Every finding on record at Timber Point Healthcare Center

A.Based on observation, interview, and record review the facility failed to ensure the medication storage rooms were kept clean and in good repair. These failures have the potential to affect all 67 residents residing in the facility.B. Based on observation, interview, and record review the facility failed to ensure opened multi-dose injectable medications were labeled with the date when opened and a multi-dose insulin pen was disposed of after the expiration date and ensure medications were stored in their original packaging until administered for three of five residents (R6, R37 and R61) reviewed for storage and labeling of medications in a sample of 33. Findings include: A. The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated [DATE] and signed by V1 (Administrator), documents 67 residents reside within the facility. The facility's Medication Room Cleaning Policy dated 6/26 documents, To maintain a clean, safe, and sanitary medication room that supports infection prevention, medication integrity, and resident safety. The medication room shall be kept clean, organized, and free of clutter at all times. Cleaning shall be performed routinely and documented according to facility procedures. Procedure: Clean and disinfect medication preparation surfaces daily and when visibly soiled. Clean sinks, handles, counters, and other high-touch surfaces daily. Sweep and mop floors daily using an approved disinfectant. Clean shelves, medication carts, and the medication refrigerator weekly or as needed. Staff shall documented completion of required cleaning tasks on the medication room cleaning log. On [DATE] at 9:27 AM the south medication room sink faucet was covered in a thick white and brown crusty substance. The south medication room floor had scattered debris. V5 (RN/Registered Nurse) stated, The facility has two medication rooms that store all the residents' medications. I am not sure when the south medication room was last cleaned. V5 verified the sink faucet was covered in a thick white and brown crusty substance and the floor had scattered debris. On [DATE] at 10:30 AM the north medication room sink was covered in a thick white crusty substance. Two bottom cabinets were missing the doors and resident medications were stored within this cabinet. Inside this cabinet was a buildup of cobwebs, dust, and dirt. V4 (RN) stated, This medication room needs cleaned. On [DATE] at 9:00 AM V22 (Housekeeper) stated, I was not aware that housekeeping was supposed to clean the medication rooms until today. We (housekeepers) never had a cleaning log for the medication rooms until today. B. The facility's Storage of Medications dated [DATE], documents Storage of Medications. Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Expiration Dating: B. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. E. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (Note: the best stickers to affix contain both a date opened and expirations notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. The facility's Insulin Storage Recommendations, undated, documents Cartridges/pens/prefilled syringes: Humalog Pen: opened-room temperature-28 days. Lantus Pen: opened- room temperature- 28 days. On [DATE] at 9:25 AM V4/RN (Registered Nurse) opened the top drawer to North medication cart. In this drawer two clear medication cups were observed with loose pills. On the outside of one of the clear medication cups it was labeled Tramadol 50mg (milligrams) and Tylenol 650mg with three loose pills in the clear medication cup. On the second clear medication cup it had labeled Calcium 500mg and Hydroxyzine 25mg. V4 stated she had prepared R61's Tramadol 50mg and Tylenol 650 mg and R61 refused the medication, so V4 stuck the clear container with the loose pills in the medication carts top drawer. V4 then stated she had popped out R37's Calcium 500mg and Hydroxyzine 25 mg ahead of time and that the pills were not due to be given until 1:00 PM. V4 verified she should not have pre-popped R37's 1:00 PM medications and the pills should have remained in their original packaging until it was time to give R37's medication. V4 also verified 61's medications should have been double locked (due to the tramadol being a narcotic) and in the medications original packaging or destroyed if R61 refused her medications. On top of V4's medication cart was a container of resident's insulin injector pens. R6's Insulin Lispro 100units/ml was opened, 1/4 full, and dated [DATE]. R6's Lantus 100units/ml was opened, ¾ full, and undated. V4 verified R6 insulin lispro was expired a few days ago and should have been discarded and R6's Lantus should have been labeled and dated when it was opened and was not. On [DATE] at 2:20 PM, V2/Director of Nursing stated that when a resident refuses medication, the nurse must wait a short period and try again. Continued refusal requires immediate disposal of the medication instead of storing it loosely in the medication cart. Furthermore, pre-popping medications are entirely unacceptable. V2 stated, Nurses are also required to use the insulin dating guide to maintain accurate expiration dates and dispose of expired insulin correctly.

Based on observation, interview, and record review, the facility failed to ensure food service sanitation and infection control practices were maintained by failing to label opened food items stored in refrigerators and dry storage racks with the date an item was opened, ensuring staff wore hair restraints while working in the kitchen, and failing to maintain proper chlorine sanitizer levels in the dishwashing machine. These failures have the potential to affect all 66 residents residing in the facility. Findings Include:The facility's Labeling and Dating Foods policy, no date, documents, Policy, prepared and packaged foods will be labeled and rotated to decrease the risk of food-borne illnesses, provide the highest quality product for the residents, and minimize waste. Refrigerator Stores, foods prepared on the premises to be held cold will be labeled with the date of preparation and time as required for cooling purposes. Potentially hazardous foods that contain a Sell by date, Use by date, or Expiration date, such as cottage cheese, milk, soft cheese, non-cured deli meats, egg products will be labelled with the date it is opened and with a discard date of Best Used By or Expiration Date or Use by Date or recommended maximum storage whichever is first. Commercially processed foods that have been prepared and packaged by a food processing place will be labeled with the date it is opened. This will be discarded by the 3rd day or by the Best Used By date. Many bulk condiments are shelf-stable if unopened and should be refrigerated after opening. When refrigerated, label with the date it is opened and with a discard date of Best Used By date or recommended maximum storage, whichever is first.The facility's Personal Hygiene policy, not dated, documents, Policy, all food handlers will report to work in uniform and practice good hygiene. Purpose: to reduce the risk of food-borne illness and Food Handler hazards. Procedure, 4. Hairnets, bonnets, or other hair-coverings must be worn at all times in the kitchen. The hair-covering must completely cover the hair.The facility's Dishwashing Procedure policy, not dated, documents, Policy, to prevent food-borne illness, all dishware will be cleaned in the dish machine. Policy specifications, 2, check chemicals to determine an adequate supply. If not, replace. Before dishes are washed, the sanitation temperature or level of chemical sanitizer in the dish machine should be tested with the correct test strip. For chemical sanitizing machines, dip the appropriate chemical sanitizer test strip in the water on the train board nearest to the opening at the clean end of the dish machine. Dip for 1 second only. The test strip should turn the appropriate color to indicate 50 ppm (parts per million) for chlorine. If the test strip does not turn the correct color, the above procedure should be repeated. If the test strip does not turn the appropriate color on the second attempt, the dish machine should be evaluated for proper functioning before the dishes are washed.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/14/26 and signed by V1 (Administrator), documents 67 residents reside within the facility.On 6/14/2026 at 9:30 AM, during the kitchen tour, upon entering the kitchen, V8 (Dietary Dish Washer) and V9 (Cook) did not have hairnets on. During kitchen tour one of the kitchen refrigerators had 3 small saran wrapped packages of yellow square cheese opened and not dated, 1 bag of mozzarella cheese opened and not dated, 2 packs of bologna opened and not dated, a large square of butter opened and not dated, a container of liquid egg thawing and not labeled or dated, and a condiment squeeze container containing a purple substance not labeled or dated.On 6/14/2026 at 9:45 AM, V8 (Dietary Dish Washer) tested the facility's high-temp dish washer using Chlorine Test Paper after the wash cycle. Test strip read 10ppm (parts per million).On 6/14/2026 at 10:00 AM, V7 (Dietary Manager) confirmed all items in the fridge should always have a label and an open date. V7 also confirmed dish washer chlorine test strip should be at 50ppm.

Based on observation, interview, and record review the facility failed to ensure a call light was in reach for four of 17 residents (R8, R48, R50, R71) reviewed for call lights in a sample of 33. Findings include:The facility's Answering Call Light Policy, dated 8/2008, documents The purpose of this procedure is to respond to the resident's requests and needs. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 1. R8's Care Plan, dated 3/30/26, documents (R8) requires assistance of 1-2 staff with ADLs (Activities of Daily Living) related to (R8's) diagnosis of sepsis, increased weakness, decreased mobility, lack of coordination, and abnormal gait and mobility. (R8's) level of function fluctuates throughout the day due to recent Urinary Tract Infection and Sepsis. Fluctuating cognitive function impacting (R8's) level of function and staff assistance needed to [NAME] her ADL/functional ability needs. On 6/14/26 at 10:00 AM, R8 was lying in her bed. R8's call light was observed out of R8's reach clipped to R8's privacy curtain. R8 stated, I like it when my call light is within reach just in case I need something. On 6/14/26 at 10:15 AM, V11/CNA (Certified Nursing Assistant) verified at this time R8's call light was clipped to R8's privacy curtain on the left side of R8's bed and R8 was unable to reach the call light. V11 stated she was unsure why it was clipped to the privacy curtain and stated it should be next to R8 within R8's reach. 2. R50's Care Plan, dated 6/2/25 documents (R50) requires supervision to substantial assist of 1-2 staff with her ADLs related to her diagnosis of COPD (Chronic Obstructive Pulmonary Disease), Cerebral Infarction, Cognitive Communication Deficit, Depression, Insomnia, Hemiplegia Left Side, PVD (Peripheral Vascular Disease), Respiratory Failure, Hypertension, Heart Disease, History of Falls, GERD (Gastro-Esophageal Reflux Disease), Schizophrenia, OSA (Obstructive Sleep Apnea), Psoriasis, Atherosclerotic Heard Disease. Fluctuating cognitive function and behaviors issues such as refusing cares at times impacts (R50's) level of function and staff assistance needed to meet (R50's) ADL needs. On 6/14/26 at 9:55 AM, R50 was lying in bed. R50's call light was lying on the right side of R50's bed on the floor out of R50's reach. R50 stated the staff always try to clip the call light to R50's bed, but it will not stay clipped to R50's bed because the call light is too heavy. R50 stated, they (facility staff) have tried to fix it, but it's not fixed yet. I would like the call light next to me. On 6/14/26 at 10:15 AM, V11/CNA verified R50's call light was on the floor. V11 stated they got new clips for the call lights and if they put the clip on the call light wrong, the call light will still fall from the bed because it will not stay clipped on the bed. V11 verified all resident call lights should be within reach. 3. R71's Care Plan, dated 5/15/26, documents (R71) has impaired ability to complete ADLs independently related to recent hospitalization for pneumonia, and candidal stomatitis. (R71) requires assistance of 2 staff for all ADLs. On 6/14/26 at 10:09 AM, R71 was sitting in his recliner in his room. R71's call light was lying on R71's bed behind R71's recliner out of R71's reach. R71 stated he would like his call light in reach because he cannot get up on his own. R71 stated they leave his call light out of reach a lot. On 6/14/26 at 10:17AM V11/CNA verified R71's call light was on the bed behind R71's recliner and out of R71's reach. V11 stated, (R71) should not be left without a call light within reach as (R71) requires assistance to transfer and with (R71's) care. 4. R48's computerized Medical Record documents that R48 is an [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Cervical Disorder at C4-C5 Level with Myelopathy, Vascular Dementia, Epilepsy, Dysphagia, and Difficulty in Walking. R48's MDS (Minimum Data Set) assessment dated [DATE] documents that R48 requires substantial assistance for toileting, hygiene, bed mobility, and partial assist for transfers. R48's Care Plan, dated 5/18/26, documents that R48 is at risk for falls. The same Care Plan documents Keep call light within reach. On 6/14/26 at 9:43 AM, R48 was lying in her bed. R48's call light was on the floor out of R48's reach. R48 stated, I do use my call light, but I don't know where it is. On 6/14/26 at 9:45 AM, V28 Registered Nurse/RN verified at this time R48's call light was on the floor and R48 was unable to reach the call light. V28 stated the call light should be within reach of V28 at all times.

Based on record review and interview, the facility failed to accurately code the MDS (Minimum Data Set) Assessments for three of 17 residents (R3, R44, and R50) reviewed for MDS Accuracy in the sample of 33. Findings include: The facility's Comprehensive Assessment/MDS Policy undated documents Policy: It is the policy of this facility to perform a comprehensive, accurate, standardized, reproducible assessment of each residence status following admission, quarterly thereafter and annually in order to obtain information vital to the development of the resident's plan of care. In addition to facility approved departmental assessment forms, the assessment shall be summarized using a standardized federally and state approved uniform data set. Standards: 11. All assigned disciplines shall participate in the completion of the MDS assessment form and shall verify accuracy and completion of each respective section by indicating the letter of the section, adding their signature and dating. The scope of each discipline's assessment is defined by professional practice or industry guidelines. The CMS's (Center's for Medicaid and Medicare) RAI Version 3.0 Manual dated 10/25 documents, Coding Instructions: Code 1, yes if PASARR (Pre-admission Screening and Resident Review) Level II screening determined that the resident has a serious mental illness and/or ID/DD (Intellectual Disability/Developmental Disability) or related condition. 1.R44's PASARR Level II Outcome dated 6/20/25 documents, You meet PASARR inclusion criteria for Serious Mental Illness with the diagnoses of Schizoaffective Disorder, Posttraumatic and Stress Disorder. Your day-to-day life has been impacted by your illness. R44's MDS (Minimum Data Set) Assessments Section A1500 Preadmission Screening and Resident Reviews dated 11/21/25 and 2/19/26 are coded as R44 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. On 6/15/26 at 10:30 AM V23 (MDS Coordinator) verified R44's MDS Section A1500 Assessments dated 11/21/25 and 2/19/26 were inaccurately coded and should have been coded as R44 does have a serious mental illness according to R44's state level II PASARR dated 6/20/25. 2. R50's PASARR Level II Outcome dated 6/23/25 documents, You meet PASARR inclusion criteria for Serious Mental Illness with the diagnoses of Schizoaffective Disorder. Your day-to-day life has been impacted by your illness. R50's MDS Assessments Section A1500 Preadmission Screening and Resident Reviews dated 3/3/26 are coded as R50 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. On 6/15/26 at 10:30 AM V23 (MDS Coordinator) verified R50's MDS Section A1500 Assessments dated 3/3/26 were inaccurately coded and should have been coded as R50 does have a serious mental illness according to R50's state level II PASARR dated 6/23/25. 3. R3's state level PASARR level II dated 6/13/2026 documents R3 has Depression and Schizophrenia. R3's MDS Assessments Section A1500 Preadmission Screening and Resident Reviews dated 9/2/25 and 6/13/26 are coded as R3 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. On 6/15/26 at 11:34 AM V23 (MDS Coordinator) verified R3's MDS Section A1500 Assessments dated 9/2/2025 and 12/11/2025 were inaccurately coded and should have been coded as R3 does have a serious mental illness according to R3's state level II PASARR dated 6/13/2025.

Based on observation, interview, and record review the facility failed to ensure residents' fingernails were kept clean and trimmed for two of 17 residents (R28 and R71) reviewed for ADLs (Activities of Daily Living) in the sample of 33.Findings include: The facility's Nail Care Guidelines dated 2/23 documents Guidelines: Nail care includes routine cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 1.R71's MDS (Minimum Data Set) Assessment, dated 5/21/26, documents R71 requires substantial/maximal assistance for personal hygiene. R71's current Care Plan documents R71 requires staff assist with R71's ADL's including bathing, dressing, grooming, transfers, and mobility as required. On 6/14/2026 at 10:09 AM, R71 was sitting in his recliner. All R71's fingernails were long, jagged, with dark brown matter underneath the nails. R71 stated he wants his fingernails trimmed and cleaned and the staff have not done it since R71 was admitted to the facility. On 6/14/36 at 10:17AM, V11/CNA (Certified Nursing Assistant) verified R71's nails were long, jagged, and had black matter under all fingernails and needed cleaned and clipped. V11 stated fingernails should be trimmed and clean with at least each shower and as needed, but if the resident is diabetic, V11 does not believe they can trim anyone's fingernails. R28's MDS (Minimum Data Set) dated 3/13/26 documents R28 is dependent on staff for personal hygiene. R28's current Care Plan documents R28 is dependent on staff for personal hygiene. On 6/14/2026 at 9:52 AM all R28's fingernails were long, jagged, and had brown debris underneath. R28 stated, My fingernails haven't been clipped in a couple of weeks. On 6/14/26 at 10:40 AM V6 (CNA/Certified Nursing Assistant) stated, We only clip the residents' fingernails whenever they ask. V6 confirmed R28's fingernails were long, jagged, and dirty and needed to be clipped.

Based on interview and record review the facility failed to identify a pressure ulcer, failed to document physician notification and treatment orders, and failed to document a pressure ulcer assessment for one of two residents (R69) reviewed for pressure ulcers in the sample of 33. Findings include:The Pressure/Skin Breakdown policy dated 1/2026 documents 2. The nurse shall assess and document/report the following: a. Full assessment of skin condition including but not limited to location, stage or partial/full thickness, length, width and depth, presence of exudates or necrotic tissue. 7. The physician will authorize pertinent orders related to wound treatments, including pressure redistribution surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc. (Etcetera), and application of topical agents. R69's computerized Medical Record documents that R69 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Fibromyalgia, Diabetes Mellitus, Morbid Obesity, Major Depressive Disorder, and Venous Insufficiency.R69's Wound Report created 6/15/26 at 12:36 PM, documents that R69 has a Pressure Ulcer to her Right Buttock Gluteal Fold that was identified on 6/14/26 at 12:36 PM. The wound measures 1 cm (centimeter) x (by) 1 cm x 0.2 cm.R69's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) of 15, indicating (cognitive intact) and R69 requires substantial assistance and partial assistance for transfers.R69's Care Plan documents that R69 is at risk for developing pressure ulcers. The intervention is to do a skin check weekly, provide incontinent care as needed, and report any signs of skin breakdown. R69's Physician Orders printed on 6/15/26 documents an order was added for Enhanced Barrier Precautions (EBP) to start on 6/14/26 however there was no treatment for R69's pressure ulcer.The Treatment Administration Record (TAR) for 6/1/26-6/30/26 printed on 6/15/26 at 12:40 PM, does not document a treatment order for R69's pressure ulcer.On 6/14/2026 at 10:02 AM, R69 stated that she has a wound on her buttock that is not being treated. R69 also stated that she has been trying to treat it herself for a couple of weeks. On 6/14/26 at 12:25 PM, V3/Wound Nurse stated that R69 does have a wound that is a stage two and measures 1 cm x 1 cm x 0.2 cm. The wound is on R69's Right Gluteal Fold. V3 also stated that the facility was not aware that V3 had a wound prior to this surveyor asking V3 to do a skin check on R69.On 6/15/26 at 1:00 PM, V3/Wound Nurse stated that she did not enter the order to the TAR for R69's pressure ulcer until today (6/15/26). V3 also stated that she did not document the pressure ulcer assessment or doctor notification in R69's medical record until 6/15/26.On 6/15/26 at 2:10 PM, V18/Regional Director of Operations stated that V3/Wound Nurse did not follow the facility policy and procedure for pressure ulcers by not documenting a wound assessment immediately, documenting physician notification, or documenting an order to treat R69's wound.

