 was care planned for risk of elopement with interventions including Resident #4 likes to go to smoking door, alert staff working near that area. Picture placed at exits to identify not to let resident out. Visualize resident every shift for risk of elopement. The facility implemented the following actions to correct the deficient practice with completion on 09/12/2023: 1. Resident #1 and Resident #2 were immediately assessed for injuries upon their return on 09/05/2023 and NP and family notified 09/05/2023. 2. All exit doors checked to ensure they were closed and secured on 09/05/2023 immediately following elopement incident. 3. Safe Surveys were immediately conducted on all residents who were deemed to be at risk for elopement with surveys completed on 09/05/2023. 4. Sign was placed on Hall A exit doors stating Emergency Exit Use Only on 09/06/2023. Pictures of residents deemed to be at risk for elopement and signs stating Attention do not let any resident out without checking with nursing staff, doors to remain closed at all times were hung at each exit by end of day 09/07/2023. 5. On 09/05/2023 Administrator notified local plumbing company who was in the building working on Hall A of incident and instructed the company to ensure when they enter or exit the building to make sure doors are closed and secure behind them. Facility received a letter dated 09/12/2023 stating plumbing company had met with all employees and instructed the employees to follow facility policy on entering/exiting the building and ensuring doors are closed behind them at time of entrance or exit. Facility developed a Vendor Acknowledgement form for all vendors to sign in and acknowledge they have been instructed to ensure all doors remain closed and secure which was completed on 09/06/2023. 6. In-serviced staff on facility's Wandering and Elopement, making sure exit doors are secure and not propped open, maintenance staff to remain with vendors while vendors are at facility, and monitoring of residents at risk for elopement every two hours. In-service started on 09/05/2023 at 4:00 p.m., with maintenance staff, and was completed with all other staff by 09/09/2023. 7. All exits of the building have secure magnetic door locks including Hall A which were checked two times a day for one week starting 09/05/2023 and after one week doors checked once a day. Documentation of all door checks placed on door check log daily. The magnetic door locks require a code to be put in or a special key to be used to unlock the doors. This process is on-going and facility does not plan to discontinue this process. 8. All resident charts were reviewed for potential new diagnosis or behaviors putting them at risk for elopement and those deemed to be at risk had elopement risk assessments performed which were completed on 09/07/2023. Charts monitored at Quality Assurance meetings. 9. Care plans for all residents deemed to be at risk for elopement had their care plans updated to include increased supervision by end of day 09/07/2023. Orders to perform visual census checks every two hours received for residents deemed to be at risk for elopement and orders placed on each residents' EMAR (Electronic Medication Administration Record). 10. Quality Assurance and Performance Improvement meeting was conducted with department heads and medical director immediately following the incident and continues to evolve identifying areas of improvement including but not limited to possibly purchasing wander guard system. The QAPI committee is reviewing the quality assurance plan weekly for the first four weeks with start date of 09/06/2023, then will review plan monthly and as needed. 11. Resident #1 was transferred to a local inpatient behavioral hospital on 09/08/2023 for further evaluation related elopement on 09/05/2023 and ongoing behaviors.

Based on record reviews, observations and interviews the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pests including ants, roaches and spiders. The deficient practice was identified on 08/14/2023 when live ants and other pests were observed in several residents' rooms and around the interior of facility. This deficient practice resulted in an immediate jeopardy on 08/14/2023 at approximately 9:15 a.m. when numerous live ants were found on F hallway crawling in the residents' rooms, around the bathroom doors, under the beds and chairs and on personal items. Further observations on 08/17/2023 revealed numerous live ants, roaches and spiders on hallways E, F, G, H, I and J with Resident #6 reported being bitten by ants in the past, live ants crawling on Resident #7 and his bed linen, live ants crawling on Resident #8's bed linens, and live ants crawling on Resident #9's gown. S14Administrator was notified on 08/17/2023 at 4:21 p.m. of the Immediate Jeopardy. The likelihood of harm or serious injury continued for the 132 residents residing in the facility per the Resident Census and Conditions of Residents Report. The facility presented the following Plan of Removal: 1. The facility will ensure that residents will be protected from being bitten by ants by having staff observe if ants are present in resident rooms and bathrooms and ensure room, bed, and clothing are free from ants to prevent ant bites. 2. If ants are noted to be present, the staff will remove ants from the residents' person, remove any bedding or clothing and move resident to a different location until ants are removed from the residents' room or bathroom. 3. Residents #6 and #7 were identified as having ant bites and Nurse Practitioner was notified and orders for topical steroid cream was given. 4. Residents #8 and #9 both had ants removed from their persons, linens and clothes were changed, head to toe skin assessments were completed and room was treated for pests and room was cleaned. 5. The facility will contact a different pest control vendor on 08/18/2023. 6. All rooms will be inspected by the administrative staff for any ants, spiders, roaches, flies and gnats twice per day for 1 week and then as discovered to ensure that the facility is free of ants, spiders, roaches, flies and gnats. If any ants, spiders, roaches, flies or gnats are discovered then the facility will protect the resident, notify maintenance department and pest control service for treatment. 7. The facility will have nursing staff assess each resident each shift for the next 3 days. The physician will be notified of any skin conditions and orders obtained to treat any injury noted. Completed by 08/21/2023. This will be repeated as needed for any observance of ants in the facility. 8. ____Pest Control Company is scheduled to come to facility on 08/19/2023 and treat the entire facility inside and out, all rooms. 9. All staff will be in-serviced on notifying administrative staff immediately when ants, spiders, roaches, flies or gnats are found and insect spray will be available to staff to treat for insects immediately. Staff on duty will be in-serviced on 08/17/2023 and all other staff will be in-serviced by 08/18/2023. 10. The administrative staff will notify new pest control provider as soon as possible for any treatments needed. 11. Estimated completion date: 08/22/2023. The Immediate Jeopardy was removed on 08/17/2023 at 10:00 p.m., after it was determined through observations and interviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings: Review of facility's Pest Control policy with the revision date of May 2008 revealed in part: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building has minimal insects and rodents. 2. Pest control services are provided by ______. 6. Maintenance services assist, when appropriate and necessary in providing pest control services. Review of facility's grievance log for the past 6 months revealed grievances related to ineffective pest control on: 05/16/2023 Resident #R10's son complained of roaches in Resident #R10's room on G hallway. 05/30/2023 Resident #R11's daughter complained of roaches in Resident #R11's room on I hallway. 07/28/2023 daughter and sister of Resident #R12 complained of bugs in Resident #R12's room on H hallway. 08/07/2023 family of Resident #R12 complained of roaches in Resident #R12's room on H hallway. Further record review revealed an email correspondence to S14Administrator from the Ombudsman on 07/27/2023 related to ineffective pest control. The Ombudsman shared residents' reports of large and small roaches and numerous other bugs all around the facility. The Ombudsman reported residents' concerns that the facility should do a better job exterminating. Observation of rooms C and D on F hallway on 08/14/2023 at 9:40 a.m. with S6Corporate Nurse revealed a very large amount of ants crawling in the residents' rooms, around the bathroom doors, and under the beds and chairs. Further observation of rooms A and B on F hallway revealed a large amount of ants crawling in the rooms and on personal items. During an interview on 8/14/2023 at 9:45 a.m. S14Administrator reported the facility has a pest control service that comes regularly. S14Administrator confirmed pest control was just here the other day and sprayed the outside of the building and is supposed to be here again to spray inside. S14Administrator acknowledged the pests are not under control. During an interview on 08/14/2023 at 9:50 a.m. S16Housekeeping acknowledged the facility has ants all over the building Observation on 08/14/2023 at 9:40 a.m. with S6Corporate Nurse revealed a large amount of ants crawling in the room, on Resident #6's personal items, refrigerator and bathroom floor on F hallway. Resident #6 with a BIMS (Brief Interview for Mental Status) of 12 indicating moderate cognitive impairment. During an interview on 08/14/2023 at 9:40 a.m. Resident #6 reported ants crawling all over the floor. Resident #6 confirmed making staff aware of the ants. Resident #6 confirmed the facility had sprayed for the ants but the spray don't work. Observation on 08/17/2023 at 11:06 a.m. revealed live ants crawling in Resident #6's room, on the refrigerator and microwave. During an interview on 08/17/2023 at 11: 08 a.m. Resident #6 stated, I told them ants crawl up my cord and get in my bed. They bit me and made whelps on my back and legs and they burn and sting. Observation on 08/17/2023 at 11:15 a.m. S14 Administrator acknowledged live ants in Resident #6's room. Observation on 08/14/2023 at 9:15 a.m. revealed ants crawling in Resident #7's room, around the bathroom doors, and under the bed on F hallway. Further observation revealed Resident #7 sitting up in his wheelchair next to the bed, feet resting on the floor and ants crawling around Resident #7's socked feet. Resident #7 unable to seek assistance with ants or ant bites. Observation on 08/17/2023 at 11:00 a.m. revealed ants crawling in Resident #7s room, under the bed and on bed linens. Resident #7 was lying in bed asleep with bed in low position and bed linens touching the floor. During an interview on 08/17/23 at 11:00 a.m. S7LPN (Licensed Practical Nurse) acknowledged ants were on Resident #7's bed linens and crawling on Resident #7. S7LPN confirmed red raised areas as ant bites on Resident #7's feet. Observation on 08/14/2023 at 9:40 a.m. with S6Corporate Nurse revealed a large amount of ants crawling in the room on Resident #8's personal items, refrigerator and bathroom on F hallway. Resident #8 was standing in slipper socks straightening her bed covers, and reported there are always ants in her room and having her own insect spray. Further observation revealed ants were noted on the floor under and around Resident #8's feet. S6Corporate Nurse acknowledged ants crawling near Resident #8's feet and on personal items. Resident #8 with a BIMS score of 11 indicating moderate cognitive impairment. During an interview on 08/14/2023 at 9:40 a.m. Resident #8 reported there are always ants in her room and she has her own insect spray. Resident #8 did not know if she had any ant bites. Observation with S7 LPN on 08/17/2023 at 11:10 a.m. revealed Resident #8 lying in bed with ants crawling on Resident #8's bed linens, refrigerator, and floor. During an interview on 08/17/2023 at 11:15 a.m., S14Administrator acknowledged numerous ants crawling on Resident #8's bed linens, refrigerator, and floor. Observation 08/17/2023 at 12:40 p.m. revealed Resident #9 asleep in Geri-chair with multiple ants crawling on Resident #9's gown on F hallway. Further observation revealed multiple ants crawling on Resident #9's floor around the Geri-chair and feeding pump pole while enteral feeding was in progress. During an interview on 08/17/2023 at 12:45 p.m., S17LPN acknowledged multiple ants were crawling on the floor near feeding pump pole. S17LPN further acknowledged multiple ants were crawling on Resident #9's gown. During an interview on 08/17/2023 at 12:50 p.m. S18CNA (Certified Nursing Assistant) and S19LPN acknowledged multiple ants crawling on Resident #9's floor near feeding pump pole. S18CNA and S19LPN further acknowledged multiple ants were crawling on Resident #9's gown. During an interview on 08/17/2023 at 11:30 a.m., S24Hospitality Aide reported she works all over the building and she has noticed ants and flies. Multiple observations on 08/17/2023 starting at 11:30 a.m. revealed in part numerous pests in residents' rooms as follows: E hallway had 1 room with live ants. F hallway had 1 room with live ants. G hallway with 3 rooms with live ants, and 5 rooms with live roaches. H hallway with 2 rooms with live ants, 2 rooms with live roaches. I hallway with 2 rooms with live ants, 2 with spiders, 3 rooms with roaches, and 1 room with flies. J hallway had 1 room with live ants, and 1 room with live roaches. During an interview on 08/17/2023 at 12:00 p.m., Resident #R13's daughter reported there are ants, roaches, and the flies are bad in her mother's room on the G hallway. Resident #R13's daughter confirmed she told management several times and they sprayed but the stuff they used was no good. Resident #R13's daughter acknowledged she went and bought bug spray, sprayed the room and continues to spray a couple times a week. During an interview on 08/17/2023 at 12:10 p.m., S25CNA reported she has seen ants on G hallway. During an interview on 08/17/2023 at 12:15 p.m., S26Ward Clerk reported ants are bad in Nurses station #2 located on O hallway. During an interview on 08/17/2023 at 12:20 p.m. S1LPN reported she has seen ants in resident rooms and all over the facility. During an interview on 08/17/2023 at 12:22 p.m. S27Transportation reported, a resident on the F hallway was complaining yesterday about getting ant bites. Observation on 08/17/2023 at 12:30 p.m. revealed several ants crawling on Resident #R15's bathroom floor on E hallway. During an interview on 08/17/2023 at 12:30 p.m. S9Housekeeper acknowledged ants crawling on Resident #R15's bathroom floor. S9Housekeeper reported ants had been an ongoing issue in Resident #R15's room. Observation of Resident #R18's room on 08/17/2023 at 12:55 p.m. revealed several ants crawling on Resident #R18's bathroom floor and toilet on F hallway. During an interview on 08/17/2023 at 12:55 p.m. S16Housekeeper acknowledged ants were crawling on the bathroom floor and toilet in Resident #R18's room. During an interview on 08/17/2023 at 7:45 p.m. with S14Administrator, and S15Regional [NAME] President, S14Administrator acknowledged the facility was aware of ants in the building and failed to maintain an effective pest control program. S15Regional [NAME] President acknowledged a pest control failure had occurred and the facility failed to protect the residents. During an interview on 08/17/2023 at 9:10 p.m. S5DON (Director of Nursing) reported they had completed the skin sweeps of all the residents and found 10 residents with ant bites; 3 residents on L hallway, 2 residents on E hallway, 2 residents on F hallway, 1 resident on G hallway and 2 residents on H hallway.

