Every finding on record at The Palms At Florence

Based on review of the facility policy, record review, and interview, the facility failed to ensure that 1 of 1 resident (Resident (R)164) reviewed for death, received continued monitoring after a change in condition and initiation of an intervention.Findings include: Review of the facility policy titled Documentation Policy dated 09/08/25, under the Policy section indicated, Each resident's medical record will contain an accurate representation of the resident status. The Procedure section of the policy indicated the following: 2. Routine Charting for all Residents lists Pertinent Nurse's Notes and Acute charting, Section 2a. lists the following: Nurse's notes may also include but not limited to the following: changes in condition; 2b. Acute charting may also include but not limited to the following: change in condition of a resident. Review of R164's Face Sheet revealed the facility admitted R164 on 03/10/26, with diagnoses including, but not limited to, Pneumonitis due to inhalation of food and vomit, Chronic Obstructive Pulmonary Disease, Dysphagia Oropharyngeal Phase, Sepsis, Solitary Pulmonary Nodule, Immunodeficiency due to conditions Classified Elsewhere and Chronic Diastolic (Congestive) Heart Failure. Review of the ongoing Physician's Orders revealed, 1) Monitor for signs and symptoms of infection including but not limited to the following: Cough, congestion, fever, changes in vital signs, changes in mental status, shortness of breath, foul smelling urine, swelling/redness/warmth to skin, abnormal lab values, signs/symptoms of wound infection, etc.) and notify MD and/or NP if these concerns arise. Review of the Nursing Advantage Skilled Evaluation Note dated 05/09/26 at 12:30 AM revealed R164's vital signs were as follows: Temperature 98.2 degrees Fahrenheit, Pulse 108-pulse type unable to determine, Respirations 24 with an Oxygen Saturation of 95% oxygen via Nasal Cannula. Under the Respiratory section of the Nurse's note states difficulty breathing noted. Nurse observed tachypnea present. Shortness of breath noted. Further review of the Nurse's Notes revealed a note on 05/09/26 at 3:04 AM, indicated R164 was observed with rapid breathing. O2 (oxygen) sat (saturation) on RA (room air) was 85%. The resident's temperature was documented at 98.2, Respirations 26, blood pressure 144/94, and pulse of 108. At that time standing order for oxygen via nasal cannula at 2 liters was initiated. R164's O2 sat increased to 95%, respirations were even and unlabored. A note was placed in the Doctor's book to assess at the next visit. Review of nurse's notes and vital signs from admission revealed R164 had never had oxygen administered until 05/09/26 at 12:30 AM. Further review of the nurse's notes revealed there was no documentation of continued monitoring for R164 after the initiation of the oxygen. Review of Nurse's note dated 05/09/26 at 6:46 AM states resident was observed with rapid breathing and extremities were cold to touch. At that time, O2 sat could not be obtained, vital signs were as follows: blood pressure 138/63, pulse 78, temperature 97 degrees Fahrenheit, respirations 24. R164 was responsive, but nonverbal. On call services were contacted and an order was received to send R164 to the hospital for Hypoxia. Prior to Emergency Medical Services arriving, R164 stopped breathing and Cardiopulmonary Resuscitation was initiated. Review of Licensed Practical Nurse (LPN)4's statement dated 06/03/26 states R164 was observed around 1 AM and was checked on at least two additional times throughout the shift and vital signs were all in range. However, there was no documentation in the vital signs section or the nurse's note section to reflect R164 was monitored throughout the night. During an interview on 06/04/26 at 10:54 AM, the Director of Nursing stated the facility charted by exception.

Based on review of facility policy, observation and interview, the facility failed to ensure the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors.Findings include:Review of the facility's policy titled, Nurse Staffing Posting Information (undated), revealed, It is the policy of this facility to make nurse staffing information available in a readable format to residents, staff, and visitors . (3) B. In a place readily accessible to residents, staff and visitors.During an observation on 06/02/26 at approximately 11:30 AM, the daily nurse staff posting was located behind the East Nurses' Station. The posting was not visible or accessible to residents or visitors.During an observation on 06/04/26 at approximately 3:23 PM, the daily nurse staffing posting remained behind the East Nurses' Station and was not accessible to residents or visitors.During an observation on 06/04/26 at approximately 5:33 PM, conducted alongside the Administrator and the Director of Nursing (DON), the daily nurse staffing posting was observed behind the East Nurses' Station. The document was physically out of reach and not readily accessible to residents or visitors.During an interview on 06/04/26 at 5:28 PM, the DON stated he was unsure of the exact facility policy requirements regarding the posting location of the daily staff data. The DON confirmed the document is exclusively posted behind the East Nurses' Station.During an interview on 06/04/26 at approximately 5:30 PM, the Administrator stated that the daily staffing information is posted at the East Hall nurses' station because that wing is central to the entrance used by most visitors. The Administrator failed to confirm or provide evidence that the posting was visible or accessible to residents or visitors.

Based on observation, interview, and review of facility policy, the facility failed to ensure the cleanliness and proper placement of the grease trap on a non-porous surface. This failure had the potential to attract insects and pests to the facility. Findings include:Review of the undated facility policy titled, Grease Trap Pumping and Maintenance Policy & Procedure, documented, It is the policy of HCSG to ensure that all grease traps are pumped, cleaned, and maintained on a quarterly basis by The Serviced Grease Trap Company contracted to comply with environmental regulations, prevent sewer blockages, eliminated odors, and maintain a safe and sanitary environment.Review of facility receipts revealed an account with, [NAME] Septic Systems that indicates the grease tank was cleaned on 01/07/26 and 03/31/26.During an observation on 06/03/26 at 11:44 AM, revealed the facility's grease trap leaking a substance that appeared to be black oil into the soil and grass surrounding the trap. In addition, an observation was made that appeared to be solidified grease that dried into a white solid substance. During an interview with the Certified Dietary Manager on 06/03/26 at approximately 11:45 AM, revealed that she was unsure of how often the grease trap is cleaned but believes that it is cleaned quarterly.During an interview with the Executive/Regional Director on 06/03/26 at approximately 11:55 AM, revealed that the grease trap is cleaned quarterly and the company that cleans the grease trap can send receipts of the recent cleanings.

Based on review of facility policy, the manufacturer's recommendation, observation and interview, the facility failed to ensure a Lantus Insulin Pen was primed correctly prior to administering insulin for Resident (R)7. Specifically, the nurse failed to ensure the needle was pointed upward to ensure the air was removed from the pen and the resident received the correct amount of insulin as ordered for 1 of 1 residents observed receiving insulin during medication pass. Findings include: Review of the facility policy titled, Insulin Pen Policy, states as the policy, It is the policy of this facility to use insulin pens to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Under the Policy Explanation: Number 6. states, Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. Review of the manufacturer's recommendations and a step-by-step guide to using your Lantus SoloStar pen states, This quick how-to guide- a short version of the leaflet included in your Lantus Solostar pen box - has been designed to help you more easily learn how to inject the right amount of insulin every time. That way, you may avoid getting too little or too much insulin, which can effect your blood sugar levels. Step 1. Remove the pen cap with clean hands. Check the reservoir to make sure the insulin is clear and colorless and has no particles - if not, use another pen. Step 2. Attach the needle. Wipe the pen tip with an alcohol swab. Remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on. Do not make the needle too tight. After you have attached the needle take off the outer needle cap and save it, (you will need it to remove the needle after the injection.) Step 3. Perform a safety test. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times, if there is still no insulin coming out, use a new needle and do the safety test again. Step 4. Make sure the window shows 0 and then select the dose. Step 5. Clean site with an alcohol swab. Keep the pen straight and insert the needle into your skin. Use your thumb to press the injection button all the way down. When the number in the dose window returns to 0 as you inject, slowly count to 10 which will ensure you get the full insulin dose. Step 6. Remove the Needle. Review of R7's Face Sheet revealed the facility admitted R7 on 11/06/2024, with diagnoses including, but not limited to, Diabetes Mellitus, long term use of insulin, and long term use of hypoglycemic drugs and chronic kidney disease. Review of R7's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/2026 revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive deficits. During an observation on 06/03/2026 at 8:12 AM, Licensed Practical Nurse (LPN)2 retrieved R7's Lantus Insulin from the medication cart. She removed the pen cap, and wiped the hub with an alcohol prep. LPN2 applied the insulin needle and removed the outer needle cover and dialed up 2 units, and holding the pen horizontal she pushed the injection/dose button. LPN2 then proceeded to administer the dosage of insulin ordered. During an interview with LPN2 after the administration of the Lantus, she confirmed that she held the insulin pen horizontal to prime the insulin pen before giving the 24 units of ordered insulin to R7. LPN2 could not confirm that R7 received the full accurate dose of Lantus insulin.

Based on review of the facility policy, observation, and interview, the facility failed to store biologicals appropriately in 2 of 4 treatment carts. Findings included: Review of the facility policy titled Storage of Mediation Requiring Refrigeration revealed the following under Section 5, Staff should observe proper storage and labeling requirements for all medications and vaccines during the performance of their daily tasks and should demonstrate safety in regard to the medication's integrity, such duties should include but not be limited to: . b. As per manufacturer's recommendation; . d. Remove any expired medications from active stock and discard medication according to facility policy. During observation of the Northeast Treatment Cart on 06/04/26 at 11:14 AM, revealed the following:(1) Calcium Alginate Dressing Lot#25114009 with an expiration date of 11/13/28- opened;(1) 250 milliliter bottle of Normal Saline 0.9% Sodium Chloride USP non pyrogenic Lot#251111250 with an expiration date of 11/24/27- opened. The label on the bottle stated do not reuse contains no antimicrobial agent or added substance. During an interview on 06/04/26 at 11:55 AM, Licensed Practical Nurse (LPN)3 confirmed the above findings and stated the dressing should have been placed in a bag and sealed or discarded. LPN3 stated the normal saline should have been discarded after use. During observation of the [NAME] Treatment Cart on 05/04/26 at 3:40 PM, revealed the following:(4) Aptima Multitest Swab Specimen Collection Kits Lot#90730V1 with an expiration date of 03/31/26. During an interview on 06/04/26 at 3:45 AM, the Director of Nursing confirmed the above findings.

Based on review of the facility policy, review of manufacturer's recommendation, record review, observation, and interview, the facility failed to ensure a medication administration error rate of less than 5 percent for 2 out of 26 opportunities for error. Specifically, the Lantus Pen was not primed according to the manufacturers recommendations for Resident (R)7 and additionally failed to ensure Resident (R)116 received a nasal spray as ordered.Findings include:Review of the undated facility policy titled, Insulin Pen Policy, states as the policy, It is the policy of this facility to use insulin pens to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare resident for self-administration of insulin therapy upon discharge. Policy Explanation: 6. Insulin pens will be primed prior to each use to avoid collection of air in the reservoir.Review of the manufacturer's recommendations for administering Insulin via a Pen revealed, How to use your Lantus Pen in 6 Steps. 1. Remove the pen cap with clean hands. Check the reservoir to make sure the insulin is clear and colorless and has no particles, if not, use another pen. 2.Wipe the pen tip (rubber seal) with an alcohol swab.3. Perform A Safety Test. Dial a test of 2 units. Hold the pen with the needle pointing up, and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you to get the most accurate dose. 4. Select the Dose. 5. Inject your Dose. 6. Remove the Needle.Review of the facility policy titled, Medication Administration, under Policy, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under Policy . 9. Ensure that the six rights of medication administration are followed. b. Dosage. 13. Administer medication as ordered.Review of the facility policy titled, Medication Discrepancies and Adverse Medication Reactions Policy, revised on 09/08/2025, states, under Definitions, Medication Discrepancy, An inappropriate or incorrect medication prescribed for, dispensed for, or given to a resident. It is also an omission of an ordered medication due to a prescribing, dispensing, or administering error.Review of R7's Face Sheet revealed the facility admitted R7 with diagnoses including, but not limited to, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease.During an observation medication pass on 06/03/2026 at 9:46 AM, revealed Licensed Practical Nurse (LPN)2 preparing to give R7 24 units of Lantus Insulin. LPN2, retrieved the pen, removed the cap and cleaned the it with an alcohol prep, then she applied the needle. LPN2 removed the needle cover and held the pen downward toward the floor and primed the pen. She did not hold the pen upward per the manufacturers recommendations.During an interview on 06/03/2026 at 9:50 AM, LPN2, confirmed that she had primed the Lantus Pen holding it downward and not upward and could not ensure the resident received the ordered dose of insulin.Review of R116's Face Sheet revealed the facility admitted R116 with diagnoses including, but not limited to, mild intermittent asthma, acute respiratory failure with hypoxia and emphysema.During an observation on 06/03/2026 at 9:11 AM, during medication pass revealed LPN1 preparing to give R116 the medication Azelastine HCI Solution 137 micrograms, 2 sprays in both nostrils twice a day. We entered the room for R116, and the nurse allowed R7 to administer the nasal spray and she inhaled one spray in each nostril. The order at this time was for 2 sprays. LPN1 did not ask the resident to instill another spray or encourage her to do so. LPN1 looked at this nurse and then the resident took the other medications that were brought in by LPN1. Then we left the room. LPN1 realized that R116 had only gotten the one spray per nostril and not the ordered 2. Later in the day on 06/03/2026, LPN1 received an order for only one spray for each nostril which was after the 9:00 AM medication pass.

Based on review of facility policy, record review and interview, the facility failed to ensure the physician for Resident (R)164 was notified related to a change in respiratory status for 1 of 1 resident reviewed for death.Findings include: Review of the facility policy titled Documentation Policy dated 09/08/25, under the Policy section indicated, Each resident's medical record will contain an accurate representation of the resident status. The Procedure section of the policy indicated the following: 2. Routine Charting for all Residents lists Pertinent Nurse's Notes and Acute charting, Section 2a. lists the following: Nurse's notes may also include but not limited to the following: changes in condition; 2b. Acute charting may also include but not limited to the following: change in condition of a resident. Review of R164's Face Sheet revealed the facility admitted R164 on 03/10/26, with diagnoses including, but not limited to, pneumonitis due to inhalation of food and vomit, Chronic Obstructive Pulmonary Disease, Dysphagia Oropharyngeal Phase, Sepsis, Solitary Pulmonary Nodule, Immunodeficiency due to conditions Classified Elsewhere and Chronic Diastolic (Congestive) Heart Failure. Review of the ongoing Physician's Orders revealed to monitor for signs and symptoms of infection including but not limited to the following: Cough, congestion, fever, changes in vital signs, changes in mental status, shortness of breath, foul smelling urine, swelling/redness/warmth to skin, abnormal lab values, signs/symptoms of wound infection, etc.) and notify MD and/or NP if these concerns arise. Review of the Nurse's Notes dated 05/09/26 at 12:30 AM, revealed R164's vital signs were as follows: Temperature 98.2 degrees Fahrenheit, Pulse 108-pulse type unable to determine, Respirations 24 with an Oxygen Saturation of 95% oxygen via Nasal Cannula. Under the Respiratory section of the Nurse's note states difficulty breathing noted. Nurse observed tachypnea present. Shortness of breath noted. Further review of the Nurse's Notes revealed a note on 05/09/26 at 3:04 AM - Resident observed w (with) rapid breathing. O2 (oxygen) sat (saturation) on RA (room air) was 85%. The resident's temperature was documented at 98.2, Respirations 26, blood pressure 144/94, and pulse of 108. At that time standing order for oxygen was initiated, placed on O2 via nasal cannula at 2 liters. Sat increased to 95%, respirations now even and unlabored, noted in Docter's (sic) book to assess at next visit. Review of nurse's notes and vital signs since admission revealed R164 had never had oxygen administered until 05/09/26 at 12:30 AM. There was no documentation in the nursing notes that R164's physician had been notified of this change in condition in which an intervention was initiated. During an interview on 06/04/26 at 10:54 AM, the Director of Nursing (DON) stated the facility charted by exception. The DON continued stating if after initiation of an intervention the resident improved, the facility would list the incident in the physician's book. If there was no improvement, then the physician would be notified.

Based on record review, interview, and policy review, the facility failed to ensure an accurate assessment for three of 31 residents reviewed in the sample (Resident (R) 12, R7, and R93). R12's assessment inaccurately documented received insulin, R7's assessment inaccurately documented he did not have a diagnosis of major mental illness defined by the Preadmission Screening and Resident Review (PASARR) program, and R93's assessment inaccurately documented she did not receive routine antipsychotic medication. These failures created a potential for lack of identification of current problems and resident needs, leading to an incomplete or ineffective plan of care. Findings include: Review of the facility's undated policy titled, Conducting an Accurate Resident Assessment revealed, Accuracy of Assessment means that the appropriate qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument . The facility will ensure that all participants in the assessment process have the requisite knowledge to complete an accurate assessment . Accurate assessments addressing each resident's status, needs, strengths, and areas of decline must be conducted by qualified staff that are knowledgeable about the resident and correctly documented in the medical record . The appropriate, qualified health professional correctly documents the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. 1. Review of R12's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including diabetes. Review of R12's Significant Change of Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/25/25 and located under the MDS tab of the EMR, revealed he had a diagnosis of diabetes. The MDS documented he received one insulin injection in the lookback period. Review of R12's January 2025 Medication Administration Record (MAR), located under the Orders tab of the EMR, revealed a physician's order, dated 11/28/24, for a Trulicity injection (dulaglutide, a non-insulin medication used for the treatment of diabetes that mimics the effects of GLP-1, a naturally occurring hormone that stimulates insulin secretion) given one time per week. The MAR documented he received the medication on 01/23/25. Review of R12's Orders tab of the EMR for January 2025 and further review of the January 2025 MAR revealed there were no orders for, or administration of, insulin documented on the MAR. During an interview on 04/04/25 at 11:11 AM, the Director of MDS (DMDS) stated R12 was not taking insulin during the lookback period; he was only receiving Trulicity, which is not considered an insulin. The DMDS stated the assessment should be modified to reflect no insulin use. 2. Review of R7's Admission Record, located in the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including schizophrenia. Review of R7's PASARR Level II South Carolina Mental Health Authority Determination, dated 01/05/22 and located under the Miscellaneous tab of the EMR, revealed he had a serious mental illness as defined by PASARR regulations and required psychiatric medication management. Review of R7's Annual MDS, with an ARD of 11/20/24 and located under the MDS tab of the EMR, revealed the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was answered, No. During an interview on 04/04/25 at 11:14 AM, the DMDS stated R7 did have a level II serious mental illness diagnosis, and the question should have been answered, Yes. 3. Review of R93's Admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including schizophrenia, Alzheimer's disease, major depression, and schizoaffective disorder. Review of R93's Quarterly MDS, with an ARD of 03/11/25 and located under the MDS tab of the EMR, revealed she received antipsychotic medication in the lookback period. However, the follow-up question related to antipsychotic medication use documented no antipsychotics were used; thus, subsequent questions regarding an attempted gradual dose reduction were not completed. Review of R7's Orders tab of the EMR revealed an active physician's order, dated 02/14/25, for quetiapine fumarate (an antipsychotic medication), 12.5 milligrams twice daily for a diagnosis of major depression with psychotic symptoms. Review of R7's March 2025 MAR, located under the Orders tab of the EMR, revealed she received the antipsychotic medication routinely twice daily as ordered. During an interview on 04/04/25 at 11:15 AM, the DMDS stated the follow-up questions regarding routine antipsychotic use and gradual dose reductions should have been completed and the assessment should be modified for accuracy.

Based on observation, staff interview, record review, and facility policy, the facility failed to ensure a medication error rate of less than 5 percent (%). There were four errors observed out of 38 opportunities for three residents (Residents (R)78, R153, and R86) out of a total sample of 31 residents resulting in an error rate of 10.53%. These failures had the potential to cause adverse drug reactions and the residents needs being met. Findings include: Review of the facility's undated policy titled, Medication Administration, revealed Medications are administered . as ordered by the physician and in accordance with professional standards of practice. Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, right documentation. 1.Review of R78's Administration Record, dated April 2025, located under the Orders tab of the electronic medical record (EMR), revealed a physician's Order dated 01/31/25 for acetaminophen extra strength tablet 500 milligrams (mg), give 2 tablets by mouth two times a day for pain. The medication was scheduled to be administered at 0800 [8:00 AM] hours and 1700 [5:00 PM] hours daily. During an observation on 04/03/25 at 9:15 AM, Licensed Practical Nurse (LPN)2 LPN2 administered two 500 mg tablets of acetaminophen to the resident. 2.Review of R153's Administration Record, dated April 2025, located under the Orders tab of the EMR, revealed a physician's order dated 03/24/25 for Aspercreme original external cream 10% (trolamine salicylate), apply to neck and left (L) hand topically two times a day for pain. The medication was scheduled to be administered at 0800 [8:00 AM] hours and 2000 [8:00 PM] hours daily. During an observation on 04/03/25 at 9:37 AM, LPN2 entered R153's room and applied the cream to R153's left hand. The cream was not applied to the residents neck per the order. 3.Review of R86's Administration Record, dated April 2025, located under the Orders tab of the EMR, revealed a physician's orders dated 04/01/25 for Ofev oral capsule 150 mg (nintedanib esylate), give one (1) capsule by mouth two time a day related to pulmonary fibrosis. The medication was scheduled to be administered at 0800 [8:00 AM] hours and 1700 [5:00 PM] hours, and an order dated 04/01/25 for fluticasone propionate suspension 50 micrograms (mcg)/actuation (act), one spray in each nostril one time a day related to allergic rhinitis. The medication was scheduled to be administered every morning. During an observation on 04/03/25 at 9:49 AM, LPN2 administered two actuations (sprays) to each nostril of fluticasone nasal spray and one 150mg-tablet of Ofev to R86. During an interview on 04/03/25 at 10:23 AM, LPN2 stated scheduled medications should be administered within one hour before or one hour after the scheduled time. The LPN confirmed the above medications were administered late, that she administered two nasal sprays in each of the residents nostrils when the order said one spray in each nostril, and confirmed the medicated cream was not applied to the residents neck per the order. During an interview on 04/04/25 at 10:55 AM, the Director of Nursing (DON) stated Medications are expected to be administered within one hour before or one hour after the scheduled time.

Based on observation, interview, record review, and facility policy review, the facility failed to administer oxygen therapy per physician's orders for one (Resident (R) 49) of two residents reviewed for respiratory care out of a total sample of 31 residents. This had the potential for the resident to experience respiratory distress. Findings include: Review of the facility's policy titled, Oxygen Concentrator(undated) revealed, Oxygen should be administered only under orders of the attending physician. Per the policy the first step in Care of the Resident revealed to Obtain physician's orders for the rate of flow and route of administration of oxygen. Review of the Admission record located in the electronic medical record (EMR) under the Diagnosis tab revealed R49 was originally admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypercapnia, and chronic respiratory failure. Review of R49's Orders located in the EMR under the Orders tab revealed an order, dated 08/16/23, for oxygen delivered via nose cannula, at 2 liters per minute (lpm). Review of the R49's Care Plan located in the EMR under the Care Plan tab revealed the resident has the potential for respiratory distress, initiated 12/12/22, with a goal to be free from signs and symptoms of respiratory distress using interventions that included providing oxygen and related interventions as needed or ordered. Review of R49's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/26/25 and located in the EMR under the MDS tab revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating the resident was cognitively intact. During an observation and interview on 04/02/25 at 10:09AM, R49 could be heard yelling at the nursing staff that she could not breathe. After Registered Nurse (RN) 1 left the resident's room the resident said she felt she was not getting any oxygen from the concentrator, but that she was okay, and the staff member was going to be handling it. Observation at the time revealed the resident's oxygen was set at 4 lpm. The resident was asked if she knew what her concentrator should be set to, and she stated that she did not. During an observation and interview on 04/03/25 at 10:42AM, R49's concentrator was running and was set at 3.5 lpm. Registered Nurse (RN)1 confirmed R49's oxygen was set at 3.5 lpm. RN1 stated that the concentrator was just replaced, and she thought it was likely placed on the wrong setting. She added that the licensed nursing staff are responsible for ensuring the settings are per the physicians' order and cannot be adjusted without orders from the resident's physician. The RN then adjusted the resident's oxygen to the correct order.

