Every finding on record at Trinity Hill Care Center

Based on observations, review of facility documentation and interviews, the facility failed to ensure resident rooms were in good repair and painted and failed to ensure proper ventilation in resident rooms that do not have an in-room air conditioning unit. The findings included:Observations on all days of the survey 5/27, 5/28, 6/1, 6/2 and 6/3/26 identified the majority of the resident rooms on the second floor identified walls that had been spackled but not painted, baseboard molding detached and peeling off of the walls, some damage to walls like holes or scrapes and marks to the walls, and exposed sheetrock that was in need of repair. All windows in the facility were nailed shut preventing them from being able to be opened. Inside building temperatures on 5/27/26 reached 81 degrees (which was within the range for regulatory expectations for internal temperature). External temperatures that day reached 85 degrees. The windows were not able to be opened for the provision of ventilation. Observations on these days also identified there was an HVAC system with ventilation in the hallways but not in all resident rooms. Additionally, the vents on the 2nd floor hallway (Rooms 201 through 215) were not blowing any air and there was a window air conditioner at the end of the hallway that was in use.Interview with LPN#3 on 6/1/26 at 9:42 AM identified that, at some point, someone may have tried to jump out of a window, and the windows were nailed shut. LPN#3 indicated that the 2nd floor gets hot and that there are only some rooms with air conditioners. She further identified that if there is a complaint, the facility will get a fan for the resident. Additionally, LPN#3 identified that maintenance completes repairs but there is a lot that is not kept up.Interview with the Director of Maintenance on 6/1/26 at 3:25 PM identified that he has worked at the facility for about a year and noted that the building was not fully equipped with air conditioning. He identified that the hallways have air conditioning and only some of the rooms due to the electrical load. The Director of Maintenance indicated that there had been a transition in maintenance assistants and due to the building being large and needing repairs, he needed more time to complete all the tasks that needed to be completed. The Director of Maintenance identified he was directed by management to ensure the windows were not able to be opened due to random people jumping the back fence and selling drugs at the windows and indicated that he was told by his supervisor and corporate person that the nails were to remain in place.Interview with NA#2 on 6/2/26 at 5:48 AM identified that the 2nd floor gets hot and could not identify whether there was central air in the building and indicated that the windows were not able to be opened.Interview with NA#3 on 6/2/26 at 6:04 AM identified the resident room windows were not able to be opened and indicated that at times, the resident rooms get very warm if they don't have an air conditioner in place. NA#3 further identified that many residents are bed bound and cannot easily move to get cool but indicated the facility provides fans if requested. Interview with the Director of Maintenance on 6/3/26 at 11:35 AM identified there were two nonfunctional air conditioner units that controlled the 1st and 2nd floor hallways (from rooms 101 through 115 and Rooms 201 through 215). The Director of Maintenance indicated that the 2nd floor had a window air conditioner at the end of the hallway but that most rooms did not have air conditioners in them because the circuit breaker load was not able to handle all rooms having an air conditioner. The Director of Maintenance identified that the mechanical services company came to service the air conditioners but that two units were still not functional. The Director of Maintenance identified that he had a plan to go through the building to patch and repair all items that needed it and then go through and paint everything but that it got away from him. He indicated that he had a change in maintenance staff and that there were other items that jumped to the top of the priority list. The Director indicated that maintenance had completed two rooms on the first floor that needed repairs and were going to be working on the rest of the facility although there was no formal plan. The Director of Maintenance identified that all work had to be approved by corporate and, at times, the approval is delayed.Observation of the 1st and 2nd floor hallways without functional hallway air conditioning with the Director of Maintenance on 6/3/26 at 11:48 AM identified resident rooms #202, 208, 209, 210, and 211 had air conditioners in the room windows (this was 5 out of 15 resident rooms on the 2nd floor wing for Rms 201-215).Observation of the 1st floor unit hallway without functional air conditioning (rooms 101 through 115) with the Director of Maintenance on 6/3/26 at 12:00 noon identified resident rooms #106 and 110 had room air conditioners. This is 2 out of 14 resident rooms (one of the rooms is used with the therapy room and not as a resident room) that has an air conditioner.Interview with Person #3, representative from the mechanical service for AC repair on 6/4/26 at 10:40 AM identified that the company had been to the facility several times to fix items but that they did not go there regularly for maintenance of the AC units, which could contribute to them not functioning. Person #3 indicated that the facility had been in receipt of the recommendations for repair of the non-functioning AC units since 4/9/26 and had not approved the repairs to date.

Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 6 sampled residents (Residents #27, #77, #78, #82, #97 and #125) who are on Methadone maintenance, the facility failed to ensure Methadone orders were transcribed correctly to reflect the Methadone that was being administered and failed to ensure the Methadone policy was followed. The findings include:Review of the clinical records for Residents #27, #77, #78, #82, #97 and #125) on 6/1/26 identified physician's orders that directed the administration of Methadone with a concentration of 10mg/5 ml. Based on knowledge of the community methadone program, this concentration is not the concentration provided by the program but should be 10mg/ml concentration.Observation on 6/2/26 at 7:30 AM of the resident specific methadone containers provided by Methadone Clinic #1 with the RN Supervisor (RN#2) identified that the labels on the bottles of methadone and the methadone chain of custody record indicated the concentration on hand was 10mg/ml, and not the 10mg/5ml as indicated in the physician's orders of Resident #27, and #78. Observation on 6/2/26 at 7:35 AM of the methadone count for the Methadone provided by Methadone Clinic #2, for 5 out of 22 residents, including Resident #125, identified the labels on the methadone bottles contained the resident name, concentration and dose. However, the chain of custody record (this is the record used when the methadone is picked up from the clinic by facility personnel), failed to include the concentration and dose. Interview with the ADNS on 6/2/26 at 8:00 AM identified that the Methadone supply was audited that morning and indicated the methadone bottles were verified against the chain of custody form that is signed when the bottle is administered. When asked to demonstrate the reconciliation process, the ADNS, after attempting to reconcile the dosage, identified that she had pulled up the physician's orders in the clinical record and verified all dosages against the physician's order in the computer as the dosage information was not present on the chain of custody records from Methadone Clinic #2.Observation on 6/2/26 at 8:06 AM of methadone administration for Resident #125 identified RN#2 provided the resident with a methadone bottle, with a label that identified the resident was receiving 90mg with a concentration of 10mg/ml which equals 9ml. The physician's order identified a methadone concentration of 10mg/5ml for a dose of 90mg which would be 45 ml and not 9ml. The physician's orders did match the dose indicated on the methadone bottle label. Observation of Methadone administration for Resident #27 with RN#2 on 6/2/26 at 8:15 AM identified the methadone administered was 10mg/ml at a dose of 160mg. This dose did not accurately reflect the physician's order directing administration of Methadone 10mg/5ml at a dose of 150 mg.Observation of methadone administration for Resident #77 with RN#2 on 6/2/26 at 8:22 AM identified RN#2 withheld the administration after comparing the dose on the bottle (160mg) with the physician's order in the EHR directing administration of 165mg. RN#2 indicated the doses were conflicting requiring her to verify the accurate dose before administering. Interview with RN#2 on 6/2/26 at 8:33 AM identified that the physician's orders should reflect the medication that is being administered. RN#2 indicated that when the methadone is brought into the facility by the transport person, the RN supervisor or ADNS are responsible for verifying the orders to make sure they accurately reflected what is being administered. RN#2 identified that the bottles provided to the facility are sealed and should be the correct dose even if the physician's orders in the electronic medical record are incorrect. Observation of methadone administration for Resident #97 with RN#2 on 6/2/26 at 9:17 AM identified RN#2 withheld the administration after checking the physician's order directing administration of 10mg/ml at a dose of 105mg and the Methadone bottle on hand for administration labeled 10mg/ml at a dose of 120mg.Resident #27 was admitted to the facility with diagnoses including opioid dependence, Bipolar and anxiety disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #27 had intact cognition, was independent with self-care and mobility, and was receiving antipsychotic, antianxiety, antidepressant and opioid medications. The care plan dated 5/12/26 identified Resident #27 had an active diagnosis of substance use disorder with interventions to participate in MAT, Methadone Addiction Treatment, program. Physician's order dated 3/5/26 and active through 6/2/26 directed administration of Methadone HCL oral solution 10mg/5ml to give 150 mls by mouth every day shift for Opioid dependence to be given by supervisor. Review of the Medication Administration Record (MAR) in the Electronic Health Record (HER) dated May 2026 and June 2026 identified Resident #27 was administered Methadone HCL Oral Solution 10mg/5ml 150 mls by mouth every day shift for Opioid dependence every day from 5/1/26 through 6/2/26. Review of Resident #27's Methadone Chain of Custody Record dated 5/16/26 identified Methadone medication provided for Resident #27 from 5/26/26 through 6/8/26 was Methadone 10mg/ml with a dose of 160 mg. The record included staff and resident initials as receiving the provided dose daily from 5/26/26 through 6/2/26. This administered dose does not accurately reflect the dose, nor the concentration, identified in the physician's order or what was signed off as administered in the MAR. Observation of Methadone administration for Resident #27 with RN# on 6/2/26 at 8:15 AM identified the Methadone administered was 10mg/ml at a dose of 160mg. This dose did not accurately reflect the physician's order directing administration of Methadone 10mg/5ml at a dose of 150 mls. Interview with the Director of Nursing for Methadone clinic #1 on 6/5/26 at 10:25 AM identified Resident #27 should be receiving Methadone 10mg/ml at 160mg daily from 3/31/26. Resident #77 was admitted to the facility with diagnoses including opioid dependence, anxiety disorder and depression.Review of the care plan dated identified Resident #77 was at risk for substance use related to a history of addiction, had a diagnosis of a substance use disorder (SUD) and recent substance use and participated in a MAT program with interventions to provide the resident with MAT as directed and if the resident shows signs or symptoms of overdose, administer Narcan as ordered and call 911.Physician's order dated 5/9/26 directed administration of Methadone HCL oral concentrate 10mg/ml to give 165 mg by mouth one time a day for SUD.Review of Resident #77's Methadone Chain of Custody Record dated 5/26/26 identified Methadone medication provided for Resident #77 from 5/26/26/26 through 6/8/26 was Methadone 10mg/ml with a dose of 160 mg. The record included staff and resident initials as receiving the provided dose daily from 5/26/26 through 6/1/26. This administered dose does not accurately reflect the dose, nor the concentration, identified in the physician's order or what was signed as administered in the MAR.Observation of the lock box in the RN supervisor's office on 6/2/26 at 7:35 AM identified 5 residents, including Resident #77 who received methadone from a community clinic. The resident bottles are in bags specific to each resident. The bottles are sealed and marked with the resident's name, the dose and the date the bottle is to be administered.Subsequent to surveyor inquiry, Physician's order dated 6/2/26 and discontinued 6/3/26 directed administration of Methadone HCL oral concentrate 10mg/ml to give 155 mg by mouth one time a day for SUD. This order does not accurately reflect the 160mg dose that is on hand and is being administered by the facility.Subsequent to surveyor inquiry, physician's order dated 6/4/26 directed administration of Methadone HCL oral concentrate 10mg/ml to give 155 mg by mouth once a day for SUD. This order does not accurately reflect the 160mg dose that was on hand and being administered by the facility.Interview with the Director of Nursing for the Methadone clinic #1, RN#6 on 6/5/26 at 10:25 AM identified Resident #77 should be receiving Methadone 10mg/ml at a dose of 155mg. RN#6 indicated the 155mg dose started on 5/26/26 and indicated the chain of custody paperwork was incorrect and the dose should be at 155mg. RN#6 indicated the dose had decreased from 160mg to 155mg on 5/26/26. RN#6 identified the dosing on the bottle should be the same as the dose on the chain of custody record and should be the same as the physician's order in the medical record. Resident #78 was admitted to the facility with diagnoses including opioid dependence, alcohol cirrhosis of liver with ascites and acute kidney failure.Review of the care plan dated 4/6/26 identified Resident #78 had a diagnosis of a substance use disorder and recent substance use and was a participant in the MAT program with intervention to provide the resident with MAT as directed.Physician's order dated 5/25/26 directed administration of Methadone 10mg/5ml oral solution at a dose of 25 mg by mouth every day shift related to opioid dependence to be given by the supervisor.Review of the MAR dated May 2026 and June 2026 identified Resident #78 was administered Methadone HCL oral solution 10mg/5ml at a dose of 25 mg by mouth every day from 5/26/26 through 6/2/26. This administration record does not accurately reflect the concentration and dose of the Methadone that was actually administered.Review of the Methadone chain of custody record dated 5/26/26 identified Resident #78 was supplied 14 doses of Methadone 10mg/ml at a dose of 30mg to be administered daily from 5/26/26 through 6/8/26. Administrations were initialized by staff and resident initials daily from 5/26/26 through 6/1/26. This record of administration does not accurately reflect the physician's order in the EHR and doesn't accurately reflect what was documented in the EHR MAR as administered.Subsequent to surveyor inquiry, physician's order dated 6/3/26 directed to administer Methadone HCL oral concentrate 10mg/ml at a dose of 30 mg by mouth every day shift for SUD.Interview with the Director of Nursing for the Methadone clinic #1, RN#6, on 6/5/26 at 10:25 AM identified Resident #78 should be receiving Methadone 10mg/ml at a dose of 30 mg. RN#6 indicated that review of Resident #78's Methadone clinic clinical record identified Resident #78 had been receiving a 30mg dose for at least the last 6 months.Resident #82 was admitted to the facility with diagnoses including Type 2 diabetes mellitus, acute kidney failure and adjustment disorder with mixed anxiety and depressed mood.The Physician's order dated 4/24/26 directed administration of Methadone HCL oral concentrate 10mg/ml at a dose of 100mg by mouth every day shift for SUD and given by an RN supervisor.Review of the care plan dated 6/1/26 identified Resident #82 participated in MAT program because of a history of substance use disorder with intervention to provide the resident with MAT as directed.Review of the MAR dated May 2026 and June 2026 identified Resident #82 was administered Methadone HCL oral concentrate 10mg/ml at a dose of 100 mg by mouth every day shift (except for 2 days 5/16 and 5/22) for SUD from 5/1/26 through 6/2/26.Review of the Methadone chain of custody record dated 5/26/26 identified Resident #82 was provided 14 doses of Methadone 10mg/ml at a dose of 110mg to be administered daily from 5/26/26 through 6/8/26. The record is initialed by a staff member and Resident #82 for daily administration from 5/26/26 through 6/1/26. This dose that was administered does not accurately reflect the physician's ordered dose or the EHR MAR documented administrations.Subsequent to surveyor inquiry, physician's order dated 6/3/26 directed Methadone HCL oral concentrate 10mg/ml at a dose of 110mg by mouth every day shift for SUD and given by RN supervisor.Interview with the Director of Nursing for the Methadone Clinic #1, RN#6, on 6/5/26 at 10:25 AM identified Resident #82 should be receiving Methadone 10mg/ml at a dose of 110mg. RN#6 indicated that this dose was started on 5/12/26. Resident #97 was admitted to the facility with diagnoses including opioid dependence, alcohol abuse, psychoactive substance abuse and nicotine dependence.Review of the care plan dated 5/10/26 identified Resident #97 was a participant in the MAT program because of a history of SUD with interventions to administer Narcan as ordered and call 911 if the resident shows signs or symptoms of overdose.The Physician's order dated 5/13/26 directed administration of Methadone HCL Intensol oral concentrate 10mg/ml with a dose of 105mg by mouth one time a day for opioid disorder.Review of the MAR dated May 2026 and June 2026 identified Resident #97 received Methadone HCL Intensol oral concentrate 10mg/ml at a dose of 105 mg by mouth every day for opioid disorder from 5/13/26 through 6/1/26. These administrations did not accurately reflect the dose supplied by the Methadone clinic and signed off as administered on the chain of custody record.Review of the Methadone chain of custody record dated 5/26/26 identified Resident #97 received 14 bottles of Methadone 10mg/ml at a dose of 120mg to be administered from 5/26/26 through 6/8/26. The record included staff and resident initials next to administrations for 5/26/26 through 6/1/26.Subsequent to surveyor inquiry, physician's order dated 6/3/26 directed administration of Methadone HCL oral concentrate 10mg/ml at a dose of 120mg by mouth every day shift for SUD.Interview with the Director of Nursing for the Methadone clinic #1 on 6/5/26 at 10:25 AM identified that Resident #97 was prescribed Methadone 10mg/ml at a dose of 115 mg until 5/31/26 and then was increased to a dose of 120 mg on 6/1/26. This Director of Nursing indicated that the chain of custody did not reflect the actual change in dosing for Resident #97 and did not accurately represent what was received from the clinic but identified that the physician's orders should be verified by the labels on the individual bottles and would look into what should be included on the chain of custody record. Resident #125 was admitted to the facility with diagnoses including opioid dependence and generalized anxiety disorder.The Annual MDS dated [DATE] identified Resident #125 had intact cognition, was independent with self-care and mobility and received antidepressant, antiplatelet and anticonvulsant medications.Review of the care plan dated 4/10/26 identified Resident #125 had an active diagnosis of substance use disorder and recent substance use within the last 30 days and was participating in a MAT program MAT program encouraged if not already participating and evaluating the need for psych/behavioral health consults and provide the resident with MAT as directed.The Physician's order dated 5/27/26 with an order start date of 3/21/25 directed administration of Methadone HCL oral solution 10mg/5ml to give 90mg by mouth every day shift for SUD.Review of the MAR dated May 2026 and June 2026 identified Resident #125 received Methadone HCL oral solution 10mg/5ml at a dose of 90 mg by mouth every day shift for SUD from 5/1/26 through 6/2/26.Review of the Chain of custody receiving institution pickup form dated 5/26/26 identified that 14 bottles of Methadone were received for Resident #125. The chain of custody form does not identify dose or concentration. The chain of custody record included staff and resident initials verifying medication administration of Methadone, with no dose noted, from 5/26/26 through 6/2/26.Observation of Methadone administration with RN Supervisor, RN#2, on 6/2/26 at 8:06 AM identified Resident #125 was administered a sealed bottle of Methadone labeled as Methadone 10mg/ml at a dose of 90mg. RN#2 verified the dose of 90mg but failed to identify the physician's order was Methadone 10mg/5ml at a dose of 90mg which was not the correct concentration of the medication administered.Subsequent to surveyor inquiry, physician's order dated 6/2/26 directed administration of Methadone HCL oral concentrate 10mg/ml at a dose of 90mg by mouth every day shift for SUD. Interview with the ADNS, DNS and the Regional Clinical Director on 6/2/26 at 9:28 AM identified that the ADNS does sometimes pick up the Methadone in the community but that there was a designated staff member, non-clinical, who is responsible most days. The ADNS indicated that when verifying for the chain of custody, the dosing is not checked and only the name of the resident and the number of bottles being taken are counted. Additionally, the receiving RN supervisor was responsible to check the Methadone bottles and dosage and make sure the physician's order in the EHR was correct.Interview with the Central Supply person on 6/3/26 at 10:19 AM identified she is the designated person who picks up the Methadone from both of the community suppliers. The Central Supply person indicated that she is responsible for verifying the names of the residents and the number of bottles that she is transporting but does not confirm the dosage of the medication. The Central Supply person indicated that she brings the transport boxes with padlocks and once she verifies the amount of bottles, they are placed in the lock boxes with the paperwork, and the padlock is put in place that only the facility supervisors have the key for. When she returns to the facility, she turns the boxes of Methadone over to the supervisor and once it is verified that the accurate amount of bottles is present, her part in the process is complete.Interview with MD #3, Medical Director for Methadone clinic #2 on 6/3/26 at 1:12 PM identified physician's orders should reflect the dosing that is listed on the bottle labels.Interview with the Director of Nursing for Methadone clinic #1 on 6/5/26 at 10:25 AM identified physician's orders should be written exactly as on the bottles to be administered. The DNS for Methadone Clinic #1 identified the dosing orders are verified by the chain of custody record and indicated that the dosing is verified on pick up and that is why there is a nurse that does the pick-up and why the DEA requires that information on the chain of custody form.Interview with the Lead Nurse for Methadone Clinic #2, RN#7, on 6/5/26 at 12:59 PM identified the chain of custody for that center does not have the actual dose that is being administered. RN#7 indicated that the labels on the bottle that identify the dosing and date of administration and that the chain of custody does reference the dates of administration, but verification of the dose could not be completed because it is not listed so the dose should be verified by the label on the bottle. RN#7 could not identify if the dose should be listed but indicated that the physician's order should reflect exactly what is labeled on the bottle. The facility Methadone Protocol identified a designated staff person will be assigned to pick up the Methadone at the clinic and will verify and sign each individual resident's Chain of Custody Record for accuracy. The policy further directed that upon return to the facility, the Methadone dose identified on the Chain of Custody Form (that matches the individual bottles) will be compared to the current Physician orders for Methadone and indicated that any discrepancies must be verified by the Methadone clinic followed by a clarification order from the Resident's attending physician. The policy identified the Physician's orders are transcribed to the MAR and that prior to administration, the LPN/RN will verify the correct name, date, and dose on the Methadone bottle to the MAR and the Chain of Custody proof of administration sheet.The facility policy for medication administration identified medication administration and documentation occur in a timely and accurate manner and indicated the MAR is the form onto which all medication orders are transcribed, from which medications are poured and administered and on which medication doses are charted. The policy identified that the responsibility of the licensed nurse was to review physician/physician assistant orders and compares against the medication administration record and assures the 5 rights: compares the medication name, strength, route and dosage schedule on the medication administration record against the prescription label and to always check three times prior to administration of medication.