Based on interviews, the facility failed to be administered in a manner that used its resources effectively and efficiently to ensure residents were protected from ant infestation and ant bites. The facility failed to ensure the facility was free of pests including ants, roaches and spiders. The deficient practice was identified on 08/14/2023 when live ants and other pests were observed in several residents' rooms and around the interior of facility. This deficient practice resulted in an immediate jeopardy on 08/14/2023 at approximately 9:15 a.m. when numerous live ants were found on F hallway crawling in the residents' rooms, around the bathroom doors, under the beds and chairs and on personal items. Further observations on 08/17/2023 revealed numerous live ants, roaches and spiders on hallways E, F, G, H, I and J with Resident #6 reported being bitten by ants in the past, live ants crawling on Resident #7 and his bed linen, live ants crawling on Resident #8's bed linens, and live ants crawling on Resident #9's gown. S14Administrator was notified on 08/17/2023 at 4:21 p.m. of the Immediate Jeopardy. The likelihood of harm or death continued for the 132 residents residing in the facility per the Resident Census and Conditions of Residents Report. The facility presented the following Plan of Removal on 08/17/2023: 1. The facility will ensure that residents will be protected from being bitten by ants by having staff observe if ants are present in resident rooms and bathrooms and ensure room, bed and clothing are free from ants to prevent ant bites. 2. If ants are noted to be present, the staff will remove ants from the residents' person, remove any bedding or clothing and move resident to a different location until ants are removed from the residents' room or bathroom. 3. Residents' #6 and #7 were identified as having ant bites and Nurse Practitioner was notified and orders for topical steroid cream was given. 4. Residents' #6 and #7 will be monitored q (every) 3 hours and as needed to ensure no anaphylactic reaction occurs. 5. Residents' #8 and #9 both had ants removed from their persons; linens and clothes were changed, head to toe skin assessments were completed and room was treated for pests and room was cleaned. 6. The facility had pest control come in on 08/15/2023 (___ Pest Control) to spray the inside of facility for ants, roaches, spiders, flies and gnats. 7. S14Administrator had maintenance spray again for ants, spiders, roaches, flies and gnats on 08/17/2023, throughout the entire facility on the inside and outside. 8. ___Pest Control will be at the facility 08/19/2023 to treat the entire building inside and out. 9. The facility will contact another pest control vendor on 08/18/2023. 10. All rooms will be inspected by the administrative staff for any ants, spiders, roaches, flies, or gnats. If any ants, spiders, roaches, flies or gnats are discovered then the facility will protect the resident and notify maintenance department and pest control service for treatment. 11. S15Regional [NAME] President will in-service administrative staff on ensuring that residents are protected from biting ants, ensure that monitoring and observing residents, their rooms and environment for presence of ants on 08/17/2023. 12. S15Regional [NAME] President will monitor S14Administrator and progress weekly beginning 08/22/2023. 13. Estimated Completion Date: 08/22/2023. The Immediate Jeopardy was removed on 08/17/2023 at 10:00 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings: Cross Reference F925. Review of facility's grievance log for the past 6 months revealed grievances related to ineffective pest control on: 05/16/2023 Resident #R10's son complained of roaches in Resident #R10's room on G hallway. 05/30/2023 Resident #R11's daughter complained of roaches in Resident #R11's room on I hallway. 07/28/2023 daughter and sister of Resident #R12 complained of bugs in Resident #R12's room on H hallway. 08/07/2023 family of Resident #R12 complained of roaches in Resident #R12's room on H hallway. Further record review revealed an email correspondence to S14Administrator from the Ombudsman on 07/27/2023 related to ineffective pest control. The Ombudsman shared residents' reports of large and small roaches and numerous other bugs all around the facility. The Ombudsman reported residents' concerns that the facility should do a better job exterminating. Observation of rooms C and D on F hallway on 08/14/2023 at 9:40 a.m. with S6Corporate Nurse revealed a very large amount of ants crawling in the residents' rooms, around the bathroom doors, and under the beds and chairs. Further observation of rooms A and B on F hallway revealed a large amount of ants crawling in the rooms and on personal items. During an interview on 08/14/2023 at 9:45 a.m. S14Administrator acknowledged the ant infestation was not under control. During an interview on 08/17/2023 at 7:45 p.m. with S14Administrator, S6Corporate Nurse and S15Regional [NAME] President, S6Corporate Nurse reported the ants and ant bites were a nursing process failure. S14Administrator acknowledged the facility was aware of ants in the building and failed to maintain an effective pest control program. S15Regional [NAME] President acknowledged a pest control failure had occurred and the facility failed to protect the residents.

Based on observations, record reviews and interviews, the facility failed to have a system in place to ensure staff supervised resident who had orders for oxygen for 1 (#1) of 4 ( #1, #3, #4,#6) out of a total of 16 (#1, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) residents who smoke. The immediate jeopardy began for Resident #1 on 02/16/2023 at 1:40 p.m. when Resident #1 entered the secured smoking patio wearing nasal cannula and tubing which were connected to his O2 (oxygen) tank. Resident #1 proceeded to light a cigarette butt and caught his face on fire. Resident #6, who was smoking on patio, removed the O2 cannula and tubing from Resident #1's face in an attempt to put out the fire. Resident #1's O2 tank was found to have been releasing oxygen at 6L (liters) per minute. Resident #1 was transported to a local hospital for burns to his neck, face, tongue and right arm, where he was then transferred to a local Burn Unit and was intubated. S1 Administrator was notified on 02/23/2023 at 12:40 p.m. of the Immediate Jeopardy. The likelihood of harm or death continued for 3 (#3, #4, #6) other residents who were identified by the facility as smokers with orders for oxygen therapy. The facility presented the following Plan of Removal on 02/23/2023: 1. Resident #1 is no longer in facility as of 02/23/2023. 2. The code was changed on the smoking door on 02/23/2023 by Maintenance. 3. Scheduled staff was in-serviced on not allowing any resident with oxygen in the smoking area. All other staff will be in-serviced prior to work completed by 02/28/2023. 4. Staff assigned to Station 2 near smoking area, will observe resident's person to ensure there is no oxygen prior to entering the smoking area, started 02/23/2023. 5. Scheduled staff will be in-serviced on not to give the code to resident and if any resident is seen putting in the code Administration will be notified immediately to address. Started on 02/23/2023. All other staff will be in-serviced prior to work and completed by 02/28/2023. 6. S2 DON (Director of Nursing) and S5 SSD (Social Services Director) will identify all smokers that have oxygen therapy prescribed. Completed on 02/17/2023. Residents - #3, #4, and #6 identified as smokers that have oxygen therapy prescribed. 7. Review of resident smokers BIM (Brief Interview for Mental Status) scores and conduct new assessments to ensure no changes have occurred since last assessment started on 02/17/2023, by S5 SSD completed by 02/20/2023. This will be reviewed by S2 DON by 02/21/2023. 8. Review all smoking assessments and conduct new smoking assessments on all residents that smoke by S5 SSD were completed by 02/20/2023 and reviewed by S2 DON, S6 LPN (Licensed Practical Nurse) and S3 Unit Manager on 02/21/2023. a. Smoking assessments will then be completed quarterly, or with significant changes or as needed. 9. All residents that smoke reviewed smoking policy and have been given a copy and sign smoking policy acknowledgment form. Started 02/17/2023, by S3 Unit Manager and S7 LPN. Completed 02/21/2023. 10. Educated all residents that smoke and are on oxygen therapy with the risk of open flames and flammable oxygen and that oxygen is not allowed in designated smoking area. S3 Unit Manager and S7 LPN completed by 02/17/2023. 11. Educate residents on oxygen therapy that smoke on how to turn O2 tanks off with return demonstration and a sign will be placed into their room with the steps listed. S3 Unit Manager and S2 DON. Completed 02/17/2023. 12. Educate the general assembly of residents on the dangers and policy of oxygen in the designated smoking area. Completed 02/16/2023 in Resident Council meeting on 02/16/2023 with S2 DON and S5 SSD. Noted in the minutes of the meeting. Ombudsman also in attendance. 13. In-service staff on the risk and identifying oxygen in the designated smoking area and that no oxygen or tubing need to be in the designated smoking area. Started on scheduled staff 02/16/2023 and to be completed by all staff prior to work by 02/28/2023. 14. Random observation started 02/17/2023 of the designated smoking area and will be conducted by members of the QAPI (Quality Assurance and Performance Improvement) committee at a minimum of 3 times per day during daylight hours for 4 weeks, then at a minimum of 3 times per week for 4 weeks, then weekly thereafter and as needed. Observations will note if there are any safety issues, oxygen in the area and all will be noted and corrected. Administrator and/or DON will be notified immediately of any concerns. 15. Any negative findings from the Random Smoking are checks will be acted on by the Administrator immediately then report findings to the QAPI weekly for 30 days, then monthly thereafter. 16. Estimated completion 02/28/2023. The Immediate Jeopardy was removed on 02/23/2023 at 7:15 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings: Review of facility's Smoking policy revealed in part: 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building . Smoking is not allowed inside the facility under any circumstances. 3. Oxygen use is prohibited in smoking areas. Resident #1 Review of Resident #1's ED notes dated 02/16/2023 revealed in part Resident #1's skin assessment noted burns to neck, face, mouth, tongue, right arm with soot and burn, and beard burned. Further review of ED notes revealed Resident #1 arrived to the ED via ambulance from the nursing home with facial burns. Resident #1 was smoking while wearing his oxygen resulting in an explosion with burns to his neck and face. Resident #1 was noted to have burns on his anterior neck, lips, tongue, nose, and oropharynx with soot noted in nares and on right arm. Resident #1 was intubated in the emergency department for airway protection. ED physician did speak with Dr. ____, consulted trauma physician, who recommends head and neck CT (Computerized Tomography). Review of MDM (Medical Decision Making) Narrative revealed in part Resident #1 has some blistering and changes which appear to be burns of the anterior tongue. Resident #1 complains of pain in his tongue and a burning sensation going from his posterior oropharynx down to his mid chest. He has soot in his nares first-degree burns around his anterior nose lower face and anterior neck. Review of Resident #1's CT report revealed in part findings of burn and smoke inhalation and trauma. Resident #1 was transferred to a local Burn Unit and was intubated. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease), major depressive disorder, anxiety disorder, gangrene and necrosis of the lung, and nicotine dependence. Resident #1 was discharged from the facility on 02/16/2023 with a return anticipated. Review of Resident #1's MDS (Minimum Data Set) dated 01/11/2023 revealed Resident #1 had a BIMS summary score of 11 out of 15 indicating Resident #1's cognition was moderately impaired. Further review of Resident #1's MDS revealed Resident #1 was coded for oxygen therapy and had experienced SOB (shortness of breath) with exertion, when sitting at rest and when lying flat during a 5 day MDS look back period. Review of Resident #1's physician's orders revealed an order dated 02/06/2023 which read O2 at 2 liters via nasal cannula as needed for SOB or Saturation (Sat.) less than 90% and O2 Sat. every shift. Review of Resident #1's current care plan revealed Resident #1 was noncompliant with oxygen by turning up oxygen above prescribed liters. A care plan revision dated 02/06/2023 revealed Resident #1 had interventions which prohibited Resident #1 from entering the smoking patio wearing oxygen or carrying oxygen tank. Review of Resident #1's Interdisciplinary notes revealed a nurse's note written by S3 Unit Manager dated 02/06/2023 at 3:43 p.m. which read in part: Met resident in hallway in wheelchair. Visibly short of breath. Insisted he go outside to smoke.sat. 83% RA (room air). Asked if he really wanted to go out and smoke with sat. of 83%. Reported Yes. Yes I do. I have been in the hospital I need to go outside. I need that oxygen in there too. Advised against decision to smoke. Continued to insist and rolled to smoking porch. Further review of Resident #1's Interdisciplinary notes revealed a nurse's note written by S9 RN (Registered Nurse) dated 02/16/2023 at 2:07 p.m. which read in part: Resident outside smoking with oxygen tank. 1:40 p.m. Alerted by S8 LPN that resident caught himself on fire. 911 called. Resident stated my lighter blew up. Resident had blackened areas to nose, face, beard, neck and bilateral hands. Areas cooled with towel . 1:50 pm Resident #1 transported to _____ ER (emergency room ). No next of kin. Incident witnessed by Resident #6 who pulled tubing from Resident #1's tank. Noted end of tubing black in color. During an interview on 02/22/2023 at 10:20 a.m. S3 Unit Manager reported oxygen was not permitted on the smoking patio. S3 Unit Manager further reported she had often redirected Resident #1 when he would wheel towards patio with O2 tank and would remind Resident #1 oxygen was not allowed on the patio. During an interview on 02/22/2023 at 11:45 a.m. Resident #6, reported he had never witnessed Resident #1 on the smoking patio with his oxygen in use prior to the accident on 02/16/2023. Resident #6 reported he was present on the smoking patio on 02/16/2023 when Resident #1 wheeled out onto the smoking patio. Resident #6 further reported Resident #1 lit a cigarette butt and was consumed in flames. Resident #6 reported Resident #1 tried to pat the fire out but the fire kept coming back. Resident #6 reported he told Resident #1 to take off his oxygen but Resident #1 responded with I can't, like he was panicked. Resident #6 reported he then snatched the tubing off of Resident #1's face and beat on the patio door for help. Resident #6 confirmed Resident #1 was wearing his nasal cannula but was very hard to see because Resident #1 had a thick beard and the tubing was clear. Resident #6 reported he could see Resident #1's O2 tank tucked into his wheelchair beside his right leg. Resident #6 further reported he himself knew the code to enter the smoking patio but Resident #1 did not know the code. During an interview on 02/22/2023 at 12:00 p.m. Resident #3, reported she had never witnessed Resident #1 on the smoking patio with oxygen. Resident #3 further reported she knew the code to get onto the patio. Resident #3 reported Resident #1 did not know the code to get out to the smoking patio. Resident #3 further reported Resident #1 would not have been physically capable of reaching the key pad since his recent hospitalization , if he did know the code. During an interview on 02/22/2023 at 1:20 p.m. S10 Relief Unit Clerk, reported when she arrived to relieve staff for lunch Resident #1 was already outside on the smoking patio. S10 Relief Unit Clerk further reported she saw the fire and went and got S8 LPN to attend to resident. S10 Relief Unit Clerk acknowledged Resident #1 would have been dependent upon staff letting him out the door to smoke. During an interview on 02/22/2023 at 1:30 p.m. S9 RN reported she was Resident #1's nurse on 02/16/2023 and was notified of the incident after the fire had been distinguished. S9 RN further reported Resident #1 was known to wheel himself around facility with oxygen on and acknowledged someone should have stopped him from going out to smoke. During an interview on 02/22/2023 at 1:55 p.m. S11 AD (Activity Director) reported she had not let Resident #1 out to the smoking patio on 02/16/2023 and was not aware of how Resident #1 gained access to the patio while wearing oxygen. S11 AD further reported some of the residents who smoke knew the code but was unsure how they were given the code. S11 AD further reported had not recalled ever seeing Resident #1 using the code to enter the smoking patio. During an interview on 02/23/2023 at 8:05 a.m. S12 Unit Clerk reported a lot of the smokers knew the code and would go out to smoke as they wanted. S12 Unit Clerk further reported she was aware Resident #1 required O2 at times and would have been able to see the nasal cannula and tubing on Resident #1, despite his facial hair. S12 Unit Clerk further reported Resident #1 required more assistance after his hospitalization and would often need help with the door to come back in from smoking. During an interview on 02/23/2023 at 08:40 a.m. S13 PT (Physical Therapist) reported Resident #1 had been very active and walked around the facility prior to his recent hospitalization . S13 PT further reported Resident #1 was dependent upon a wheelchair to get around after returning to facility. During an interview on 02/23/2023 at 8:50 a.m. Resident #7 reported he witnessed Resident #1 on the patio on 2/16/2023 wearing his nasal cannula. Resident #7 further reported he and Resident #1 discussed the flammability and risks of having oxygen on the smoking patio prior to Resident #1 smoking. Resident #7 reported Resident #1 turned off his oxygen and retrieved a cigarette butt from the ash tray caddy. Resident #7 further reported Resident #1 proceeded to light the cigarette butt and the fire ignited. Resident #7 reported that Resident #1 must have turned his oxygen up and not off. During an interview on 02/23/2023 at 9:50 a.m. S5 SSD reported Resident #1 had always been independent and knew the code to the smoking patio. S5 SSD further reported Resident #1 would go out and smoke with his girlfriend and would even go out at night after hours utilizing the key pad, in the past. S5 SSD further reported she conducted the Safe Smoking Assessment on Resident #1 upon return from hospital and Resident #1 was designated as a safe smoker. S5 SSD further reported Resident #1 was very weak from his recent hospitalization and was not going out to smoke as much. S5 SSD further reported Resident #1 had received a wheelchair and began to start smoking again. During an interview on 02/22/23 at 2:20 p.m. S2 DON confirmed some of the residents who smoke know the code to unlock the door to the smoking area. S2 DON acknowledged even if residents were aware of the code to get to the smoking area, the facility was still responsible for the residents' safety. S2 DON reported Station 2's staff should confirm residents have removed their oxygen prior to going into the smoking area. S2 DON acknowledged staff were aware Resident #1 had orders for oxygen. S2 DON acknowledged facility had no policy regarding code access to smoking patio. During an interview on 02/23/2023 at 12:45 p.m. S2 DON reported she interviewed Resident #1 via telephone today and Resident #1 reported he rolled to the door on 02/16/2023 and someone let him out. During an interview on 02/23/2023 at 6:00 p.m. S1 Administrator and S14 Regional [NAME] President acknowledged the facility failed to supervise Resident #1 from entering the smoking patio with Oxygen in place. S1 Administrator and S14 Regional [NAME] President confirmed Resident #1 suffered harm when Resident #1 attempted to light a cigarette while receiving oxygen via nasal cannula.

Based on interviews, the facility failed to be administered in a manner that used its resources effectively and efficiently to ensure staff supervised resident who had orders for oxygen for 1 (#1) of 4 ( #1, #3, #4,#6) out of a total of 16 (#1, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) residents who smoke. The immediate jeopardy began for Resident #1 on 02/16/2023 at 1:40 p.m. when Resident #1 entered the secured smoking patio wearing nasal cannula and tubing which were connected to his O2 (oxygen) tank. Resident #1 proceeded to light a cigarette butt and caught his face on fire. Resident #6, who was smoking on patio, removed the O2 cannula and tubing from Resident #1's face in an attempt to put out the fire. Resident #1's O2 tank was found to have been releasing oxygen at 6L (liters) per minute. Resident #1 was transported to a local hospital for burns to his neck, face, tongue and right arm, where he was then transferred to a local Burn Unit and was intubated. S1 Administrator was notified on 02/23/2023 at 12:40 p.m. of the Immediate Jeopardy. The likelihood of harm or death continued for 3 (#3, #4, #6) other residents who were identified by the facility as smokers with orders for oxygen therapy. The facility presented the following Plan of Removal: 1. S14 RVP (Regional [NAME] President) will in-service S1 Administrator to ensure an adequate system is in place to ensure residents are supervised to prevent smoking with oxygen in the smoking area. Started and completed on 02/23/2023. 2. S14 RVP or a QI (Quality Improvement) nurse will randomly review system to ensure S1 Administrator and S2 DON (Director of Nursing) maintain an adequate system in place to ensure residents are supervised to prevent smoking with oxygen in the smoking area. Started 02/23/2023 and to be completed by 02/28/2023. 3. The Administrative staff will conduct and complete random smoking area checks on 02/23/2023 to ensure that any further potential injuries will not occur. a. Random smoking area checks will be conducted by Administrative designees daily for 30 days, then weekly thereafter. b. Any negative finding will be reported to the Administrator and acted on immediately. 4. S1 Administrator reviewed the completed random smoking area checks on 02/23/2023 to determine if any potential injuries had occurred. a. Random smoking area checks will be reviewed by S1 Administrator daily for 30 days then weekly thereafter. Any negative finding will be acted upon immediately. 5. Any negative findings from the random smoking area checks will be acted on by S1 Administrator immediately then report findings to the QAPI (Quality Assurance and Performance Improvement) committee weekly for 30 days, then monthly thereafter. 6. Estimated completion date 02/28/2023. The Immediate Jeopardy was removed on 02/23/2023 at 7:15 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings, Cross Reference F689: During an interview on 02/22/23 at 2:20 p.m. S2 DON confirmed some of the residents who smoke know the code to unlock the door to the smoking area. S2 DON acknowledged even if residents were aware of the code to get to the smoking area, the facility was still responsible for the residents' safety while smoking. S2 DON reported Station 2's staff should confirm residents have removed their oxygen prior to going into the smoking area. S2 DON acknowledged staff were aware Resident #1 had orders for oxygen. S2 DON acknowledged facility had no policy regarding code access to smoking patio. During an interview on 02/23/2023 at 12:45 p.m. S2 DON reported she interviewed Resident #1 via telephone today and Resident #1 reported he rolled to the door on 02/16/2023 and someone let him out. During an interview on 02/23/23 at 6:00 p.m. S1 Administrator and S14 Regional [NAME] President acknowledged the facility failed to supervise Resident #1 from entering the smoking patio with oxygen in place. S1 Administrator and S14 Regional [NAME] President confirmed Resident #1 suffered harm when Resident #1 attempted to light a cigarette while receiving oxygen via nasal cannula.