Based on observation, interview, record review, and policy review, the facility failed to identify a wound and provide interventions for wound prevention for two of five sampled residents (Resident (R) 244 and R76) reviewed for pressure sores. This resulted in harm when R244 developed a necrotic wound on the heel. The failure led to a missed opportunity to prevent and treat a necrotic wound that developed after admission. Findings include: 1. Review of the facility's policy titled, Pressure Injury/Wound/Skin Management, dated 08/2016, provided by the facility revealed .each resident will be assessed upon admission for skin skin/breakdown and findings will be documented in the resident's record; the Braden Scale will be completed on admission, weekly x 4 week, quarterly and with significant changes as indicated. CNAs will observe the resident's skin with bathing and incontinent care and report findings of skin problems to nurse as indicated; a licensed nurse performs a weekly body audit, wound measurements, and documents findings in the medical record; when pressure injury is present, Registered Nurses will assess and stage as indicated and licensed nurses will treat and monitor the pressure ulcer as well as observe for pain and treat pain as indicated; residents who score 17 or less on the Braden Scale are considered at higher risk for skin breakdown, Clinical Condition form is completed per Nursing and MD as indicated . Review of R244's undated Admission Record, found in the resident's Electronic Medical Record (EMR) under the Resident Profile revealed the resident was admitted to the facility on [DATE] with diagnoses which included reduced mobility and dementia. Review of R244's Discharge Summary from the hospital on 09/29/23, provided by the facility, revealed no documentation of abnormal skin integrity for the right heel. Review of R244's Clinical Admission assessment dated [DATE], provided by the facility revealed no documentation of abnormal skin integrity for the right heel. Review of R244's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 09/29/23 provided by the facility revealed R244 scored a 14 which indicated the resident was at moderate risk of developing a pressure ulcer. There were no additional weekly Braden Scale for Predicting Pressure Ulcer Risk Evaluations provided by the facility. Review of R244's admission Minimum Data Set (MDS), with an assessment reference date of 10/04/23, provided by the facility revealed documentation that R244 was at risk for developing pressure ulcers/injuries. There were no documentation entries indicating that R244 had a pressure ulcer. Review of R244's Baseline Care Plan with a review date of 10/18/23, provided by the facility, revealed R244's risk for pressure ulcers was care planned with interventions which included bed mobility bars float heels off bed as tolerated while resident is in bed, monitor for skin breakdown, inform medical doctor (MD)/ nurse practitioner (NP) and responsible party (RR) of any skin breakdown. Review of R244's Weekly Body Check assessment found under the Assessment tab in the EMR revealed, Weekly Body Checks for 09/29/23, 10/3/23, and 10/23/23. There were no weekly assessments entered for the weeks of 10/09/23 through 10/13/23 or 10/16/23 through 10/20/23. Review of the Weekly Body Check dated 09/29/23 revealed no mention of R244's right heel condition. Review of the Weekly Body Check dated 10/03/23 revealed no mention of R244's right heel condition. Review of the Weekly Body Check dated 10/23/23 revealed no to skin issues noted and no mention of the right heel condition. Review of R244's Progress Note dated 09/30/23 found in the resident's EMR under the Assessment Tab revealed a notation of Redness to both heels. Soft spot to left heel. Dressing was applied. During an observation on 10/25/23 at 10:45 AM, R244's right heel revealed an unstageable heel ulcer. In an interview immediately following the observation Registered Nurse (RN)1 stated she was not aware that R244 had an ulcer on her foot. RN1 further stated she did not know how she missed it. During an interview on 10/25/23 at 11:34 AM, Licensed Practical Nurse (LPN)1 confirmed that she completed R244's Clinical Admission Assessment on 09/29/23 and did not see any redness to R244's heels. She further stated that she had completed the Braden Scale for Predicting Pressure Ulcer Risk Evaluation on 09/29/23. LPN1 stated that R244 was high risk for development of a pressure injury. During an interview on 10/25/23 at 1:00 PM the Director of Nursing (DON), documentation from 09/30/23 to present was requested regarding R244's reddened heels, any physician notifications, or facility interventions implemented. During an interview on 10/25/23 at 1:33 PM, Certified Nursing Aide (CNA)2 stated that she did not know that R244 had an ulcer to her right foot. CNA2 further stated that R244 has had Allevyn foam dressings on both heels since she was admitted . CNA2 stated that she does not remove the dressings, that the nurses remove the dressings before the bath and reapply after. During an interview on 10/25/23 at 3:30 PM, RN1 stated that she had applied Allevyn dressings to R244's heels since her admission on 09/29/23. RN1 stated she applied the Allevyn dressings as a preventative measure for pressure ulcer development because R244 rubbed her feet on the bed linens creating friction. She stated that the dressings were changed every three days. RN1 stated her normal skin assessment process was to assess the skin, identify concerns, and notify the Nurse Practitioner (NP) of any concerns. RN1 stated that she was also responsible for the skin assessments on admission, weekly skin assessments, documentation, and Braden scale assessments. RN1 stated that she had gotten behind on her documentation and now had a day in the office to help keep her current. RN1 stated she was not aware of another nurse who might have changed the dressings. When asked if she should have known that the wound was present, she stated yes she should have known. She further stated that she had no explanation for how she missed it and when she changed the dressing, she just did not see it. Review of R244's Physician's Order, located in the resident's EMR under the Orders tab revealed an order dated 10/24/23 to apply Allevyn heel protectors for prevention once a day and change every three days. Review of R244's Physician's Order dated 10/25/23, located in the resident's EMR under the Orders tab revealed staff were to monitor the wound dressing every shift, if intact sign, if not perform a PRN (as needed) dressing change and sign in treatment record, to cleanse right heel, apply Allevyn dressing every three days and PRN (as needed) and apply Allevyn heel protector to left heel for protection, once every three days. During an interview on 10/25/23 at 2:52 PM, NP2 stated she was notified on 10/25/23 regarding R244's new ulcer. NP2 stated she gave new orders for the care of the ulcer. NP2 further stated she did not recall being notified of redness to R244's heels on 09/30/23. NP2 stated her expectation was the resident's wound would heal in two weeks, but it would depend on how well the resident tolerated the interventions of heel protectors and offloading of her heels. NP2 further stated it was her expectation the nursing staff would notify her immediately of any changes in skin integrity such as redness or open areas so that it can be treated that same day. During an interview on 10/25/23 at 3:40 PM, NP2 stated she had found an On Call Physician note dated 09/30/23, that stated the nursing staff reported R244's redness on bilateral heels and the on-call provider instructed nursing staff to continue bilateral heel protectors and elevating bilateral heels off mattress as patient tolerated. During an interview on 10/25/23 at 4:15 PM, the Regional Clinical Operations (RCO), facility documentation was requested regarding R244's right heel redness, progress, and interventions implemented. Review of R244's Progress Note dated 10/25/23, provided by the facility, revealed R244 had an unstageable pressure ulcer/injury to her right heel measuring length 2.3 centimeters (cm) x width 2 cm with a necrotic wound bed. During an interview on 10/25/23 at 5:00 PM, with the RCO, the missing Weekly Body Checks were requested along with any additional details of the skin assessments such as measurements, location of redness, or open areas. No additional Weekly Body Check assessments were provided by the facility. Review of R244's Treatment Administration Record for October 2023, provided by the facility revealed a treatment to apply Allevyn heel protectors for prevention one time a day every three days with a start date of 10/25/23. During an interview on 10/25/23 at 5:15 PM, the DON stated since the onset date of redness to R244's heels on 9/30/23, no new interventions had been initiated. 2. Review of the facility's policy titled Pressure Injury/Wound/Skin Management, dated 08/2016, revealed This facility is committed to a preventative and treatment skin care program for our residents. Residents will receive the care and services needed according to established practice guidelines. A Licensed Nurse performs a weekly body audit, wound measurements, and documents findings in the medical record. All residents will receive routine skin care. Routine skin care includes but is not limited to the following: . b. heel protectors d. Routine ADL care and skin inspection . 2. Review of R76's quarterly MDS with an ARD of 09/08/23, located in the MDS tab of the EMR, revealed an admitted [DATE]. Continued review of the MDS revealed the facility assessed the resident's cognition was severely impaired, was totally dependent on two persons for bed mobility, and had diagnoses of dementia, diabetes mellitus, and renal failure. Review of R76's undated Admission Record, located in the Profile tab of the EMR, revealed R76 had a history of pressure ulcer of right heel, stage 4 and pressure ulcer of left heel, unstageable. Review of R76's undated Kardex (computerized system of communication) located in the Care Plan tab of the EMR, revealed Bilateral heel protectors on WIB [while in bed] except during bathing/care provision. No socks bilaterally while wearing off-loading boots. Review of R76's Physician Order located in the Orders tab of the EMR, dated 12/05/22 revealed Heel protector boots on while in bed at all times as tolerated for prevention. No socks bilaterally while wearing off-loading boots, every shift. Review of R76's 05/04/23 Care Plan, located in the Care Plan tab of the EMR, revealed Resident is at risk for Pressure Ulcers and Skin Tears r/t [related to] B/B [bowel/bladder] incontinence, Fragile Skin, Impaired mobility, and has a hx [history] of facility acquired pressure wound to left abdomen and an intervention of Bilateral heel protectors on WIB except during bathing/care provision. No socks bilaterally while wearing off-loading boots. Review of R76's Pressure Ulcer Risk Evaluation, dated 09/08/23, located in the Assessment tab of the EMR, revealed a score of 14, indicating a moderate risk. Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR), dated 09/01/23 through 10/24/23, located in the EMR under the Orders tab, revealed that the nursing staff signed heel protector boots were applied as ordered. However, review of the MAR/TAR, dated 10/23/23 and 10/24/23, located in the EMR under the Orders tab, revealed the nursing staff documented the boots were applied despite observations made that the boots were not applied. During observations on 10/23/23 at 10:06 AM and at 3:35 PM, R76 was observed lying in bed with her eyes closed. No heel protector boots were in place and no heel protector boots were observed in or around R76's bed. During an observation on 10/24/23 at 9:24 AM, R76 was observed in bed with no heel protector boots in place. No heel protector boots were observed in or around R76's bed. During an observation on 10/25/23 at 10:57 AM, R76's heels were observed while R76 was leaning back in a geriatric chair with her feet up as a CNA1 took off R76's socks. R76's heels had no open areas, only scarred areas from past wounds. CNA1 confirmed she cared for R76 regularly and she had never put heel protector boots on R76. During an interview on 10/25/23 at 11:03 AM, LPN1 was asked if R76 should be wearing heel protectors. LPN1 stated if R76 had an order for heel protectors then R76 should be wearing them. LPN1 went on to say she was not aware of an order. LPN1 was informed R76 had an order for heel protector boots. LPN1 was then asked if the heel protectors were in R76's room and what would they look like. LPN1 stated the heel protectors would be cushioned Velcro (nylon straps designed for easy fastening and unfastening) boots. LPN1 was observed searching R76's closet for the heel protectors and found only one large blue cushioned boot with Velcro. The second boot was not found in the closet or in R76's room at that time. During an interview on 10/25/23 at 2:30 PM, the DON was asked if R76 had a history of wounds on her heels and the DON stated, Yes. The DON was then asked about R76's order for heel protector boots and observations of R76 not wearing them while in bed on 10/23/23 and 10/24/23 while in bed. The DON stated R76 had the tendency to get agitated with care including the boots. The DON was asked why only one boot was located on the top of R76's closet and had it been a while since R76 wore the heel protector boots. The DON responded, It's probably been a while. During a telephone interview on 10/25/23 at 3:02 PM, NP1 was asked if she was aware R76 had not been wearing the ordered heel protector boots. NP1 stated, Yes, as she was notified this afternoon. Continued interview with NP1 revealed the resident was ordered the heal protector boots due to her history of wounds to her heels. NP1 stated it was her expectation the staff would have applied the heel protector boots per the order. During a follow up interview on 10/25/23 at 5:07 PM, DON was asked why the nursing staff signed the October 2023 MAR/TAR that the heel protector boots were applied during the survey days, 10/23/23 and 10/24/23 while R76 was in bed when observations contradicted this. The DON stated she was not sure.

Based on observation, record review, staff interviews, manufacturer's guidelines for medication use, and review of the facility's policy and procedures, the facility failed to ensure that four of six residents (Resident (R) R113, R109, R85, and R19) were free from unnecessary [CONDITION(S)] medications. Findings include: Review of the facility's policy entitled The Use of [CONDITION(S)] Drug Policy (not dated) revealed Policy: Residents are not given [CONDITION(S)] drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).Policy Explanation and Compliance Guidelines: 1. A [CONDITION(S)] drug is any drug that affects brain activities associated with mental processes and behavior. [CONDITION(S)] drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety and hypnotics.2. The indications for initiating, withdrawing, or withholding medications(s), as well as the use on non-pharmacological approaches, will be determined by: a. Assessing the resident's underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment. b. Identification of underlying causes (when possible).3. The attending physician will assume leadership in medication management by developing, monitoring and modifying the medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team. 4. The indications for use of any [CONDITION(S)] drug will be documented in the medical record. a. Pre-admission screening and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility. b. For [CONDITION(S)] drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. i. [CONDITION(S)] medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. ii. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation 10. The effects of the [CONDITION(S)] medications on a resident's physical, mental, and psychosocial well being will be evaluated on an ongoing basis, such as: a. Upon physician evaluation (routine and as needed), b. During the pharmacist's monthly medication regimen review, c. During MDS review (quarterly, annually, significant change), and d. In accordance with the nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. Review of the [MEDICATION(S)] (quetipine [MEDICATION(S)]) (an antipsychotic) by AstraZeneca Pharmaceutical package insert guidelines under FULL PRESCRIBING INFORMATION (last revised October 2013) revealed that the drug has a Black Box Warning (The United States Food and Drug Administration's most serious warning about drugs or medical devices. A drug or device with a black box warning has side effects that may cause serious injury or death.) which states: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED [CONDITION(S)]. AstraZeneca Pharmaceuticals specified INDICATIONS AND USAGE states: 1.1 [MEDICATION(S)] is indicated for the treatment of [CONDITION(S)] and 1.2 [MEDICATION(S)] is indicated as monotherapy for the acute treatment of manic episodes associated with [CONDITION(S)] I disorder, both as monotherapy and as an adjunct to [MEDICATION(S)] or [MEDICATION(S)]. Review of the [MEDICATION(S)] DR/ER ([MEDICATION(S)] sodium delayed release/extended release) ([CONDITION(S)], acute manic) by AbbVie package insert Indications (last revised July 2020) revealed that the medication is indicated for the treatment of acute manic or mixed episodes associated with [CONDITION(S)], with or without psychotic features. On 12/1/21 at approximately 12:15 PM, a review of the medical records for R113 who was admitted to the facility from Encompass Health Rehabilitation Hospital of [NAME] on 9/27/21 with diagnoses including, but not limited to, dementia with behaviors and [CONDITION(S)] of right upper limb. The Encompass Health discharge record for R113 states postoperatively had some agitation and was started on [MEDICATION(S)] with discharge orders for [MEDICATION(S)] 25 mg (milligram) daily. On 12/1/21 at approximately 12:25 PM, review of the medical record for R113 revealed that upon admission to the facility on [DATE], [MEDICATION(S)] 25 mg daily was prescribed for dementia with behaviors and on 9/28/21 [MEDICATION(S)] DR/ER 125 mg bid (twice daily) was prescribed for dementia and behaviors. On 12/1/21 at approximately 1:05 PM, review of the medical record revealed that on 10/30/21 R113 was discharged to [NAME] Hospital due to worsened swelling of right hand where [MEDICATION(S)] was increased from 25 mg once a day to twice a day and [MEDICATION(S)] was increased from 125 mg to 250 mg twice daily. On 12/1/21 at approximately 1:30 PM review of the medical record showed that on 11/2/21 R113 was readmitted to the facility whereby the hospital orders for [MEDICATION(S)] 25 mg twice daily and [MEDICATION(S)] DR 250 mg twice daily were continued. On 12/1/21 at approximately 1:45 PM a review of the MAR (medication administration record) for R113 showed that all doses of [MEDICATION(S)] and [MEDICATION(S)] had been administered as ordered from 9/27/21 to 10/30/21 and from 11/2/21 to 12/2/21 and that there was a physician's order: Monitor behaviors every shift for hitting, biting, scratching, fighting, kicking, hallucination, delusions, or continuous crying out, yelling, screaming, side effects lethargy, loss of appetite. Notify MD (physician) if side effects noted. Further review of the MAR since admission on 9/27/21 revealed no charted behaviors. On 12/1/21 at approximately 2:30 PM, Registered Nurse (RN) 1 was interviewed and stated R113 rarely has any behaviors other than being confused and going back and forth between his room and the nursing station. RN1 confirmed that behaviors were monitored twice daily and that there had been no behaviors documented since R113 was admitted on [DATE]. On 12/2/21 at approximately 9:40 AM, Certified Nursing Assistant (CNA) 1 stated that R113 was frequently confused, did not have any bad behaviors and was easy to redirect when necessary. On 12/2/21 at approximately 11:54 AM, the Consultant Pharmacist MRR (Medication Regimen Review) for R113 dated 11/29/21 was provided by the DON (Director of Nursing) and Nurse Consultant. The MRR included a recommendation, not yet acted upon by the physician, to attempt to taper and discontinue [MEDICATION(S)] [MEDICATION(S)] 25 mg twice daily because of the Black Box Warning: It may increase the risk of death when used to treat mental related issues caused by dementia in elderly patients. Most of the deaths were linked to heart problems or infection. This medicine is not approved to treat mental related issues caused by dementia. Do you feel we could attempt to taper and discontinue medication? If you feel the benefits outweigh the risks, please document rationale below for continuing medication. On 12/2/21 at approximately 12:20 PM the DON and Nurse Consultant provided a copy of the Medical Director's verbal order dated 1/2/21 stating Resident has no behaviors, stable on current meds. Reduce to 25 mg qhs (bedtime) x 1 month an then D/C (discontinue). On 12/2/21 at approximately 10:36 AM, a review of the medical records for R109 who had been admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia with behavioral disturbances. Further review of the physician's orders since August 2021 revealed medication orders for [MEDICATION(S)] 25 mg twice a day dated 1/16/21 for unspecified dementia with behavioral disturbance and [MEDICATION(S)]) Sprinkles, delayed release 125 mg x 2 (250 mg) twice a day dated 5/26/21 for unspecified dementia with behavioral disturbance. Further medical record review revealed a physician's order: Monitor behaviors every shift for hitting, biting, scratching, fighting, kicking, hallucination, delusions, or continuous crying out, yelling, screaming, side effects lethargy, loss of appetite. Notify MD (physician) if side effects noted. twice a day since 5/3/19. Review of the MAR since August, 2021 revealed no charted behaviors and that all scheduled doses for [MEDICATION(S)] and [MEDICATION(S)] had been administered. On 12/2/21 at approximately 11:54 AM the Consultant Pharmacist MMR for R109 dated 11/29/21 was provided by the DON and Nurse Consultant and included a recommendation, not yet acted upon by the physician, to attempt to taper and discontinue [MEDICATION(S)] 25 mg (milligram) twice daily because of the Black Box Warning: It may increase the risk of death when used to treat mental elated issues caused by dementia in elderly patients. Most of the deaths were linked to heart problems or in infection. This medicine is not approved to treat mental related issues caused by dementia. On 12/2/21 at approximately 12:20 PM, the DON and Nurse Consultant provided a copy of the Medical Director's verbal order dated 12/2/21 stating [MEDICATION(S)] 25 mg q (every) hs should be continued for 1 month, then discontinued. On 12/2/21 at approximately 1:15 PM further medical record review for R109 revealed a psych (Psychiatry) consult ordered by the physician on 6/23/21 and a Psychiatry Follow Up Note from LifeSource, Inc. dated 11/2/21 which states Diagnoses of concern during today's encounter include: dementia. The LifeSource notes under Current Medications revealed: [MEDICATION(S)], Dose 25mg, Frequency: BID (twice daily) Continue [MEDICATION(S)] as prescribed, the patient is stable at current dose and/or needs more time to see beneficial effect. Dose reduction attempted and/or reduction will cause decompensation of patient and [MEDICATION(S)], Dose 250 mg/1, Unit: TABLET, EXTENDED RELEASE, ORAL, Qty: 1, Frequency: BID Continue [MEDICATION(S)] as prescribed, the patient is stable at current dose and/or needs more time to see beneficial effect. Dose reduction attempted and/or reduction will cause decompensation of patient. The LifeSource Psychiatry Follow Up Note included a recommendations made on 11/2/21 to Decrease [MEDICATION(S)] 12.5 mg bid. There was no evidence in the medical record that this recommendation had been acted upon. On 12/2/21 at approximately 1:30 PM RN2 was interviewed and stated R109 rarely had any behaviors other than occasionally being confused. On 12/2/21 at approximately 1:40 PM CNA2 stated that R109 occasionally becomes frustrated with her roommate, but that she is easily redirected with coloring pictures from a coloring book with crayons. CNA2 stated that R109 enjoys doing this activity in the day room and with her roommate. On 12/2/21 at approximately 2:00 PM the Medical Director (MD)/Attending Physician was interviewed via telephone. The MD stated he had been with the facility for about [AGE] years and his training included geriatrics during his residency, but he is not a gerontologist. He stated that he is in the facility at least weekly and is on the phone with someone at the facility daily. He receives Consultant Pharmacist recommendations regularly and has a Nurse Practioner who visits the facility frequently. He makes behavioral rounds, meets with families and gets resident decision-making assessments from nursing. When asked about medication use management for residents prescribed anti-psychotics while in the facility or admitted on anti-psychotics he stated that he understands the rule about how they are to be prescribed, but it is a thin line and he cuts back when appropriate. The facility admitted R85 on 4/20/21 with diagnoses including, but not limited to, [CONDITION(S)], [CONDITION(S)] Disorder and Major Depressive Disorder. Review on 12/2/21 at 1:28 PM of the Medication Administration History for R85 indicated that R85 was admitted on [MEDICATION(S)] 100 milligrams, an antipsychotic medication. He was increased to 200 milligrams of [MEDICATION(S)] on 7/19/21, due to an episode of anxiety. [MEDICATION(S)] is not an antianxiety medication. The nurses notes did include documentation of the episode of anxiety. Review on 12/2/21 at 1:45 PM of the Behavior Monitoring Sheets for R85 did not include any episodes of anxiety or any behaviors for this resident. In the medical record, behavior monitoring sheets dated 11/1/21-11/30/21 did not indicate behaviors were present. During an interview on 12/2/21 at 1:50 PM with the Registered Nurse Consultant, she confirmed that November was the only month behaviors were monitored and that there were none. The consultant stated, there are no behavior monitoring sheets in the medical record for R85. No documentation of a diagnosis could be found in the medical record for R85 to ensure the medication [MEDICATION(S)] was a necessary medication for this resident. Review of Centers for Medicare and Medicaid S&Q Memo Ref 13-35-NH dated May 24, 2013, revealed: . The problematic use of medications, such as antipsychotics, is part of a larger, growing concern. This concern is that nursing homes and other settings (i.e., hospitals, ambulatory care) may use medications as a quick fix for behavioral symptoms or as a substitute for a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized, person-centered interventions . When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective. In addition, they commonly cause complications such as movement disorders, falls, hip fractures, [CONDITION(S)] adverse events ([CONDITION(S)] accidents and transient ischemic events) and increased risk of death . Review of the manufacture's guidelines for the use of the medication [MEDICATION(S)] last updated 10/20 revealed, .Approved Uses [MEDICATION(S)] is a once-daily tablet approved in adults for major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; [CONDITION(S)]; acute manic or mixed episodes in [CONDITION(S)] alone or with [MEDICATION(S)] or [MEDICATION(S)]; long-term treatment of [CONDITION(S)] with [MEDICATION(S)] or [MEDICATION(S)]; and [CONDITION(S)] .Elderly patients with dementia-related [CONDITION(S)] (having lost touch with reality due to confusion and memory loss) treated with this type of medicine are at an increased risk of death, compared to placebo (sugar pill). [MEDICATION(S)] is not approved for treating these patients . A review of R19's Face Sheet in the electronic medical record (EMR) revealed R19 was admitted on [DATE] with diagnoses of vascular dementia with behavioral disturbance, cerebral infarction, and unspecified dementia without behavioral disturbance. Review of R19's EMR admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/25/21, revealed R19 had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated R53 was cognitively impaired. Further review of the MDS assessment revealed R19's behaviors were limited to occasional wandering. Further review of the MDS assessment revealed R19 received routine antipsychotics seven (7) days of the ARD period. Review of R19's EMR quarterly MDS assessment, with an ARD of 08/25/21, revealed R19 had a BIMS score of 06 out of 15, which indicated R19 was severely cognitively impaired. Further review of the MDS assessment revealed R19 displayed verbal behaviors, episodes of wandering, and rejection of care. Further review of the MDS assessment revealed R19 received antipsychotics routinely for seven (7) days of the ARD period. Review of R19's Physician Orders dated from 02/19/21 through 12/02/21, located on the EMR under the Orders tab revealed R19 had been prescribed [MEDICATION(S)] (an antipsychotic medication) daily, starting 02/19/21 with 50mg (milligrams) at bedtime. This dosage was reduced to 25mg at bedtime on 10/18/21, and then raised to 50mg on 11/18/21. Review of the pharmacy Consultation Report for R19, dated 05/07/21, revealed that the consultant pharmacist recommended a gradual dose reduction (GDR) for [MEDICATION(S)] from 50mg to 25mg with a goal of eventually discontinuing the order. A written memo at the bottom of the report notes that the request was Verbally declined per MD (Medical Doctor) r/t (related to) unable to tolerate GDR. Behaviors stable with current order. There was no medical rationale documented in R19's EMR to support the continued use and increase in the antipsychotic medication [MEDICATION(S)]. Review of R19's pharmacy Consultation Report for GDR recommendations dated 10/09/21, revealed documentation that the pharmacy recommended the reduction of [MEDICATION(S)] to 25mg with the goal of eventual discontinuation. The physician accepted the recommendation, and the order was reduced to 25mg on 10/18/21, however, then raised to 50mg on 11/18/21 with no documented medical rationale to support the increase in the antipsychotic medication [MEDICATION(S)]. Review of EMR Progress Notes for the months of October and November revealed that R19 was monitored daily for behaviors, with no documented behaviors noted related to the use of the medication [MEDICATION(S)]. Review of EMR Progress Notes dated 11/15/21, 11/16/21 and 11/17/21 revealed the resident was agitated and demonstrated verbal behaviors regarding noises from other residents and noises the resident could hear from the hallway. The notes on 11/17/21 noted that the resident was easily redirected. There were no notes on 11/15/21 and 11/16/21 to show the staff attempted non-pharmacological interventions to redirect R19's behavior prior to the increase of the medication [MEDICATION(S)] as there were on 11/17/21. Review of the EMR Progress Notes dated 11/18/21 revealed that R19's order for [MEDICATION(S)] had been increased to 50mg with no documented medical rationale. R19 was observed on 12/02/21 at 10:53 AM resting calmly in bed. In an interview with LPN3 on 12/02/21 at 11:00 AM, stated that R19 sometimes blurted out obscenities when agitated, but noticed that R19 had been much calmer since the change in R19's medication. When asked about non-pharmacological interventions used with R19 for exhibited behaviors, LPN3 stated R19 was easily redirected by offering a snack.

Based on interview and record review, the facility failed to ensure four of five sampled resident (Residents (R) 82, 85, 97 and 114) had a Level II Pre-Admission Screening and Resident Review (PASARR) evaluations completed despite being diagnosed with a serious mental disorder or intellectual disability. This failure placed the residents at risk for unmet care needs and at risk for not receiving appropriate mental health support/services needed. Findings Include: 1. Review of R82's electronic medical record (EMR), Face Sheet stated, R82 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R82's EMR, admission Minimum Data Set (MDS) (an assessment used to determine plan of care for a resident) dated 4/22/21, documented in Section C - Cognitive Patterns R82 scored a 13 on the Brief Instrument for Mental Status (BIMS) assessment (an assessment to determine level of cognition). In Section D - Mood documented R82 had symptoms of feeling down, depressed, or hopeless. In Section E - Behaviors, no behaviors were documented for R82. In Section G - Functional Status, R82 was documented to need extensive to total dependence on staff assistance for activities of daily living (ADLs). Review of the R82's PASARR level 1 dated 04/06/21, identified the resident as having [CONDITION(S)] disorder under section .II. Screening for Mental Illness Indicators . Under section IV, Recommendation of Reviewer, No further evaluation recommended was checked, with the reason given in the comments being that the resident's [CONDITION(S)] [is] controlled on meds. In an interview with the Social Worker (SW) on 12/01/21 at 2:20 PM, when inquired about the lack of a PASSAR Level II, the SW indicated that the Level II was not necessary because the resident's behavior was under control with medications and had not been hospitalized for reasons pertaining to the resident's mental diagnosis. The facility admitted R85 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Preadmission Screening and Resident Review (PASARR) Level 1 for R85 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of behaviors, but he was started on 100 milligrams of [MEDICATION(S)], an antipsychotic medication and due to a episode of anxiety, the [MEDICATION(S)] was increased to 200 milligrams . The facility did not ensure a PASARR Level II evaluation for R85 was completed due to a mental disorder or related condition to ensure he receives the care and services appropriate for his needs. The facility admitted R97 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Preadmission Screening and Resident Review (PASARR) for R97 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R97 has a mental illness that requires a PASARR Level 11 to ensure he receives care and services appropriate for his needs. During an interview on 12/2/21 at approximately 1:15 PM with the SW, she stated she had been at the facility about 60 days now and was not aware the previous SW was not reviewing for Level 2 PASARRs being completed. She confirmed after reviewing the 4 residents reviewed during the survey, that the residents should have had a level 2 completed due to their Mental Health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed the facility's policy and procedure was not followed. Review on 12/2/21 at approximately 1:30 PM of the facility policy titled, PASARR Policy, states under Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Number 5 (a) states, The facility must screen the individual using the State's Level 1 screening process and refer any resident who has or may have Mental Disabilities or Intellectual Disabilities or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. Number 9 states, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred to the state mental health or intellectual disability authority for a Level II resident review.

Based on an observation, interview and review of the facility policy titled, Lint Screen Policy, the facility failed to ensure a large amount of lint build-up was removed from above the lint baskets on the wiring and the upper three sides of 2 of 3 clothes dryers. The finding include: An observation on 12/2/21 at 1:23 PM of the laundry department revealed 2 of 3 clothes dryers with a large amount of lint build up above the lint baskets on the wiring and on the upper three sides of 2 of 3 clothes dryers. An interview on 12/2/21 at 1:24 PM with the Laundry Lead confirmed the findings. Review on 12/2/21 at 2:00 PM of the facility policy titled, Lint Screen Policy, states, Lint screens and dryer compartments will be cleaned according to CMS/State Guidelines. Number 1 states, Laundry staff will clean the lint screens after every drying cycle to prevent build-up. Number 2 states, Maintenance techs will vacuum and clean the lint screen compartment, the top compartment and back of dryers monthly to prevent build-up.

Based on observation, interview and review of the facility policy titled Dressing Change, (Clean Technique), the facility failed to ensure a pressure ulcer for Resident (R) 94 was cleaned using a technique to prohibit infection or the spread of infection during wound care for 1 of 3 residents reviewed for Pressure Ulcers. The findings include: The facility admitted R94 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 12/1/21 at 9:25 AM of wound care for R94 was observed as follows: Licensed Practical Nurse (LPN)2 applied his gloves and opened the 4x4s, sprayed the wound cleanser on the 4x4s, wiped inside out x1, on the second swipe, he sprayed the wound cleanser and wiped down x2 using the same gauze with the same wound cleanser. He cleaned the over the bed table and removed his gloves but did not remove the bagged trash from the resident's room. During an interview on 12/2/21 at 10:45 AM with LPN2, he stated he was aware that he had wiped down the wound 2 times using the same soaked gauze. He did not discard the gauze after one use. Review on 12/2/21 at 12:15 PM of the facility policy titled, Dressing Change (Clean Technique), number 15 states, Clean the wound according to order. Clean from center outward. Linear wound may be cleansed from top to bottom.

Based on record reviews, interview and review of the facility policy titled, Pneumococcal Vaccine Program, the facility failed to ensure the physician was consulted for the receipt of the Pneumonia Vaccine for Resident (R)5 and further failed to ensure R29 was offered the Pneumonia Vaccine PPSV 23 for 2 of 5 residents reviewed for the Influenza and Pneumococcal vaccines. The findings include: The facility admitted R5 with diagnoses including, but not limited to, Cerebrovascular Accident, Vascular Dementia, Neuropathy and Malaise. Review on 12/2/21 at 12:45 PM of the Immunizations for R5 revealed a signed consent by R5's Responsible Party on 5/14/21, for R5 to receive the Pneumococcal Vaccine. The form contained a hand written note that stated, will check with doctor. No documentation could be found in the medical record for R5 to ensure the issue was followed up on with the attending physician. To date, R5 has not received the Pneumococcal Vaccine. The facility admitted R29 with diagnoses including but not limited to, Major Depressive Disorder and Anxiety Disorder. R29 has a BIMS score of 15/15 which indicates she is able to make her own health care decisions. Review on 12/2/21 at 12:45 PM of the immunization documentation for R29 indicated that R29 was not offered the PPSV23. During an interview on 12/2/21 at 1:10 PM with Licensed Practical Nurse (LPN) 2, the facility's immunization nurse, confirmed the findings and stated he did not know why the physician was not contacted concerning the Pneumococcal Vaccines for this resident. LPN2 also did not know why R29 was not offered the PPSV23 (the second Pneumonia vaccine). Review on 12/2/21 at 1:30 PM of the facility policy titled, Pneumococcal Vaccine Program, states, It is the policy of this facility that residents will be offered immunization against pneumococcal disease. Number 10 states, If patients do not know their vaccination history for pneumococcal vaccine should be given both vaccines according to the CDC recommendations.

Based on observation, record reviews, staff interview, manufacturer's guidelines for medication administration, and review of the facility's competency checklist for Insulin Injection the facility failed to ensure that it was free of significant medication errors based on 1 of 34 medication pass observations. Findings include: On 11/29/21 at approximately 8:43 PM, Licensed Practical Nurse (LPN) 1 administered [MEDICATION(S)] Insulin 38 units using a [MEDICATION(S)] [MEDICATION(S)] Pen to Resident (R) 54 on the right side of her belly after stating to the Surveyor that no air shot is required. On 11/29/21 at approximately 8:45 PM, review of the [MEDICATION(S)] [MEDICATION(S)] Pen by Sanofi Aventis package insert states Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by ensuring that the pen and needle work properly and removing air bubbles. A. Select a dose of 2 units by turning the dosage selector B. Take off the outer needle cap and keep it to remove the used needle after the injection. Take off the inner needle cap and discard it. C. Hold the pen with the needle pointing upwards D. Tap the insulin reservoir so that any air bubbles rise up towards the needle. E. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. The facility's Competency Checklist for Insulin Injection states under Steps of Procedure 5. FOR PEN: Twist open and remove outer cover from the safety pen needle. 6. Screw the pen safety needle onto the insulin pen. 7. Dial 2 units by turning the dose selector clockwise pointing the needle up, push the plunger, and watch to see that at least one drop of insulin appears on the top of the needle. If not, repeat until at least one drop appears. On 11/29/21 at approximately 8:49 PM, LPN1, after reviewing the manufacturer's guidelines, acknowledged that a safety test had not been performed prior to administering the dose of insulin to R54.