Based on observation, interview, and record review, the facility failed to ensure restorative services were provided for two (R4, R7) of two residents reviewed for range of motion in a sample of 33.Findings Include:The facility's Rehabilitative Nursing Care policy dated/revised April 2007 documents, policy statement, rehabilitative nursing care is provided for each resident admitted . Policy interpretation and implementation, 4. Rehabilitative nursing care is provided to residents who require it. Such a program includes but is not limited to: f. assisting residents with their routine range of motion exercises. 5, through the resident care plan, the goals of rehabilitative nursing care are reinforced in the Activities Program, Therapy Services, etc.On 6/14/2026 at 11:00 AM, R4 was in bed resting, dressed, and pleasant. R4 stated he never has any staff member coming in and helping him with range of motion or any exercises in bed for his arms or legs. R4 stated he would like to have someone do this, he feels his joints would feel better and not be sore and cramped.R4's Care Plan dated 6/16/2026 documents, R4 requires an active range of motion to upper extremities related to his diagnosis of osteoarthritis and diabetic neuropathy and requires a restorative AROM (active range of motion) program. This same document also states, Bed Mobility, R4 is limited in ability to move independently in the bed related to decreased mobility and weakness and requires a restorative bed mobility program.R4's last three months of Point of Care Restorative Nursing charting documents 39 occurrences where R4 was not provided ROM (range of motion) as per R4's plan of care.On 6/16/2026 at 1:00 PM, R7 was in bed, resting, watching television, and waiting to go to his dialysis treatment at another facility. R7 stated that no staff has done any range of motion exercises with him since he was admitted to the facility. R7 stated he would like someone to help him do a range of motion exercises to help his joints not get contracted due to his conditions and lack of strength to move like he used to.R7's Care Plan dated 6/16/2026 documents, R7 requires an active range of motion to upper extremities to upper extremities related to the diagnosis of paraplegia and requires a restorative AROM (active range of motion) program. This same document states, R7 is limited in functional status regarding the ability to transfer and dress self-related paraplegia status. R7 will perform 3 sets of 10 reps of AROM to upper extremities 6-7 days/week through next review.R7's last three months of Point of Care Restorative Nursing charting documents 48 occurrences where R7 was not provided ROM (range of motion) as directed in R7's plan of care. On 6/16/2026 at 1:00 PM, V23 (Medical Data Set Coordinator) provided R3 and R7's Point of Care Restorative Nursing charting documents and stated: boy, the Certified Nursing Assistants are really shining. V23 stated R4 and R7's restoratives should have been done as directed by R4 and R7's care plan.

Based on observation, interview, and record review the facility failed to follow physician orders when administering insulin for one of five residents (R6) reviewed for significant medication errors in a sample of 33.Findings include:The facility's Preventing and Detecting Adverse Consequences and Medication Errors, dated, [DATE], documents Procedures C. Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness, when the following conditions occur: 1) A clinically significant change in condition/status. 2. Addition or discontinuation of medications and/or non-pharmacologic interventions. 6. Medication error, example: wrong or expired medication. D. When any of the above occurs, the prescriber and/or staff rule out medication as a cause and document it in the resident's clinic record. 1) A review of medications potential causes of permanent significant change that requires a Significant Change of Status MDS (Minimum Data Set) Assessment should be performed within the required 14-day observation period. F. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the residents' safety and welfare. Significant is defined as: 1. Requiring medication discontinuation or dose modification. G. The attending physician is notified promptly of any significant error or adverse consequence. H. The physician's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. J. The following information is documented in an incident report and in the resident's clinical record: 8. Factual description of the error or adverse consequence. 9. Name of physician and time notified. 10. Physician's subsequent orders. 11. Resident's condition for 24 to 72 hours as directed.R6's Face Sheet documents R6 is a [AGE] year-old female who admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Heart Failure, Post-Traumatic Stress Disorder, Acute Kidney Failure, Type Two Diabetes Mellitus with Diabetic Neuropathy, Anxiety Disorder, and Depression.R6's Physician Orders documents a physician order for insulin lispro 100units/ml (milliliter) administer per sliding scale before meals and at bedtime with a start date of [DATE] and a discontinued date of [DATE].R6's Referral Form dated [DATE] and signed by V30/R6's Physician documents Discontinue Sliding Scale Insulin. Change Accu-Check to twice a day. Call if sugar is above 250.R6's MAR (Medication Administration Record), dated [DATE]st through [DATE]th, 2026, documents R6 received insulin lispro 100units/ml per sliding scale 12 times after the physician order was discontinued on [DATE].On [DATE] at 11:24 AM, V4/Registered Nurse checked R6's blood glucose level, which was 181 mg (milligrams)/dL (deciliter). V4 stated, (R6) receives insulin lispro per sliding scale, so based on (R6's) sliding scale, (R6) would need 5 units of lispro insulin. V4 then prepared and administered R6's insulin lispro into R6's right lower abdominal quadrant.On [DATE] at 9:32 AM, V2/Director of Nursing verified R6's insulin lispro was given 12 times after the order was discontinued on [DATE]. V2 stated, I would say it is a significant medication error because the medication was insulin, and it was given when it wasn't ordered.

Based on record review and interview the facility failed to provide physical therapy and occupational therapy services as ordered by the physician for two of two residents (R1 and R9) reviewed for therapy services in the sample of 33.Findings include:The facility's Specialized Rehabilitation Services policy dated 2/20/26 documents, It is the policy of this facility to provide specialized and supportive rehabilitative services either directly, or through arrangements with services provider. Services shall be provided in accordance with the assessment results, the written comprehensive plan of care, and in accordance with physician's orders. Rehabilitative services shall be provided to all residents whose physician has determined a need and the resident or their legal representative consents to the service. A qualified therapist shall evaluate the resident and develop a plan of care which includes the amount, frequency, and duration within three days of the physician's order. The qualified therapist will assess the resident and develop a plan of care including the type, amount, frequency and duration of treatment and measurement of progress no later than one working day of the physician's order. The therapist will provide the attending physician assessment results and obtain specific treatment orders prior to initiating service.1.R1's Progress Notes dated 5/26/26 at 4:59 AM and signed by V5 (Registered Nurse) documents, (V27/Physician) and students here today. Physical Therapy (PT) for declines ADLs (Activities of Daily Living).R1's Physician's Order dated 5/26/26 documents, Physical Therapy-declined ADLs.R1's Electronic Health Record does not include evidence of a Physical Therapy evaluation or treatment as ordered on 5/26/26.On 6/15/26 at 10:55 AM V25 (Occupational Therapist) stated, (R1) has not received a Physical Therapy evaluation or treatment for an ADL decline. We (therapy department) were not aware of (R1) having an order for PT until today.2.R9's Wound Assessment and Plan Treatment Order dated 5/26/26, 6/2/26, and 6/11/26 and signed by V24 (Advance Practice Registered Nurse/APRN) documents, Recommend PT/OT (Physical Therapy/Occupational Therapy) for offloading needs and appropriately fitted (pressure-relieving) cushion. Follow-up again this week.R9's Electronic Health Record does not include evidence of a PT/OT consult for offloading needs and a pressure-relieving cushion as ordered since 5/26/26.On 6/15/26 at 11:00 AM V26/Physical Therapist verified R9 has not had a Physical or Occupational Consultation done regarding offloading needs or evaluation of a pressure-relieving cushion. V26 stated, I was not aware (R9) had an order for a PT/OT consult for offloading or a pressure relieving cushion.On 6/15/26 at 11:10 AM V24 (APRN) stated, I have been asking for PT/OT to consult with (R9) for offloading needs and a properly fitting wheelchair cushion for around two weeks. I was not aware that it has not been done.

Based on observation, interview, and record review the facility failed to ensure the daily resident census and direct care staff posting was posted in an area accessible to residents and visitors. This failure has the potential to affect all 67 residents residing in the facility.Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/14/26 and signed by V1 (Administrator), documents 67 residents reside within the facility.The facility's Posting Direct Care Daily Staffing Numbers policy dated 08/08 documents, Our facility will post on a daily status for each shift, the number of nursing personnel responsible for providing direct care to residents. At the beginning of each shift facility shall post the nurse staffing data as required by state and federal regulations. The information should be clean and readable format. The information should be posted in a prominent place accessible to residents and visitors. Shit staffing information shall be recorded on the form provided by the facility's Administrator for each shift. The information recorded on the from shall include the name of the facility, the date for which the information is posted, the resident census at the beginning of the shift for which the information is posted, twenty-four hour shift schedule operated by the facility, the shift for which the information is posted, type and category of nursing staff working during that shift for each category and type of nursing staff, total number of license and non-licensed nursing staff working for the posted shift.On 6/14/26 at 10:30 AM a tour was done of the facility. During this tour the direct care staffing report was posted in the front lobby behind glass doors in a cabinet on the wall. The direct care staffing report was dated 6/9/26 through 6/15/26. This report did not document the census or direct care staffing hours for 6/10/26, 6/11/26, 6/12/26, 6/13/26, or 6/14/26.On 6/14/26 at 10:35 AM V1 (Administrator) verified the direct care staffing report including the direct care staffing and census was not posted within the facility from 6/10/26 through 6/14/26. V1 stated, I usually post the direct care staffing report and forgot.

Based on interview and record review the facility failed to accurately assess a resident's risk of abuse and failed to adequately supervise a resident to prevent resident-to-resident physical abuse for two of three residents (R2 and R3) reviewed for abuse in the sample of four. These findings resulted in R2 and R3 physically assaulting each other and R3 experiencing pain, ongoing increased anxiety, fear, and restlessness.Findings Include:The facility's Abuse and Retaliation Policy Prevention Program Policy dated 1/2026 documents, Policy: The facility affirms the right of our resident to be free from abuse, neglect, exploitation, retaliation, misappropriation or property, deprivation of goods and services by staff, or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation or property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident-sensitive and resident-secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation or property, deprivation of goods and services by staff, and mistreatment of residents. Abuse means any physical or mental injury, retaliation, or sexual assault inflicted upon a resident other than by accidental means. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means, and that requires medical attention. Physical abuse including hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Sexual abuse included, but is not limited to, sexual harassment, sexual coercion, or sexual assault including non-consensual or non-competent to consent sexual activity. Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches that would reduce the changes of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches regularly and update as necessary.1.R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 was severely cognitively impaired.R2's current Face Sheet documents R2 was a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Vascular Dementia with other behavioral disturbance, Schizoaffective Disorder, and Delusional Disorder. This same Face Sheet documents R2 expired on [DATE].R2's Progress Notes dated [DATE] at 11:26 PM and signed by V3 (Registered Nurse/RN) document, This nurse heard yelling from the middle hall. Upon entering room noted (R2) wheeling out of a female resident's room (R3's). (R3) stated that (R2) allegedly crawled on top of (R3) in her bed and punched (R3) on the right side of (R3's) face three times and then (R3) punched (R2) back and (R3) pushed (R2) off of (R3). This same note documents R2 was sent to the emergency room for psychiatric treatment due to increased agitation.R2's Hospital Emergency Department Notes dated [DATE] document, You (R2) were seen in the emergency department on [DATE] with the chief complaint of combative. EMS (Emergency Medical Services) report that (R2) allegedly hit another resident (R3) earlier today.2.R3's MDS assessment dated [DATE] documents R3 is cognitively intact and has no behaviors.R3's current Face Sheet documents R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Chronic Obstructive Pulmonary Disease, Hypertension, Generalized Anxiety Disorder, and Insomnia.R3's Progress Notes dated [DATE] at 11:38 PM and signed by V3 (RN) document, 10:00 PM (R3) states a male resident (R2) allegedly crawled on top of (R3) and punched (R3) three times to the right side of (R3's) face. (R3) assessed for injuries with no injuries noted. No redness noted to face. (R3) asked if she feels safe to stay in her room and she states she does feel safe. (R3) assured that we (facility staff) would shut her door and monitor the hallway. No complaints of pain or distress noted. Bed in low position with call light in reach. Will continue to monitor.R3's Physician's Progress Notes dated [DATE] and signed by V10 (Psychiatric Advanced Practical Nurse/APN) document, APN met with (R3) to discuss recent increase in anxiety symptoms. Today (R3) describes a triggering event in which another resident (R2) entered (R3's) room, confused, and attempted to climb on (R3's) bed. This triggered fear and anxiety in (R3). Describes thoughts that (R3) may have caused or contributed to this (happening). (R3) interested in therapy to further process. Continued leg bouncing and describes feeling restless.R3's Physician's Progress Notes dated [DATE] and signed by V10 document, APN met with (R3) to discuss recent increase in anxiety concerns. Last visit increased Prozac dosage. Discussed increase in Hydroxyzine. Today (R3) reports continued concerns with anxiety and worry. Reports feeling recent incident of other resident (R2) coming in (R3's) room and trying to get on (R3's) bed was somehow her fault. Discuss plans to further process this with therapist.R3's Physician's Orders dated [DATE] and signed by V10 (APN) document, Increase Prozac from 10 mg (milligrams) to 20 mg daily. Change Hydroxyzine 50 mg BID (twice daily) PRN (as needed) to BID scheduled.R3's Physician's Orders dated [DATE] and signed by V10 document, Change Hydroxyzine 50 mg BID to 25 mg TID (three times daily).R3's current Care Plan documents R3 has episodes of anxiety. This same Care Plan does not address R3's allegations of abuse or any interventions to address or protect R3 from R2 after R3 made allegations of resident-to-resident (R2 to R3) abuse on [DATE].R3's Abuse Risk Review dated [DATE] and signed by V8 (Social Service Director) documents R3 has not experienced or made allegations of any type of abuse (including resident-to-resident altercations) since the last review dated [DATE], therefore no further care plan recommendations were needed.On [DATE] at 9:30 AM R3 was lying in bed. R3 stated, A few months ago, (R2) kept trying to have a relationship with me and I was not interested. (R2) lived in the room next to me. One time (R2) came up to me in the hallway and tried to touch my breasts. I blocked (R2) from touching my breasts. I told the staff. I cannot recall who I reported this too. It was too long ago. (R2) would always follow me around in the hallways and I would have to tell (R2) Leave me alone! I am not a whore! I did not want any kind of relationship with (R2). One night ([DATE]) I had dozed off asleep and woke up to (R2) rubbing my stomach. (R2) had his knees on my bed (left side of the bed) and was leaning over me. I yelled for help and yelled at (R2) to, Get the h**l off of me and get out of my room! (R2) started punching me in the head. It hurt my head. I drew my fist back and hit (R2). When I hit (R2) it knocked (R2) backwards and (R2) got back into (R2's) wheelchair. I was stunned and traumatized. I felt like (R2) was going to try and sexually attack me. Since then, I have been afraid and scared of men. I sleep in my shorts and a jacket every night, so I do not expose myself and have had to start seeing a therapist to help me cope with what (R2) did to me. How would you feel if a man came into your room during the night and you were woken up to that? I was so scared.On [DATE] at 11:25 AM R4 was sitting in a wheelchair in her room. R4 stated, On ([DATE]) I was lying in bed and was woke up to (R3) yelling of help and no one came to help (R3). I saw (R2) crawling on top of (R3) in bed. (R3) was trying to get (R2) off of her. I saw (R3) hitting (R2) and (R2) finally got off (R2) and got back into his wheelchair. (R3) told me that (R2) hit her on the head. (R2) had tried to come into our room several nights before this. I was scared of (R2) and did not want (R2) to do anything to me. I told (V1/Administrator) everything that (R2) did to (R3) that night.On [DATE] at 12:30 PM V8 (Social Service Director) stated, I completed (R3's) abuse risk review on [DATE] and it is inaccurate. When I completed the abuse risk I did not know that (R3) had made an allegation of abuse on [DATE]. At this time V8 confirmed R3's care plan has not been updated with interventions to address R3's abuse allegations or with interventions to protect R3 from further abuse or address R3's increase in anxiety or fear.On [DATE] at 2:00 PM V10 (Psychiatric APN) stated I have been seeing (R3) monthly. (R3) was really upset and anxious about (R2) coming into her room. (R3) kept feeling like she was dressing wrong and giving (R2) the wrong impression. I told (R3) it was not her fault. I have had to increase (R3's) medications to try and treat (R3's) anxiety from this.On [DATE] at 8:20 PM V3 (RN) stated, On the night of [DATE] I heard (R3) screaming for help. I went to (R3's) room and (R2) was in his wheelchair in (R2's) room. (R3) told me (R2) got in bed with her and (R2) hit (R3) in the head. (R3) stated she hit (R3) back. (R2) was showing signs of increased mania that night and should not have been in (R3's) room. (R2) was capable of transferring himself from his wheelchair into (R3's) bed. (R3) would have no reason to lie. I sent (R2) to the emergency room immediately for treatment. It was not safe to leave (R2) in the building with the behaviors (R2) was having. I immediately called (V1/Administrator) and told (V1) that (R3) reported that (R2) got in bed with (R3) and hit (R3) in the head, and (R3) hit (R2) back.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse for two of three residents (R2 and R3) reviewed for abuse in the sample of four.Findings include:The facility's Abuse and Retaliation Policy Prevention Program Policy dated 1/2026 documents, Internal Investigation: Any incident or allegation involving abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation or resident property will result in an investigation. Investigation Procedures: The appointed investigation will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical record or other documents.R2's Progress Notes dated 1/2/26 at 11:26 PM and signed by V3 (Registered Nurse/RN) document, This nurse heard yelling from the middle hall. Upon entering room noted (R2) wheeling out of a female resident's room (R3's). (R3) stated that (R2) allegedly crawled on top of (R3) in her bed and punched (R3) on the right side of (R3's) face three times and then (R3) punched (R2) back and (R3) pushed (R2) off of (R3). This same note documents R2 was sent to the emergency room for psychiatric treatment due to increased agitation.R2's Hospital Emergency Department Notes dated 1/2/26 document, You (R2) were seen in the emergency department on 1/3/26 with the chief complaint of combative. EMS (Emergency Medical Services) report that (R2) allegedly hit another resident (R3) earlier today.R3's Progress Notes dated 1/2/26 at 11:38 PM and signed by V3 (RN) document, 10:00 PM (R3) states a male resident (R2) allegedly crawled on top of (R3) and punched (R3) three times to the right side of (R3's) face. (R3) assessed for injuries with no injuries noted. No redness noted to face. (R3) asked if she feels safe to stay in her room and she states she does feel safe. (R3) assured that we (facility staff) would shut her door and monitor the hallway. No complaints of pain or distress noted. Bed in low position with call light in reach. Will continue to monitor.R2 and R3's Abuse Investigations and Witness Statements dated 1/2/26 through 1/6/26 and signed by V1 (Administrator) only include two statements obtained from R4 and V3 (RN) and does not include documentation of R2 crawling on top of R3 and hitting R3, or R2 hitting R3 back.On 2/14/26 at 11:00 AM V1 (Administrator) stated, I am sorry. I did not know (R2) hit (R3) and (R3) hit (R2) back (on 1/2/26). I only have interviews from (V3) and (R4/R3's Roommate). I did not interview anyone else regarding the incident and did not know (V3) had charted that (R2) and (R3) had hit each other. At this time V1 verified the abuse investigation should have been more thorough and should have included more statements from other staff working and other residents. V1 also verified her abuse investigation did not identify that R2 and R3 had hit each other.On 2/14/26 at 8:20 PM V3 (RN) stated, I reported to (V1) immediately on 1/2/26 that (R3) reported (R2) was on top of (R3) in bed and hit (R3) in the head. I also reported that (R3) hit (R2) back.