Based on observations and interviews, the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to ensure: 1. Resident #1 was not physically and verbally abused and psychosocially harmed by staff 2. A system was put in place to ensure physical and verbal abuse and psychosocial harm will not happen again and put in place ongoing monitoring of residents for evidence of abuse 3. All residents were assessed and/or interviewed regarding concerns of mental, physical, verbal and/or sexual abuse 4. Facility staff was assessed for burnout sign and symptoms. This deficient practice resulted in an immediate jeopardy for Resident #1, who is cognitively impaired, on 10/18/2022 when S3 CNA (Certified Nursing Assistant) physically and verbally abused Resident #1 in Resident #1's room by aggressively pulling Resident #1's head up when sitting on the floor and yelled directly into Resident #1's ear, Stop Yelling. Resident #1 was noted to be agitated and fearful and told S3 CNA Don't kill me, don't kill me. On 10/19/2022 S1 Administrator and S2 DON (Director of Nursing) were made aware of the abuse by S3 CNA by viewing the video surveillance provided by Resident #1's Responsible Party (RP). Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical and verbal abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. The facility failed to implement protective measures to protect the other vulnerable residents in the facility. S1 Administrator and S2 DON (Director of Nursing) were notified of the Immediate Jeopardy on 12/14/2022 at 5:10 p.m. The Immediate Jeopardy was removed on 12/15/2022 at 5:47 p.m. Through record reviews, interviews and observations the surveyor confirmed the following components of the Plan of Removal (POR) have been initiated and/or implemented prior to exit. The facility's POR included: 1. Administrator was in-serviced by Regional [NAME] President (RVP) on Abuse Investigation and Reporting on 12/14/2022 at 7:30 p.m. 2. Administrator was in-serviced by RVP on Burn Out/Signs and Symptoms on 12/15/2022. a. RVP or Quality Improvement Nurse (QI) Nurse will ensure Administrator/Designee is conducting random observation of staff interactions with residents weekly times 30 days. 3. The Administrative Staff will conduct and complete safe survey checks on 12/15/2022 to ensure that any further potential abuse, neglect or mistreatment is prevented. a. Safe survey checks will be conducted by administrative staff or designees on random residents weekly for 30 days, then monthly thereafter. b. Any negative finding will be reported to the Administrator and acted on immediately. 4. The Administrator reviewed the completed safe survey checks on 12/15/2022 to determine if any abuse, neglect or mistreatment has occurred. a. Safe survey checks will be reviewed by Administrator weekly for 30 days, then monthly thereafter. Any negative findings will be acted upon immediately. 5. After abuse investigation is completed by the facility it will be reviewed by Regional [NAME] President or Quality Improvement Nurse prior to closing SIMS. 6. Any negative findings from the safe survey checks will be acted on by the Administrator immediately then report findings to the Q.A.P.I. (Quality Assurance/Performance Improvement) weekly for 30 days, then monthly thereafter. 7. Estimated completion date 12/19/2022. Findings, Cross Reference F600: Review of the facility Abuse and Neglect - Clinical Protocol (Revised October 15, 2022) revealed in part: Policy Statement: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy Interpretation and Implementation - Staff to Resident Abuse of any Types: Deals with diverse populations including residents with dementia, mental disorders, intellectual disabilities The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident. Staff are expected to be in control of their behavior and behave professionally. The facility will not accept for an employee to claim his/her action was reflexive or a knee-jerk reaction and was not intended to cause harm. Retaliation from staff is abuse, regardless of whether harm was intended. Definitions: Verbal Abuse - the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend or disability. Physical Abuse - this includes but is not limited to hitting, slapping, pinching, and kicking. During an interview on 12/15/2022 at 4:35 p.m., S1 Administrator and S2 DON acknowledged the facility did not assess all residents for any abuse or mistreatment after an abuse allegation was revealed to S1 Administrator and S2 DON and the facility did not assess staff for burnout signs and symptoms. During an interview on 12/15/22 at 5:00 p.m., S1 Administrator verified they did not put a system in place to ensure the deficient practice will not happen again. S1 Administrator further verified they did not conduct any ongoing monitoring of residents for evidence of abuse. S1 Administrator confirmed they did not conduct any ongoing monitoring of staff to detect signs and symptoms of burnout.

Based on observations, record review, and interviews, the facility failed to protect the resident's right to be free from physical and verbal abuse and psychosocial harm by a staff member for 1 (Resident #1) of 8 (Residents #1, #2, #3, #4, #5, #6, #7, #8) sampled residents. This deficient practice resulted in an immediate jeopardy for Resident #1, who is cognitively impaired, on 10/18/2022 when S3 CNA (Certified Nursing Assistant) physically and verbally abused Resident #1 in Resident #1's room by aggressively pulling Resident #1's head up when sitting on the floor and yelled directly into Resident #1's ear, Stop Yelling. Resident #1 was noted to be agitated and fearful and told S3 CNA Don't kill me, don't kill me. On 10/19/2022 S1 Administrator and S2 DON (Director of Nursing) were made aware of the abuse by S3 CNA by viewing the video surveillance provided by Resident #1's Responsible Party (RP). Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical and verbal abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. The facility failed to implement protective measures to protect the other vulnerable residents in the facility. S1 Administrator and S2 DON were notified of the immediate jeopardy on 12/14/2022 at 5:10 p.m. The immediate jeopardy was removed on 12/15/2022 at 5:47 p.m. Through record reviews, interviews and observations the surveyor confirmed the following components of the Plan of Removal (POR) have been initiated and/or implemented prior to exit. The facility's POR included the following: 1. Resident #1 was assessed with no injuries noted from abuse on 10/19/2022 by S4 RN (registered nurse). 2. Staff member in question was terminated on 10/20/2022. 3. Safe survey checks were conducted and completed on 12/15/2022 on all residents by Administration staff to assess, identify, and prevent abuse. a. Safe Survey Checks will be conducted by Administrative staff or designees on random residents weekly for 30 days, then monthly thereafter. Any negative finding will be reported to the Administrator and acted on immediately. 4. The Safe Survey Checks were reviewed and checked by the Administrator for any abuse or mistreatment of residents on 12/15/2022. a. Safe Survey Checks will be reviewed by Administrator weekly for 30 days then monthly thereafter. Any negative finding will be acted upon immediately. 5. The Director of Nursing and Administrator will in-service all scheduled employees on abuse and mistreatment of residents prior to shift start, by Administrative staff or designee by 12/19/2022. 6. We are going to put in place an Abuse Prevention Program initiated by Administration. The Administrator will provide opportunities for staff to express challenges related to their job and work environment by open door practice starting 12/14/2022. a. The Director of Nursing and Administrator will in-service all scheduled staff starting on 12/14/2022 on abuse prevention program. b. All remaining employees will be in-serviced on abuse prevention program prior to the shift start, by Administrative staff or designee by 12/19/2022. 7. Administrator/Designee will in-service all scheduled staff related to Burn Out/Signs and Symptoms, and report to the administrator starting 12/15/2022. a. All remaining employees will be in-serviced on burn out prior to shift start, by Administrative staff or designee by 12/19/2022. b. Administrator/Designee will do random observation of staff interactions with residents to monitor for signs and symptoms of burn out, three times a week for 30 days, then monthly thereafter. Starting 12/19/2022. c. RVP (Regional [NAME] President) or QI (Quality Improvement) nurse will ensure Administrator/Designee is conducting random observation of staff interactions with residents weekly times 30 days. 8. Any negative findings from the Safe Survey Checks will be acted on by the Administrator immediately, then report findings to the Q.A.P.I. (Quality Assurance/Performance Improvement) weekly for 30 days, then monthly thereafter. 9. Estimated completion date 12/19/2022. Findings: Review of the facility Abuse and Neglect - Clinical Protocol (Revised October 15, 2022) revealed in part: Policy Statement: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy Interpretation and Implementation - Staff to Resident Abuse of any Types: Deals with diverse populations including residents with dementia, mental disorders, intellectual disabilities The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident. Staff are expected to be in control of their behavior and behave professionally. The facility will not accept for an employee to claim his/her action was reflexive or a knee-jerk reaction and was not intended to cause harm. Retaliation from staff is abuse, regardless of whether harm was intended. Definitions: Verbal Abuse - the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend or disability. Physical Abuse - this includes but is not limited to hitting, slapping, pinching, and kicking. Record review of Resident #1's medical record revealed the following diagnoses, in part: Alzheimer's disease, Schizoaffective disorder, anxiety disorder, dementia, and depression. Record review of Resident #1's care plans revealed the following, in part: Impaired thought process related to Alzheimer's, dementia, Schizoaffective disorder, and aphasia. Interventions included, provide consistent caregiver on all shifts, call light in reach, monitor and document resident behavior and status as needed and report cognitive status to MD (Medical Doctor). Electronic monitoring/camera in room per resident and family request, managed by family related to resident dignity will be maintained and protected the next review. Interventions included placement of camera to ensure privacy during care for resident and roommate and keep sign posted on door. Record review of Resident # 1's MDS (minimum data set) dated 10/4/22 revealed the resident's BIMS (brief interview of mental status) score was 99, which indicated unable to complete the interview. Observation with an interview on 12/12/2022 at 11:25 a.m., revealed Resident #1 in reclining chair that was reclined. Appearance was clean and kept. No foul odors noted. Resident #1 was able to say he was doing okay when asked. Resident #1 would partially talk normal then would do a loud moaning sound that was not understandable. Observation on 12/13/2022 at 6:40 a.m., revealed Resident #1 resting in bed with eyes closed. No foul odors noted. Resident #1 had clean and kept appearance. Bed sheet and blankets were arranged in an orderly manner. Room appeared clean. During a telephone interview on 12/12/2022 at 3:15 p.m., Resident #1's RP indicated after she saw the videos of 10/18/2022 of S3 CNA handling Resident #1 roughly she showed the videos to S1 Administrator and S2 DON. Resident #1's RP confirmed the video showed S3 CNA was attempting to assist Resident #1 out of the recliner. S3 CNA got Resident #1 up and Resident #1 went to the floor. S3 CNA attempted to get Resident #1 off the floor, by grabbing the back of Resident #1's head and pulling his head up in a rough manner. After S3 CNA got Resident #1 back in bed, S3 CNA leaned over and put her mouth right by the resident's ear, close enough to kiss his ear, and yelled at the top of her lungs, Stop yelling! Resident #1's RP stated Resident #1 was a preacher and he served to help others and he did not deserve to be treated this way. Review of five video clips, with audio, provided by Resident #1's RP dated 10/18/2022, time-stamped from 12:51p.m. through 1:04 p.m., revealed in summary Resident #1 was in a recliner that was positioned towards the right lower side of the bed. S3 CNA grabbed Resident #1's hands attempting to assist Resident #1 out of the recliner. Resident #1 was unable to stand and S3 CNA guided him to the floor where he landed softly on his buttocks. S3 CNA then moved the Resident #1 next to the side of the bed while the resident remained on the floor. Resident #1 was next to the bed and S3 CNA grabbed the back of Resident #1's head/neck and aggressively pulled Resident #'s head upwards towards her. S3 CNA left the room while Resident #1 was sitting on floor with upper torso leaning on the side of the bed. S3 CNA reentered the room and appeared to be texting on her phone. S3 CNA then exited the room again. The next video showed Resident #1 was in bed with S3 CNA was next to bed. Another staff member was present for a short time before exiting the room. S3 CNA was seen changing Resident #1's adult diaper. S3 CNA was verbally yelling in the room almost constantly, I hate this place, I am getting out of here, you need a man to take care of you, I am over this . S3 CNA put bed sheet over Resident #1 after completing adult diaper change. Resident #1 yelled out and S3 CNA leaned over and placed her mouth right next to Resident #1's right ear and screamed very loudly, Stop yelling! S3 CNA then lowered the bed Resident #1 was