Based on observations, interviews and review of the facility policy titled, Dignity, the facility failed to promote resident rights and to treat each resident with respect and dignity as evidenced by staff not knocking on resident room doors during the lunch meal service for 2 of 2 observations of the lunch meal service. The findings include: An observation on 11/30/21 at 11:45 AM of the lunch service on the West Hall revealed staff not knocking on resident room doors before entering with the meal trays. An additional observation on 12/1/21 at 11:40 AM revealed staff entering resident rooms with meal trays without knocking on their doors and awaiting for permission to enter. Interviews on 12/1/21 at 11:55 AM with Certified Nursing Assistant #3 and #4 stated they should be knocking on the doors before entering and confirmed that they had not knocked and waited for permission to enter. Review on 12/2/21 at 9:45 AM of the facility policy titled, Dignity, states, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity. Compliance Guidelines, under number 4. states, Respect resident's living space and personal possessions. Number 5. states, Maintain resident privacy.

Based on observations, interviews, and record review of the facility's medication storage policy, the facility failed to remove expired medication from other medications being stored for 4 out of 4 units, 6 out of 8 medication carts, 4 out of 5 medication storage rooms, and 3 out of 4 treatment carts. The findings include: A review of the medication storage room refrigerator on the West hall of the facility conducted on [DATE] at 4:00 PM revealed a vial of [MEDICATION NAME] Purified Protein ([MEDICATION NAME]) for house supply opened with an opened date of [DATE] written on the vial. In addition, further review revealed another vial of [MEDICATION NAME] Purified Protein ([MEDICATION NAME]) for house supply open with no opened dated noted on the vial. Directions on the medication cartons for both medications read Discard open product after 30 days. On [DATE] at 4:05 PM, LPN # 1 confirmed the medications should have been discarded after 30 days. A review of the medication cart (cart #1) for the South front hall conducted on [DATE] at 9:40 AM revealed open Liquid [MEDICATION NAME], oral suspension 240 ml (milliliter) bottle, read 25mg/5ml for urinary tract antibacterial, 10 ml two times a day with no opened date found. In addition, further review revealed a 16 ounce bottle (473 ml) of [MEDICATION NAME] for house supply open with no opened date noted on the bottle. On [DATE] at 9:55 AM, LPN #2 confirmed the medications should have an opened date on the containers. Continued review of another medication cart (cart #2) for the South back hall on [DATE] at 10:00 AM revealed a resident medication, Levetircetam ([MEDICATION NAME]) 100mg/1ml 300ml open bottle with no opened date noted on the bottle. Also, further review revealed a 16 ounce bottle of Milk of Magnesia (473 ml) for house supply open with no opened date on the bottle. Further review of cart #2 revealed a resident medication [MEDICATION NAME] Acetate oral suspension 40mg/ml 240 ml (8 fluid ounces) open with no opened date on the bottle. Also, review revealed 2 resident packages of [MEDICATION NAME] and [MEDICATION NAME] Inhalation Solution 0.5mg/3mg per ml with instruction for 3 ml inhalation every 6 hours as needed open with no opened date noted on the packages or the cartons for either one. On [DATE] at 10:30 AM LPN #2 confirmed the medications on cart #2 should have an opened date on the containers. Review of the treatment cart for the facility on [DATE] at 11:23 AM with the facility treatment nurse LPN # 3 ,who was working on South hall, revealed a bottle of Sterile Water 100ml open with no opened date on the bottle. Also, continued review of the treatment cart revealed an open container of [MEDICATION NAME] packing strips, ½ inch x 5 yards, on the cart with an expiration date of ,[DATE]. In addition, further review disclosed a container of [MEDICATION NAME] Ointment (house supply) open with no opened date on the container. On [DATE] at 11:35 AM, LPN # 3 confirmed the open medications should have an opened date on the container and the expired medication should have been disposed before the expiration date. Continued review of the treatment cart for South hall on [DATE] at 11:46 AM revealed medication SSD (Silver [MEDICATION NAME]) Cream 1% as needed for a resident irritated area of abdomen next to stoma was open with no opened date on the tube. In addition, another tube of SSD Cream 1% for a resident with directions for two times daily to buttock, sacrum and left lower leg was open with no opened date on the tube. On [DATE] at 11:50 AM, LPN # 2 confirmed the open medications should have an opened date on the tubes. Review of the treatment cart on West hall on [DATE] at 11:49 AM revealed a tube of [MEDICATION NAME] Sodium Topical Gel 1% open with no opened date, resident name, or instructions on the tube. Further review revealed another tube of [MEDICATION NAME] Sodium Topical Gel 1% for a resident with instructions for use three times a day to the left arm, shoulder, elbow and left wrist. The tube was open with no opened date noted on the tube. On [DATE] at 12:05 PM, LPN # 1 confirmed the tubes should have the date the medication was opened listed on the tube. The findings include: On [DATE] at 03:40pm review of the North East Medication Cart revealed (1) vitamin D3 5000 IU bottle with expiration date ,[DATE] within the floor stock medication. Review of Medication Cart #2 on [DATE] at 4:20 PM revealed (42) [MEDICATION NAME]-Acet 2XXX,[DATE]mg tablets with expiration date [DATE] within the narcotics medication and (18) [MEDICATION NAME] and [MEDICATION NAME] inhalation solution 0XXX,[DATE]mg per 3ml tubes with expiration date ,[DATE]. Review of the North East Medication Storage Rooms on [DATE] at 4:48 PM revealed (10) Diff-stat packets with expiration date ,[DATE] within the floor stock medication, and (2) UTI-stat bottles with expiration date [DATE] within the floor stock medication. On [DATE] at 05:05pm review of the 2nd medication storage room revealed (3) vitamin D3 5000 IU bottles each containing (100) capsules with expiration date ,[DATE]. On [DATE] at 09:40am review of the East Unit Medication Carts revealed (13) [MEDICATION NAME] HCL tablets 12.5mg with expiration date [DATE] and (30) Atorvastatin Calcium tablets 40mg with expiration date [DATE]. On [DATE] at 10:30am review of the East Unit Treatment Cart revealed (1) ½ bag of Epsom salt with expiration date ,[DATE], (61) hemoccult sensa single slides with expiration date ,[DATE], (1) hemoccult sensa solution with expiration date ,[DATE], (1) [MEDICATION NAME] shampoo with expiration date ,[DATE], (1) M9 odor eliminator spray with expiration date ,[DATE], (1) [MEDICATION NAME] ointment with expiration date ,[DATE], (1) muscle rub gel with expiration date ,[DATE], (1) athlete's foot cream with expiration date ,[DATE], and (1) ammonium [MEDICATION NAME] lotion with expiration date ,[DATE]. Review of the facility policy, 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles, revealed under procedure (16.) Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guideline and other Applicable Law .

Based on record reviews, interviews and review of the facility policy titled, Abuse, Neglect, and Exploitation Policy, the facility failed to ensure Resident #1, #2, #3, #4, #5 and #6 were free from misappropriation of resident property for 6 of 6 residents reviewed with the missing medication, [MEDICATION NAME]. The findings included: The facility admitted Resident #1, #2, #3, #4, #5 and #6 with [DIAGNOSES REDACTED]. Review on 2/1/2021 at approximately 11:00 AM of the medical records for Resident #1, #2, #3. #4, #5 and #6 revealed each resident missing the medication [MEDICATION NAME]. Review on 2/1/2021 of the reportable for misappropriation of resident property, sent to the state agency, revealed on 2 different days, 1/8/2021 and 1/9/2021, the above mentioned residents had missing [MEDICATION NAME] from the medication cart. The medications were to be stored with other medications for these 6 residents and other residents of the nursing facility. Review on 2/2/2021 at approximately 11:20 AM of the facility policy titled, Abuse, Neglect, and Exploitations Policy, states under Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Further review on 2/2/2021 at approximately 11:20 AM of the facility for abuse states under, Definitions, Misappropriations of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings, or money without the resident's consent to include the diversion of a resident's medication, including but not limited to controlled substances for staff use or personal gain.

Based on observation, interview, record review, and review of the facility's Cardiopulmonary Resuscitation (CPR) policy, the facility failed to ensure that care and services were provided for 2 sampled residents reviewed for care and services. Resident #97 had dried flaky skin with no treatment provided. Resident #140 designated a full code status did not receive CPR as ordered. The facility Administrator was informed on [DATE] at approximately 3:35 PM that Immediate Jeopardy existed on [DATE]. The facility provided an Immediate Jeopardy Removal Plan that was accepted on [DATE] at approximately 2:21 PM and the Immediate Jeopardy at F684 was removed with an effective completion date of [DATE] and lowered to the scope and severity of D. The findings included: The facility admitted Resident #97 on [DATE] with [DIAGNOSES REDACTED]. An observation and interview on [DATE] at approximately 9:26 AM revealed Resident #97 dressed in street clothes (dark tee shirt with shorts). The resident's dark tee shirt was noted with multiple white flakes. Resident #97 stated he/she would like to get his/her facial hair trimmed when asked by surveyor. The resident pointed out that the white flaky specks on his/her shirt were from his/her beard. The resident proceeded to show the surveyor the area and as he/she touched the area, more dried white flakes fell on the dark tee shirt. As the surveyor looked closer at the resident's face, dry flaky skin was noted around both side of the resident's nose near his/her beard. The resident stated he/she had not seen a physician for the skin condition. A review of the medical record on [DATE] at approximately 9:39 AM revealed nurses notes from [DATE] to present. There was no documentation to indicate the resident refused to have dry flaky skin addressed. In an interview on [DATE] at approximately 11:26 AM with Licensed Practical Nurse (LPN) #1 related to Resident #97's noticeable dry facial skin, LPN #1 stated he/she wrote a new order on [DATE]. A review of the physician's order revealed the order did not indicate the route of the medication. LPN #1 stated he/she did not note on the physician's order the route of the medication and that he/she would make the correction to indicate the medication should be applied on the resident's face. An interview on [DATE] at approximately 3:09 PM with LPN #1 revealed he/she did call the physician for an order of skin cream and that the resident's family was called but the he/she did not document this until he/she spoke to the surveyor. The facility admitted Resident #140 on [DATE] with [DIAGNOSES REDACTED]. On [DATE], Resident #140 had a change in condition. CPR was not administered and the resident expired. A review of the medical record on [DATE] at 4:23 PM and [DATE] at 8:21 AM revealed Resident #140 had monthly cumulative physician's orders that indicated the resident was a full code and CPR was to be given. A review of nurse's notes dated [DATE] at 6:34 PM indicated the resident had a decline in status. Respirations even and unlabored with severe weakness noted. Difficult to arouse at times with some chest congestion noted. A nurse's note dated [DATE] at 6:38 PM indicated the resident continues to decline and during meals resident holds food in mouth refusing to swallow liquids or solids. The nurse's note further indicated resident was very hard to arouse. A nurse's note dated [DATE] at 7:15 AM indicated the resident's breathing was labored and shallow. Unable to elicit response from the resident. The resident's family member was called and updated on condition. A nurse's note dated [DATE] at 12:18 PM indicated the resident was noted with periods of Apnea and staff was unable to obtain oxygen saturation and blood pressure at this time. A nurse's noted dated [DATE] at 12:20 PM indicated the resident was without pulse/respiration/blood pressure. There was no documentation to indicate that CPR was given as ordered. An interview on [DATE] at approximately 8:42 AM with Licensed Practical Nurse (LPN) #1 confirmed there was no physician's order for DNR in the electronic medical record but that there may be on in the paper chart. In an interview on [DATE] at approximately 9:16 AM, Unit Clerk #1 called medical records to see if there was a physician's order for DNR for Resident #140. An interview on [DATE] at approximately 10:02 AM with Unit Clerk #1 revealed the facility was still looking for the physician's written DNR order. An interview on [DATE] at approximately 10:29 AM with LPN #1 revealed there was no physician's order for DNR. A review of the facility's Cardiopulmonary Resuscitation (CPR) policy revealed under policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). The policy further indicated under Policy Explanation and Compliance Guidelines: #2. If a resident experiences a [MEDICAL CONDITION], facility staff will provide basic life support, including CPR, prior to arrival of emergency medical services and: (a) In accordance with the resident's advance directive, or (b) In the absence of advance directives or a Do Not Resuscitate order; and (c) If the resident does not show obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition). The Immediate Jeopardy Removal Plan included the following: Summary of Incident: Resident #140 was admitted to the facility on [DATE] with an admission order of full code. The resident had an advance directive that was signed on [DATE] by physician and health care agent. On [DATE] resident had a condition change. Call made to family member who was indicated as the resident's health care agent as to the condition change status. CPR was not administered. The resident expired. For other residents assessed to be a risk, the facility has initiated the following steps: Review all residents records to determine if they are accurately documented related to Do Not Resuscitate or Full Code. Will be completed on [DATE]. Review all residents records to assess accuracy of advance directives. Will be completed on [DATE] Upon review of resident records, the facility will notify the attending physician and resident/resident representative if revisions or updates are indicated. Will be completed on [DATE]. Physician's orders and care plans will be updated if indicated. Will be completed on [DATE]. The facility has initiated the below education plan for all admission, social services and licensed nursing staff. Immediate Changes to Facility Systems: The facility reviewed and revised the following policies: Admission process to include a comprehensive review of advances directives and code status; advance directive policy and procedure, changes of condition physician notification related to adherence to code status/advance directive. Upon admission, readmission, sudden life-threatening change of condition in resident's health status the nurse will review the physician's order for full code. The resident's advanced care planning will be identified and updated. This will be completed on [DATE]. The facility will include in its daily morning meeting/clinical meeting review of: will review code status of new admission, readmission an sudden life threatening change of condition in resident's health status, 24 hour report for change condition and documentation of physician's notification per policy; review of new and readmission for code status, applicable documentation and advance directive accuracy per policy. The facility has developed a daily check audit for morning meeting that includes code status for admission, readmission, and any life-threatening change of condition. The administrator and/or designee will monitor the corrective actions to ensure effectiveness of he daily audit tool and conduct a weekly audit X 4 weeks. The status will be validated by review of the written physician's order. The core team will perform a Root Cause Analysis (RCA) to identify root cause and immediate interventions if a break in policy was identified. Actions steps for improvement will be initiated as indicated. Education Plan: Upon notification of the immediate jeopardy- education was initiated immediately for admission, social services and licensed nursing staff related their respective roles and responsibilities for advance directive accuracy, accurate documentation related to DNR and Code status. In addition, licensed nursing staff will receive training on change of condition physician notification and corresponding documentation. Admission, social services and licensed nursing staff currently on the schedule will be education today per the plan. All other identified staff indicated above, will be required to completed education outlined prior to their next shift. Monitor removal plan outcomes: NHA and clinical designee will complete a weekly audit of all new/readmissions for advance directive accuracy and accurate code status documentation for four weeks. The results of monitoring of the corrective actions (track, trend and analysis) will be reported to the facility QAPI Committee monthly for three months. Upon this review, systems revisions and/or staff education will be implemented if indicated via an action plan. Completion Date: [DATE]

Based on record review and interview, the facility failed to notify the physician of a change/decline in the resident's health status for 1 of 1 expired resident with Cardiopulmonary Resuscitation (CPR) not given as ordered. Resident #140 had a documented decline in health status and the physician was not called until the resident expired. The facility Administrator was informed on [DATE] at approximately 3:35 PM that Immediate Jeopardy existed on [DATE]. The facility provided an Immediate Jeopardy Removal Plan that was accepted on [DATE] at approximately 2:21 PM and the Immediate Jeopardy at F580 removed with an effective completion date of [DATE] and lowered to the scope and severity of D. The findings included: The facility admitted Resident #140 on [DATE] with [DIAGNOSES REDACTED]. On [DATE], Resident #140 had a change in condition. CPR was not administered and the resident expired. A review of the medical record on [DATE] at 4:23 PM and [DATE] at 8:21 AM revealed Resident #140 had monthly cumulative physician's orders [REDACTED]. A review of the medical record on [DATE] at 4:23 PM and [DATE] at 8:21 AM revealed nurse's notes dated [DATE] at 6:34 PM that indicated the resident had a decline in status. Respirations even and unlabored with severe weakness noted. Difficult to arouse at times with some chest congestion noted. A nurse's note dated [DATE] at 6:38 PM indicated the resident continues to decline and during meals resident holds food in mouth refusing to swallow liquids or solids. The nurse's note further indicated resident was very hard to arouse. A nurse's note dated [DATE] at 7:15 AM indicated the resident's breathing was labored and shallow. Unable to elicit response from the resident. The resident's family member was called and updated on condition. A nurse's note dated [DATE] at 12:18 PM indicated the resident was noted with periods of Apnea and staff was unable to obtain oxygen saturation and blood pressure at this time. A nurse's noted dated [DATE] at 12:20 PM indicated the resident was without pulse/respiration/blood pressure with the physician and family being notified. Further review of the medical record revealed the physician was not notified until the resident was without pulse/respiration/blood pressure. An interview on [DATE] at 8:42 AM with Licensed Practical Nurse #1 confirmed there was no documentation to indicate the physician had been notified until the resident had no pulse/respiration/blood pressure. The Immediate Jeopardy Removal Plan included the following: Summary of Incident: Resident #140 was admitted to the facility on [DATE] with an admission order of full code. The resident had an advance directive that was signed on [DATE] by physician and health care agent. On [DATE] resident had a condition change. Call made to family member who was indicated as the resident's health care agent as to the condition change status. CPR was not administered. The resident expired. For other residents assessed to be a risk, the facility has initiated the following steps: Review all residents records to determine if they are accurately documented related to Do Not Resuscitate or Full Code. Will be completed on [DATE]. Review all residents records to assess accuracy of advance directives. Will be completed on [DATE] Upon review of resident records, the facility will notify the attending physician and resident/resident representative if revisions or updates are indicated. Will be completed on [DATE]. physician's orders [REDACTED]. Will be completed on [DATE]. The facility has initiated the below education plan for all admission, social services and licensed nursing staff. Immediate Changes to Facility Systems: The facility reviewed and revised the following policies: Admission process to include a comprehensive review of advances directives and code status; advance directive policy and procedure, changes of condition physician notification related to adherence to code status/advance directive. Upon admission, readmission, sudden life-threatening change of condition in resident's health status the nurse will review the physician's orders [REDACTED]. This will be completed on [DATE]. The facility will include in its daily morning meeting/clinical meeting review of: will review code status of new admission, readmission an sudden life threatening change of condition in resident's health status, 24 hour report for change condition and documentation of physician's notification per policy; review of new and readmission for code status, applicable documentation and advance directive accuracy per policy. The facility has developed a daily check audit for morning meeting that includes code status for admission, readmission, and any life-threatening change of condition. The administrator and/or designee will monitor the corrective actions to ensure effectiveness of he daily audit tool and conduct a weekly audit X 4 weeks. The status will be validated by review of the written physician's orders [REDACTED]. Actions steps for improvement will be initiated as indicated. Education Plan: Upon notification of the immediate jeopardy- education was initiated immediately for admission, social services and licensed nursing staff related their respective roles and responsibilities for advance directive accuracy, accurate documentation related to DNR and Code status. In addition, licensed nursing staff will receive training on change of condition physician notification and corresponding documentation. Admission, social services and licensed nursing staff currently on the schedule will be education today per the plan. All other identified staff indicated above, will be required to completed education outlined prior to their next shift. Monitor removal plan outcomes: NHA and clinical designee will complete a weekly audit of all new/readmissions for advance directive accuracy and accurate code status documentation for four weeks. The results of monitoring of the corrective actions (track, trend and analysis) will be reported to the facility QAPI Committee monthly for three months. Upon this review, systems revisions and/or staff education will be implemented if indicated via an action plan. Completion Date: [DATE]

Based on record review, interview, and review of the facility policy entitled Communication of Code Status, the facility failed to ensure 1 of 1 expired residents reviewed for Advance Directives had the opportunity to make a health care decision. Resident #140's Emergency Medical Services Do Not Resuscitate Order was signed by a family member without two physician's signatures to determine decisional capacity. The facility Administrator was informed on [DATE] at approximately 3:35 PM that Immediate Jeopardy existed on [DATE]. The facility provided an Immediate Jeopardy Removal Plan that was accepted on [DATE] at approximately 2:21 PM and the Immediate Jeopardy at F578 was removed with an effective completion date of [DATE] and lowered to the scope and severity of D. The findings included: The facility admitted Resident #140 on [DATE] with [DIAGNOSES REDACTED]. On [DATE], Resident #140 had a change in condition. Cardiopulmonary resuscitation (CPR) was not administered and the resident expired. A review of the medical record on [DATE] at 8:21 AM revealed Resident #140 was admitted with a full code on [DATE]. A review of the monthly cumulative physician's orders for the months of June, (MONTH) and (MONTH) 2019 revealed the resident was a full code Further record review revealed a South [NAME]ina Emergency Medical Services form dated May/2015 signed by a family member. There was no documentation in the medical record to indicate if two physician's signatures were present to indicate the resident could not make his/her own health care decisions. There was no physician's order for Do Not Resuscitate (DNR) in the electronic medical records. An interview on [DATE] at approximately 8:42 AM with Licensed Practical Nurse (LPN) #1 confirmed there was no physician's order for DNR in the electronic medical record but that there may be one in the paper chart. In an interview on [DATE] at approximately 9:16 AM, Unit Clerk #1 called medical records to see if there was a physician's order for DNR for Resident #140. An interview on [DATE] at approximately 10:02 AM with Unit Clerk #1 revealed the facility was still looking for the physician's written DNR order. An interview on [DATE] at approximately 10:29 AM with LPN #1 revealed there was no physician's order for DNR. An interview on [DATE] at approximately 11:20 AM with LPN #1 revealed there was no documentation in the medical record to indicate there were two physician's signatures to determine Resident #140's decisional capacity. A review of the facility's Communication of Code Status policy revealed under policy: It is the policy of the facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. The Communication of Code Status under #2 indicated, When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented included, but not limited to: Full Code, Do Not Resuscitate, Do Not Intubate and Do Not Hospitalize. It was further indicated that the nurse who notates the physician's order has the responsibility for documenting the directions in all relevant sections of the medical record. The Immediate Jeopardy Removal Plan included the following: Summary of Incident: Resident #140 was admitted to the facility on [DATE] with an admission order of full code. The resident had an advance directive that was signed on [DATE] by physician and health care agent. On [DATE] resident had a condition change. Call made to family member who was indicated as the resident's health care agent as to the condition change status. CPR was not administered. The resident expired. For other residents assessed to be a risk, the facility has initiated the following steps: Review all residents records to determine if they are accurately documented related to Do Not Resuscitate or Full Code. Will be completed on [DATE]. Review all residents records to assess accuracy of advance directives. Will be completed on [DATE] Upon review of resident records, the facility will notify the attending physician and resident/resident representative if revisions or updates are indicated. Will be completed on [DATE]. Physician's orders and care plans will be updated if indicated. Will be completed on [DATE]. The facility has initiated the below education plan for all admission, social services and licensed nursing staff. Immediate Changes to Facility Systems: The facility reviewed and revised the following policies: Admission process to include a comprehensive review of advances directives and code status; advance directive policy and procedure, changes of condition physician notification related to adherence to code status/advance directive. Upon admission, readmission, sudden life-threatening change of condition in resident's health status the nurse will review the physician's order for full code. The resident's advanced care planning will be identified and updated. This will be completed on [DATE]. The facility will include in its daily morning meeting/clinical meeting review of: will review code status of new admission, readmission an sudden life threatening change of condition in resident's health status, 24 hour report for change condition and documentation of physician's notification per policy; review of new and readmission for code status, applicable documentation and advance directive accuracy per policy. The facility has developed a daily check audit for morning meeting that includes code status for admission, readmission, and any life-threatening change of condition. The administrator and/or designee will monitor the corrective actions to ensure effectiveness of he daily audit tool and conduct a weekly audit X 4 weeks. The status will be validated by review of the written physician's order. The core team will perform a Root Cause Analysis (RCA) to identify root cause and immediate interventions if a break in policy was identified. Actions steps for improvement will be initiated as indicated. Education Plan: Upon notification of the immediate jeopardy- education was initiated immediately for admission, social services and licensed nursing staff related their respective roles and responsibilities for advance directive accuracy, accurate documentation related to DNR and Code status. In addition, licensed nursing staff will receive training on change of condition physician notification and corresponding documentation. Admission, social services and licensed nursing staff currently on the schedule will be education today per the plan. All other identified staff indicated above, will be required to completed education outlined prior to their next shift. Monitor removal plan outcomes: NHA and clinical designee will complete a weekly audit of all new/readmissions for advance directive accuracy and accurate code status documentation for four weeks. The results of monitoring of the corrective actions (track, trend and analysis) will be reported to the facility QAPI Committee monthly for three months. Upon this review, systems revisions and/or staff education will be implemented if indicated via an action plan. Completion Date: [DATE]

Based on record review, interview, and review of the facility policy titled Pressure Ulcer Prevention Guidelines, the facility failed to identify and failed to follow physician orders for 2 of 5 residents reviewed for pressure ulcer. Resident #121's pressure ulcer first identified as a Stage III. Resident #138's pressure ulcer was not treated per physician orders. The findings included: The facility admitted Resident #121 with [DIAGNOSES REDACTED]. Record review on 8/27/19 at 11:21 AM revealed a current physician's order to clean wound bed to left ischial with normal saline, apply Mesalt dampened with Dakins solution, cover with dry gauze, cover with dry ABD, secure with dressing tape. Review of the skin observation sheet dated 6/28/19 revealed Resident #121's skin was documented to be intact. Review of the skin observation sheet dated 7/5/19 did not list any concern with Resident #121's left ischial area. Further review of the medical record revealed an area to the left ischium was first identified on 7/11/19 and was staged as a Stage III measuring 4 centimeters (cm) x 3 cm x .1 cm. The wound was described as having 100% granulation with moderate serosanguineous drainage. Current wound measurements dated 8/27/19 listed Resident #121's left ischium as unstageable measuring 3.5 cm x 4.6 cm x 4 cm. The wound was described as having 50% granulation and 50% slough with moderate tan/brown drainage and mild odor. During an interview with Registered Nurse (RN) #1 on 8/29/19 at approximately 2:30 PM, s/he confirmed it was concerning the area where the wound was located was not identified until the wound was classified a Stage III and did not have an explanation as to why the wound was not identified until it was a Stage III. The facility admitted Resident #138 with [DIAGNOSES REDACTED]. Record review on 8/27/19 at approximately 1:00 PM revealed current physician treatment orders to apply skin prep to left heel twice daily and off load heels with green boots as tolerated. Review of an investigative report dated 8/9/19 revealed Licensed Practical Nurse (LPN) #6 and LPN #3 did not follow physician's orders related to the treatment of [REDACTED]. Prior to the Allevyn placement on 8/2/19 and 8/4/19, Resident #138's wound bed was documented on 7/30/19 as 100% stable eschar. On 8/5/19, the left heel was examined by RN #1 and described as 100% soft eschar. During an interview with LPN #6 on 8/27/19 at 5:30 PM, s/he stated s/he was not a wound care nurse and had replaced the dressing with what s/he had removed from Resident #138's left heel. S/he continued by stating the physician orders should have been reviewed prior to the treatment. During an interview with LPN #3 on 8/27/19 at 5:53 PM, s/he stated skin prep was applied to the area but since there was no green boots, s/he applied an Allevyn dressing to protect the area. S/he further stated s/he had meant to go back and chart the findings and write a new order until the boots were available but had become distracted by aiding other residents. Review of the facility policy titled Pressure Ulcer Prevention Guidelines revealed under the Preventive Skin Care the following: 1. Inspect skin while providing care, paying close attention to bony prominences.

Based on record review, interview, and review of the facility's policy on proper use of side rails, the facility failed to conduct regular inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for Resident #9 (1 of 2 residents reviewed for accidents). The findings included: Resident #9 was originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's physician's orders [REDACTED]. Review of Resident #9's discharge summary revealed that the resident received hospice care and expired on [DATE]. Record review of Resident #9's closed medical record revealed there was no assessment of side rails/bed rails. Record review of random resident medical records (#14, #16, and #20) revealed each file contained a complete assessment for side rails/bed rails. During an interview on [DATE] at approximately 9:30 AM, the current Director of Nursing (DON) stated that the former DON did not conduct regular inspections and assessments of side rails/bed rails, which included Resident #9. The DON also stated that during the week of (MONTH) 14, 2019, current assessments for all residents who use side rails/bed rails were completed and each unit nurse now completes a daily side rail/bed rail check list for residents that use them. Review of the facility's policy titled Proper Use of Side Rails revealed under policy explanation and compliance guidelines: 5. If after an attempted alternative to side rails/bed rails has been made and determined that these alternatives do not meet the resident's needs, the facility will asses the resident for the risks of entrapment and possible benefits of side rails/bed rails. In determining whether to use side rails/bed rails to meet the needs of a resident, the following components of the assessment should be considered including, but not limited to: Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; size and weight; sleep habits; and medication.