Based on observation, review of facility documentation and interviews the facility failed to ensure adequate ventilation by means of opened windows, or mechanical ventilation, or a combination of the two was in place consistently in the building. The findings include:Observations on all days of the survey 5/27, 5/28, 6/1, 6/2 and 6/3/26 identified all windows in resident rooms on the 1st, 2nd and 3rd floors had screws in the windows that prevented them from being opened at all. There are no screens in the resident room windows. Inside building temperatures on 5/27/26 ranged from 77 degrees to 81 degrees (which was within the range for regulatory expectations for internal temperature). External temperatures that day reached 85 degrees. Observations on these days also identified there was an HVAC system with ventilation in the hallways but not in resident rooms and only some resident rooms contained air conditioners. Additionally, the vents on the 2nd floor hallway (Rooms 201 through 215) were not blowing any air and there was a window air conditioner at the end of the hallway that was in use.Interview with LPN#3 on 6/1/26 at 9:42 AM identified working at the facility for about 30 years and indicated that not much had changed in the building. LPN#3 identified that, at some point, someone may have tried to jump out of a window and the windows were screwed shut. LPN#3 indicated that the 2nd floor does get hot and that there are only some rooms with air conditioners, but identified that if there is a complaint, the facility will get a fan for the resident.Interview with the Director of Maintenance on 6/1/26 at 3:25 PM identified he has worked at the facility for about a year and indicated the building was not fully equipped with air conditioning. The Director of Maintenance hallways have air conditioning and only some of the rooms due to the electrical load not being able to handle running air conditioner units in every resident room. The Director of Maintenance identified he was directed by the management to ensure the windows were not able to be opened due to random people jumping the back fence and selling drugs at the windows and indicated that although he was told by BFSI to remove the screws, he was told by his supervisor and corporate person that the screws were to remain in place.Interview with NA#2 on 6/2/26 at 5:48 AM identified that the 2nd floor does get hot and could not identify whether there was central air in the building but did indicate the windows were not able to be opened.Interview with NA#3 on 6/2/26 at 6:04 AM identified the resident room windows were not able to be opened and indicated that, at times, the resident rooms do get very warm if they aren't the rooms with the AC. NA#3 identified that many residents are bed bound and cannot easily move to get cool but indicated the facility provided fans if requested.Interview with the Director of Maintenance on 6/3/26 at 11:35 AM identified there were two non-functional air conditioner units that controlled the 1st and 2nd floor hallways (from rooms 101 through 115 and Rooms 201 through 215). The Director of Maintenance indicated that the 2nd floor had a window air conditioner at the end of the hallway but that most rooms did not have air conditioners in them because of the circuit breaker load was not able to handle all rooms having an air conditioner. The Director of Maintenance identified that the mechanical services company came to service the air conditioners but that two units were still not functional. The Director of Maintenance identified all work had to be approved by the corporate and, at times, it was delayed.Observation of the 1st and 2nd floor hallways without functional hallway air conditioning with the Director of Maintenance on 6/3/26 at 11:48 AM identified resident rooms #202, 208, 209, 210, and 211 had air conditioners in the room windows (this was 5 out of 15 resident rooms on the 2nd floor wing for Rms 201-215).Observation of the 1st floor unit hallway without functional air conditioning (rooms 101 through 115) with the Director of Maintenance on 6/3/26 at 12:00 noon identified resident rooms #106 and 110 had room air conditioners. This is 2 out of 14 resident rooms (one of the rooms is used with the therapy room and not as a resident room) that has an air conditioner.Interview with Person #3, representative from the mechanical service for AC repair on 6/4/26 at 10:40 AM identified that the company had been to the facility several times to fix items but that they did not go there regularly for maintenance of the AC units, which could contribute to them not functioning. Person #3 indicated that the facility had been in receipt of the recommendations for repair of the non-functioning AC units since 4/9/26 and had not approved the repairs to date.

Based on review of the clinical records, review of facility policy and interviews for two sampled residents (Resident #5 and Resident #15) with physician's orders for a screening test for colon cancer, facility failed to ensure the test kit was obtained and the testing completed and for one of three sampled residents (Resident #65) reviewed for mood/behavior, the facility failed to ensure medications were administered as ordered. The findings include: Resident #5's diagnoses included gastro-esophageal reflux disease, chronic viral hepatitis and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #5 had intact cognition, independent with personal, toileting hygiene, transfers and ambulation. The assessment further identified Resident #5 was always continent of bowel and bladder. The physician's order dated 4/7/26 directed to send stool once for Cologuard for colon cancer screening and to discontinue once specimen is sent. Review of Resident #5's nursing progress notes for the period of 4/7/26 through 6/1/26 failed to identify that a stool specimen was collected for colon cancer screening, nor did the record indicate that the resident refused to provide the specimen. The record also failed to identify any results of a Cologuard test. Interview with the Nursing Supervisor (RN #2) on 6/1/26 at 12:30 PM identified the APRN is responsible for ordering the Cologuard kit from the company. The company would then send the kit to the facility, and the supervisor would receive the kit to provide to the charge nurse. RN #2 identified the facility currently does not have the Cologuard kits and cannot recall being notified that Resident #5 needed or did not have the Cologuard kit. She further identified that when the nurse saw the order and did not have the kit for the residents, they should have notified the supervisor or the APRN/MD so it could be ordered. Interview with MD #2 on 6/1/26 at 12:41 PM identified she ordered the Cologuard for colon cancer screening, and completed the Cologuard form, then placed it in the unit secretary's box. MD #2 further identified she does not know what the process entails after the form is completed and placed in the unit secretary mailbox. MD #2 identified she ordered the Cologuard for a few residents because it is easier than the colonoscopy, even though colonoscopy is the golden standard, and the residents who had the orders for the Cologuard are low risk residents. MD #2 identified she noticed that the nurses were ignoring the Cologuard orders for both Resident #5, and Resident #15 and other residents when she completed her 30-day review. However, she had not reported the issue to administration as this was on the lower level of her priority list. MD #2 further identified she was not made aware that the tests were not being completed by staff and she was the one who knew they were not being done when she reviewed the record. MD #2 identified she expects when she writes an order that it will be carried through within a week, and to be notified of any issues with the orders as to why it would not be followed through/completed. Interview with the Unit Secretary #1 on 6/1/26 at 1:50 PM identified she had not received any paperwork in her mailbox regarding an order form for Cologuard and if she had she would have brought it to the DNS attention. The Unit Secretary further identified the APRN's order the Cologuard kit and she is responsible for scanning information such as the results in the resident's electronic record. Interview with APRN #1 identified she is new to the facility and had not ordered any Cologuard testing kits for any of the residents. APRN #1 further identified she is unaware of the resident who has orders for Cologuard and was not asked to address the Cologuard orders but was asked if she had ordered the Cologuard at another facility and knew about the process for ordering the kit. She further identified that Cologuard would not be her first option for colon cancer screening. Interview with the DNS on 6/1/26 at 2:32 PM identified she was not aware that the Cologuard kits were not in the facility. She identified that she was reviewing a resident's record when she identified that the Cologuard order was in place and was not completed. The DNS identified she then started her own investigation and asked the APRN's how the kits are ordered as it cannot be ordered by the nurses as well as reaching out to the company to provide in-service to the staff. The DNS further identified that she would expect the nurses to have reported to the supervisors or the APRN that the kits were not available so that the issue could be addressed sooner. Interview with LPN #2 on 6/1/26 at 3:15 PM identified the specimen was not collected as the Cologuard kit was not available. She identified she would check with the supervisor for the kit, and they would respond that they don't have the kit. LPN #2 further identified she should have reported it to the APRN or let the supervisor know, so that an order could be obtained to discontinue or place the order on hold until the Cologuard kits were available. Interview with the evening shift Nursing Supervisor (RN #1) on 6/3/26 at 9:50 AM identified she recalled being made aware once that the Cologuard kit was not available and she placed a note in the APRN book for the morning shift to call the company to find out about the kits. RN #1 further identified she did not receive any further reports of the Cologuard kits, so she assumed the issue was resolved. Interview with the Medical Director (MD #1) on 6/3/26 at 2:15 PM identified the Cologuard test is an appropriate test to use in the community setting and a colonoscopy is the golden standard. He identified if a Cologuard test comes back positive the resident would have to then do a colonoscopy. MD #1 identified that this should have been brought to his attention prior and this clearly is a breakdown in communication. Review of the Physician Orders-Transcription policy identified physician's orders will be transcribed (prescriber written) or directly entered (verbal or phone) into the EMR (electronic medical record) by a licensed nurse and followed through in a manner consistent with quality standard of care practices. Resident #15's diagnoses included gastro-esophageal reflux disease, hypertensive heart disease with heart failure, and lymphedema. The quarterly MDS assessment dated [DATE] identified Resident #15 had intact cognition, independent with toileting hygiene, upper body dressing, and bed mobility. The assessment further identified Resident #15 was always continent of bowel and bladder. Review of Resident #15's nursing progress notes for the period of 4/7/26 through 6/1/26 failed to identify that a stool specimen was collected for colon cancer screening, nor did the record indicate that the resident refused to provide the specimen. The record also failed to identify any results of a Cologuard test. Interview with the Nursing Supervisor (RN #2) on 6/1/26 at 12:30 PM identified the APRN is responsible for ordering the Cologuard kit from the company. The company would then send the kit to the facility, and the supervisor would receive the kit to provide to the charge nurse. RN #2 identified the facility currently does not have the Cologuard kits and cannot recall being notified that Resident #5 and Resident #15 needed or did not have the Cologuard kit. She further identified that when the nurse saw the order and did not have the kit for the residents, they should have notified the supervisor or the APRN/MD so it could be ordered. Interview with MD #2 on 6/1/26 at 12:41 PM identified she ordered the Cologuard for colon cancer screening, and completed the Cologuard form, then placed it in the unit secretary's box. MD #2 further identified she does not know what the process entails after the form is completed and placed in the unit secretary mailbox. MD #2 identified she ordered the Cologuard for a few residents because it is easier than the colonoscopy, even though colonoscopy is the golden standard, and the residents who had the orders for the Cologuard are low risk residents. MD #2 identified she noticed that the nurses were ignoring the Cologuard orders for Resident #15 and other residents when she completed her 30-day review. However, she had not reported the issue to administration as this was on the lower level of her priority list. MD #2 further identified she was not made aware that the tests were not being completed by staff and she was the one who knew they were not being done when she reviewed the record. MD #2 identified she expects when she writes an order that it will be carried through within a week, and to be notified of any issues with the orders as to why it would not be followed through/completed. Interview with the Unit Secretary #1 on 6/1/26 at 1:50 PM identified she had not received any paperwork in her mailbox regarding an order form for Cologuard and if she had she would have brought it to the DNS attention. The Unit Secretary further identified the APRN's order the Cologuard kit and she is responsible for scanning information such as the results in the resident's electronic record. Interview with APRN #1 identified she is new to the facility and had not ordered any Cologuard testing kits for any of the residents. APRN #1 further identified she is unaware of the resident who has orders for Cologuard and was not asked to address the Cologuard orders but was asked if she had ordered the Cologuard at another facility and knew about the process for ordering the kit. She further identified that Cologuard would not be her first option for colon cancer screening. Interview with the DNS on 6/1/26 at 2:32 PM identified she was not aware that the Cologuard kits were not in the facility. She identified that she was reviewing a resident's record when she identified that the Cologuard order was in place and was not completed. The DNS identified she then started her own investigation and asked the APRN's how the kits are ordered as it cannot be ordered by the nurses as well as reaching out to the company to provide in-service to the staff. The DNS further identified that she would expect the nurses to have reported to the supervisors or the APRN that the kits were not available so that the issue could be addressed sooner. Interview with LPN #2 on 6/1/26 at 3:15 PM identified the specimen was not collected as the Cologuard kit was not available. She identified she would check with the supervisor for the kit, and they would respond that they don't have the kit. LPN #2 further identified she should have reported it to the APRN or let the supervisor know, so that an order could be obtained to discontinue or place the order on hold until the Cologuard kits were available. Interview with the evening shift Nursing Supervisor (RN #1) on 6/3/26 at 9:50 AM identified she recalled being made aware once that the Cologuard kit was not available and she placed a note in the APRN book for the morning shift to call the company to find out about the kits. RN #1 further identified she did not receive any further reports of the Cologuard kits, so she assumed the issue was resolved. Interview with the Medical Director (MD #1) on 6/3/26 at 2:15 PM identified the Cologuard test is an appropriate test to use in the community setting and a colonoscopy is the golden standard. He identified if a Cologuard test comes back positive the resident would have to then do a colonoscopy. MD #1 identified that this should have been brought to his attention prior and this clearly is a breakdown in communication. Review of the Physician Orders-Transcription policy identified physician's orders will be transcribed (prescriber written) or directly entered (verbal or phone) into the EMR (electronic medical record) by a licensed nurse and followed through in a manner consistent with quality standard of care practices. Resident #65's diagnoses included anxiety, depression, and pain. The quarterly MDS assessment dated [DATE] identified Resident #65 was cognitively intact, was independent with bed mobility, transfers, dressings and personal hygiene. It further identified the resident was non-ambulatory and utilized a wheelchair for mobility. The care plan dated 3/25/26 identified Resident #65 was at risk for depression with interventions that included administer medications as ordered, monitor/document for side effects and effectiveness, arrange for a psychiatric consult, and follow up as indicated. Physician's order dated 5/1/26 directed clonidine HCl oral table 0.2mg to be given every morning and at bedtime for anxiety. The MAR for May 2026 identified 7 missed doses of clonidine 0.2mg between 5/14/26 and 5/18/26. Interview on 5/27/26 at 10:05AM with Resident #65 identified that there were 4 days about a week and a half prior that she/he missed their scheduled clonidine. The resident experienced increased anxiety during this time and was told there was a pharmacy issue as to why they could not receive their medication. Interview on 6/1/26 at 11:10AM with LPN#1 identified she was aware that the clonidine was not given a couple of times when she worked during 5/14/26 and 5/18/26. LPN #1 identified that when she went to administer the medication, it was not there and when she went to reorder from the pharmacy, she was told that it was too soon to reorder the medication. Further, she identified that she told the supervisor, and the supervisor told the APRN that the medication was not available. LPN#1 was not aware if the medication was available in the omni cell (emergency medication supply) in the facility and did not check when the medication was not available. LPN#1 identified she has access to the medication but had not checked the emergency supply. LPN #1 reviewed the medication orders, and it indicated that the medication was ordered on 5/18/26 and dispensed on 5/18/26. Interview on 6/1/26 at 11:30 with APRN#1 identified that she was made aware from one of the nurses about Resident #65 being out of clonidine however she does not prescribe the medication, so she notified the Psychiatric APRN (#2). APRN#1 believes that she texted APRN#2 however had no documentation or text regarding the communication. Further interview with APRN#1 at 12:15PM identified that she may have spoken to one of the APRN's in person or left the information in the psychiatric aprn's binder as she could not find a text. APRN#1 also identified that there was a pharmacy issue where they thought the medication was sent on one day (unsure which day) and it actually was not included in the delivery, so it was sent the following day. Interview on 6/1/26 at 11:30AM with APRN#2 identified she did not get a text nor recalls any correspondence with APRN#1 regarding the out-of-stock clonidine for Resident #65. APRN#2 identified that without receiving the medication Resident #65 could be at an increased risk for anxiety. APRN#2 identified that she had not been the last provider to see Resident #65 and that APRN#3 may have been the provider notified. Interview on 6/1/26 at 2:51PM with APRN#3 identified she was visiting Resident#65's roommate when Resident #65 told her about the missed clonidine and feeling increased anxiety. APRN#3 identified she did not get notified from anyone at the facility; the first notification was from the resident. At the time of notification, the resident had just received their dose from the pharmacy of the clonidine therefore APRN#3 did not need to put any interventions in place as the issue was resolved. APRN#3 even stated in her note from the visit on 5/18/26 with Resident #65 that the resident stated the clonidine was received earlier that day and had increased anxiety/restlessness due to not receiving the scheduled clonidine. APRN#3 would expect to be notified if there is a medication not given or unavailable due to the fact she would like to know what the barriers were to not receive the medication. Side effects that the resident could experience due to not receiving the medication could be increased in anxiety, restlessness, irritability, trouble sleeping, troubles with socialization. Interview on 6/3/26 at 9:40AM with RN#1 identified that she did not recall any of the nurses notifying her that the medication was out, however she worked the floor one day during that time on 5/16/26 and went to administer the medication and it was not available. She believed she called pharmacy and may have put the information in the APRN book and believed that the medication would have been sent the following day. RN#1 identified that she did have access to the omni-cell but did not think that the clonidine was available in the omni-cell. Interview on 6/3/26 at 11:30AM with the DNS identified that she was unaware of the clonidine being unavailable for Resident #65 and none of the supervisors had notified her of the issue. The DNS identified that the expectation would be for the nurse to contact the pharmacy for refill, if refill was unavailable then she would expect the nurse supervisor to be aware and contact the APRN. Once the APRN was contacted she would expect them to contact the ordering provider of the medication. If the medication was available in the omni cell she would have expected the whole issue to be avoided by the nurse pulling from the Omni-cell. If the resident was on a 0.2mg dose of clonidine then she would expect the nurse to give two 0.1mg tablets if that was what was available. They could call the provider as well if they needed to get clarification or change in order due to the dose being different. Review of the omni-cell (electronic dispensing emergency medication supply) in the facility identified as of 5/14/26 the cycle count identified there were 8 clonidine 0.1mg tablets in stock in the omni cell. On 5/15/26 it was identified that there were 8 restocked on 5/15/26. No further transactions were identified for May 2026 for this medication in the omni cell. Review of the Medication Unavailable policy directed if the medication is unavailable for any reason, the facility shall act promptly to notify appropriate practitioners for orders to be followed and the pharmacy to obtain medications in accordance with the updated orders. The facility shall investigate all instances where medications are not available, to assess whether appropriate actions were taken to ensure continuity of care.