lying in to low position. During a telephone interview on 12/14/2022 at 12:34 p.m., S3 CNA indicated the day of the incident with Resident #1, she got him in the recliner and when checking on the resident she noticed his diaper was wet. S3 CNA confirmed when she attempted to get Resident #1 up he wouldn't stand up and help and resident #1wound up sitting on floor. S3 CNA left the room to try to find somebody to help her. S3 CNA brought another CNA to help her and they got Resident #1 in bed and she changed Resident #1's diaper. S3 CNA admitted that when she was trying to get Resident #1 into bed from the recliner she did not do it correctly. S3 CNA indicated she did not jerked the resident by his head and she quietly told Resident #1 to stop yelling. S3 CNA indicated she was called to S1 Administrator's office two days later and she was terminated. During an interview on 12/12/2022 at 2:15 p.m., S5 LPN (licensed practical nurse) indicated she knew Resident #1 RP had shown S1 Administrator and S2 DON the videos of S3 CNA handling Resident #1 roughly. S5 LPN indicated she did not see the videos but she heard from other staff members S3 CNA grabbed Resident #1's neck roughly when attempting to get the resident off of the floor. S5 LPN further indicated S3 CNA was terminated after the incident. S5 LPN then indicated that another resident (Resident #3) informed her that S3 CNA told Resident #3, I'm sick of all y'all lazy a** people not doing anything for yourself. S5 LPN indicated this was told to her after S3 CNA was terminated and S5 LPN reported it to S2 DON. During an interview on 12/12/2022 at 2:30 p.m., Resident #3 indicated that S3 CNA would always talk to her mean, saying things like she hated this place and hating her job. Resident #3 confirmed S3 CNA told her, Y'all know what y'all need?, Y'all need to get off your lazy a**es and start doing for yourself. Review of Resident #3's medical record revealed a 9/30/2022 BIMS (Brief Interview of Mental Status) score of 10 out of 15 indicating mildly impaired. During an interview on 12/13/22022 at 1:15 p.m., Resident #6 did not know S3 CNA was terminated and at first she was hesitant to say anything. Resident #6 was informed S3 CNA had been terminated, Resident #6 indicated S3 CNA would talk very rough and mean to her. Resident #6's son was at bedside during the interview and he asked his mother, Was that the one you called me about being rough? and then Resident #6 replied to her son, yes. Review of Resident #6's medical record revealed a BIMS score on 11/10/2022 of 4 out of 15 indicating a cognitive status of moderately impaired. During an interview on 12/13/2022 at 1:30 p.m., S6 CNA indicated S3 CNA talked mean to her. S6 CNA worked the opposite side of the hall, S3 CNA told her to stay on her side and don't come down S3 CNA'S hallway. S6 CNA also indicated she would go to another hall to get ice for her residents because she didn't want to go to S3 CNA's hall to get the ice. During an interview on 12/13/2022 at 1:45 p.m., Resident #5 indicated S3 CNA had a real bad attitude and kept everything in an uproar. Resident #5 acknowledged once S3 CNA was gone, things got a lot better. Review of Resident #5's medical record revealed a BIMS score on 10/28/2022 of 12 out of 15 indicating a cognitive status of mildly impaired. During an interview on 12/13/2022 at 7:05 a.m., S2 DON indicated Resident #1's RP showed her the video of S3 CNA interacting with Resident #1. S2 DON indicated the videos showed Resident #1 on the floor by his bed, S3 CNA took her hands and placed them behind the resident's neck and then roughly yanked the resident to an upright position. Another video showed S3 CNA putting her mouth directly next to Resident #1's ear and S5 CNA screamed, Shut up! into his ear. S1 Administrator and S2 DON called S3 CNA to the office, S3 CNA told them she just, Lost it. and S3CNA was terminated. S2 DON acknowledged the facility did not assess all residents for any abuse or mistreatment after an abuse allegation was revealed. During an interview on 12/13/2022 at 10:35 a.m., S1 Administrator indicated he had watched the videos shown to him by Resident #1's RP and it showed S3 CNA grab the back of Resident #1's head and forcefully pulled him in upright position. S1 Administrator confirmed the video also showed S3 CNA screaming into Resident #1's ear, Stop hollering! S1 Administrator called S3 CNA to his office and S3 CNA indicated that she Lost it. S3 CNA was terminated on 10/20/2022. S1 Administrator was asked by the surveyor if law enforcement was notified of the staff to resident abuse to which he replied No. During an interview on 12/15/22 at 5:00 p.m., S1 Administrator verified they did not put a system in place to ensure the deficient practice will not happen again. S1 Administrator further verified they did not conduct any ongoing monitoring of residents for evidence of abuse.

Based on record reviews and interviews the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable psychosocial well-being for 1 (#1) of 5 (#1, #2, #3, #4, #5) residents reviewed out of a total census of 147 according to Resident Census and Conditions of Residents dated [DATE]. The facility failed to ensure: 1. Staff accurately assess a resident's weight loss and Nutritional Status 2. Staff follow the Facility Policy on Weight/Height 3. Ensure [MEDICAL CONDITION] [DIAGNOSES REDACTED]. 4. Physician was notified of a resident's refusal of medications The deficient practice resulted in an actual harm on [DATE] for resident #1, diagnosed with [REDACTED]. Resident #1's computerized weight records revealed a constant decline in weight from 186.2 pounds on [DATE] to a weight of 158.2 pounds on [DATE] with no assessment of the weight loss in order to incorporate interventions to prevent further weight loss. The facility's failed practice resulted in actual harm on [DATE] at 12:30 p.m. when resident #1, diagnosed with [REDACTED]. Resident #1 fell out of his wheelchair and hit his head on the floor The unit manager failed to communicate the information given to him by the residents/responsible party concerning the resident having a [MEDICAL CONDITION] disorder to the interdisciplinary committee so that the resident could be assessed and interventions put into place for his care. The resident was transported to the hospital via ambulance and the emergency room note read, he was found to have a [MEDICATION NAME] Level of 5.4. Findings: 1. Cross refer to findings at tag F278. 2. Cross refer to findings at tag F309. 3. Cross refer to findings at tag F325. Review of the Facility Policy: Weight/Height revealed the following: 5. Any resident with significant weight loss or gain will be addressed by the Registered Dietitian unless the change is planned, expected or part of an end stage disease process. 6. The DON or designee will distribute verified weights to the Registered Dietician during scheduled clinical visits and the Dietary Manager Monthly. 7. The MDS Coordinator will code significant weight changes on the resident's scheduled MDS. 8. If the resident has unplanned or unexpected weight change, interventions will be analyzed to determine their need and instituted as appropriate. 9. Some examples of interventions are oral supplements, enteral feeding, liberalized diet, speech therapy consult, adaptive utensils assistance and/or increased time to eat. The weight loss care plan and goals will be periodically evaluated and if not met, alternative approaches attempted. Review of the Facility Policy: Lab Work - Diagnostic Testing revealed the following: Policy: The physician will be notified the same day results are received. Purpose: Prompt and consistent follow through regarding information on resident status. Procedure: 1. Review all lab work as soon as it is received. 2. Document in nurse's note or on the actual result form; the time and type of physician notification. 3. Document in nurses' notes, when applicable. 4. If the lab value or results are at a critical level, notify the physician as soon as possible. Review of the Facility Policy: Admission of Resident revealed the following: 6. Review any medical information provided by transferring facility or family. 1. Weight Loss: Review of resident #1's Face Sheet revealed an admission date of [DATE] and accumulative [DIAGNOSES REDACTED]. Review of resident #1's Facility Weight Record revealed an admission weight of 185.4 pounds. Further review of the record revealed the following: [DATE] 182.6 pounds [DATE] 160.8 pounds [DATE] 164.2 pounds [DATE] 158.2 pounds During an interview on [DATE] at 2:29 p.m. S6Licensed Practical Nurse stated she cared for resident #1 and he normally wore his clothes baggy so she wasn't really sure if he had lost weight or not. During an interview on [DATE] at 8:45 a.m. S4Unit Manager stated if a resident has a rapid weight loss the following interventions would be put into place: Obtain an order for [REDACTED].#1 to address his weight loss. S4Unit Manager further acknowledged the Dietary Manager, Nurse Practitioner and Physician were not notified of resident #1's severe weight loss. 2. [MEDICAL CONDITION]: Review of resident #1's History and Physical from S2Primary Physician revealed the following: Resident #1 is a [AGE] year old white male with Dow[DIAGNOSES REDACTED]. He has mental [MEDICAL CONDITION] (mild to moderate). Resident #1 does have problems with behavior disorder and does have [MEDICAL CONDITION] . Laboratory: [MEDICATION NAME] Level is 97.1. Review of resident #1's Admission Packet revealed S2Primary Physician was resident #1's physician prior to admission to the facility and S3Facility Physician assumed care of resident #1 after admission to the facility on [DATE]. Review of resident #1's Face Sheet revealed an admission date of [DATE] with accumulative [DIAGNOSES REDACTED]. discharge date of [DATE]. Further review of resident #1's accumulative [DIAGNOSES REDACTED]. Review of resident #1's Initial Nursing assessment dated [DATE] failed to reveal resident #1 had a [DIAGNOSES REDACTED]. During an interview on [DATE] at 8:45 a.m. S4Unit Manager stated the facility's practice is to notify the Nurse Practitioner or Physician when residents refuse their medications. S4 Unit Manager acknowledged there was no documentation the nurse notified the physician or nurse practitioner that resident #1 refused any of his medications. During an interview on [DATE] at 9:20 a.m. S4Unit Manager stated when resident #1 was admitted to the facility he reviewed a hand written list of medications provided by resident #1's sister-in-law/responsible party. S4Unit Manager stated resident #1's sister-in-law/responsible party said the resident was on [MEDICATION NAME] for [MEDICAL CONDITION]. S4Unit Manager further stated he did not know if resident #1 had [MEDICAL CONDITION] disorder listed on his list of [DIAGNOSES REDACTED]. During an interview on [DATE] at 9:30 S7Nurse Practitioner stated she had not seen resident #1's preadmission History and Physical and was not aware resident #1 had a [DIAGNOSES REDACTED].#1 did not talk and she only heard him say hey or yea and that was the extent of his verbal communications. S7Nurse Practitioner stated she was not made aware resident #1 was on [MEDICATION NAME] for [MEDICAL CONDITION]. S7Nurse Practitioner stated her understanding was resident #1 was on [MEDICATION NAME] for behavioral issues. S7Nurse Practitioner further stated the dosing for resident #1's [MEDICATION NAME] for behaviors would be adjusted to the behaviors and a lower therapeutic level would be acceptable. S7Nurse Practitioner stated if she had known resident #1 was taking the [MEDICATION NAME] for [MEDICAL CONDITION] she would have adjusted the [MEDICATION NAME] based on the lab drawn on [DATE] with resident #1's [MEDICATION NAME] level at 48.4. S7Nurse Practitioner further stated she had not been notified resident #1 had refused his [MEDICATION NAME] and this would have also influenced her to possibly change the dosages of his medications. S7Nurse Practitioner further stated if she had been made aware resident #1 was refusing his medications she would have pursued family involvement to try to increase medication compliance. S7Nurse Practitioner stated she talks with S3Facility Physician regarding care of residents under his care and he never mentioned resident #1 had a [MEDICAL CONDITION] disorder. During an interview on [DATE] at 10:00 a.m. S5MDS/Care Plan Nurse acknowledged resident #1's History and Physical from the hospital prior to resident #1's admission to the facility listed [MEDICAL CONDITION] as one of resident #1's diagnoses. S5MDS/Care Plan Nurse further stated resident #1 was not assessed or care planned for [MEDICAL CONDITION]. S5MDS/Care Plan Nurse acknowledged resident #1's MDS on admission did not code resident #1 for a history of [MEDICAL CONDITION]. Review of resident #1's Hospital emergency room Note revealed the following: History of Present Illness: The patient presented to the emergency room via Emergency Medical Services after a [MEDICAL CONDITION] at the nursing home The patient was in his wheelchair when he suffered a [MEDICAL CONDITION] and projected forward out of the wheelchair and hit his head on the ground . not sure how long the [MEDICAL CONDITION] lasted but he was brought to the emergency room where he was found to have a [MEDICATION NAME] Level of 5.4 he does have a frontal fracture that extends down through the orbit anteriorly and medially. Assessment/Plan: Breakthrough [MEDICAL CONDITION] in a patient with [MEDICAL CONDITION] disorder and a subtherapeutic [MEDICATION NAME] acid ([MEDICATION NAME]) level . Right Frontal Skull fracture status [REDACTED].Weight Loss . Resident #1 was transferred via Emergency Medical Services to a local hospital on [DATE]. Resident #1 was discharged from the hospital home with Hospice Care on [DATE]. Resident #1 expired at home on [DATE].