Based on record review and interview, the facility failed to ensure the environment remained free of accident hazards by failing to identify potential entrapment related to siderails for Resident #9 (1 of 2 residents reviewed for accidents). The findings included: Resident #9 was originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's physician's orders [REDACTED]. Review of Resident #9's discharge summary revealed that the resident received hospice care and expired on [DATE]. Record review of a facility reportable incident dated [DATE] revealed that on [DATE] Resident #9's air mattress (low air loss) malfunctioned and Resident#9 slid down between the siderails and the mattress. Staff heard Resident #9 yelling for help and observed Resident #9 on his/her knees with head and neck between siderail and mattress and the mattress deflated on the right side. Resident #9's sustained a bruise on the right jaw line, scraped area on the left cheek, and the right elbow had a red spot with scant bleeding. Review of License Practical Nurse (LPN) #4's written statement revealed s/he found Resident #9 on the floor side of his/her bed on his/her knees leaning against the siderail. LPN #4 got the resident back into the bed with assistance. Review of the written statement from the former Director of Nursing (DON) revealed that nurses were at east nursing station and heard somebody yelling. Resident #9 was observed on his/her knees with his/her head and neck between the siderail and mattress. The air mattress malfunctioned and was deflated. The siderail was removed, bolsters were placed on the bed, and maintenance and housekeeper supervisors were notified to check all beds with air mattresses for function. Interview with the DON on [DATE] at approximately 9:45 AM revealed that there were no siderail or air mattress assessments done before this incident happened and that the former DON who reported the incident had resigned from the facility. This surveyor left two phone messages for LPN #4 to call back with no reply.

Based on record review and interview, the facility failed to provide treatment for 3 days and failed to provide ongoing assessment of a wound for Resident #12 (1 of 1 resident reviewed with a wound). The findings included: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/31/19 at approximately 01:00 PM, review of the facility's Initial 2/24-Hour Report dated 07/02/19 indicated neglect related to resident wound care. Further review revealed a Five-Day Follow-Up Report dated 07/08/19 that indicated two nurses failed to follow physician's orders [REDACTED]. Further review revealed a Statement from Licensed Practical Nurse (LPN) #7 that stated on 07/02/19 the dressing in place was dated 06/28/19 and stated it was a [MEDICATION NAME] and [MEDICATION NAME] dressing. The statement also indicated the wound was 100% slough with a mild odor and that the peri-wound had [DIAGNOSES REDACTED] and maceration. Review of the Treatment Administration Record (TAR) on 07/31/19 at 02:38 PM revealed an order to apply [MEDICATION NAME] to abrasions on back of lower left extremity and cover with a dry dressing daily and as needed until healed. Review of the facility wound documentation revealed no documentation of the left posterior lower extremity wound until 07/02/19. In the wound nurse's statement dated 07/02/19, the nurse noted the resident's wound had a mild odor, was 100% slough and had [DIAGNOSES REDACTED] and maceration of the peri-wound. A wound assessment dated [DATE] indicated the measurement of the left posterior lower extremity wound was 4.6 x 3.7 x 0.2 cm (centimeters). The assessment further indicated the onset date of the wound was 06/19/19. During an interview with LPN #7 on 08/01/19, LPN #7 confirmed s/he was unable to locate any assessment of the wound prior to 07/02/19.

Based on record review, interview, and review of the the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure residents were free from abuse and neglect for 9 of 20 allegations reviewed involving Residents #1, #2, #13, #14, #7, #8, #12, #19, #3, #10, #11, and #20. The findings included: The facility admitted Resident #1 on 8/8/2018 with [DIAGNOSES REDACTED]. A BIMS (Brief Interview of Mental Status) score of 13/15 on the MDS (Minimum Data Set) assessment dated [DATE]. The facility admitted Resident #2 on 1/16/2015 and readmitted Resident #2 on 6/22/2018 with [DIAGNOSES REDACTED]. A BIMS score of 5/15 on the MDS assessment dated [DATE] and was coded for long and short term memory deficits. Review on 7/30/2019 at approximately 3:28 PM of the medical record for Resident #1 revealed a form titled, Certification of Resident's Inability to Consent, and states, Resident lacks the capacity to make own decisions due to a long term psychiatric illness and is not expected to improve. The form was signed by 2 physicians in (MONTH) of (YEAR). Review on 7/30/2019 at approximately 3:48 PM of the medical record for Resident #2 revealed a form titled, Certification of Resident's Inability to Consent, and states, Resident lacks capacity to make own decisions due to [MEDICAL CONDITION] and will remain so permanently. The form was signed by 2 physicians in (MONTH) of (YEAR). Review on 7/30/2019 at approximately 3:50 PM of an incident reported to the state agency involving Resident #1 and Resident #2 indicated that Resident #1 was in Resident #2's room with his/her hand under Resident #2's shirt. The incident was observed by Licensed Practical Nurse (LPN) #10. Further review on 7/30/2019 at approximately 3:55 PM of the facility investigation of the incident revealed a statement by LPN #10 and reads, I passed the room of Resident #2 and noticed that Resident #1 had a hand down his/her shirt. I spoke with Resident #1 and told him/her that he/she could not do that. I think that he/she understood that what he/she was doing was wrong. LPN #10 was unavailable for interview and this surveyor was not able to reach him/her by phone. Resident #2's right to be free from sexual abuse by Resident #1 was not protected. The facility admitted Resident #13 on 9/26/2017 with [DIAGNOSES REDACTED]. The facility admitted Resident #14 on 6/11/2013 with [DIAGNOSES REDACTED]. Review on 7/31/2019 at approximately 11:47 AM of the MDS for Resident #13 dated 7/16/2019 revealed a BIMS of 99 indicating that a Brief Interview of Mental Status could not be conducted and there are long and short term memory deficits. Resident #13 is coded on the MDS as having behaviors during the look back period and is coded with a 3 at C-1000 for cognitive skills for daily decision making as severely impaired. Review on 7/31/2019 at approximately 12:00 Noon of the MDS for Resident #14 dated 5/27/2019 indicated a BIMS of 3/15 and has delusions, verbal behaviors and aggression. Review on 7/31/2019 at approximately 2:20 PM of a facility reported incident between Resident #13 and Resident #14 alleged that while both residents were in the dining room Resident #14 was yelling out and Resident #13 picked up a flower vase from the dining room table and threw it at Resident #14. Review on 7/31/2019 at approximately 2:30 PM of the facility 5 day follow up stated, The incident did occur. No injuries were noted. Neither Resident exhibited any psychosocial stress following the incident. Resident #14 was not protected from resident to resident abuse. The facility admitted Resident #7 on 2/5/2016 with [DIAGNOSES REDACTED]. The facility admitted Resident #8 on 10/23/2018 with [DIAGNOSES REDACTED]. Review on 7/31/2019 at approximately 3:51 PM of the medical record for Resident #7 revealed a MDS dated [DATE] and indicated a BIMS score of 15/15. and a history of altercations with others. Review on 8/1/2018 at approximately 11:31 AM of the medical record for Resident #8 revealed a MDS dated [DATE] and indicated a BIMS of 8/15. Resident #8 was documented as having verbal behaviors. Review on 8/1/2019 at approximately 12:00 Noon of the 5 day follow up report states, 'Resident #8 does not like change and gets upset when things get in his/her way. Resident #7 was trying to get to the nurses station, and Resident #8 started cursing and started a verbal altercation between residents. Resident #7 did not move out of Resident #8's way and not always willing to move for the other resident. Resident #7 slapped Resident #8's hand with no injury. Neither resident was willing to move out of the way. Staff to observe residents as close as possible Neither Resident #7 or #8 were safeguarded against resident to resident abuse. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/31/19 at approximately 01:00 PM, review of the facility's Initial 2/24-Hour Report dated 07/02/19 indicated neglect related to resident wound care. The report was submitted to the State Agency on 07/02/19 at 18:12 PM. There was no documentation of the time the incident occurred on 07/02/19, therefore, timeliness could not be determined. Further review revealed a Five-Day Follow-Up Report dated 07/08/19 indicated the nurses who failed to follow physician order [REDACTED]. Treatment nurse will follow up on wound care for residents. Review of the reportable file revealed no statements obtained from any staff members except LPN #7 who reported the possible neglect. The statement dated 07/08/19 stated that on (MONTH) 2, 2019 the dressing in place was dated 06/28/19 and stated it was a [MEDICATION NAME] and [MEDICATION NAME] dressing. The statement also indicated the wound was 100% slough with a mild odor and that the peri-wound had [DIAGNOSES REDACTED] and maceration. In a face-to-face interview on 08/01/19 at 10:27 AM, LPN #7 confirmed the accuracy of her/his statement and stated that the dressing change not done was the left posterior leg wound. In a telephone interview with the surveyor on 07/31/19 at approximately 10:00 AM, LPN #5 s/he did not give a statement related to the dressing changes. S/he stated the Director of Nursing (DON) called her/him about dressings not being done around 06/28/19. S/he further stated that s/he worked the whole weekend including the 29th and 30th of (MONTH) and thought I changed the dressing but the DON said the dressings were dated 06/28 so I guess I may have somehow missed them. The LPN also stated s/he did not attend an inservice related to wound care following the incident. The facility admitted Resident #19 on 01/11/19 with [DIAGNOSES REDACTED]. A Facility Reported Incident was received by the State Agency alleging abuse of Resident #19 by CNA #4. On 08/01/19 at 02:22 PM, review of the facility's Five-Day Follow-Up Report dated 03/18/19 indicated the allegation that the CNA told Resident #19 to go to the bathroom in her/him brief and s/he would come back and change the resident was substantiated. In a face-to-face interview on 07/30/19 at 02:32 PM, CNA #4 stated that s/he did tell the resident to use go in her/his brief and further stated that the facility-obtained statement was not accurate. The CNA stated s/he was busy at the time and didn't recall the incident when asked for a statement. The CNA stated that when s/he told the resident to go in her/his brief, s/he also told her/him that s/he would be back in about 10 minutes to change her/him. The CNA stated that the meal trays were coming out and s/he wanted to get her/him changed before the meal. Resident #3 reported to the facility on two different occasions that CNA #5 was rude, mean, and hateful during care. Resident #10 reported to the facility that CNA #5 treated (him/her) roughly and with an attitude. Resident #11 reported to the facility that CNA #5 caused (him/her) leg pain during care. The facility's investigation report revealed that the facility failed to report an allegation of verbal abuse involving Resident #3 dated 12/18/18 within the two hours as required. The allegation was reported to the facility at 11:50 AM, but the facility did not report it to Stage Agency until 5:36 PM. The facility's investigation report dated 12/18/19 and reviewed on 7/29/19 at 11:00 AM indicated that Resident #3's family-member reported to the social worker that Resident #3 told (him/her) that CNA #5 did not change soiled underclothing for four hours and when she was changing (him/her) the CNA mocked the resident. Resident #3 reported to the Director of Nursing (DON) and Social Worker in an interview related to allegation (his/her) family member made that CNA #5 had a bad attitude. The resident stated that the CNA said to (him/her), go ahead and turn over; they say you can turn over. Resident #3 also reported to the DON and Social Worker that (s/he) was afraid of the CN[NAME] On 4/24/19 at 4:15 PM Resident # 3 reported to the facility that CNA #3 verbally abused (him/her). The facility did not report the allegation to the State Agency until 4/25/19 at 1:09 PM. Resident #3 was discharged to the community on 12/28/18, but was readmitted to the facility on [DATE]. On 4/29/19, Resident #3 reported to the facility that CNA #5 was rude to (him/her) and made comments about needing two people to wash the resident. The resident stated to the Social Worker that CNA #5 was rude to (him/her). The resident reported that CNA #5 stood in (his/her) doorway and made the remark, I ain't washing (him/her) by myself, and it takes two people to wash (him/her). Resident #3 stated the CNA was not talking to anyone or directing the comment to (him/her), but the CNA made a comment where other residents could hear (him/her). In an interview with Resident #3 on 7/29/19 at 2:30 PM, (s/he) stated the CNA #3 was rough when providing care and had an attitude. The resident also said that when (s/he) pushed the call light on CNA #3 would come in the room and turn the light off and leave without providing care. The nursing assistant would say to the resident, I am coming right back, but would not come back until the resident had waited and pushed the call light several more times. Resident #3 report that CNA #3 would stand by the door and yell out things such as, It takes two people to wash (him/her) off, where other residents could hear it. The resident said, No one wants to be treated like that. On 6/20/19, Resident #10 reported to the facility during the council meeting at approximately 2:00 PM that on 6/16/19 CNA #5 treated (him/her) roughly and had an attitude. Resident #10 stated that while bathing the CNA was washing (him/her) too hard, especially on (his/her) stomach where (s/he) had recent surgery. The resident made a comment to the CNA about being rough, but the CNA acted as if (s/he) did not hear resident. After the CNA finished providing care to the resident, (s/he) was complaining about the job expectations and slamming things and doors. The incident was not reported to the State Agency until approximately 7:00 PM. In an interview with Resident #10 on 7/30/19 at 10:45 AM, (s/he) stated CNA #5 was rough with me that morning. I don't know if (s/he) was having some issues at home or what but (s/he) was pushing me around hard and was very upset about something. S/he was throwing things around and slamming doors. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Post-Traumatic Stress Disorder, Constipation, Hypertension, Depression [MEDICAL CONDITION] Arthritis, Idiopathic Gout, Shortness of Breath, Congested Heart failure, and Type 2 Diabetes. The resident's MDS reviewed on 7/30/19 at approximately 11:15 AM revealed that Resident #11 had a BIMS of 12. The resident's total severity score for mood was a zero and (s/he) did not exhibit behaviors. Resident #11 required extensive assistance with dressing and toilet use. The resident was totally dependent for bed mobility but limited assistance with transferring. On 6/24/19, Resident #11 reported to the facility that CNA #5 snatched (him/her) while providing care causing (his/her) legs to spread apart which caused (him/her) pain. The facility did not report this incident until 6/25/19. In an interview with Resident #11 on 7/30/19 at 10:45 AM, (s/he) stated (s/he) told CNA #5 resident that (his/her) legs were fragile. The resident said, I got shot on my leg a long time ago. I asked (him/her) not to play with them, but (s/he) did not listen. S/he just grabbed my legs and threw them. I called the nurse and told (him/her) in front of the CN[NAME] The CNA said, 'How are you going to do me like that.' Interview with LPN #1 on 7/30/19 at 10:29 AM revealed (s/he) only knew of Resident #3's complaint about CNA #5 having an attitude and being too rough with (him/her) during care. The CNA was moved to another hall, and social services and the DON were informed. In an interview with the Social Worker on 7/30/19 at 10:06 PM, (s/he) stated, I know that CNA #5 was terminated related to the last incident involving Resident #11. The Social worker acknowledged that the attitude of the CNA was upsetting to residents. Resident#20 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #20 was not in the facility because Resident #20 was discharged to home 04/29/2019. Review of Licensed Practical Nurse (LPN) #1's written statement dated 02/26/2019 revealed Resident #20 was sitting at the at nurses station on 02/25/2019. When LPN #1 approached Resident #20 and asked how he/she was doing, Resident #20 became physically aggressive swinging his/her left arm and striking LPN #1, which hit the vital signs machine. LPN #1 advised Resident #20 that this behavior was inappropriate and to go to his/her room until s/he could calm down. Resident#20 continued with verbal aggression, but allowed LPN #1 to take him/her to his/her room. Review of Social Worker written statement revealed s/he was made aware of an incident that occurred on 02/25/2019 involving Resident #20 and LPN #1. Resident #20 stated this incident occurred around 10:30 PM. S/he stated s/he left his/her room and went to the nurse's station just to talk. S/he stated there were no other residents at the nurse's station and s/he was not being loud or disruptive. S/he stated s/he pulled up to the nurse's station and was told s/he needed to move. S/he told LPN #1 that s/he was not doing anything wrong, but LPN #1 got mad and pulled his/her wheelchair from behind and pushed him/her down the hall toward his/her room. When asked how s/s/he received scratches on his/her arm, s/he stated LPN #1 grabbed his/her arm and Resident #20 pulled away. Three scratches were observed on Resident #20's arm and it appeared that they were bleeding. When asked if Resident #20 was provided treatment for [REDACTED]. During an interview on 07/30/2019 at approximately 10:35 AM, the Social Worker stated that his/her written statement dated 02/27/2019 was accurate. Review of LPN #10's written statement revealed that Resident #20 was sitting at the nursing cart with a drink. S/he put the drink on the nurse's cart. LPN #1 argued with Resident #20 about moving the drink and getting away from the nursing cart. Resident #20 went to the other side of the desk away from the cart. Resident #20 asked where LPN #11 was. I advised him/her that s/he would be back in few minutes. Resident #20 waited until LPN #1 returned as s/he talked and drank his/her soda. LPN #11 came out of the bathroom and advised Resident #20 the s/he had to move and could not sit where s/he was. Resident #20 stated he/she wasn't bothering anyone. LPN #1 stated, No, you are moving now because I don't have time for this tonight. LPN #1 went to move the chair. Resident #20 said, No then swung his/her hand at LPN #1. LPN#1 deflected the swing a couple of times. LPN #1 then pushed him/her to his/her room. During the incident, Resident #20 obtained scratches to his/her left middle arm. During the days of survey, LPN #10 was on vacation and phone messages were left to contact the surveyor. Review of LPN #11's written statement dated 02/26/2019 revealed Resident #20 was at the nurse's station in his/her wheelchair. I was standing on the other side of the nurses station at the medication cart and LPN #1 walked up and spoke to Resident #20 and then walked past him/her. Resident #20 then just started hitting at LPN #1 with his/her left hand. Resident #20 hit the vital signs machine a few times trying to hit LPN #1. LPN#1 then pushed him/her to his/her room and told him/her that this behavior was inappropriate. During the days of survey, LPN #11 was not scheduled to work and phone messages were left to contact the surveyor. Review on 7/29/2019 at approximately 4:30 PM of the facility policy titled, Abuse, Neglect, and Exploitation, states under policy, Each resident has the right to be free for abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals.

Based on record review, interview, and review of the the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to implement written policies and procedures to prevent abuse and neglect, and ensure reporting and investigation of allegations of abuse and neglect for 11 of 20 allegations reviewed involving Residents #20, #12, #19, #21, #1, #2, #23, #13, #14, #7, #8, #3, #10, and #11. The findings included: Resident#20 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #20 was not in the facility because Resident #20 was discharged to home 04/29/2019. Review of Licensed Practical Nurse (LPN) #1's written statement dated 02/26/2019 revealed Resident #20 was sitting at the at nurses station on 02/25/2019. When LPN #1 approached Resident #20 and asked how he/she was doing, Resident #20 became physically aggressive swinging his/her left arm and striking LPN #1, which hit the vital signs machine. LPN #1 advised Resident #20 that this behavior was inappropriate and to go to his/her room until s/he could calm down. Resident#20 continued with verbal aggression, but allowed LPN #1 to take him/her to his/her room. Review of Social Worker written statement revealed s/he was made aware of an incident that occurred on 02/25/2019 involving Resident #20 and LPN #1. Resident #20 stated this incident occurred around 10:30 PM. S/he stated s/he left his/her room and went to the nurse's station just to talk. S/he stated there were no other residents at the nurse's station and s/he was not being loud or disruptive. S/he stated s/he pulled up to the nurse's station and was told s/he needed to move. S/he told LPN #1 that s/he was not doing anything wrong, but LPN #1 got mad and pulled his/her wheelchair from behind and pushed him/her down the hall toward his/her room. When asked how s/s/he received scratches on his/her arm, s/he stated LPN #1 grabbed his/her arm and Resident #20 pulled away. Three scratches were observed on Resident #20's arm and it appeared that they were bleeding. When asked if Resident #20 was provided treatment for [REDACTED]. During an interview on 07/30/2019 at approximately 10:35 AM, the Social Worker stated that his/her written statement dated 02/27/2019 was accurate. Review of LPN #10's written statement revealed that Resident #20 was sitting at the nursing cart with a drink. S/he put the drink on the nurse's cart. LPN #1 argued with Resident #20 about moving the drink and getting away from the nursing cart. Resident #20 went to the other side of the desk away from the cart. Resident #20 asked where LPN #11 was. I advised him/her that s/he would be back in few minutes. Resident #20 waited until LPN #1 returned as s/he talked and drank his/her soda. LPN #11 came out of the bathroom and advised Resident #20 the s/he had to move and could not sit where s/he was. Resident #20 stated he/she wasn't bothering anyone. LPN #1 stated, No, you are moving now because I don't have time for this tonight. LPN #1 went to move the chair. Resident #20 said, No then swung his/her hand at LPN #1. LPN#1 deflected the swing a couple of times. LPN #1 then pushed him/her to his/her room. During the incident, Resident #20 obtained scratches to his/her left middle arm. During the days of survey, LPN #10 was on vacation and phone messages were left to contact the surveyor. Review of LPN #11's written statement dated 02/26/2019 revealed Resident #20 was at the nurse's station in his/her wheelchair. I was standing on the other side of the nurses station at the medication cart and LPN #1 walked up and spoke to Resident #20 and then walked past him/her. Resident #20 then just started hitting at LPN #1 with his/her left hand. Resident #20 hit the vital signs machine a few times trying to hit LPN #1. LPN#1 then pushed him/her to his/her room and told him/her that this behavior was inappropriate. During the days of survey, LPN #11 was not scheduled to work and phone messages were left to contact the surveyor. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/31/19 at approximately 01:00 PM, review of the facility ' s Initial 2/24-Hour Report dated 07/02/19 indicated neglect related to resident wound care. Further review revealed a Five-Day Follow-Up Report dated 07/08/19 that indicated the nurses who failed to follow physician order [REDACTED]. Treatment nurse will follow up on wound care for residents. Review of the reportable file revealed no statements obtained from the staff members who perpetrated the neglect. A statement was obtained only from LPN #7 who reported the possible neglect. In a telephone interview with the surveyor on 07/31/19 at approximately 10:00 AM, LPN #5 stated s/he did not give a statement related to the dressing changes. On 08/01/19 at 11:20 AM, the Interim Director of Nursing (IDON) confirmed no statements were obtained from the alleged perpetrators, verified it was not a thorough investigation and that the policy was not followed. The facility admitted Resident #19 on 01/11/19 with [DIAGNOSES REDACTED]. A Facility Reported Incident was received by the State Agency alleging abuse of Resident #19 by Certified Nursing Assistant (CNA) #4. On 08/01/19 at 02:21 PM, review of the facility's Initial 2/24-Hour Report revealed the incident occurred on 03/13/19. The report for alleged verbal abuse was reported to the State Agency on 03/14/19. On 08/01/19 02:22 PM Review of the facility's Five-Day Follow-Up Report dated 03/18/19 indicated the allegation was substantiated. On 08/01/19 at 02:35 PM, review of the employee file revealed CNA #4 received a warning on 03/20/19 and was re-educated on abuse. During an interview on 8/01/19 at 02:58 PM, the IDON confirmed the CNA was not suspended pending the investigation to protect other residents and stated that the CNA should have been terminated and that the policy was not followed to provide protection to the residents. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Initial 2/24-Hour Report dated indicated Resident #21 reported on 01/10/19 at 03:02 PM that CNA#1 refused to get her/him out of bed to see her/his daughter who was also a resident at the facility earlier in the week. Further review revealed the report was submitted to the State Agency on 01/11/19 at 17:37 PM. During an interview on 07/30/19 at 04:52 PM, the IDON confirmed the report was not submitted timely within the 2 hour required time frame and that the policy was not followed to report all allegations of abuse to the state agency within specified timeframes. Review of the facility's Abuse, Neglect, and Exploitation Policy revealed VI Suspend the accused employee pending completion of the investigation. The Policy further stated Immediately report all alleged violations to the Administrator, state agency, Ombudsman and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes. Further review revealed Section V: When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. The policy also stated that a component of the investigation included Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. The facility admitted Resident #1 on 8/8/2018 with [DIAGNOSES REDACTED]. A BIMS (Brief Interview of Mental Status) score of 13/15 on the MDS (Minimum Data Set) assessment dated [DATE]. The facility admitted Resident #2 on 1/16/2015 and readmitted Resident #2 on 6/22/2018 with [DIAGNOSES REDACTED]. A BIMS score of 5/15 on the MDS assessment dated [DATE] and was coded for long and short term memory deficits. Review on 7/30/2019 at approximately 3:28 PM of the medical record for Resident #1 revealed a form titled, Certification of Resident's Inability to Consent, and states, Resident lacks the capacity to make own decisions due to a long term psychiatric illness and is not expected to improve. The form was signed by 2 physicians in (MONTH) of (YEAR). Review on 7/30/2019 at approximately 3:48 PM of the medical record for Resident #2 revealed a form titled, Certification of Resident's Inability to Consent, and states, Resident lacks capacity to make own decisions due to [MEDICAL CONDITION] and will remain so permanently. The form was signed by 2 physicians in (MONTH) of (YEAR). Review on 7/30/2019 at approximately 3:50 PM of an incident reported to the state agency involving Resident #1 and Resident #2 indicated that Resident #1 was in Resident #2's room with his/her hand under Resident #2's shirt. The incident was observed by LPN #10. Further review on 7/30/2019 at approximately 3:55 PM of the facility investigation of the incident revealed a statement by LPN #10 and reads, I passed the room of Resident #2 and noticed that Resident #1 had a hand down his/her shirt. I spoke with Resident #1 and told him/her that he/she could not do that. I think that he/she understood that what he/she was doing was wrong. LPN #10 was unavailable for interview and this surveyor was not able to reach him/her by phone. Resident #2's right to be free from sexual abuse by Resident #1 was not protected. The facility admitted Resident #23 on 2/24/2017 with [DIAGNOSES REDACTED]. Review on 7/30/2019 at approximately 4:23 PM of the medical record for Resident #23 revealed alleged neglect in which Resident #23 reported that he had not received his nightly medications on 2 different Tuesdays for 2 weeks. Resident #23 has a BIMS of 15/15. The allegation was not reported timely and thoroughly investigated according to the records reviewed. The incident was reported to the facility on [DATE] and the state agency received notification on 11/15/2018 at 9:17 AM. The facility admitted Resident #13 on 9/26/2017 with [DIAGNOSES REDACTED]. The facility admitted Resident #14 on 6/11/2013 with [DIAGNOSES REDACTED]. Review on 7/31/2019 at approximately 11:47 AM of the MDS for Resident #13 dated 7/16/2019 revealed a BIMS of 99 indicating that a Brief Interview of Mental Status could not be conducted and there are long and short term memory deficits. Resident #13 is coded on the MDS as having behaviors during the look back period and is coded with a 3 at C-1000 for cognitive skills for daily decision making as severely impaired. Review on 7/31/2019 at approximately 12:00 Noon of the MDS for Resident #14 dated 5/27/2019 indicated a BIMS of 3/15 and has delusions, verbal behaviors and aggression. Review on 7/31/2019 at approximately 2:20 PM of a facility reported incident between Resident #13 and Resident #14 alleged that while both residents were in the dining room Resident #14 was yelling out and Resident #13 picked up a flower vase from the dining room table and threw it at Resident #14. Review on 7/31/2019 at approximately 2:30 PM of the facility 5 day follow up states, The incident did occur. No injuries were noted. Neither Resident exhibited any psychosocial stress following the incident. Resident #14 was not protected from resident to resident abuse. The facility admitted Resident #7 on 2/5/2016 with [DIAGNOSES REDACTED]. The facility admitted Resident #8 on 10/23/2018 with [DIAGNOSES REDACTED]. Review on 7/31/2019 at approximately 3:51 PM of the medical record for Resident #7 revealed a MDS dated [DATE] and indicated a BIMS score of 15/15. and a history of altercations with others. Review on 8/1/2018 at approximately 11:31 AM of the medical record for Resident #8 revealed a MDS dated [DATE] and indicated a BIMS of 8/15. Resident #8 was documented as having verbal behaviors. Review on 8/1/2019 at approximately 12:00 Noon of the 5 day follow up report states, 'Resident #8 does not like change and gets upset when things get in his/her way. Resident #7 was trying to get to the nurses station, and Resident #8 started cursing and started a verbal altercation between residents. Resident #7 did not move out of Resident #8's way and not always willing to move for the other resident. Resident #7 slapped Resident #8's hand with no injury. Neither resident was willing to move out of the way. Staff to observe residents as close as possible Neither Resident #7 or #8 were safeguarded against resident to resident abuse. Resident #3 reported to the facility on two different occasions that CNA #5 was rude, mean, and hateful during care. Resident #10 reported to the facility that CNA #5 treated (him/her) roughly and with an attitude. Resident #11 reported to the facility that CNA #5 caused (him/her) leg pain during care. The facility's investigation report revealed that the facility failed to report an allegation of verbal abuse involving Resident #3 dated 12/18/18 within the two hours as required. The allegation was reported to the facility at 11:50 AM, but the facility did not report it to Stage Agency until 5:36 PM. The facility's investigation report dated 12/18/19 and reviewed on 7/29/19 at 11:00 AM indicated that Resident #3's family-member reported to the social worker that Resident #3 told (him/her) that CNA #5 did not change soiled underclothing for four hours and when she was changing (him/her) the CNA mocked the resident. Resident #3 reported to the Director of Nursing (DON) and Social Worker in an interview related to allegation (his/her) family member made that CNA #5 had a bad attitude. The resident stated that the CNA said to (him/her), go ahead and turn over; they say you can turn over. Resident #3 also reported to the DON and Social Worker that (s/he) was afraid of the CN[NAME] On 4/24/19 at 4:15 PM Resident # 3 reported to the facility that CNA #3 verbally abused (him/her). The facility did not report the allegation to the State Agency until 4/25/19 at 1:09 PM. Resident #3 was discharged to the community on 12/28/18, but was readmitted to the facility on [DATE]. On 4/29/19, Resident #3 reported to the facility that CNA #5 was rude to (him/her) and made comments about needing two people to wash the resident. The resident stated to the Social Worker that CNA #5 was rude to (him/her). The resident reported that CNA #5 stood in (his/her) doorway and made the remark, I ain't washing (him/her) by myself, and it takes two people to wash (him/her). Resident #3 stated the CNA was not talking to anyone or directing the comment to (him/her), but the CNA made a comment where other residents could hear (him/her). In an interview with Resident #3 on 7/29/19 at 2:30 PM, (s/he) stated the CNA #3 was rough when providing care and had an attitude. The resident also said that when (s/he) pushed the call light on CNA #3 would come in the room and turn the light off and leave without providing care. The nursing assistant would say to the resident, I am coming right back, but would not come back until the resident had waited and pushed the call light several more times. Resident #3 report that CNA #3 would stand by the door and yell out things such as, It takes two people to wash (him/her) off, where other residents could hear it. The resident said, No one wants to be treated like that. On 6/20/19, Resident #10 reported to the facility during the council meeting at approximately 2:00 PM that on 6/16/19 CNA #5 treated (him/her) roughly and had an attitude. Resident #10 stated that while bathing the CNA was washing (him/her) too hard, especially on (his/her) stomach where (s/he) had recent surgery. The resident made a comment to the CNA about being rough, but the CNA acted as if (s/he) did not hear resident. After the CNA finished providing care to the resident, (s/he) was complaining about the job expectations and slamming things and doors. The incident was not reported to the State Agency until approximately 7:00 PM. In an interview with Resident #10 on 7/30/19 at 10:45 AM, (s/he) stated CNA #5 was rough with me that morning. I don't know if (s/he) was having some issues at home or what but (s/he) was pushing me around hard and was very upset about something. S/he was throwing things around and slamming doors. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Post-Traumatic Stress Disorder, Constipation, Hypertension, Depression [MEDICAL CONDITION] Arthritis, Idiopathic Gout, Shortness of Breath, Congested Heart failure, and Type 2 Diabetes. The resident's MDS reviewed on 7/30/19 at approximately 11:15 AM revealed that Resident #11 had a BIMS of 12. The resident's total severity score for mood was a zero and (s/he) did not exhibit behaviors. Resident #11 required extensive assistance with dressing and toilet use. The resident was totally dependent for bed mobility but limited assistance with transferring. On 6/24/19, Resident #11 reported to the facility that CNA #5 snatched (him/her) while providing care causing (his/her) legs to spread apart which caused (him/her) pain. The facility did not report this incident until 6/25/19. In an interview with Resident #11 on 7/30/19 at 10:45 AM, (s/he) stated (s/he) told CNA #5 resident that (his/her) legs were fragile. The resident said, I got shot on my leg a long time ago. I asked (him/her) not to play with them, but (s/he) did not listen. S/he just grabbed my legs and threw them. I called the nurse and told (him/her) in front of the CN[NAME] The CNA said, 'How are you going to do me like that.' Interview with LPN #1 on 7/30/19 at 10:29 AM revealed (s/he) only knew of Resident #3's complaint about CNA #5 having an attitude and being too rough with (him/her) during care. The CNA was moved to another hall, and social services and the DON were informed. The facility failed to report allegations of abuse according to its policy. In an interview with the Social Worker on 7/30/19 at 10:06 PM, (s/he) stated, I know that CNA #5 was terminated related to the last incident involving Resident #11. The Social worker acknowledged that the attitude of the CNA was upsetting to residents. Review on 7/29/2019 at approximately 4:30 PM of the facility policy titled, Abuse, Neglect, and Exploitation, states under policy, Each resident has the right to be free for abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Further review on 7/29/2019 at approximately 4:30 PM of the facility policy titled, Abuse, Neglect, and Exploitation, states under VII. Reporting/Response of Abuse, Neglect and Exploitation, When abuse, neglect or exploitation is suspected: In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: - Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation or resident property, are reported immediately immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Section V. Investigation of Alleged Abuse, Neglect, and Exploitation states, When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Components of an investigation should include: Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #1 was found with his/her arm bound in their brief. One of four residents reviewed for abuse. The findings included: Cross refer to incident as documented in F0604 Review of the facility's Abuse, Neglect, and Exploitation Policy revealed each resident has the right to be free from abuse. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from any physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Resident #1 was found with his/her left arm bound in brief and taped over. One of four residents reviewed for abuse/neglect. The findings included: The facility reported an allegation of abuse to the State Agency on 8/31/18 for Resident #1 that indicated the resident's left arm was bound in brief and taped over arm. The date and time of the incident was noted as 8/31/18 at 7:00 AM. Review of the facility's Five-Day Follow-Up Report dated 9/5/18 revealed Resident #1 had no injury on left arm. CNA #1 was suspended and was to return to work with monitoring by the nurse on a different group. Resident has been known to put hand in brief at times. Review of Resident #1's medical record revealed no documentation of the resident putting his/her hand in brief at times. Review of the resident's care plan revealed no documentation of the resident putting hand in brief. Review of the resident's care plan revealed resident with potential for periods of agitation and/or resistance to care was identified as a problem area. The care plan indicated staff reports resident continues to experience periods of agitation becoming verbally and physically abusive toward staff when approached for care. Review of Resident #1's medical record revealed the residents' [DIAGNOSES REDACTED]. The surveyor reviewed Resident #1's Progress Notes from 6/1/18-11/8/18 with no documentation of resident placing hand in brief. Review of the resident's Medication Administration Record [REDACTED]. Special instructions indicated to document in progress notes any new/changes in behaviors. There were 3 entries for behavior monitoring. On 8/2/18 the resident was noted to be tearful. On 8/15/18 the resident was noted to be combative. On 8/23/18 the resident was noted to be combative. Review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The resident was agitated on 9/3/18 and refused medications on 9/4/18. Review of Resident #1's Significant Change Minimum (MDS) data set [DATE] revealed the resident had short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. CNA #2's facility-obtained statement dated 8/31/18 indicated s/he witnessed her resident's hand restrained with his/her brief. Resident #1's hand was restrained with his/her brief with his/her left arm a little more than halfway in the brief. LPN #1's facility-obtained statement dated 8/31/18 indicated s/he was called to the room by CNA #2. Resident #1's left arm was inside his/her brief and the brief had been taped over arm. CNA #1 was the CNA that worked the night shift. In an interview with the surveyor on 11/15/18 at approximately 3:20 PM, LPN #1 stated the CNA called him/her to the room and Resident #1's left arm was in the brief and the brief was taped over. LPN #1 stated the brief was intact and had not been opened. LPN #1 stated s/he is usually assigned to Resident #1 and s/he has not seen or been told that Resident #1 puts his/her hand in his/her brief. LPN #1 stated the resident will fight and pull on you when staff is providing care. LPN #1 stated s/he thinks they put the resident's hand in the brief on purpose. LPN #1 went and got LPN #2 to witness the incident. LPN #1 stated CNA #2 seemed upset about the incident. LPN #2's facility-obtained statement dated 8/31/18 indicated s/he was called to Resident #1's room and found resident with left arm bound in brief. The tabs were tight and keeping the resident's hand in place. LPN #2 indicated it did not look as if the resident put his/her hand down brief. In an interview with the surveyor on 11/15/18 at approximately 3:30 PM, LPN #2 stated Resident #1 is known to be combative when you provide care. LPN #2 stated usually if a resident goes in their brief, it is loose. The brief was tabbed tight over Resident #1's hand and it looked suspicious. In a telephone interview with the surveyor on 11/20/18 at approximately 4:35 PM, the Director of Nursing stated Resident #1 was known to put his/her hand in brief. The nurses and CNAs felt it was put in the brief intentionally the way that it was found. CNA #1 was suspended for 2 days and was supposed to return to work with nurse supervision. The CNA did not come back to work.