Based on observation, interview, and record review the facility failed to update the care plan with pressure relieving interventions, implement pressure relieving interventions to prevent facility acquired pressure ulcers, conduct routine skin checks, and perform Braden Scale Assessments (Pressure Risk Assessments) quarterly as directed by the facility's policy for three of five residents (R4, R10, and R32) reviewed for pressure ulcers in the sample of 44. These failures resulted in R4 developing two facility acquired painful stage two pressure ulcers to R4's buttocks, R32 developing a facility acquired unstageable deep tissue pressure injury to R32's right heel that continues to worsen, and R10 developing a facility acquired painful unstageable pressure ulcer to R10's right heel that required surgical debridement (removing of damaged tissue). Findings include: The facility's Measurement of Alterations in Skin Integrity policy dated [DATE] documents Policy: 1. At first observation of any skin condition, the charge nurse or treatment nurse is responsible to measure and/or describe skin condition in the clinical record. 2. All measurements will be recorded in centimeters. All wounds/ulcers (i.e. (example) pressure, arterial, diabetic, venous) will be measured weekly and results recorded in a clinical record. Wound Assessment: 2. Pressure Injuries: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose fat is visible in the ulcer and granulation tissue epibole (rolled wound edges) are often present. Sloth and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If sloth or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. (example) dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precedes skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent or tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness, pressure injury (Unstageable Stage 3 or Stage 4). Do not use (DTPI) (Deep Tissue Pressure Injury) to describe vascular, traumatic, neuropathic, or dermatologic conditions. The facility's Prevention of Pressure Wounds policy dated [DATE] documents Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. See policy and procedure for specific task, such as bathing, incontinent care, and repositioning. General Guidelines: 1. Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. 2. The most common site of a pressure injury is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulders blades, backbone, hips, knees, heels, ankles, and toes. 3. Pressure can also come from splints, casts, badges, and wrinkles in the bed linen. If pressure injuries are not treated when discovered, they quickly get larger, become very painful for the resident, and often time become infected. 4. Pressure injuries are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e. (example), perspiration, feces, urine, wound discharge, soap residue, etc. (et cetera) decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. 5. Once a pressure injury develops, it can be extremely difficult to heal. Pressure injuries are a serious skin condition for the resident. 6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Interventions and Preventive Measures: General Preventive Measures 1. Identify risk factors for pressure injury development. 2. For a person in bed: a. Change position at least every two hours or more frequently if needed; b. Determine if resident needs a special mattress; c. If a special mattress is needed, use one that contains foam, air, as indicated; 13. Protect bony prominence's as needed. Residents with Risk Factors - Bed-fast 1. Change position at least every two hours and more frequently as needed. 2. Use a special mattress that meets clinical condition. 5. Unless resident has both sacral and ischial pressure injuries, avoid placing directly on the greater trochanter for more than momentary placement. Resident with Risk Factors -Chair-fast 2. Residents who are able to cooperate and understand should be taught to shift weight every 15 minutes while sitting in a chair. Equipment and Supplies 1. Tools for assessing skin and pressure injury risk: a. Braden Risk Assessment Form. The facility's Braden Pressure Ulcer Risk Assessment Tool dated [DATE] documents The Braden scale is recognized by the AHCPR (Agency for Healthcare Research and Quality) as being an appropriate clinical tool for determining Pressure ulcer risk because of the amount of clinical research supporting its reliability and validity. The Braden Scale has 6 (six) subscales: sensor, perception, moisture, activity, mobility, nutrition, and friction/shear. Form Completion Instructions: 1. This form should be completed for every new admission, weekly for the first month, at least quarterly, and with any significant change in condition. 7. Use the scale listed on the top of the page to determine the resident's Risk Level. A score of 19 or above indicates no risk. A score of 18 or less indicates risk of pressure ulcer development. 9. Review the subscales scores in each category to determine appropriate individualized interventions to be implemented where needed. These individualized interventions should be part of the plan of care. 1.) R10's current Physician's Order Report dated [DATE] through [DATE] documents R10 is an [AGE] year-old with the diagnoses of a history of a right femur fracture with closed reduction, Type II Diabetes Mellitus, Transient Cerebral Ischemic Attack, Hyperlipidemia, and Lack of Coordination. R10's MDS (Minimum Data Set) assessment dated [DATE] documents required substantial/maximum assistance of staff for rolling left and right and transfers, was at risk for developing pressure ulcers, and currently had no pressure ulcers at that time. R10's MDS assessment dated [DATE] documents R10 is severely cognitively impaired, requires substantial/maximum assistance of staff for rolling left and right and transfers. This same MDS documents R10 is at risk for developing pressure ulcers and currently has an unstageable pressure ulcer that was facility acquired. R10's Electronic Health Record dated [DATE] through [DATE] does not document that R10 receives routine skin checks. R10's Braden Scale assessment dated [DATE] documents R10 had a score of 15, indicating R10 was at a mild risk of developing a pressure ulcer. This same assessment documents R10's mobility was very limited. R10's Braden Scale assessment dated [DATE] documents R10 had a score of 16, indicating R10 was at a mild risk of developing a pressure ulcer. This same assessment documents R10's mobility was slightly limited. R10's Electronic Health Record does not include any further Braden Scale Assessment since [DATE]. R10's Pressure Ulcer assessment dated [DATE] documents, Date Pressure Ulcer Observed: [DATE]. Length 3.5 cm (centimeters) by width 2.0 cm by depth 0.5 cm. Moderate serosanguinous (pale red to pink, thin, and watery) exudate (drainage). Stage: Unstageable-slough (dead tissue) and or eschar (layer of dead tissue). R10's Progress Notes dated [DATE] documents, Pressure ulcer noted to right heel. R10's current Care Plan does not include any pressure relieving interventions until [DATE], once R10 already developed a pressure ulcer to the right heel. R10's Wound Center Progress Notes dated 5-28-25 and signed by V20 (Advanced Practice Nurse) documents, History of Present Illness: [DATE]: Has heel boots, however at nursing home, not been consistently applied. [DATE]: Follow/up for right heel pressure injury. (R10) has not had foam heel lift boot on during the day, only at night. Bilateral heel lift boots. (R10) still complains of pain. Discussed the importance of off-loading. [DATE]: Follow/up for right heel pressure injury. Slough debrided today. Wound Assessment: Right heel is a chronic stage three pressure injury pressure ulcer acquired on [DATE] and has received a status of not healed. [DATE] subsequent wound encounter measurements are 2.5 cm (centimeters) length by 0.7 cm width, by 0.1 cm depth. There is a moderate amount of sero-sanguineous drainage noted. 1-25% (percent) slough, 51-75% eschar. The peri-wound skin exhibited edema. (R10) to wear heel lift boots at all times even when in the wheelchair during the day. Start betadine (anti-septic solution) paint to the area. Continue with heel lift boots. On [DATE] from 9:30 AM to 10:15 AM R10 was sitting in her wheelchair with her heels in padded boots. These boots did not have a pressure off-loading cavity to the heels, therefore pressure was not being relieved to either of R10's heels. On [DATE] at 10:00 AM V7 (Registered Nurse/RN) provided a treatment of betadine solution to R10's right heel pressure ulcer. R10's right pressure ulcer was dark purple in color and approximately 2.5 cm long by 0.6 cm wide with an unmeasurable depth. On [DATE] at 10:15 AM V7 (RN) stated, (R10's) wound to the right heel was caused by pressure. (R10) did not wear any kind of pressure relieving boots and did not have her heel off-loaded while in bed prior to development of the pressure ulcer. On [DATE] V2 (Director of Nursing/DON) stated, Braden Scale Assessments are supposed to be performed quarterly and with a significant change in status. (R10) has not had a Braden Scale Assessment completed since [DATE]. (R10) was due to have a Braden Scale Assessment done on [DATE]. Either I or (V11/MDS Coordinator) were responsible for completing (R10's) Braden Scale Assessment in April. On [DATE] at 11:20 AM V20 (Wound Clinic Advanced Practice Registered Nurse) stated, (R10's) wound to the right heel was caused by pressure. (R10) should have had her heels off-loaded and pressure relieving interventions implemented prior to (R10) developing the pressure ulcer to the right heel. That would have help to prevent (R10) from developing a pressure ulcer to the right heel. (R10's) pressure relieving boots should have had a hole cutout in the heel to prevent pressure. Regular padded boots would not relieve pressure and (R10) would need her heels always off-loaded if the boots did not have a heel cutout. (R10) does have pain to the right heel pressure ulcer. I had to surgically debride (R10's) right heel wound on [DATE]. (R10) should always have someone doing weekly skin checks while at the facility. On [DATE] at 11:30 AM V2 (DON) stated, I looked back in (R10's) medical record and (R10) has not been receiving skin checks since [DATE]. Somehow this was missed. If (R10) was receiving skin checks prior to [DATE] the pressure ulcer would have been found before it was found as bad as it was. When the pressure ulcer to (R10's) right heel was found it was unstageable and very big. (R10) did not have any care planned pressure relieving interventions prior to the development of (R10's) pressure ulcer to the right heel. 2.) On [DATE] at 8:49 AM, R4 was laying supine in R4's bed. R4 stated that R4 has a wound on her coccyx. R4 stated the staff don't put a bandage on the area, but they clean it when she is changed. R4 further stated R4's bottom hurts all the time. R4's mattress was a standard foam mattress. On [DATE] at 9:40 AM, V17 (Certified Nursing Assistant), V18 (Certified Nursing Assistant), and V19 (Certified Nursing Assistant) provided perineal care to R4 in R4's bed. V17 cleaned barrier cream off R4's coccyx and there were two small open areas each comparable in size to a pea at the top of each side of R4's buttocks. V17 confirmed R4 was not on a pressure relieving air mattress. V17, V18, and V19 stated they were unsure of how long R4's coccyx had openings. R4's current care plan documents R4 is at risk for developing pressure ulcers related to decreased mobility, incontinence, and morbid obesity. This same care plan documents R4 requires extensive assistance for mobility and transfers with a mechanical lift. R4's Braden assessment dated [DATE], documents R4 has mild risk for skin impairment. R4's current care plan documents R4 is to have a pressure relieving mattress on R4's bed. R4's Physician order dated [DATE] documents R4's bed is to have a pressure relieving mattress. On [DATE] at 10:00 AM, V23 (Registered Nurse) stated V23 was not aware R4 had open areas on R4's buttocks. On [DATE] at 10:05 AM, R4's electronic medical chart does not contain documentation of any pressure areas on R4's buttock. R4's Nurse progress note dated [DATE] by V2 (Director of Nursing) documents R4 has two stage two pressure ulcers on R4's coccyx and wound nurse will evaluate. 3.) R32's Nurse Progress Note dated [DATE] at 11:13 AM, documents R32 received a shower and R32's heels on R32's feet were soft and boggy and R32 seemed like R32 had pain when heels were touched. R32's right heel appears to have a deep tissue injury (DTI). R32 was placed in heel boots for protection and comfort. Staff educated on ensuring repositioning every two hours and offloading heels. R32's MDS dated [DATE] documents R32 is severely cognitively impaired. R32's MDS documents R32 is dependent on staff for all ADLs. R32's Braden assessment dated [DATE] documents R49 is at high risk for skin alterations. R32's current care plan documents R32 is at risk for skin alterations related to dementia, poor safety awareness, and fragile skin. R32's current care plan does not contain pressure relieving interventions to prevent pressure ulcers. R32's Wound Note dated [DATE] documents to apply zero pressure heel boots while in bed with a wedge cushion and skin prep (preparation) twice daily. R32's Wound Note dated [DATE] documents R32 has an unstageable pressure ulcer to the right heel measuring 2.5 cm x 4 cm that continues to worsen. This note documents R32's pressure ulcer was found [DATE] and the area was pale and soft. R32's pressure ulcer on [DATE] was dark red in color and unblanchable. R32 has orders for skin prep to heels twice daily, heel protectors while in bed, and turn and reposition while in bed every two hours. R32 is unable to communicate her needs due to cognitive decline secondary to dementia. R32 is non ambulatory. R32's Nurse Progress Note dated [DATE] documents R32's left heel has a 3.5 cm x 2.0 cm intact wound that was black in color and was irregular shaped. Skin prep as ordered, and heel protectors are in place. On [DATE] at 9:30 AM, R3 was sitting in R32's high back wheelchair with socks on R32's feet. R32's heels were touching the floor of the dining room with no pressure relieving interventions in place, including heel protector boots as ordered. On [DATE] at 11:41 PM, R32 's right heel was open to air and R32's heel had a large dark brown/black pressure ulcer covering the right heel. R32 was lying in bed with bilateral heels on a foam mattress. R32 did not have an air mattress and did not have heel protector boots on as ordered. On [DATE] at 2:21 PM, V26 (Nurse Practitioner) stated R32's right heel continues to worsen and V26 states it's because pressure is not being relieved to the heel as V26 directed the staff to do. V26 further stated whether it's when R32 is sitting up in R32's chair or in bed and the boots are not being applied correctly, the continued pressure to R32's heel is still an issue that would cause R32's right heel pressure ulcer to worsen.

Based on observation, interview, and record review the facility failed monitor and record cool down temperatures for prepared meats, label opened food items in the refrigerators, label opened dry foods, and failed to use correct dish machine sanitizing test strips. These failures have the potential to affect all 69 residents residing in the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility. The facility's two stage cool down process policy (not dated), documents, Potentially hazardous foods will be cooled properly to prevent food borne illness. Foods will be cooled to proper temperatures. The time and temperature of food cooling will be documented at two- and four-hour intervals. The facility's labeling and dating food policy (not dated), documents, Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality of product for the residents and minimize waste. Bagged or boxed food once removed from original package will be placed in an ingredient bin that is labeled with the common name of the food, date the item is placed, use by date: mark with the date or day or number of days from opened date. Use by date will be based either from manufacturers use by date first or recommended maximum storage period. The facility's dishwashing procedure policy (not dated), documents, To prevent food borne illness, all dish wares will be cleaned in the dish machine. For temperature sanitizing machines attach a 160 EF (EfferSan sanitizing test strip) to a clean, dry, cool plate; weave a 10-degree Fahrenheit test strip in the tines of a fork; or run through the wash/rinse cycle a maximum reading thermometer to determine if the sanitizing water reaches 180 degrees Fahrenheit. On 6/2/2025 at 9:00 AM, on one of the facility's kitchen counters there was a bag of opened hot dog buns with no date opened with the top folded over. V15 (Dietary Manager) confirmed these should have been sealed and dated. On 6/2/2025 at 9:00 AM, the facility's refrigerator located in the back of the kitchen contained several opened undated foods such as liquid eggs, onion, shredded cheese, and an open bottle of soda not belonging to a resident. V15 confirmed these items should have been dated and the soda should not have been in the refrigerator. On 6/2/2025 at 9:10 AM, V15 removed quaternary test strips to use in the sanitizing machine, placed strip on a small white plate, placed the plate on a dish washing rack, then placed a clear plastic cup on top of test strip and ran this through a cycle in the sanitizing machine. On 6/2/2025 at 9:15 AM, V15 confirmed she did not know what test strips to use on the sanitizing machine and she did not have the correct test strips. V15 confirmed this dishwasher needs 160 EF sanitizer test strips to accurately measure the dish machine for sanitizer levels and the facility does not have the correct test strips to test the dish machine. On 6/2/2025 at 9:30 AM, V16 (Kitchen Cook) stated she was cooking a pork loin for 5/3/2025. V15 confirmed kitchen staff were not using a cool down log for meals cooked ahead of time.

Based on interview and record review the facility failed to track infections of individuals who enter or live in the facility per CMS (Central Management Services) requirement. This failure had the potential to affect all 69 residents residing in the facility. Findings Include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility. The facility's Infection Prevention and Control Manual Infection Prevention and Control Program (not dated) documents, A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards. A system of surveillance that is designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. When and to whom possible incidents of communicable disease or infections should be reported to. On 6/3/2025 at 1:30 PM, V2 (Director of Nursing/DON) confirmed they had no tracking of infections currently or in the past for residents or employees.

Based on interview and record review the facility failed to designate or hire a full-time infection preventionist per CMS (Central Management Services) requirement. This failure had the potential to affect all 69 residents residing in the facility. Findings Include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility. The facility's Infection Prevention and Control Manual Infection Prevention and Control Program (not dated) documents, The facility will designate one or more individual(s) as the infection preventionist(s)(IP)(s) who is responsible for the facility's IPCP (infection prevention control program). The infection preventionist will have primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field. Is qualified by education, training, experience, or certification, works at least part time at the facility, has completed specialized training in infection prevention and control. The facility IP will also be a member of the facility's quarterly assessment and assurance committee and report to the committee on the IPCP on a regular basis. On 6-1-25 at 11:08 AM V1 (Administrator) stated, We (the facility) terminated (V6/Prior Infection Preventionist) on 2-13-25. (V4) is working on the Infection Preventionist Training but has not completed the training yet. The facility has not had a full-time Infection Preventionist since 2-13-25.

Based on record review and interview the facility failed to ensure all Certified Nursing Assistants received 12 hours of annual in-service training. This failure has the potential to affect all 69 residents residing within the facility. Findings Include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility. All CNA (Certified Nursing Assistant) trainings from 1/1/2024 through 6/2/2025 were reviewed and no CNAs received 12 hours of required annual in-service training. On 6/3/2025 at 1:30 PM, V2 (DON/Director of Nursing) confirmed all CNAs currently employed at the facility have not received 12 hours of annual in-service training required.

