Every finding on record at Watkins-Logan-Garrison Texas State Veteran's Home

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 9 (Building E) facility kitchens. The facility failed to ensure: *Dark brown sugar and corn starch were not re-sealed after opening.*A zippered bag of yellow powder was not labeled and dated.*2 pans of gravy, a pitcher of unsweet tea, a nectar thick dairy product, a container of pureed stewed tomatoes were not discarded by the discard date. *silverware drawer contained food debris.These failures could place residents who ate food from the kitchen at risk of foodborne illness.Findings included:During observations and interviews on 08/10/2026 of the kitchen in Building E the following was noted:*at 9:37 AM in the cabinet above the steam table area:1-1 lb. box of dark brown sugar opened and had been re-sealed and re-opened and not sealed again.1-1lb. box corn starch opened and not re-sealed.1 small zippered bag contained a yellow powder that was not labeled or dated.*at 9:40 AM in the kitchen refrigerator: 1-1/4 size stainless steel pan labeled turkey gravy dated 8/11-1/4 size stainless steel pan labeled gravy dated 8/71-quart pitcher labeled unsweet tea dated 07/13/26 had clumpy, brown material floating in the tea.1-32 oz. Nectar Thick Dairy product had 2 labels: one dated 7/16/26 and 1 labeled opened 8/4. The packaging indicated Refrigerate after opening. Discard if not used within 4 days of opening.*at 9:45 AM the silverware drawer had food debris in the bottom of the drawer.*at 9:46 AM in the pantry refrigerator: 1 plastic container contained pureed stewed tomatoes dated 8/5/26.During an interview on 08/10/2026 at 9:56 AM [NAME] A said leftovers were to be kept about 3 days and then discarded.During an interview on 08/10/2026 at 12:07 PM ECA B said the ECAs and the cooks were responsible for the items in the refrigerator and making sure items were properly labeled and dated. She said they should throw away any leftovers after 3 days.During an interview on 08/11/2026 at 2:07 PM, the DM said leftovers should be thrown away after 3 days. She said the ECAs make tea, punch, powdered fruit drinks in the individual houses but the pitchers are to be labeled and dated when made and discarded after 3 days also. She said the thickened liquids, like water, tea and juice, are good for 10 days after opening. She said the thickened dairy product was only good for 4 days after opening. She said she did not know for sure but if the container had 2 labels the older date was probably the date it was delivered to the kitchen and the next label would have been the actual open date.Review of the facility policy titled Food Storage, dated June 1, 2019, indicated .1. d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated.2.d. Date, label, and tightly seal all refrigerated items using clean, nonabsorbent, covered containers that are approved for storage. c. Uses all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 2 medication carts (RN Cart H-house and RN Cart J-house) and 1 of 5 residents (Resident #90) reviewed for pharmacy service. 1.RN K signed the controlled substance count sheets for the end of their shift at the beginning of their shift on RN Cart H-house and RN Cart J-house [DATE]. 2. The facility failed to follow manufacturers or provider pharmacy recommendations on outdated or deteriorated medications, and immediately removed from stock, disposed of according to procedures for medication disposal for Resident #90 in RN's medication cart H-house. These failures had the potential to place residents at risk for not receiving the intended therapeutic effect of prescribed medications, ineffective treatment, administration of medications that are no longer safe or effective, and inaccurate medication control practices. Findings included: 1. During a record review on [DATE] at 4:35 PM., RN K signed the controlled substance count sheets for both the oncoming and off-going shift count at the beginning of the shift on RN cart H-house and RN cart J-house on [DATE] the 7AM to 7PM. shift.During an interview on [DATE] at 09:45 AM., with RN K, she said she was aware that the off-going controlled substance count documentation should not be signed until the end of her shift. RN K said she signed the off-going shift count to save time and because she knew the count would be accurate since she was in possession of the keys. She said this practice may result in inaccurate medication counts, and failure to identify discrepancies. 2. During an observation and interview on [DATE] at 10:30AM., LVN M's nurse med-cart revealed Resident #90's Tramadol 50mg expired on [DATE]. The narcotic medication card was removed from the nurses' med-cart, verified as expired by LVN M and RN L, the nurse supervisor. The DON was notified by RN L, and the expired narcotic card was given to the DON to be stored under double lock. LVN M said expired or discontinue medication on nurse's med-carts were reviewed every month and expired narcotic medication should be given to the DON and expired non-narcotic disposed of in the pharmacy's destruction bin. LVN M said this practice could lead to medication administration that is no longer safe or effective. During an interview on [DATE] at 10:50 AM., RN L said she expected the LVNs and the RNs' to immediately remove medications that were outdated, contaminated, discontinued, or deteriorated removed according to procedures for medication disposal. RN L further said expired narcotic medications were to be given to the DON and expired non-narcotic disposed of in the pharmacy's destruction bin. She said this practice for not receiving the intended therapeutic response of prescribed medications and not having accurate records of medication administration could result in diminished health and well-being. During an interview on [DATE] at 11:00 AM., the DON stated nurses should only sign and acknowledge the controlled drug count after verifying the medications on hand and confirmed the quantity of each medication matched the quantity documented on the controlled drug count record. She further stated she was not aware staff nurses were not signing the count sheets at the correct times, and it was the RN Supervisor and the DON responsibility to monitor the nurses. She said she expected the nurses' to immediately remove from med-carts medications that were outdated, contaminated, discontinued, or deteriorated according to procedures for medication disposal. The DON said controlled medication accountability records and audits record are kept on the medication cart. When completed, audit and accountability records are submitted to the DON and kept on file. A record review of the facility's policy and procedure document titled Controlled Substance -Administration & Accountability, dated 2026 indicated all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II -V of the comprehensive Drug Abuse and Control Act of 1976) copyright 2026.#2. Patient-specific controlled substances are stored under double lock medications that were outdated, contaminated, discontinued, or deteriorated medications according to procedures for medication disposal.#9. Nursing staff coming on duty and nurses going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living received the necessary services to maintain or improve his or her ability to communicate for 1 of 5 residents (Resident #96) assessed for quality of life. The facility failed to ensure Resident #96's hearing aids were placed in his ears. This failure could place residents with hearing loss at risk for poor communication, dignity issues, and a decline in quality of life. Findings included: Record review of a face sheet dated 08/12/2026 indicated Resident #96 was an [AGE] year-old male who admitted to the facility 02/16/2026. He had diagnoses which included hearing loss, dementia (a decline in mental ability that interferes with daily life including memory loss, poor judgment, and communication changes), and Parkinson's disease (a nervous system disorder that affects movement and worsens over time). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #96 had a BIMS score of 9 indicating his cognition was moderately impaired. Further review of the same MDS indicated Resident #96 was dependent on staff for bathing and hygiene, assistance with transfers and ambulation, and was frequently incontinent. The MDS indicated Resident #96 required the assistance of at least 1 (one) person for most activities of daily living. Record review of Resident #96's care plan indicated there were focus/concern areas which included decreased hearing ability, communication problem due to poor hearing, and was at risk for depression and low self-esteem. The care plan also included a focus on personalized care and included items deemed important to Resident #96 which included doing things with groups of people, having access to tv, listening to music, and participating in religious services. The care plan listed interventions to address these focus areas which included assisting Resident #96 with the application of his hearing aids. During observation and interview on 08/10/2026 at 10:12 AM, Resident #96 was observed sitting in a recliner in his room. A set of hearing aids were noted lying in a container on the overbed table beside his chair. When asked how he was, Resident #96 responded, Huh? Resident said a few more words that were not understood. During observation on 08/10/2026 at 11:45 AM, Resident #96 was observed sitting at the dining room table. Resident #96 was noted to not be wearing his hearing aids. When asked by a staff person who was standing behind Resident #96's chair if he wanted a clothing protector, Resident #96 did not respond. During observation of Resident #96 on 08/10/2026 at 01:15 PM, Resident #96 was noted reclining in his chair in his room and his eyes were closed. He did not respond to his name being called. Resident #96's hearing aids were again noted lying in a container on the overbed table. During an observation of Resident #96 on 08/10/2026 at 04:25 PM, Resident #96 was observed sitting at the dining room table. Resident #96 was noted to not be wearing his hearing aids. During observation of Resident #96 on 08/11/2026 at 09:45 AM, Resident #96 was noted sitting in a wheelchair and being wheeled from his room to the common area and placed where he could see the tv. Resident #96 did not have his hearing aids in his ears. The hearing aids were again noted to be lying in a container on the overbed table in his room. During an observation and interview on 08/11/2026 at 10:15 AM, LVN said he did not know why Resident #96 did not have his hearing aids in his ears. LVN-E immediately took Resident #96 to his room and placed the hearing aids in Resident #96's ears and then brought him back to the tv area. When surveyor asked if he could hear the tv, Resident #96 said he could and smiled. During an interview on 08/12/2026 at 01:40 PM, ECA-F said the ECAs knew which residents needed hearing aids because the task of assisting residents with their hearing aides was on the ECAs plan of care. She said Resident #96's hearing aids were supposed to be put on in the morning when he got up and removed when he went to bed at night. ECA-F said if the hearing aids were not put in the resident's ears, then he could not hear very well. During an interview on 08/12/2026 at 02:41 PM, LVN-G said the ECAs were responsible for assisting residents with their hearing aids. LVN-G said without the hearing aids, residents with hearing loss would not be able to hear what was said to them, hear music or the tv, and be at a disadvantage for interacting socially. During an interview and review of records with the DON, the DON said the application of hearing aids for Resident #96 was not on the ECAs plan of care. She said it was on the charge nurses LNAR and it was the charge nurses' responsibility to ensure residents had their hearing aids in place. The DON said being able to hear was important for communication and functioning in activities of daily life. Record review of the facility's policy undated policy titled Care and Use of Hearing Aids included the following: Policy: It is the practice of this facility to assist residents in using their hearing aids, and to provide care to the hearing aids to ensure they are clean and protected from loss and breakage when not being worn.

Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for one (Resident #75) of nine residents reviewed for hazards. The facility failed remove a rug from Resident #75's room creating a trip hazard. These failures could place resident at risk of living in an unsafe environment. Findings included: A record review of Resident #75 face sheet, dated 8/10/2026, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident( #75) had diagnoses of essential hypertension (high blood pressure), anxiety disorder, insomnia, hyperlipidemia (high cholesterol), intervertebral disc disorders with radiculopathy (damaged spinal disc presses on nerve root causing pain), psychosis (mental state where person loses touch with reality), osteoarthritis (join disease caused by the breakdown of protective cartilage), dementia, history of falling. Review of Resident #75's MDS assessment, dated 7/2/2026, revealed the resident had a BIMS score of 4 which indicated severe cognitive impairment, coded for fall in past 90 days with bruising injury, and coded toileting hygiene independently. Observation on 8/10/2026 at 9:48 am noted a small grey rug, measuring 36 inches by 24 inches, had been placed in the bathroom of Resident #75. The placement of the rug was observed, and it was noted that located in front of commode unsecured. Observation on 8/10/2026 at 3:02 pm noted a small grey rug, measuring 36 inches by 24 inches, had been placed in the bathroom of Resident #75. The placement of the rug was observed and remained in the same location in front of commode unsecured. Interview and observation on 8/11/2026 at 8:09 a.m., interview with ECA D was conducted immediately following the observation of Resident #75's bathroom floor where a grey rug measuring 36 inches by 24 inches was located. ECA D stated that she was unsure how long the rug had been on the bathroom floor or how the rug had ended up in the resident's room. ECA D acknowledged the safety risk, stating that she should remove the rug because it could be a fall hazard. Interview conducted on 8/11/2026 at 8:14 a.m., LVN C stated that he was unaware of the rug on the bathroom floor of Resident #75. He acknowledged that an unsecure rug could be a tripping hazard, was unsafe, and placed the resident at risk for a fall. LVN C stated that he would make sure removal of the rug. Interview conducted on 8/11/2026 at 11:29 p.m., the DON stated that rugs are not allowed because they create a fall hazard. Staff have removed the rug from Resident #75's bathroom floor. The DON stated she was not aware how the rug got placed in the bathroom. The DON stated that staff should do rounds aimed to protect residents from such safety risks. Interview conducted 8/11/2026 at 2:25 p.m., the ADM stated that she was unaware of a rug being in any of the residents' rooms. She explained that she had been at the facility for approximately thirty days and understood that residents and families received education at the time of admission regarding items prohibited for safety reasons. The ADM stated that these guidelines were also covered during resident council meetings. The ADM stated that the risk of having a rug on the floor was that it became a trip hazard. A record review of the facility's policy dated 2025 titled Accidents and Supervision read: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.