Based on a review of clinical records, facility documentation, facility policy, and interviews for one of three residents (Resident #3) reviewed for abuse, the facility failed to ensure the residents were free from abuse and failed to ensure adequate supervision to prevent a resident-to-resident altercation with an injury. These failures resulted in a finding of Immediate Jeopardy. The findings include: a. Resident #1's diagnoses included anxiety and schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment, and was self-mobile in a wheelchair. The Resident Care Plan (RCP) dated 11/25/2024 identified Resident #1 had a potential for aggressive behaviors toward other residents. Interventions directed every 15-minute checks as indicated, administer medications as ordered, counseled to seek assistance of staff for issues with peers, psychiatric and social services follow up as indicated, when resident becomes agitated intervene before agitation escalates, guide away from source of distress, and if aggressive to staff to walk away calmly and reapproach later. Record review identified Resident #1 had prior resident-to-resident altercations. On 9/16/2023 Resident #1 hit his/her roommate, in a bathroom that was shared by both residents, on the head with a trash bin causing the bin to break into pieces and caused two (2) abrasions to the other resident's leg. The care plan was updated to move the roommate to another room. On 12/3/2023 Resident #1 slapped another resident, at the nursing station, and a scratch was noted on the other resident. The care plan was updated to include every 15-minutes checks until cleared by psychiatry and social work was to follow up. On 2/19/2024 Resident #1 slapped another resident at the nurse's station. The care plan was updated to direct every 15-minute checks until cleared by psychiatry, staff to monitor Resident #1 by constant community awareness, and psychiatry and social service follow up as needed. On 11/25/2024 when Resident #1 attempted to transfer into a chair at the nurse's station, another resident moved the chair and Resident #1 then pushed the other resident. The care plan was updated to direct every 15-minute monitoring, and the chair was removed from the nurse's station. b. Resident #2's diagnoses included anxiety, dementia, schizoaffective disorder, and bipolar disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a BIMS score of ten out of fifteen, indicative of moderate cognitive impairment, and was self-mobile in a wheelchair. The RCP dated 11/14/2024 identified dementia. Interventions directed to administer medications as directed and ask yes/no questions to determine resident needs. Facility reportable event dated 1/20/2025 at 4:30 PM identified Resident #1 reported Resident #2 said bad words and Resident #1 hit Resident #2, then Resident #2 hit Resident #1. Resident #1 was noted with an abrasion to the left side of his/her face, and orders were obtained for bacitracin to the area and left open to air. The residents were immediately separated and placed on every 15-minute monitoring. Resident #2 was moved to another unit. Record review identified that every 15-minute monitoring was discontinued by psychiatry on 1/25/2025. The facility summary dated 1/22/2025 identified no additional interventions. c. Resident #3's diagnoses included atrial fibrillation and dementia. The quarterly (MDS assessment dated [DATE] identified that Resident #3 had a BIMS score of five out of fifteen, indicative of severe cognitive impairment, had no behaviors, required assistance with wheelchair mobility, and identified English was not Resident #3's preferred language. The RCP dated 4/15/2025 identified impaired cognition and a pacemaker due to atrial fibrillation. Interventions directed to administer medications as ordered and ask yes/no questions to determine resident needs. Physician order dated 4/9/2025 directed Eliquis (blood thinner) 5 milligrams (mg) tablet, one (1) tablet by mouth, two (2) times a day, and Clopidogrel (Plavix) (blood thinner prevents blood clotting) 75 mg, one (1) tablet by mouth, one time a day. Facility reportable event dated 4/20/2025 at 12:30 PM identified Resident #3 was hit in the face by Resident #1 (unwitnessed by staff). Staff responded to both residents talking loudly in the hallway and noted Resident #3 had a two (2) centimeter (cm) laceration to the temporal area (near the ear) with bleeding. Resident #1 stated he/she hit Resident #3 because Resident #3 stole toilet paper from his/her bathroom. The report further indicated that Resident #3 was dependent on staff for bathroom use and unable to use the bathroom independently. The residents were separated. Resident #1 was placed on 1:1 monitoring until transfer to the hospital for evaluation. Neurological assessment was completed for Resident #3, who was transferred to the hospital for evaluation. Nursing note for Resident #1 dated 4/20/2025 at 12:14 PM identified Resident #3 was in Resident #1's way in the hallway. Resident #3 did not move, and Resident #1 hit Resident #3 in the face causing an open area to the temporal area. Nursing note for Resident #3 dated 4/20/2025 at 1:42 PM identified that an RN assessment was completed after the resident-to-resident physical altercation. Resident #3 was alert, oriented to self with confusion at baseline, and did not state what happened. Redness was noted to the left eye and left upper eyelid. Unequal pupillary reaction/constriction was noted during assessment, the right eye had a brisk response, the left eye had a sluggish response, and active bleeding was observed from the left temporal region and oozing/running down the left side of face. A left temporal region laceration was noted, measuring approximately 2 by 0.1 cm and 0.75 cm in depth. Direct pressure was applied to the lacerated area, but persistent bleeding. The APRN was notified, and Resident #3 was transferred to the hospital for evaluation. Facility incident summary dated 4/24/2025 identified the facility as unable to substantiate that abuse occurred because there was no willful or deliberate action against Resident #3. The summary identified Resident #3 was admitted to the hospital with a subdural hematoma (bleeding near the brain that can occur after trauma), related to medication regime of anticoagulants. The summary further indicated that upon Resident #1's return from the hospital with a no harm letter, Resident #1 was placed on enhanced observation. A virtual APRN visit was conducted on 4/21/2024 with medication adjustments and a plan for continued enhanced monitoring. Education was also provided to residents to have staff assist with resident-to-resident conflicts. Record review identified that monitoring (1:1 monitoring and every 15-minute checks) was discontinued as of 4/28/2025. Review of Resident #3's hospital history and physical dated 4/20/2025 identified Resident #3 was diagnosed with a hyperacute right temporo-parieto-occipital subdural hematoma (a complex area where the temporal, parietal and occipital brain lobes meet; area has a crucial role in integrating sensory information, attention, language, reasoning and memory) and was admitted to the intensive care unit (ICU). Hospital records identified Resident #3 was treated with a craniotomy (surgical opening into the skull to relieve pressure on the brain/remove the hematoma) on 4/28 and 5/6/2025. Further review identified that Resident #3 remained at the hospital during the time of the survey (30 days after the incident). Hospital medicine progress note dated 5/19/2025 identified Resident #3 had a principle problem of subdural hematoma. Resident #3 underwent craniotomy with evacuation of the subdural hematoma followed by MMA embolization (Middle Meningeal Artery embolization is a minimally invasive procedure used to block blood supply to the area affected by a subdural hematoma). Resident #3 was still encephalopathic (medical term that describes a general condition where the brain does not function properly). Interview with Resident #1 on 5/14/2025 at 12:58 PM identified that he/she had garbled speech and stated he/she hit a resident in the bathroom in the past. Resident #1 denied hitting another resident in the hallway or near the nurse's station. Interview, clinical record review, and hospital record review with MD #1/attending MD on 5/14/2025 at 11:29 AM identified that trauma, such as a hit to the head, could cause a subdural hematoma, and Resident #3 had a visible injury to the left side of the head. MD #1 stated an injury on the left side of the head could cause an injury on the right side of the brain (the opposite side) as the brain moves within the skull in a coup and contrecoup effect (rebound/recoil effect with the internal injury on the opposite side of the external force). Further, MD #1 stated Resident #3's injury was caused by the hit on the side of the head, because of how quickly Resident #3 had the bleeding after the injury occurred, he stated in his opinion, the hyperacute right temporo-parieto-occipital subdural hematoma was likely ninety percent certain caused by the trauma. Interview, clinical record review, and facility documentation review on 5/14/2025 at 2:39 PM with the DNS identified that Resident #1 admitted to hitting Resident #3 on 4/20/2025. The DNS stated Resident #1 was initially unable to provide a clear explanation regarding the incident, and then Resident #1 indicated Resident #3 took toilet paper from Resident #1's bathroom, however, Resident #3 did not use the bathroom and required total care for toileting. The DNS stated Resident #1 should not have hit Resident #3, and the facility did not substantiate abuse because Resident #1 did not willfully seek out Resident #3, and because Resident #1's story of the incident changed. The interview failed to identify the facility substantiated the abuse based on Resident #1 hitting Resident #3, and the subsequent diagnosed injury that required an extensive hospital admission. Interview, review of clinical record on 5/14/2025 at 8:55 AM with APRN #1 identified that Resident #1 had good motor control and did not have a lack of coordination or issues with swinging his/her arms. APRN #1 indicated Resident #1 was able to navigate hallways independently in a wheelchair and had full purposeful use of extremities (did not have uncontrolled movements of his/her extremities). Subsequent to surveyor inquiry, Resident #1 was placed on one-to-one (1:1) observations on 5/14/2025. Review of the facility Abuse Policy dated 3/20/2024 directed in part, physical abuse included hitting, slapping, pinching, kicking, etc. The Policy further directs that residents will not be subjected to abuse by anyone, including other residents.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #3) reviewed for abuse, the facility failed to develop a comprehensive care plan for a resident receiving anticoagulant medication (blood thinners). The findings include: Resident #3's diagnoses included atrial fibrillation. Physician's order for Resident #3 dated 4/9/2025 directed Eliquis (blood thinner) 5 mg tablet, one (1) tablet orally two (2) times a day related to atrial fibrillation and Clopidogrel (Plavix) (prevents blood clotting) 75 mg, one (1) tablet orally, one time a day related for atrial fibrillation. Record review identified Resident #3 was on Eliquis and Plavix upon admission to the facility during 5/2024. The quarterly MDS assessment dated [DATE] identified Resident #3 was admitted during 5/2024, had a BIMS score of five out of fifteen, indicative of severe cognitive impairment, had no behaviors, and received anticoagulants during the prior seven (7) days. The RCP dated 4/15/2025 identified impaired cognition and a pacemaker due to atrial fibrillation. Interventions directed to administer medications as ordered and ask yes/no questions to determine resident needs. Additional record review failed to identify Resident #3 had a care plan for Eliquis and Plavix use and risk of bleeding. Interview and record review with the DON on 5/20/2025 at 1:15 PM identified Resident #3 should have a care plan for bleeding risk related to the anticoagulant use, and was unable to identify a care plan for Eliquis and Plavix use and risk of bleeding. Subsequent to surveyor inquiry, the DON provided a care plan for Eliquis and Plavix use and risk of bleeding and was unable to identify when the care plan was written. Interview, clinical record and facility documentation review on 5/20/2025 at 2:04 PM with (RN #2)/MDS Coordinator identified when Resident #3 was admitted to the facility, he/she was receiving Eliquis and Plavix. RN #2 stated Resident #3 should have a care plan for risk of bleeding. Interview identified RN #2 created the risk of bleeding care plan on 5/20/2025. RN #2 stated during prior admissions, Resident #2 had a care plan for risk of bleeding due to Eliquis and Plavix use, but stated the facility had a different electronic medical record system at that time. RN #2 stated the electronic medical record system in use currently did not have an option for risk of bleeding, and he did not create the care plan for Resident #3. RN #2 stated he should have created the care plan, and he forgot to do it. Review of facility Care Plan Policy directed in part, to develop a comprehensive person-centered plan of care. The Policy further directed, within seven days of completing the MDS and CAA's (Care Area Assessments), to develop and review the plan of care to ensure it is person-centered and individualized to meet the needs of the resident.

Based on a review of clinical records, facility documentation, facility policy, and interviews for one of three residents (Resident #3) reviewed for abuse, the facility failed to ensure adequate supervision for a resident with known aggressive behaviors directed toward others, and to prevent a resident-to-resident incident with a resident injury. The findings include: a. Resident #1's diagnoses included anxiety and schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment, and was self-mobile in a wheelchair. The Resident Care Plan (RCP) dated 11/25/2024 identified Resident #1 had a potential for aggressive behaviors toward other residents. Interventions directed every 15-minute checks as indicated, administer medications as ordered, counseled to seek assistance of staff for issues with peers, psychiatric and social services follow up as indicated, when resident becomes agitated intervene before agitation escalates, guide away from source of distress, and if aggressive to staff to walk away calmly and reapproach later. Record review identified Resident #1 had prior resident-to-resident altercations. On 9/16/2023 Resident #1 hit his/her roommate in a bathroom that was shared by both residents on the head with a trash bin causing the bin to break into pieces and caused two (2) abrasions to the other resident's leg. The care plan was updated to move the roommate to another room. On 12/3/2023 Resident #1 slapped another resident, at the nursing station, and a scratch was noted on the other resident. The care plan was updated to include every 15-minutes checks until cleared by psychiatry and social work was to follow up. On 2/19/2024 Resident #1 slapped another resident at the nurse's station. The care plan was updated to direct every 15-minute checks until cleared by psychiatry, staff to monitor Resident #1 by constant community awareness, and psychiatry and social service follow up as needed. On 11/25/2024 when Resident #1 attempted to transfer into a chair at the nurse's station, another resident moved the chair and Resident #1 then pushed the other resident. The care plan was updated to direct every 15-minute monitoring, and the chair was removed from the nurse's station. On 1/20/2025 Resident #1 reported another resident said bad words in the hallway, and both residents hit each other. Resident #1 was noted with an abrasion on the left side of his/her face. The residents were placed on every 15-minute monitoring and the other resident was moved to another unit. Record review identified Resident #1's every 15-minute monitoring was discontinued by psychiatry on 1/25/2025. b. Resident #3's diagnoses included atrial fibrillation and dementia. The quarterly (MDS assessment dated [DATE] identified Resident #3 had a BIMS score of five out of fifteen, indicative of severe cognitive impairment, had no behaviors, required assistance with wheelchair mobility, and identified English was not Resident #3's preferred language. The RCP dated 4/15/2025 identified impaired cognition and a pacemaker due to atrial fibrillation. Interventions directed to administer medications as ordered and ask yes/no questions to determine resident needs. Physician order dated 4/9/2025 directed Eliquis (blood thinner) 5 milligrams (mg) tablet, one (1) tablet by mouth, two (2) times a day, and Clopidogrel (Plavix) (blood thinner prevents blood clotting) 75 mg, one (1) tablet by mouth, one time a day. Facility reportable event dated 4/20/2025 at 12:30 PM identified Resident #3 was hit in the face by Resident #1 (unwitnessed by staff). Staff responded to both residents talking loudly in the hallway and noted Resident #3 had a two (2) centimeter (cm) laceration to the temporal area (near the ear) with bleeding. Resident #1 stated he/she hit Resident #3 because Resident #3 stole toilet paper from his/her bathroom. The report further indicated that Resident #3 was dependent on staff for bathroom use and unable to use the bathroom independently. The residents were separated. Resident #1 was placed on 1:1 monitoring until transfer to the hospital for evaluation. Neurological assessment was completed for Resident #3, who was transferred to the hospital for evaluation. Nursing note for Resident #1 dated 4/20/2025 at 12:14 PM identified Resident #3 was in Resident #1's way in the hallway. Resident #3 did not move, and Resident #1 hit Resident #3 in the face causing an open area to the temporal area. Nursing note for Resident #3 dated 4/20/2025 at 1:42 PM identified an RN assessment was completed after the resident-to-resident physical altercation. Resident #3 was alert, oriented to self with confusion at baseline, and did not state what happened. Redness was noted to the left eye and left upper eyelid. Unequal pupillary reaction/constriction was noted during assessment, the right eye had a brisk response, the left eye had a sluggish response, and active bleeding was observed from the left temporal region and oozing/running down the left side of face. A left temporal region laceration was noted, measuring approximately 2 by 0.1 cm and 0.75 cm in depth. Direct pressure was applied to the lacerated area, but persistent bleeding. The APRN was notified, and Resident #3 was transferred to the hospital for evaluation. Facility incident summary dated 4/24/2025 identified the facility as unable to substantiate that abuse occurred because there was no willful or deliberate action against Resident #3. The summary identified Resident #3 was admitted to the hospital with a subdural hematoma (bleeding near the brain that can occur after trauma), related to medication regime of anticoagulants. The summary further indicated that upon Resident #1's return from the hospital with a no harm letter, Resident #1 was placed on enhanced observation. A virtual APRN visit was conducted on 4/21/2024 with medication adjustments and a plan for continued enhanced monitoring. Education was also provided to residents to have staff assist with resident-to-resident conflicts. Record review identified that monitoring (1:1 monitoring and every 15-minute checks) was discontinued as of 4/28/2025. Review of Resident #3's hospital history and physical dated 4/20/2025 identified Resident #3 was diagnosed with a hyperacute right temporo-parieto-occipital subdural hematoma (a complex area where the temporal, parietal and occipital brain lobes meet; area has a crucial role in integrating sensory information, attention, language, reasoning and memory) and was admitted to the intensive care unit (ICU). Hospital records identified Resident #3 was treated with a craniotomy (surgical opening into the skull to relieve pressure on the brain/remove the hematoma) on 4/28 and 5/6/2025. Further review identified that Resident #3 remained at the hospital during the time of the survey (30 days after the incident). Hospital medicine progress note dated 5/19/2025 identified Resident #3 had a principle problem of subdural hematoma. Resident #3 underwent craniotomy with evacuation of the subdural hematoma followed by MMA embolization (Middle Meningeal Artery embolization is a minimally invasive procedure used to block blood supply to the area affected by a subdural hematoma). Resident #3 was still encephalopathic (medical term that describes a general condition where the brain does not function properly). Please cross reference F600. Interview with Resident #1 on 5/14/2025 at 12:58 PM identified that he/she had garbled speech and stated he/she hit a resident in the bathroom in the past. Resident #1 denied hitting another resident in the hallway or near the nurse's station. Interview, clinical record review, and hospital record review with MD #1/attending MD on 5/14/2025 at 11:29 AM identified that trauma, such as a hit to the head, could cause a subdural hematoma, and Resident #3 had a visible injury to the left side of the head. MD #1 stated an injury on the left side of the head could cause an injury on the right side of the brain (the opposite side) as the brain moves within the skull in a coup and contrecoup effect (rebound/recoil effect with the internal injury on the opposite side of the external force). Further, MD #1 stated Resident #3's injury was caused by the hit on the side of the head, because of how quickly Resident #3 had the bleeding after the injury occurred, he stated in his opinion, the hyperacute right temporo-parieto-occipital subdural hematoma was likely ninety percent certain caused by the trauma. Interview, clinical record review, and facility documentation review on 5/14/2025 at 2:39 PM with the DNS identified that Resident #1 admitted to hitting Resident #3 on 4/20/2025. The DNS stated Resident #1 was initially unable to provide a clear explanation regarding the incident, and then Resident #1 indicated Resident #3 took toilet paper from Resident #1's bathroom, however, Resident #3 did not use the bathroom and required total care for toileting. The DNS stated Resident #1 should not have hit Resident #3, and the facility did not substantiate abuse because Resident #1 did not willfully seek out Resident #3, and because Resident #1's story of the incident changed. The interview failed to identify if adequate supervision was provided for a resident with known behaviors directed toward others to prevent a resident injury. Subsequent to surveyor inquiry, Resident #1 was placed on one-to-one (1:1) observations on 5/14/2025. Review of the facility Close Observation Policy dated 4/17/2024 directed in part, the facility will provide staff with guidance in applying close observation levels for the purpose of ensuring resident safety. The Policy further directed, there are several conditions or circumstances that may indicate a possible risk of harm or injury to the resident or others; risk factors include de-compensated mental status (i.e. impulsivity, impaired judgment, agitation).

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and #2) reviewed for abuse, the facility failed to ensure the residents were seen by a physician/designee with orders reviewed and renewed at least once every 60 days. The findings included: a. Resident #1's diagnoses included anxiety and schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment and was self-mobile in wheelchair. The Resident Care Plan (RCP) dated 11/25/2024 identified Resident #1 had a potential to be aggressive. Interventions directed every 15-minute checks, administer medications as ordered, counseled to seek assistance of staff for issues with peers, psychiatric and social services follow up, when resident becomes agitated intervene before agitation escalates, guide away from source of distress, if aggressive to staff walk away calmly and approach later. Record review identified Resident #1 was on a 60-day schedule for review and renew of physician orders. Record review identified although physician orders were signed by MD #1 on 11/2/2024, review identified the record had no additional physician orders signed until 3/8/2025 (127 days after they were last signed). b. Resident #2's diagnoses included anxiety, dementia, bipolar disorder and schizoaffective disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment and was self-mobile in wheelchair. The Resident Care Plan (RCP) dated 11/14/2024 identified Resident #2 had a self-care performance deficit related to dementia. Interventions directed encourage to participate to the fullest extent possible. Record review identified Resident #1 was on a 60-day schedule for review and renew physician orders. Record review identified although physician orders were signed by MD #1 on 11/2/2024, review identified the record had no additional physician orders signed until 3/8/2025 (127 days after they were last signed). Interview and review of record with DNS and Administrator on 5/14/2025 at 2:39 PM DNS identified the facility was unable to provide documentation that Resident #1 and Resident #2's physician orders were signed at least every 60 days. The DNS stated the orders should have been signed and was unable to identify why the orders were not signed timely. Interview and record review with MD #1/Medical Director on 5/14/2025 at 11:29 AM identified that he signs the resident orders monthly, and that he began signing orders electronically as of November 2024. He indicated that Resident #1 and Resident #2's orders should have been signed, but it was possible that he missed them. MD #1 further indicated he had not signed the April 2025 orders yet and was behind in signing resident orders. Although the surveyor requested a policy regarding medical visits, a policy was not provided for surveyor review.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident (Resident #1) was free from physical abuse. The findings include: a. Resident #1's diagnoses included vascular dementia and schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, alert and disoriented, no behaviors and was dependent for wheelchair mobility. The Resident Care Plan (RCP) dated 3/26/2025 identified Resident #1 had dementia and an alteration in mobility. Interventions directed to administer medications as ordered, and custom modified wheelchair for mobility. b. Resident #2's diagnoses included dementia, paranoid schizophrenia, and schizoaffective disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was severely cognitively impaired, alert and oriented to self only, had no behaviors, and was independent with ADLs and ambulation. The Resident Care Plan (RCP) dated 2/13/2025 identified Resident #2 had the potential to be physically aggressive related to dementia. Interventions directed to administer medications as ordered, and psychiatry follow up as indicated. Facility reportable event dated 3/25/2025 identified at 12:45 PM, NA #1 witnessed Resident #2, unprovoked, slap Resident #1. Resident #1 was sitting in a wheelchair in the hall when Resident #2 walked up to Resident #1 and slapped the left side of his/her face. Residents were separated and assessed, and Resident #1's face was observed to be reddened. Resident #2 was placed on one-to-one (1:1) monitoring and transferred to the hospital for evaluation. The facility summary dated 3/27/2025 identified Resident #2 returned from the hospital and remained on 1:1 observation until psychiatry visit. Record review identified Resident #2 had prior resident to resident altercations on 6/19/2024 at 2 PM, 8/18/2024 at 10:10 AM, and 10/18/2024 at 1 PM. Review of NA #1's statement dated 3/25/2025, identified she was collecting lunch trays when a non-staff member notified her that Resident #1 was hit. NA #1 then looked at Resident #1 and observed Resident #2 hit Resident #1 a second time. Interview and review of facility documentation with NA #1 on 4/14/2025 at 11:57 AM identified she heard a non-staff member yell, hey don't do that. NA #1 stated she looked down the hall and saw Resident #1 sitting in hallway, and observed Resident #2 slap Resident #1 for the second time on the left side of the face with his/her right hand. Interview, clinical record and facility documentation review with SW #1 and SW #2 on 4/14/2025 at 12:56 PM identified Resident #2 was on a waitlist for an evaluation for an in-patient psychiatric stay due to a history of refusing to take medications prior to the 3/25/2025 altercation with Resident #1, and remained on the wait list for that facility. Resident #2 was independently mobile, continued on every 15-minute checks, and was followed by psychiatric services until he/she is accepted for transfer to another facility. On 4/14/2025 at 2:22 PM interview, clinical record and facility documentation review with the DNS, the Administrator and RN #1 identified that there were two witnesses to Resident #2 slapping Resident #1 on the face. The first witness was Lab Tech #1, however although Lab Tech #1 reported the incident, he/she refused to provide a witness statement, and NA #1 was the second witness. RN #1 identified that Resident #2 had a similar occurrence several months prior when Resident #2 was not taking his/her medication and Resident #1 was not specifically targeted by Resident #1. The DNS stated the hospital administered a faster onset anti-psychotic medication and made additional medication adjustments for Resident #2 Resident #2 remained on every 15-minute checks and was followed by psychiatric services. RN #1 identified there was physical contact made by Resident #2 to Resident #1 but the facility did not consider it willful contact by Resident #2. Review of facility Abuse Policy directed in part, abuse was defined as the willful infliction of injury, and included physical abuse. Physical abuse was defined as hitting, slapping, pinching and kicking. The Policy directed residents will not be subjected to abuse by anyone, including but not limited to facility staff, other residents, or other individuals. Review of facility Abuse Policy directed in part residents will not be subjected to abuse by anyone, including but not limited facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.

Based on review of resident council minutes, review of facility policy, and interviews, the facility failed to provide documentation of the facility's response to resident council's grievances. The findings include: Review of the monthly resident council group meeting minutes from May 2024 to September 2024 identified the following concerns: In the May 2024 resident council meeting minutes residents voiced concerns regarding staff not folding or hanging cleaned clothing up after it was laundered, staff using cellphones while providing care, and residents not being able to choose when to be put back to bed. The June 2024 resident council minutes identified the facility's documented resolution to the expressed concerns were to provide staff education concerning the hanging and folding of resident clothing, storage of the clothing neatly, no cellphone usage in resident care areas, and giving residents the choice to decide the time they want to go to bed. In the August 2024 resident council meeting minutes, the concern about the staff's usage of cellphones was again voiced. The September 2024 resident council minutes identified the facility's resolution was that staff would again receive education regarding cellphone usage. The completed staff education was requested, and the facility provided documentation that the cellphone usage was addressed in June of 2024. There was no other education provided regarding the in-servicing of the staff regarding cell phone usage in resident areas. Interview with Recreation Director (RD #1) on 10/24/24 at 10:20 AM identified he is responsible for scheduling and organizing the monthly resident council meetings. He further identified that during the meetings he reviews the previous month's minutes and concerns with the resolution to the concern. He further identified that the department head of each department is responsible for resolving the expressed residents' concerns brought up during the meetings. Interview with the Staff Development Nurse (LPN #2) on 10/24/24 at 10:45 AM identified she is responsible for staff education. She noted that she was not aware that the staff required education on ensuring resident clothing is folded and hung up, or respecting the resident's choice of when to go to bed or staff cellphone usage in resident areas. She further identified the former DNS may have addressed the documented concerns. Interview with the former DNS (RN #1) on 10/24/24 at 11:00 AM identified that when she was the DNS, she was responsible for providing the resolution for nursing concerns voiced in the monthly resident council meetings. She also identified that depending on LPN #2 the issue/concern she would initiate staff education and pass it on to LPN #2 to continue the staff education. She further identified that she could not remember whether or not she communicated to LPN #2 that the staff needed to be educated on ensuring resident clothing was folded and stored properly, the residents' choice of when to go back to bed, and staff cellphone usage in resident care areas. Additionally, she identified that she had not conducted the staff education regarding the concerns. The Resident and Family Council policy identified that any issues raised at the resident council meeting would be addressed by the respective department head and responses to a concern would be forwarded for review at the subsequent council meeting.