Based on interview, and record review the facility failed to resolve several repeated grievances for eight of eight residents (R5, R14, R23, R30, R31, R47, R50, R58) reviewed for grievances in a sample of 44. Finding Include: The facility's grievance policy dated/revised 1/2025, documents, To provide a process to assist residents, their representatives such as other interested family members or other resident advocates in filing grievances or complaints when such requests are made. Consistent with 483.12(c)(1), by anyone furnishing services on behalf of the provider, all alleged violations involving neglect, abuse, including injuries of unknown source and/or misappropriation of resident property will be immediately reported to the administrator of the provider as required by state law. Written grievance decisions will include the date the grievance was received, a summary statement of the resident grievance, steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents concern(s), a statement as to whether the grievance as confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, the date the written decision was issued. R5's grievance form dated 12/19/2024, documents R5 filed a grievance of missing clothing items. R14's grievance form dated 1/13/2025, documents R14 filed a grievance of missing clothing items. R23's grievance forms dated 8/20/2024 and 12/19/2024 document R23 filed grievances of missing clothing items. R30's grievance form dated 5/27/2025, documents R30 filed a grievance of missing clothing items. R31's grievance forms dated 8/20/2024, and 12/19/2024, documents R31 filed grievances of missing clothing items. R47's grievance form dated 8/20/2025, documents R47 filed a grievance of missing clothing items. R50's grievance form dated 1/24/2025, documents R50 filed a grievance of missing clothing items. R58's grievance form dated 12/19/2024, documents R58 filed a grievance of missing clothing items. The facility's Resident Council Grievance form dated 6/18/2024, documents continuing issue of missing clothing items. On 6/2/2025 at 10:02 AM during resident council meeting R5, R14, R23, R30, R31, R47, R50, and R58 stated they have made numerous grievances of their clothes missing and their clothes have never been found or resolved. On 6/3/2025 at 11:00 AM, V1 (Administrator) confirmed missing laundry is an ongoing issue.

Based on observation, interview, and record review the facility failed to ensure oxygen tubing was changed weekly as ordered and dated for five of five residents (R5, R12, R13, R38, and R39) reviewed for oxygen in the sample of 44. Findings include: The facility's Respiratory Therapy Prevention of Infection policy dated 8/2008 documents The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure - Infection Control Considerations Related to Oxygen Administration 7. Change the oxygen cannula and tubing every seven (7) days, or as needed. 8. Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. Documentation - The following information should be recorded in the resident's medical record: 1. The date and time the respirator therapy was performed. 1.) R38's current Physician Order Report documents, 04/22/25 Oxygen: Change tubing and mask weekly and PRN (as needed). R38's Treatment Administration Records (TARs) dated 06/01/25 through 06/02/25 document, Oxygen: Change tubing and mask weekly and as needed on Sundays. These same TARs document R38's oxygen tubing was not changed on Sunday (06/01/25). On 06/01/25 at 10:29 AM R38 was lying in bed with oxygen on at two liters via nasal cannula. R38's nasal cannula and oxygen tubing were not labeled with a date. 2.) R5's Medical Record documents that R5 was admitted to the facility on [DATE] with diagnoses which included Emphysema and Acute and Chronic Respiratory Failure with Hypoxia. R5's Physicians Orders printed 6/3/25, documents Oxygen at four liters continuous. Order date 11/18/24. Change oxygen tubing weekly and as needed (label) once a day on Sunday night. Order date 5/16/24. R5's Treatment Flowsheet dated 6/1/25 - 6/30/25 documents to change oxygen tubing weekly and as needed (label) once a day on Sunday night. It was not signed as being done on Sunday 6/1/25. On 6/01/25 at 9:52 AM R5 was sitting in a chair in her room wearing oxygen by nasal cannula. The tubing was dated 5/11/25. R5 stated that the oxygen tubing has not been changed in a while. R5 removed the nasal cannula from her nose and stated, This nose piece is dirty and gummed up. 3.) R12's Medical Record documents that R12 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease. R12's Physicians Orders printed 6/3/25, documents Oxygen at two liters as needed. Order date 12/18/23. Change oxygen tubing and clean filters weekly on Sundays. Order date 5/1/24. On 6/1/25 at 10:00 AM, R12 was wearing oxygen lying in bed resting. R12's oxygen tubing was not labeled with the date or initials. R12 stated that she does not know when the tubing was last changed but it is not changed weekly. 4.) On 06/01/25 at 9:59 AM, R39's oxygen tubing was connected to the oxygen concentrator in R39's room. R39's oxygen tubing was not labeled with the date. 5.) On 6/1/25 at 10:02 AM, R13's oxygen tubing was connected to the oxygen concentrator in R13's room. R13's oxygen tubing was not labeled with the date. On 6/2/25 at 10:00 AM, V23 (Registered Nurse) stated all oxygen tubing should be dated. On 06/2/25 at 11:58 AM V2 (Director of Nursing) stated, All oxygen tubing should be labeled with the date changed and should be changed every week on Sundays.

Based on record review and interview the facility failed to develop a plan of care to address advanced directives for one of two residents (R44) reviewed for advanced directives in the sample of 44. Findings include: The facility's Advanced Directive and Advanced Care Planning/POLST (Physician Orders for Life Sustaining Treatment) Guideline dated [DATE] documents Purpose: It is the practice of the facility to establish, implement and maintain written guidelines for advanced directives and advanced care planning/POLST. The resident has the right and the facility will assist the resident to formulate an advance directive at their option. Procedure: G. During the quarterly RAI (Resident Assessment Instrument) process and with any significant changes of condition, facility staff will a. Identify, clarify, and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directive. e. Changes to the resident choices for advanced directives will be documented, included in the resident plan of care, State specific documents will be updated as necessary, physician orders will be obtained to reflect new choices as applicable, and all items will be communicated to staff providing resident care. Advance Care Planning A. In order for a resident to exercise his or her right to make informed choices about care and treatment in preparation for a time when the resident may not be able to make decisions, designated personnel and/or physician will assist with defining and clarifying medical issues and presenting the information regarding relevant health care issues to the resident or his/her legal representative, in a language that the resident can understand, as appropriate. B. The interdisciplinary team will identify, clarify, and review, as part of the comprehensive care planning process, the existing care instructions along with resident's goals wishes as the resident's medical condition changes. R44's IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form dated 4-9-24 and signed by V12 (R44's) Power of Attorney documents, No CPR: Do Not Attempt Resuscitation (DNR). Comfort-Focused Treatment. R44's Current Care Plan does not include a plan of care to address R44's advanced directives. On [DATE] at 1:48 PM V11 (Care Plan Coordinator) stated, (R44) does not have a current Advanced Directives Care Plan.

Based on observation, interview, and record review the facility failed to administer prescribed opioid medications to keep residents' pain controlled, failed to perform a pain assessment while the residents were not receiving their prescribed opioid medications, and failed to develop a pain plan of care for two of three residents (R1 and R2) reviewed for pain in the sample of three. These findings resulted in R1, who suffers from bone cancer, experiencing uncontrolled lower back pain and resulted in R2, who suffers from Osteomyelitis from a flesh-eating wound caused by a spider bite, experiencing uncontrolled severe continuous and unbearable pain to his right lower leg wound. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3-11-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The facility's Pain Management policy dated 07/2019 documents, Policy: It is the policy of the facility to facilitate resident safety, independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish the goals through an effective pain management program. The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. Pain assessment protocol may be initiated under any of the following situations: Resident received routine pain medication and/or pain is not controlled and a change in pain identification related to behavior, cognition, or mood. An immediate care plan will be initiated at the time of admission for any resident with physician orders for pain management, when the resident expresses pain, or exhibits behaviors indicative of having pain. An interdisciplinary process and care plan will be developed and implemented based on the assessed findings, pain rating scale, and pain-relieving strategies (interventions). A provision of pain treatment that includes pharmacological and non-pharmacological interventions will be included in the care plan. Responsible use of opioid's medications will include the monitoring of the use of opioids. The United States Food and Drug Administration Safety Communication Website article dated 4-9-19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Rapid discontinuation can result in uncontrolled pain. R1's History and Physical dated 8-10-23 documents, Chief complaint is intractable back pain. Multiple Myeloma. (R1) has known Multiple Myeloma has been under therapy by Oncology. (R1's) pain has become severe. (R1) cannot ambulate. Pains all up and down (R1's) spine. (R1) apparently has lesions at various levels of the spine with her myeloma. R1's Face Sheet documents R1 is an [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Multiple Myeloma not having achieved remission and low back pain. R1's Admission Orders dated 8-23-24 document R1 was admitted to the facility on Fentanyl (Opioid) 75 mcg (microgram)/hour transdermal extended release one all up patch every 72 hours. Morning time is a hard time of day regarding pain. (R1) is able to sleep at night. Location (of pain) is mid-back today. Planning to increase fentanyl patch (dose). R1's Care Plan dated 8-23-23 (Admission) through 3-7-24 does not include a plan of care to address R1's chronic pain due to Multiple Myeloma. R1's Progress Notes dated 10-4-24 and signed by V4 (R1's Palliative Physician) document, (R1) is being seen in the geriatric clinic today for palliative care follow-up regarding pain management associated with Multiple Myeloma. R1's Progress Notes dated 10-5-24 and signed by V6 (RN/Registered Nurse) document, (R1) seen by (V4/R1's Palliative Care Physician) with Fentanyl patch increased to 100 mcg per hour for diagnosis of cancer pain. Follow-up with (V4) in four months. Will continue to monitor. R1's Physician's Orders dated 10-5-24 through 3-8-24 document, Fentanyl 100 mcg per hour one patch transdermal once a day every three days at 9:00 PM for the diagnoses of Multiple Myeloma not having achieved remission. R1's Medication Flow Sheets dated 1-1-24 through 2-31-24 document R1's Fentanyl Patch 100 mcg/hour transdermal placed at 9:00 PM was not administered as scheduled on 1-25-24, 1-28-24, 1-31-24, or 2-3-24. These same Medication Flow Sheets document R1 did not have a Fentanyl 100 mcg/hour patch applied until 2-6-24. The facility's email dated 2-5-24 and sent to the facility's pharmacy from V2 (Director of Nursing) states, I am not sure how things need to be fixed, but (R1) has been without her Fentanyl patch going on two weeks which is completely unacceptable. This is becoming a huge problem of people going days without their narcotics and is causing residents to being in a great deal of pain or even worse going into withdrawals. R1's Progress Notes dated 2-21-24 and signed by V4 (R1's Physician) document, A few weeks ago (R1) was having significant issues with delirium at night and there was a night where an ambulance had to be called. On further investigation from family, turns out (R1) had not been getting her fentanyl patches. I am unsure about what efforts (if any) the facility pursued to get (R1) her pain medications. Not only was my office unavailable during this time, the patient's primary care provider's office was available and our nurse practitioner who rounds at the facility would have also been available to help troubleshoot. This appears to be inadequate care and my duty as a mandatory reporter required me to report this. Assessment and recommendations: 1. Encounter for palliative care. 2. Multiple Myeloma not having achieved remission. 3. Bone Metastasis. 4. Cancer related pain. R1's Medical Record does not include a completion of a pain assessment after R1 did not receive her scheduled Fentanyl patch from 1-25-24 through 2-6-24. On 3-8-24 at 9:30 AM R1 was lying in bed in her room. R1 stated, I did not know I wasn't getting my pain medication. I know my lower back was on fire. Most all of my pain is in my lower back. On 3-8-24 at 9:45 AM V2 (Director of Nursing/DON) stated R1 went without her scheduled Fentanyl Patch for from 1-25-24 through 2-6-24. V2 also stated R1's Fentanyl Patch was given for R1's pain related to bone cancer. V2 confirmed R1 did not have a pain assessment conducted after missing her Fentanyl Patch dose. On 3-8-24 at 11:00 AM V4 (R1's Palliative Care Physician) stated, I am responsible for (R1's) palliative care. I saw (R1) in my office on 2-21-24. I was told on 2-21-24 that (R1) did not receive her Fentanyl patch for two weeks. I was not informed by the nursing home of (R1's) Fentanyl patch not being available or administered. (R1) should not have gone two weeks without Fentanyl. Fentanyl is the only medication that keeps (R1's) pain control. (R1) has excruciating pain from bone cancer and I have had to increase (R1's) Fentanyl dose to keep the pain under control. No other pain medication has been effective. On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, I did not know (R1) had went without Fentanyl for two weeks. (R1) should not have never been without her Fentanyl, especially for two weeks. I was only notified one day (1-19-24) of the need for a signed prescription. (R1) has bone cancer to her spine and her pain is very detrimental to her. On 3-8-24 at 12:25 PM V8 (R1's Power of Attorney) stated, On 2-1-24 I called the nurse (V9/RN), and she told me (R1) had been out of her Fentanyl patch for two weeks and that was causing her night terrors. (R1) was going crazy and was in such pain while being out of her Fentanyl. It was just awful. (R1) has terrible bone pain and cancer. On 3-8-24 at 4:25 PM V10 (MDS/Minimum Data Set Coordinator) stated, (R1) did not have a pain plan of care developed prior to today. I am responsible for developing pain care plans. I do not have a reason as to why (R1) did not have a pain care plan. 2. R2's Face Sheet documents R2 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Type II Diabetes Mellitus and a non-pressure chronic ulcer of unspecified part of right lower leg. R2's MDS assessment dated [DATE] documents R2 is cognitively intact and has frequent pain at a pain intensity of 7 on a 0-10 pain scale (zero being no pain and ten as the worst pain you can imagine). R2's Pain Observation assessment dated [DATE] documents R2 had almost constant moderate pain at a 7 and received scheduled and as needed pain medications for pain control. R2's Progress Notes dated 1-8-24 and signed by V7 (Nurse Practitioner) document, (R2) requested to see me due to pain not currently controlled with Oxycodone 10 mg every four hours PRN (as needed). New orders: Schedule Oxycodone 10 mg tablets three times daily and continue with current Oxycodone 10 mg one tablet every four hours as needed. R2's Care Plan dated 8-16-23 (Admission) through 3-7-24 does not include a plan of care to address R2's chronic pain due to Osteomyelitis and wound to the right lower leg. R2's Physician's Order Report date 3-1-24 through 3-8-24 documents, Order date 1-8-24 to current: Oxycodone 10 mg (milligram) tablet two tablets three times daily. Order date 11-30-23 to current: Oxycodone 10 mg one tablet every four hours as needed (PRN).` R2's Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2's Oxycodone 10 mg two tablets was not administered as ordered on 1-26-24 at 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, and 1-28-24 at 8:00 AM. These same Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2 did not receive a PRN dose of Oxycodone 10 mg on 1-26-24 through 1-31-24. R2's Progress Notes dated 1-28-24 at 3:11 PM and signed by V9 (RN) documents R2 was complaining of increased pain and withdrawals due to his scheduled pain medication not being available from pharmacy due to insurance. This same not documents R2 remained in bed and was not eating meals. R2's Progress Notes dated 1-29-24 at 1:47 PM and signed by V11 (RN) documents, (R2) has remained in bed thus far today. (R2) went all weekend and today without pain medication. R2's Medical Record does not include a completion of a pain assessment after R2 did not receive his scheduled Oxycodone on 1-26-24 through 1-28-24. On 3-8-24 at 11:10 AM R2 was lying in bed. R2's right lower leg was wrapped in gauze. R2 stated, I was out of the Oxycodone for three days. I was bit by a recluse spider and that is why I am here for treatment. When I was out of the Oxycodone, I was having withdrawals of nausea, vomiting, and dry heaving and I was having pain at an 11 on a 1-10 pain scale. The pain was continuous and unbearable. It felt like my wound was split open and burning. On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, I oversee (R2's) care at the facility. (R2) ran out of Oxycodone on 1-26-24. I was not notified of the need for a prior authorization until (R2) already ran out. (R2) did not get his medication for three days. (R2) got bitten by a [NAME] Recluse spider that caused a wound with bone exposure. (R2) has Osteomyelitis (bone infection) and has had several debridements done and has a lot of pain with this wound. I am sure his pain was excruciating when he had to go without his Oxycodone. On 3-8-24 at 9:45 AM V2 (DON) confirmed that R2 did not have a pain assessment completed after missing his scheduled doses of Oxycodone on 1-26-24 through 1-29-24. On 3-8-24 at 4:25 PM V10 (MDS Coordinator) stated, (R2) did not have a pain plan of care developed prior to today. I am responsible for developing pain care plans. I do not have a reason as to why (R2) did not have a pain plan of care. The Immediate Jeopardy started on 1-25-24 at 9:00 PM when R1's scheduled Fentanyl patch 100 mcg/hour was not administered to treat R1's excruciating bone cancer pain. V1 (Administrator) and V2 (DON) were notified of the Immediate Jeopardy on 3-11-24 at 9:36 AM. On 3-13-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3-13-24 R1's opioid pain medications were available and being administered. On 3-11-24 R1 was assessed and re-evaluated by V10 (MDS/Minimum Data Set Coordinator) for adequate pain control and pain levels that were tolerable, and V10 updated R1's care plan to include pain relieving interventions/medications. 2. On 3-13-24 R2's opioid pain medications were available and being administered. On 3-11-24 R2 was assessed and re-evaluated by V10 for adequate pain control and pain levels that were tolerable, and V10 updated R2's care plan to include pain relieving interventions/medications. 3. On 3-13-24 all residents who currently had orders for opioid pain medications had their pain medications available and were being administered. 4. On 3-11-24 V1, V2, and V10 assessed and re-evaluated all residents for adequate pain control and pain levels that were tolerable. 5. On 3-11-24 V1 and V2 ensured all residents had tolerable pain levels. 6. On 3-11-24 V1 and V2 in-serviced all facility nurses and department heads on the facility's Pain Clinical policy and procedure, performing pain assessments with changes in pain management or an increase in pain, and the facility's Pain Management policy. 7. On 3-11-24 V1 and V2 in-serviced all facility nurses and department heads on developing pain care plans and implementing pain relieving interventions. 9. On 3-11-24 V13 (Medical Director) made aware of the Immediate Jeopardy regarding pain control concerns. 10. On 3-11-24 the facility conducted an emergency QA (Quality Assurance) meeting regarding all Pain policies and procedures and concerns with pain control. Date of Completion: 3/11/2024