Based on interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 3 residents reviewed for misappropriation of resident property. (Resident #2) The facility failed to prevent ECA A from accepting checks from Resident #2 after making him believe she was in a financial bind and would be thrown out of her home. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: Record review of Resident #2's face sheet dated 7/7/2026 indicated Resident #2 was a [AGE] year-old male who was readmitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease (a buildup of fats, cholesterol, and other substances in and on the artery walls), Peripheral vascular disease (a slow and progressive disorder of the blood vessels causing narrowing, blockage, or spasms in a blood vessel), Hypertension with chronic kidney disease (a condition caused from high blood pressure that constrict and narrow the blood vessels in the kidneys, which reduces blood flow and stops kidney from working well), emphysema (a long-term lung condition that causes shortness of breath), and urinary tract infections (an infection in any part of the urinary system). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated cognitively intact. The MDS indicated Resident #2 was independent with dressing upper body and maintained personal hygiene. Record review of Resident #2's care plan revised on 11/18/2025 indicated Resident #2 voiced feelings of loneliness on occasion to staff due to his transition into a facility and Resident #2 often missed his home and dog. Interventions included counseling offered, but resident declined, social services support, and staff to monitor changes in mood or behavior. The care plan also indicated Resident #2 had potential to be verbally aggressive related to ineffective coping skills with certain situations to living at the facility. Interventions included analyzing key times, places, circumstances, trigger and what de-escalates behavior and document, provide positive feedback for good behavior, and emphasize the positive aspects of compliance. Record review of the MAR dated 5/1/2026-5/31/2026 indicated Resident #2 was administered Amoxicillin-Potassium Clavulanate 875-125 mg (a combination antibiotic to treat bacterial infections) twice daily for urinary tract infection/bacteria infection for 7 days. Resident #2 received antibiotic starting on 5/13/2026-5/19/2026. Record review of a Provider Investigation Report dated 6/23/2026, indicated on 5/21/2026, Resident #2 wrote a check in the amount of $900 payable to ECA A. The report indicated the RP brought a check to the facility to determine whether the check had been made payable to a facility employee. RP met with the facility social worker, who verified the check was made payable to ECA A. According to the report, the RP stated Resident #2 independently managed his own finances and maintained full control of his bank account. RP indicated she wanted to make the facility aware of the transaction. Upon notification of concern, the facility contacted local law enforcement and filed a police report. ECA A was interviewed regarding the matter and denied knowledge of the check or the circumstances surrounding it and stated that she would follow up with the facilities Human Resources representative. The report indicated multiple attempts were made to contact ECA A and no phone calls were returned. The report indicated initially Resident #2 had stated he had not written the check. A brief interview for mental status score was completed and was 15, indicating Resident #2 was cognitively intact. The report indicated that ECA A was immediately suspended and her failure to respond to the facility attempts to contact and absence of further communication led to her termination. The report indicated there were no injuries, no psychological changes in Resident #2's well-being and he stated he wrote the check. The staff were educated on misappropriation and not taking money from residents.Record review of an in-service titled Abuse In-Service dated 6/23/2026 indicated 89 staff members were in-serviced. The in-service reviewed questionnaire about following:What is Exploitation?What are some examples of exploitation?Who can exploit resident?What are some risk factors for exploitation?What are staff responsibilities to prevent exploitation or when exploitation was suspected or witnessed?What are the different types of abuse? Record review of copies of following checks from RP bank statement were written to ECA A, signed and cashed:Check # 1353 written on 5/21/2026 in the amount of $900.00.Check # 1355 written on 6/3/2026 in the amount of $150.00.Check # 1356 written on 6/10/2026 in the amount of $100.00.Check # 1357 written on 6/10/2026 in the amount of $500.00. Record review of the monthly work schedules dated May-June 2026 for ECA A, indicated following dates worked at the time the checks were written:ECA A worked 5/21/2026 from 3:00 PM- 11:00 PM Record review of monthly work schedule dated June 2026 for ECA A, indicated following dates worked at the time the checks were written:ECA A worked 6/3/2026 from 3:00 PM- 11:00 PM.ECA A worked 6/10/2026 from 3:00 PM- 11:00 PM. Record review of a police report dated 6/23/2026 at 4:01 PM, indicated a call was placed for a report regarding a possible theft at the facility. The report indicated that the RP informed Officer she had reviewed Resident #2's bank account and noticed $900 was missing, prompting her to contact Resident #2's bank. The bank identified the check was written on 5/21/2026 and was cashed on 5/22/2026. The report indicated the DON had spoken to Resident #2 and denied writing the check. The report indicated the DON had contacted ECA A and she acknowledged Resident #2 had written her a $100 check, which she cashed for him and returned the cash. The report stated ECA A had previously received cash from Resident #2 to buy him cigarettes. The Officer indicated ECA A worked at the facility 3-5 times a week. A picture copy of the check was attached to the case file. Record review of the Detective supplemental report dated 6/30/2026 indicated he had contacted the RP. The report indicated ECA A had been placed on suspension. The report indicated the RP had observed the handwriting to be Resident #2's and she did not know why a check would be written to ECA A. the RP was advised to speak to Resident #2 to determine if he wrote the check voluntarily and the Detective would move forward with questioning ECA A. Record review of termination letter dated 7/1/2026, indicated ECA A was terminated officially on 6/26/2026 for cashing a check from Resident #2 on 5/22/2026, dated 5/19/2026 for $900. The termination letter indicated an investigation began on 6/24/2026 and the results of the investigation substantiated the allegation due to evidence indicating a violation of the company's corrective action policy II.C.19. Soliciting and/or accepting a loan of money or property from a resident or family. Record review of the Detective supplemental report dated 7/6/2026, indicated the Detective spoke with RP and was notified Resident #2 did write the check to ECA A voluntarily. The report indicated the RP had Resident #2's check book and ECA A was released from the facility for violation of policy. The report indicated no criminal offense was committed and the case would be closed. Record review of employee file on 7/7/2026 for ECA A indicated she was hired on 7/24/2025. ECA A was suspended on 6/24/2026 and terminated on 6/26/2026. ECA A completed her training on 8/13/2025 regarding resident abuse and resident rights. ECA A was current on her licensure and certification expiration date was 2/13/2027. The employee file provided did not indicate any previous misconduct or criminal misconduct. During a phone interview on 7/7/2026 at 1:53 PM, the RP said Resident #2 was currently in the hospital and had been treated for a urinary tract infection. The RP indicated Resident #2 had kept his checkbook with him and she had seen where he had written a check to an employee. RP said the story she had received from the social worker was Resident #2 could not recall writing the check. RP said the check was written in his handwriting. RP said Resident #2 had a heart for helping others. RP said she did not know how