Based on record review, interviews, and review of the facility's Abuse, Neglect and Exploitation Policy, the facility failed to ensure that all allegations of abuse/neglect were immediately reported to the State Agency according to required timeframes. The facility failed to identify 2 of 3 resident-reported allegations/complaints reviewed as abuse/neglect and failed to report 3 of 3 abuse/neglect allegations to the proper authorities as required. Staff failure to assist Resident #58 with proper toileting procedures as requested and instruction to use her/his brief, failed Resident #56 by being rough and speaking abusively at times to him/her and failed Resident #131 by not changing his/her brief all day and allowing the resident to remain wet for several hours, facility policies were not followed for reporting the allegation to appropriate authorities within the required timeframes, and conducting a thorough investigation. The allegations were not reported to the State Agency within 2 hours as required. The findings included: The facility admitted Resident #58 on 10/19/17 with [DIAGNOSES REDACTED]. Review of the 10-25-17 Admission and 4-27-18 Quarterly Minimum Data Set Assessments revealed that the resident had a consistent Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. On 7-12-18, during an investigation of responses to concerns addressed during the Resident Council meeting on 7/11/18 at 10:30 AM, the Grievance Log was reviewed. The investigation file noted that Resident #58 reported an incident that occurred on 12-18-17 to Social Services on 12-19-17. According to the 12-19-17 Social Service note, the resident stated s/he put the call light on at 8:30-9 PM because s/he needed to go to the bathroom. When Certified Nursing Assistant (CNA) #3 answered the light, s/he told her (him) to go in her (his) brief. When the resident stated she (he) would be wet, the CNA told her/him to just do it. She (He) stated she (he) did wet her/himself. The resident also reported that CNA #3 was very short with her (him), but stated this is not the first time she (he) has been ugly to her (him). Further review of the file revealed a statement dated 12-19-17 by Licensed Practical Nurse (LPN) #6 which noted s/he was Called to room by CNA. CNA very upset, resident present. Stated she (he) wasn't going to be talk(ed) to like that from a resident and if this nurse didn't report it to (Social Services), she (he) would. Unable to understand really what CNA was upset about. After CNA left room, this nurse apologized to resident for behavior of staff member. Resident stated CNA was mad. CNA told her (him) to pee in chair and resident requested to lay down in the bed. DON (Director of Nurses) notified and explained to resident this would be reported. The allegation of neglect was not reported to the State Agency until the Initial 24-Hour Report was faxed on 12-20-17 at 12:40 PM, 2 days after staff were aware of the incident. During an interview on 7/12/18 at 2:01 PM, the DON reviewed the 12-18-17 complaint voiced by Resident #58. After review of the investigation file, the DON stated s/he reported the incident on 12-20-17, as soon as s/he was aware of it. The facility's Abuse, Neglect and Exploitation Policy states: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Policy Explanation and Compliance Guidelines included: 'Neglect means failure . to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The components of the facility abuse prohibition plan included: 6. Identification . The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents including, but not limited to the following possible indicators : a. Resident, staff, or family report of abuse h. Failure to provide care needs . 9. Response and Reporting . When abuse, neglect, or exploitation is suspected, the Licensed Nurse should: . b. Notify the Director of Nursing and Administrator (document) .f. Contact the State Agency and the local Ombudsman office to report the alleged abuse . 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect . are reported immediately, but not later than 2 hours after the allegation is made . The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Review on 7/13/2018 at approximately 10:47 PM of a Grievance Form dated 5/3/2018 by Resident #56 revealed to the Social Worker that a Certified Nursing Assistant (CNA) was rough with him/her at times and fusses with him/her at times. Further review of the Grievance Form revealed a hand written note from the DON (Director of Nurses) stating, Talked with staff to prevent any incident as above, be mindful of resident needs and prevent further anxiety for them. No documentation could be found that the allegation was identified as potential abuse, investigated or reported to the State Agency as per the facility's abuse policies. During an interview on 7/13/2018 at approximately 10:40 AM, Resident #56 confirmed the above allegations. He/she also stated that he/she was in a lot of pain due to previous broken hips and that one broken hip was inoperable and caused him/her excruciating pain. This surveyor asked Resident #56 how it made him/her feel when the perpetrator had been rough and fussed at him/her and he/she began to cry and could not answer. During an interview on 7/13/2018 at approximately 11:45 AM, CNA #3 indicated that he/she had worked numerous years with residents and treated them as if he/she would like to be treated. CNA #3 went on to say that he/she had never gotten upset with any resident at any time and if a resident gets upset or does not want care at the time it is offered then he/she will leave the room, notify the nurse and return later. During an interview on 7-12-18 at 1:25 PM, the Director of Nurse (DON) reviewed the 5-3-18 complaint/concern voiced by Resident #56 regarding rough handling and stated s/he had not identified this as abuse. The DON confirmed that this incident was not reported to the State Agency or investigated as an allegation of abuse/neglect. The DON stated s/he did talk to staff but had no written statements. Upon review of the Grievance Log, it was noted that Resident #131 voiced a grievance/concern on 5-8-18 to Social Services (SS) regarding staff failure to provide incontinent care from 7 AM to 4 PM on 4-28-18. She (He) stated she (he) sat in a wet brief with a puddle under her chair. (Resident # 131) stated no one checked on her (him) throughout the morning . the cubical curtain is usually pulled between her (him) and roommate and stated staff does not usually come in to check on her (him). She (he) is able to propel her/himself and stated she (he) she (he) went to lunch and then to a singing activity without being changed. Documentation by the Director of Nurses (DON) on 5-10-18 on the SS note stated: After talking with staff, this did not occur. Resident experiences intermittent confusion. There was no evidence of how the DON came to this conclusion. There was no evidence of any investigation of the complaint. There were no docu mented subsequent interviews with the resident in an attempt to validate the information. There were no written statements by staff or documented staff or roommate interviews. There was no evidence that the incident was reported to the State Agency. During an interview on 7-12-18 at 1:25 PM, the Director of Nurse (DON) reviewed the 5-8-18 grievance/concern voiced by Resident #131and stated s/he had not identified this as abuse.The DON confirmed that the incident was not reported to the State Agency or investigated as allegations of abuse/neglect. The DON stated s/he did talk to staff but had no written statements. During an interview on 7/13/18 at 10:31 AM, Resident #131 stated s/he was supposed to be changed (incontinent care) twice daily but s/he stays all wet. The resident noted that sometimes the staff would not answer the call light and that during lunch,they will serve the people before changing. Based on full and/or limited record reviews, interviews and review of facility policies, it was determined on 7/13/18 at 11:10 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility in the following areas. The Director of Nurses (DON) and the Administrator were notified of this determination at 12:30 PM. The deficiencies involved were as follows: F600 Free from Abuse and Neglect - as it relates to residents involved in allegations of abuse. F607 Implement abuse policies - as it relates to the facility's failure to implement abuse policies, that included reporting and investigating allegations. F609 Repoerting of alleged violations - as it relates to the facility's failure to report alleged abuse to the SA timely. F610 Investigate alleged violations- as it relates to the facility's faiure to investigate alleged abuse thoroughly. F835 Administration - as it relates to the Administrator's failure to administer the facility in a way to ensure each resident's highest well-being. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable that included the following: Abuse IJ Nursing and/or Social services notified the Responsible Party and the Physician of the identified residents as to the allegations of abuse/neglect. Residents identified during the survey did not receive any injuries from the allegations. The DON and/or Social Services will review all Abuse/Neglect allegations, following the facility written policies and regulations. Social Workiers will attempt to interview residents and gather witness statements pertaining to the allegations. Staff, including any staff with information regarding the allegations, will be interviewed and the information given to and discussed with the DON. Allegations will be reported timely to the proper persons. The DON has modified the original Abuse investigation for the resident cited to show that staff was interviewed, Responsible Party notified and physician notified. The results of the investigation will be sent for the 5 day review. The two other residents had their allegations reported on 7/13/18, to the appropriate State personnel and further investigation will be done if necessary. The Social Workers interviewed and received statements from all employees caring for the residents cited and there were no further incidents noted. The Compliance with Reporting Allegations of Abuse/Neglect/Exploitation form will be utilized for all allegations and this form will be kept in a folder for review of QAPI at least monthly. All staff will be in-serviced on the facility Abuse Policy and appropriate interventions for resident reactions through the Hand in Hand Modules by 7/17/18. All staff not in-serviced, PRN staff and those on vacation, will receive training before performing duties. All residents will be assessed and the development of the care plan will be reviewed to include appropriate care for residents with needs and behaviors which could lead to conflict by 7/17/18. On (MONTH) 18, (YEAR) Team members began the Extended survey process. They reviewed the A[NAME] and ensured implementation by interviewing staff, reviewing resident clinical records, reviewed staff inservice sheets and made facility observations. That morning the team removed the Immediate Jeopardy and lowered the scope and severity of F600, F607, F609, F610, F835 to an F. They concluded the facility had removed the immediacy by implementing their A[NAME] on 7/17/18.

Based on record review, interviews, and review of the facility's Abuse, Neglect and Exploitation Policy, the facility failed to ensure that 3 of 3 reported allegations of abuse/neglect were thoroughly investigated. The facility failed to identify allegations/complaints as abuse/neglect, immediately implement safeguards to prevent further violations while the investigations were in process,and take appropriate corrective action to prevent recurrence for 3 of 3 sampled residents who reported abuse/neglect. The facility failed to conduct a thorough investigation and put procedures in place to prevent further abuse/neglect after Resident #58 complained that staff did not assist her/him with proper toileting procedures as requested, failed Resident #56 by being rough and speaking abusively at times to him/her and failed Resident #131 by not changing his/her brief all day and allowing the resident to remain wet for several hours. Facility policies were not followed for reporting the allegation to appropriate authorities within the required timeframes, and conducting a thorough investigation. The findings included: The facility admitted Resident #58 on 10/19/17 with [DIAGNOSES REDACTED]. Review of the 10-25-17 Admission and 4-27-18 Quarterly Minimum Data Set Assessments revealed that the resident had a consistent Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. On 7-12-18, during an investigation of responses to concerns addressed during the Resident Council meeting on 7/11/18 at 10:30 AM, the Grievance Log was reviewed. The investigation file noted that Resident #58 reported an incident that occurred on 12-18-17 to Social Services on 12-19-17. According to the 12-19-17 Social Service note, the resident stated s/he put the call light on at 8:30-9 PM because s/he needed to go to the bathroom. When Certified Nursing Assistant (CNA) #2 answered the light, s/he told her (him) to go in her (his) brief. When the resident stated she (he) would be wet, the CNA told her/him to just do it. She (He) stated she (he) did wet her/himself. The resident also reported that CNA # 2 was very short with her (him), but stated this is not the first time she (he) has been ugly to her (him). Further review of the file revealed that it contained only 2 staff statements, those of the alleged perpetrator (CNA #2) and Licensed Practical Nurse (LPN) #6, who was on the East Unit. On 12-19-17, a statement by LPN #6 noted s/he was Called to room by CNA. CNA very upset, resident present. Stated she (he) wasn't going to be talk(ed) to like that from a resident and if this nurse didn't report it to (Social Services), she (he) would. Unable to understand really what CNA was upset about. After CNA left room, this nurse apologized to resident for behavior of staff member. Resident stated CNA was mad. CNA told her (him) to pee in chair and resident requested to lay down in the bed. DON (Director of Nurses) notified and explained to resident this would be reported. CNA #2's statement, dated 12-25-17, stated, On Dec(ember) 18, (YEAR) (Resident # 58) when putting her (him) to bed she (he) got upset because her (his) Hoyer pad got wet. She (He) started yelling and cursing. I tried to explain to her (him) that happens when you do not want to go to bed to relieve yourself. The Initial 24-Hour Report was faxed to the State Agency on 12-20-17 at 12:40 PM. The Five-Day Follow-up Report noted that the resident was alert and oriented x 3. Pleasant. Witnesses and other staff on duty at time of/prior to Reportable Incident included only the names of LPN #6 and CNA #2. No other staff were noted to be on duty. The Details of Reportable Incident completed by the DON stated: Resident was late returning from activities, incontinent of bowel and bladder, was wet and soaked Hoyer sling. Resident stated CNA told her (him) to go in chair but put her (him) (to) bed . It was her (his) tone. She (he) was not mistreated. The Immediate corrective action/assessment following Reportable Incident noted Nurse asked CNA to leave room and investigation initiated. There was no record of interviews with the resident, her/his roommate, or other staff members on duty at the time of the incident. During an interview on 7/12/18 at 2:01 PM, the DON reviewed the 12-18-17 complaint voiced by Resident #58. After review of the investigation file, the DON verified there was no evidence of interviews of the resident's roommate or other staff on duty at the time of the incident. When asked about the investigation, the DON stated s/he had interviewed the nurse, but there was no record of this. Review of the nurse's written statement reiterated the resident's claim but was more focused on the CNA being upset than the condition of the resident. When asked if the resident had a roommate, the DON stated the resident had one but s/he had not talked to her/him. When asked about other staff on duty, the DON stated there were 3 or 4 other CNAs on duty at the time but they were not interviewed because they were on the other end. When asked what interventions had been put in place with CNA #2 to protect this and other residents due to lack of evidence in the file, the DON stated, I don't know. I report it to the administrator and he (she) makes the decision about suspension. Review of CNA #2's time card revealed it did not indicate suspension and there was no record in the investigation/reportable file of how other residents were protected during the investigation. On 7-15-18, the DON presented a form that documented counseling/training for CNA #2. During an interview on 7-12-18 at 1:25 PM, the Director of Nurse (DON) reviewed the 5-8-18 grievance/concern voiced by Resident #131 who complained of no assistance with toileting from 7 AM to 4 PM and stated s/he had not identified this as abuse. The DON also reviewed the 5-3-18 complaint/concern voiced by Resident #56 regarding rough handling and stated s/he had not identified this as abuse. The DON confirmed that these incidents were not reported to the State Agency or investigated as allegations of abuse/neglect. The DON stated s/he did talk to staff but had no written statements. The facility's Abuse, Neglect and Exploitation Policy states: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Policy Explanation and Compliance Guidelines included: 'Neglect means failure . to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The components of the facility abuse prohibition plan included: 6. Identification . The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents including, but not limited to the following possible indicators : a. Resident, staff, or family report of abuse h. Failure to provide care needs . 7 . Components of an investigation may include : a. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements . should be signed and dated d. Document the entire investigation chronologically . 8. Resident Protection . The facility will make efforts to protect all residents after alleged abuse, neglect, and/or exploitation. Examples of ways to protect a resident from harm during an investigation . may include, but are not limited to: .g. Reassignment of nursing staff duties, h. Time off for nursing staff . 9. Response and Reporting . When abuse, neglect, or exploitation is suspected, the Licensed Nurse should: ) c. Initiate an investigation immediately .e. Obtain witness statements. May/may not suspend the accused employee pending completion of the investigation. May/may not remove the employee from resident care areas immediately .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: . b. Have evidence that all alleged violations are thoroughly investigated. c. Prevent further potential abuse, neglect . while the investigation is in process. d. Report the results of all investigations to the Administrator or his or her designated representative and to the other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken . The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Review on 7/13/2018 at approximately 10:47 PM of a Grievance Form dated 5/3/2018 by Resident #56 revealed to the Social Worker that a Certified Nursing Assistant (CNA) was rough with him/her at times and fusses with him/her at times. Further review of the Grievance Form revealed a hand written note from the DON (Director of Nurses) stating, Talked with staff to prevent any incident as above, be mindful of resident needs and prevent further anxiety for them. No documentation could be found that the allegation was identified as potential abuse, investigated or reported to the State Agency as per the facility's abuse policies. During an interview on 7/13/2018 at approximately 10:40 AM, Resident #56 confirmed the above allegations. He/she also stated that he/she was in a lot of pain due to previous broken hips and that one broken hip was inoperable and caused him/her excruciating pain. This surveyor asked Resident #56 how it made him/her feel when the perpetrator had been rough and fussed at him/her and he/she began to cry and could not answer. During an interview on 7/13/2018 at approximately 11:45 AM, CNA #3 indicated that he/she had worked numerous years with residents and treated them as if he/she would like to be treated. CNA #3 went on to say that he/she had never gotten upset with any resident at any time and if a resident gets upset or does not want care at the time it is offered then he/she will leave the room, notify the nurse and return later. During an interview on 7-12-18 at 1:25 PM, the Director of Nurse (DON) reviewed the 5-3-18 complaint/concern voiced by Resident #56 regarding rough handling and stated s/he had not identified this as abuse. The DON confirmed that this incident was not reported to the State Agency or investigated as an allegation of abuse/neglect. The DON stated s/he did talk to staff but had no written statements. Upon review of the Grievance Log, it was noted that Resident #131 voiced a grievance/concern on 5-8-18 to Social Services (SS) regarding staff failure to provide incontinent care from 7 AM to 4 PM on 4-28-18. She (He) stated she (he) sat in a wet brief with a puddle under her chair. (Resident # 131) stated no one checked on her (him) throughout the morning . the cubical curtain is usually pulled between her (him) and roommate and stated staff does not usually come in to check on her (him). She (he) is able to propel her/himself and stated she (he) she (he) went to lunch and then to a singing activity without being changed. Documentation by the Director of Nurses (DON) on 5-10-18 on the SS note stated: After talking with staff, this did not occur. Resident experiences intermittent confusion. There was no evidence of how the DON came to this conclusion. There was no evidence of any investigation of the complaint. There were no docu mented subsequent interviews with the resident in an attempt to validate the information. There were no written statements by staff or documented staff or roommate interviews. There was no evidence that the incident was reported to the State Agency. During an interview on 7-12-18 at 1:25 PM, the Director of Nurse (DON) reviewed the 5-8-18 grievance/concern voiced by Resident #131and stated s/he had not identified this as abuse.The DON confirmed that the incident was not reported to the State Agency or investigated as allegations of abuse/neglect. The DON stated s/he did talk to staff but had no written statements. During an interview on 7/13/18 at 10:31 AM, Resident #131 stated s/he was supposed to be changed (incontinent care) twice daily but s/he stays all wet. The resident noted that sometimes the staff would not answer the call light and that during lunch,they will serve the people before changing. Based on full and/or limited record reviews, interviews and review of facility policies, it was determined on 7/13/18 at 11:10 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility in the following areas. The Director of Nurses (DON) and the Administrator were notified of this determination at 12:30 PM. The deficiencies involved were as follows: F600 Free from Abuse and Neglect - as it relates to residents involved in allegations of abuse. F607 Implement abuse policies - as it relates to the facility's failure to implement abuse policies, that included reporting and investigating allegations. F609 Repoerting of alleged violations - as it relates to the facility's failure to report alleged abuse to the SA timely. F610 Investigate alleged violations- as it relates to the facility's faiure to investigate alleged abuse thoroughly. F835 Administration - as it relates to the Administrator's failure to administer the facility in a way to ensure each resident's highest well-being. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable that included the following: Abuse IJ Nursing and/or Social services notified the Responsible Party and the Physician of the identified residents as to the allegations of abuse/neglect. Residents identified during the survey did not receive any injuries from the allegations. The DON and/or Social Services will review all Abuse/Neglect allegations, following the facility written policies and regulations. Social Workiers will attempt to interview residents and gather witness statements pertaining to the allegations. Staff, including any staff with information regarding the allegations, will be interviewed and the information given to and discussed with the DON. Allegations will be reported timely to the proper persons. The DON has modified the original Abuse investigation for the resident cited to show that staff was interviewed, Responsible Party notified and physician notified. The results of the investigation will be sent for the 5 day review. The two other residents had their allegations reported on 7/13/18, to the appropriate State personnel and further investigation will be done if necessary. The Social Workers interviewed and received statements from all employees caring for the residents cited and there were no further incidents noted. The Compliance with Reporting Allegations of Abuse/Neglect/Exploitation form will be utilized for all allegations and this form will be kept in a folder for review of QAPI at least monthly. All staff will be in-serviced on the facility Abuse Policy and appropriate interventions for resident reactions through the Hand in Hand Modules by 7/17/18. All staff not in-serviced, PRN staff and those on vacation, will receive training before performing duties. All residents will be assessed and the development of the care plan will be reviewed to include appropriate care for residents with needs and behaviors which could lead to conflict by 7/17/18. On (MONTH) 18, (YEAR) Team members began the Extended survey process. They reviewed the A[NAME] and ensured implementation by interviewing staff, reviewing resident clinical records, reviewed staff inservice sheets and made facility observations. That morning the team removed the Immediate Jeopardy and lowered the scope and severity of F600, F607, F609, F610, F835 to an F. They concluded the facility had removed the immediacy by implementing their A[NAME] on 7/17/18.