Based on observation, interview, and record review the facility failed to obtain scheduled opioid medications from the pharmacy for two of three residents (R1 and R2) reviewed for pharmacy services in the sample of three. This failure resulted in R1 abruptly stopping and missing her scheduled Fentanyl patch (Opioid Medication) for two weeks resulting in R1 experiencing withdrawal symptoms of a fall, night terrors, drooped eyes with continuous blinking, shallow and quick breaths, non-reactive pupils, garbled speech, and hypertensive. This failure also resulted in R2 abruptly stopping his scheduled Oxycodone (Opioid Medications) for three days resulting in R2 experiencing withdrawal symptoms of refusing to eat, chills, nausea, and vomiting. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3-11-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The facility Pharmacy's Preventing and Detecting Adverse Consequences and Medication Errors policy dated 10-25-14 documents, Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness, when the following conditions occur: 1. A clinical significant change in condition/status. a. An unexplained decline in function or cognition. b. A worsening of an existing problem or condition. c. A new or worsening psychiatric manifestation or distressed behavior. d. Acute onset of signs or symptoms or worsening of a chronic problem. Medication error. G. The attending physician is notified promptly of any significant error or adverse consequence. J. The following information is documented in an incident report and in the resident's clinical record: Factual description of the error or adverse consequence. Name of physician and time notified. Physician's subsequent orders. Resident's condition for 24 to 72 hours or as directed. The United States Food and Drug Administration Safety Communication Website article dated 4-9-19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Patients taking opioid pain medicines long-term should not suddenly stop taking your medicines without first discussing with hour health care professional a plan for how to slowly decrease the dose of the opioid and continue to manage your pain. Even when the opioid dose is decreased gradually, you may experience symptoms of withdrawal. Rapid discontinuation can result in uncontrolled pain or withdrawal symptoms. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide. R1's Face Sheet documents R1 is an [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Multiple Myeloma not having achieved remission and low back pain. R1's Admission Orders dated 8-23-24 document R1 was admitted to the facility on Fentanyl (Opioid) 75 mcg (microgram)/hour transdermal extended release one all up patch every 72 hours. R1's Care Plan dated 9-29-23 documents, (R1) is at risk for falling related to her recent hospital stay for COPD (Chronic Obstructive Pulmonary Disease), cancer with chemotherapy treatments, and generalized weakness. Approach: 1-29-24 (R1) will be schedules to see her physician for night terrors. R1's Physician's Orders dated 10-5-24 through 3-8-24 document, Fentanyl 100 mcg per hour one patch transdermal once a day every three days at 9:00 PM for the diagnoses of Multiple Myeloma not having achieved remission. R1's Medication Flow Sheets dated 1-1-24 through 2-31-24 document R1's Fentanyl Patch 100 mcg/hour transdermal placed at 9:00 PM was not administered as scheduled on 1-25-24, 1-28-24, 1-31-24, or 2-3-24. These same Medication Flow Sheets document R1 did not have a Fentanyl 100 mcg/hour patch applied until 2-6-24. R1's Clinical Record does not include documentation, as directed by the facility pharmacy's Preventing and Detecting Adverse Consequences and Medication Errors policy. of physician notification or a factual description of why R1 did not receive her scheduled Fentanyl Patch from 1-25-24 through 2-6-24, or R1's condition while missing the scheduled dose of her Fentanyl Patch from 1-25-24 through 2-6-24. R1's Progress Notes dated 1-29-24 at 5:49 AM and signed by V5 (RN/Registered Nurse) document, At 5:45 am (R1) heard yelling (female's name) and had fallen in room. Fall was witnessed by roommate who states (R1) was having a nightmare and got out of bed unaware. (R1) was observed trying to stand herself up when this nurse entered the room. (R1) states she hit her knees a bit and her back. (R1) states this is a normal occurrence for her, and she needs to see someone about the night terrors. No other noticed injuries other than some bruising starting to bilateral knees. R1's Medication Error Report signed by V1 (Administrator) and V2 (Director of Nursing) on 1-31-24 documents, Medication as ordered: Fentanyl 100 mcg (micrograms)/hour patch. Description of error: Medication unavailable/no refills. Date of error: 1-25-24, 1-28-24, and 1-31-24. Reason for error: Pharmacy error. Corrective action taken: Working with pharmacy and physician to get resolution. Measures taken to prevent recurrence (this section is incomplete). R1's Progress Notes dated 2-3-25 at 12:57 AM and signed by V5 (RN) document, This nurse was called into resident's room by the CNA (Certified Nursing Assistant) asking me to lay eyes on (R1). (R1) at this time was having a night terror. Upon assessment, (R1) was noted to have drooped eyes with continuous blinking, shallow, quick breaths, non-reactive pupils, and hypertensive. (R1) was responding appropriately to some questions but speech was also garbled and hard to comprehend. This nurse asked another nurse to also lay eyes and 911 was called at 4:32 AM. Shortly after, (R1) became more responsive and appeared to just be having a night terror that she had not fully come out of. EMS arrived at 4:35 AM and evaluated and was determined to be stable. The facility's email dated 2-5-24 and sent to the facility's pharmacy from V2 (Director of Nursing) states, I am not sure how things need to be fixed, but (R1) has been without her Fentanyl patch going on two weeks which is completely unacceptable. Last week I spoke with pharmacy, and they stated that they needed a renewal script signed and sent over by the doctor of which was done on 1-29-24. Today I find out that these patches still have not been sent and my nurse was told my pharmacy that there was no dosage attached to the ordered. I was not notified of this nor was the doctor notified of anything. (V7/Nurse Practitioner) pulled the order that she personally send last week and the correct dosage that you can see in the forwarded message. The dosage is clearly attached. This is becoming a huge problem of people going days without their narcotics and is causing residents to being in a great deal of pain or even worse going into withdrawals. There needs to be something figures out or communications sent from the pharmacy to me as well as the prescriber for narcotics needing new scripts signed/renewed so that I can follow-up before the resident runs out of the medication. R1's Physician's Progress Notes dated 2-21-24 and signed by V4 (R1's Palliative Care Physician) document, A few weeks ago (R1) was having significant issues with delirium at night and there was a night where an ambulance had to be called. On further investigation from family, turns out (R1) had not been getting her fentanyl patches. There was a list of excuses that the nursing home provided, though (V2/Director of Nursing) never did get back to the family about why the patches had no bed obtained from pharmacy or why physician involvement was no pursed in order to get the right order. The nursing home did not send a med (medication) list with (R1) so we will work on getting one. About four to six weeks ago (R1) went through opioid withdrawal because the facility did not have (R1's) fentanyl patches. I am unsure about what efforts (if any) the facility pursued to get (R1) her pain medications. Not only was my office unavailable during this time, the patient's primary care provider's office was available and our nurse practitioner who rounds at the facility would have also been available to help troubleshoot. This appears to be inadequate care and my duty as a mandatory reporter required me to report this. Assessment and recommendations: 1. Encounter for palliative care. 2. Multiple Myeloma not having achieved remission. 3. Bone Metastasis. 4. Cancer related pain. 5. Drug-induced constipation. 5. Opioid withdraw delirium resolved. On 3-8-24 at 9:30 AM R1 was lying in bed in her room. R1 stated, I did not know I wasn't getting my pain medication. I know my lower back was on fire. Most all of my pain is in my lower back. I fell and was not feeling very well a few weeks ago. On 3-8-24 at 9:45 AM V2 (Director of Nursing/DON) stated, I was informed on 1-25-24 that (R1's) Fentanyl patch was not delivered by pharmacy, and we needed a renewal slip from the physician. On 1-30-24 I was told (R1) still did not have her Fentanyl delivered by pharmacy. I called pharmacy and they said the script (V7/Nurse Practitioner) sent on 1-29-24 did not include the amount. I looked at the script and it did include the amount. I called the pharmacy again on 1-31-24 and (R1) still had not received the Fentanyl patch and said they still did not have a physician script. On 2-5-24 I was told (R1's) Fentanyl was still not delivered by pharmacy. I sent an email on 2-5-24 and told them it us unacceptable for (R1) to have to go two weeks without her Fentanyl. Finally, the pharmacy delivered it that night. I did not know (V4/R1's Palliative Care Physician) was the physician prescribing (R1's) Fentanyl. The facility switched pharmacies on 1-1-24 and pharmacy has communication issues. On 3-8-24 at 11:00 AM V4 (R1's Palliative Care Physician) stated, I am responsible for (R1's) Palliative care. I saw (R1) in my office on 2-21-24. I was told on 2-21-24 that (R1) did not receive her Fentanyl patch for two weeks and was experiencing withdrawals. I was not informed by the nursing home of (R1's) Fentanyl patch not being available or administered. It is very dangerous to abruptly stop Fentanyl. (R1's) experiencing night terrors, garbled speech, shallow respirations, and falls would have definitely been withdrawal symptoms from abruptly stopping her Fentanyl. When the pharmacy was not sending the Fentanyl I should have been contacted. The facility should have been doing everything in their power to get the Fentanyl and should have been following up with me and pharmacy daily. (R1) should not have gone two weeks without Fentanyl. Fentanyl is the only medication that keeps (R1's) pain control. (R1) has excruciating pain from bone cancer and I have had to increase (R1's) Fentanyl dose to keep the pain under control. No other pain medication has been effective. On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, The pharmacy the facility started using a new pharmacy January 1, 2024, and this pharmacy has not been good. I did not know (R1) had went without Fentanyl for two weeks. (R1) should not have never been without her Fentanyl, especially for two weeks. I was only notified one day (1-19-24) of the need for a signed prescription. (R1) has bone cancer to her spine and her pain is very detrimental to her. The facility should have been notifying a physician and pharmacy daily to get (R1's) Fentanyl in before it ran out or used an alternate pharmacy to get the medication. The facility should not be letting their residents run out of medications. On 3-8-24 at 12:25 PM V8 (R1's Power of Attorney) stated, (R1) told me that she fell out of bed because she had nightmares. (R1) said 911 was called and came to see her. On 2-1-24 I called the nurse (V9/RN), and she told me (R1) had been out of her Fentanyl patch for two weeks and that was causing her night terrors. (V9) told me 911 had a hard time waking her up and thought she was having seizure like activity. I called (V2) on a Monday (2-5-24) and told (V2) that (R1) was out of her pain patch and (V2) told me she was not out of the pain patch and was not aware of (R1) being out of the pain patch. I did not hear back from (V2), so I called back on a Wednesday (2-7-24) and spoke to (V2). (V2) did say (R1) fell out of bed once and had been out of her Fentanyl patch for two weeks. (V2) said (V7) tried to send the prescription in to pharmacy, but the facility still did not receive the prescription. I was never notified of (R1) falling out of bed or being out of Fentanyl or 911 being called. (V2) told me the pharmacy got the Fentanyl on 2-8-24. On 3-8-24 at 1:00 PM V9 (RN/Registered Nurse) stated, (R1) did not have her Fentanyl patch for two weeks and was having withdrawals and night terrors. 2. R2's Face Sheet documents R2 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Type II Diabetes Mellitus and a non-pressure chronic ulcer of unspecified part of right lower leg. R2's Physician's Order Report date 3-1-24 through 3-8-24 documents, Order date 1-8-24 to current: Oxycodone 10 mg (milligram) tablet two tablets three times daily. Order date 11-30-23 to current: Oxycodone 10 mg one tablet every four hours as needed (PRN). ` R2's Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2's Oxycodone 10 mg two tablets was not administered as ordered on 1-26-24 at 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, and 1-28-24 at 8:00 AM. These same Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2 did not receive a PRN dose of Oxycodone 10 mg on 1-26-24 through 1-31-24. R2's Progress Notes dated 1-28-24 at 3:11 PM and signed by V9 (RN) documents R2 was complaining of increased pain and withdrawals due to his scheduled pain medication not being available from pharmacy due to insurance. This same not documents R2 remained in bed and was not eating meals. R2's Progress Notes dated 1-29-24 at 1:47 PM and signed by V11 (RN) documents, (R2) has remained in bed thus far today. Withdrawal symptoms present due to new script needing written for Oxycodone. (R2) went all weekend and today without pain medication. Complained of chills, feeling hot, nausea, vomiting, and overall feeling sick. (R2) refused both breakfast and lunch. On 3-8-24 at 11:10 AM R2 was lying in bed. R2's right lower leg was wrapped in gauze. R2 stated, I was out of the Oxycodone for three days. I was bit by a [NAME] Recluse spider and that is why I am here for treatment. When I was out of the Oxycodone, I was having withdrawals of nausea, vomiting, and dry heaving and I was having pain at an 11 on a 1-10 pain scale. The pain was continuous and unbearable. It felt like my wound was split open and burning. On 3-8-24 at 9:45 AM V2 (Director of Nursing/DON) stated, (R2) had to go without his Oxycodone for three days because the pharmacy said they did not receive his prior authorization. (R2) experienced withdrawal symptoms. On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, The facility should not be letting their residents run out of medications. I oversee (R2's) care at the facility. (R2) ran out of Oxycodone on 1-26-24. I was not notified of the need for a prior authorization until (R2) already ran out. (R2) did not get his medication for three days until I called (V2) and told her the facility needs to pay for the medication until (R2's) prior authorization gets sent. (R2) got bitten by a [NAME] Recluse spider that caused a wound with bone exposure. (R2) was having withdrawals and should not have gone without his Oxycodone. The Immediate Jeopardy started on 1-25-24 at 9:00 PM when R1's scheduled Fentanyl patch 100 mcg/hour was not delivered by pharmacy to treat R1's bone cancer pain, causing R1 to experience opioid withdrawals symptoms. V1 (Administrator) and V2 (DON) were notified of the Immediate Jeopardy on 3-11-24 at 9:36 AM. On 3-13-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3-13-24 R1's opioid pain medications were available and being administered. 2. On 3-13-24 R2's opioid pain medications were available and being administered. 3. On 3-13-24 all residents who currently had orders for opioid pain medications had their pain medications available and were being administered. 4. On 3-11-24 V1 and V2 reviewed the facility's Controlled Substance Prescriptions Policy to ensure the policy included ordering and receiving controlled medications to ensure that all controlled (opioids) are filled immediately. 5. On 3-11-24 V1 and V2 in-serviced all facility nurses and department heads on notifying V1 and V2 immediately when opioid medication is not delivered by the pharmacy and V2's responsibility of contacting the pharmacy and taking action to ensure the medication is available and /or administered as ordered by the physician. 6. Pharmacy has been sending a controlled substance requiring prescription report daily to V1's and V2's email since 3-11-24 and this report has been reviewed daily by V1 and V2. 7. On 3-11-24 V2 in-serviced all facility nurses and department heads on notifying the attending physician, and /or nurse practitioner, V2, and V1 when a medication is not administered as ordered by the physician, ensuring all residents medications are obtained prior to the medications running out, and ordering and faxing medication refills to the pharmacy. 8. On 3-11-24 V13 (Medical Director) pharmacy staff were in-serviced by V1 and V2 regarding the facility's Controlled Substance Prescription Policy to ensure Opioid medications are filled and delivered to the facility immediately. 9. On 3-11-24 V13 (Medical Director) made aware of the Immediate Jeopardy regarding pharmacy concerns and opioid medications not being available for administration. 10. On 3-11-24 the facility conducted an emergency QA (Quality Assurance) meeting regarding all of the new pharmacy policies and procedures. 13. On 3-13-24 the pharmacy conducted an in-service with all nurses regarding medication pass guidelines for controlled substances. Date of Completion: 3/11/2024

Based on observation, interview, and record review, the facility failed to ensure a resident's pain was controlled, and assess pain on a daily basis for one of one reviewed for pain in the sample of three. These failures resulted in R2 having excruciating pain during wound care. Findings include: The facility's Pain-Clinical Protocol, dated 2008, documents, The staff will discuss significant changes in levels of comfort with the attending physician who will adjust interventions accordingly. This may include adjustments of regular and PRN (as needed) analgesic doses to find the best combination of effectiveness and tolerable side effects, or possible addition of non-pharmacological interventions. R2's Care plan, dated 11/14/23, documents, R2 has increased potential for complications and discomfort related to the diagnosis of arthritis. The care plan also documents the following interventions: Monitor and record any complaints of pain: location, duration, quantity, quality, alleviating factors, aggravating factors; Monitor and record any non-verbal signs of pain: (e.g. guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc.); Use pain relief measures: (distraction, imagery, relaxation, etc.) Evaluate/record/report effectiveness. R2's Physician's orders, dated 1/14-2/14/24, document that R2 has the following pain medication orders: oxycodone-acetaminophen 7.5-325 mg one tablet every six hours; ibuprofen 400 mg one tablet every eight hours; Tylenol 325 mg two tablets every four hours as needed for pain. R2's Pain Observation, dated 2/7/24, documents that R2 states that she has almost constant pain. R2's MAR (Medication Administration Record), dated 2/1-2/15/24, has no documentation of R2's pain being assessed on a daily basis with the administration of pain medication. On 2/13/24 at 11:13 a.m., R2 was alert leaning forward in her wheelchair. R2 stated I have two pressure ulcers on my backside. I have a really big area on my right calf. It is from a stocking thing that was way to tight and I told that CNA (Certified Nurse Aide) to not put it on. They tell me I need to lay down more, but I hate to use the (full mechanical lift) more than I need to I don't like that thing. It hurts so bad when they get me up and down. I've got a bad hip that if they move that leg it's instant awful pain. The hip needs replaced, but they won't do surgery on me. I absolutely dread when they change my dressings. The one on my leg is awful. It burns so bad when they do it. I swear every single time I cry. The one on my backside hurts when they do it as well. I feel like I'm going to cry, but I'm able to hold that one in normally. I just pray they would heal up so I wouldn't have to go through that pain. On 2/14/24 at 9:10 am,, R2 was alert lying in bed. R2 asked V3 (wound nurse) if V3 could do her buttocks wound dressing changes before doing her legs since it was so painful for the dressing changes on her legs. V2 (Director of Nursing) was also present during R2's wound care. R2 stated, I'm sorry I'm going to yell out and probably cry because these hurt so bad. V3 removed a silicone border foam dressing from R2's coccyx and R2's left ischium. V3 cleansed both wounds with normal saline. During the cleansing, R2 was grimacing. R2's coccyx wound was a open area with depth. The base of R2's coccyx pressure ulcer was 75% covered yellow gray tissue (slough). So it is undetermined as to how deep the actual wound is. V3 began to pack the coccyx wound, and R2 began to cry out, Ow (Ouch) it hurts. Please stop. Ow!. V3 replied with I'm sorry, and continued performing wound care. R2 continued to cry out until V3 covered the wound with a silicone border foam dressing. R2 also had an open area with depth to R2's left ischium. As V3 began packing that area, R2 started crying out in pain again until the wound was covered with the silicone border foam dressing. Then, V3 began to remove the gauze roll from R2's right leg, and R2 began to cry stating, I don't like this one it burns so bad! V3 proceeded to removed the dressing covering R2's right calf. R2 began to bite her blanket to muffle her crying out as tears were coming out of her eyes. She began to scream, Ow! What are you doing? Don't! Please stop it's burning so bad! R2's entire back of her right calf was a large open/raw area. V3 began to cleanse the wound with normal saline and R2 began yelling out again for V3 to stop because it was burning so bad. V3 covered the wound with (Sodium Chloride impregnated gauze dressing)and and ABD (abdominal) pad. Then, she covered it all with a gauze roll while R2 continued to cry out. After the treatment was completed R2 kept repeating, I'm so sorry I was crying and yelling those dressing changes just hurt so bad! On 2/15/24 at 9:40 a.m., V3 stated that prior to wound care, R2 had pain medication at 6:00 a.m. when she received Ibuprofen 400 mg and oxycodone-acetaminophen 7.5 -325 mg (milligrams). On 2/20/24 at 10:52 a.m., V4 (Registered Nurse) stated, (R2) has a lot of pain, especially in her hips and her legs. She cries out a lot still. She cries if we turn her, roll her, or even if someone bumps her wheelchair. When we do her dressing changes she complains a lot about the burning in her right calf. She will keep repeating, 'It burns. It burns.' She normally gets her scheduled oxycodone at 6:00 a.m., and then we do her dressing changes between 6:30-7:00 a.m. Even when we give it at that time she still complains about the wound care and positioning during it as well. She has a horribly bad hip. It hurts her more to lay down then be up in her wheelchair. On 2/20/24 at 10:45 a.m., V6 CNA stated that (R3) cries out in pain when they transfer her in the (full mechanical lift). She complains about her legs hurting her. She complains that her right calf burns and is painful pretty frequently. On 2/20/24 at 9:40 a.m., V5 (Nurse Practitioner) stated, I'm not aware that (R2) doesn't lay down because of it hurting during the transfer. She has a hip that she needs replaced, but the surgeons are not wanting to replace it, and it causes her pain with movement. I know that she struggles with pain during the dressing changes, especially her right calf dressing change. If her pain isn't under control with the oxycodone, I'm going to have to try something different. On 2/20/24 at 11:10 a.m., V2 stated, (R2) did cry out quite a bit during the dressing change last Thursday (2/15/24). I've never heard her cry out like that before, but we continued to do the wound care. She had her scheduled pain medication that morning, but she doesn't have anything PRN. The scheduled pain medication should cover her. She complains of the right calf wound burning with the dressing change. If someone complains of pain during a dressing change I just try to get it done faster so the pain will stop sooner.