Resident #2 was doing the day he wrote the check. RP stated she had gone through Resident #2's phone and found Resident #2 and ECA A were friends on a social media platform and were texting on phone. RP said Resident #2 had a phone call from ECA A on his phone last Monday 6/29/2026. RP sent a screenshot (a picture from phone) of the text message, and it read I hope so, I'm worried sick bout my job. RP sent the copy of the check and checkbook, indicating Resident #2 wrote a check for $900 on 5/21/2026 and was credited to the account of ECA A on 5/20/2026. During a phone interview on 7/7/2026 at 3:12 PM, ECA A said she was employed at the facility and had been an employee for about 2 years. ECA A started talking fast over the phone and unable to understand. ECA A then hung up on surveyor. This surveyor attempted to call ECA A back and ECA A did not answer her phone. During an interview on 7/8/2026 at 9:05 AM, ECA B said she had been in-serviced on abuse, neglect, and exploitation. ECA B said the last in-service was within the last 6 weeks. ECA B said the staff were not allowed to accept anything from residents including personal belongings, money, or checks. ECA B said she had no knowledge of any staff accepting cash or checks from residents. ECA B said all staff were responsible for not accepting gifts. She said a resident may feel bad if they were not able to help a staff member. ECA B said she had no knowledge of ECA A because she worked at a different home at the facility. During an interview on 7/8/2026 at 9:41 AM, Resident #2 was in his room after returning from hospital on the evening of 7/7/2026. Resident #2 said he was treated with dignity and respect. Resident #2 admitted to writing a check to ECA A for $800 dollars. Resident #2 said ECA A got in a bind and he wanted to help. Resident #2 said that was the first time he had given her money. Resident #2 said he somewhat made his own decisions, but he did not elaborate. Resident #2 denied talking with ECA A since he had given her the money. Resident #2 stated her phone number had disappeared from his phone. Resident #2 said they were just friends. Resident #2 told him she was having problems and she needed to pay her rent before she was thrown out of her home. Resident #2 said he had been in the hospital, and he was not aware that ECA A was fired. Resident #2 said he was in no financial harm due to giving ECA A money. During an interview on 7/8/2026 at 9:51 AM, ECA C said she had been in-serviced on ANE and misappropriation. ECA C said the facility did an in-service about 2 weeks ago. ECA C said she was not allowed to accept gifts, money, or gum from residents. ECA C said she was not aware of any staff member accepting gifts from residents. She said she would report immediately if she was made aware of staff accepting gifts. ECA C said staff should not be discussing personal business with residents. She said it could make a resident want to help the staff members because they are kind. She said it could make a resident feel bad if they were not able to help the staff member and be empathetic. ECA C said residents naturally want to help and be empathetic. She said she considered it deceitful, manipulative and exploitation. ECA C said she was not aware of Resident [NAME] giving gifts to any staff member. ECA C said staff should not give out their personal number or befriend residents on social media. During an interview on 7/8/2026 at 10:01 AM, ECA D said she was in-serviced on ANE and misappropriation. She said the last training was about 1 month ago. ECA D said ECA A got along with her residents, and she catered to them and she worked well with her. ECA D said Resident #2 was awake, alert, oriented x3 (fully conscious and cognitively aware), friendly and gives staff no problems. ECA D said no gifts should be accepted by staff and she was not aware of Resident #2 giving staff any gifts. ECA D said she would report any staff accepting gifts to the ADM immediately. ECA D said she had not observed or overheard staff talking with residents about their personal business or finances. She said talking to a resident about personal business could make the resident feel guilty or sad, making them want to help. ECA D said accepting gifts or money from a resident takes away from the resident and would not have their needs met. She said it could make a resident feel hopeless. ECA D said residents have drawers with locks and lockboxes. ECA D said the nurse and administrator were responsible for ensuring staff were not accepting gifts from residents. During an interview on 7/8/2026 at 10:35 AM, RN E said Resident #2 was doing good and had returned to the facility yesterday. RN E said she had been in-serviced on abuse, neglect, exploitation, and misappropriation last week. RN E said staff members should not accept gifts, personal items, or money from residents. RN E said the staff should not give residents their personal cell phone numbers or be friends with residents on social media. RN E said staff should not discuss their personal business with residents. RN E said she was not aware of any staff accepting gifts or money from residents on her shift. She said she would report it immediately if she was made aware. RN E said everyone was responsible for not accepting money or gifts from residents. She said it could make a resident feel like staff were asking for something or felt they needed to help them. RN E said she would consider it exploitation. RN E said the residents may not have the funds for their own personal use or needs. During an interview on 7/8/2026 at 11:04 AM, ADON F said the staff were in-serviced on abuse, neglect, and exploitation last week which included misappropriation. ADON F said it was against the facility policy for staff to accept gifts of money from residents. ADON F said she expected staff to notify the ADM immediately if they were aware of any staff accepting a gift from a resident. ADON F said she would take a staff member back to the resident and give any gifts back to the resident and let the staff member know accepting gifts was not allowed. ADON F said staff should not be talking about their personal business or finances with residents. ADON F said naturally, a resident would want to help. ADON F said the facility staff build relationships with residents and they become like family. ADON F said she thought exploitation was the motive behind it and knowing the residents are not supposed to help the staff members. ADON F said if a staff member accepted something they knew they were not supposed to have and the staff member was taking away the residents' finances. ADON F said she was not aware of any staff accepting money from residents. During an interview on 7/8/2026 at 12:42 PM, the DON said the last in-service on abuse, neglect and exploitation was on 6/23/2026. The DON said misappropriation was included in the in-service. The DON said gifts included cookies, money, checks or any monetary gift. The DON said the staff had been educated not to accept gifts. The DON said staff should not have conversations regarding their personal business or finances. The DON said it could make a resident feel empathetic toward a financial situation and naturally want to help. The DON said family helps family and the facility does not want residents to feel sad about a staff member's situation where they feel like they need help. The DON said all staff were responsible for making sure we do not accept gifts from residents. The DON said human resources had reviewed responsibility of staff not accepting gifts or personal belongings from residents and the staff had been in-serviced and against facility policy. The DON said the abuse coordinator was the ADM and, in her absence, the staff could notify her. The DON said she would want to be notified immediately if a resident was attempting to give away money to staff. The DON said the facility staff would investigate and talk with the residents and their families to help manage their behavior. The DON said staff should not be contacting residents on their personal phone and residents should not have the staff phone number. The DON said staff should not be texting residents or communicating with residents outside of work. The DON said staff should