Based on observations, review of clinical records, review of facility documentation, review of facility policy, and interviews for two of five sampled residents (Residents #30, #31, #35 and #51) reviewed for abuse, the facility failed to ensure the residents were free from abuse. The findings include: 1. Resident #30's diagnoses included dementia, anxiety and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #30 had moderate cognitive impairment, no behaviors, and was independent with ambulation. The care plan dated 5/3/24 identified Resident #30 had an altercation with another resident with interventions that directed to assist in keeping the residents separated, encourage resident to voice his/her frustrations to staff and to have close observation levels applied as indicated. The care plan further identified Resident #30 was admitted to the behavioral health program located on the secured unit due to the diagnoses of schizophrenia and behaviors and symptoms such as delusions, verbal aggression, physical aggression, social disruptiveness, inappropriate acts towards others, sexually inappropriate comments towards staff with interventions that included resident would not be involved in altercations with others, provide increased attention/observation when needed and provide mental health professional services as indicated or ordered. Review of the behavioral intervention monthly flow record for the month of May through June 2024 identified Resident #30 was monitored for inappropriate sexual behaviors and agitation. Resident #32's diagnoses included alcohol induced dementia, anxiety disorder and adjustment disorder. The quarterly MDS assessment dated [DATE] identified Resident #32 had moderate cognitive impairment, no behaviors, required moderate assistance with personal hygiene, independent with bed mobility, and ambulation. The care plan dated 4/24/24 identified Resident #32 had a history of resident-to-resident altercations due to being unable to recognize appropriate boundaries with interventions that included if resident is bothered by the presence of another resident, assist in keeping them separated, encourage resident to voice his/her frustrations to staff and to have resident seen by psychiatry for medication and symptom management. The care plan further identified Resident #32 was at risk for psychosocial well-being due to chronic medical and/or psychological conditions with interventions that included refer to facility's social worker for any newly identified psychosocial concerns as needed and refer to psychiatric consultants as needed for significant impaired coping or psychosocial complications. Review of the behavioral intervention monthly flow record for the month of May through June 2024 identified Resident #32 was monitored for depression and physical aggression. The Reportable Event Report dated 6/3/24 identified at 9:30 AM LPN #7 witnessed Resident #32 throw a chair at Resident #30 hitting the resident on the right lower extremity resulting in a skin tear to the right ankle that measured 1.0 centimeter (cm) by 0.5 cm. The report further noted Resident #30 complained of pain to the left ankle. Resident #32 identified that he/she was annoyed that Resident #30 was walking up and down the hall singing. Resident #32 was placed on one-to-one observation until seen by psychiatry. The Reportable Event Report further identified Resident #32 was moved to a different unit with less stimulation and both residents were seen by the psychiatric service provider. The facility's investigation dated 6/3/24 identified Resident #32 was agitated with the housekeeper for emptying the garbage and was last seen in his/her room at 8:50 AM. Resident #30's physician's order dated 6/3/24 directed to wash the excoriated area to the right lower extremity with normal saline, pat dry, apply Bactroban and cover with a bordered gauze on a daily basis and as needed for 10 days and to monitor the area for any signs or symptoms of infection. The Psychiatric evaluation and consultation dated 6/3/24 identified Resident #30 was pleasant, loud, engaged in conversation and offered no memory or report of the event that took place in the AM. The note further noted to continue to offer supportive nursing care and behavioral monitoring. Social Worker #2's progress note dated 6/3/24 at 9:59 AM identified she was notified that Resident #30 was involved in a resident-to resident altercation. The note further identified Resident #30 was doing well and sitting in a chair by the nurse's station in good spirits. Observation on 10/23/24 at 2:30 PM identified Resident #30 seated in a wheelchair near other residents close to the nursing station and appeared pleasant and engaging with staff. Interview with LPN #7 on 10/25/24 at 10:31 AM identified at the time of the incident, he observed Resident #30 walking ahead of Resident #32 in the hallway and heard both residents talking but was unable to understand what the conversation was about. LPN #7 further noted he then saw Resident #32 pick up a chair that was in front of the nurse's station and walk towards Resident #30. LPN #7 further identified that he ran down the hallway calling out to Resident #32 and when he got to Resident #32, the resident threw the chair and hit Resident #30 on the ankle. LPN #7 indicated that he made it to Resident #32 just in time and stated that Resident #30's injury would have been worse had he not attempted to stop Resident #32 while the resident was in the process of trying to hit Resident #30 with the chair. In addition, LPN #7 identified Resident #32 had a history of displaying aggressive behaviors toward others, and he/she was unpredictable with his/her actions. Review of the Abuse policy identified that abuse, neglect, exploitation, and/or mistreatment of residents or misappropriation of resident property was prohibited. The policy further identified that residents would not be subjected to abuse by anyone including not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. 2. Resident #31's diagnoses included vascular dementia, major depressive disorder and heart failure. The quarterly MDS assessment dated [DATE] identified resident #31 had severe cognitive impairment, no behaviors, required maximal assistance with personal hygiene, was non-ambulatory and utilized wheelchair for mobility. The care plan dated 4/24/24 identified Resident #31 was admitted to the behavioral health program located on the secured unit due to the diagnoses of dementia with behavioral disturbances, due to the following behaviors and symptoms of delusions, intrusions, social disruptiveness, and attempts to leave the unit. Interventions included monitor resident in common areas, provide increased attention/observation when needed, redirect when needed/direct and provide mental health professional services as indicated or ordered. Review of the behavioral intervention monthly flow record for the month of May through June 2024 identified Resident #31 was monitored for restlessness and tearfulness. Resident #32's diagnoses included alcohol induced dementia, anxiety disorder and adjustment disorder. The quarterly MDS assessment dated [DATE] identified Resident #32 had moderate cognitive impairment, no behaviors, required moderate assistance with personal hygiene, independent with bed mobility, and ambulation. The Reportable Event Report dated 6/8/24 identified that at 10:15 AM NA #2 witnessed Resident #32 hit Resident #31 in the face. Resident #31. Resident #31 was not noted to have any visible injuries and vital signs, and neurological assessments were ordered for the next 72 hours. Resident #32 was placed on one-to-one observation prior to being transfer to the emergency room for evaluation. NA #2's written statement dated 6/8/24 at 10:15 AM identified Resident #32 was ambulating in the hallway then screamed and punched Resident #31 in the face and appeared very agitated and upset. The Reportable Event report summary dated 6/14/24 identified Resident #32 was moved to another unit when he/she returned from the hospital. The nurse's note dated 6/8/24 at 10:15 AM identified Resident #31 was hit in the face by another resident with no obvious painful distress, no redness, swelling or open areas noted. The note further identified that neurological checks were initiated, and resident remained at baseline. Social Worker #2's progress note dated 6/10/24 at 1:17 PM identified she met with Resident #31, and he/she was doing well after the incident with Resident #32. The note further identified the resident was provided with emotional support. The psychiatric evaluation and consultation dated 6/12/24 identified Resident #31 was seen after being involved in a peer-to-peer altercation wherein the resident was not the aggressor, nor did he/she retaliate according to the nursing staff. The note further identified Resident #31 offered no meaningful information during the visit, made eye contact when name called with no vocalization. The note further noted to continue supportive nursing care and psycho pharmacotherapies as prescribed. Observation on 10/25/24 at 10:25 AM identified Resident #31 in his/her room lying in bed and attempts to interact with the resident identified he/she was not communicative. An interview was attempted with NA #2 on 10/25/24 which was unsuccessful. The DNS on 10/25/24 identified that she was unable to reach NA #2 after several attempts. Interview with LPN #7 on 10/25/24 at 10:31 AM identified Resident #31 does not speak much and only responds when his/her name is called and was unaware of any prior incidents between Resident #31 and Resident #32. Review of the Abuse policy identified that abuse, neglect, exploitation, and/or mistreatment of residents or misappropriation of resident property was prohibited. The policy further identified that residents would not be subjected to abuse by anyone including not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. 3. Resident #31's diagnoses included vascular dementia, traumatic brain injury, and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 had a Brief Interview for Mental Status (BIMS) score of one out of fifteen (1/15), indicative of severe impaired cognition and required supervision for mobility with a wheelchair. The Resident Care Plan (RCP) dated 9/11/2024 identified Resident #31 was at risk for altered mood and behaviors related to dementia with behavioral disturbances and wandering. Interventions directed to redirect with minimal cues if exhibiting socially inappropriate behavior, allow to vent feelings in a non-confrontational manner, and offer unit programs/times as directed by resident's safety level/status. Resident #112's diagnoses included vascular dementia with agitation, anxiety disorder, and depression. The admission MDS assessment dated [DATE] identified Resident #112 had a BIMS score of six out of fifteen (6/15), indicative of severe impaired cognition and required partial assistance for mobility with a wheelchair. The RCP dated 9/10/2024 identified Resident #112 was at risk for altered mood and behaviors related to vascular dementia and a history of threatening to inflict physical injury on residents/staff. Interventions directed to encourage appropriate and therapeutic expression of emotions, use calming/gentle approach due to a low frustration level. A facility reportable event form and investigation dated 10/2/2024 at 7:15 PM identified LPN #9 and LPN #10 witnessed a physical altercation between Resident #112 and Resident #31; Resident #112 slapped Resident #1 in the face, punched him/her in the neck and kicked him/her on the left side of the chest and staff immediately separated the residents. Resident #112 reported that he/she was upset because Resident #31 went into his/her drawer. Resident #112 was immediately placed on a one-to-one (1:1) observation until transferred to the hospital. Resident #31 complained of head/back and neck pain, with two (2) scratches noted to the left chest and left side of the face. Resident #31 was transferred to the hospital and returned without any further interventions/treatment plans. A nursing note dated 10/2/2024 at 10:44 PM written by RN #6 identified she was called to the unit at approximately 7:15 PM. Resident #112 was upset that Resident #31 entered his/her room and went into his/her bureau, and staff witnessed Resident #112 hit Resident #31. Resident #31 was in the hallway, when Resident #112 came into the hallway yelling and poured urine on Resident #31 and started punching him/her in the back of neck/head, slapping him/her in the face and kicking him/her on the side of the body and the residents were immediately separated. Resident #112 appeared agitated, and RN #6 spoke with Resident #112 to try to calm him/her down. Resident #112 reported that he/she was going to hit Resident #31 anytime he/she sees Resident #31 and reported that he/she doesn't care if the nursing staff calls the police. Resident #112 placed on a 1:1 until transferred to the hospital. Interview with LPN #10 on 10/29/2024 at 11:25 AM identified on 10/2/2024, LPN #10 witnessed Resident #112 poured urine on Resident #31 and began hitting and kicking him/her and staff immediately separated the residents. Resident #112 identified that he/she was upset because Resident #31 went into his/her bureau, and alleged Resident #31 took unidentified belongings. LPN #10 identified that Resident #112 had a stop sign on his/her door, but Resident #31 had removed it prior to entering the room. LPN #10 indicated Resident #31 had a reddened area to the right side of his/her neck/face and was transferred to the hospital for evaluation and Resident #112 was placed on a 1:1 monitoring until transferred to the hospital. Although attempted, interview with LPN #9 was unable to be obtained during survey. Interview with the DON and Administrator on 10/29/2024 at 2:30 PM identified the incident involved a physical interaction between the residents. Interview further identified the facility did not substantiate the incident as abuse because the residents were confused. 4. Resident #51's diagnoses included vascular dementia, schizoaffective disorder, post-traumatic stress disorder, and depression. The annual MDS assessment dated [DATE] identified Resident #51 had a BIMS score of fourteen out of fifteen (14/15), indicative of being alert and oriented and was supervision for mobility with a wheelchair. The RCP dated 9/20/2024 identified Resident #51 was at risk for psychotic symptoms such as delusions, hallucinations, and disorganization of thoughts and behaviors related to schizoaffective disorder, depression, and post-traumatic stress disorder. Interventions directed to encourage to voice frustrations to staff, and to offer support and kindness. Resident #35's diagnoses included vascular dementia with behavior disturbances, schizoaffective disorder, and anxiety disorder. The RCP dated 9/25/2024 identified Resident #35 was at risk for altered mood and behaviors related to schizoaffective disorder and dementia with behavioral disturbances, as evidence by exhibiting symptoms such as verbal and physical aggression, intrusion, socially disruptive, and combative with care. Interventions directed use calm and gentle approaches to redirect resident to a quiet environment, encourage diversional activities and psychiatric/social services as needed. The annual MDS assessment dated [DATE] identified Resident #35 had a BIMS score of three out of fifteen (3/15), indicative of severe impaired cognition and was dependent for mobility with a wheelchair. A facility reportable event form and investigation dated 10/3/2024 at 7:00 PM identified LPN #11 and NA #3 witnessed Resident #51 in his/her wheelchair wheeling past Resident #35, when Resident #35 grabbed Resident #51's arm and hit him/her. Both residents then began to hit each other. The residents were immediately separated, and Resident #35 was placed on a 1:1 observation until he/she was transferred to a different unit and floor. Psych and social services to followed up with both residents and no injuries were noted on either resident. A nursing note dated 10/4/2024 at 1:53 AM written by RN #6 identified on 10/3/2024 about 7 PM, Residents #51 and #35 were involved in a physical altercation and the residents were immediately separated. Resident #35 indicated he/she hit Resident #51 first, and his/her flexed muscles. Resident #35 complained of right wrist pain, redness was noted to the right side of the face and a scratch was noted to right nose crease, right hand and wrist. APRN #1 notified, an x-ray was obtained of Resident #35's right wrist and results were negative. Review of LPN #11's written statement dated 10/3/2024 at 7:00 PM identified LPN #11 witnessed Resident #51 and #35 grabbing and hitting each other in the hallway. Staff intervened, both residents stopped, and they were separated. Review of NA #3's written statement dated 10/3/2024 without a timeframe identified NA #3 heard Resident #35 screaming, and NA #3 looked over and saw Resident #51 and #5 grabbing each other's arms. Although attempted, interview with LPN #11 and NA #3 was unable to be obtained during survey. Interview with the DON and Administrator on 10/29/2024 at 2:30 PM identified the incident involved a physical interaction between the residents. Interview further identified the facility did not substantiate the incident as abuse because the residents were confused. Review of facility Abuse Policy dated 3/20/2024 directed in part, abuse of residents is prohibited. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. 47900

Based on review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for three of five sampled residents (Resident #30, Resident #31, Resident #32) reviewed for abuse, and one of two residents reviewed for choices, the facility failed to ensure that the residents' care plan was reviewed and revised following an incident of abuse and failed to ensure interdisciplinary care plan meetings were conducted following the completion of the admission and quarterly MDS. The findings include: 1. Resident #30's diagnoses included dementia, anxiety and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #30 had moderate cognitive impairment, had no behaviors, and was independent with personal hygiene and ambulation. The care plan dated 5/3/24 identified Resident #30 had an altercation with another resident with interventions that directed to assist in keeping the residents separated, encourage resident to voice his/her frustrations to staff and to have close observation levels applied as indicated. The care plan further identified Resident #30 was admitted to the behavioral health program located on the secured unit due to the diagnoses of schizophrenia and behaviors and symptoms such as delusions, verbal aggression, physical aggression, social disruptiveness, inappropriate acts towards others, sexually inappropriate comments towards staff with interventions that included resident would not be involved in altercations with others, provide increased attention/observation when needed and provide mental health professional services as indicated or ordered. The Reportable Event Report dated 6/3/24 identified at 9:30 AM LPN #7 witnessed Resident #32 throw a chair at Resident #30 hitting the resident on the right lower extremity resulting in a skin tear to the right ankle that measured 1.0 centimeter (cm) by 0.5 cm. The report further noted Resident #30 complained of pain to the left ankle. Resident #32 identified that he/she was annoyed that Resident #30 was walking up and down the hall singing. Resident #32 was placed on one-to-one observation until seen by psychiatry. The Reportable Event Report further identified Resident #32 was moved to a different unit with less stimulation and both residents were seen by the psychiatric service provider. Review of Resident #30's care plan failed to identify the resident-to-resident altercation that took place on 6/3/24 and failed to identify interventions put in place as a result of the altercation that resulted in an injury. Interview on 10/25/24 at 11:34 AM with the DNS, the Regional Nurse (RN #6) and the Regional Clinical Director failed to identify why Resident #30's care plan was not reviewed and/or revised to reflect the resident-to-resident altercation and interventions to address how to provide support and/or protection of Resident #30. Interview with the DNS on 10/25/24 at 11:34 AM identified that it was the responsibility of the Social Worker to develop and implement the care plan for both the victim and the perpetrator. The DNS further identified that it is the responsibility of the DNS and the Administrator to review the reportable event reports to ensure that the state agency was updated, investigation was completed, summary and care plan was completed. Interview with the Director of Social Services (SW #1) and SW #2 on 10/25/24 at 1:12 PM identified that it is the Social Worker's responsibility to update the resident's care plan following a resident-to-resident incident and to review and revise the psychosocial care plans quarterly and annually. SW #1 and SW #2 identified that both the victim and the perpetrator care plans would be updated. SW #1 further identified that Resident #30's care plan should have been updated to identify the date of the incident, the initials of the abuser, brief information about the altercation and what it was related to with interventions that were specific to the incident such as social worker one to one visits and psychiatric team for therapy. Additionally, interview with SW #2 on 10/25/24 at 2:55 PM identified that she had failed to address Resident #30's care plan following the incident with Resident #32. 2. Resident #31's diagnoses included vascular dementia, major depressive disorder and heart failure. The quarterly MDS assessment dated [DATE] identified resident #31 had severe cognitive impairment, had no behaviors, required maximal assistance with personal hygiene, and did not ambulate. The assessment further identified that Resident #31 utilized a wheelchair for ambulation. The care plan dated 4/24/24 identified Resident #31 was admitted to the behavioral health program located on the secured unit due to the diagnoses of dementia with behavioral disturbances, due to the following behaviors and symptoms of delusions, intrusions, social disruptiveness, and attempts to leave the unit. Interventions included monitor resident in common areas, provide increased attention/observation when needed, redirect when needed/direct and provide mental health professional services as indicated or ordered. The Reportable Event report summary identified Resident #31 was seated in his/her wheelchair in the hallway when Resident #32 walked by Resident #31 and struck the resident on the head unprovoked. The summary further identified that both residents were separated, Resident #31 did not sustain any injury while Resident #32 was place on one-to-one observation pending transfer to hospital, and upon return from the hospital was moved to another unit. Resident #31's care plan dated 3/27/24 was reviewed with the DNS, the Regional Nurse (RN #6) and Regional Clinical Director Nurse on 10/25/24 at 11:34 AM failed to identify the resident-to-resident altercation incident that occurred on 6/8/24 between Resident #30 and Resident #32. Interview with the DNS on 10/25/24 at 11:34 AM identified that it was the responsibility of the Social Worker to develop and implement the care plan for both the victim and the perpetrator. The DNS further identified that it was the responsibility of the DNS and the Administrator to review accidents and incident reports to ensure that the state agency was updated, investigation was completed, summary and care plan was completed. Interview with the Director of Social Services (SW #1) and SW #2 on 10/25/24 at 1:12 PM identified that it was the Social Worker's responsibility to update the resident's care plan following a resident-to-resident incident and to review and revised the psychosocial care plans quarterly and annually. The SW #1 and SW #2 identified that both the victim and the perpetrator care plans would be updated. SW #1 further identified that the incident that occurred on 6/8/24 was the first resident to resident incident for Resident #31, hence the care plan would had identified that Resident #31 was treated in an abusive manner by peer (Resident #32) with goal to feel safe from risk of physical harm or mental anguish while receiving care at the facility, and the interventions would include psychiatric team for therapy, one to one visit with the social worker, provide counseling approaches that focus on comfort and satisfaction and to remove resident from individuals know to bother the resident. Interview with SW #2 on 10/25/24 at 2:55 PM identified that after reviewing Resident #31's care plan she failed to identify any mention or interventions implemented following the incident that occurred on 6/8/24 between Resident #31 and Resident #32. 3. Resident #32's diagnoses included alcohol induced dementia, anxiety disorder and adjustment disorder. The quarterly MDS assessment dated [DATE] identified Resident #32 had moderate cognitive impairment, had no behaviors, required moderate assistance with personal hygiene, dressing, independent with bed mobility, transfers and ambulation. The care plan dated 4/24/24 identified Resident #32 had a history of resident-to-resident altercations due to being unable to recognized appropriate boundaries with interventions that included if the resident was bothered by the presence of some to assist in keeping them separated, encourage resident to voice his/her frustrations to staff and to have resident seen by psychiatry for medication and symptom management. The care plan further identified Resident #32 at risk for psychosocial well-being due to chronic medical and/or psychological conditions with interventions that included nursing staff would refer to facility's social worker for any newly identified psychosocial or concerns as needed and would refer to the facility's contracted psychiatric consultants as needed for significant impaired coping or psychosocial complications. The Reportable Event dated 6/3/24 identified that at 9:30 AM Resident #32 threw a chair hitting Resident #30 on the right lower extremity which was witnessed by one of the charge nurses on the floor, LPN #7. When asked what occurred Resident #32 stated he was annoyed that Resident #30 was walking up and down the hall singing. The report further identified that Resident #30 was noted to have a skin tear to the right ankle that measured 1.0 centimeter (cm) by 0.5 cm and complained of pain to the left ankle. In addition, the report further identified that both residents were separated, Resident #32 was placed on one-to-one observation until the he/she was cleared by psychiatry. Resident #32' care plan dated 4/24/24 was reviewed with the DNS, the Regional Nurse (RN #6) and Regional Clinical Director Nurse on 10/25/24 at 11:34 AM failed to identify that resident had a room change related to the resident-to-resident altercation incident that occurred on 6/3/24 between Resident #30 and Resident #32. The Reportable Event report summary identified Resident #31 was seated in his/her wheelchair in the hallway when Resident #32 walked by Resident #31 and struck the resident on the head unprovoked. The summary further identified that both residents were separated, Resident #31 did not sustain any injury while Resident #32 was place on one-to-one observation pending transfer to hospital, and upon return from the hospital was moved to another unit. Resident #32's care plan dated 4/24/24 was reviewed with the DNS, the Regional Nurse (RN #6) and Regional Clinical Director on 10/25/24 at 11:34 AM failed to identify any resident-to-resident altercation incident that occurred on 6/8/24 between resident #31 and resident #32. Interview with the DNS on 10/25/24 at 11:34 AM identified that it was the responsibility of the Social Worker to develop and implement the care plan for both the victim and the perpetrator. The DNS further identified that it was the responsibility of the DNS and the Administrator to review accidents and incident reports to ensure that the state agency was updated, investigation was completed, summary and care plan was completed. Interview with the Director of Social Services (SW #1) and SW #2 on 10/25/24 at 1:12 PM identified that it was the Social Worker's responsibility to update the resident's care plan following a resident-to-resident incident and to review and revised the psychosocial care plans quarterly and annually. The SW #1 and SW #2 identified that both the victim and the perpetrator care plans would be updated. SW #1 identified that since this was not Resident #32's first resident to resident altercation that the date of the incident along with the initial of the resident would be added with the new interventions such as Resident #32 was sent to the hospital and room change to the exiting care plan. Interview with SW #2 on 10/25/24 at 2:55 PM identified that after reviewing Resident #32's care plan she failed to identify any mention or interventions implemented following the incident that occurred on 6/8/24 between Resident #31 and Resident #32 and the incident occurred on 6/3/24 did not include all the interventions that was implemented. Review of the Care Plan policy identified that the facility to develop a comprehensive person-centered plan of care for its residents that is consistent with residents' rights for them to attain and/or maintain their highest practicable level of physical, mental, and psychosocial well-being. 4. Resident #59 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, schizoaffective disorder, polyneuropathy, and extrapyramidal symptoms. The baseline care plan dated 6/18/24 identified Resident #59 was at risk for behaviors related to psychiatric disorders, with interventions that included: consult with conservator of person regarding the exercise resident's rights, encourage participation in behavioral program and recreational groups, residence on secured unit, monitor behaviors, provide mental health professional services as indicated, and the care plan noted that the resident/representative was involved and/or informed of the plan of care. The admission MDS assessment dated [DATE] identified Resident #59 was cognitively intact, had no behaviors, was independent with hygiene, dressing, eating, transfers and mobility. The assessment further identified the resident was taking antipsychotic, antianxiety and antidepressant medication. The resident also had a quarterly MDS assessment dated [DATE]. Review of Resident #59's clinical record failed to identify that an interdisciplinary team care plan conference meeting inclusive of the resident and/or the resident's responsible party took place between 6/18/24 and 10/24/24. Review of the and social service progress notes from 6/18/24 through 10/24/24 failed to identify documentation notification of Resident #39's admission to the facility was made to the resident's conservator and or that the conservator was invited to participate in the care plan process, it also failed to identify that the resident was included in the care planning process. Interview on 10/24/24 at 10:14 AM with the MDS Coordinator identified there had not been an interdisciplinary care plan meeting held for Resident #59 after the completion of the admission MDS or the quarterly MDS. 47900