Based on observation, interview, and record review, the facility failed to ensure a resident's care plan was reviewed and updated to include interventions to address their level of dependence for activities of daily living, including bed mobility, for one of three residents (R1) reviewed for care plans in a sample of three. This failure resulted in R1's care plan not including Minimum Data Set (MDS) assessment data which documented R1 required extensive assistance of two people for cares which also resulted in R1 falling out of bed while being cared for by only one staff member causing R1 to sustain two forehead lacerations and a fractured cervical vertebrae. Findings include: A Care Plans (Comprehensive) policy dated 4/2015 documents, An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. This policy also documents, Care plans are revised as changes in the resident's condition dictates. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is moderately cognitively impaired, requires extensive assistance of two people for bed mobility, toilet use, personal hygiene, and is totally dependent on two people for transfers. R1's current Care Plan documents that R1, is limited in her ability to move independently in the bed r/t (related to) decreased mobility and generalized weakness and requires a restorative bed mobility program. This same Care Plan does not include interventions to address R1's requirement to have two people provide extensive assistance with bed mobility, toilet use, or personal hygiene. R1's Occurrence Report dated 1/29/22 states that (R1) observed on floor with CNA (Certified Nurse Aide) attempting to hold resident up, blood noted on floor, and Staff was rolling resident (R1) to left side using (incontinence) pads as support. Staff had (R1) on left side and bed moved out to right and resident started to roll left, on to staff. Staff attempted to move oxygen concentrator but unsuccessful. Resident hit concentration with her head. This report further documents R1 sustained two lacerations to her forehead and a nondisplaced cervical spine fracture. On 2/9/22 at 3:05p.m. R1 was lying in bed with her eyes closed. R1 had two large lacerations situated vertically on the right side of R1's forehead. One laceration measured approximately 7cm (centimeters) long and the second one measured approximately 5cm long. R1 was wearing a neck brace around her neck. On 2/10/22 at 9:54a.m. V6 (Certified Nurse Aide/CNA) stated she was the CNA caring for R1 when R1 fell from the bed on 1/29/22. V6 stated that some CNAs use two people to provide incontinence care, which includes bed mobility, when caring for R1. V6 stated that she believes R1 is calmer when only one person is in the room providing care. V6 stated that because of this V6 does not use the assistance of another staff person when providing bed mobility, toileting, or personal hygiene to R1. V6 stated that on 1/29/22, while she was providing care for R1 by herself, V6 turned R1 to her side facing the window. V6 stated that she isn't sure if the bed moved, but something happened to cause R1 to tumble forwards out of bed and onto V6's lap. V6 stated that R1 hit her head on the oxygen machine during the fall causing two large lacerations to R1's forehead. V6 stated that she was not given any instructions to use two staff members while providing activities of daily living (ADL) care for R1, including bed mobility. V6 stated the only time two staff members are required to assist R1 is when R1 is transferred using the mechanical lift. On 2/10/22 at 11:30a.m. V1 (Administrator) stated that she recently became the Administrator for the facility after serving as the Director of Nurses for eight years. V1 verified that R1's MDS dated [DATE] documents that R1 requires extensive assistance of two staff for activities of daily living including bed mobility. V1 verified that R1's care plan does not indicate that R1 requires the extensive assistance of two staff for ADLs, including bed mobility. V1 stated R1's care plan should have included this information for how to provide R1's care. V1 stated that CNA staff do not have access to residents MDS assessments. V1 stated that CNA staff, including V6, do have access to each residents' care plan so they can review what interventions are required to care for them.

Based on observation, interview, and record review, the facility failed to ensure two staff assisted with bed mobility as assessed in the Minimum Data Set (MDS) assessment and failed to identify the root cause of a fall for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 falling off the bed while being provided bed mobility by one staff person and sustaining two lacerations to the forehead which required hospitalization for sutures and treatment for a nondisplaced fracture of R1's C6 spine. Findings include: An Accident and Incident Investigation Guidelines policy (undated) documents, An accident/incident investigation is not designed to find fault or blame, it is an analysis to determine causative factors that can be controlled or eliminated to prevent future occurrences, potential injuries or abuse. A Falls-Clinical Protocol policy dated 2005 documents, For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. This policy documents, Causes refer to factors that are associated with or that directly result in a fall, and The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is moderately cognitively impaired, requires extensive assistance of two people for bed mobility, toilet use, personal hygiene, and is totally dependent on two people for transfers. R1's current Care Plan documents that R1, is limited in her ability to move independently in the bed r/t (related to) decreased mobility and generalized weakness, and (R1) is at risk for falling R/T immobility, dependence on staff for bed mobility. R1's Facility Incident Report Form dated 1/29/22 documents that on 1/29/22 while R1 was lying on her left side during cares, R1's locked bed moved to the right causing R1 to roll out of bed and onto a staff member. This report documents that R1's head hit the oxygen machine during the fall causing two forehead lacerations and a nondisplaced fracture to the C6 cervical spine. R1's incident report form documents that the occurrence resolution was that R1's bed would be inspected and serviced by maintenance to fix any mechanical problems. R1's Occurrence Report dated 1/29/22 documents that, (R1) observed on floor with CNA (Certified Nurse Aide) attempting to hold resident up, blood noted on floor, and Staff was rolling resident to left side using (incontinence) pads as support. Staff had (R1) on left side and bed moved out to right and resident started to roll left, on to staff. Staff attempted to move oxygen concentrator but unsuccessful. Resident hit concentration with her head. This report further documents R1 sustained two lacerations to her forehead and a nondisplaced cervical spine fracture. R1's hospital Physician's progress notes dated 1/30/22 document that R1 sustained an acute head injury, a nondisplaced C6 (Cervical) vertebral body fracture and a right forehead scalp hematoma/laceration as a result of a fall at the facility. R1's CT (Computerized Tomography) Cervical Spine report dated 1/29/22 documents, Findings are suspicious for a nondisplaced fracture through the anterior superior endplate of C6. On 2/9/22 at 3:05p.m. R1 was lying in bed with her eyes closed. R1 had two large lacerations situated vertically on the right side of R1's forehead. One laceration measured approximately 7cm (centimeters) long and the second one measured approximately 5cm long. R1 was wearing a neck brace around her neck. V4 (Maintenance) entered R1's room to demonstrate that after R1's fall, he applied a block under R1's wheel at the end of her bed to prevent R1's locked bed from moving. The block was flat on the bottom but curved on top where the wheel sat on top of the block. V4 stated that he does not understand how R1's bed could have moved with the wheels locked. V4 stated R1's bed is brand new and has features which prevent the bed from moving easily when the wheels are in the locked position. V4 stated after R1's fall, he inspected R1's bed and had to use extreme pressure to cause R1's locked bed to move. V4 stated he can't understand how R1's bed could have moved with the wheels locked and during normal resident care activities. V4 stated that despite his difficulty moving R1's locked bed, he applied a block underneath R1's bed wheel to prevent it from accidentally moving during cares in the future. On 2/10/22 at 9:15a.m. V2 (Director of Nurses) stated she was R1's nurse the day R1 fell out of bed on 1/29/22. V2 stated V6 (Certified Nurse Aide/CNA) was providing cares for R1 without the assistance of another CNA. V2 stated that V6 was providing R1 with incontinence care and dressing her before getting R1 up in a chair for lunch. V2 stated that normally there are at least two if not three staff assisting with R1's cares. V2 stated she prefers that at least two staff are in R1's room during cares because of R1's size and because of R1's ADL (Activities of Daily Living) abilities. V2 stated that R1 is a larger resident requiring a bariatric mechanical lift and she also gets anxious during cares which makes R1 shaky. V2 stated that at times there will be two staff on one side of R1 and two staff on the other side to turn and reposition R1 for bed mobility. V2 stated, When I have helped with (R1) it has been difficult for (R1) to stay on her side. One time we had two (staff) on one side (of R1) and one on the other side. I felt safer that way so we could give her (R1) extra help. V2 stated, With incontinence care (for R1), I would have two (Staff). I would prefer two. V2 stated that on 1/29/22, V6 started hollering for help. V2 stated that when she entered R1's room, (R1) was lying on the floor. (V6) had worked herself out from under (R1) and was still down with (R1) trying to support (R1). V2 stated another nurse and a CNA came into the room to help. V2 stated they tried to move the bed out of the way so the stretcher could be brought into the room by paramedics. V2 stated R1's bed did not move freely. V2 stated that R1's bed also had an air mattress in place which was inflated to help prevent R1 from developing pressure ulcers. V2 stated that in her opinion, while V6 was trying to hold R1 up on her side, without assistance from another person, R1's air mattress inflated behind R1 pushing R1 out of the bed. V2 stated, It should have been two people, providing R1's cares because of R1's size, ADL abilities, and because of the air mattress. On 2/10/22 at 9:54a.m. V6 stated she was the CNA caring for R1 when R1 fell from the bed on 1/29/22. V6 stated she was the only person in R1's room providing care. V6 stated that some CNAs use two people to provide incontinence care for R1, which includes bed mobility. V6 stated that she believes R1 is calmer when only one person is in the room providing care. V6 stated that because of this, V6 does not use the assistance of another staff person when providing bed mobility, toileting, or personal hygiene to R1. V6 stated that on 1/29/22 while she was turning R1 in the bed while preparing to get her up for lunch, V6 turned R1 to her left side facing the window. V6 stated that she isn't sure if the bed moved, but something happened to cause R1 to tumble forwards out of bed and onto V6's lap. V6 stated that R1 hit her head on the oxygen machine during the fall causing two large lacerations to R1's forehead. V6 stated that she was not given any instructions to use two staff members while providing activities of daily living (ADL) care for R1, including bed mobility. V6 stated the only time two staff members are required to assist R1 is when R1 is being transferred using the mechanical lift. On 2/10/22 at 11:30a.m. V1 (Administrator) stated that she recently became the Administrator for the facility after serving as the Director of Nurses for eight years. V1 verified that R1's MDS assessment dated [DATE] documents that R1 requires extensive assistance of two staff for activities of daily living including bed mobility. V1 also verified that V6 was the only person in R1's room providing cares on 1/29/22 when R1 fell out of bed. V1 stated the facility concluded R1's fall was because R1's bed may have moved while the wheels were locked and while V6 was turning R1 in her bed. V1 verified that R1's MDS assessment, which was completed prior to R1's fall, documents R1 requires the extensive assistance of two people for activities of daily living including bed mobility.

Based on interview and record review, the facility failed to ensure a resident (R1) was not administered medications prescribed for another resident which affected one of four residents (R1) reviewed for significant medication errors in the sample of six. This failure resulted in R1 receiving another resident's prescribed medications and becoming ill with vomiting, loss of consciousness, decreased blood pressure, slow respirations and a decrease in blood oxygen saturation level and subsequently being transported to a local emergency room . This failure resulted in an Immediate Jeopardy. Findings include: The Facility Medication Administration Policy dated March 2014 states, Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates; Setting up doses for more than one (1) scheduled administration is not permitted; Medications or supplies intended for one resident will not be administered to another resident. The Pharmacy Policy and Procedure Manual dated April 24, 2017 states, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. R1's Progress notes dated 10/01/2021 at 11:12 a.m., document, (R1) received another resident's (R2's) medications at 800 a.m. this morning. At 830 a.m., (R1) was eating breakfast in the North Dining Room when staff noted (R1) to have lost consciousness and had an emesis (vomiting). (R1) was immediately taken to room and laid down in bed, (vital signs) were taken by a nurse and resident (R1) was noted to have low (blood pressure-86/44) and SpO2 (oxygen levels) <90%. 911 was called. EMS (emergency medical personnel) arrived at 8:50 a.m. Report given to them; All paperwork given along with list of medications (R1) had received. EMS left with resident at 9:00 a.m. (R1's) HCPOA (health care power of attorney) was notified at that time. MD (Physician) updated. R1's local hospital visit summary dated 10/1/2021 documents that R1 was seen in the emergency room with chief complaint, Received another resident's medications today at 8:00am, decreased level of consciousness along with vomiting. A facility incident report form dated 10/1/2021 documents: (R1) and (V3) RN (Registered Nurse) were involved with a medication error incident and that (R1) at 8:00 a.m., received medications that were not prescribed to R1 and were prescribed for R2. (R1's) Physician was notified immediately after. (R1) was sent to emergency room for evaluation (returned to facility that same day). On 10/1/2021, an investigation was conducted after (R1) received medications that were not prescribed to R1, the nurse (V3) was found to have not followed the facilities medication administration policy. A facility Medication Error Report dated 10/1/2021 documents: (V3, RN) gave (R2)'s 8:00 AM medications to (R1). The following medications were listed on the Medication Error report indicating these medications has been administered to R1: [MEDICATION(S)] (antipsychotic) 50 milligram (mg), Aspirin 81 mg, [MEDICATION(S)] (blood pressure) 20 mg, Calcium 600 mg, [MEDICATION(S)] (blood pressure) 25 mg, [MEDICATION(S)] Extended Release (blood pressure) 24 hour 240 mg, [MEDICATION(S)] 150 mg, [MEDICATION(S)], Magnesium [MEDICATION(S)] 27 mg, Vitamin D3 4000 Unit, Vitamin C 500 mg, [MEDICATION(S)] 100 mg, [MEDICATION(S)] (antidepressant) 50 mg, [MEDICATION(S)] 17 gram, [MEDICATION(S)] (blood pressure) 25 mg, and Probichew 1 gram. (R1) sent to hospital. (V3 RN) educated and then sent home. In-service provided on 10/1/2021 to all nurses on medication administration. All pre-poured medications discarded. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's POS dated 10/1/2021 documents that R2's medications ordered for 8:00 a.m. on 10/1/2021 were [MEDICATION(S)] (antipsychotic) 50 mg, Aspirin 81 mg, [MEDICATION(S)] (blood pressure) 20 mg, Calcium 600 mg, [MEDICATION(S)] (blood pressure) 25 mg, [MEDICATION(S)] Extended Release (blood pressure) 24 hour 240 mg, [MEDICATION(S)] 150 mg, [MEDICATION(S)], Magnesium [MEDICATION(S)] 27 mg, Vitamin D3 4000 Unit, Vitamin C 500 mg, [MEDICATION(S)] 100 mg, [MEDICATION(S)] (antidepressant) 50 mg, [MEDICATION(S)] 17 gram, [MEDICATION(S)] (blood pressure/fluid retention) 25 mg, and Probichew 1 gram and R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) Assessment, Brief Interview for Mental Status (BIMs) dated 7/15/2021, documents that R1 scored a 9, indicating R1 had moderately impaired cognition. On 10/13/2021 at 9:00 a.m., V3, Registered Nurse, stated that on 10/1/2021 she began the 8:00 a.m. medication pass between 6:00 a.m. and 7:00 a.m. by opening and pre-pouring all of the medications for each resident on V3's hall and then put them in individual pill cups, labeled with resident names, ahead of time . V3 then put the pill cups in the drawer, so she wouldn't be so slow during medication pass. V3 stated that during the medication pass, she must have picked up R2's medications and giventhem to R1. R1 took the medications because R1 is cognitively impaired. V3 then stated, a dining room staff came and reported that R1 just had an emesis (vomiting) and that R1 wasn't waking up. V3 stated that R1 was unconscious, at first, with decreased awareness. R1 wasn't responding to any stimulation, had decreased respirations, was moaning and was not verbally responsive. A wheelchair was brought in and staff got R1 to room and took vitals . R1's blood pressure was very low (86/44). V3 then stated that another nurse came in and assisted V3. After about 20 or 30 minutes, V3 went back to the medication cart to finish the medication pass. That is when V3 realized she had given R1 someone else's medications. V3, RN then stated that she immediately reported the medication error to V2 (Director of Nursing) and 911 was called. V3 stated that R1 was sent to a local emergency room and R1 returned to the facility that evening and has had no adverse effects as of today, which has been 13 days. V3 also stated that she was given immediate education by V2 and then V3 left for the day. V3 stated that she knew better and should never have pre-poured medications for all the residents ahead of time. V3 stated, That (Pre-pouring medications) goes against what our medication policy states and I should have done one resident at a time. On 10/13/2021 at 9:25 a.m., V5, Nurse Practitioner stated, Obviously, those medications (given by V3 on 10/1/21) were not ordered for (R1) and initially did some harm as (R1) vomited, had a loss in consciousness, low blood pressure, was not verbally responsive and a few other immediate reactions, but (R1) was returned that same day and has had no adverse effects. (R1) was monitored for several days once returned and the Pharmacist gave us signs and symptoms to watch for after ingesting those medications. (R1) has been stable since that day with no long-[MEDICATION(S)] effects. An Immediate Jeopardy was identified on 10/14/2021 at 2:45 p.m. The Immediate Jeopardy began on 10-1-21 when the facility failed to ensure facility policies and procedures were followed during medication pass resulting in a resident (R1) being administered medications prescribed for another resident. This failure resulted in V3 (Registered Nurse) pre-pouring R1, a cognitively impaired resident, and R2's medications, administering R2's medications to R1 and R1 ingesting R2's medications and becoming ill with emesis, loss of consciousness, a drop in blood pressure, slow respirations, decreased oxygen saturation and being transported to a local emergency room . On 10/15/2021 at 10:00 a.m., V1 (Administrator) was notified of the Immediate Jeopardy. On 10/13/21, the surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: On 10/1/21, R1 was sent to the local emergency department for evaluation due to ingesting R2's medications. R1 returned in stable condition with no new orders. On 10/1/21, V3 (Registered Nurse) received education regarding the facility's Medication Administration policy and was suspended from resident care. On 10/1/21, V2 (Director of Nursing) checked V3's Medication cart to ensure no pre-poured medications were present. All pre-poured medications were destroyed and medications were administered according to facility policy. On 10/1/21, V2 (Director of Nursing) in-serviced all staff nurses on the facility's policy and procedure for Medication Administration and following the Five Rights of administering medications. On 10/1/21, V2 (Director of Nursing) conducted a Quality Assurance (QA) audit on all of the facility medication carts to ensure there were no pre-poured medications.