Based on record reviews and interviews the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1(#1) of 5 (#1, #2, #3, #4, #5) residents reviewed for nutrition out of a total census of 147 according to Resident Census and Condition of Residents form dated 7/25/16. The deficient practice resulted in an actual harm on 6/22/16 for resident #1, diagnosed with [REDACTED]. Resident #1's computerized weight records revealed a constant decline in weight from 182.6 pounds on 6/15/16 to a weight of 158.2 pounds on 7/6/16 with no assessment of the weight loss in order to incorporate interventions to prevent further weight loss. Findings: Review of resident #1's Face Sheet revealed an admission date of [DATE] and accumulative [DIAGNOSES REDACTED]. Review of the Facility Policy: Weight/Height revealed the following: 5. Any resident with significant weight loss or gain will be addressed by the Registered Dietitian unless the change is planned, expected or part of an end stage disease process. 6. The DON or designee will distribute verified weights to the Registered Dietician during scheduled clinical visits and the Dietary Manager Monthly. 7. The MDS Coordinator will code significant weight changes on the resident's scheduled MDS. 8. If the resident has unplanned or unexpected weight change, interventions will be analyzed to determine their need and instituted as appropriate. 9. Some examples of interventions are oral supplements, enteral feeding, liberalized diet, speech therapy consult, adaptive utensils assistance and/or increased time to eat. The weight loss care plan and goals will be periodically evaluated and if not met, alternative approaches attempted. Review of resident #1's Facility Weight Record revealed an admission weight of 185.4 pounds on 4/1/16. Further review of the record revealed the following: 6/15/16 182.6 pounds 6/22/16 160.8 pounds 6/29/16 164.2 pounds 7/06/16 158.2 pounds Review of resident #1's lab results dated 6/28/16 revealed Total protein level of 5.9 - Low (normal is 6.4-8.3) and [MEDICATION NAME] level of 3.4 (normal is 3.5-5.0). Review of resident #1's June 2016 and July 2016 physician orders revealed an order dated 4/1/16 for a regular diet. Further review of the orders failed to reveal an order for [REDACTED].>Review of June 2016 and July 2016 Dietary Notes and Registered Dietician Notes did not reveal entries regarding recommendations to address resident #1's severe weight loss. During an interview on 7/27/16 at 8:45 a.m. S4Unit Manager stated he did not notify the Dietary Manager of Resident #1's severe weight loss of 24.4 pounds. Review of Resident #1's Discharge Minimum (MDS) data set [DATE] revealed in Section K: Swallowing/Nutritional Status a height of 5 feet 2 inches and a weight of 158 pounds. The MDS was coded as a 0 = (no weight loss). Review of resident #1's comprehensive care plans revealed a care plan for Altered Nutrition - diet as ordered, monitor meal consumption and compliance with diet and notify Registered Dietitian regarding problems, complaints, or request, assist with dining/encourage to eat, weigh per schedule, and encourage fluids. Review of resident #1's meal consumption record revealed documentation the resident consumed 50% to 100% of meals. During an interview on 7/26/16 at 2:29 p.m. S6Licensed Practical Nurse stated she cared for resident #1 and he normally wore his clothes baggy so she wasn't really sure if he had lost weight or not. During an interview on 7/27/16 at 8:45 a.m. S4Unit Manager stated if a resident has a rapid weight loss the following interventions would be put into place: Obtain an order for [REDACTED].#1 to address his weight loss. S4Unit Manager further acknowledged the Dietary Manager, Nurse Practitioner and Physician were not notified of resident #1's severe weight loss.

Based on record reviews and interviews the facility failed to ensure 1 (#1) of 5 (#1, 2, 3, 4, 5) residents reviewed out of a facility census of 147 based on the facility Resident Census and Conditions of Residents Report dated [DATE] received the necessary care and services to maintain their highest practicable physical wellbeing. The facility failed to ensure: 1. Staff reviewed all documents presented by the family and relayed the information obtained from the family to the interdisciplinary care planning team. 2. Physician was notified of a Resident refusing to take his medications. 3. Abnormal Valporic acid level was acted upon to maintain the therapeutic range (50 - 100) required for the treatment of [REDACTED]. The facility's failed practice resulted in actual harm on [DATE] at 12:30 p.m. when Resident #1, diagnosed with [REDACTED]. Resident #1 fell out of his wheelchair and hit his head on the floor. The resident had been refusing his [MEDICATION NAME] and the facility was not aware of the resident having a [MEDICAL CONDITION] disorder. The doctor was never notified that the resident was not taking his [MEDICATION NAME]. The resident was transported to the Hospital via ambulance and the emergency room note read, he was found to have a [MEDICATION NAME] Level of 5.4. Findings: Review of Resident #1's History and Physical (prior to admission to the facility) from S2Primary Physician dated [DATE] revealed the following: [AGE] year old white male with Dow[DIAGNOSES REDACTED]. He has mental [MEDICAL CONDITION] (mild to moderate). Resident #1 does have problems with behavior disorder and does have [MEDICAL CONDITION] .Laboratory: [MEDICATION NAME] Level ([MEDICATION NAME] Acid) on [DATE] was 97.1 (Normal Range 50 - 100). Review of Resident #1's Face Sheet revealed an admission date of [DATE] with accumulative [DIAGNOSES REDACTED]. The accumulative [DIAGNOSES REDACTED].#1 failed to reveal a [DIAGNOSES REDACTED]. Review of the facility's investigation of the incident revealed the following: [DATE] 12:30 p.m. Resident #1 appears to have had a [MEDICAL CONDITION] while the CNA (Certified Nursing Assistant) was escorting him to his room from the dining room. Resident #1 fell out of his wheelchair and hit his head on the floor; Resident #1 was unconscious, 911 was called, Resident #1 was transported to the hospital; family and physician were notified. Review of Resident #1's Hospital emergency room Note revealed the following: History of Present Illness: The patient presented to the emergency room via Emergency Medical Services after a [MEDICAL CONDITION] at the nursing home The patient was in his wheelchair when he suffered a [MEDICAL CONDITION] and projected forward out of the wheelchair and hit his head on the ground .not sure how long the [MEDICAL CONDITION] lasted but he was brought to the emergency room where he was found to have a [MEDICATION NAME] Level of 5.4 he does have a frontal fracture that extends down through the orbit anteriorly and medially. Assessment/Plan: Breakthrough [MEDICAL CONDITION] in a patient with [MEDICAL CONDITION] disorder and a subtherapeutic [MEDICATION NAME] acid ([MEDICATION NAME]) level .Right Frontal Skull fracture status [REDACTED].Weight Loss . Review of Resident #1's Initial Nursing assessment dated [DATE] failed to reveal Resident #1 had [MEDICAL CONDITION] or was at risk for [MEDICAL CONDITION]. Review of Resident #1's Admission Minimum (MDS) data set [DATE] failed to reveal Resident #1 was coded for the [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive care plans failed to reveal Resident #1 was careplanned for [MEDICAL CONDITION] or [MEDICAL CONDITION]. Review of Resident #1's [DATE] Physician order [REDACTED]. Review of Resident #1's June and [DATE] Medication Administration Records classified [MEDICATION NAME] Acid as an Antipsychotic Medication. Further review of Resident #1's [DATE] and [DATE] MARs (Medication Administration Records) revealed the following missed doses: [DATE] at 9:00 p.m. [DATE] at 9:00 a.m. [DATE] at 9:00 p.m. [DATE] at 9:00 a.m. and 9:00 p.m. [DATE] at 9:00 a.m. and 9:00 p.m. [DATE] at 9:00 a.m. and 9:00 p.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. [DATE] at 9:00 p.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. Resident #1's medical record revealed blood was drawn on [DATE] and his [MEDICATION NAME] level was 48.4. (Normal Range 50 - 100). During an interview on [DATE] at 2:29 p.m. S6LPN stated she cared for Resident #1 and was not sure why Resident #1 was on [MEDICATION NAME]. Review of National Institutes of Health Guidelines for [MEDICATION NAME] Acid revealed the following: [MEDICATION NAME] acid is used alone or with other medications to treat certain types of [MEDICAL CONDITION] .[MEDICATION NAME] acid is in a class of medications called anti-convulsants .Take [MEDICATION NAME] acid at around the same time every day .take [MEDICATION NAME] acid exactly as directed .Do not stop taking [MEDICATION NAME] acid without talking to your doctor .If you suddenly stop taking [MEDICATION NAME] acid, you may experience a severe, long [MEDICATION NAME] and possibly life-threatening [MEDICAL CONDITION]. During an interview on [DATE] at 8:45 a.m. S4Unit Manager stated the facility's practice is to notify the Nurse Practitioner or Physician when residents refuse their medications. S4 Unit Manager acknowledged there was no documentation the nurse notified the physician or nurse practitioner that Resident #1 refused any of his medications. During an interview on [DATE] at 9:20 a.m. S4Unit Manager stated when Resident #1 was admitted he (S4Unit Manager) reviewed a hand written list of medications provided by Resident #1's sister-in-law/responsible party. S4Unit Manager stated Resident #1's sister-in-law/responsible party stated the resident was on [MEDICATION NAME] for [MEDICAL CONDITION]. S4Unit Manager further stated he did not know if the resident had [MEDICAL CONDITION] disorder listed on his list of [DIAGNOSES REDACTED]. During an interview on [DATE] at 9:30 S7Nurse Practitioner stated she had not seen Resident #1's preadmission History and Physical and was not aware Resident #1 had a [DIAGNOSES REDACTED].#1 did not talk and she only heard him say hey or yea and that was the extent of his verbal communications. S7Nurse Practitioner stated she was not made aware Resident #1 was on [MEDICATION NAME] for [MEDICAL CONDITION]. S7Nurse Practitioner stated her understanding was Resident #1 was on [MEDICATION NAME] for behavioral issues. S7Nurse Practitioner further stated the dosing for Resident #1's [MEDICATION NAME] for behaviors would be adjusted to the behaviors and a lower therapeutic level would be acceptable. S7Nurse Practitioner stated if she had known Resident #1 was taking the [MEDICATION NAME] for [MEDICAL CONDITION] she would have adjusted the [MEDICATION NAME] based on the lab drawn on [DATE] with Resident #1's [MEDICATION NAME] level at 48.4. S7Nurse Practitioner further stated she had not been notified Resident #1 had refused his [MEDICATION NAME] and this would have also influenced her to possibly change the dosages of his medications. S7Nurse Practitioner further stated if she had been made aware Resident #1 was refusing his medications she would have pursued family involvement to try to increase medication compliance. S7Nurse Practitioner stated she talks with S3Facility Physician regarding care of residents under his care and he never mentioned Resident #1 had a [MEDICAL CONDITION] disorder. During an interview on [DATE] at 10:00 a.m. S5MDS/Care Plan Nurse acknowledged Resident #1's History and Physical from the hospital prior to Resident #1's admission to the facility listed [MEDICAL CONDITION] as one of Resident#1's diagnoses. S5MDS/Care Plan Nurse further stated Resident #1 was not assessed or care planned for [MEDICAL CONDITION]. S5MDS/Care Plan Nurse acknowledged Resident #1's MDS on admission did not list that the resident had a history of [REDACTED]. During an interview on [DATE] at 10:00 a.m. S5MDS/Care Plan Nurse reviewed Resident #1's June Medication Administration Record [REDACTED]. S5MDS/Care Plan Nurse reviewed Resident #1's July Medication Administration Record [REDACTED]. S5MDS/Care Plan Nurse stated the facility practice is to notify the physician if a resident refuses medications. S5MDS/Care Plan Nurse acknowledged the Medication Administration Records comments did not reveal the physician or nurse practitioner were notified of resident #1's refusal of medications. S5MDS/Care Plan Nurse reviewed the Physician and Nurse Practitioner notes and acknowledged there was no documentation that the resident was refusing his medications. During an interview on [DATE] at 10:35 a.m. S8LPN stated she was present on [DATE] when Resident #1 had a [MEDICAL CONDITION]. S7LPN stated Resident #1 stood up and fell face forward to the floor and hit his head. S7LPN stated Resident #1 was placed on his side and vital signs were obtained. S7LPN stated 911 was called. S7LPN stated the [MEDICAL CONDITION] lasted approximately a few minutes and it looked like Resident #1 was having another [MEDICAL CONDITION] as the Emergency Medical Technicians were transporting the resident out of the facility. During an interview on [DATE] at 3:45 p.m. S5MDS/Care Plan nurse stated Resident #1 was discharged from a local hospital on [DATE] on Hospice Care and expired on [DATE].