Based on review of the clinical record, review of facility policy/procedures and interviews for one of five sampled residents (Resident #78) reviewed for unnecessary medications, the facility failed to ensure the pharmacy recommendations were reviewed by the provider, and present in the resident clinical chart. Additionally, the facility did not have an established policy and procedure for processing of the pharmacy recommendations. The findings included: Resident #78's diagnoses included traumatic brain injury, vascular dementia and, anxiety disorder. The quarterly MDS dated [DATE] identified the resident had severely impaired cognition, did not exhibit inattention, disorganized thinking, or altered level of consciousness. The Care plan dated 9/13/24 identified Resident #78 was at risk for Behavioral Health and participated in the Behavioral Health Program related to depressive disorder, bi-polar, and anxiety. Interventions included placement on a secured unit, and to monitor for psychotropic medication side effects. Physician's orders dated 10/12/24 directed to administer 50 mg of Trazodone every night at bedtime, 1mg of Risperidone twice per day, 850 mg of Metformin once a day, 200 mg of Lamotrigine once a day, 0.1 mg Fludrocortisone once a day, 250 mg Divalproex Delayed Release once every 12 hours, 1mg of Clonazepam three times a day, 2.5 mg Bromocriptine once a day, 40 mg of atorvastatin once a day, and 100 mg of amantadine twice a day. Additional medications included over the counter medications. Review of the Pharmacy progress notes dated 3/3/26/24, 4/16/24, 7/22/24, and 9/25/24 identified the Pharmacy review was completed, and recommendations were made to the provider. Review of the clinical chart on 11/23/24 at 12:00 PM, included the paper chart and 2 electronic health records, failed to produce the above listed pharmacy reviews with the recommendations, and failed to contain lab results for the resident. Interview on 10/25/24 at 11:15 AM with the DNS and Regional Clinical Director identified the recommendations were not all in the charts at that time and the facility was in the process of redoing the process for the processing of pharmacy recommendations. They identified the process for pharmacy recommendations was as follows: 1. The recommendations are emailed to the DNS and ADNS. 2. Whomever is reviewing prints the recommendation, makes a copy and gives a copy to the APRN 3. The APRN will sign off on them and agree or disagree with the recommendations and give it back to the DNS. 4. The DNS makes a copy, keeps one copy and places the other into the resident chart. 5. The APRN makes changes, if needed, and the DNS checks for implementation. Interview on 10/25/24 at 1:31 PM with the Regional Clinical Director identified that the recommendations were reprinted and indicated they were not signed by the APRN. She identified that she was reviewing the charts to see if the recommendations were implemented. Pharmacy recommendations reviewed on 10/25/24 at 2:00 PM, after they were provided by the facility included the following: Drug Regimen Review dated 3/26/24 that indicated the resident was taking Metformin and the pharmacist was unable to locate recent HbA1C in the chart. Additionally, it was indicated that this test was recommended every 6 months. The Prescriber response was Agree; will do and was signed by the APRN 3/27/24. Drug Regimen Review dated 4/15/24 identified HBA1C was ordered on 3/27/24, results not located on chart. Please follow up and obtain a duplicate copy, or consider reordering, if necessary. The follow up comments indicated the test was re-ordered. This form was signed by an RN and dated 4/16/24. Drug Regimen Review dated 7/22/24 identified the resident was receiving Atorvastatin (Lipitor) for dyslipidemia. Unable to locate recent serum lipid profile in chart. Recommended 3 months after start then annually thereafter. Please consider ordering. This recommendation was not reviewed and not signed by the provider. Unable to locate blood test results. Drug Regimen Review dated 9/25/24 identified a 2nd request that indicated the resident was receiving Atorvastatin (Lipitor) for dyslipidemia. The consultant identified the serum lipid profile was not able to be located and recommended the serum be obtained 3 months after start and annually thereafter. Additionally, a second recommendation identified the resident was receiving Metformin and the HbA1C was unable to be located in the chart and recommended this test every 6 months. This review was not signed by the provider. Interview on 10/29/24 at 10:10 AM with APRN identified that the Drug Regimen Reviews are printed and placed in her inbox. The APRN indicated she addressed them and sometimes gave a verbal order or sometimes wrote on the Physician Order sheets. She identified that with the new electronic health record, the orders would be put directly into the resident's chart. Additionally, the APRN identified she was notified about the 7/22/24 and 9/25/24 Drug regimen reviews this day and had placed orders for a blood draw to obtain a lipid panel and an A1C or blood glucose test. The APRN identified there were no negative effects by delaying these tests. The facility policy for chart order and thinning/retention guidelines identified active residents' paperwork should be kept on the unit. Advance directives, consents to treat for the facility or psych group, and all care plans are permanent and should not be removed from the clinical chart. Pharmacy recommendations should include the current 1 year. The Consultant Pharmacist Service Agreement identified the pharmacy consultant shall be responsible for the performance of each resident's drug regimen review monthly, with reports of all findings or irregularities to the Director of Nursing for distribution to the attending Physician. Although requested the facility did not provide a policy that identified the procedure for processing the Drug Regimen Reviews.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedure and interviews for one of two sampled residents (Resident #119) reviewed for dental, the facility failed to ensure the resident was seen by a dentist/hygienist. The findings include: Resident #119 was admitted to the facility in May of 2024 with diagnoses that included fracture of right femur, fracture of left tibia and fibula, depression and anxiety. The admission MDS assessment dated [DATE] identified Resident #119 was cognitively intact, required total dependence with oral hygiene, dressing, personal hygiene, transfers and did not ambulate. The assessment further identified that the resident had obvious or likely cavity or broken natural teeth. The care plan dated 6/11/24 identified Resident #119 required assistance with ADL's related to bilateral lower extremity fractures with interventions that included monitor resident's status for any changes, improvement, decline and report to MD and therapy, and allow resident to do as much of ADL's as he/she can. The nurse's note dated 6/22/24 at 3:45 PM identified Resident #119 complained of pain and discomfort to teeth. Review of the monthly physician's orders for June/2024 identified an order that directed that the resident be referred to dental for evaluation and Chlorhexidine 0.12 % solution to take 15 milliliters (ml) by mouth and swish for 30 seconds twice a day for a total of 14 days with origination date of 6/24/24 at 11:04 AM. Review of the monthly physician's orders for August/2024 identified an order that directed that the resident be referred to dental for evaluation and Chlorhexidine 0.12 % solution to take 15 milliliters (ml) by mouth and swish for 30 seconds and spit twice a day with origination date of 8/14/24 at 10:25 AM. Review of the clinical records failed to identify any dental or hygienist evaluation and/or notes that Resident #119 refused any dental visits. APRN #1's medical progress note dated 6/27/24 at 3:54 PM identified that resident's teeth were examined, which noted no discoloration, healthy gums, minimal gingivitis no fracture or chip tooth with a plan to follow up with dental. The nurse's note dated 8/13/24 at 11:07 PM identified Resident #119 complained of pain to teeth. APRN #1's medical progress note dated 8/14/24 identified resident complained of dental pain and was referred to dental on 6/24/24 but has not been seen yet. The progress noted further identified resident had missing teeth, and some gingivitis with a plan to refer resident to dental and start chlorhexidine 0.12 % solution to take 15ml by mouth and swish for 30 seconds and spit twice daily. Interview with the Charge Nurse LPN #5 on 10/23/24 at 9:30 AM identified when asked if Resident #119 had requested to see the dentist in which LPN #5 identified that the resident did request to see a dentist and was seen by APRN #1 who had written orders for mouthwash and to see the dentist. LPN #1 identified that she was on schedule at the when the orders were written for a dental consult, however, was not the nurse who noted the physician's order. LPN #5 further identified that it was the responsibility of the nurse who noted the order to contact the unit secretary via phone call or write the request on a paper and place it in her mailbox. After which, the unit secretary would then make and schedule the appointment for the resident. LPN #5 identified that she could not recall if the resident had seen the dentist or the hygienist. Request was made to the DNS for the contact information of the nurse who noted the physician's order on 6/24/24 for Resident #119, on 10/24/24 at 10:15 AM, the DNS indicated that the nurse was an agency staff and would provide the number, however, the facility failed to provide the contact information. Another request was made to the DNS on 10/25/24 at 8:11 AM and throughout the day which the DNS facility failed to provide the contact information and the facility indicated that were unable to contact the staff. Interview with Unit Secretary #1 on 10/23/24 at 12:14 PM identified that Resident #119 was not seen by the dentist or hygienist since being admitted to the facility. The Unit Secretary identified that she never received any request from nursing that Resident #119 had a referral for dental, as if she had received the request for the referral, it would have been made. She further identified that the process for sending referral to her was that the nurse on the unit would complete the consult form indicating the type of consultation needed then leave it in my mailbox located on the first floor and the nurses would also call or let me know directly. Unit Secretary #1 further identified that she had only received a request for podiatry early last week from nursing and checks her mailbox daily for any request. Interview with the Infection Preventionist (LPN #2) on 10/23/24 at 12:30 PM identified she had not received any request from nursing that Resident #119 needed a dental evaluation. LPN #2 further identified that she had completed a facility audit on dental, podiatry and vision, which identified that Resident #119 had not being seen by either of the providers from the outside company since admission. Interview with APRN #1 on 10/24/24 at 10:10 AM identified that she had written an order for Resident #119 for dental evaluation and mouth was on 6/24/24 and flag the order for the nursing to note the order. The APRN #1 was asked if she followed up on orders in which she responded that she does especially when the resident states it was not done and receives complain from nursing about the same issue. The APRN #1 identified that she did not receive any further complaints from staff, or the Resident #119 complaining of teeth pain and assumed it was resolved until August of 2024 when another complaint about tooth pain was made, then she made another referral for a dental evaluation and an order of the same mouthwash ordered in June. APRN #1 indicated that she had mentioned of the follow-up on dental evaluation in her notes in July but knew the company who does the evaluation may have not had seen the resident due to certain requirements. Interview with the DNS on 10/24/24 at 10:14 AM identified she was new to the facility, but the expectation was that the nurse who noted the physician's order for dental evaluation would ensure that the individual(s) responsible for making the appointment at the facility was made aware of the referral whether by phone or by completing the consult sheet. A review of the Dentist's and Dental Hygienist's service dates at the facility for the period of June 18, 2024, to October 17, 2024, identified that the Dentist visited the facility a total of 6 times and the Dental Hygienist visited the facility a total of 3 times to provide dental services. Interview with LPN #2 on 10/25/24 at 12:30 PM identified that Resident #119 was not seen by the Dentist nor the Dental Hygienist at any of their visits to the facility from June 2024 to present time. Review of the Oral Health Evaluation policy identified that a dental examination and evaluation would be performed by a qualified professional such as dentist, dental hygienist. Review of the Physician Orders-Transcription policy identified that physician would be transcribe by a licensed nurse and followed through in a manner consistent with quality-of-care practices. The policy and procedure further identified that the orders would be reviewed on the physician order sheet and transcribe onto the appropriate worksheets and the licensed staff signs off the order.

Based on review of facility documentation, review of facility policy and interviews, reviewed for the infection control and prevention program, the facility failed to ensure that the annual water management plan meeting was conducted. The findings include: Review of the facility Water Management Plan for 2023 to 2024 with the Director of Maintenance on 10/24/24 at 2:23 PM failed to identify that the facility had a water management meeting to review the updated and revised plan provided by the company that was contracted by the facility to manage the facility's water management plan. Review of the safety committee meeting minutes dated 5/29/24 identified that the water management meeting (quarterly) was schedule to be completed on 7/12/2024. Interview with the Director of Maintenance on 10/24/24 at 3:27 PM identified that it was the policy of the facility to have an annual meeting to discuss and review the water management plan revision and update provided by the contracted company. The Director of Maintenance identified that the meeting was not done as he lost track of time, as the meeting was to be held in July. Interview with the Administration on 10/25/24 at 1: 54 PM identified that the water management was not completed, as it was the practice that in the safety committee meeting minutes, the minutes would have identified what was discussed regarding the water management plan based on his experience in working for this company. Review of the Annual Water Management Plan Revision and Updates dated 7/12/23 and 7/11/24 that was provided to the facility by the contracted company identified that the water committee shall meet and review the water management plan, record the topics discussed and record meeting minutes with signatures of attendees, which meeting minutes are conducted by the facility. Review of the Water Management Plan policy identified that environmental assessments shall be updated annually.

Based on review of the clinical record, review of facility policy and interviews for one of twenty-four sampled residents (Resident #377) reviewed for advance directives, the facility failed to ensure the physician's order accurately reflected the resident's chosen code status. The findings include: Resident #377's diagnoses included osteomyelitis, viral hepatitis C and major depressive disorder. The Nursing Admission assessment dated [DATE] identified Resident #377 was cognitively intact. Resident #377's Advance Directives/Code Status Consent form indicated the resident elected a code status of Do Not Resuscitate (DNR), which means to withhold cardiopulmonary resuscitation (CPR)in the event that the resident stops breathing. The form was signed by APRN #1 on [DATE]. Review of the MD Order/Progress Note form dated [DATE] and also located in the same location of the clinical record as the advance directives/code status consent form identified APRN #1 reviewed advance directives with Resident #377 and determined that the resident's medical condition and prognosis were appropriate for the code status of do not resuscitate (DNR). The form was signed by APRN #1. The physician's order dated [DATE] identified a code status of full code (rather than DNR). A full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. Interview with the Charge Nurse (LPN #5) on [DATE] at 11:55 AM identified that if Resident #377 had a life-threatening emergency where it would be necessary to provide CPR or withhold CPR, she would look in the clinical record under the advance directive section and review the advance directive/code status form, and the physician's order in the clinical record and she would also check the resident's status in the electronic health record. After reviewing the advance directive/code status consent form, the physician's orders and the electronic health record with LPN #5, she noted that the physician's order and the electronic health record indicated full code while the advance directive/code status consent form indicated DNR. Additionally, LPN #5 identified that the physician's order should match the advance directive/code status consent form. LPN #5 identified that after the provider reviews and signs the advance directive/code status consent form, the form is flagged in the chart for the charge nurse/nursing supervisor on the unit to transcribe the order. Interview with APRN #1 on [DATE] at 12:10 PM identified that she reviewed and discussed the advance directive/code status consent form with Resident #377 on [DATE] due to his/her selection of the DNR status. After reviewing the advance directive/code status form and the physician's order for full code with APRN #1, she noted that it was her signature on the consent form dated [DATE] and the physician's order directing a code status of full code which she signed on [DATE] after discussing with Resident #377. APRN #1 identified that she signed the advanced directive/code status consent form, then flagged the form in the resident's chart for the nurses to transcribe and note the order. APRN #1 further added that although she reviewed and signed the order for full code, she acknowledged that it was done in error and should have reflected that the resident had a code status of DNR. Review of the Code Status policy identified that the upon admission and thereafter the Code Status is established identifying decisions regarding cardiopulmonary resuscitation. The policy further identified that once the resident's preferred status has been established, the attending physician will document the order of either CPR or DNR in the resident's clinical record.

Based on review of the clinical record, review of facility policy and interviews for one of two sampled residents (Resident #59) reviewed for choices, the facility failed to ensure the implementation of the admissions policy when the resident was admitted to the facility. Resident #59 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder recurrent severe with psychotic symptoms, schizoaffective disorder, polyneuropathy, and extrapyramidal symptoms. The admission face sheet located in the electronic health record identified Resident #59 was conserved and indicated the conservator's contact information. The baseline care plan dated 6/18/24 identified Resident #59 was at risk for behaviors related to psychiatric disorders. Interventions included: encourage participation in behavioral program and recreational groups, residence on a secured unit, monitor behaviors, and provide mental health professional services as indicated The admission MDS assessment dated [DATE] identified Resident #59 was cognitively intact, had no behaviors, was independent with hygiene, dressing, eating, transfers and mobility. The assessment further identified Resident #59 was taking antipsychotic, antianxiety and antidepressant medication. Review of Resident #59's clinical record on 10/21/24 at 10:00 AM identified the following forms were not completed: the behavioral program unit resident review, behavioral health program individualized assessment of resident safety status and the behavioral program unit resident review. Further review failed to identify other admission consent forms outlined in the admission's checklist were completed. The record did contain a consent to voluntarily reside on a secured unit dated 6/18/24 that was signed by the resident and a witness. Review of the social services progress notes from 6/18/24 through 10/24/24 failed to identify that contact with Resident #59's conservator was attempted. Review of nurse's notes from 6/18/24 through 10/24/24 failed to identify that notification was made to Resident #59's conservator regarding the resident's admission to the facility. Observation on 10/21/24 at 11:07 AM identified Resident #59 resided on the secured unit in the facility. Interview on 10/22/24 at 2:00 PM with the Regional Clinical Director identified the facility consent admission paperwork is supposed to be completed by the RN supervisor. Interview on 10/23/24 at 10:23 AM with SW #2 (designated social worker for the secured unit), identified that when a resident is conserved, the RN supervisor is responsible for reviewing and getting the admission forms signed by the resident's conservator. Following SW #2's review of the clinical record, she identified that the admission paperwork in the chart should include the completion of the following forms: advance directive, consent for treatment, and consent for residing on the secured unit. Interview on 10/23/24 at 10:46 AM with Resident #59's Conservator identified that she was unaware of Resident #59's admission to the facility and that the facility had not contacted her regarding admission paperwork or admission consent forms that required her attention. Interview on 10/23/24 at 10:57 AM with the DNS identified the facility had not contacted Resident #59's Conservator regarding the resident's admission to the facility and had not elicited the Conservator's permission's and consents required on admission. Additionally, she indicated that regardless of the resident's cognitive status, if the resident is conserved, the paperwork should be signed (completed) by the conservator. Interview on 10/24/24 at 10:14 AM with the MDS Coordinator identified that the Social Worker is responsible for obtaining the conservator's signature on the admission paperwork. Interview on 10/24/24 at 10:40 AM with SW#1, the Social Work Director, identified the admission paperwork is discussed with the resident, although, if the resident is conserved the paperwork gets emailed or faxed to the conservator. The Social Work Director was unable to identify that the conservator was contacted for admission signatures. The facility admission policy identified that the nurse is responsible for completing the admission documentation and it should be completed within 24 hours. The policy further identified the admission checklist identified consents to be signed on admission include the following: Consent to treat Vaccine Pneumonia/Flu Vaccine Covid Advance Directive Privacy Act Notification statement Receipt of Privacy Practices Use and Disclosure - Facility Directory Harvest Consent Supportive Care Consent Health Drive Consent SUD program if applicable (substance use disorder) Secure unit Residency if applicable GHMCC disclosure statement if applicable Additionally, the admission checklist identified the completion of the admission was the responsibility of all three shifts, not just the shift that the resident arrives on and directed to pass the checklist on from supervisor to supervisor.