Based on interview and record review the facility failed to ensure a resident was not administered a medication prescribed for another resident for one of one residents (R74) reviewed for significant medication errors in a sample of 22. This failure resulted in R74 receiving a diabetic medication meant for another resident which caused R74 to have severe low blood sugar levels, [MEDICAL CONDITION] and [MEDICAL CONDITION] resulting in prolonged hospitalization . Findings include: A Pharmacy Policy and Procedure Manual dated (MONTH) 24, (YEAR) page 37 states, Medications are administrated as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Page 38 of the policy states, Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. Page 39 of the policy states, The resident's MAR (Medication Administration Record) is initialed by the person administrating the medication, in the space provided under the date, and on the line for that specific medication dose administration. A facility Medication Administration Policy dated (MONTH) 2014 states, 19. The Medication Administration Record will be verified against the physician's orders [REDACTED]. Medications shall be recorded on the MAR promptly after each administration by the individual who administered the drug. A current [MEDICATION NAME] drug disease interactions sheet from Drugs.com documents, [MEDICATION NAME] is a sulfonylureas classification and states, patients with impaired liver and/or renal function treated with sulfonylureas may be exposed to higher serum drug concentrations, which can increase the potential for severe hypoglycemic episodes induced by these agents. [DIAGNOSES REDACTED], if it occurs during treatment, may be prolonged in these patients because of slow metabolism and/or excretion of the drugs. R74's Face Sheet documents [DIAGNOSES REDACTED]. R74's Facesheet does not include a [DIAGNOSES REDACTED]. On 06/03/18 at 10:21 a.m., R74 stated on 4/28/18 R74 was having a [MEDICAL CONDITION] of some kind and had to be sent out to a hospital. R74 later found out it was actually due to low blood sugar from an incorrect medication given to R74 that began with a G. R74 stated that 911 was called and he was taken to the hospital. R74 further stated that he was hospitalized from [DATE] through 5/14/18 at a local hospital in the intensive care unit (ICU). R74 stated that his blood sugar was as low as 20mg/dl (milligrams per deciliter) during his hospital stay. Progress notes for R74 dated 4/28/18 at 8:42 a.m., states, 7:00 a.m. called to (R74's) room per C.N.A. (Certified Nurse Aide). (R74) was jerking, unresponsive. B/P 72/40 per palpitation. Diaphoretic at top of head. Blood sugar 48. (V14) physician called and ordered to send to (local ER emergency room ). Ambulance called, wife and daughter were notified. 7:15 a.m., ambulance here. Ambulance started IV and was given medicine per IV. Blood sugar up to 125. Resident was arousing and stated felt like he was having a stroke. Ambulance wanted (V14) called to see if wanted resident still sent d/t was arousing. (V14) was called and ordered to send resident to ER due to this was unusual for resident; DON notified. Progress notes dated 4/28/18 at 1:27 p.m., for R74 documents: Resident being admitted to local hospital; [DIAGNOSES REDACTED]. A facility incident report dated 4/28/18 at 8:40 a.m., documents that R74 had been observed to be unresponsive with jerking movements, blood pressure 72/40 palpable, and blood glucose 48. A facility incident report form dated 4/30/18 at 8:30 a.m., documents that R74 was admitted to the hospital with [REDACTED]. R74's local hospital history and physical and emergency records dated 4/28/18 states (R74) resides at a nursing home, apparently was recently started on [MEDICATION NAME]. Blood sugars dropped down profoundly and (R74) was having apparently [MEDICAL CONDITION] activity and he was transferred to the ER, had to be started on a glucose drip and transferred to the ICU (intensive care unit). Assessment and Plan, 1) Refractory [DIAGNOSES REDACTED], almost certainly secondary to [MEDICATION NAME]. ED Assessment: (R74) was brought in from his rehabilitation facility for altered mental status and hypoglycemic episodes. Given the high probability of a clinically significant life-threatening deterioration, (R74) required the highest level of care to intervene emergently. (R74) will be admitted to the ICU for the ongoing hypoglycemic episodes associated with [MEDICAL CONDITION] activity. A local hospital discharge summary from V14 physician for R74's hospital stay of 4/28/18 through 5/14/18 states, (R74) will be discharged to (previous facility) today. (R74) was dialyzed and stable, seen and examined, evaluated earlier today, See history and physical and follow up notes. (R74) came in with profound [DIAGNOSES REDACTED].[MEDICAL CONDITION] at that time was ruled out. We did not think he had a depletion of glycogen stores. There was a question about receiving oral hypoglycemics. The issue is still in flux as the nursing home is convinced that even though the order got on the wrong chart, he was never given an oral hypoglycemic, but he certainly acted that way clinically as his sugar continued to go down repeatedly in spite of multiple amps of D50 (fluids given intravenously with [MEDICATION NAME]) and he was started on D10. (R74) also was hypotensive, which is not new, but intermittently required intensive care management for close monitoring of his blood sugar and management of this blood pressure. A letter (undated) from V17 Pharmacist of the prescribing pharmacy states The dose pack for R74 for the dates of 4/27/18 and 4/28/18 was delivered to the facility on [DATE] late evening or just after midnight and contained [MEDICATION NAME] 10 mg along with two other medications [MEDICATION NAME] 800-Ultra D and Fludrocortisone for 8:00 a.m. and 5:00 p.m. administration on 4/27/18. On 6/5/18 at 10:30 a.m., V16 Pharmacist stated that an electronic order was received from the facility for resident R74 for [MEDICATION NAME] 10 mg and was processed and shipped on 4/26/18. A medication error report dated 4/30/18 documents that a transcription error for [MEDICATION NAME] 10 mg was entered into Electronic Medical Record and added to the physician order [REDACTED]. On 06/05/18 at 9:40 a.m., V13 Licensed Practical Nurse (LPN) stated, I was instructed by V2, Director of Nursing (DON) to write the medication [MEDICATION NAME] on R74's medication administration record on 4/26/18 due to a new order that was transcribed by V2 from the Physician order [REDACTED]. V13 further stated that R74 is not diabetic. On 6/5/18 at 10:03 a.m., V14 Physician stated that V14 has never given an order for [REDACTED]. On 6/5/18 at 2:45 p.m., V2 Director of Nursing stated that on 4/26/18 V2 transcribed a physician's orders [REDACTED]. V2 stated, The medication ([MEDICATION NAME]) was for a different resident.

Based on record review and interview the facility failed to provide physician ordered scheduled medication for one of three residents (R1) reviewed for medication availability in the sample of six. This failure resulted in R1 having increased negative behaviors, increased nervousness, and an altered mental status, which required treatment at the emergency department for benzodiazepine withdrawal. Finding include: The facility's Medication Administration Policy dated 03/2014 documents, Drugs will be administered in accordance with the orders of licensed medical practitioners. Medical errors, drug side effects, and adverse reactions will be immediately reported to the Director of Nursing and the pharmacist. The error or clinical symptoms will be documented in the clinical record and on the facility designated form. 1. R1's physician's orders [REDACTED]. R1's Medication Administration Record [REDACTED]. R1's Progress Notes dated 6-8-17 at 10:50 p.m. and signed by E12 (Registered Nurse/RN), document R1 started having increased behaviors of yelling at R6, becoming physically aggressive toward R6 and staff, having increased paranoia, and slamming a walker. These same notes document staff attempted redirection of R1 which was unsuccessful, 911 was called, and R1 was sent to the emergency room for evaluation. R1's Progress Notes dated 6-10-17 at 6:15 a.m., document R1 was argumentative with staff, interrupting staff report, and was unable to be redirected. R1's Progress Notes dated 6-11-17 at 4:38 p.m., documents R1 was yelling at certified nursing assistants, cursing, and, threw a shoe. R1's Progress Notes dated 6-13-17 at 4:30 a.m. and signed by E12 (RN), document R1 spent the entire shift yelling at peers and staff, was physical with the writer (E12/RN) and with R4, was standing over R4 yelling with a clenched fist, Shut the f*** up God d*** it, and was verbally aggressive to R4 and R5 for using the bathroom. This same Progress Note documents R1 was redirected without success and R1 was sent to the emergency room for evaluation. R1's ED (Emergency Department) Record dated 6-8-17 documents R1 presented to the ED with combativeness towards staff members and agitation. This same note indicates R1 had not been receiving her scheduled [MEDICATION NAME] and was given [MEDICATION NAME] at the ED. R1 then calmed down and was sent back to the facility with orders to continue R1's normal medication regimen. R1's Hospital ED (Emergency Department) assessment dated [DATE] documents R1 had a change in mental status and has not had [MEDICATION NAME] for several days. R1's ED Discharge instructions dated 6-13-17 and signed by Z7 (R1's ED Attending Physician) document R1 had an Altered Mental Status and Agitation due to a Benzodiazepine ([MEDICATION NAME]) withdrawal and an order was given to resume R1's normal dose of [MEDICATION NAME]. On 6-20-17 at 8:25 a.m., Z2 (Emergency Department Registered Nurse) stated, (R1) came to the emergency department with behaviors after not receiving her scheduled [MEDICATION NAME] for days prior. There is no reason why (R1) has not had her scheduled [MEDICATION NAME] at the facility and has to come to the emergency department on two different occasions within a week to get the [MEDICATION NAME]. On arrival to the emergency department on 6-13-17, (R1) was agitated and combative with staff. (R1) was a fall risk and was trying to hit anyone she could. I gave (R1) [MEDICATION NAME]. (R1) calmed down and the agitation was relieved after giving the [MEDICATION NAME]. (Z7/Emergency Department Attending Physician) said (R1's) behaviors were due to benzodiazepine withdrawal. After receiving [MEDICATION NAME] at the emergency room (R1) returned to baseline status and was returned to the facility with orders to ensure (R1) receives ordered [MEDICATION NAME]. On 6-19-17 at 9:30 a.m., E5 (Certified Nursing Assistant/CNA) stated, (R1's) behaviors have gotten a lot worse since a few weeks ago. There is no re-directing her anymore. On 6-19-17 at 9:35 a.m., E4 (RN) stated, (R1's) behaviors worsened when she was out of [MEDICATION NAME]. (R1) would get more physical and yell more. (R1) could not be re-directed. (R1) required being sent to the emergency room for treatment several times when she was out of her [MEDICATION NAME]. On 6-20-17 at 10:45 a.m., E8 (CNA) stated, Over the last couple of weeks (R1's) behaviors are worse. (R1) gets agitated more easily and yells more. On 6-20-17 at 11:00 a.m., E9 (CNA) stated, (R1's) behaviors have worsened over the last two to three weeks. (R1) is loud and rude. (R1) has been saying 'I am nervous.' (R1) has been very anxious. On 6-20-17 at 11:15 a.m., Z6 (R1's Power Of Attorney) stated, (R1) has had increased agitation. The emergency department doctor said (R1) had been out of her medication for several days and it caused (R1) to have behaviors. (R1) had never required emergency room treatment before for behaviors. It is disturbing to me that the facility let (R1's) [MEDICATION NAME] run out and (R1) had to go to the hospital to get it. (R1) should not have had to suffer withdrawal and behaviors because of running out of [MEDICATION NAME]. On 6-20-17 at 12:30 p.m., E2 (Director Of Nursing) stated, (R1) has been out of scheduled [MEDICATION NAME] from 6-4-17 through 6-13-17 and 5-1-17 through 5-4-17. We have had multiple issues with the pharmacy sending the [MEDICATION NAME], and with the physician signing a prescription refill. That is why (R1) has not had her [MEDICATION NAME]. I was never informed that (R1) did not have her [MEDICATION NAME]. A Medication Incident form has never been completed from the nursing staff for R1 being out of [MEDICATION NAME]. According to the facility's medication administration policy a medication incident should have been done. I should have been told within twenty four hours of the first missed dose. No staff have reported to me that (R1's) agitation had gotten worse. If I had known I would have assessed her and got a psychiatrist involved. The cause of (R1's) emergency room visits and increased agitation was due to (R1) not getting her [MEDICATION NAME] as ordered. On 6-20-17 at 1:00 p.m., E1 (Administrator) stated, (R1) should have never went without her [MEDICATION NAME]. We have had way to many issues with the pharmacy and communication. On 6-21-17 at 11:30 a.m., E12 (RN) stated, (R1's) behaviors had worsened since she wasn't getting her [MEDICATION NAME]. I have never noticed (R1's) behaviors to be this extreme before missing her [MEDICATION NAME], and I took care of her at the facility prior to this facility.

Based on observation, interview and record review, the facility failed to prevent the mistreatment and abuse of a resident by staff, failed to establish a resident sensitive environment, failed to identify resident behaviors as potential risk factors for abuse, failed to ensure all staff were knowledgeable on appropriate approaches to redirect resident behavior, and failed to follow Operational Policies and Procedures regarding abuse, for one of six (R21) residents reviewed for abuse, in a sample of 15. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/26/13, the facility remains out of compliance at a Severity Level II as the facility continues to monitor the effectiveness of training regarding Abuse Prevention. Findings include: On 3/26/13 at 1:57 p.m., E4 (Certified Nursing Assistant) and E5 (Certified Nursing Assistant) were preparing to transfer R21 from the wheelchair to the bed for incontinence care. R21 repeatedly stated she did not want to lay down in bed and that she preferred to remain upright in the wheelchair. E4 instructed R21 that they would be laying her down in the bed for a few minutes, and that R21 could get back up in the wheelchair when they were finished with incontinence care. R21 continued to state, "No, I don't want to lay down" and "leave me alone." At that point, E4 and E5 each hooked their arms underneath R21's axilla, lifted R21 up out of the wheelchair. E4 grabbed the elastic waistband of R21's pants with her left hand and pulled upwards on R21's pants as they lifted R21 up out of the wheelchair and into the bed. R21's feet barely touched the floor and R21 did not bear any weight during the transfer. Throughout the transfer, R21 repeatedly stated "leave me alone" and "stop it." E4 and E5 proceeded to situate R21 in the bed and E4 started to pull down R21's pants. R21 began to squirm in the bed and E5 used her hands to hold R21's forearms against her chest in an attempt to keep her still. R21 repeatedly yelled throughout the incontinence care, "stop it", "you're hurting me" and "why do you do that." E5 did not speak to R21, attempt to redirect or calm R21 throughout the incontinence care and continued to hold R21's arms close to her chest for several minutes, until R21 was turned to the right side. E4 did not attempt to calm or redirect R21, did not stop the incontinence care and repeatedly wiped R21's buttocks and perineum vigorously. E4 stated, to R21, "I don't want to do this anymore than you want it done." Once positioned to the right side, R21 continued to yell, "you're hurting me...STOP." At that point, E4 stated to R21, in a stern voice, "HEY!" E6 (Certified Nursing Assistant) then entered the room, with additional incontinence supplies and was present throughout the remainder of incontinence care. As E4 began applying protective cream to R21's buttocks, R21 cried out, "please stop!" and E4 yelled back at R21, "No, you stop!" Upon completion of incontinence care, R21 was left in her bed and was not returned to her wheelchair, as previously requested. On 3/26/13 at 2:15 p.m., upon the completion of incontinence care, E4 stated "nothing will redirect her (R21). Sometimes, if you leave and come back, (R21) will respond better, but it depends on her mood." On 3/26/13 at 3:10 p.m., E1 (Administrator/Abuse Coordinator) was notified of the 1:57 p.m. incident with R21, E4, E5 and E6. E1 stated nothing had been reported by staff present in the room during the incident, as potential abuse or mistreatment. E1 immediately began an investigation in to the incident. Attempts to call E4 and E5 for interviews were unsuccessful. A physician's orders [REDACTED]. A Plan of Care dated 1/14/13, documents R21 has an "Altered Thought Process" and "Depression", but does not indicate R21 has any aggressive behaviors. The 1/14/13 Plan of Care, under "Altered Thought Process", instructs staff to "reorient/redirect, speak slowly/clearly, allow time to respond, explain procedures." On 3/27/13 at 10:40 a.m., E7 (Licensed Practical Nurse) stated R21's aggressive behaviors and resistance to care have gotten worse over the last two months. On 3/27/13 at 12:42 p.m., E3 (Assistant Director of Nursing) stated it is known that R21 can often be resistive to cares, be verbally aggressive and strike out. E3 stated R21's Plan of Care should identify specific approaches for staff to utilize when R21 is being aggressive or resistive to cares. On 3/27/13 at 9:35 a.m., E8 (Psycho/Social Rehabilitation Coordinator) stated "when notified of a resident's behaviors or resistance to care", he will "assist in developing appropriate care plan interventions" related to those specific behaviors. E8 stated he was "unaware" R21 was verbally/physically resistive to cares, as it was not communicated to him by staff. On 4/01/13 at 12:14 p.m., Z3 (Spouse), who was present outside the door of R21's room on 3/26/13 at 1:57 p.m., stated he could hear R21 yelling. Z3 stated R21 "often gets like that" and it's "upsetting" for him to hear R21 yell over and over that way. The facility policy, titled "Abuse Prevention Program", documents "This facility prohibits mistreatment, neglect or abuse of its residents by:...orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect, and abuse; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment..." The "Abuse Prevention Program" policy, further documents abuse as "the willful infliction of injury, unreasonable confinement, intimidation or punishment with the resulting physical harm, pain, or mental anguish" and verbal abuse as "the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents...." On 3/27/13 an Immediate Jeopardy was identified to have begun on 03/26/13 when staff failed to establish a resident sensitive environment, used disparaging language towards R21, and used physical force to hold down R21's arms. E1 was informed of the Immediate Jeopardy on 3/27/12 at 3:00 p.m. The surveyor confirmed through observation, interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. On 3/26/13, R21 was assessed for any injury and/or negative outcomes. Z2 (Physician) was notified of the incident, in addition to the family representative. Staff continued to monitor R21 for any adverse reactions/outcomes. 2. On 3/26/13, R4 and R5 were suspended pending the investigation of the allegation. 3. On 3/27/13, E6 was suspended and given a one-to-one inservice by E1 on facility Abuse and Neglect Policies and Procedures, stressing the impotence of the staff obligation to prevent and report abuse immediately to the Administrator. 4. On 3/27/13, the facility identified all residents as having the potential to be affected by this alleged deficient practice. 5. On 3/27/13, all staff were inserviced regarding the facility's Abuse and Neglect Policies and Procedures. This staff training will include specific information on: a. Sensitivity to resident rights and resident needs; b. What constitutes abuse, neglect and misappropriation of resident property; c. Staff obligations to prevent and report abuse. 6. On 3/27/13, a monitoring tool was implemented to assure that measures described are effective and ongoing. A Quality Assurance audit tool will be completed on a random sample of 10 employees weekly for 60 days to ensure the employees knowledge of the Abuse and Neglect Policies and Procedures.