not be friends with residents on social media and stated she had educated staff. The DON said she was not aware of any conversations on social media or phone. The DON said a resident could feel there was a relationship with a staff member and feel responsible for maintaining the relationship no matter how it may be viewed like a daughter or friend. The DON said Resident #2 later said he gave ECA A the money and he did not mention her talking about her personal business. The DON said if ECA A gave Resident #2 a reason she needed the money; she considered it exploitation. The DON said Resident #2 gave ECA A a considerable amount of money and considered it exploitation according to the facility policy. During an interview on 7/8/2026 at 1:23 PM, the Business Office Manager said a nurse came to verify and look at the verified signature and she pulled another check to look at it. The Business Office Manager did not talk with the RP. She said staff were not allowed to accept checks from residents. The Business Office Manager said it could negatively impact a resident because the resident could lose trust in people or the resident could be confused and taken advantage of if they do not know what they were doing. During an interview on 7/8/2026 at 1:52 PM, the ADM said she was aware of a report made for Resident #2's $900 dollar check. The ADM said she expected staff to follow facility protocol and not accept gifts or money from residents. She said she expected staff not to discuss personal information about their business with residents. The ADM said she expected staff to decline money and report the incident so the facility staff could educate and reinforce with the residents. The ADM said she expected staff to report to her immediately if money was offered or given to a staff member. The ADM said it could negatively impact a resident by placing the resident in a financial hardship. The ADM said all staff were responsible for ensuring gifts were not accepted and were provided education at the time of hire. The ADM said the facility would do another round of education on acceptance of gifts or money to make clear what the facility policy was. Review of facility policy titled Abuse Police and Definitions dated October 2022, indicated, .Purpose.To identify, prohibit, and prevent resident abuse. Policy Explanation and compliance guidelines.1. Each resident has the right to be free from abuse, corporal punishment.2. Resident must not be subjected to abuse by anyone.3. Abuse.willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.4. The facility will ensure the resident is free from physical or chemical restraints.5. The categories of abuse include a. Crime.b. Exploitation: taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion. E. Misappropriation of Resident property: the deliberate misplacement, exploitation, or wrongful (temporary or permanent) use of a resident's belongings or money without the resident's consent.6. Any allegations of abuse will be immediately reported to the facility Administrator.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to ensure that Resident #1's care plan included interventions for aggressive behavior. This failure could place residents at an increased risk of not having individualized, person-centered care plans developed and maintained to address their identified needs, goals, and interventions necessary to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The findings included: A record review of a facesheet dated 06/10/2026 indicated Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included Alzheimer's disease with late onset (a neurodegenerative disease that primarily affects memory, thinking, and behavior); chronic atrial fibrillation (a heart condition characterized by an irregular and often rapid heartbeat); type 2 diabetes mellitus without complications; heart failure; and major depressive disorder, recurrent. A record review of the Resident #1's Quarterly MDS dated [DATE] indicated Resident #1 had a BIMS of 4, which indicated severely impaired cognition. The MDS indicated Resident #1 exhibited physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) every 1 to 3 days. A record review of a progress note dated 05/23/2026 at 11:15 AM indicated Resident #1 told another resident to get the [f-word] away from me and hit that resident in the left jaw. The progress note indicated Resident #1 was transferred to the hospital following the incident. A progress note dated 05/23/2026 at 11:07 PM indicated Resident #1 returned from the hospital to the facility. A record review of Resident #1's psychiatric subsequent assessment dated [DATE] indicated an increase in Depakote Sprinkle 250 milligrams twice a day (a mood stabilizer that can reduce symptoms like agitation, impulsivity, aggression, and mood swings) from and a new prescription of Sertraline 150 milligrams once daily (an antidepressant that can improve mood and alleviate symptoms of depression and anxiety). Resident #1 was also prescribed Memantine 10 milligrams twice a day (a medication used to help manage symptoms of Alzheimer's disease including memory loss, confusion, and difficulties with daily activities) and Melatonin 5 mg every night at bedtime (a hormone that regulates and supports sleep). A record review of a progress note dated 06/01/2026 at 7:40 PM indicated Resident #1 was observed hitting another resident in the face with his hands. The progress note indicated Resident #1 was transferred from the facility to the hospital on [DATE]. A record review of Resident #1's comprehensive care plan most recently revised on 06/10/2026 indicated Resident #1 was not care planned for the potential to be physically aggressive until 06/10/2026. The care plan indicated Resident #1 had the potential to be physically aggressive related to Alzheimer's. Interventions indicated on the care plan included one-to-one close observation for agitation, administer medications as ordered and monitor/document for side effects and effectiveness, and psychiatric/psychogeriatric consult as needed. During an interview on 06/10/2026 at 3:13 PM, the DON stated the MDS Coordinator oversees the care plans, any member of the IDT was able to update the care plan, and the SW could have ensured Resident #1's aggressive behavior was placed in the care plan. The DON stated that her expectation was that residents' behaviors align with their care plan. The DON stated she felt that staff were completing interventions including psychiatric consultation, medication changes, and seeking further placement though these interventions were not inserted into the care plan. The DON stated that the care plan should reflect what is going on with the resident. During an interview on 06/10/2026 at 3:18 PM, the SW stated she assisted in completing care plans. The SW stated every morning she ran a report on behaviors and it provided her with the last 24 hours of behaviors and she updated the care plan. The SW stated she did not find out about Resident #1's incident of aggression on 05/23/2026 until several days later and after Resident #1's incident of aggression on 06/01/2026 he was transferred to the hospital. The SW stated she did not and should have updated Resident #1's care plan. The SW stated developing and implementing care plans are a team effort, but it was her responsibility to ensure behaviors are reflected appropriately in the care plan. The SW stated if the care plan is not updated things could be missed and there is a potential for further aggression by the resident. During an interview on 06/10/2026 at 3:39 PM, the MDS Coordinator stated she completes care plans to ensure it reflected the resident as accurately as possible, so the plan of care could be ongoing, and to ensure everyone was aware of what was going on with the resident. The MDS Coordinator stated ensuring Resident #1's aggressive behavior should have been placed in the care plan by the SW, but she reviewed assessments and would ensure anything missed was updated. The MDS Coordinator stated the risks to residents for not having an updated care plan after an aggressive incident would include other residents safety and staff not being aware of what was going on with the residents to be able to properly care for them. During