Based on observation, review of the clinical record, review of facility policy and interviews for one sampled resident (Resident #377) reviewed for antibiotic use, the facility failed to ensure admission orders were verified prior to administration and failed to ensure that a physician's orders directing the treatment and care a a central line catheter. The findings include: Resident #377 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis, viral hepatitis C and major depressive disorder. The Nursing Admission assessment dated [DATE] identified Resident #377 was cognitively intact and had a peripherally inserted central catheter (PICC). Review of the Inter-Agency Referral Report (W-10) from the hospital dated 10/11/24 identified the following discharge medications: 1. Bisacodyl 5milligram (mg) Enteric Coated (EC) give 10mg by mouth daily as needed 2. Bisacodyl 10mg suppository rectally daily as needed 3. Ceftriaxone 1 gram give 2 grams intravenous daily 4. Folic Acid 1mg by mouth daily 5. Gabapentin 300mg, give 900mg by mouth three times daily 6. Milk of Magnesia 30 milliliters (ml) daily as needed 7. Melatonin 3mg by mouth at bedtime (nightly) as needed 8. Methocarbamol give 500mg by mouth four times daily 9. Nicotine 21mg/24 hour apply one patch daily 10. Nicotine Polacrilex 4mg gum by mouth every 2 hours as needed 11. Oxycodone 10mg by mouth every 8 hours 12. Glycolax 17gram by moth twice daily 13. Seroquel 100mg give 100mg by mouth at bedtime 14. Senokot-S 8.6-50 mg, give 2 tabs by mouth at bedtime (nightly) 15. Thiamine 100mg by mouth daily 16. Trazadone 50mg by mouth nightly as needed 17. Vancomycin in 0.9% sodium chloride give 1500 mg intravenous every 12 hours 18. Methadone 10mg/ml solution 130mg by moth daily 19. Epclusa 400-100 mg give one tablet daily 20. PICC line care 21. Flush non-valved when not in use daily 22. Intermittent access minimum 5ml normal saline (NS) pre -administration of medication minimum 5ml NS post administration 23. Volume before and after blood draw: 5ml NS pre-draw and 10 ml post-draw 24. Volume before and after blood product: 5ml NS pre transfusion 10 ml post transfusion 25. Heparin locking for non-valved PICC: 5ml 10unit/ml Heparin 26. Heparin locking for valved PICC: 5ml NS -DO not use Heparin The physician's orders in the physical chart failed to identify that the discharge medications listed on the W-10 were verified with the provider at the time of admission on 10/11/24 and that flushes and care of the central line catheter were ordered. Observation on 10/23/24 at 9:49 AM identified Resident #377 self-propelling his/her wheelchair in the hallway while antibiotic was infusing via PICC line with 2 lumen that had a clamp which indicates the catheter was a non-valve catheter. Review of Resident #377's Medication Administration record identified the following medications were administered on 10/11/24 to 10/13/24: 1. Ceftriaxone 1 gram give 2 grams intravenous daily 2. Vancomycin in 0.9% sodium chloride give 1500 mg intravenous every 12 hours 3. Folic Acid 1mg by mouth daily 4. Gabapentin 300mg, give 900mg by mouth three times daily 5. Methocarbamol 500mg by mouth 4 time daily 6. Seroquel 100mg give 100mg by mouth at bedtime 7. Thiamine 100mg by mouth daily 8. Senokot-S 8.6-50 mg, give 2 tabs by mouth at bedtime (nightly) 9. Methadone 10mg/ml solution 130mg by moth daily 10. Tylenol 650mg by moth every six hours for pain or elevated temperature 11. Oxycodone 10mg by mouth every 8 hours as needed for pain 12. Trazadone 50mg by mouth nightly as needed for insomnia 13. Melatonin 3mg by mouth at bedtime (nightly) as needed for insomnia 14. Intermittent access minimum 5ml normal saline (NS) pre -administration of medication minimum 5ml NS post administration. 15. Change of the changing of the tubing every 24 hours 16. Change dressing weekly Interview with the Nursing Supervisor (RN #3) on 10/23/24 at 8:21 AM identified that Resident #377 arrived at the facility on the day shift. RN #3 identified that she received the hospital paperwork from the Infection Preventionist (IP) nurse and the ADNS was still in the facility. RN #3 identified that she did not verify the orders with the provider as she had received the paperwork from the IP nurse and the ADNS and thought they had verified the orders as she was just told to input the orders in the electronic medical record system. She indicated that she was assisting the 3:00 PM to 11:00 PM nursing supervisor as they were both agency staff and was new to the facility. RN #3 indicated that the communication was poor at the facility and that she was not told to write the orders on the paper physician's order sheet. Interview with APRN #1 on 10/23/24 at 9:48 AM identified she did not verify any orders for Resident #377 as she was not working on 10/11/24. The APRN #1 identified that she verified the orders on 10/14/24 and thought that was the date that the resident was admitted to facility as the physician's order sheet read new admission. Interview with the Infection Preventionist (LPN #2) on 10/23/24 at 10:02 AM identified she did not verify the admission orders when the resident arrived at the facility. LPN #2 identified that she only took the hospital discharge summary which was in the Methadone box so that she could pick-up the Methadone and bring to the facility on Saturday. Interview with the ADNS on 10/23/24 at 10:48 AM identified that she was in the building when Resident #377 arrived at the facility. The ADNS identified that she did not verify the admission orders on 10/11/24 as it was the responsibility of the nursing supervisor on duty to verify the orders. The ADNS identified that the DNS had reviewed the chart on 10/14/24 and identified that the admission orders were not written on the paper physician order sheet and asked her to follow-up. The ADNS indicated that she utilized the W-10 and review the orders and have APRN #1 verify the orders and sign the physician's order sheet on 10/14/24. Interview with the DNS on 10/24/24 at 10:19 AM identified that she had reviewed Resident #377 chart on 10/14/24 and identified that the orders were not written on the paper physician order sheet and asked the ADNS to follow-up. The DNS identified that there is a notice in the supervisor's office that indicates that all admission and re-admission orders must be put into the electronic medical record as well as written in the physical physician orders as well as on the paper medication administration record and the treatment administration record. Interview with APRN #2 on 10/25/24 at 10:56 AM identified that she was not working on 10/11/24. Interview with MD #1 on 10/25/24 at 3:31 PM identified that he is always on call but did not verify any orders for Resident #377 on 10/11/24. He identified that probably an on-call physician would have verified the order. MD #1 was asked when does the answering service started, which he responded at 5:00 PM. MD #1 was made aware that the resident arrived at the facility at 2:00 PM, then he responded that the on-call provider would have then not been called to verify the admission orders. Review of the Physician Orders Transcription policy identified that physician orders would be transcribed by a licensed staff and followed through in a manner consistent with quality standard of care practices. The policy further identified that admission orders will be transcribed from the W-10 or discharge order to the facility's physician's order sheet, followed by calling the attending physician to confirm orders, then add the date, time, and sign physician's name, your name and orders confirmed on the physician's order sheet. Review of the Central Line Catheter protocol identified the flushing protocol for non-valved catheters 5ml of NS before Medication administration and 5ml of NS after medication administration then 5ml of 10units/ml heparin flush. For unused lumen of PICC line non-valved catheter to be flushed every 12 hours each lumen with 5ml of NS then 5ml of 10units/ml heparin flush. Treatment protocol includes change tubing 24 hours of primary intermittent, change needless connection on admission, every week and as needed, change dressing every week and as needed.

Based on observations, review of the clinical record, review of facility policy, and interviews for one sampled resident (Resident #70) reviewed for respiratory care, the facility failed to ensure a physician's order was in place directing the use of oxygen therapy for a resident utilizing oxygen. The findings included: Resident #70s diagnoses included end stage renal disease, chronic obstructive pulmonary disease, anxiety, and heart failure. The quarterly MDS assessment dated [DATE], identified Resident #70 was cognitively intact, required moderate assistance with transfers, toileting, personal hygiene, and identified that the resident utilized a wheelchair for mobility. The assessment did not indicate the use of oxygen. The care plan dated 8/31/24 identified Resident #70 was at risk for breathing problems related to chronic pulmonary disease, with interventions that included providing oxygen as needed to maintain oxygen levels. Elevating the head of the bed to prevent shortness of breath, and to monitor for any symptoms of difficulty breathing. Observation on 10/23/24 at 10:10 AM in Resident #70's room, identified oxygen was being administered at 2 liters via nasal cannula. The oxygen tubing was labeled, and dated 10/17/24, and appeared clean. Interview at the time of the observation with Resident #70, identified he/she utilized oxygen on a regular basis for shortness of breath. Interview on 10/23/24 at 10:39 AM with LPN #1 Unit/medication nurse 3rd floor identified that there should be an order for oxygen. Resident #70 usually uses the oxygen upon return from dialysis, and it used as needed. The oxygen order must have fallen off the medication administration record (MAR). The 11-7 nurse changes the oxygen tubing weekly, labels and dates the tubing. LPN #1 was unable to locate a physician's order for oxygen in the resident's medical record (paper chart, or in the electronic medical record) and an order was not located on either the MAR or on the treatment administration record (TAR). Subsequent to surveyor inquiry; observation on 10/24/24 at 1:06 PM with LPN #4 third floor unit/medication nurse, identified a new order dated 10/23/24 for oxygen 2 liters via nasal cannula every shift as needed, change oxygen tubing every week on Sunday 11-7 shift, and check oxygen levels (pulse oximetry) every shift. Orders had been transcribed onto the treatment administration record (TAR). Review of the Medication Order Transcription policy-Paper Systems, directed in part, that prescribers' medication orders will be accurately transcribed and executed in a timely manner to ensure accurate administration of all physicians' orders. Review of the Oxygen Administration policy dated 4/17/24, directed in part, to verify that there is a physician's order in place for this procedure or facility protocol.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedure and interviews for one sampled resident (Resident #115) reviewed for pain, the facility failed to administer pain medication in a timely manner. The findings included: Resident #115's diagnoses included puncture wound without foreign body of the right thigh, and muscle weakness. The admission MDS assessment dated [DATE] identified Resident #115 was cognitively intact, had no behaviors, required set up or clean up assistance with eating, oral hygiene, utilized partial to moderate assistance with toileting, showers, personal hygiene and dressing. The assessment further identified Resident #115 utilized a wheelchair for mobility, and almost constantly was in pain with a rating of 10 in pain intensity on a scale of 0-10 with 10 being the most intense. The care plan dated 7/16/24 identified Resident #115 had pain related to a gunshot wound with interventions that included provide pain medication as ordered and observe effectiveness, for complaints of break through pain offer another one of the medications ordered for pain and offer to help find a comfortable position. Physician's order dated 7/18/24 directed Oxycodone 5mg tab by mouth every 6 hours as needed for pain for 1 week then Oxycodone 5mg tab by mouth every 8 hours for pain as needed. Physician's order dated 8/13/24 directed to start Ibuprofen 800mg by mouth every 8 hours as needed for 14 days. Review of facility documentation (interview form) dated 8/14/24 at 11:00 PM identified LPN #3 indicated she went to the break room around 10:45 PM and when she returned Resident #115 was waiting for medication and spoke to her using profanity. Review of facility documentation (interview form) dated 8/14/24 at 11:45 PM identified Resident #115 indicated he/she rang the call bell twice around 9:00 PM and spoke with the same NA#1 who said she had notified the nurse that he/she was wanted pain medication. After waiting over two and a half hours the nurse finally showed up after a fall out of bed onto the floor. The documentation further noted that LPN#3 conveyed she wasn't going to give the medication. A grievance form dated 8/14/24 identified Resident #115 asked LPN #3 after ringing the call bell twice and waiting for more than two hours, her response was that she was not giving the resident anything and to get it from the supervisor, and who did the resident think they were for telling her when to give medication, this grievance was turned into a reportable event. Interview form dated 8/15/24 at 2:37 PM from NA#1 indicated that she told the charge nurse twice that Resident#115 needed pain medication as the resident was ringing the call bell requesting medication, once around 7:30 PM and once around 8:30 PM. Review of the MAR for the month of August 2024 identified no PRN Oxycodone 5mg or Ibuprofen 800mg was signed off as passed to Resident #115 on 8/14/24. Review of the Control Substance Disposition record for Oxycodone IR 5mg identified 1 tab was passed at 1:50 PM therefore the next dose could be passed 8 hours later meaning any time after 9:50 PM. The medication was signed off passed on 8/14/24 at 11:12 PM. Interview with Resident #115 on 10/21/24 at 10:15 AM indicated he/she was in severe pain on 8/14/24 and had told NA#1 twice to let the nurse know about the pain, once around 8:00 PM and a second time closer to 9:00 PM. Resident #115 identified he/she fell while trying to move to the bed due to the intense pain. Resident #115 identified that LPN#3 could not be located for a period and that NA#1 was trying to help locate the nurse to get him/her the medication. By the time LPN#3 was located Resident #115 admitted he/she was frustrated and was in severe pain. A formal grievance was written, and Resident #115 stated he/she never received a reply from the grievance, but that LPN #3 had been back to work on his/her unit. Interview on 10/24/24 at 11:04 AM with NA#1 identified the nurse that evening seemed annoyed and or frustrated as another patient had said a bandage was too tight and she told them she only gets paid for 8 hours and that she was not putting it on again. Resident #115 did ring the call bell twice once around 7:30 PM and once around 8:30 PM and each time she notified the nurse that he wanted his PRN pain medication, she seemed annoyed after the second time I told her. The third time Resident #115 rang the call bell NA#1 said she would find the nurse however could not locate the nurse for approximately 45 minutes to 1 hour. She went back to resident #115 and said LPN #3 must be on break. Resident #115 self-reported a fall after coming out of his/her room towards the nurses station towards the end of the shift when the nurse was getting back to the unit, however no one witnessed it. Interview on 10/24/24 at 11:19 AM with LPN #3 indicated that she was very busy that evening of 8/14/24 because there was a new admission, and that she did go off the floor towards the end of the night for a phone call. She knew Resident #115 could have received pain medication between 9-10pm, however said she wasn't aware from the NA#1 that he was in pain and no PRN medications were passed to Resident #115 on her shift on 8/14/24, including the Ibuprofen 800mg PRN. When she returned to the unit Resident #115 was very upset wanting medication and angry. She said she would not pass Resident #115 his/her medications because he/she was so angry, she requested the supervisor pass the requested medication. Interview with the DNS on 10/29/24 at 10:15 AM identified if a NA tells a nurse that a resident is in pain it is the nurse's responsibility to assess the pain and administer medications as ordered. Review of the Medication Administration and Documentation policy directed The Medication Administration Record (MAR) is the form onto which all medication orders are transcribed, from which medications are poured and administered and on which medication doses are charted. The MAR is a permanent part of the residents' record. Review of the Pain Management policy directed pain strategies to include as applicable, pharmacologic, and non-pharmacologic interventions.

Based on a review of the clinical record, a review of the facility documentation, staff interviews and a review of the facility policy for one of two sampled residents (Resident #2), who was reviewed for an allegation of mistreatment, the facility failed to ensure the resident was free from abuse. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition, independent with transfers, ambulation and locomotion. The resident care plan dated 7/21/20 identified an [CONDITION(S)] disease with interventions that included standard precautions, administer anti-infective medications as ordered, and monitor for signs and symptoms of infection. Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] identified severe cognitive impairment, total dependence with bed mobility and transfers. The resident care plan dated 8/12/20 identified [CONDITION(S)] disorder with hallucinations (the resident would often have conversations with individuals who were not present), depression, and anxiety, with interventions that included one to one visits with the social worker, monitor the residents symptoms, and psychiatric consultation for symptom control and medication management. Review of the reportable event form dated 9/19/20 at 2:50 PM identified the charge nurse went into Resident #2's room and observed Resident #2 engaged in an intimate encounter with Resident #1. The residents were immediately separated and Resident #1 was placed on constant observation. The nurse's noted dated 9/19/20 at 3:30 PM identified Resident #2 was in bed and remained confused. A full body assessment was conducted. The conservator and the physician were notified and Resident #2 was send to the hospital for an evaluation. The nurse's note dated 9/19/20 at 7:02 PM identified a resident to resident altercation. LPN #1 went to Resident #2's room to administer scheduled medications. Upon arrival LPN #1 noticed the curtain was closed. LPN #1 called out Resident #2's name to notify the resident she was entering the room. When LPN #1 pulled the curtain back, she observed Resident #1 and Resident #2 engaged in a sexual act. Resident #1 was removed from Resident #2's room. The nurse's note dated 9/19/20 at 11:09 PM identified Resident #2 was transferred back from the hospital on 9/19/20 at 10:45 PM. The hospital documentation indicated they were unable to reach the conservator therefore they did not conduct a sexual assault examination. The nurse's note dated 9/20/20 at 4:44 PM, identified Resident #2 was sent to the hospital on 9/19/20 for a sexual act perpetrated against Resident #2 by Resident #1 who had an [CONDITION(S)] disease. Resident #2 was unable to recall the event. Based on the hospital report, the hospital was unable to provide prophylaxis treatment (antiviral medication), due to the inability of the hospital to reach Resident #2's conservator for approval. The psychiatric evaluation dated 9/20/20 identified Resident #2 was involved in a sexual encounter with Resident #1 in the facility. Resident #2 was alert and oriented, however his/her insight and judgement were impaired. Resident #2 was transferred to an alternate floor in the facility. The resident evaluation checklist dated 9/21/20 identified Resident #2 was unable to fully consent to a sexual relationship due to his/her mental capacity. Furthermore, Resident #2 did not want a consensual relationship with Resident #1 and could not fully consent. Resident #2 did not recall the incident on 9/19/20 with Resident #1. One to one observation for Resident #1 was implemented to prevent nonconsensual sexual activity. Physicians orders for Resident #2 dated 9/21/20 at 12:30 PM directed the administration of [MEDICATION(S)] (antiviral medication) 50 milligrams (mg) by mouth daily for 4 weeks, and [MEDICATION(S)]/[MEDICATION(S)]/Tenofovir (a [CONDITION(S)] inhibitor) 200mg/300 mg by mouth daily for 4 weeks. [CONDITION(S)] serum testing and a basic metabolic panel was ordered. Review of the social work progress note dated 9/21/20 at 3:05 PM identified Resident #1 and Resident #2 engaged in an intimate situation. The staff redirected Resident #1, and Resident #2 was moved to alternate floor. Resident #2 believed that he/she lived at college and he/she moved dorm rooms. Resident #2 liked his/her new room and did not recall the incident. The conservator was informed of the incident and provided authorization to administer antiviral medications and obtain laboratory testing to check for infectious or [CONDITION(S)] conditions. Interview with Resident #1 on 9/23/20 at 10:10 AM identified he/she went into Resident #2's room to speak with the resident and his/her roommate. Resident #1 indicated Resident #2 initiated the intimate encounter and Resident #2 acquiesced. Resident #1 indicated LPN #1 came into the room during the interaction and separated the residents. Resident #1 indicated he/she was placed on one to one observation. Interview with Resident #2 on 9/23/20 at 10:20 AM identified Resident #2 was confused to time and place, and the resident's thoughts were disorganized. Resident #2 was unable to recall the incident from 9/19/20. Interview with LPN #1 on 9/23/20 at 11:20 AM identified she entered Resident #2's room to administer medications. As she entered Resident #2's room, the door was opened however the curtain was pulled. LPN #1 pulled the curtain open and identified Resident #1 and #2 were engaged in a sexual encounter. LPN #1 identified she told Resident #1 this interaction was inappropriate asked Resident #1 to leave the room. Resident #1 indicated he/she was sorry and would not do it again. LPN #1 reported the incident to the supervisor and placed Resident #1 on one to one observation immediately. Interview with Person #1 (Conservator) on 9/25/20 at 9:15 AM identified a consensual sexual relationship for Resident #2 at the facility was never discussed during the care conferences and Person #1 was never asked to consent for this type of relationship prior to the incident on 9/19/20. Person #1 indicated he/she would be opposed to a sexual relationship if there was a medical contraindication. The facility abuse policy directed in part, that residents would not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family member or legal guardians, friends or other individuals.