Based on record reviews and interviews, the administration of the facility failed to ensure that resident care policies regarding abuse/neglect were followed. Two of 3 allegations of abuse/neglect were not identified as such. Three (3) of 3 were not investigated and/or reported to appropriate authorities within the required timeframes. In 3 of 3 cases, management failed to immediately implement safeguards to protect these and other residents from recurrence of the abuse/neglect. The findings included: On 7-12-18, during an investigation of responses to concerns addressed during the Resident Council meeting on 7/11/18 at 10:30 AM, the Grievance Log was reviewed. Resident #58 reported an incident of abuse/neglect that occurred on 12-18-17 when Certified Nursing Assistant (CNA) #3 instructed the resident to go in her/his brief. The named grievance official, the Director of Nurses (DON), did not report to the State Agency in a timely manner or thoroughly investigate the incident. During an interview on 7/12/18 at 2:01 PM, the DON stated that the Administrator made the decisions related to disciplinary action. In this case, management failed to immediately implement safeguards to protect these and other residents from recurrence of the abuse/neglect by the alleged perpetrator. The only action taken was counseling/education. Resident #56 reported rough handling and possible verbal abuse by the same CNA #3 to the Social Worker (SW) on 5-3-18. The DON failed to identify the incident as possible abuse and implement reporting and investigation policies. During an interview on 7/13/2018 at approximately 10:40 AM when questioned about the incident, the resident confirmed the allegations and began to cry. On 5-8-18, Resident #131 reported staff failure to provide incontinent care over a 9 hour period on 4-28-18. The DON failed to identify the incident as an allegation of abuse/neglect and implement reporting and investigation policies. The DON failed to identify the incident as possible abuse and implement reporting and investigation policies. During an interview on 7/15/18 at 4:45 PM, the Administrator stated that s/he is made aware of allegations of abuse immediately. When asked how incidents of abuse are handled, the Administrator stated,When incidents occur we find out what happened and make decisions about the incidents to include moving the CNA to another unit or assign them to another resident if needed. The facility's Abuse, Neglect and Exploitation Policy states: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Policy Explanation and Compliance Guidelines included: 'Neglect' means failure . to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The components of the facility abuse prohibition plan included: 6. Identification . The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents including, but not limited to the following possible indicators : a. Resident, staff, or family report of abuse h. Failure to provide care needs . 7 . Components of an investigation may include : a. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements . should be signed and dated d. Document the entire investigation chronologically . 8. Resident Protection . The facility will make efforts to protect all residents after alleged abuse, neglect, and/or exploitation. Examples of ways to protect a resident from harm during an investigation . may include, but are not limited to: .g. Reassignment of nursing staff duties, h. Time off for nursing staff . 9. Response and Reporting . When abuse, neglect, or exploitation is suspected, the Licensed Nurse should: a. Respond to the needs of the resident and protect them from further incident (document). b. Notify the Director of Nursing and Administrator (document). c. Initiate an investigation immediately. d. Notify the attending physician, resident's family/legal representative and Medical Director. e. Obtain witness statements. May/may not suspend the accused employee pending completion of the investigation. May/may not remove the employee from resident care areas immediately. f. Contact the State Agency and the local Ombudsman office to report the alleged abuse . 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect . are reported immediately, but not later than 2 hours after the allegation is made . b. Have evidence that all alleged violations are thoroughly investigated. c. Prevent further potential abuse neglect . while the investigation is in process. d. Report the results of all investigations to the Administrator or his or her designated representative and to the other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken . Based on full and/or limited record reviews, interviews and review of facility policies, it was determined on 7/13/18 at 11:10 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility in the following areas. The Director of Nurses (DON) and the Administrator were notified of this determination at 12:30 PM. The deficiencies involved were as follows: F600 Free from Abuse and Neglect - as it relates to residents involved in allegations of abuse. F607 Implement abuse policies - as it relates to the facility's failure to implement abuse policies, that included reporting and investigating allegations. F609 Reporting of alleged violations - as it relates to the facility's failure to report alleged abuse to the SA timely. F610 Investigate alleged violations- as it relates to the facility's faiure to investigate alleged abuse thoroughly. F835 Administration - as it relates to the Administrator's failure to administer the facility in a way to ensure each resident's highest well-being. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable that included the following: Abuse IJ Nursing and/or Social services notified the Responsible Party and the Physician of the identified residents as to the allegations of abuse/neglect. Residents identified during the survey did not receive any injuries from the allegations. The DON and/or Social Services will review all Abuse/Neglect allegations, following the facility written policies and regulations. Social Workiers will attempt to interview residents and gather witness statements pertaining to the allegations. Staff, including any staff with information regarding the allegations, will be interviewed and the information given to and discussed with the DON. Allegations will be reported timely to the proper persons. The DON has modified the original Abuse investigation for the resident cited to show that staff was interviewed, Responsible Party notified and physician notified. The results of the investigation will be sent for the 5 day review. The two other residents had their allegations reported on 7/13/18, to the appropriate State personnel and further investigation will be done if necessary. The Social Workers interviewed and received statements from all employees caring for the residents cited and there were no further incidents noted. The Compliance with Reporting Allegations of Abuse/Neglect/Exploitation form will be utilized for all allegations and this form will be kept in a folder for review of QAPI at least monthly. All staff will be in-serviced on the facility Abuse Policy and appropriate interventions for resident reactions through the Hand in Hand Modules by 7/17/18. All staff not in-serviced, PRN staff and those on vacation, will receive training before performing duties. All residents will be assessed and the development of the care plan will be reviewed to include appropriate care for residents with needs and behaviors which could lead to conflict by 7/17/18. On (MONTH) 18, (YEAR) Team members began the Extended survey process. They reviewed the A[NAME] and ensured implementation by interviewing staff, reviewing resident clinical records, reviewed staff inservice sheets and made facility observations. That morning the team removed the Immediate Jeopardy and lowered the scope and severity of F600, F607, F609, F610, F835 to an F. They concluded the facility had removed the immediacy by implementing their A[NAME] on 7/17/18.

Based on record review, interviews, and review of the facility's Abuse, Neglect and Exploitation Policy, the facility failed to implement established policies related to identification, investigation, protection, and/or reporting of abuse/neglect for 3 of 3 sampled residents reviewed who had voiced allegations of abuse/neglect. When staff failed to provide necessary care related to toileting and instructed Resident #58 to go in her/his disposable brief, staff failed to assist Resident #58 with proper toileting procedures as requested and instructed her/him to use her/his disposable brief, failed Resident #56 by being rough and speaking abusively at times to him/her and failed Resident #131 by not changing his/her brief all day and allowing the resident to remain wet for several hours, facility policies were not followed regarding implementation of safeguards to prevent further violations, reporting the allegation to appropriate authorities within the required timeframes, and conducting a thorough investigation. The findings included: The facility admitted Resident #58 on 10/19/17 with [DIAGNOSES REDACTED]. Review of the 10-25-17 Admission and 4-27-18 Quarterly Minimum Data Set Assessments revealed that the resident had a consistent Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. Review of the reportable investigation file noted that Resident #58 reported an incident that occurred on 12-18-17 to Social Services on 12-19-17. According to the 12-19-17 Social Service note, the resident stated s/he put the call light on at 8:30-9 PM because s/he needed to go to the bathroom. When Certified Nursing Assistant (CNA) # 3 answered the light, s/he told her (him) to go in her (his) brief. When the resident stated she (he) would be wet, the CNA told her/him to just do it. She (He) stated she (he) did wet her/himself. The resident also reported that CNA #3 was very short with her (him), but stated this is not the first time she (he) has been ugly to her (him). Further review of the file revealed that it contained only 2 staff statements, those of the alleged perpetrator (CNA #3) and Licensed Practical Nurse (LPN) #6, who was on the East Unit. On 12-19-17, a statement by LPN #6 noted s/he was Called to room by CNA. CNA very upset, resident present. Stated she (he) wasn't going to be talk(ed) to like that from a resident and if this nurse didn't report it to (Social Services) , she (he) would. Unable to understand really what CNA was upset about. After CNA left room, this nurse apologized to resident for behavior of staff member. Resident stated CNA was mad. CNA told her (him) to pee in chair and resident requested to lay down in the bed. DON notified and explained to resident this would be reported. CNA #3's statement, dated 12-25-17, stated, On Dec(ember) 18, (YEAR) (Resident # 58) when putting her (him) to bed she (he) got upset because her (his) Hoyer pad got wet. She (He) started yelling and cursing. I tried to explain to her (him) that happens when you do not want to go to bed to relieve yourself. The allegation of neglect was not reported to the State Agency until the Initial 24-Hour Report was faxed on 12-20-17 at 12:40 PM, 2 days after staff were aware of the incident. The Five-Day Follow-up Report completed by the Director of Nurses noted that the resident was alert and oriented x 3. Pleasant. Witnesses and other staff on duty at time of/prior to Reportable Incident included only the names of LPN #6 and CNA #3. No other staff were noted to be on duty. The Details of Reportable Incident stated: Resident was late returning from activities, incontinent of bowel and bladder, was wet and soaked Hoyer sling. Resident stated CNA told her (him) to go in chair but put her (him) (to) bed. It was her (his) tone. She was not mistreated. There were no resident or witness statements to substantiate this assumption. The Immediate corrective action/assessment following Reportable Incident noted Nurse asked CNA to leave room and investigation initiated. There was no record of interviews with the resident, her/his roommate, or other staff members on duty at the time of the incident. During an interview on 7/12/18 at 2:01 PM, the DON reviewed the 12-18-17 complaint voiced by Resident #58. After review of the investigation file, the DON stated s/he reported the incident on 12-20-17, as soon as s/he was aware of it, but not within 2 hours. S/he verified there was no evidence of interviews of other staff on duty at the time of the incident. When asked about the investigation, the DON stated s/he had interviewed the nurse, but there was no record of this. Review of the nurse's written statement reiterated the resident's claim but was more focused on the CNA being upset than the condition of the resident. When asked if the resident had a roommate, the DON stated the resident had one but s/he had not talked to her/him. When asked about other staff on duty, the DON stated there were 3 or 4 other CNAs on duty at the time but they were not interviewed because they were on the other end. When asked what interventions had been put in place with CNA #3 to protect this and other residents due to lack of evidence in the file, the DON stated, I don't know. I report it to the administrator and he (she) makes the decision about suspension. Review of CNA #3's time card revealed it did not indicate suspension and there was no record in the investigation/reportable file of how other residents were protected during the investigation. On 7-15-18, the DON presented a form that documented counseling/training for CNA #3. During an interview on 7/13/18 at 10:29 AM, Resident #58 verified the events of 12-18-17 as s/he stated to the nurse on 12-18-17 and Social Services on 12-19-17. S/he stated, I told her (him) (Social Services) the next day. When asked if s/he knew when s/he had to use the bathroom, Resident #58 stated s/he did and had been going to the bathroom using a lift. I tried the sit to stand but had to change to the full body lift. The resident reported that when s/he moved into her/his current room, s/he started to use the bedpan in bed because the bathroom was too small to use the lift. S/he stated, I try to hold it because I know they're busy. The facility's Abuse, Neglect and Exploitation Policy states: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Policy Explanation and Compliance Guidelines included: 'Neglect' means failure . to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The components of the facility abuse prohibition plan included: 6. Identification . The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents including, but not limited to the following possible indicators : a. Resident, staff, or family report of abuse h. Failure to provide care needs . 7 . Components of an investigation may include : a. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements . should be signed and dated d. Document the entire investigation chronologically . 8. Resident Protection . The facility will make efforts to protect all residents after alleged abuse, neglect, and/or exploitation. Examples of ways to protect a resident from harm during an investigation . may include, but are not limited to: .g. Reassignment of nursing staff duties, h. Time off for nursing staff . 9. Response and Reporting . When abuse, neglect, or exploitation is suspected, the Licensed Nurse should: a. Respond to the needs of the resident and protect them from further incident (document). b. Notify the Director of Nursing and Administrator (document). c. Initiate an investigation immediately. d. Notify the attending physician, resident's family/legal representative and Medical Director. e. Obtain witness statements. May/may not suspend the accused employee pending completion of the investigation. May/may not remove the employee from resident care areas immediately. f. Contact the State Agency and the local Ombudsman office to report the alleged abuse . 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect . are reported immediately, but not later than 2 hours after the allegation is made . b. Have evidence that all alleged violations are thoroughly investigated. c. Prevent further potential abuse neglect . while the investigation is in process. d. Report the results of all investigations to the Administrator or his or her designated representative and to the other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken . The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Review on 7/13/2018 at approximately 10:47 PM of a Grievance Form dated 5/3/2018 by Resident #56 revealed to the Social Worker that a Certified Nursing Assistant (CNA) was rough with him/her at times and fusses with him/her at times. Further review of the Grievance Form revealed a hand written note from the DON (Director of Nurses) stating, Talked with staff to prevent any incident as above, be mindful of resident needs and prevent further anxiety for them. No documentation could be found that the allegation was identified as potential abuse, investigated or reported to the State Agency as per the facility's abuse policies. During an interview on 7/13/2018 at approximately 10:40 AM, Resident #56 confirmed the above allegations. He/she also stated that he/she was in a lot of pain due to previous broken hips and that one broken hip was inoperable and caused him/her excruciating pain. This surveyor asked Resident #56 how it made him/her feel when the perpetrator had been rough and fussed at him/her and he/she began to cry and could not answer. During an interview on 7/13/2018 at approximately 11:45 AM, CNA #3 indicated that he/she had worked numerous years with residents and treated them as if he/she would like to be treated. CNA #3 went on to say that he/she had never gotten upset with any resident at any time and if a resident gets upset or does not want care at the time it is offered then he/she will leave the room, notify the nurse and return later. During an interview on 7-12-18 at 1:25 PM, the Director of Nurse (DON) reviewed the 5-3-18 complaint/concern voiced by Resident #56 regarding rough handling and stated s/he had not identified this as abuse. The DON confirmed that this incident was not reported to the State Agency or investigated as an allegation of abuse/neglect. The DON stated s/he did talk to staff but had no written statements. Upon review of the Grievance Log, it was noted that Resident #131 voiced a grievance/concern on 5-8-18 to Social Services (SS) regarding staff failure to provide incontinent care from 7 AM to 4 PM on 4-28-18. She (He) stated she (he) sat in a wet brief with a puddle under her chair. (Resident # 131) stated no one checked on her (him) throughout the morning . the cubical curtain is usually pulled between her (him) and roommate and stated staff does not usually come in to check on her (him). She (he) is able to propel her/himself and stated she (he) she (he) went to lunch and then to a singing activity without being changed. Documentation by the Director of Nurses (DON) on 5-10-18 on the SS note stated: After talking with staff, this did not occur. Resident experiences intermittent confusion. There was no evidence of how the DON came to this conclusion. There was no evidence of any investigation of the complaint. There were no docu mented subsequent interviews with the resident in an attempt to validate the information. There were no written statements by staff or documented staff or roommate interviews. There was no evidence that the incident was reported to the State Agency. During an interview on 7-12-18 at 1:25 PM, the Director of Nurse (DON) reviewed the 5-8-18 grievance/concern voiced by Resident #131and stated s/he had not identified this as abuse.The DON confirmed that the incident was not reported to the State Agency or investigated as allegations of abuse/neglect. The DON stated s/he did talk to staff but had no written statements. During an interview on 7/13/18 at 10:31 AM, Resident #131 stated s/he was supposed to be changed (incontinent care) twice daily but s/he stays all wet. The resident noted that sometimes the staff would not answer the call light and that during lunch,they will serve the people before changing. Based on full and/or limited record reviews, interviews and review of facility policies, it was determined on 7/13/18 at 11:10 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility in the following areas. The Director of Nurses (DON) and the Administrator were notified of this determination at 12:30 PM. The deficiencies involved were as follows: F600 Free from Abuse and Neglect - as it relates to residents involved in allegations of abuse. F607 Implement abuse policies - as it relates to the facility's failure to implement abuse policies, that included reporting and investigating allegations. F609 Repoerting of alleged violations - as it relates to the facility's failure to report alleged abuse to the SA timely. F610 Investigate alleged violations- as it relates to the facility's faiure to investigate alleged abuse thoroughly. F835 Administration - as it relates to the Administrator's failure to administer the facility in a way to ensure each resident's highest well-being. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable that included the following: Abuse IJ Nursing and/or Social services notified the Responsible Party and the Physician of the identified residents as to the allegations of abuse/neglect. Residents identified during the survey did not receive any injuries from the allegations. The DON and/or Social Services will review all Abuse/Neglect allegations, following the facility written policies and regulations. Social Workiers will attempt to interview residents and gather witness statements pertaining to the allegations. Staff, including any staff with information regarding the allegations, will be interviewed and the information given to and discussed with the DON. Allegations will be reported timely to the proper persons. The DON has modified the original Abuse investigation for the resident cited to show that staff was interviewed, Responsible Party notified and physician notified. The results of the investigation will be sent for the 5 day review. The two other residents had their allegations reported on 7/13/18, to the appropriate State personnel and further investigation will be done if necessary. The Social Workers interviewed and received statements from all employees caring for the residents cited and there were no further incidents noted. The Compliance with Reporting Allegations of Abuse/Neglect/Exploitation form will be utilized for all allegations and this form will be kept in a folder for review of QAPI at least monthly. All staff will be in-serviced on the facility Abuse Policy and appropriate interventions for resident reactions through the Hand in Hand Modules by 7/17/18. All staff not in-serviced, PRN staff and those on vacation, will receive training before performing duties. All residents will be assessed and the development of the care plan will be reviewed to include appropriate care for residents with needs and behaviors which could lead to conflict by 7/17/18. On (MONTH) 18, (YEAR) Team members began the Extended survey process. They reviewed the A[NAME] and ensured implementation by interviewing staff, reviewing resident clinical records, reviewed staff inservice sheets and made facility observations. That morning the team removed the Immediate Jeopardy and lowered the scope and severity of F600, F607, F609, F610, F835 to an F. They concluded the facility had removed the immediacy by implementing their A[NAME] on 7/17/18.

Based on record review, interviews, and review of the facility's Abuse, Neglect and Exploitation Policy, the facility failed to ensure that all residents remained free of abuse/neglect. The facility failed to identify allegations/complaints as abuse/neglect, immediately implement safeguards to prevent further violations, report the allegations to appropriate authorities within the required timeframes, and failed to conduct thorough investigations for 3 of 3 sampled residents who reported abuse/neglect. Staff failed to assist Resident #58 with proper toileting procedures as requested and instructed her/him to use her/his disposable brief which would reasonably result in shame/humiliation. Staff were rough and spoke abusively at times to Resident #56. Staff failed to provide incontinent care to Resident #131 over a 9 hour period. The findings included: The facility admitted Resident #58 on 10/19/17 with [DIAGNOSES REDACTED]. Review of the 10-25-17 Admission and 4-27-18 Quarterly Minimum Data Set Assessments revealed that the resident had a consistent Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. On 7-12-18, during an investigation of responses to concerns addressed during the Resident Council meeting on 7/11/18 at 10:30 AM, the Grievance Log was reviewed. The investigation file noted that Resident #58 reported an incident that occurred on 12-18-17 to Social Services on 12-19-17. According to the 12-19-17 Social Service note, the resident stated s/he put the call light on at 8:30-9 PM because s/he needed to go to the bathroom. When Certified Nursing Assistant (CNA) #3 answered the light, s/he told her (him) to go in her (his) brief. When the resident stated she (he) would be wet, the CNA told her/him to just do it. She (He) stated she (he) did wet her/himself. The resident also reported that CNA #3 was very short with her (him), but stated this is not the first time she (he) has been ugly to her (him). Further review of the file revealed that it contained only 2 staff statements, those of the alleged perpetrator (CNA #3) and Licensed Practical Nurse (LPN) #6, who was on the East Unit. On 12-19-17, a statement by LPN #6 noted s/he was Called to room by CNA. CNA very upset, resident present. Stated she (he) wasn't going to be talk(ed) to like that from a resident and if this nurse didn't report it to (Social Services), she (he) would. Unable to understand really what CNA was upset about. After CNA left room, this nurse apologized to resident for behavior of staff member. Resident stated CNA was mad. CNA told her (him) to pee in chair and resident requested to lay down in the bed. DON (Director of Nurses) notified and explained to resident this would be reported. CNA #3's statement, dated 12-25-17, stated, On Dec(ember) 18, (YEAR) (Resident # 58) when putting her (him) to bed she (he) got upset because her (his) Hoyer pad got wet. She (He) started yelling and cursing. I tried to explain to her (him) that happens when you do not want to go to bed to relieve yourself. The Initial 24-Hour Report was faxed to the State Agency on 12-20-17 at 12:40 PM. The Five-Day Follow-up Report noted that the resident was alert and oriented x 3. Pleasant. Witnesses and other staff on duty at time of/prior to Reportable Incident included only the names of LPN #6 and CNA #3. No other staff were noted to be on duty. The Details of Reportable Incident completed by the DON stated: Resident was late returning from activities, incontinent of bowel and bladder, was wet and soaked Hoyer sling. Resident stated CNA told her (him) to go in chair but put her (him) (to) bed . It was her (his) tone. She (he) was not mistreated. The Immediate corrective action/assessment following Reportable Incident noted Nurse asked CNA to leave room and investigation initiated. There was no record of interviews with the resident, her/his roommate, or other staff members on duty at the time of the incident. During an interview on 7/12/18 at 2:01 PM, the DON reviewed the 12-18-17 complaint voiced by Resident #58. After review of the investigation file, the DON stated s/he reported the incident on 12-20-17, as soon as s/he was aware of it. S/he verified there was no evidence of interviews of the resident's roommate or other staff on duty at the time of the incident. When asked about the investigation, the DON stated s/he had interviewed the nurse, but there was no record of this. Review of the nurse's written statement reiterated the resident's claim but was more focused on the CNA being upset than the condition of the resident. When asked if the resident had a roommate, the DON stated the resident had one but s/he had not talked to her/him. When asked about other staff on duty, the DON stated there were 3 or 4 other CNAs on duty at the time but they were not interviewed because they were on the other end. When asked what interventions had been put in place with CNA #3 to protect this and other residents due to lack of evidence in the file, the DON stated, I don't know. I report it to the administrator and he (she) makes the decision about suspension. Review of CNA #3's time card revealed it did not indicate suspension and there was no record in the investigation/reportable file of how other residents were protected during the investigation. On 7-15-18, the DON presented a form that documented counseling/training for CNA #3. Review of the grievance log on 7-11-18 revealed no evidence of how identified concerns/complaints were investigated or that written responses were given to residents and/or their representatives. During an interview on 7-12-18 at 1:25 PM, the DON verified that no written responses were given to residents for complaints. During an interview on 7/13/18 at 10:29 AM, Resident #58 verified the events of 12-18-17 as s/he stated to the nurse on 12-18-17 and Social Services on 12-19-17. S/he stated, I told her (him) (Social Services) the next day. When asked if s/he knew when s/he had to use the bathroom, Resident #58 stated s/he did and had been going to the bathroom using a lift. I tried the sit to stand but had to change to the full body lift. The resident reported that when s/he moved into her/his current room, s/he started to use the bedpan in bed because the bathroom was too small to use the lift. S/he stated, I try to hold it because I know they're busy. During an interview on 7-12-18 at 1:25 PM, the Director of Nurse (DON) reviewed the 5-8-18 grievance/concern voiced by Resident #131 who complained of no assistance with toileting from 7 AM to 4 PM and stated s/he had not identified this as abuse. The DON also reviewed the 5-3-18 complaint/concern voiced by Resident #56 regarding rough handling and stated s/he had not identified this as abuse. The DON confirmed that these incidents were not reported to the State Agency or investigated as allegations of abuse/neglect. The DON stated s/he did talk to staff but had no written statements. The facility's Abuse, Neglect and Exploitation Policy states: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Policy Explanation and Compliance Guidelines included: 'Neglect means failure . to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The components of the facility abuse prohibition plan included: 6. Identification . The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents including, but not limited to the following possible indicators : a. Resident, staff, or family report of abuse h. Failure to provide care needs . 7 . Components of an investigation may include : a. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements . should be signed and dated d. Document the entire investigation chronologically . 8. Resident Protection . The facility will make efforts to protect all residents after alleged abuse, neglect, and/or exploitation. Examples of ways to protect a resident from harm during an investigation . may include, but are not limited to: .g. Reassignment of nursing staff duties, h. Time off for nursing staff . 9. Response and Reporting . When abuse, neglect, or exploitation is suspected, the Licensed Nurse should: a. Respond to the needs of the resident and protect them from further incident (document). b. Notify the Director of Nursing and Administrator (document). c. Initiate an investigation immediately. d. Notify the attending physician, resident's family/legal representative and Medical Director. e. Obtain witness statements. May/may not suspend the accused employee pending completion of the investigation. May/may not remove the employee from resident care areas immediately. f. Contact the State Agency and the local Ombudsman office to report the alleged abuse . 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect . are reported immediately, but not later than 2 hours after the allegation is made . b. Have evidence that all alleged violations are thoroughly investigated. c. Prevent further potential abuse, neglect . while the investigation is in process. d. Report the results of all investigations to the Administrator or his or her designated representative and to the other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken . The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Review on 7/13/2018 at approximately 10:47 PM of a Grievance Form dated 5/3/2018 by Resident #56 revealed to the Social Worker that a CNA (Certified Nursing Assistant) is rough with him/her at times and fusses with him/her at times. No documentation could be found to ensure the alleged abuse was identified, investigated or reported to the state agency. Further review on 7/13/2018 at approximately 10:50 AM of the Grievance Form dated 5/3/2018 revealed a hand written note from the DON (Director of Nurses) stating, Talked with staff to prevent any incident as above, be mindful of resident needs and prevent further anxiety for them. There was no indication that the facility had followed it's abuse policy to prevent abuse and to ensure each resident has the right to be free from abuse of any kind. During an interview on 7/13/2018 at approximately 10:40 AM with Resident #56, s/he confirmed the above allegations. S/he also stated that s/he was in a lot of pain due to previous broken hips and that one broken hip was inoperable and caused him/her excruciating pain. This surveyor asked Resident #56 how it made him/her feel when the perpetrator had been rough and fussed at him/her and s/he began to cry and could not answer. During an interview on 7/13/2018 at approximately 11:45 AM, Certified Nursing Assistant (CNA) #3 indicated that he/she had worked numerous years with residents and treated them as he/she would like to be treated. CNA #3 went on to say that he/she had never gotten upset with any resident at any time and if a resident gets upset or does not want care at the time that is offered then he/she will leave the room, notify the nurse and return later. During an interview on 7-12-18 at 1:25 PM, the Director of Nurse (DON) reviewed the 5-3-18 complaint/concern voiced by Resident #56 regarding rough handling and stated s/he had not identified this as abuse. The DON confirmed that this incident was not reported to the State Agency or investigated as an allegation of abuse/neglect. The DON stated s/he did talk to staff but had no written statements. Upon review of the Grievance Log, it was noted that Resident #131 voiced a grievance/concern on 5-8-18 to Social Services (SS) regarding staff failure to provide incontinent care from 7 AM to 4 PM on 4-28-18. She (He) stated she (he) sat in a wet brief with a puddle under her chair. (Resident # 131) stated no one checked on her (him) throughout the morning . the cubical curtain is usually pulled between her (him) and roommate and stated staff does not usually come in to check on her (him). She (he) is able to propel her/himself and stated she (he) she (he) went to lunch and then to a singing activity without being changed. Documentation by the Director of Nurses (DON) on 5-10-18 on the SS note stated: After talking with staff, this did not occur. Resident experiences intermittent confusion. There was no evidence of how the DON came to this conclusion. There was no evidence of any investigation of the complaint. There were no documented subsequent interviews with the resident in an attempt to validate the information. There were no written statements by staff or documented staff or roommate interviews. There was no evidence that the incident was reported to the State Agency. During an interview on 7-12-18 at 1:25 PM, the Director of Nurse (DON) reviewed the 5-8-18 grievance/concern voiced by Resident #131and stated s/he had not identified this as abuse.The DON confirmed that the incident was not reported to the State Agency or investigated as allegations of abuse/neglect. The DON stated s/he did talk to staff but had no written statements. During an interview on 7/13/18 at 10:31 AM, Resident #131 stated s/he was supposed to be changed (incontinent care) twice daily but s/he stays all wet. The resident noted that sometimes the staff would not answer the call light and that during lunch,they will serve the people before changing. Based on full and/or limited record reviews, interviews and review of facility policies, it was determined on 7/13/18 at 11:10 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility in the following areas. The Director of Nurses (DON) and the Administrator were notified of this determination at 12:30 PM. The deficiencies involved were as follows: F600 Free from Abuse and Neglect - as it relates to residents involved in allegations of abuse. F607 Implement abuse policies - as it relates to the facility's failure to implement abuse policies, that included reporting and investigating allegations. F609 Repoerting of alleged violations - as it relates to the facility's failure to report alleged abuse to the SA timely. F610 Investigate alleged violations- as it relates to the facility's faiure to investigate alleged abuse thoroughly. F835 Administration - as it relates to the Administrator's failure to administer the facility in a way to ensure each resident's highest well-being. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable that included the following: Abuse IJ Nursing and/or Social services notified the Responsible Party and the Physician of the identified residents as to the allegations of abuse/neglect. Residents identified during the survey did not receive any injuries from the allegations. The DON and/or Social Services will review all Abuse/Neglect allegations, following the facility written policies and regulations. Social Workiers will attempt to interview residents and gather witness statements pertaining to the allegations. Staff, including any staff with information regarding the allegations, will be interviewed and the information given to and discussed with the DON. Allegations will be reported timely to the proper persons. The DON has modified the original Abuse investigation for the resident cited to show that staff was interviewed, Responsible Party notified and physician notified. The results of the investigation will be sent for the 5 day review. The two other residents had their allegations reported on 7/13/18, to the appropriate State personnel and further investigation will be done if necessary. The Social Workers interviewed and received statements from all employees caring for the residents cited and there were no further incidents noted. The Compliance with Reporting Allegations of Abuse/Neglect/Exploitation form will be utilized for all allegations and this form will be kept in a folder for review of QAPI at least monthly. All staff will be in-serviced on the facility Abuse Policy and appropriate interventions for resident reactions through the Hand in Hand Modules by 7/17/18. All staff not in-serviced, PRN staff and those on vacation, will receive training before performing duties. All residents will be assessed and the development of the care plan will be reviewed to include appropriate care for residents with needs and behaviors which could lead to conflict by 7/17/18. On (MONTH) 18, (YEAR) Team members began the Extended survey process. They reviewed the A[NAME] and ensured implementation by interviewing staff, reviewing resident clinical records, reviewed staff inservice sheets and made facility observations. That morning the team removed the Immediate Jeopardy and lowered the scope and severity of F600, F607, F609, F610, F835 to an F. They concluded the facility had removed the immediacy by implementing their A[NAME] on 7/17/18.