an interview on 06/11/2026 at 9:41 AM, the Regional Director of Clinical Operations stated the IDT was responsible for updating care plans. The Regional Director of Clinical Operations stated care plans were updated after a comprehensive MDS and on admission and added there was no timeframe for when they should be updated after an incident occurs and the facility policy does not support a timeframe. The Regional Director of Clinical Operations stated that after a resident-to-resident altercation a review of the care plan should be completed and interventions as indicated should be updated. When asked how not updating the care plan can negatively affect the residents, the Regional Director of Clinical Operations stated there was no harm. The Regional Director of Clinical Operations stated the DON is responsible for overseeing the updating of care plans by the responsible staff. A record review of the facility's policy dated June 2019 titled Care Plans (Comprehensive) indicated the following: Purpose: To develop an interdisciplinary resident centered comprehensive care plan to meet the individual needs of each resident. Policy Explanation and Compliance GuidelinesThe interdisciplinary team develops and maintains a comprehensive care plan for each resident.The comprehensive care plan has been designed to:Identify care needs that include the resident's strengths, history, and preferences;Incorporate risk factors; Establish goals in measurable outcomes; Include individualized approaches to meet resident's goals.The resident's comprehensive care plan is developed within seven (7) days after the completion of the MDS assessment. New residents will have a comprehensive care plan within seven (7) days after the completion of the MDS assessment, not to exceed twenty one (21) days from the date of admission.Care plans are revised as changes are indicated.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 7 residents (Resident #1 and Resident #2) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was being supervised during one-to-one supervision, resulting in a resident-to-resident altercation with Resident #2. This failure could place residents at an increased risk of avoidable accidents, abuse, and resident-to-resident altercations due to the failure to consistently implement interventions. The findings included: 1. A record review of a facesheet dated 06/10/2026 indicated Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included Alzheimer's disease with late onset (a neurodegenerative disease that primarily affects memory, thinking, and behavior); chronic atrial fibrillation (a heart condition characterized by an irregular and often rapid heartbeat); type 2 diabetes mellitus without complications; heart failure; and major depressive disorder, recurrent. A record review of the Resident #1's Quarterly MDS dated [DATE] indicated Resident #1 had a BIMS of 4, which indicated severely impaired cognition. The MDS indicated Resident #1 exhibited physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) every 1 to 3 days. A record review of a progress note for Resident #1 dated 05/23/2026 at 11:15 AM indicated Resident #1 told Resident #2 to get the [f-word] away from me and hit Resident #2 in the left jaw. The progress note indicated Resident #1 was transferred to the hospital following the incident. A record review of an incident/accident report dated 05/23/2026 at 11:15 AM indicated Resident #1 was sent to the emergency department for evaluation due to aggression, Resident #1 was be placed on one-to-one observation for safety, and behavior monitoring was in place for aggression. A progress note dated 05/23/2026 at 11:07 PM indicated Resident #1 returned from the hospital to the facility. A record review of Resident #1's psychiatric subsequent assessment dated [DATE] indicated an increase in Depakote Sprinkle 250 milligrams twice a day (a mood stabilizer that can reduce symptoms like agitation, impulsivity, aggression, and mood swings) from and a new prescription of Sertraline 150 milligrams once daily (an antidepressant that can improve mood and alleviate symptoms of depression and anxiety). Resident #1 was also prescribed Memantine 10 milligrams twice a day (a medication used to help manage symptoms of Alzheimer's disease including memory loss, confusion, and difficulties with daily activities) and Melatonin 5 mg every night at bedtime (a hormone that regulates and supports sleep). A record review of a progress note for Resident #1 dated 06/01/2026 at 7:40 PM indicated Resident #1 was observed by CNA B hitting Resident #2 in the face with his hands. The progress note indicated Resident #1 was transferred from the facility to the hospital on [DATE]. 2. A record review of a face sheet dated 06/10/2026 indicated Resident #2 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had diagnoses which included Alzheimer's disease, unspecified (a neurodegenerative disease that primarily affects memory, thinking, and behavior) and unspecified dementia, moderate, with other behavioral disturbance (a decline in cognitive abilities that affects memory, thinking, reasoning, and behavior). A record review of Resident #2's most recent Quarterly MDS dated [DATE] indicated Resident #2 had a BIMS of 3, which indicated severe cognitive impairment. The MDS indicated Resident #2 had not exhibited physical or verbal behavioral symptoms directed at others or other behavioral symptoms not directed at others. A record review of a progress note for Resident #2 dated 05/23/2026 at 11:20 AM indicated Resident #2 was assessed for injuries and pain and none was noted. The progress note indicated Resident #2 was assessed by emergency services and that Resident #2's family declined for him to be taken to the hospital for evaluation. A record review of a progress note for Resident #2 dated 06/01/2026 at 7:26 PM indicated Resident #1 hit Resident #2 in the face with his hands. The progress note indicated Residents #1 and #2 were separated by CNA C and Resident #2 was assessed and did not have any distress, skin issues, or pain. During an interview on 06/10/2026 at 9:13 AM, ADON D stated Resident #2 was outgoing and Resident #1 preferred space, so after the altercation on 05/23/2026 Resident #1 was placed on one-to-one supervision. ADON D stated when the altercation on 06/01/2026 occurred CNA A had stepped away briefly. ADON D stated there was no way to know but, had CNA A not stepped away the altercation might not have happened. ADON D stated there had been no incidents of aggression when Resident #1 was being supervised consistently. ADON D stated she did not expect staff assigned to one-to-one supervision to step away from the resident being supervised. During an interview on 06/10/2026 at 10:35 AM, CNA A stated she was assigned to the one-to-one supervision with Resident #1 on 06/01/2026. CNA A stated Resident #1 had walked outdoors, and she stayed indoors and watched him through the window. CNA A stated Resident #1 had been agitated the day of 06/01/2026 prior to the altercation. CNA A stated she stepped away for a couple of minutes to assist with another resident who had entered the wrong room. CNA A stated that while she was assisting the other resident, CNA C ran outside and stated Resident #1 had hit Resident #2. CNA A stated she had received training for one-to-one supervision and the training indicated to be within the line of sight of the resident being supervised. CNA A stated if she could go back, she would have done it differently and hollered at another staff member to go help with the other resident so she could keep Resident #1 in her line of sight. During an interview on 06/10/2026 at 10:45 AM, the Regional Director of Clinical Operations stated there was no facility policy regarding one-to-one supervision and she was unsure if staff had been trained on expectations for one-to-one supervision. During an interview on 06/10/2026 at 12:34 PM, CNA B stated she had been in-serviced on one-to-one supervision a little over a month ago. CNA B stated she did not believe it would be okay to be indoors while the resident on supervision was outdoors. CNA B stated that an in-service on one-to-one supervision was sent out to be completed by staff at 11:09 AM on the morning of 