Based on clinical record reviews, review of facility documentation, policies, and interviews for one of three sampled residents (Resident #1) who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2019 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set assessment dated [DATE] identified Resident #1 was alert, oriented to person, place, and time, required extensive one (1) person assistance with eating and toilet use, was incontinent of bowel and bladder, received a mechanically altered diet, and had no recent weight loss. The Resident Care Plan dated 8/27/19 identified the potential for an alteration in cardiac status, nutritional risk and weight loss related to the difficulty swallowing, hypertension and [MEDICATION(S)] [CONDITION(S)]. Interventions included to administer medications as ordered, labs as ordered, vital signs as ordered, observe for signs of cardiac distress, chest pain, changes in heart rate and record and report changes or concerns to the physician, to monitor the meal percentage intake and dietary consult as indicated. The nurse's note dated 8/28/19 at 2:08 PM identified Resident #1 with physical status changes, a poor oral intake, blood pressure was 101/70 (resident's normal range 130's/60's), pulse 107 (normal range in the 50-60's), respiration 22 (normal range 14-18), an oxygen saturation level of 97% and temperature of 98. The note indicated the Advanced Practice Registered Nurse (APRN) assessed Resident #1 and there was a discussion of changing the resident's code status, the Conservator was contacted, social service to fax the documents to the Conservator and the facility was waiting for the Conservator's decision. Review of the meals, snacks and fluids roster from 8/26/19 through 8/27/19 identified Resident #1's meal consumption was 25% and from 8/27/19 through 8/29/19 the resident's meal consumption was zero (0) and the nurse was notified each time by the nurse aide. Upon further review, the roster identified Resident #1's fluid consumption went from 1,200cc on 8/26/19 to 0cc on 8/29/19. Review of the clinical record from 8/28/19 through 8/29/19 failed to reflect documentation Resident #1's blood sugar levels and/or vital signs were obtained and that the resident was assessed for signs and symptoms of hyper/[CONDITION(S)] and dehydration with the change in condition. Review of the August 2019 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated 8/29/19 at 6:24 PM indicated that Resident #1 was transferred to an acute care hospital secondary to lethargy and poor oral intake after consulting with the Conservator. The note identified prior to transfer Resident #1's blood pressure was noted to be 88/58 and 79/56 with a pulse rate of 155 beats per minute and respiration 24. The hospital's intensive care unit resident admission history and physical dated 8/29/19 identified in the emergency department Resident #1 was initially febrile, [CONDITION(S)] with a heart rate in the 150's and hypotensive and Resident #1 was cardioverted with synchronized cardioversion and heart rate subsequently decrease to around 100. The note identified the following bloodwork results: White Blood Count (WBC) of 14.6 (normal range 4.0-11.0), Sodium 138 (normal range 136-145), Potassium 5.5 (normal range 3.4-5.3), Blood Urea [MEDICATION(S)] (BUN) was 119 (normal range 8-21), creatinine of 5.0 (normal 0.5-1.3) and a glucose of 943 (normal 65-99). The notes identified the staff were unable to insert a foley catheter and an urologist would be consulted. The clinical record indicated that Resident #1 was started on an insulin infusion for the glucose level over 900 and the admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the facility's 7AM-3PM charge nurse, Licensed Practical nurse (LPN) #1, on 9/19/19 at 12:23 PM she indicated that on the morning of 8/28/19 Resident #1 was noted to be coughing and pocketing food during the meal and the Advanced Practice Registered Nurse (APRN), APRN #1, was updated. In an interview with APRN #1 on 9/19/19 at 1:00 PM he indicated that on 8/28/19 Resident #1 was noted with a decline in condition. APRN #1 stated for a diabetic with the change in condition the nurses should monitor the resident's blood sugar and vital signs. In an interview with NA #1 on 9/19/19 at 1:18 PM she indicated that Resident #1 required total assistance with meals on 8/26, 8/27 and 8/28 the resident did not eat breakfast and/or lunch and the charge nurse was updated. Interview with the Assistant Director of Nursing (ADON) on 9/19/19 at 2:45 PM she identified although Resident #1 had a documented change in condition on 8/28/19 during the 7AM-3PM shift, the clinical record failed to reflect documentation the resident was assessed and/or monitored for more than twenty-four (24) hours. The ADON indicated the charge nurse on each shift should have monitored the resident and documented resident's condition in the clinical record. During an interview with RN #2 on 9/19/19 at 3:30 PM she indicated that she was not made aware of Resident #1's change in condition on the evening of 8/28/19 and on 8/29/19 when she assessed Resident #1, the Resident's blood pressure was noted to be low, the heart rate and respirations were fast and the resident was transferred to an acute care hospital for evaluation. In an interview with the Director of Nursing on 10/3/19 at 11:40 AM she indicated that at the time Resident #1 exhibited the change in condition, the charge nurse should have monitored the resident's vital signs and blood sugar. The DON stated when Resident #1 was noted to have a change in condition on 8/28/19 the nursing staff on each shift should have monitored the resident and documented on the resident's status in the electronic medical record. The facility's Diabetic Protocols identify it is the policy of the facility to access diabetic residents for signs and symptoms of [CONDITION(S)] and [CONDITION(S)] to ensure timely intervention and treatment.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (R #1) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The finding includes: R #1's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified R #1 was able to recall words, required cuing to report the correct day, month and year, and was independent with locomotion on and off the unit. The Resident Care Plan (RCP) dated 9/4/18 identified R #1 smoked. Interventions directed to supervise smoking and observe for any signs of unsafe smoking. A physician's orders [REDACTED]. Review of a nurse's note dated 11/15/18 at 2:55 PM identified that at 2:45 PM, she was called to the nurses station by a certified nursing assistant (NA) and observed R #1 with blood running down the left side of his/her face and an abrasion over the left eye. The resident reported that s/he was hit in the face by staff. The supervisor was notified who performed an assessment. Review of RN #1's nurse's note dated 11/15/18 at 3:08 PM identified that staff reported the resident was bleeding from the eye. Assessment noted that the resident's left eye was ecchymotic with blood running down his/her face. Ice was applied to the eye, the resident was placed on 1:1 monitoring for safety, the physician directed that the resident be transferred to the hospital for an evaluation, and the police were notified. Review of the facility incident report and investigation dated 11/15/18 at 2:45 PM identified Housekeeper #1 had notified the nursing supervisor that R #1 had a cigarette on his/her person. After Housekeeper #1 reported that R #1 had a cigarette, R #1 sought out Housekeeper #1 and found him washing floors in the dining room. Review of the surveillance video noted that R#1 confronted Housekeeper #1 and swung in an attempt to hit him. It was unclear if contact was made, however interview with Housekeeper #1 stated he was hit first and reacted to the situation. Review of the video did identify that Housekeeper #1 punched R #1 in the face with a closed fist, s/he shuffled backwards then sat down in a chair as Housekeeper #1 exited the room. The facility substantiated abuse and Housekeeper #1 was subsequently terminated for resident abuse. A nurse's note dated 11/20/18 identified a late entry for 11/15/18 that the resident returned from the ED at 11:50 PM with two (2) stitches above the left eye with noted discoloration around the left eye. Review of Housekeeper #1's written statement (signed and dated 11/15/18), and interview with Housekeeper #1 on 12/10/18 at 12:06 PM identified he observed R #1 with a partially smoked cigarette and he informed R #1 he was going to inform the proper people because s/he shouldn't have a cigarette. Housekeeper #1 then notified RN #1 of his observation. R #1 reported that s/he knew who told and was going to get him. R #1 then found Housekeeper #1 in the dining room, and punched me in the head/face and he hit the resident back in response. Housekeeper #1 further stated that he was immediately suspended and employment was subsequently terminated. Interview, clinical record review, and facility documentation review with the DON on 12/6/18 at 1:15 PM identified Housekeeper #1 had reported to RN #1 that he observed R #1 with a part of a cigarette. RN #1 searched R #1 for a cigarette and did not find any cigarette on R #1. R #1 then went to Housekeeper #1 and was hit in the face by Housekeeper #1 causing a laceration over R #1's left eye. Review of facility Abuse Policy directed in part, abuse or mistreatment of [REDACTED]. Review of facility Resident Rights Policy directed in part, residents have the right to be treated with consideration, respect and full recognition of their dignity. Policy further directed the resident has the right to be free from verbal, sexual, physical or mental abuse

Based on clinical record review, facility documentation, interviews, and observations, for one of three patients who experienced pain on a daily basis (Resident #4), the facility failed to ensure a physician prescribed pain medication was available for administration. The findings include: Resident #4 had a [DIAGNOSES REDACTED]. A quarterly minimum (MDS) data set [DATE] identified that the resident was alert and oriented, was independent for activities of daily living and experienced pain that limited day to day activities. A resident care plan dated 4/24/18 identified that the resident had an alteration in comfort related to [MEDICAL CONDITION] in the bilateral hips and had bilateral knee replacements, with interventions that included to administer pain medication as ordered, and to report any concerns to the physician. Physician orders [REDACTED]. Further review of physician's orders [REDACTED]. Observation and interview of Resident #4 on 7/12/18 at 8:45 AM identified that the resident was tearful and stated that her pain level in her feet and legs was a 10 out of 10, and the facility had run out of her [MEDICATION NAME] at 11:00 am on 7/11/18, and the nurses were using the emergency supply to medicate him/her but that supply had also run out. Resident #4 further identified that although she had been medicated with her [MEDICATION NAME] during the night, it had worn off and she was now in needed her [MEDICATION NAME] for breakthrough pain, and had requested it and was told the facility had run out. Review of the controlled substance disposition log for Resident #4's [MEDICATION NAME] IR 10 mg identified that it had been administered at 3:00 AM on 7/12/18. Review of the controlled substance disposition log for Resident #4's [MEDICATION NAME] 50 milligrams identified that a 30 pills were delivered on 6/22/18 the last dose was administered on 7/8/18 at 10:00 PM. Review of the emergency controlled substance disposition record for [MEDICATION NAME] 50 milligrams identified that the resident had last received a dose of [MEDICATION NAME] on 7/11/18 at 11:35 AM, the last dose available in the emergency box was administered on 7/11/18 at 5:00 PM for another resident. Interview with Licensed Practical Nurse #1 on 7/12/18 at 12:00 PM identified that the resident had come to the nurse's station and complained of pain, and requested [MEDICATION NAME] around 12:00 AM on 7/12/18. LPN#1 checked to ensure that the resident was due for the pain medication, and went to administer the medication but the resident did not have any left, the resident was offered Tylenol, but the resident refused and became very upset. LPN#1 then notified the supervisor who checked the emergency supply for the [MEDICATION NAME], which was also depleted. The supervisor told LPN#1 to wait and see if the medication was delivered on the next pharmacy run. LPN#1 stated that he did not see the resident for the rest of his shift. Interview with the 11:00 PM to 7:00 AM nursing supervisor, Registered Nurse (RN) #1 in 7/12/18 at 1:30 PM identified that on 7/12/18 when LPN#1 requested [MEDICATION NAME] from the emergency supply there was none left. RN#1 stated that the resident was complaining of burning in her feet, and was requesting his/her [MEDICATION NAME], she called the pharmacy but it was closed, and also called the physician but did not receive a call back, and stated that her night had gotten busy, and the resident was asleep so she did not try calling the physician again. Interview with LPN#2 on 7/12/18 at 8:55 AM identified that she worked on 7/11/18 and noted that Resident #4 requested [MEDICATION NAME] for complaints of leg pain, but the resident's [MEDICATION NAME] supply was out so she requested the supervisor to get it from the emergency supply. On 7/12/18 at 8:30 AM, although the resident asked when his/her [MEDICATION NAME] would be in, she did not say she was in pain. LPN #1 stated that the resident was medicated with his/her as needed [MEDICATION NAME] at 9:00 AM, and the supervisor called the pharmacy and requested a STAT delivery of the [MEDICATION NAME]. Interview with the 7:00 AM to 3:00 PM nursing supervisor, RN#2 on 7/12/18 at 9:00 AM identified that she was notified by Resident #4 that she did not have any [MEDICATION NAME] left that morning, she then checked with the nurse and the emergency supply and there was no [MEDICATION NAME] 50 mg left. RN#2 stated that she called the pharmacy and requested a STAT delivery of the medication. Further interview with LPN #2 at 11:00 AM identified that she had called the Advanced Practice Registered Nurse (APRN) around 10:30 AM because the resident was still complaining of pain, the APRN ordered an extra dose of [MEDICATION NAME] to be given. Interview with Advanced Practice Registered Nurse (APRN) #1 on 7/12/18 at 12:30 PM identified that Resident #4 has chronic pain from [MEDICAL CONDITION] in his/her hip and feet, and she uses the [MEDICATION NAME] for break through pain when the effect of the [MEDICATION NAME] wears off. APRN #1 further identified that the facility had contacted her that morning to notify her that the resident did not have any [MEDICATION NAME] left, and was in pain, so she ordered an extra dose of [MEDICATION NAME] 10 mg to be administered. Interview with the pharmacy's account manager on 7/12/18 at 9:30 AM identified that the expectation is that the facility order a medication seventy two hours before the medication supply is depleted, and the emergency supply should be ordered before the last dose is administered. The account manager further identified that there were no refills for the [MEDICATION NAME] ordered since 6/22/18, and no request for was made for the facility's emergency supply. The pharmacy records indicated that the facility called at 8:44 AM to request a STAT delivery of [MEDICATION NAME]. Interview with the Director of Nurses on 7/12/18 at 11:00 AM identified that it would be her expectation for the nurse to re-order the medication before the supply was depleted and to attempt to call the physician back if she did not receive a return call. Review of the pain main management policy identified that the facility will provide pain control with both pharmacological and non-pharmacological interventions.

Based on review of clinical records, review of facility documentation, review of facility policies, and interviews, for one of four residents reviewed for visitation rights, (Resident #186), the facility failed to ensure the resident was provided with services in order to attain his/her highest practicable mental and psychosocial well being when the resident's access to visitors was restricted and/or for one of two residents reviewed for Hospice services (Resident #123), the facility failed to follow recommendations made by the hospice team for pain management in a timely manner and/or failed to accurately document medication administration and/or effect of a pain medication and/or for one of four residents reviewed for medication administration, (Resident #108), the facility failed to administer a medication per physician orders, and/or for one of three residents reviewed for mistreatment, (Resident #178), the facility failed to assess a resident after the resident reported catching his/her arm in a siderail. The findings include: 1. Resident #186 (R #186) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Although the admission physician orders [REDACTED]. The history and physical documentation failed to identify the substances abused and/or whether or not the substance abuse was current, recent, or in the resident's past history only. Although the facility has an established program available for substance abuse recovery, (I Recovery), the clinical record lacked documentation to reflect that R #186 was involved/enrolled in the program during his/her admission to the facility. The admission nursing assessment dated [DATE] identified that R #186 was oriented to person, place and time, and required assistance of one staff for personal care. Review of the initial Resident Care Plan (RCP) dated [DATE] identified that R #186 had a self-care deficit with interventions that included to provide assistance with ADLs. Review of the initial Social Service assessment dated [DATE] identified that R #186 had a very close and involved family who were very supportive and wanted R #186 to return home to live with his/her family. Review of behavioral health notes dated [DATE] identified that R #186 was seen due to sad affect with several episodes of crying and was evaluated for increased depression. Review of the resident's behavioral treatment plan dated [DATE] identified that R #186 was seen for intermittent anxiety and depression based on a chronic illness that required continuing care that began prior to admission. The documentation identified that although R #186 did have a history of heroin abuse, the resident had been clean for decades. Review of facility documentation that included visitor records identified R #186 was listed as to be able to have supervised visits only. Interview with Receptionist #1 on [DATE] at 3:05 PM identified that family and/or friends who wished to visit a resident at the facility who had been determined to require supervised visits, needed to make an appointment with the security guard prior to visiting and that their visits would be supervised by the facility's security staff. Review of documentation provided by Person #1 dated [DATE] identified that R #186's family members were restricted to thirty minute supervised visits and that when the restriction was questioned, the family was told that it was a mistake. Review of R #186's clinical record, review of facility documentation, review of facility policies, and subsequent interviews with the Administrator and the DNS and on [DATE] at 1:45 PM identified that facility staff reviewed R #186's pre-admission paperwork which listed a history of polysubstance abuse and the team decided to have all visits supervised due to the documentation of a history of polysubstance. Although the Administrator and DNS indicated that a team meeting was held in determining that R #186 required supervised visits, after multiple reviews of the clinical record in the presence of the surveyors, the facility was unable to provide documentation of the meeting, notes/documentation related to the rationale for the decision to limit the residents ability to visit privately with friends/family, and/or a visitor risk assessment upon admission. The Administrator further indicated that when residents who have polysubstance abuse issues are admitted to the facility, as part of the Recovery Program, visitors may be restricted and indicated that the Visitor Risk Assessment was not part of the chart/clinical record. However, R #186 was not involved and/or enrolled in the facility's established recovery program. During the interview, the DNS indicated that another meeting was held on [DATE] to review the status of R #186's supervised visits and that an assessment was completed. Review of the Visitor Risk assessment dated [DATE], located in the resident's clinical record, identified that the outcome of the assessment was that R #186 could only have visitors who had been preapproved, at a prescheduled time, and with staff supervision. Review of the [DATE] Visitor Risk assessment, used to make this determination, allowed for restriction of visitors if even one of the questions was answered Yes. Although two responses in the assessment were Yes responses the Yes responses were with regard to the resident's failure to attend the I Recovery program in a satisfactory manner and that the resident's pain medication program was failing to alleviate pain after the issue was addressed with the physician. Review of the clinical record with facility staff on ,[DATE] and [DATE] lacked documentation to reflect that R #186 was part of the I Recovery program and that although seen regularly by the facility's psychiatric services personnel, no recommendation had been made for him/her to do so. In addition, pain management was being assessed in coordination with an outside oncology staff as R #186 had Stage IV [MEDICAL CONDITION], a recent surgery for [REDACTED]. Review of the Resident Visitor Policy directed in part that residents who have a documented history of abusing illegal drugs or alcohol thirty days prior to admission, will have all visits supervised for the first seventy two hours following admission and that continued supervision visitation would be determined by the interdisciplinary team. The facility failed to provide an adequate assessment and/or supportive documentation to reflect their decision to implement restrictions on R #186, who was admitted to the facility for support of his/her Stage IV [MEDICAL CONDITION], in visiting with family and friends without supervision of a security guard and/or the need to make an appointment in order to visit the resident. Resident #186 continued to be seen by Behavioral health serives for sadness with several episodes of crying, tearfulness, and depression. On [DATE], the Medical Oncology consultant recommended that R #186's pain medication be increased and that the resident be placed on Hospice services. Review of the clinical record and facility documentation identified that R #186 remained on supervised visits throughout his/her admission to the facility. R #186 was unavailable for interview as the resident expired on [DATE]. Facility policies on Resident's Bill of Rights directed in part that residents had the right to make choices about aspects of their lives that are important to them and had the right to privacy with persons in both written and spoken communication, the right to visit with your family and the right to be visit privately. 2a. Resident #123 (R #123) had a [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The admission MDS dated [DATE] identified that the resident was cognitively intact and required limited assistance with ADL's. Review of a Hospice narrative note dated [DATE], written by Hospice Nurse #1, identified that the current dose of [MEDICATION NAME] may have not be enough and the resident may benefit from gradually increasing [MEDICATION NAME]. Hospice Nurse #1's recommendations included direction for staff to discontinue [MEDICATION NAME] two milligrams and to increase the resident's [MEDICATION NAME] to three milligrams every four hours for pain. Review of the medication administration record identified that the resident had his/her pain level monitored every shift based on a zero through ten pain scale (0 being no pain and10 being severe pain). The clinical record identified that on [DATE], R #123 reported his/her pain level as an eight out of ten, on [DATE] as an eight out of ten, and on [DATE] as an eight out of ten. Review of the controlled substance disposition record and the MAR identified that the resident was medicated with one milliliter (ml) of [MEDICATION NAME] (which equaled two milligrams) on [DATE] at 1:00 AM with fair effect, at 6:00 AM with fair effect, at 10:00 AM with fair effect, at 5:00 PM, and at 11:00 PM with no effect. On [DATE], R #123 received [MEDICATION NAME] 1 milliliter (two milligrams) at 9:00 AM, at 2:30 PM, and at 9:30 PM with no effect documented after administration. On [DATE], R #123 received [MEDICATION NAME] 1 milliliter (two milligrams) at 3:00 AM with fair effect , and at 11:15 AM and 5:15 PM with no effect documented. Physician orders [REDACTED]. A notation was added to follow up with MD #1 in the morning to continue the order as recommended by the Hospice team as the on call physician approved the increase in [MEDICATION NAME] for twenty four hours only. Physician orders [REDACTED]. Interview with RN #3 on [DATE] at 2:30 PM identified it is the responsibility of the charge nurse to follow through on the recommendations made by the Hospice team and the physician should be contacted with recommendations on the same day the recommendation is made. RN #3 identified that he/she had reviewed the medical record and concluded that the recommendation written on [DATE] was discovered by nursing on [DATE]. Subsequently, the covering physician was notified and the increase in the resident's [MEDICATION NAME] was made for twenty four hours. R #123's primary physician was to be notified the next day to continue the order. The resident's primary physician was notified on [DATE] and the order was written to increase the [MEDICATION NAME] sulfate to from two milligrams to three milligrams every four hours as needed for pain as recommended by the Hospice team on [DATE]. Review of the clinical record lacked documentation to reflect that the Hospice team's recommendation for an increase in pain medication was instituted until [DATE], three days after the initial recommendation was made during which time, R #123 continued to experience pain at levels of eight out of ten. b. Review of the controlled substance disposition record [DATE] to [DATE] for the [MEDICATION NAME] 10mg/5ml ordered for R #123 identified the following: Review of the disposition record dated [DATE] identified that R #123 received [MEDICATION NAME] at 1:00 AM, 6:00 AM, 10:00 AM, 5:00 PM, and 11:00 PM. Review of the MAR for [DATE] identified that nursing staff documented the 1:00 AM dose and the 6:00 AM dose, but lacked documentation to reflect that the 10:00 AM, 5:00 PM and 11:00 PM doses were administered. Review of the disposition record dated [DATE] identified that R #123 received [MEDICATION NAME] at 9:00 AM, 2:30 PM, and 9:30 PM. Review of the MAR for [DATE] identified that only the resident's 9:30 PM dose was documented on the MAR. Review of the disposition record dated [DATE] identified that R #123 received [MEDICATION NAME] at 3:00 AM, 11:15 AM and 5:15 PM. Review of the MAR for [DATE] identified that only the 3:00 AM dose was documented and that the 11:15 AM and 5:15 PM doses was not documented. Interview with RN # 3 on [DATE] at 1:15 PM identified that the nurses should be documenting on the MAR every time a medication is given. Review of the medication administration policy directed in part that after medication administration, the nurse should document the necessary medication administration information including the effectiveness of pain medication intervention. 3. Resident #108 (R #108) had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of R #108's [DATE] Medication Administration Record (MAR) identified that although the MAR was blocked out to direct administration of the [MEDICATION NAME] on the 7:00 AM to 3:00 PM shift on [DATE], the MAR lacked documentation to reflect that the medication was administered per physician orders. Interview with LPN #5 on [DATE] at 2:00 PM identified that he/she had worked the ,[DATE] shift on [DATE] but could not recall if he/she had administered the injection on [DATE], but would have documented on the kardex if he/she had administered the drug to R #108. Review of the medication administration policy directed in part that after medication administration, staff was to document necessary medication administration information. 4. Resident #178 (R #178) had [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified that the resident was cognitively intact and needed limited assistance of one person with ADL's including bed mobility. Interview with R #178 on [DATE] at 1:30 PM identified that sometime before Christmas he/she had gotten his/her bad arm entangled in the side rail during the night shift. R #178 stated that he/she rang his/her call bell to ask for assistance. R #178 reported that a nursing assistant entered the room and that when he/she requested assistance, the NA responded untangle yourself and left the room. R #178 further stated that he/she was unsure of the NA's name but he thought it began with a T. R #178 stated that he/she told the Administrator about the incident the next morning including the NA's response to his/her request. Review of a social work note dated [DATE] identified that R #178 told the SW about the incident that had occurred on third shift sometime in December, before Christmas. The resident reported that he/she woke up at 2:00 AM and realized his/her hand was stuck in the railing. The resident reported to the SW that he/she pressed his/her call bell for help and that when the NA entered his/her room, the NA told him/her to untangle it yourself. Interview with the Administrator on [DATE] at 1:30 PM identified that he/she recalled that R #178 had reported to him/her that his/her arm became caught in the side rail. The Administrator denied that the resident reported mistreatment and/or that a NA had told him/her to untangle his/her arm him/herself. The Administrator indicated that he/she had a conversation with R #178 regarding his/her need for the side rail, that the resident stated he/she did not need the side rail, and therefore, the Administrator directed the Maintenance Director to remove the resident's side rail. The Administrator identified that while he/she was aware that the resident had his/her arm caught in the side rail, he/she may have only told nursing staff in passing that the resident had gotten his/her arm caught in the side rail. Interview with the DNS on [DATE] at 2:30 PM identified that it would be his/her expectation that if nursing was aware that if a resident's had arm became entangled in the side rail, that an assessment would have been completed. Interview with RN #3 on [DATE] at 2:45 PM identified that he/she was unable to locate an assessment of R #178's arm after the resident had told the Administrator that his/her arm had become entangled in the side rail. Review of the clinical record on [DATE] at 3:00 PM with facility staff lacked documentation to reflect that an assessment for possible injury was provided after R #178 reported that his/her arm had become entangled in the side rail.