Based on record reviews and staff interviews, the facility failed to ensure each portion of the assessments were accurate and complete for 1 (#1) of 5 (#1, 2, 3, 4, 5) residents reviewed for assessments out of a total facility census of 147 according to the Resident Census and Conditions of Residents Report dated [DATE]. The deficient practice resulted in an actual harm on [DATE] for Resident #1, diagnosed with [REDACTED]. Resident #1's computerized weight records revealed a constant decline in weight from 182.6 pounds on [DATE] to a weight of 158.2 pounds on [DATE] with no assessment of the weight loss in order to incorporate interventions to prevent further weight loss. The facility's failed practice resulted in actual harm on [DATE] at 12:30 p.m. when Resident #1, diagnosed with [REDACTED]. Resident #1 fell out of his wheelchair and hit his head on the floor. The unit manager failed to communicate the information given to him by the residents/responsible party concerning the resident having a [MEDICAL CONDITION] disorder to the interdisciplinary committee so that the resident could be assessed and interventions put into place for his care. The resident was transported to the hospital via ambulance and the emergency room note read, he was found to have a [MEDICATION NAME] Level of 5.4. Findings: 1. Assessment for Weight Loss: Review of Resident #1's Face Sheet revealed an admission date of [DATE] with accumulative [DIAGNOSES REDACTED]. Review of Resident #1's History and Physical from S2Primary Physician dated [DATE] revealed the following: Resident #1 is a [AGE] year old white male with Dow[DIAGNOSES REDACTED]. He has mental [MEDICAL CONDITION] (mild to moderate). Review of Resident #1's Facility Weight Record revealed an admission weight of 185.4 pounds. Further review of the record revealed the following: [DATE] 182.6 pounds [DATE] 160.8 pounds [DATE] 164.2 pounds [DATE] 158.2 pounds Review of Resident #1's lab results dated [DATE] revealed a Total protein level of 5.9 - Low (normal range is 6XXX,[DATE].3) and [MEDICATION NAME] level of 3.4 (normal is 3XXX,[DATE].0). Review of Resident #1's [DATE] and [DATE] physician orders revealed an order dated [DATE] for a regular diet. Further review of Resident #1's orders failed to reveal resident was on a planned weight loss program. Review of Resident #1's Meal Report form dated [DATE] revealed documentation resident consumed 50% to 100% at each meal. Review of [DATE] and [DATE] Dietary Notes and Registered Dietician Notes failed to reveal entries regarding recommendations to address Resident #1's severe weight loss. During an interview on [DATE] at 8:45 a.m. S4Unit Manager stated he did not notify the Dietary Manager of Resident #1's severe weight loss of 24.4 pounds. Review of Resident #1's Discharge Minimum (MDS) data set [DATE] revealed in Section K: Swallowing/Nutritional Status a height of 5 feet 2 inches and a weight of 158 pounds. The MDS was coded as a 0 = (no weight loss). Review of Resident #1's comprehensive care plans revealed a care plan for Altered Nutrition with approaches that included the following: diet as ordered, monitor meal consumption, monitor compliance with diet and notify Registered Dietitian regarding problems, complaints, or request, assist with dining/encourage to eat, weigh per schedule, and encourage fluids. During an interview on [DATE] at 8:45 a.m. S4Unit Manager stated if a resident has a rapid weight loss the following interventions would be put into place: Obtain an order for [REDACTED].#1 in order to address his weight loss. S4Unit Manager further acknowledged he did not notify the Dietary Manager, Nurse Practitioner or Physician that resident #1 had a severe weight loss. Review of the Facility Policy: Weight/Height revealed the following: 5. Any resident with significant weight loss or gain will be addressed by the Registered Dietitian unless the change is planned, expected or part of an end stage disease process. 6. The DON or designee will distribute verified weights to the Registered Dietician during scheduled clinical visits and the Dietary Manager Monthly. 7. The MDS Coordinator will code significant weight changes on the resident's scheduled MDS. 8. If the resident has unplanned or unexpected weight change, interventions will be analyzed to determine their need and instituted as appropriate. 9. Some examples of interventions are oral supplements, enteral feeding, liberalized diet, speech therapy consult, adaptive utensils assistance and/or increased time to eat. The weight loss care plan and goals will be periodically evaluated and if not met, alternative approaches attempted. 2. Assessment for [MEDICAL CONDITION]: Review of Resident #1's History and Physical form completed by S2Primary Physician dated [DATE] revealed the following: Resident #1 is a [AGE] year old white male with Dow[DIAGNOSES REDACTED]. He has mental [MEDICAL CONDITION] (mild to moderate). Resident #1 does have problems with behavior disorder and does have [MEDICAL CONDITION] . Laboratory: [MEDICATION NAME] Level is 97.1 (normal range 50 - 100). Review of Resident #1's Face Sheet revealed an admission date of [DATE] with accumulative [DIAGNOSES REDACTED]. Further review of the Face Sheet revealed Resident #1 was discharged on [DATE]. The accumulative [DIAGNOSES REDACTED].#1 failed to reveal a [DIAGNOSES REDACTED]. Review of Resident #1's Initial Nursing assessment dated [DATE] failed to reveal Resident #1 had [MEDICAL CONDITION]. Review of Resident #1's [DATE] Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] Acid 250 milligrams/5 milliliters orally give 15 milliliters (750 milligrams) by mouth twice a day. Review of Resident #1's June and [DATE] Medication Administration Records classified [MEDICATION NAME] Acid as an Antipsychotic Medication. Further review of Resident #1's [DATE] and [DATE] MARs (Medication Administration Records) revealed the following missed doses: [DATE] at 9:00 p.m. [DATE] at 9:00 a.m. [DATE] at 9:00 p.m. [DATE] at 9:00 a.m. and 9:00 p.m. [DATE] at 9:00 a.m. and 9:00 p.m. [DATE] at 9:00 a.m. and 9:00 p.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. [DATE] at 9:00 p.m. [DATE] at 9:00 a.m. [DATE] at 9:00 a.m. Review of Resident #1's Discharge Minimum (MDS) data set [DATE] failed to reveal resident #1 was coded for the [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive care plans failed to reveal resident #1 was careplanned for [MEDICAL CONDITION] or [MEDICAL CONDITION]. During an interview on [DATE] at 2:29 p.m. S6LPN stated she cared for Resident #1 and was not sure why Resident #1 was on [MEDICATION NAME]. During an interview on [DATE] at 8:45 a.m. S4Unit Manager stated the facility's practice is to notify the Nurse Practitioner or Physician when residents refuse their medications. S4Unit Manager acknowledged there was no documentation that the nurse notified the physician or nurse practitioner that Resident #1 refused any of his medications. During an interview on [DATE] at 9:20 a.m. S4Unit Manager stated when Resident #1 was admitted he reviewed a hand written list of medications provided by resident #1's sister-in-law/responsible party. S4Unit Manager stated Resident #1's sister-in-law/responsible party stated the resident was on [MEDICATION NAME] for [MEDICAL CONDITION]. S4Unit Manager further stated he did not know if the resident had [MEDICAL CONDITION] disorder listed on his list of [DIAGNOSES REDACTED]. During an interview on [DATE] at 9:30 S7Nurse Practitioner stated she had not seen Resident #1's preadmission History and Physical and was not aware Resident #1 had a [DIAGNOSES REDACTED].#1's did not talk and she only heard him say hey or yea and that was the extent of his verbal communications. S7Nurse Practitioner stated she was not made aware Resident #1 was on [MEDICATION NAME] for [MEDICAL CONDITION]. S7Nurse Practitioner stated her understanding was Resident #1 was on [MEDICATION NAME] for behavioral issues. S7Nurse Practitioner further stated the dosing for Resident #1's [MEDICATION NAME] for behaviors would be adjusted to the behaviors and a lower therapeutic level would be acceptable. S7Nurse Practitioner stated if she had known Resident #1 was taking the [MEDICATION NAME] for [MEDICAL CONDITION] she would have adjusted the [MEDICATION NAME] based on the lab drawn on [DATE] with Resident #1's [MEDICATION NAME] level at 48.4. S7Nurse Practitioner further stated she had not been notified Resident #1 had refused his [MEDICATION NAME] and this would have also influenced her to possibly change the dosages of his medications. S7Nurse Practitioner further stated if she had been made aware Resident #1 was refusing his medications she would have pursued family involvement to try to increase medication compliance. S7Nurse Practitioner stated she talks with S3Facility Physician regarding care of residents under his care and he never mentioned Resident #1 had a [MEDICAL CONDITION] disorder. During an interview on [DATE] at 10:00 a.m. S5MDS/Care Plan Nurse acknowledged Resident #1's History and Physical from the hospital prior to Resident #1's admission to the facility listed [MEDICAL CONDITION] as one of Resident #1's diagnoses. S5MDS/Care Plan Nurse further stated Resident #1 was not assessed or care planned for [MEDICAL CONDITION]. S5MDS/Care Plan Nurse acknowledged Resident #1's MDS on admission did not list that the resident had a history of [REDACTED]. During an interview on [DATE] at 10:35 a.m. S8LPN stated she was present on [DATE] when Resident #1 had a [MEDICAL CONDITION]. S7LPN stated Resident #1 stood up and fell face forward to the floor and hit his head. S7LPN stated Resident #1 was placed on his side and vital signs were obtained. S7LPN stated 911 was called. S7LPN stated the [MEDICAL CONDITION] lasted approximately a few minutes and it looked like Resident #1 was having another [MEDICAL CONDITION] as the Emergency Medical Technicians were transporting the resident out of the facility. During an interview on [DATE] at 3:45 p.m. S5MDS/Care Plan nurse stated Resident #1 was discharged from a local hospital on [DATE] on Hospice and expired on [DATE]. Review of Resident #1's Hospital emergency room Note revealed the following: History of Present Illness: The patient presented to the emergency room via Emergency Medical Services after a [MEDICAL CONDITION] at the nursing home The patient was in his wheelchair when he suffered a [MEDICAL CONDITION] and projected forward out of the wheelchair and hit his head on the ground .not sure how long the [MEDICAL CONDITION] lasted but he was brought to the emergency room where he was found to have a [MEDICATION NAME] Level of 5.4 he does have a frontal fracture that extends down through the orbit anteriorly and medially. Assessment/Plan: Breakthrough [MEDICAL CONDITION] in a patient with [MEDICAL CONDITION] disorder and a subtherapeutic [MEDICATION NAME] acid ([MEDICATION NAME]) level .Right Frontal Skull fracture status [REDACTED].Weight Loss . Resident #1 was transferred via Emergency Medical Services to a local hospital on [DATE]. Resident #1 was discharged from the hospital home with Hospice Care on [DATE]. Resident #1 expired at home on [DATE].

Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that used resources effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being for 1 (#93) of 10 (#138,140,113,101,84,75,172,78,40, 93) expanded sampled residents reviewed for pain during wound care treatments in the facility. According to the Resident Census and Conditions of Residents Report provided by the facility on 5/23/16 revealed a total of 15 residents with pressure ulcers resided in the facility. Administration failed to: 1. Enforce their system to ensure nursing staff assessed a resident for pain associated with wound treatments and identify signs and symptoms of pain and non-verbal cues of pain. 2. Enforce their system to ensure administration of pain medications to manage pain associated with wound treatments. 3. Follow their Policy and Procedure for Pain Management. The facility's failures resulted in Immediate Jeopardy for Resident #93. S1 Administrator was notified of the Immediate Jeopardy on 5/25/2016 at 4:55 p.m. The Immediate Jeopardy began for resident #93 on 3/29/2016 when a Stage 3 sacrum wound was identified according to the facility's Wound Assessment Report dated 3/29/2016. Further review of the Wound Assessment Report revealed yes was entered in the blank which indicated Resident #93 had pain with wound/treatment and yes was entered in the blank to indicate pain intensity for Resident #93 was crying. On 5/25/2015 at 1:45 p.m., S6 Wound Care LPN initiated wound care to the Stage 3 sacral wound of Resident #93. Resident #93 immediately began to scream out and cry when S6 Wound Care LPN touched the wound. The Immediate Jeopardy was lifted on 5/26/2016 at 4:40 p.m. following observations of wound care to residents at risk for pain revealed components of the Plan Removal was implemented. The deficient practice continued at pattern for harm. Findings: During an interview on 5/25/2016 at 1:35 p.m., S6 Wound Care LPN stated she does not medicate residents for pain before delivering wound care. S6 Wound Care LPN stated the floor nurse is responsible to administer pain medication prior to providing wound care. During an interview on 5/25/2016 at 2:00 p.m., S6 Wound Care LPN stated Resident #93 did not receive pain medication prior to the wound care treatment. S6 Wound Care LPN acknowledged Resident #93 was in pain during the treatment she had provided. S6 Wound Care LPN further stated the resident responds with screaming and crying during each wound treatment. Review of the May 2016 Medication Administration Record [REDACTED] Review of the Wound Assessment Reports from 3/29/16 thru 5/25/16 revealed resident #93 was not given pain medications prior to or during the wound care treatments she received. During an interview on 5/25/2016 at 5:00 p.m. S1 Administrator stated we had just gotten complacent in care for Resident #93. S1 Administrator stated we were just not identifying her pain. During an interview on 5/25/2016 at 5:00 p.m. S2 DON agreed with S1 Administrator. S2 DON stated she would immediately have a nurse give resident #93 something for pain. She further stated would notify hospice and obtain an order for [REDACTED]. Review of the facility's Policy and Procedures regarding pain revealed the following: Policy Statement Effective pain recognition and management requires an ongoing facility-wide-commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain. Nursing home residents are at high risk for having pain that may affect function, impair mood, or disturb sleep, and diminish quality of life. The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's reports of pain, or nonverbal signs suggesting pain, be evaluated. Policy Interpretation and Implementation 1. A pain assessment will be completed upon admission, readmission, and any new episode of pain or exacerbation of pain. 2. A care plan will be developed to identify a resident's pain and interventions to assist with care of the resident, and updated with any changes in interventions. 3. A pain evaluation MDS (Minimum Data Set) must be completed for a patient/resident upon admission, quarterly, and with any significant change in condition. 4. Patients/Residents are routinely assessed each shift for pain. 5. If the patient/resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [REDACTED].>6. Patient/Resident should be evaluated for any needed pain medication prior to treatments (i.e. wounds) or care. 7. The plan of care for a Hospice resident should include any directives for managing pain and other uncomfortable symptoms and updated as necessary.

Based on observations, record reviews, interviews the facility failed to ensure a resident's need for pain medication was assessed and pain medication administered prior to the delivery of wound care treatment for 1 (#93) of 10 (#138,140,113,101,84,75,172,78,40, and 93) sampled residents, expanded for review of wound care in the facility. According to the Resident and Census Condition Report 15 residents with pressure ulcers resided in the facility. The facility failed to: 1. Assess a resident with pain associated with wound treatments and identify signs and symptoms of pain and non-verbal cues of pain. 2. Administer pain medications to manage pain associated with wound treatments. 3. Follow their Policy and Procedure for Pain Management. The facility's failures resulted in Immediate Jeopardy for Resident #93. The Immediate Jeopardy began for resident #93 on 3/29/2016 when a Stage 3 sacrum wound was identified according to the facility's Wound Assessment Report dated 3/29/2016. Further review of the Wound Assessment Report revealed yes was entered in the blank which indicated Resident #93 had pain with wound/treatment and yes was entered in the blank to indicate pain intensity for Resident #93 was crying. On 5/25/2015 at 1:45 p.m., S6 Wound Care LPN initiated wound care to the Stage 3 sacral wound of Resident #93. S6 Wound Care LPN did not review the resident ' s Medication record to determine when the resident last received pain medication. Resident #93 immediately began to scream out and cry when S6 Wound Care LPN touched the wound. S6 Wound Care LPN continued with the wound care without the resident receiving pain medication. On 5/25/16 at 4:55 p.m. the survey team notified S1 Administrator of the IJ situation. The following facility's Plan of Removal was received by the survey team on 5/25/2016 at 6:30 p.m. 1. Resident #93 was administered pain medication by S16 LPN at 5:15 p.m. 2. Pain will be assessed in 30 minutes for effectiveness. 3. Director of nursing to contact hospice regarding a possible increase in pain medication. 4. S6 Wound Care LPN was counseled and in-serviced at 5:15 p.m. regarding pain assessment and pain medication administration prior to dressing changes for resident #93 and all residents with pressure ulcers or wounds. 5. The physician will be called and an order received to pre-medicate resident #93 before dressing changes. 6. All nursing staff will be in-serviced on pain assessment and aggressive treatment for [REDACTED]. 7. The Director of Nursing will monitor the treatment nurse daily to assure that pain control is addressed. Any problems found will be reported to the QA committee. 8. The QA committee will review pain control issues weekly The facility's Plan of Removal was accepted at 7:00 p.m. The Immediate Jeopardy was lifted on 5/26/2016 at 4:40 p.m. following observations of wound care to residents at risk for pain revealed components of the Plan Removal was implemented. The deficient practice continued at a pattern for harm. Findings: During an interview on 5/25/2016 at 1:35 p.m., S6 Wound Care LPN stated she does not medicate residents for pain before delivering wound care. S6 Wound Care LPN stated the floor nurse is responsible to administer pain medication prior to providing wound care. During an observation on 5/25/2015 at 1:45 p.m., S6 Wound Care LPN initiated wound care to the Stage 3 sacral wound of Resident #93. Resident #93 immediately began to scream out and cry when S6 Wound Care LPN touched the wound. Further observation revealed S6 Wound Care LPN continued the treatment and stated, We will be through in a little bit, just hold on; it will be okay in a little bit. We are almost done. Further observation revealed Resident #93 continued to scream out and cry during the wound treatment. During an interview on 5/25/2016 at 2:00 p.m., S6 Wound Care LPN stated Resident #93 did not receive pain medication prior to the wound care treatment. S6 Wound Care LPN acknowledged Resident #93 was in pain during the treatment she had provided. S6 Wound Care LPN further stated the resident responds with screaming and crying during each wound treatment. During an interview on 5/25/2016 at 2:00 p.m., S17 CNA stated she had seen Resident #93 crying during wound treatments. S17 CNA further stated she had seen Resident #93 with tears running down her face while wound care was delivered. S17 CNA stated Resident #93 hollers and cries during her wound care treatments every day. During an interview on 5/25/2016 at 2:20 p.m. S18 LPN stated Resident #93 was last medicated for pain on 5/25/2016 at 7:30 a.m. S18 LPN further stated she did not give pain medication to Resident #93 to minimize pain during wound care treatments. Review of resident #93's May 2016 Medication Administration Record [REDACTED] Review of resident #93's March 2016 and April 2016 MARs further failed to reveal resident had received her prn pain medication as a pre-medication prior to her dressing changes. Review of resident #93's Weekly Wound Assessment Report forms from 3/29/16 thru 5/25/16 revealed resident #93 had a Stage 3 sacral wound that was identified in facility on 3/29/16. Further review of the Weekly Wound Assessment Report forms revealed multiple forms where yes was entered in the blank which indicated Resident #93 had pain with wound/treatment and yes was entered in the blank to indicate pain intensity for Resident #93 was crying. Review of resident #93's Weekly Wound Assessment Report forms from 3/29/16 thru 5/25/16 revealed resident #93 was not given pain medications prior to or during the wound care treatments she received. Review of resident #93's Significant Change MDS dated [DATE] revealed resident was assessed as having [MEDICAL CONDITION] and also assessed as having a BIMS (Brief Interview for Mental Status) score of 3 (00-15 with 15= cognitive). During an interview on 5/25/2016 at 5:00 p.m. S1 Administrator stated we had just gotten complacent in care for Resident #93. S1 Administrator stated we were just not identifying her pain. During an interview on 5/25/2016 at 5:00 p.m. S2 DON agreed with S1 Administrator. S2 DON stated she would immediately have a nurse give resident #93 something for pain. She further stated would notify hospice and obtain an order for [REDACTED]. Review of the facility's Policy and Procedures regarding pain revealed the following: Policy Statement Effective pain recognition and management requires an ongoing facility-wide-commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain. Nursing home residents are at high risk for having pain that may affect function, impair mood, or disturb sleep, and diminish quality of life. The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's reports of pain, or nonverbal signs suggesting pain, be evaluated. Policy Interpretation and Implementation 1. A pain assessment will be completed upon admission, readmission, and any new episode of pain or exacerbation of pain. 2. A care plan will be developed to identify a resident's pain and interventions to assist with care of the resident, and updated with any changes in interventions. 3. A pain evaluation MDS (Minimum Data Set) must be completed for a patient/resident upon admission, quarterly, and with any significant change in condition. 4. Patients/Residents are routinely assessed each shift for pain. 5. If the patient/resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [REDACTED].>6. Patient/Resident should be evaluated for any needed pain medication prior to treatments (i.e. wounds) or care. 7. The plan of care for a Hospice resident should include any directives for managing pain and other uncomfortable symptoms and updated as necessary. According to the Quick Reference Guide, the National Pressure Ulcer Advisory Panel, second edition, published 2014: Pressure ulcers are painful. Individuals with pressure ulcers experience ulcer related pain that can be quantified and differentiated from other pain, and this pain occurs during procedures and at rest. To manage pressure ulcer pain, organize care delivery to ensure that it is coordinated with pain medication administration and that minimal interruptions follow. Pain management includes performing care after administration of pain medication to minimize pain experienced and interruptions to comfort the individual.