06/10/2026. During an observation on 06/10/2026 at 12:50 PM, Resident #2 appeared clean, did not have any bruising or redness to the skin, and did not appear afraid. An interview was attempted with Resident #2, though he was unable to appropriately respond to questions asked and would respond with everything is good. During an interview on 06/10/2026 at 1:14 PM, the DON stated she prefaced staff with the meaning of one-to-one supervision depending on why the resident was on it. The DON stated she expected staff to make sure if Resident #1 showed signs of anxiety or irritation they would be there to intervene, staying within his line of sight. The DON stated she did an in-service with CNA A on one-to-one supervision. The DON stated her expectation was that Resident #1 would have remained in the line of sight of CNA A and her preference was that CNA A would have been outdoors with him. The DON stated the moment Resident #2 went outside with Resident #1 she should have gone out there as well, but she did not see this happen because Resident #1 was no longer in her line of sight when she was assisting the other resident. During an interview on 06/10/2026 at 1:19 PM, CNA C stated Resident #1 was on one-to-one supervision on 06/01/2026. CNA C stated he was in the kitchen washing dishes and could see outdoors from the window. CNA C stated he looked up and saw Resident #1 throw a closed fist open swing and hit Resident #2 twice on one side of the face and once on the other. CNA C stated he was unsure if those were the only times Resident #1 had hit Resident #2 during that altercation as there was nobody watching them. CNA C stated at the time of the altercation, CNA A was redirecting another resident. CNA C stated he had not been in-serviced on one-to-one supervision, and he believed one-to-one supervision to mean keeping eyes on the resident being supervised at all times. CNA C stated he did not think it was okay for CNA A to be indoors while Resident #1 was outdoors, but he could understand due to the temperature outdoors being warm. CNA C stated there was an indoor den room near the patio where he believed it to be okay to sit and watch a resident on the patio if the supervised resident were outdoors alone. CNA C then stated if an event were to occur, he would lose line of sight with the resident being supervised going around the corner to the door leading outside. During an interview on 06/10/2026 at 2:50 PM, the Regional Director of Clinical Operations stated she could not find any prior in-services on one-to-one supervision. An observation on 06/11/2026 at 9:04 AM revealed that the outdoors patio could be seen from the window of the den, however, to get outdoors there was a corner that would disrupt the line of sight. During an interview on 06/11/2026 at 9:48 AM, the Regional Director of Clinical Operations stated the CNA assigned to the shift was responsible for providing Resident #1 supervision on 06/01/2026. The Regional Director of Clinical Operations stated her expectations of the assigned staff when providing one-to-one supervision was to ensure they were monitoring the residents behavior. The Regional Director of Clinical Operations stated she did not believe that not providing proper one-to-one supervision had a negative impact on Resident #2 as he did not recall the incident and there was no bruising or injury. The Regional Director of Clinical Operations stated there was a difference in being punched and being hit with a weak man. The Regional Director of Clinical Operations stated staff were aware of the expectation of keeping residents on one-to-one supervision within their line of sight. The Regional Director of Clinical Operations stated she was not overseeing staff at all times and could not be there every shift to know where they were. A record review of an in-service dated 06/01/2026 signed only by CNA A indicated the following: Topic: Staff assigned to 1:1 supervision are expected to remain at the resident's bedside or within direct line of sight at all times. Continuous monitoring must be provided to ensure the resident's safety. A record review of an Employee Counseling Form dated 06/01/2026 signed by CNA A indicated the following: Performance ExpectationsStaff assigned to one on one supervision are expected to remain with the resident at all times and provide continuous monitoring to ensure the safety of the resident and others. Failure to do so places residents at risk for injury and is inconsistent with facility expectations and standards of care.

Based on, interview, and record review, the facility failed to ensure resident received adequate supervision and assistance devices to prevent accidents for 1 of 20 resident reviewed for accidents. (Resident #68) The facility did not provide adequate supervision on 05/29/2025 at 7:45AM while transporting Resident #68 in the facility van by the transportation coordinator which resulted in Resident #68 who obtained a fall in the facility van and was sent to the hospital. This failure could place residents at risk for serious injury and accidents. Findings included: Record review of Resident #68's face sheet, printed on 6/10/2025, indicated he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses including muscle weakness (a lack of muscle strength), sciatica, right side, dysphagia, unsteadiness on feet, urinary tract infection, tinnitus of right ear, sepsis, wound myiasis, hyperlipidemia, dementia, nicotine/alcohol dependence, anxiety disorder, hypertension, benign prostatic hyperplasia, adult failure to thrive, more parts of the body), PTSD (a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety), and Type 2 diabetes with chronic kidney disease (a chronic condition that happens when you have persistently high blood sugar levels), polyneuropathy (affects the peripheral nerves, which are the nerves that control the movement of the arms and legs) and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the revised care plan initiated on 6/10/2025 indicated the following: Focus - Resident #68 was at risk for complications due to impaired mobility regarding weakness of right BKA (Below-Knee Amputation), requires assistance with activity of daily living impaired mobility, at risk for injury falls r/t weakness. The right BKA is a surgical removal of the leg below the knee, often due to severe vascular disease or trauma. Record review of Resident #68's quarterly MDS dated [DATE] #68 had a BIMS score of 15, which indicated he a BIMS (Brief Interview for Mental Status) score of 15 indicates that the individual's cognitive function is intact. Record review of the complaint and incident intake worksheet in TULIP created on 5/30/2025 on Resident #68 indicated: Date and time of the incident 5/29/2025 at 11:39am; Date facility first learned of incident 5/30/2025 at 4:17 pm indicated: Update on Resident #68 The driver of the bus called the transportation coordinator who is a licensed vocational nurse. The transportation coordinator alerted the administrator and the director of nursing. They instructed that EMS be called to assess the resident and transport him to the hospital. At the hospital, a CT (CT scan, also known as a computed tomography scan or CAT scan, is a medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body) scan of the spine and head/brain were negative. After a three view X-ray there is no definite injury of the right hand. Per facility intake Resident #68. On 5/29/25 at around 7:43 am the facility van was transporting resident #68 to an appointment when he fell back in his chair. As per facility policy the van parked and called EMS. EMS came to assess resident and was then taken local hospital, Resident returned from hospital at 2:00 PM with abrasion on right hand. The driver claimed that she had secured the front straps to Resident #68 prior to the appointment. The facility interviewed two employees, ECA C and ECA D, who were in the van at the time of the incident. In their statement they could not recall if front straps to wheelchair were secured or not. When Resident #68 returned he testified that the driver, did not apply front straps to his wheelchair and only back straps were applied. A decision was made to terminate the employee (transportation coordinator). Record