Based on observation, interview and record review, the facility failed to ensure staff reported mistreatment and abuse of a resident by staff and failed to follow Operational Policies and Procedures regarding abuse, for one of six (R21) residents reviewed for abuse, in a sample of 15. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/26/13, the facility remains out of compliance at a Severity Level II as the facility continues to monitor the effectiveness of training regarding Abuse Prevention. Findings include: On 3/26/13 at 1:57 p.m., E4 (Certified Nursing Assistant) and E5 (Certified Nursing Assistant) were preparing to transfer R21 from the wheelchair to the bed for incontinence care. R21 repeatedly stated she did not want to lay down in bed and that she preferred to remain upright in the wheelchair. E4 instructed R21 that they would be laying her down in the bed for a few minutes, and that R21 could get back up in the wheelchair when they were finished with incontinence care. R21 continued to state, "No, I don't want to lay down" and "leave me alone." At that point, E4 and E5 each hooked their arms underneath R21's axilla, lifted R21 up out of the wheelchair. E4 grabbed the elastic waistband of R21's pants with her left hand and pulled upwards on R21's pants as they lifted R21 up out of the wheelchair and into the bed. R21's feet barely touched the floor and R21 did not bear any weight during the transfer. Throughout the transfer, R21 repeatedly stated "leave me alone" and "stop it." E4 and E5 proceeded to situate R21 in the bed and E4 started to pull down R21's pants. R21 began to squirm in the bed and E5 used her hands to hold R21's forearms against her chest in an attempt to keep her still. R21 repeatedly yelled throughout the incontinence care, "stop it", "you're hurting me" and "why do you do that." E5 did not speak to R21, attempt to redirect or calm R21 throughout the incontinence care and continued to hold R21's arms close to her chest for several minutes, until R21 was turned to the right side. E4 did not attempt to calm or redirect R21, did not stop the incontinence care and repeatedly wiped R21's buttocks and perineum vigorously. E4 stated, to R21, "I don't want to do this anymore than you want it done." Once positioned to the right side, R21 continued to yell, "you're hurting me...STOP." At that point, E4 stated to R21, in a stern voice, "HEY!" E6 (Certified Nursing Assistant) then entered the room, with additional incontinence supplies and was present throughout the remainder of incontinence care. As E4 began applying protective cream to R21's buttocks, R21 cried out, "please stop!" and E4 yelled back at R21, "No, you stop!" Upon completion of incontinence care, R21 was left in her bed and was not returned to her wheelchair, as previously requested. On 3/26/13 at 3:10 p.m., E1 (Administrator/Abuse Coordinator) was notified of the 1:57 p.m. incident with R21, E4, E5 and E6. E1 stated nothing had been reported by staff present in the room during the incident, as potential abuse or mistreatment. E1 immediately began an investigation in to the incident. Attempts to call E4 and E5 for interviews were unsuccessful. On 4/01/13 at 10:03 a.m., E1 stated, "if the incident occurred as reported to him", he would have expected (R5 or R6) to report the occurrence as potential abuse to him immediately. A physician's orders [REDACTED]. A Plan of Care dated 1/14/13, documents R21 has an "Altered Thought Process" and "Depression", but does not indicate R21 has any aggressive behaviors. The 1/14/13 Plan of Care, under "Altered Thought Process", instructs staff to "reorient/redirect, speak slowly/clearly, allow time to respond, explain procedures." The facility policy, titled "Abuse Prevention Program", documents "This facility prohibits mistreatment, neglect or abuse of its residents by:...orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect, and abuse; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment..." The facility policy, titled "Abuse Prevention Program", documents "Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or misappropriation of property to the administrator or an immediate supervisor, who must then immediately report it to the administrator." On 3/27/13 an Immediate Jeopardy was identified to have begun on 03/26/13 when staff failed to notify the Administrator of disparaging language towards R21, and use of physical force to hold down R21's arms. E1 was informed of the Immediate Jeopardy on 3/27/12 at 3:00 p.m. The surveyor confirmed through observation, interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. On 3/26/13, R21 was assessed for any injury and/or negative outcomes. Z2 (Physician) was notified of the incident, in addition to the family representative. Staff continued to monitor R21 for any adverse reactions/outcomes. 2. On 3/26/13, R4 and R5 were suspended pending the investigation of the allegation. 3. On 3/27/13, E6 was suspended and given a one-to-one inservice by E1 on facility Abuse and Neglect Policies and Procedures, stressing the impotence of the staff obligation to prevent and report abuse immediately to the Administrator. 4. On 3/27/13, the facility identified all residents as having the potential to be affected by this alleged deficient practice. 5. On 3/27/13, all staff were inserviced regarding the facility's Abuse and Neglect Policies and Procedures. This staff training will include specific information on: a. Sensitivity to resident rights and resident needs; b. What constitutes abuse, neglect and misappropriation of resident property; c. Staff obligations to prevent and report abuse. 6. On 3/27/13, a monitoring tool was implemented to assure that measures described are effective and ongoing. A Quality Assurance audit tool will be completed on a random sample of 10 employees weekly for 60 days to ensure the employees knowledge of the Abuse and Neglect Policies and Procedures.

Based on record review and interview, the facility failed to ensure staff immediately reported mistreatment and abuse of residents by staff and failed to follow Operational Policies and Procedures regarding abuse, for one of eight (R31) residents reviewed for abuse, in a sample of eight, and for two (R36, R37) residents in the supplemental sample. This failure had the potential to affect all 57 residents who were in the facility from 4/28/13 through 5/01/13. Findings include: On 6/11/13 at 1:20 p.m., E5 (Certified Nursing Assistants) stated, on the evening of 4/28/13, E6 (Certified Nursing Assistant) was assisting R37 to bed. E5 observed R37 call E5 a "Son of a B****" and E5 attempted to calm R37 so he would not exhibit any further verbal behaviors. E5 stated E6, then "got in (R37's) face" and yelled, "I'm a worthless Son of a B**** and I'm not going to help you." E5 stated she raised R37 up into the mechanical lift to transfer R37 into bed and E6 began "ramming" the mechanical lift repeatedly to get it into place, with R37 in it. After this incident, E5 was in R36's room preparing to get R36 ready for bed. E5 stated E6 came into the room and picked R36 up under (R36's) arms out of the wheelchair and "threw (R36) into the bed." E5 stated R36 cried out, "Please, don't hurt me." E5 stated she "should have reported (E6) right away, but didn't." E5 stated she did just receive training on the types of abuse and who/when to report abuse to. E5 stated she chose not to report E6 on 4/28/13, because she was intimidated by E6 and she had "told on him before" to the previous Administrator, but nothing happened. E5 stated she did tell E4 (Registered Nurse), on 5/02/13, what she observed E6 do to R36 and R37 on 4/28/13. E5 stated E4 immediately contacted E1 (Administrator) by phone and had her give a detailed report of what had occurred 4/28/13. On 6/11/13 at 1:00 p.m., E4 stated she was on break with E5 and E7 (Certified Nursing Assistant) on 5/02/13. E4 stated E5 informed her E6 had yelled and "cussed" at R37 when they were putting R37 to bed on 4/28/13. E5 also informed E4 that E6 had picked up R36 out of the wheelchair and "bounced (R36) onto the mattress" that same night. E7 then informed E4 that, on 4/28/13, she observed E6 "push (R31's) head down into the bed" and tell him to "go to f***ing sleep." E4 stated she immediately encouraged E5 and E7 to report E6's actions to E1, and they did via phone. On 6/11/13 at 2:00 p.m., E1 stated E5 and E7 should have reported E6's actions on 4/28/13, "right away" and they were reprimanded and given further training regarding the reporting of abuse. E1 stated E6 did work two subsequent shifts (4/30/13 and 5/01/13) after the alleged abuse, but was suspended on 5/02/13. E1 fully investigated the alleged abuse by E6. However, E1 was unable to substantiate the abuse due to a lack of witnesses and interviews with R31, R36, and other residents. E6 is no longer employed by the facility for "other reasons based on his treatment of [REDACTED]. An Abuse Protection Investigation Procedure report, dated 5/02/13, documents E1 investigated three separate allegations of abuse by E6. These allegations were reported by E5 and E7, on 5/02/13, as occurring on the second shift of 4/28/13. The Abuse Protection Investigation Procedure report documents, E5 and E7 did not report the abuse timely because, "(E5) wasn't sure the new administrator would do anything about (E6) ... ", and "(E7) was afraid of (E6) ....(and)didn't know if this administrator would handle the situation (with E6) or let it continue." The facility policy, titled "Abuse Prevention Program", documents "This facility prohibits mistreatment, neglect or abuse of its residents by:...orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect, and abuse; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment..." The "Abuse Prevention Program" policy further documents, "Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or misappropriation of property to the administrator or an immediate supervisor, who must then immediately report it to the administrator." The Resident Census and Condition Report, dated 4/28/13 through 5/01/13, documents there were a total of 57 residents in the facility.

Based on observation, interview and record review, the facility failed to ensure staff intervened during the mistreatment and abuse of a resident and failed to follow Operational Policies and Procedures regarding resident protection from abuse, for one of six (R21) residents reviewed for abuse, in a sample of 15. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/26/13, the facility remains out of compliance at a Severity Level II as the facility continues to monitor the effectiveness of training regarding Abuse Prevention. Findings include: On 3/26/13 at 1:57 p.m., E4 (Certified Nursing Assistant) and E5 (Certified Nursing Assistant) were preparing to transfer R21 from the wheelchair to the bed for incontinence care. R21 repeatedly stated she did not want to lay down in bed and that she preferred to remain upright in the wheelchair. E4 instructed R21 that they would be laying her down in the bed for a few minutes, and that R21 could get back up in the wheelchair when they were finished with incontinence care. R21 continued to state, "No, I don't want to lay down" and "leave me alone." At that point, E4 and E5 each hooked their arms underneath R21's axilla, lifted R21 up out of the wheelchair. E4 grabbed the elastic waistband of R21's pants with her left hand and pulled upwards on R21's pants as they lifted R21 up out of the wheelchair and into the bed. R21's feet barely touched the floor and R21 did not bear any weight during the transfer. Throughout the transfer, R21 repeatedly stated "leave me alone" and "stop it." E4 and E5 proceeded to situate R21 in the bed and E4 started to pull down R21's pants. R21 began to squirm in the bed and E5 used her hands to hold R21's forearms against her chest in an attempt to keep her still. R21 repeatedly yelled throughout the incontinence care, "stop it", "you're hurting me" and "why do you do that." E5 did not speak to R21, attempt to redirect or calm R21 throughout the incontinence care and continued to hold R21's arms close to her chest for several minutes, until R21 was turned to the right side. E4 did not attempt to calm or redirect R21, did not stop the incontinence care and repeatedly wiped R21's buttocks and perineum vigorously. E4 stated, to R21, "I don't want to do this anymore than you want it done." Once positioned to the right side, R21 continued to yell, "you're hurting me...STOP." At that point, E4 stated to R21, in a stern voice, "HEY!" E6 (Certified Nursing Assistant) then entered the room, with additional incontinence supplies and was present throughout the remainder of incontinence care. As E4 began applying protective cream to R21's buttocks, R21 cried out, "please stop!" and E4 yelled back at R21, "No, you stop!" Upon completion of incontinence care, R21 was left in her bed and was not returned to her wheelchair, as previously requested. R6 did not attempt to intervene after E4 yelled "No, you stop!" at R21. On 3/26/13 at 3:10 p.m., E1 (Administrator/Abuse Coordinator) was notified of the 1:57 p.m. incident with R21, E4, E5 and E6. E1 stated nothing had been reported by staff present in the room during the incident, as potential abuse or mistreatment. E1 immediately began an investigation in to the incident. Attempts to call E4 and E5 for interviews were unsuccessful. On 4/01/13 at 10:03 a.m., E1 stated, if the "incident" occurred as reported to him, he would have expected (R5 or R6) to intervene and report the occurrence as potential abuse to him immediately. A physician's orders [REDACTED]. A Plan of Care dated 1/14/13, documents R21 has an Altered Thought Process and Depression. The facility policy, titled "Abuse Prevention Program", documents "This facility prohibits mistreatment, neglect or abuse of its residents by:...orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect, and abuse; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse..." On 3/27/13 an Immediate Jeopardy was identified to have begun on 03/26/13 when staff failed to intervene during the use of disparaging language towards R21. E1 was informed of the Immediate Jeopardy on 3/27/12 at 3:00 p.m. The surveyor confirmed through observation, interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. On 3/26/13, R21 was assessed for any injury and/or negative outcomes. Z2 (Physician) was notified of the incident, in addition to the family representative. Staff continued to monitor R21 for any adverse reactions/outcomes. 2. On 3/26/13, R4 and R5 were suspended pending the investigation of the allegation. 3. On 3/27/13, E6 was suspended and given a one-to-one inservice by E1 on facility Abuse and Neglect Policies and Procedures, stressing the impotence of the staff obligation to prevent and report abuse immediately to the Administrator. 4. On 3/27/13, the facility identified all residents as having the potential to be affected by this alleged deficient practice. 5. On 3/27/13, all staff were inserviced regarding the facility's Abuse and Neglect Policies and Procedures. This staff training will include specific information on: a. Sensitivity to resident rights and resident needs; b. What constitutes abuse, neglect and misappropriation of resident property; c. Staff obligations to prevent and report abuse. 6. On 3/27/13, a monitoring tool was implemented to assure that measures described are effective and ongoing. A Quality Assurance audit tool will be completed on a random sample of 10 employees weekly for 60 days to ensure the employees knowledge of the Abuse and Neglect Policies and Procedures.

Based on interview and record review, the facility failed to ensure staff immediately reported mistreatment and abuse of residents, allowing staff to continue to work for a total of three shifts, and failed to follow Operational Policies and Procedures regarding resident protection from abuse, for one of eight (R31) residents reviewed for abuse, in a sample of eight, and for two (R36, R37) residents in the supplemental sample. This failure had the potential to affect all 57 residents who were in the facility from 4/28/13 through 5/01/13. Findings include: The facility policy, titled "Abuse Prevention Program", documents "This facility prohibits mistreatment, neglect or abuse of its residents by:...orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect, and abuse; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse..." The "Abuse Prevention Program", further documents, "Employees of this facility who have been accused of possible mistreatment will be removed from resident contact immediately, until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible mistreatment shall not complete the shift as a direct care provider to residents." On 6/11/13 at 1:00 p.m., E4 (Registered Nurse) stated she was on break with E5 (Certified Nursing Assistant) and E7 (Certified Nursing Assistant) on 5/02/13. E4 stated E5 informed her E6 (Certified Nursing Assistant) had yelled and "cussed" at R37 when they were putting R37 to bed on 4/28/13. E5 also informed E4 that E6 had picked up R36 out of the wheelchair and "bounced (R36) onto the mattress" that same night. E7 then informed E4 that, on 4/28/13, she observed E6 "push (R31's) head down into the bed" and tell him to "go to f**** sleep." E4 stated she immediately encouraged E5 and E7 to report E6's actions to E1 (Administrator), and they did via phone. E4 stated E1 asked her to escort E6 out of the building at that time. E4 stated E6 had worked at least one shift after the alleged incident occurred on 4/28/13. On 6/11/13 at 1:20 p.m., E5 stated, on the evening of 4/28/13, E6 was assisting R37 to bed. E5 observed R37 call E5 a "Son of a B***" and E5 attempted to calm R37 so he would not exhibit any further verbal behaviors. E5 stated E6, then " got in (R37's) face "and yelled, "I'm a worthless Son of a B**** and I'm not going to help you." E5 stated she raised R37 up into the mechanical lift to transfer R37 into bed and E6 began "ramming" the mechanical lift repeatedly to get it into place, with R37 in it. After this incident, E5 was in R36 ' s room preparing to get R36 ready for bed. E5 stated E6 came into the room and picked R36 up under her arms out of the wheelchair and "threw (R36) into the bed." E5 stated R36 cried out, "Please, don't hurt me." E5 stated she "should have reported (E6) right away, but didn't." E5 stated she did just receive training on the types of abuse and who/when to report abuse to. E5 stated she chose not to report E6 on 4/28/13, because she was intimidated by E6 and she had "told on him before" to the previous Administrator, but nothing happened. E5 stated E6 worked the remainder of his shift, having direct resident contact, on 4/28/13 and subsequent shifts. E5 stated she did tell E4, on 5/02/13, what she observed E6 do to R36 and R37 on 4/28/13. E5 stated E4 immediately contacted E1 by phone and had her give a detailed report of what had occurred 4/28/13. On 6/11/13 at 2:00 p.m., E1 stated E5 and E7 should have reported E6's actions on 4/28/13, "right away." E1 stated E6 did work a full shift on 4/28/13 two subsequent shifts (4/30/13 and 5/01/13) after the alleged abuse, but was suspended on 5/02/13. Staffing Schedules for April and May 2013, document R6 was in the facility from 10:00 a.m. to 10:00 p.m. on 4/28/13 and for the evening shifts (2:00 p.m. to 10:00 p.m.), 4/30/13 and 5/01/13.