Based on review of the clinical record, review of facility policies, observations and interviews the facility failed to ensure that one resident (Resident #7) who had a fall from the bed, was assessed prior to being moved, in accordance with professional standards of practice and/or for three of ten sampled residents, Residents #6, #43, #72, and #148, the facility failed to follow professional standards of practice related to the identification of residents prior to medication administration. The findings include: a. Resident #7's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified that the resident had short and long term memory problems with moderately impaired cognition, was rarely understood and required limited assistance with transfers and bed mobility. A care plan dated 1/9/12 identified that the resident had the potential for falls and potential for alteration in comfort. Interventions included to record and report any changes to the physician as needed, bed in lowest position, mat on the floor next to the bed, and utilize a bed alarm while in bed every shift. A nurse's note dated 2/17/12 at 6:00 AM identified that RN#4 was notified that the resident was noted with a swollen area to the right thigh. An assessment identified that a non-movable nodule was noted upon palpation and the resident displayed some tenderness when RN #4 attempted to stretch the resident's right leg. RN#4 directed LPN#5 to administer pain medication in accordance with the physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of a nurses note dated 2/17/12 at 8:00 AM identified that the resident was noted with increased swelling to the right hip and grimaced and groaned when RN#3 attempted to extend the resident's right leg. MD#1 was notified and directed to obtain an X-ray of the right hip, right leg and right foot. Review of the clinical record identified that an X-ray was obtained on 2/17/12 at 11:00 AM and identified that a right femoral fracture was suspected. The physician was notified and directed to transfer the resident to the Emergency Department for evaluation. The record failed to identify the time that the resident was transferred. Review of hospital records identified that on 2/17/12, an Orthopedic Surgeon evaluated the resident's right femur fracture with a decision to treat conservatively with pain medication and bed rest. The resident was transferred back to the facility on a pain management regimen on 2/18/12. Review of the facility investigation dated 2/18/12 identified that R#7 was found lying on the floor mat on 2/17/12 at 2:30 AM by NA#2. NA#2 notified licensed staff that the resident was laying on the mat however licensed staff failed to assess the resident before the resident was manually lifted back to bed by NA#2, 3 and 4. Interviews with facility staff on 4/13/12, 4/16/12 and 4/17/12 were inconsistent however, staff (NA#2, NA#3, NA#4 and LPN#5) identified that the resident had fallen from bed landing on the floor mat on 2/17/12 at approximately 2:30 AM and was not assessed until approximately 6:00 AM when NA#2 noticed that the resident had a bump on his/her right hip and reported it to LPN#5. Interview with RN#3 on 4/17/12 at 11:00 AM identified that on 2/17/12 she was assigned to supervise for the 7:00 AM -3:00 PM shift and when she arrived, she and RN#4 assessed the resident and noted increased swelling to the resident's right hip. RN#4 stated that she was not informed that the resident had a fall during the 11:00 PM - 7:00 AM shift. Review of the facility's fall policy identified in part, that a fall refers to unintentionally coming to rest on the ground or other lower level and if a resident is observed on the floor mat it is considered a fall and the resident must be assessed prior to getting the resident up from the mat. According to Clinical Nursing Skills, Fifth Edition, 2008, assessment requires skilled observation, reasoning, and a theoretical knowledge base to gather and differentiate, verify, and organize data, and document the findings. Assessment is a critical phase because all the other steps in the process depend on the accuracy and reliability of the assessment. b. During a review of medication administration at the facility, the following observations were made: 1. Observation on 4/12/12 at 12:00 PM identified that RN #3 did not identify Resident #6 in accordance with facility policies prior to administering the resident's medication. Although the resident had an identifying name band in place, RN #1 did not utilize the resident's name band for identification purposes. 2. Observation on 4/11/12 at 8:45 AM identified that LPN #1 did not identify Resident #43 in accordance with facility policies prior to administering the resident's medication. Further observation identified that the resident was wearing an identifying name band. Interview with LPN #1 at the time of the observation identified that he/she had just forgotten to check the resident's name band. 3. Observation on 4/11/12 at 12:00 PM identified that LPN #3 did not identify Resident #72 in accordance with facility policies prior to administering the resident's medication. Further observation identified that R #148 did not have an identifying name band in place and that no picture of the resident was readily available. 4. Observation on 4/11/12 at 8:35 AM identified that LPN #2 did not identify Resident #148 in accordance with facility policies prior to administering the resident's medication. Interview with LPN #2 at the time of the observation identified that he/she "knew" the resident and that there was probably a picture of the resident in another book. Further observation identified that R #148 did not have an identifying name band in place and that no picture of the resident was available Review of facility policy for administration of medications directed that each resident shall be identified by name band and/or photo identification before any medication is given. According to Pharmacology and Nursing Management, Fifth Edition, accurate and full identification of the resident before administration of each dose of medication ensures that the right person gets the right medication. Checking the resident's name on the wristband and/or nametag is the most reliable mode of identification.

Based on observation, clinical record review, review of policies and procedures and interviews, for one resident who sustained an injury,(Resident #7) the facility failed to ensure that the resident was assessed for pain when observed on the floor and/or that the resident was transferred in accordance with the physician's orders [REDACTED].#48) and/or for one of ten residents reviewed for medication administration (Resident #43), and/or for one sampled resident reviewed for [MEDICAL TREATMENT] (Resident #74) the facility failed to ensure that the resident received the appropriate liquid consistency and/or medication in accordance with physician's orders [REDACTED]. The findings include: a. Resident #7's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified that the resident had short and long term memory problems with moderately impaired cognition, was rarely understood and required limited assistance with transfers and bed mobility. A care plan dated 1/9/12 identified that the resident had the potential for falls and potential for alteration in comfort. Interventions included to monitor the resident's pain, medication as ordered, record and report any changes to the physician as needed, keep bed in lowest position and utilize mat on the floor next to the bed. Review of a physician's orders [REDACTED]. Review of a nurse's note dated 2/17/12 at 6:00 AM identified that RN#4 was notified that the resident was noted with a swollen area to the right thigh. An assessment identified that a non moveable nodule was noted upon palpation and the resident displayed some tenderness when RN #4 attempted to stretch the resident's right leg. Review of the MAR indicated [REDACTED]. Review of a nurses note dated 2/17/12 at 8:00 AM identified that the resident was noted with increased swelling to the right hip and grimaced and groaned when RN#4 attempted to extend the resident's right leg. MD# 1 was notified and directed to obtain an X-ray of the right hip, right leg and right foot. Review of the clinical record identified that the resident had a right fractured femur. Review of the facility investigation dated 2/18/12 identified that R#7 was found lying on the floor mat on 2/17/12 at 2:30 AM by NA#2. NA#2 notified licensed staff that the resident was laying on the mat however licensed staff failed to assess the resident before the resident was manually transferred back to bed with the assistance of three staff, without the benefit of a Hoyer lift as directed by the physician. Although the resident was found lying on the mat at 2:30 AM, the resident was not assessed for pain until 6:00 AM. Review of the Fall Prevention Program identified that in the event a fall occurs an assessment will be conducted. Review of facility's Assessment Policy directs that pain will be addressed. b. Resident #48 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified that Resident #48 required a mechanically altered diet that included thickened liquids. Review of care plan dated 2/6/12 identified that Resident #48 had the potential for alteration in nutritional status related to difficulty with swallowing with interventions that included nectar thickened liquids and to maintain aspiration precautions. physician's orders [REDACTED]. Observation on 4/10/12 at 12:00 PM identified that Resident #48 was being fed by Recreation Director #1. The staff member lifted the coffee cup and assisted the resident to drink through a straw, the liquid was observed to slightly spill over the top of the cup. Upon further observation, the consistency of the coffee was observed to be thinner than the directed nectar consistency. Interview with the Food Service Supervisor (FSS) at the time of the observation identified that although most fluids served at the facility came from the supplier pre-thickened, coffee was thickened by dietary staff by adding thickener. Despite further mixing of Resident #48 coffee by the FSS, the liquid did not reach nectar thick consistency as directed by physician's orders [REDACTED]. Subsequent intermittent observations on 4/13/12 during the noon meal identified that coffee served to residents who required nectar thickened fluids was appropriately thickened. Interview with the Administrator on 4/16/12 at 2:30 PM identified that the facility did not have a current policy in place to address the administration of thickened fluids. c. Resident #43 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified that Resident #43 was not cognitively impaired, received regularly scheduled pain medications, and additional pain medications as needed. The care plan dated 1/30/12 identified the potential for alteration in comfort related to Resident #43 left BKA with interventions that included administration of medications as ordered, to monitor for non-verbal symptoms of pain, and to encourage the resident to report pain at onset. Physician's progress notes dated 3/21/12 identified that Resident #43 reported to the physician that he/she had been experiencing recurrent phantom pain. The progress note identified that the physician planned to have Resident #43 resume taking [MEDICATION NAME] ([MEDICATION NAME]) four hundred milligrams (400 mg) three times daily. physician's orders [REDACTED]. Observation on 4/11/12 at 8:45 AM identified that LPN#1 administered one hundred milligrams (100 mg) of [MEDICATION NAME]. Review of the clinical record, with RN #1 following the observation identified that the incorrect dose had been administered. Interview with RN#1 on 4/11/12 at 9 a.m. identified that he/she would notify the physician for clarification of the [MEDICATION NAME] order. Physician orders [REDACTED]. be administered three times daily. Although review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with Resident #43 on 4/12/12 at 1:45 p.m. the resident was observed to reach for his/her absent left lower extremity, reported his/her pain at a level of six out of ten, and reported that the pain woke him/her up at night. Review of the facilities policy for transcription of physician's orders [REDACTED]. Facility policy directed that medications be administered in accordance with physician orders. d. Resident #74 [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The physician's orders [REDACTED]. A care plan dated 4/20/11 indicated [MEDICAL TREATMENT] via perma cath with access to left leg and to monitor access device for infection/[MEDICAL CONDITION]/ulceration. The care plan failed to identify how often the site should be monitored. Although care plan indicated perma cath in left leg, during observation of resident's [MEDICAL TREATMENT] with RN#1 on 4/16/12 at 11:30 AM Resident #74's [MEDICAL TREATMENT] was noted to be in the right leg. Review of the nurses notes dated 12/13/11 through 4/16/12 failed to reflect documentation that the [MEDICAL TREATMENT] was monitored for patency. Further review of nurses notes indicated the resident refused [MEDICAL TREATMENT] treatment 11 times between 12/13/11 and 4/16/12. Review of the facility's policy for care of a [MEDICAL TREATMENT] resident dated 3/19/08 directed that the facility will evaluate the resident on return from their treatment to include an evaluation of their access site and the evaluation will be documented in the clinical record. Facility documentation further indicated evaluate access site every shift. Interview with RN#1 on 4/16/12 at 11:35 AM indicated that staff nurse should check [MEDICAL TREATMENT] for bruit and thrill after [MEDICAL TREATMENT]. Review of the April 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Subsequent to surveyor inquiry RN#1 indicated that she will educate nursing staff to monitor bruit and thrill and document in nursing notes.

Based on clinical record reviews, interview and review of facility documentation for one of three residents (R# 28) with behavioral issues, the facility failed to provide adequate supervision to prevent an accident. The finding included: Resident #28's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified that the resident was alert and oriented, was independent with transfers and independent with locomotion via wheelchair. A care plan dated 2/13/12 identified that the resident had a history of [REDACTED]. Review of a nurse's note dated 3/27/12 that identified that R#28 allegedly hit another resident with a baseball bat. The note indicated that R#28 reported that his/her roommate (R#111) kept him/her up all night. The record failed to identify the time of the incident and/or the resident's mood/behavioral status prior to the event. Resident #111's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified that the resident had moderately impaired cognition with mood indicators including trouble sleeping and restlessness, independent with transfers and ambulation. A care plan dated 2/22/12 identified that the resident had wandering behavior with interventions that directed a secured unit, encourage resident to voice needs, report and record any changes in the resident's status. Review of R#111's nurse's note dated 3/27/12 identified that the resident was allegedly hit in the face by another resident (R#28) and the resident was observed to have a bruised and swollen area below the left eye. The note identified that the resident refused an assessment and locked him/herself in the bathroom until EMS arrived. Review of the R#111's clinical record failed to identify the time that EMS arrived and when the resident was transferred to the Emergency Department for evaluation. Review of facility documentation dated 3/27/12 and interview with the Director of Nurses on 4/13/12 at 3:15 PM identified that LPN#6 observed R#111 in the hallway at 5:35 AM. The documentation identified that R#28 was last seen by LPN#6 at 5:40 AM when he/she came to the nurse's station to report that his/her roommate (R#111) was bothering him/her and that he/she had enough. LPN# 6 stated that s/he told R#28 that s/he would come to his/her room. When LPN#6 arrived to R#28 and R#111's room at 5:45 AM, R# 111 was observed with a swollen bruise under the left eye. In response to a phone message left with LPN#6 on 4/17/12 at 2:00 PM, an interview on 4/19/12 at 11:00 AM with LPN#6 identified that in the early morning of 3/27/12, at about 5:40 AM, while s/he was preparing for a medication pass, R#28 came to the nurses station and stated that his/her roommate (R#111) was bothering him/her and he/she had enough. LPN#6 stated that s/he told R#28 that s/he would come to the room and R#28 proceeded to leave the station and return to his/her room. LPN#6 stated that s/he secured the med room door, took her medication cart and proceeded to the residents' room. As LPN#6 approached the room R#111 was standing in the hallway outside the room. LPN #6 observed R#111 had a bruise below the left eye. When LPN#6 asked R#111 what happened, R#111 stated that he/she was "going to press charges". LPN#6 identified that R#28 stated that he/she hit R#111. LPN#6 notified the RN Supervisor. Both residents remained separated and were monitored 1:1 until transferred to the Emergency department. The facility failed to ensure that adequate supervision was provided when R#28 with a known abusive behavior voiced his/her agitation/frustration toward R #111.

Based on clinical record review, review of facility documentation and interviews for one of four sampled residents (Resident #109) who the Interdisciplinary Team had determined was capable of an independent Leave of Absence (LOA) for three hours (9:00 AM-12:00 PM) two times a week, the facility failed to implement the facility's policy when the resident did not return. The findings include: Resident #109's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #109 had no cognitive impairments, was independent with activities of daily living, and received an antipsychotic medication daily. The Resident Care Plan dated 10/11/10 identified the resident with a potential for an unauthorized leave and/or injury. Interventions directed, in part, for a psychiatric evaluation as needed, medications as ordered, and encourage the resident to voice their needs and/or concerns. A care plan revision dated 1/11/11 noted that Resident #109 had requested an independent Leave of Absence (LOA) and the decision would be determined in the next behavioral health meeting. A revision to the care plan dated 1/13/11 identified that the resident was able to meet basic needs. An intervention directed to allow the resident an independent LOA per the physician's orders [REDACTED].#109 had the capacity to meet his/her minimal basic needs outside the facility. The resident had provided an acceptable response to each of six questions. Review of the social service notes from 1/11/11 through 1/13/11 identified that Resident #109 had requested an independent LOA to look for an apartment, the resident still had difficulty with speech, the resident will be seen by psychiatry and will speak with the Interdisciplinary Team (IDT) regarding wishes. The 1/14/11 social service note identified that Resident #109 was seen by psychiatry and they referred that Resident #109 be seen by the psychiatrist to give a final approval, the biggest concern was the resident ' s speech and being able to communicate to others. The Behavioral Health Follow-Up dated 1/13/11 identified the Social Worker asked that Resident #109 be seen by the Advanced Practice Registered Nurse (APRN) for an independent LOA request. The report identified that Resident #109 was examined by the APRN on 1/13/11 and the APRN had discussed the LOA with the nurse who felt that the resident may be a risk to go out on his/her own and although the resident seemed competent there was a concern that the resident may be incapable of managing without someone. The APRN recommended that the psychiatrist evaluate and give the final approval for an independent LOA. The Behavioral Follow-Up dated 1/24/11 identified that the psychiatrist was asked to determine Resident #109's ability for an independent LOA. The report identified that the resident was oriented to person and place, had impaired short term memory and diminished concentration. The assessment noted that the resident was a poor historian and responded to simple questions. The plan indicated that in the psychiatrist's opinion the resident had significant neuro/psych impairments from the cerebro vascular accident, that due to the resident's disabilities Resident #109 was not capable of an independent LOA and would need a chaperone if he/she was to leave the facility. Review of the LOA Safety Guide for Resident #109's independent LOA request dated 1/24/11 identified that the multidisciplinary team recommended starting next week, 1/31/11, the resident may have an independent LOA two times weekly for three hours, no weekends and obtain a urine toxicity screen upon return. The physician's orders [REDACTED]. On 2/18/11 the physician's orders [REDACTED]. The nurse's note dated 3/2/11 at 10:00 AM identified that Resident #109 went out on an independent LOA after breakfast, a Green Bracelet was placed on the resident and 9:00 AM medications were given prior to the resident leaving. The 3/2/11 note at 10:30 PM identified that Resident #109 did not return from the LOA throughout the shift and that several attempts to contact the family were made, however the number was out of service. The nurse's note dated 3/2/11 at 11:50 PM identified that the resident went on a LOA at approximately 9:00 AM, was due to return around 12:00 PM. Although the resident did not return from the LOA at 12:00 PM the RN #3 Supervisor was not notified until 10:30 PM. At that time the resident's family, local hospitals, the police and the Director of Nurses (DON) were contacted and a facility search was initiated. The nurse's note dated 3/3/11 at 7:00 AM identified that Resident #109 remained on a LOA. Review of the March Medication Administration Record (MAR) identified that Resident #109 did not receive the following medications on 3/2/11: Seroquel 12.5 milligrams (mg) at 12:00 PM and 4:00 PM, Vitamin C 500 mg at 4:00 PM, Coreg 6.25 mg at 4:00 PM, and Coumadin 5 mg at 5:00 PM. The nurse's note dated 3/3/11 at 10:00 AM identified that the resident returned from the LOA. Resident #109 appeared intoxicated, smelled of alcohol and the resident was transferred to the hospital for an evaluation and returned to the facility at 4:00 PM with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Reportable Event Form dated 3/2/11 at 10:30 PM identified that Resident #109 signed out for a LOA and did not return within the scheduled time. Review of the facility's documentation (failure to return from authorized independent LOA) identified that on 3/3/11 at 8:00 AM six search teams were mobilized. At 9:36 AM Resident #109 was located at a gas station on Albany Avenue by staff and escorted back to the facility. Interview with Licensed Practical Nurse (LPN) #1 on 3/10/11 at 11:05 AM identified that at the end of the 7AM-3PM shift she realized that Resident #109 had not returned from the LOA and although she reported this to the 3PM-11PM oncoming charge nurse she did not inform the 7-3PM Nursing Supervisor. Interview with the 3-11PM Registered Nurse, RN #1, on 3/10/11 at 4:20 PM identified that during shift report LPN #1 reported that Resident #109 did not come back from the LOA. RN #1 indicated that when Resident #109 did not come back at the end of the shift, at 10:30 PM, he (RN #1) informed the 3-11PM Supervisor. Review of the facility's missing resident policy revised on 11/3/09 identified that if a resident has failed to return from an authorized LOA and has failed to call within two (2) hours of the designated time out for the resident's return or if the resident is observed leaving the facility without authorization and staff are unable to prevent the resident's leaving the supervisor will notify the Administrator and Director of Nurses. Interview with Resident #109's attending physician, MD #1, on 3/11/11 at 1:15 PM identified that when a psychiatrist makes recommendations the facility will call and/or fax the recommendations to his office. MD #1 indicated that he was not aware of the psychiatrist's recommendations. MD #1 identified that if he was aware of the psychiatrist's report then he would not have given an order for [REDACTED]. Review of the facility's corrective action plan identified that the charge nurse failed to notify the supervisors that a resident under their care failed to return from an approved LOA, you are required to attend an inservice regarding reporting to the supervisor when a resident has not returned, as well as change in condition and documentation. RN #1 received the same corrective action as LPN #1. Subsequent to the incident the facility revised the independent LOA policy and procedure. Interview with the Administrator on 3/15/11 at 11:50 AM identified that on 3/2/11 the charge nurse was responsible for placing the Green Bracelet on the resident, signing the resident out and monitoring the resident's return. Subsequent to the incident, the Administrator identified that the procedure was revised. There are two sign out logs, one at the nurse's station and one with the receptionist. The receptionist now has a binder with a picture and the orders for the each residents' LOA. The receptionist keeps track of the resident's return and if the resident is not back at the correct time, the charge nurse will be notified. On 3/4/11 all staff was inserviced regarding the location and missing resident.