Based on record reviews, interviews, and review of the facility policies titled, Notification of Changes, and [DIAGNOSES REDACTED] Protocol, the facility failed to notify the physician and/or personal representative of significant weight loss for 4 of 9 sampled residents reviewed for Nutrition (Residents #116, #128, #50 and #140) for weight loss. The facility also failed to notify the physician and personal representative of abnormal blood sugars requiring intervention for 1 of 1 sampled resident reviewed with blood sugar abnormalities (Resident #16). The findings included: The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Review on 7/9/2018 at approximately 1:20 PM of the medical record for Resident #128 revealed a weight of 170 pounds on 12/1/2017. Further review on 7/9/2018 at approximately 1:25 PM of the medical record for Resident #128 revealed a weight of 134 pounds on 6/8/2018, indicating a 21 percent weight loss in 6 months. Review of the 4/1/2018 through 7/11/2018 Medication Administration Records (MARs) on 7/11/2018 at approximately 10:11 AM revealed the supplement AWC Prostat to improve weight loss was ordered by the physician on 9/12/2017. The MAR indicated [REDACTED]. Review of the 5/1/2018 through 5/31/2018 MAR indicated [REDACTED]. Review of the 6/1/2018 through 6/30/2018 revealed that Resident #128 refused the AWC Prostat on 6/1, 6/2, 6/3, 6/4, 6/5, 6/6, 6/8, 6/9, 6/11, 6/12, 6/13, 6/14 6/15, 6/16. 6/17, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/24, 6/25, 6/26, 6/28, 6/29 and 6/30/2018. Review of the 7/1/2018 through 7/11/2018 MAR indicated [REDACTED]. No documentation could be found in the medical record that the physician and responsible party were notified of the significant weight loss or the refusal of AWC Prostat over an extended period. Review on 7/11/2018 at approximately 2:38 PM of the Nurses Notes dated from 4/1/2018 through 7/11/2018 for Resident #128 revealed no documentation that the physician was notified of the refusal of the supplement AWC Prostat, or that Resident #128 continued to lose weight. During an interview on 7/11/2018 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #5 confirmed there was no documentation in the medical record for Resident #128 that the physician and family had been notified of a significant weight loss or the refusal of the AWC Prostat. LPN #5 went on to say, I told the physician and he (she) is aware but I did not document that anywhere in the medical record. LPN #5 did not comment on the fact that no documentation could be found to ensure the personal representative for Resident #128 had been notified of a significant weight loss. During an interview on 7/11/2018 at approximately 2:48 PM, the Dietary Consultant stated the he/she was not aware of Resident #128 refusing the AWC Prostat. The Dietary Consultant also stated the Registered Dietician would be in the facility the next day and would review Resident #128's weight loss and medical record. During an interview on 7/11/2018 at approximately 3:10 PM, the facility's Certified Dietary Manager stated, I am not aware of a weight loss for (Resident #128). The Certified Dietary Manager also stated he/she was not aware that the resident was refusing the AWC Prostat supplement. Review of the 9/1/2017 through 7/12/2018 Dietary Progress Notes for Resident #128 on 7/12/2018 at approximately 10:02 AM did not include a list of the food the resident likes and/or dislikes. The note from the RD (Registered Dietician) stated, the estimated protein is at 1.4 grams/kilogram of body weight is 78 grams. Resident is receiving a Multi Vitamin with Iron and Fortified Juice with meals to provide an additional 600 calories and 18 grams of protein. Resident also receives No Added Sugar ice cream with lunch and supper. His/her appetite is between 1 to 50 percent. The resident feeds self meals with tray set up. Continue to encourage intake at meals and offer assistance as needed. The facility policy titled, Weight Monitoring, states under Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The Compliance Guidelines state under #1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors. b. Evaluating and analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary. Under #7. Documentation: a. states, The physician should be informed of a significant change in weight and may order nutritional interventions. b. The physician should be encouraged to document the [DIAGNOSES REDACTED]. c. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed. d. If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietitian, Dietary Manager or the nursing department may initiate this process. e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. f. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. g. The interdisciplinary plan of care communicates care instructions to the staff. The policy titled, Weekly Weight and Nutritional Assessment Policy and Procedure, states: 1. Dietary runs a weekly log of weight gain and loss and it is presented at the weekly meeting. 2. The Dietary Manager will notify the Dietary Consultant when there is a weight loss/gain by telephone. 3. Nursing orders Med Pass 4 oz. BID (2 times daily) for the residents with weight loss that are on a PO (by mouth) diet. 4. When the Consultant or RD visits the facility, they will address the weight loss and any other recommendations. 5. If the resident is not consuming the Med Pass, they will visit the resident and determine if there is another supplement that the resident will consume. 6. If continued weight loss, the resident is put on weekly weights until the resident's weight is stabilized. 7. If the resident is fed by enteral that has a weight loss, the Dietary Manager will notify the Dietary Consultant and/or the RD and recommendations are made by telephone and an assessment or progress note is written. The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Record review on 7/14/2018 at approximately 3:23 PM revealed Nurses Notes dated 7/11/2018 at 7:30 PM which stated, Nurse called to resident room. Resident was sweating and non responsive to verbal and tactile stimulation, blood sugar found to be 27. The physician and the personal representative were not notified. A Nurses Note on 7/10/2018 at 9:19 PM stated, Finger stick blood sugar is 278 tonight, and the resident refused coverage. The physician and the personal representative were not notified. A nurses note dated 6/3/2018 at 11:00 PM stated the blood sugar was 303 and the resident refused insulin coverage and stated it would drop the blood sugar too low. The physician and the personal representative were not notified. A Nurses Note dated 5/21/2018 at 8:00 PM stated, Resident finger stick blood sugar is 39. Intramuscular [MEDICATION NAME] given. Resident is alert and able to respond verbally. Apple juice and a sandwich is given. The physician and the personal representative were not notified. A Nurses Note dated 5/10/2018 at 1:06 AM stated, Blood sugar is 29, gave grape juice and 2 packets of sugar. The physician and personal representative were not notified. On 4/9/2018 at 2:24 PM, the resident's blood sugar was 23. One milligram of [MEDICATION NAME] was given. The physician and personal representative were not notified. During an interview on 7/14/2018 at approximately 4:03 PM, when asked what he/she would do if a resident had a blood sugar of 29, LPN #4 stated, I would give the [MEDICATION NAME] 1 milligram intramuscularly and then call the physician and the personal representative. The facility policy titled, [DIAGNOSES REDACTED] Protocol, states: Symptoms of [DIAGNOSES REDACTED]: pallor, clammy skin, hunger, restless sleep, fatigue, headache, confusion, sweatiness, irritability, shaky, lethargic, and decreased level of consciousness. If blood sugar is 50-69 give one of the following: 4 ounces of orange/apple juice add 2 packets of sugar, 4 ounces of non-diet soda, 3 graham crackers, 1 tube of glucose gel. If the blood sugar is less than 50 in an alert resident give one of the following.8 ounces of milk and 3 graham crackers, 8 ounces of orange/apple juice and add 2 packets of sugar, 8 ounces of non diet soda, 2 tubes of glucose gel. If blood sugar is less than 70 and the resident is unconscious, immediately administer: [MEDICATION NAME] 1 gram intramuscularly or subcutaneous. Roll resident onto their side. Monitor for vomiting and aspiration risk. Recheck blood sugar in 15 minutes. If blood glucose is less than 70, notify the physician. Notify the physician of any treatment administered per the physician's orders [REDACTED].#16 that the physician or the personal representative was notified of the extremely low blood sugars which required [MEDICATION NAME] 1 gram intramuscularly. The facility admitted Resident #116 on 2/16/15 with [DIAGNOSES REDACTED]. Review of Progress Notes on 7/14/18 at 2:57 PM revealed that the resident had a history of [REDACTED]. According to the Notes, on 5-9-18, the resident again experienced coffee ground emesis. There was no evidence that the resident's representative/ family was notified of the change in condition. During an interview on 7-14-18 at 6:15 PM, Licensed Practical Nurse (LPN) #2 reviewed the Progress Notes and was unable to locate family notification. Review of weight records on 7-14-18 at 6:05 PM revealed that the resident's weight was recorded as 200 pounds (#) on 1-1-18, 1-8-18 , and 1-10-18. On 1/26/18, the weight was recorded at 185#, a 15# loss (7.5%) with no evidence of a reweight. On 2-10-18, her/his weight was again at 200#, but the weight following it on 2-14-18 was 180#. This would be equivalent to a 20# loss or 10% of her/his body weight in one month. The resident continued to lose weight and on 4-13-18, the resident weighed 178#, a loss of 22# in 3 months (11%). On 7-10-18, the resident's weight was recorded as 174#, a loss of 26# in 6 months (13%). Further review of the Progress Notes revealed no evidence that the physician had been made aware of these significant weight losses. The physician visited on 4-17-18, 5-14-18, 6-11-18, and 7-9-18 and there was no notation made by her/him in the record of the weight loss. During an interview on 7-14-18 at 6:15 PM, LPN #2 reviewed the Progress Notes and was unable to locate physician notification of weight loss. The facility admitted Resident #140 on 5-12-17 with [DIAGNOSES REDACTED]. Record review on 7/10/18 at 4:48 PM revealed physician's orders [REDACTED].>130 Monday, Wednesday, Friday-rotate sites. Review of the Vitals Report with Licensed Practical Nurse (LPN) #2 on 7/12/18 at 10:12 AM revealed recorded blood pressures of 190/80 on 6-22-18, 190/98 on 7-4-18, and 198/88 on 7-10-18. Review of Progress Notes revealed no evidence of physician notification. Review of falls revealed a notification guideline on the facility Event Form which stated that the physician should be notified of systolic pressures >180 or < 90. During the interview, LPN #2 confirmed this policy. S/he reviewed the Progress Notes but was unable to locate physician notification. When asked if the facility had any other guidance/policy for physician notification related to vital sign parameters, no information was provided. Continued review on 7/10/18 at 4:48 PM revealed physician's orders [REDACTED]. Review of the 1-18 through 7-18 weight records on 7-9-18 at 2:47 PM revealed that the resident sustained [REDACTED].# to 126.7#. From the 1-31-18 weight of 140.8#, the resident lost down to 132# on 2-7-18 (8.8# or 6.3%),127.6 on 2-9-18, 120# on 4-4-18 (14.8# from 1-18 average or 10.9 % in 3 months). Following hospitalization from [DATE] to 5-15-18, the resident weighed 122.3#. The resident was hospitalized again from 5-18-18 to 5-23-18, and on 5-30-18, s/he weighed 110.9# (11.4# loss in less than 1 month). S/he had a gastrostomy (G-) tube inserted during a 6-3-18 to 6-8-18 hospitalization . During an interview on 7/12/18 at 10:12 AM, Licensed Practical Nurse (LPN) #2 stated that the weights were recorded from [MEDICAL TREATMENT]. Review of Progress Notes on 7/11/18 at 12:21 PM revealed no evidence of physician notification at the time the weight loss was identified. physician progress notes [REDACTED]. The Progress Note for the physician visit on 4-18-18 did document a 10# weight loss but no changes in interventions were ordered. During an interview on 7/12/18 at 3:16 PM, LPN #2 stated that they only entered the weights into the record on [MEDICAL TREATMENT] residents and that the physician and dietitian at the [MEDICAL TREATMENT] center reviewed the weights and let them know about any changes needed. When asked about specific interventions in place, LPN #2 stated that the resident had been on [MEDICATION NAME] Renal three times daily with meals since 1-18 on up until she (he) got the G(astrostomy)-tube. The facility admitted Resident #50 on 2-16-15 with [DIAGNOSES REDACTED]. Review of weights on 7/10/18 at 10:43 AM revealed that the resident weighed weighed 90# on 1-10-18 and 2-19-18. S/he weighed 92# on 3-2-18, 4-9-18, and 5-7-18. On 6-12-18, the resident sustained [REDACTED].#, equivalent to 6.5%. By 6-21-18, s/he was down to 84#, having lost 8.7% of her/his body weight since 5-7-18. Record review on 7/13/18 at 2:49 PM revealed that physician's orders [REDACTED]. On 6-20-18, the physician increased the Med Pass 4 ounces to 4 times daily. Review of Progress Notes revealed no evidence of physician notification of the weight loss until the order was written for the increase in Med Pass on 6-20-18. The last physician's Progress Note in the record was dated 6-11-18. During an interview on 7/13/18 at 3:37 PM, LPN #2 verified the above information. The facility policy entitled Notification of Changes (2017) states: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: . 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health .status. This may include: a. life-threatening conditions, or b. clinical complications. Based on full and/or limited record reviews, interviews and review of facility policies, it was determined on 7/12/18 at 6:49 PM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility in the following areas. The Director of Nurses (DON) was notified of this determination at 7:05 PM. The deficiencies involved were as follows: F580 Notification of Significant Changes - as it relates to 6 of 9 reviewed residents for nutrition. The residents experienced weight loss which the physician was not notified of. F657 Revised Care Plans - as it relates to 3 of 9 reviewed residents for nutrition. The residents experienced weight loss with no updating of their care plan to address this. F684 Quality of Care - Enteral Feedings - As it relates to 2 residents with gastrostomy feedings with failure to monitor the amount to ensure maintenance of nutrition parameters F692 Nutrition/Hydration Status Maintenance- as it relates to the facility's failure to follow-up on a significant weight loss and put interventions in place to address the issue. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable that included the following: Nutrition IJ The Medical Director was notified of residents' weight loss. He has evaluated the residents that he is the attending physician (3 of the 5 identified) for weight loss, possible cause, review of P[NAME] & all interventions to be implemented to control/correct weight loss. Attending physician for other 2 residents was also notified and will be in the facility to evaluate the residents. Residents identified during the survey with weight loss have been weighed again. This weight will be used to begin weight monitoring & weight loss program. Weight monitoring and weight loss program has been established. An LPN has been appointed as Team Leader for this program. Two Certified Nursing Assistants have also been appointed to this committee and will be in charge of weighing all residents in the facility as deemed necessary- monthly, weekly, etc. All responsibilities of the Weight Monitoring & Weight Loss Program will be determined and in place by Monday (MONTH) 16, (YEAR). The DON will work closely with the Weight Monitoring & Weight Loss Program Team Leader and will evaluate the program weekly at a minimum of 4 weeks and then monthly and PRN. The Administrator will check weight books weekly and communicate with the Weight Loss & Weight Monitoring Team Leader at least weekly. The Registered Dietitian will assess the residents identified during the survey with weight loss (MONTH) 13, (YEAR). Weights for the last year for the residents identified during the survey for weight loss have been documented/evaluated. Percentage of weight loss monthly, quarterly and annually will be calculated by the RD and Dietary Manager in AM on (MONTH) 13, (YEAR). All residents in the facility will be assessed for weight loss by Monday (MONTH) 16, (YEAR) by the Weight Monitoring & Weight Loss program Team Leader. Care Plans for these residents will be reviewed (MONTH) 16, (YEAR). The RD will assess these residents by (MONTH) 17, (YEAR). All residents with a 5% weight loss or more in 30 days or 10% in 180 days or 7.5% in 90 days will be weighed weekly times four weeks and then monthly thereafter if weights are stable. All new admissions will be weighed on admission and then daily times 2 days times 4 2weeks and then monthly, if no weight issues are identified. Readmissions will be weighed on readmission then weekly times four weeks then monthly if no weight issues are identified. The method of weighing will be documented for each weight and will be consistent, unless otherwise noted and explained for each resident. The attending physician and the responsible party will be notified of meal refusal and weight loss as defined by regulations. On (MONTH) 18, (YEAR) Team members began the Extended survey process. They reviewed the A[NAME] and ensured implementation by interviewing staff, reviewing resident clinical records, reviewed staff inservice sheets and made facility observations. That morning the team removed the Immediate Jeopardy and lowered the scope and severity of F580, F657, F684 and F692 to an E. The Team concluded the facility had removed the immediacy by implementing their A[NAME] on 7/17/18.

Based on record review and interviews, the facility failed to ensure that the care plans were reviewed and updated to reflect the current status of 3 of 9 sampled residents reviewed for nutrition and 1 of 11 sampled residents reviewed for activities. The care plans for Residents #50, #116, and #140 were not updated to reflect weight loss with viable goals and interventions implemented in a timely manner to address the weight loss. The care plan for activities was not reviewed and revised as needed for Resident #71 following hospitalization . In addition, a dietary representative did not participate in the development of the care plan for 1 of 2 sampled residents reviewed for care planning (Resident #63). The findings included: The facility admitted Resident #50 on 2-16-15 with [DIAGNOSES REDACTED]. Review of weights on 7/10/18 at 10:43 AM revealed that the resident weighed 90# on 1-10-18 and 2-19-18. S/he weighed 92# on 3-2-18, 4-9-18, and 5-7-18. On 6-12-18, the resident sustained [REDACTED].#, equivalent to 6.5%. No reweight was documented as having been completed. By 6-21-18, Resident #50 was down to 84#, having lost 8.7% of her/his body weight since 5-7-18. Record review on 7/13/18 at 2:49 PM revealed that physician's orders [REDACTED]. On 9-11-17, there was an order to Encourage fluids Q (every) shift. On 6-20-18, the physician increased the Med Pass to 4 times daily. Review of Progress Notes on 7/13/18 at 3:08 PM revealed that, following the documented weight loss on 6-12-18, the Weight Committee did not meet until 6-22-18, 10 days later, at which time notes acknowledged the 6-12-18 weight loss based on the reweight done on 6- 21-18 (9 days after the loss was noted), and the increase in Med Pass. During an interview on 7/13/18 at 1:24 PM, Licensed Practical Nurse (LPN) #2 stated that Certified Nursing Assistant (CNA) #2 was responsible for obtaining weights. During an interview on 7/13/18 at 1:39 PM, CNA #2 stated, I give copies of the weights to Care Plans, the DON (Director of Nursing), dietary gets 2 copies, the Charge Nurse Supervisor when we had one, and the hall nurse gets a copy of the weights. Review of the Care Plan on 7/13/18 at 7:29 PM revealed that it had not been updated with the significant weight loss, including implementing interventions to address the weight loss. During an interview on 7/14/18 at 9:20 AM, Minimum Data Set (MDS) Coordinator #1 verified that the Care Plan had not been updated with the weight loss until 7-13-18. S/he stated s/he had not been aware of it until that time. The facility admitted Resident #116 on 2/16/15 with [DIAGNOSES REDACTED]. Review of weight records on 7-14-18 at 6:05 PM revealed that the resident's weight was recorded as 200 pounds (#) on 1-1-18, 1-8-18 , and 1-10-18. On 1/26/18, the weight was recorded at 185#, a 15# loss (7.5%) in less than 1 month with no evidence of a reweight. On 2-10-18, her/his weight was again at 200#, but the weight following it on 2-14-18 was 180#. This would be equivalent to a 20# loss or 10% of her/his body weight in one month. Again, there was no evidence of a reweight until 5 days later when a weight of 188# was recorded. The resident continued to lose weight and on 4-13-18, the resident weighed 178#, a loss of 22# in 3 months (11%). On 5-7-18, the last recorded weight prior to completion of the MDS, the resident weighed 177# , a 23# loss (11.5%) in less than 6 months. On 7-10-18, the resident's weight was recorded as 174#, a loss of 26# in 6 months (13%). Weekly weights were not ordered or completed. Review of the Care Plan on 7/14/18 at 5:40 PM revealed that it had not been updated with the weight losses including implementation of interventions to address the weight loss. During an interview on 7-15-18 at 10 AM, MDS Coordinator #1 reviewed the Care Plan and confirmed that it had not been updated with the weight loss. The facility admitted Resident #140 on 5-12-17 with [DIAGNOSES REDACTED]. Record review on 7/10/18 at 4:48 PM revealed physician's orders [REDACTED]. Review of the 1-18 through 7-18 weight records on 7-9-18 at 2:47 PM revealed that the resident sustained [REDACTED].# to 126.7#. From the 1-31-18 weight of 140.8#, the resident lost down to 132# on 2-7-18 (8.8# or 6.3%),127.6 on 2-9-18, and 120# on 4-4-18 (14.8# from 1-18 average or 10.9 % in 3 months). Following hospitalization from [DATE] to 5-15-18, the resident weighed 122.3#. The resident was hospitalized again from 5-18-18 to 5-23-18 and 5-24-18 to 5-29-18 and on 5-30-18, s/he weighed 110.9# (11.4# loss in less than 1 month). The resident finally had a gastrostomy (G-) tube inserted during a 6-3-18 to 6-8-18 hospitalization after refusal of intake. When asked about specific interventions in place, LPN #2 stated that the resident had been on [MEDICATION NAME] Renal three times daily with meals since 1-18 on up until she (he) got the G(astrostomy)-tube. Review of the Care Plan on 7/14/18 at 12:44 PM revealed that it had not been updated with the weight losses including implementation of specific interventions to address the weight loss. During an interview on 7/14/18 at 11:44 AM, MDS Coordinator #1 confirmed the Care Plan had not been updated in 4-18 or 5-18 to address weight loss. S/he stated it had not been updated until 7-13-18 when notified of the weight loss. The facility admitted Resident #71 with [DIAGNOSES REDACTED]. Review of the 4/1/2018 through 7/11/2018 activity attendance sheets for Resident #71 on 7/12/2018 at approximately 1:35 PM revealed very few activities offered to Resident #71. Review of the Plan of Care on 7/12/2018 at approximately 1:45 PM revealed a goal which stated, Resident will participate in facility activities as ability will allow. Further review revealed approaches: Greet, invite, and encourage activity participation. Assess for leisure interests and abilities. Offer any needed materials for self-directed activities. Transport to and from activities as needed. No activity interests were listed on the plan of care for Resident #71. At this time the activity director confirmed the findings. A care plan was not implemented for activities of interest for Resident #71. After a discharge to the hospital and readmission the Plan of Care was not reviewed and revised to include activities of interest. The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Review of the 5/2/2018 Care Plan Conference Sheet for Resident #63 on 7/15/2018 at approximately 9:15 AM revealed that the CDM (Certified Dietary Manager) did not have input into developing the Plan of Care for Resident #63. An interview on 7/15/2018 at approximately 10:30 AM with the CDM confirmed that s/he had not been included in the developing of the plan of care for Resident #63.

Based on record reviews, and interviews, the facility failed to ensure enteral feeding calculations were correct per shift for Resident #90 and Resident #56 resulting in significant weight loss for 2 of 3 residents reviewed with enteral feedings. The facility further failed to ensure neurological checks were completed as ordered by the physician for Resident #71, 1 of 5 residents reviewed for accidents. The findings included: The facility admitted Resident #71 with [DIAGNOSES REDACTED]. Review on 7/12/2018 at approximately 2:15 AM of an incident report dated 7/8/2018 at 11:45 AM for Resident #71 stated, Resident was transferring self to wheel chair and fell to the floor. Resident obtained a skin tear to left lower arm, skin tear and bruise to left knee, and redness noted to left side of abdomen. Moderate amount of blood noted to skin tear on left lower arm and left knee. Cleansed areas with normal saline, applied Triple Antibiotic Ointment and a dry dressing. No active bleeding at this time. Notified the physician and the responsible party. Resident complained of pain to left knee. Administered Tylenol as ordered. The physician order [REDACTED]. Review on 7/12/2018 at approximately 2:30 PM of the form titled Neurological/Vital Sign Check, revealed Resident #71 was only monitored for 24 hours after the fall and not for the physician ordered 72 hours. During an interview on 7/12/2018 at approximately 3:00 PM, the DON stated, We usually do not do 72 hour neurological checks, but since this was the physician's orders [REDACTED]. The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Syndrome, Cognitive Communication Deficit, Anxiety Disorder, [MEDICAL CONDITIONS], Oxygen Dependency, Urinary System Disorder, [MEDICAL CONDITION], Gastrostomy with Tube Feeding, Depression and Hypertension. Review on 7/13/2018 at approximately 9:42 AM of the physician orders [REDACTED]. The intake of tube feeding and the water flush was to be calculated at 11:00 AM and 11:00 PM. Review on 7/13/2018 at approximately 9:50 AM of the medical record for Resident #56 revealed the calculations of tube feeding from 11:00 PM to 11:00 AM for a 12 hour period is calculated at 540 mls and for an eight hour period is calculated at 360 mls for a total of 900 mls for a twenty hour period. The calculations of water for a 12 hour period is 600 mls and the calculations for an eight hour period is 400 mls for a total of 1000 mls for a twenty hour period. Review on 7/13/2018 at approximately 10:20 AM of the medication administration history from 4/1/2018 through 7/12/2018 revealed an excessive amount of days each month where the calculations did not add up to the 900 mls of tube feeding and the 1000 mls of water as ordered by the physician to ensure no weight loss. Review of the 3/2/2018 to 7/2/2018 weights on 7/13/2018 at approximately 10:45 AM revealed that Resident #56 had a 12.72 % weight loss over a 4 month period. On 3/2/2018, Resident #56 weighed 195 pounds and on 7/2/2018 s/he weighed 173 pounds. During an interview on 7/13/2018 at approximately 11:40 AM, Licensed Practical Nurse (LPN) #3 confirmed that the total amounts should have been closer to the 900 mls of tube feeding for the 20 hour period and the water should have been closer to the 1000 mls in a 20 hour period. During an interview on 7/13/2018 at approximately 2:56 PM, the DON (Director of Nursing) was informed of the tube feeding and the water flush totals for the period from 4/1/2018 through 7/12/2018 and the fact that neither the feeding nor the flushes matched the physician ordered amounts of intake from feeding pump. The DON was also informed of the weight loss. The facility admitted Resident #90 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], and Atheroscleoris of Native Arteries of Extremities with Gangrene, Gastrostomy Status. The Physician order [REDACTED].#90, noted a Physician order [REDACTED]. Tube Feeding: [MEDICATION NAME] Renal 55 cc(cubic centimeters)/h(ou)r with a 45 cc/hr H2O Flush per Peg Daily. Start at 8:00 PM, Turn off at 12:00 Noon. Special Instructions: Start Tube Feeding at 8 PM. Off at Noon. An additional Physician order [REDACTED]. Another Physician order [REDACTED]. Review of the Medication Administration History did not show a daily total amount for the amount of feeding or water flushes received at the end of each day. The Care Plan for Resident #90 stated: Problem Start Date: 5/24/2018, Potential for complications related to tube feeding. A. Fluid Overload, B. Dehydrating, AC. Aspiration , Approach Monitor tube feeding and flush tube as ordered. During an interview with the DON on 07/16/18 at 10:28 AM regarding the total amount of tube feeding and flushes that Resident #90 received each day, s/he verified that the MAR indicated [REDACTED]. The facility policy and procedure titled, Appropriate Use of Feeding Tubes, Copyright (YEAR), states, Policy: It is a policy of this facility to ensure that a resident maintains acceptable parameters of nutritional and hydration status, 10. The amount of tube feeding is to be determined by the Physician with Dietitian Input. The nurses record the amount of tube feeding given every shift, on the Medication Administration Record [REDACTED] Based on full and/or limited record reviews, interviews and review of facility policies, it was determined on 7/12/18 at 6:49 PM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility in the following areas. The Director of Nurses (DON) was notified of this determination at 7:05 PM. The deficiencies involved were as follows: F580 Notification of Significant Changes - as it relates to 6 of 9 reviewed residents for nutrition. The residents experienced weight loss which the physician was not notified of. F657 Revised Care Plans - as it relates to 3 of 9 reviewed residents for nutrition. The residents experienced weight loss with no updating of their care plan to address this. F684 Quality of Care - Enteral Feedings - As it relates to 2 residents with gastrostomy feedings with failure to monitor the amount to ensure maintenance of nutrition parameters F692 Nutrition/Hydration Status Maintenance- as it relates to the facility's failure to follow-up on a significant weight loss and put interventions in place to address the issue. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable that included the following: Nutrition IJ The Medical Director was notified of residents' weight loss. He has evaluated the residents that he is the attending physician (3 of the 5 identified) for weight loss, possible cause, review of P[NAME] & all interventions to be implemented to control/correct weight loss. Attending physician for other 2 residents was also notified and will be in the facility to evaluate the residents. Residents identified during the survey with weight loss have been weighed again. This weight will be used to begin weight monitoring & weight loss program. Weight monitoring and weight loss program has been established. An LPN has been appointed as Team Leader for this program. Two Certified Nursing Assistants have also been appointed to this committee and will be in charge of weighing all residents in the facility as deemed necessary- monthly, weekly, etc. All responsibilities of the Weight Monitoring & Weight Loss Program will be determined and in place by Monday (MONTH) 16, (YEAR). The DON will work closely with the Weight Monitoring & Weight Loss Program Team Leader and will evaluate the program weekly at a minimum of 4 weeks and then monthly and PRN. The Administrator will check weight books weekly and communicate with the Weight Loss & Weight Monitoring Team Leader at least weekly. The Registered Dietitian will assess the residents identified during the survey with weight loss (MONTH) 13, (YEAR). Weights for the last year for the residents identified during the survey for weight loss have been documented/evaluated. Percentage of weight loss monthly, quarterly and annually will be calculated by the RD and Dietary Manager in AM on (MONTH) 13, (YEAR). All residents in the facility will be assessed for weight loss by Monday (MONTH) 16, (YEAR) by the Weight Monitoring & Weight Loss program Team Leader. Care Plans for these residents will be reviewed (MONTH) 16, (YEAR). The RD will assess these residents by (MONTH) 17, (YEAR). All residents with a 5% weight loss or more in 30 days or 10% in 180 days or 7.5% in 90 days will be weighed weekly times four weeks and then monthly thereafter if weights are stable. All new admissions will be weighed on admission and then daily times 2 days times 4 2weeks and then monthly, if no weight issues are identified. Readmissions will be weighed on readmission then weekly times four weeks then monthly if no weight issues are identified. The method of weighing will be documented for each weight and will be consistent, unless otherwise noted and explained for each resident. The attending physician and the responsible party will be notified of meal refusal and weight loss as defined by regulations. On (MONTH) 18, (YEAR) Team members began the Extended survey process. They reviewed the A[NAME] and ensured implementation by interviewing staff, reviewing resident clinical records, reviewed staff inservice sheets and made facility observations. That morning the team removed the Immediate Jeopardy and lowered the scope and severity of F580, F657, F684 and F692 to an E. The Team concluded the facility had removed the immediacy by implementing their A[NAME] on 7/17/18.

Based on observations, interviews and review of facility policies titled Notification of Changes (2017), the facility failed to identify and address weight losses in a timely manner, notify the physician of significant weight losses, follow physician's orders [REDACTED]. The mechanically altered diet ordered by the physician was not followed for Resident #18. The facility failed to identify significant weight losses for Residents #50, #116, #128, #56, #87 and #140, notify the physician in a timely manner, assess causal factors, monitor meal intake and weights according to facility policy, and implement timely interventions. Resident #140 suffered a decline in ability to perform activities of daily living in conjunction with the weight loss. The findings included: The facility admitted Resident #18 on 9/28/17 with [DIAGNOSES REDACTED]. Review of Physicians Orders on 7-12-18 revealed that Resident #18 was to be on a mechanical soft diet with chopped meats. During a dining observation on 7-9-18 at 12:27 PM, Resident #18 was observed in the main dining room feeding her/himself. S/he pushed all of her/his one-inch square-cut meat to the side and did not eat it. Review of the diet card noted the resident was on a mechanical soft diet with chopped meats. Review of the extended menus supplied by the facility during the Entrance Conference revealed that the resident should have received ground encrusted pork loin. On 7/11/18 at 12:31 PM, resident dining was again observed. For the main entree, the resident received what appeared to be pulled chicken in 2.5-3 long stringy pieces which s/he again did not consume. Review of the extended menus revealed that the resident should have received ground fried chicken. During an interview on 7-13-18 at 2:30 PM, in the presence of Licensed Practical Nurse (LPN) #2, when asked about why s/he was on the mechanically altered diet, Resident #18 stated s/he had no teeth on top. I guess that's why. During an interview on 7/11/18 at 9:40 AM, the Speech Therapist (ST) was asked about diet textures, specifically the mechanical soft diet. ST stated s/he most often orders ground meat as the translation for chopped meat because chopped can be very subjective. S/he further stated s/he never discharges anyone on a chopped meat diet and that typically the texture residents are sent home on is the ground meat. During an interview on 7/11/18 at approximately 10 AM, when advised how the resident's meat was served on 7-9-18, the Certified Dietary Manager (CDM) stated, That is the way it comes. At that time, s/he provided a copy of the Diet for Dysphagia Mechanically Altered Diet. The Diet and Nutrition Care Manual for Mechanically altered diet states: Foods Allowed: Meats, poultry and fish must be tender and moist, ground or chopped to less than 1/4 inch cubes as tolerated. During an interview on 7/16/18 at 11:15 AM, the CDM Dietary Consultant stated s/he was not aware of any difficulty with chewing or swallowing for the resident to be on mechanical soft diet. The facility admitted Resident #50 on 2-16-15 with [DIAGNOSES REDACTED]. Record review and interviews revealed that the facility failed to identify significant weight loss and notify the physician in a timely manner, assess causal factors, monitor the resident according to facility policy, and implement timely interventions. Observations throughout the survey revealed that, when out of bed, the resident was constantly aimlessly propelling her/himself in a wheelchair in the hallway. At lunch time on 7-11-18 and 7-13-18, staff had to refocus and return her/him to the table multiple times with little or no intake noted. During the survey, on 7-11-18, a Mighty Shake was ordered 3 times daily with meals. On 7/13/18 at 1:35 PM, the surveyor observed Resident #50 leave the table without eating. Certified Nursing Assistant (CNA) #2 confirmed this and stated that the resident had not received a shake from the kitchen for lunch. She (he) got Med Pass. Review of weights on 7/10/18 at 10:43 AM revealed that the resident weighed 90# on 1-10-18 and 2-19-18. S/he weighed 92# on 3-2-18, 4-9-18, and 5-7-18. On 6-12-18, the resident sustained [REDACTED].#, equivalent to 6.5%. No reweight was documented as having been completed. By 6-21-18, Resident #50 was down to 84#, having lost 8.7% of her/his body weight since 5-7-18. Record review on 7/13/18 at 2:49 PM revealed that physician's orders [REDACTED]. On 9-11-17, there was an order to Encourage fluids Q (every) shift. On 6-20-18, the physician increased the Med Pass to 4 times daily. Monthly orders included to weigh the resident only on a monthly basis. Review of Progress Notes on 7/13/18 at 3:08 PM revealed no evidence of physician notification of the weight loss until the order was written for the increase in Med Pass on 6-20-18. The last Physician's Progress Note in the record was dated 6-11-18. Continued review of Progress Notes revealed that, following the documented weight loss on 6-12-18, the Weight Committee did not meet until 6-22-18, 10 days later, at which time notes acknowledged the 6-12-18 weight loss based on the reweight done on 6- 21-18 (9 days after the loss was noted), and the increase in Med Pass. The Weight Committee met on 6-26-18 to review weight loss, but no additional information was noted other than a plan to reweigh the resident. On 7-5-18, the Committee met to review weights. Resident has shown a weight loss in 31 days. Will reweigh resident and review next week. Continue P[NAME] (plan of care). The next weight recorded was on 7-12-18. There was no assessment by the Registered Dietitian (RD) following the weight loss and the CDM Dietary Consultant did not see the resident until 7-9-18. During an interview on 7/13/18 at 1:24 PM, Licensed Practical Nurse (LPN) #2 stated that Certified Nursing Assistant (CNA) #2 was responsible for obtaining weights. During an interview on 7/13/18 at 1:39 PM, CNA #2 stated s/he did not participate in the Weight Committee. The CNA stated, I give copies of the weights to Care Plans, the DON (Director of Nursing), dietary gets 2 copies, the Charge Nurse Supervisor when we had one, and the hall nurse gets a copy of the weights. S/he stated s/he did not routinely get requests for reweights. If needed, the nurse or CNA assigned to the resident would do them. Review of the 6/18 and 7/18 Medication Administration Records (MARs) on 7-13-18 revealed no references to the amount of Med Pass dietary supplement or liquids had been consumed. During an interview on 7/13/18 at 3:26 PM, LPN #2 reviewed of the Point of Care History report with the surveyor. S/he confirmed that intake percentages of supplements given with meals were not recorded. The intake records were also reviewed and it was noted that the recording of meal and fluid intake was inconsistent. From 6-1-18 through 7-10-18, out of a total of 40 days, 28 days were incomplete. During interviews on 7/13/18 at 1:20 PM and 3:37 PM, LPN #2 verified the significant weight loss, physician's orders [REDACTED]. S/he verified that weekly weights were neither ordered nor documented. S/he confirmed that the last physician visit had been 6-11-18, prior to the documented weight loss and there was no evidence that the physician had been notified of the loss until 6-22-18. The nurse reviewed the Weight Committee Progress Notes and verified that reweighs were not recorded as recommended. Review of the 4-23-18 Quarterly and 1-21-18 Annual Minimum Data Set (MDS) Assessments on 7/13/18 at 5:42 PM revealed that the resident was coded as being on a therapeutic diet during the look-back period. Review of the Care Plan on 7/13/18 at 7:29 PM revealed that it had not been updated with the significant weight loss, including implementing interventions to address the weight loss. During an interview on 7/14/18 at 9:20 AM, MDS Coordinator #1 verified that the assessment was not accurate related to diet type and that the Care Plan had not been updated with the weight loss until 7-13-18. S/he stated s/he had not been aware of it until that time. The facility admitted Resident #116 on 2/16/15 with [DIAGNOSES REDACTED]. Record review and interviews revealed that the facility failed to identify significant weight loss and notify the physician in a timely manner, assess causal factors, monitor the resident according to facility policy, and implement timely interventions. Review of weight records on 7-14-18 at 6:05 PM revealed that the resident's weight was recorded as 200 pounds (#) on 1-1-18, 1-8-18 , and 1-10-18. On 1/26/18, the weight was recorded at 185#, a 15# loss (7.5%) in less than 1 month with no evidence of a reweight. On 2-10-18, her/his weight was again at 200#, but the weight following it on 2-14-18 was 180#. This would be equivalent to a 20# loss or 10% of her/his body weight in one month. Again, there was no evidence of a reweight until 5 days later when a weight of 188# was recorded. The resident continued to lose weight and on 4-13-18, the resident weighed 178#, a loss of 22# in 3 months (11%). On 5-7-18, the last recorded weight prior to completion of the MDS, the resident weighed 177# , a 23# loss (11.5%) in less than 6 months. On 7-10-18, the resident's weight was recorded as 174#, a loss of 26# in 6 months (13%). Weekly weights were not ordered or completed. Review of the Progress Notes revealed no evidence that the physician had been made aware of the significant weight losses. The physician visited on 4-17-18, 5-14-18, 6-11-18, and 7-9-18 but there was no notation made by her/him in the record regarding the weight loss. Further review revealed no evidence of assessment by the RD or CDM following the weight loss. During an interview on 7-14-18 at 6:15 PM, LPN #2 reviewed the Progress Notes and was unable to locate physician notification of weight loss. Record review on 7/14/18 at 3:32 PM revealed 12-29-17 physician's orders [REDACTED]. Review of the 4/18 through 7/18 MARs and supplemental documentation revealed no evidence that the magic cup had been provided as ordered and the amount consumed. Review of the meal intake records revealed that the recording of meal and fluid intake was inconsistent. From 6-1-18 through 7-10-18, out of a total of 40 days, 20 days were incomplete. During an interview on 7/13/18 at approximately 4 PM, LPN #2 reviewed the MatrixCare meal and fluid intake reports and verified that were not recorded consistently. Review of the 6-5-18 Quarterly Minimum Data Set (MDS) Assessment on 07/14/18 at 4:03 PM revealed that the resident was coded as not having sustained a significant weight loss. Review of the Care Plan on 7/14/18 at 5:40 PM revealed that it had not been updated with the weight losses including implementation of interventions to address the weight loss. During an interview on 7-15-18 at 10 AM, MDS Coordinator #1 reviewed the MDS and Care Plan. S/he stated that dietary was responsible for Section K of the MDS but in their absence verified that the weight loss of greater than 10% over 6 months had not been coded. The nurse also confirmed that the Care Plan had not been updated with the weight loss. The facility admitted Resident #140 on 5-12-17 with [DIAGNOSES REDACTED]. Record review and interviews revealed that the facility failed to identify significant weight losses, notify the physician in a timely manner, assess causal factors, monitor meal intake and weights according to facility policy, and implement timely interventions. Record review on 7/10/18 at 4:48 PM revealed physician's orders [REDACTED]. Review of the 1-18 through 7-18 weight records on 7-9-18 at 2:47 PM revealed that the resident sustained [REDACTED].# to 126.7#. From the 1-31-18 weight of 140.8#, the resident lost down to 132# on 2-7-18 (8.8# or 6.3%),127.6 on 2-9-18, and 120# on 4-4-18 (14.8# from 1-18 average or 10.9 % in 3 months). Following hospitalization from [DATE] to 5-15-18, the resident weighed 122.3#. The resident was hospitalized again from 5-18-18 to 5-23-18 and 5-24-18 to 5-29-18 and on 5-30-18, s/he weighed 110.9# (11.4# loss in less than 1 month). The resident finally had a gastrostomy (G-) tube inserted during a 6-3-18 to 6-8-18 hospitalization after refusal of intake. During an interview on 7/11/18 at 1:06 PM, LPN #2 reviewed the recorded weights and confirmed the losses as noted. S/he stated that the facility staff only entered the weights into the record on [MEDICAL TREATMENT] residents and that the physician and dietitian at the [MEDICAL TREATMENT] center reviewed the weights and let them know about any changes needed. S/he reviewed the [MEDICAL TREATMENT] communication sheets for the dates surrounding when significant weight losses were identified and found no directions regarding changes in the resident's plan of care. While reviewing the weight losses, the LPN verified the documented weights and admitted that s/he had been comparing pre- and post-[MEDICAL TREATMENT] weights and had not been comparing month to month weights. When asked about specific interventions in place, LPN #2 stated that the resident had been on [MEDICATION NAME] Renal three times daily with meals since 1-18 on up until she (he) got the G(astrostomy)-tube. When asked about documentation of supplemental intake on 7-14-18, s/he provided a copy of the MatrixCare report on intake of supplements for the period of 4-1-18 to 7-14-18. Only 7 intake percentages were documented. Review of the 4-18 MAR indicated [REDACTED]. The 5-18 MAR indicated [REDACTED]. Review of the 4-18 and 5-18 MatrixCare reports on meal intake with LPN #2 on 7-11-18 at 1:06 PM revealed that meal intake percentages were not consistently monitored. Twenty-two (22) of 30 days were incomplete for 4-18 and 19 days of 21 were incomplete for 5-18. Review of physician's orders [REDACTED]. physician progress notes [REDACTED].#. The 2-26-18 and 3-15-18 Physician's Progress Notes indicated knowledge of a 1 to 4 pound loss but no changes in orders/interventions were noted. The Progress Note for the physician visit on 4-18-18 (following the documented loss on 4-4-18) did note a 10# weight loss but no changes in interventions were ordered/implemented. Continued review of Progress Notes revealed there were no dietary notes or Weight Committee entries in the record from 1-26-18 until after the resident had the [DEVICE] placed. There was no RD assessment since the noted weight losses and the CDM Dietary Consultant did not see the resident until 5-17-18. On that date, s/he noted significant weight losses and intake of 0-25 %, but no recommendations were made to address the weight loss or poor intake. On 6-1-18, the CDM Dietary Consultant noted a weight loss of 21.4 % since 11-17 and 13.1% since 4-30-18. S/he recommended an appetite stimulant and/or feeding tube placement as the resident had had a nasogastric tube during her/his last hospitalization . There was no evidence in the record that the physician was notified of the recommendation regarding the appetite stimulant. During an interview on 7/14/18 at 11:15 AM, the CDM Dietary Consultant verified the weight loss as noted on 5-17-18. S/he stated the resident had been on Prostat and [MEDICATION NAME] Renal at meal times and verified s/he had made no recommendations. The CDM stated s/he looked at [MEDICAL TREATMENT] flowsheets and the weight had been fairly consistent & within range. The CDM Consultant verified that the resident did have a loss of 12.1% since November. S/he did not notify the physician and s/he was unable to find evidence of physician notification in the record. During an interview on 7/14/18 at 11:59 AM, the Registered Nurse Consultant reviewed the medical record and stated that the resident had not been seen by the RD since at least 1-1-18. Review of the 2-19-18 Quarterly through the 6-25-18 14 Day Minimum Data Set Assessments on 7/14/18 at 10:19 AM revealed that a SCSA had not been completed though the following changes had been noted: (1) A [DEVICE] was inserted during the 6-3-18 hospitalization . (2) The resident went from independent with locomotion to requiring extensive assistance. (3) The resident declined from requiring limited to extensive assistance with dressing. (4) The resident declined from requiring limited to total assistance with eating. (5) The resident declined from requiring supervision only with hygiene to requiring extensive assistance. (6) The resident declined from being frequently incontinent to always being incontinent. [MEDICAL TREATMENT] During an interview on 7/14/18 at 1:56 PM, MDS Coordinator #1 verified that no SCSA had been completed. Review of the 5-24-18 and 6-3-18 Discharge MDS assessments revealed that Section K indicated the resident had sustained no significant weight loss, though the resident was being admitted to the hospital on 6-3-18 with the intent to place a gastostomy tube due to resident refusal to eat. During an interview on 7/14/18 at 1:56 PM, MDS Coordinator #1 verified the data entries and that the resident had sustained a significant weight loss of greater than 5% in 1 month from 127.82# to 108#. Review of the Care Plan on 7/14/18 at 12:44 PM revealed that it had not been updated with the weight losses including implementation of specific interventions to address the weight loss. During an interview on 7/14/18 at 11:44 AM, MDS Coordinator #1 confirmed the Care Plan had not been updated in 4-18 or 5-18 to address weight loss. S/he stated it had been updated on 7-13-18. Review of the facility's weight policy revealed it was not followed related to physician notification of weight loss, meal consumption documentation, weekly weights, nutritional assessment, and consultation with the RD or CDM. The policy did not include the procedure to follow if weights were discrepant or to verify actual weight loss. The facility policy entitled Notification of Changes (2017) states: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: . 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health .status. This may include: a. life-threatening conditions, or b. clinical complications. The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Review of the medical record for Resident #128 on 7/9/2018 at approximately 1:20 PM revealed a weight of 170 pounds on 12/1/2017 and 134 pounds on 6/8/2018, indicating a 21 percent weight loss in 6 months. No documentation could be found in the medical record for Resident #128 that the physician and the responsible party were notified of a significant weight loss and refusal of AWC Prostat over an extended period. Review on 7/11/2018 at approximately 10:11 AM of the MAR (Medication Administration Record) for Resident #128 from 4/1/2018 through 7/11/2018 revealed the supplement AWC Prostat to improve weight loss was ordered by the physician on 9/12/2017. The MAR indicated [REDACTED]. Resident #128 also refused the AWC Prostat on 4/21/2018, 4/22, 4/25, 4/26 and 4/30. Further review on 7/11/2018 at approximately 10:11 AM of the MAR indicated [REDACTED]. Resident #128 also refused the dietary supplement AWC Prostat, used to improve weight loss, on 5/21/2018, 5/22, 5/23, 5/24, 5/25, 5/27, 5/28 and 5/31/2018. Review on 7/11/2018 at approximately 10:15 AM of the MAR for Resident #128 dated 6/1/2018 through 6/30/2018 revealed that Resident #128 had refused the AWC Prostat on 6/1/2018, 6/2, 6/3, 6/4, 6/5, 6/6, 6/8, 6/9, 6/11, 6/12, 6/13, 6/14 6/15, and 6/16. Resident #128 continued to refuse the AWC Prostat Supplement on 6/17/2018, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/24, 6/25, 6/26, 6/28, 6/29 and 6/30/2018. Review on 7/11/2018 at approximately 10:15 AM of the MAR for Resident #128 dated 7/1/2018 through 7/11/2018 revealed that Resident #12 continued to refuse the AWC Prostat on 7/1/2018, 7/2, 7/4, 7/5, 7/6, 7/7 and 7/9/2018. No documentation could be found in the medical record for Resident #128 to ensure the physician had been notified of the significant weight loss and the refusal of the dietary supplement AWC Prostat ordered to aide in preventing weight loss or that Resident #128 continued to lose weight. No documentation could be found in the medical record for Resident #128 to ensure the personal representative for Resident #128 was notified of the weight loss. Review on 7/11/2018 at approximately 2:38 PM of the Nurses Notes dated from 4/1/2018 through 7/11/2018 for Resident #128 revealed no documentation to ensure the physician was notified of the refusal of the supplement AWC Prostat, or that Resident #128 continued to lose weight. During an interview on 7/11/2018 at approximately 2:45 PM with LPN (Licensed Practical Nurse) #5 confirmed there was not documentation in the medical record for Resident #128 to ensure the physician was notified of a significant weight loss or that Resident #128 was constantly refusing the AWC Prostat, for weight loss. LPN #5 went on to say, I told the physician and he/she is aware but I did not document that anywhere in the medical record. LPN #5 did not comment on the fact that no documentation could be found to ensure the personal representative for Resident #128 had been notified of a significant weight loss. During an interview on 7/11/2018 at approximately 2:48 PM with the Dietary Consultant, he/she stated the he/she was not aware of Resident #128 refusing the AWC Prostat. The Dietary Consultant also stated the Registered Dietician would be in the facility the next day and would review Resident #128's weight loss and medical record. During an interview on 7/11/2018 at approximately 3:10 PM with the facility's Certified Dietary Manager, he/she stated, I am not aware of a weight loss for Resident #128. The Certified Dietary Manager also stated, he/she was not aware that the resident was refusing the AWC Prostat supplement. The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Review on 7/9/2018 at approximately 1:20 PM of the medical record for Resident #128 revealed a a weight of 170 pounds on 12/1/2017. Further review on 7/9/2018 at approximately 1:25 PM of the medical record for Resident #128 revealed a weight of 134 pounds on 6/8/2018. indicating a 21 percent weight loss in 6 months. No documentation could be found in the medical record for Resident #128 to ensure the physician and the responsible party were notified of a significant weight loss and refusal of AWC Prostat over an extended period. Review on 7/11/2018 at approximately 10:11 AM of the MAR (Medication Administration Record) for Resident #128 from 4/1/2018 through 7/11/2018 revealed the supplement AWC Prostat to improve weight loss was ordered by the physician on 9/12/2017. The MAR indicated [REDACTED]. Resident #128 also refused the AWC Prostat on 4/21/2018, 4/22, 4/25, 4/26 and 4/30. Further review on 7/11/2018 at approximately 10:11 AM of the MAR indicated [REDACTED]. Resident #128 also refused the dietary supplement AWC Prostat, used to improve weight loss, on 5/21/2018, 5/22, 5/23, 5/24, 5/25, 5/27, 5/28 and 5/31/2018. Review on 7/11/2018 at approximately 10:15 AM of the MAR for Resident #128 dated 6/1/2018 through 6/30/2018 revealed that Resident #128 had refused the AWC Prostat on 6/1/2018, 6/2, 6/3, 6/4, 6/5, 6/6, 6/8, 6/9, 6/11, 6/12, 6/13, 6/14 6/15, and 6/16. Resident #128 continued to refuse the AWC Prostat Supplement on 6/17/2018, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/24, 6/25, 6/26, 6/28, 6/29 and 6/30/2018. Review on 7/11/2018 at approximately 10:15 AM of the MAR for Resident #128 dated 7/1/2018 through 7/11/2018 revealed that Resident #12 continued to refuse the AWC Prostat on 7/1/2018, 7/2, 7/4, 7/5, 7/6, 7/7 and 7/9/2018. No documentation could be found in the medical record for Resident #128 to ensure the physician had been notified of the significant weight loss and the refusal of the dietary supplement AWC Prostat ordered to aide in preventing weight loss or that Resident #128 continued to lose weight. No documentation could be found in the medical record for Resident #128 to ensure the personal representative for Resident #128 was notified of the weight loss. Review on 7/11/2018 at approximately 2:38 PM of the Nurses Notes dated from 4/1/2018 through 7/11/2018 for Resident #128 revealed no documentation to ensure the physician was notified of the refusal of the supplement AWC Prostat, or that Resident #128 continued to lose weight. During an interview on 7/11/2018 at approximately 2:45 PM with LPN (Licensed Practical Nurse) #5 confirmed there was not documentation in the medical record for Resident #128 to ensure the physician was notified of a significant weight loss or that Resident #128 was constantly refusing the AWC Prostat, for weight loss. LPN #5 went on to say, I told the physician and he/she is aware but I did not document that anywhere in the medical record. LPN #5 did not comment on the fact that no documentation could be found to ensure the personal representative for Resident #128 had been notified of a significant weight loss. During an interview on 7/11/2018 at approximately 2:48 PM with the Dietary Consultant, he/she stated the he/she was not aware of Resident #128 refusing the AWC Prostat. The Dietary Consultant also stated the Registered Dietician would be in the facility the next day and would review Resident #128's weight loss and medical record. During an interview on 7/11/2018 at approximately 3:10 PM with the facility's Certified Dietary Manager, he/she stated, I am not aware of a weight loss for Resident #128. The Certified Dietary Manager also stated, he/she was not aware that the resident was refusing the AWC Prostat supplement. Review on 7/12/2018 at approximately 10:02 AM of the Dietary Progress Notes for Resident #128 from 9/1/2017 through 7/12/2018 did not include a list of the food the resident likes and or dislikes. The note from the RD (Registered Dietician) states, the estimated protein is at 1.4 grams/kilogram of body weight is 78 grams. Resident is receiving a Multi Vitamin with Iron and Fortified Juice with meals to provide and additional 600 calories and 18 grams of protein. Resident also receives No Added Sugar ice cream with lunch and supper. His/her appetite is between 1 to 50 percent. The resident feeds self meals with tray set up. Continue to encourage intake at meals and offer assistance as needed. The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Syndrome, Cognitive Communication Deficit, Anxiety Disorder, [MEDICAL CONDITIONS], Oxygen Dependency, Urinary System Disorder, [MEDICAL CONDITION], Gastrostomy with Tube Feeding, Depression and Hypertension. Review of the 4/1/2018 through 7/12/2018 physician orders [REDACTED]. The intake of tube feeding and the water flush was to be calculated at 11:00 AM and 11:00 PM. Review on 7/13/2018 at approximately 9:50 AM of the medical record for Resident #56 revealed the calculations of tube feeding from 11:00 PM to 11:00 AM for a 12 hour period is calculated at 540 mls and for an eight hour period is calculated at 360 mls for a total of 900 mls for a twenty hour period. The calculations of water for a 12 hour period is 600 mls and the calculations for an eight hour period is 400 mls for a total of 1000 mls for a twenty hour period. Review on 7/13/2018 at approximately 10:20 AM of the medication administration history from 4/1/2018 through 7/12/2018 revealed an excessive amount of days each month where the calculations did not add up to the 900 mls of tube feeding and the 1000 mls of water as ordered by the physician to ensure no weight loss. Review on 7/13/2018 at approximately 10:45 AM of the weights for Resident #56 from 3/2/2018 to 7/2/2018, a 4 month period, Resident #56 had a 12.72% weight loss. On 3/2/2018 Resident #56 weighed 195 pounds and on 7/2/2018 Resident #56 weighed 173 pounds. No documentation could be found in the medical record for Resident #56 to address the weight loss or to ensure no further weight loss. During an interview on 7/13/2018 at approximately 11:40 AM with LPN (Licensed Practical Nurse) #3 confirmed that the total amounts should have been closer to the 900 mls of tube feeding for the 20 hour period and the water should have been closer to the 1000 mls in a 20 hour period. During an interview on 7/13/2018 at approximately 2:56 PM the DON (Director of Nursing) was informed of the tube feeding and the water flushes totals for the period from 4/1/2018 through 7/12/2018 and the fact that neither the feeding nor the flushes matched the physician ordered amounts of intake from feeding pump. The DON was also informed of the weight loss with no interventions to prevent further weight loss. Review on 7/13/2018 at approximately 4:10 PM of the facility policy titled, Weight Monitoring, states under Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents ma (TRUNCATED)

Based on observations, record reviews and interviews, the facility failed to provide ongoing services to maintain, improve, and/or prevent a decline in range of motion (ROM) for 3 of 5 sampled residents reviewed for limited ROM. physician's orders [REDACTED].#50 and #116 and there was no evidence of ongoing provision of restorative services to prevent further decline in ROM. Resident #56 was admitted without contractures and there was no evidence of provision of services to prevent decline in functional mobility resulting in the development of contractures of the left ankle and bilateral knees. The findings included: The facility admitted Resident #50 on 2-16-15 with [DIAGNOSES REDACTED]. Observation of Resident #50 on 7-9-18 at 12:33 PM revealed that the resident had contractures of the left arm and hand with no splint or positioning devices in place. Subsequent observations (on 7-9-18 at 3:46 PM; on 7-10-18 at 9:33 AM; on 7-11-18 at 9:50 AM, 10:11 AM, 1:12 PM, 03:45 PM; on 7/12/18 at 8:49 AM, and on 7/13/18 at 1:35 PM) also revealed no splinting or positioning devices in place for the left upper extremity. Review of the 1-21-18 Annual and 4-23-18 Quarterly Minimum Data Set (MDS) Assessments on 7/13/18 at 5:42 PM revealed that functional ROM was impaired on the upper and lower extremities on one side. No ROM or splint assistance was documented as having been provided in the look-back period. Record review on 7/13/18 at 2:49 PM revealed a 4-19-17 physician's orders [REDACTED]. Review of the Treatment Administration Record revealed that the palm guard was documented as refused daily. During an interview on 7/13/18 at 3:37 PM, Licensed Practical Nurse (LPN) #2 supplied copies of the Point of Care History for provision of ROM and verified that the service was not documented as completed as ordered. S/he stated that the resident may be refusing but confirmed that it was not documented as such. The Point of Care History report for 7/18 revealed that ROM was only documented as having been completed 4 times. Review of the Care Plan on 7/13/18 at 7:29 PM revealed a problem with contractures of the left upper arm, hand, and ankle. Approaches included Range of motion with AM and PM care as tolerated and Palm guard to left hand at all times except for bathing or laundering. The Care Plan did not specifically address resident refusal of the palm guard. The facility admitted Resident #116 on 2/16/15 with [DIAGNOSES REDACTED]. Observations on 7-9-18 at 12:52 PM and throughout the survey revealed Resident #116 with apparent contractures of extremities. Record review on 7/14/18 at 3:32 PM revealed physician's orders [REDACTED]. Review of the 6-5-18 Quarterly and 9-2-17 Annual MDS Assessments on 7/14/18 at 4:03 PM revealed that functional ROM was impaired on the one upper and both lower extremities. No restorative ROM or splint assistance was documented as having been provided in the look-back period. Review of the Care Plan on 7/14/18 at 5:40 PM revealed a problem with contractures of bilateral knees. Approaches included Range of motion with AM and PM care as tolerated. During an interview on 7/14/18 at 2:30 PM, LPN #2 supplied copies of the Point of Care History for provision of ROM and verified that the service was not consistently documented as completed as ordered. Review of the Point of Care History report on 7/14/18 at 8:31 PM revealed that ROM was not provided as ordered 32 times in 4/18, 31 times in 5/18, and 33 times in 6/18. The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Syndrome, Cognitive Communication Deficit, Anxiety Disorder, [MEDICAL CONDITIONS], Oxygen Dependency, Urinary System Disorder, [MEDICAL CONDITION], Gastrostomy with Tube Feeding, Depression and Hypertension. Review of the Plan of Care for Resident #56 on 7/14/2018 at approximately 9:25 AM revealed a problem which read, Resident has a contracture of left ankle and bilateral knees. No documentation in the medical record supported this problem which was noted with a start date of 5/2/2018 by the Care Plan Coordinator. Review of the 10/24/2017 and 4/26/2018 Minimum Data Set (MDS) assessments on 7/14/2018 at approximately 8:56 AM made no mention of contractures of the left ankle and bilateral knees. During an interview on 7/14/2018 at approximately 11:10 AM, the MDS/Care Plan Coordinator stated that Physical Therapy had provided a list of residents with contractures and Resident #56 was on the list. No documentation could be found in the medical record to ensure the contractures had been addressed by physical therapy or restorative nursing. The physical therapists were unavailable for interview. An interview and observation on 7/14/2018 at approximately 4:23 PM with Licensed Practical Nurse (LPN) #4 confirmed the contractures of the left ankle and bilateral knees for Resident #56. \