review of the After Visit Summary dated5/29/2025 indicated the following: Resident #68 you have been evaluated in the Emergency Department today for your head injury. Your CT scan did not show signs of bleeds or fractures in your head. We recommend you take 600 mg ibuprofen every 6 hours or Tylenol 650 mg every 6 hours as needed for pain. Diagnoses: closed head injury, initial encounter, ground level fall, abrasion of right hand, initial encounter. During an interview on 6/10/2025 with Resident #68 who said he remembers the incident from couple of weeks ago he went out for an 8:00 am appointment to the VA for hearing exam. During an interview on 6/10/2025 with HR Director that on 5/29/2025 she notified the nurse at 7:45AM his nurse that Resident #98 had a fall while on transport. It was reported that resident was in his wheelchair on transport van when he fell backwards in wheelchair hitting his head. No bleeding noted. Instructions given to send resident to nearest emergency room for further evaluation and care. Termination of employee (transportation coordinator), review of processes/policies regarding van safety on 5/29/25 by Regional [NAME] President, Regional Clinical Consultant, Maintenance Director and Senior Maintenance Director. Staff educated regarding policy on van safety and response. Drivers to complete safety rounds of van using check list including checking the securement system daily implemented. The Safety Rounds checklist to be provided daily to Maintenance Director to ensure completion implemented. Driver had performed return demonstration regarding van safety rounds and wheelchair securement on 5/29/25. During an interview with maintenance Director on 6/10/2025 at 1:00 pm who said he was responsible for passenger securement safety audits, which was the training of anyone driving the facility van. He said he did a walk around and safety check on 5/28/2025 with the van Driver (transportation coordinator) who they fired, they have now implemented a two-person safety check and walk around. During an interview and demonstrations of van safety on 6/11/2025 at 1:30pm with the administrator/Maintenance Director. Both stated, they could not prove that the van Driver did not strap Resident #68 fully in, but they had implemented a policy to double check on residents being transported via van, they now have a ECA who also checks the securement of the resident in the van. Review of Policy transportation incidents revised June 2025: Purpose to provide transportation for facility residents for appointment and activities away from the facility grounds. .9. Wheelchair residents will utilize vehicle lift according to manufacturer instructions. Wheelchairs will be secured per manufacturer instructions. 10. Prior to moving vehicle, driver will personally assure that all riders have been safely secured . 12. In the event of any issue that involves a resident tripping, falling, or becoming unsecured or any other situation that may cause an injury to anyone during transportation, including any vehicle accident, the following procedures will be followed. a) The van will immediately move to the nearest safe location off the road and emergency flashers are to be turned on. b) The resident or injured person should not be moved. c) The Nursing Supervisor is to be contacted immediately, director of nursing, and/or administrator. d) In the event of an injury or accident 911 is to be called and EMS and/or police to respond as indicated to evaluate the situation. e) Obtain in writing all details of incident, time, locations, and all persons in the vehicle. f) Prior to moving the transportation vehicle driver must ensure all persons are safe. g) Any time an incident occurs during transport that results in wheelchair tipping in any direction or a resident landing on floor of van, EMS is to be called. Resident is to be evaluated at emergency room. Under no circumstances is the resident to continue to be transported by facility vehicle. h) Upon learning of any incident regarding more that basic first aid from bumping against the lift or doorway of van, the administrator, DON, Regional [NAME] President, Regional Clinical Consultant, Director of Risk Management and Senior Director of Facility Services are to be notified

Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident # 72) reviewed for pharmacy services. RN A administered a medication prepared by LVN B nurse without verifying the physician's order for the medication and ensuring the medication was the right dose. This failure could place residents at risk for receiving the wrong medication or the wrong dose of a medication resulting in a decline in health status. Findings included: A review of Resident #72's clinical records indicated he was an [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included anxiety, pain, diabetes, dysphagia (difficulty swallowing), gastroesophageal reflux disease (a digestive disease in which stomach acid or bile flows into the food pipe and irritates the lining), and gastrostomy placement (also called a G-tube and is a tube inserted through the belly into the stomach and used for delivering liquid nutrition and water into the stomach). A review of a quarterly MDS dated [DATE] noted Resident #72 had a BIMS score of 9 indicating his cognition was moderately impaired. The same MDS indicated he received nutrition and medications via the G-tube. He was dependent on staff for all activities of daily living. A review of Resident #72's physician orders dated0 6/10/2025 indicated multiple medication orders which included hydrocodone-acetaminophen 5-325 mg tablet every 6 hours via G-tube, lorazepam 0.5mg tablet 3 times daily, and gabapentin 300mg capsule 3 times daily via G-tube. During observation and interviews 06/10/2025 at 12:30 PM, LVN B was observed to prepare 1 tablet hydrocodone-acetaminophen 5-325mg, 1 tablet lorazepam 0.5mg and 1 capsule gabapentin 300mg for administration to Resident #72 via his G-tube. She crushed the tablets, opened the capsule, and placed each medication in its own individual plastic medication cup. She diluted each medication with 5mls of water and carried the 3 medications to Resident #72's bedside table. She administered the 2 tablets separately During the medication administration process, the cup containing the gabapentin medication turned over and part of the medication solution spilled onto the table. She said she would have to obtain and prepare another dose of the gabapentin. RN A who was standing by the wall just inside the room donned (to put on an article of clothing) a gown and gloves and told LVN B that she would hold the G-tube while LVN B prepared another dose of the medication that had spilled. LVN B left the room and went to the medication cart, withdrew a gabapentin 300mg capsule from the cart, opened the capsule, emptied it into a plastic medication cup, diluted the capsule contents with 5mls of water, and re-entered the room. RN A turned toward LVN B and said, Can I do it? LVN B handed the plastic medication cup to RN A and stepped back. RN A poured the medication cup contents into the G-Tube, flushed the tube with 30mls of water, closed the tube, and repositioned Resident #72's clothing. When RN A was asked what medication she gave, she said she gave gabapentin but did not know what the dose was. RN A said she should not have given the medication because she had not prepared it and could not say for sure if the medication was gabapentin, if it was what was ordered by the physician, or if it was the right dose. During an interview on 06/10/2025 at 01:30 PM, LVN B said she should not have given the medication to the RN to administer. She said since she was the one who obtained, checked, and prepared the medication, then she was responsible for giving it. She said nurses were not supposed to give medications prepared by someone other than themselves. She said RN A could have given the wrong medication or the wrong dose because she had not checked the orders to ensure she was giving the right dose and the right drug. During an interview on 06/11/2025 at 08:15 AM RN A said she should have let the LVN administer the medication because the LVN was the one who prepared it. She said she had not checked the medication to ensure it was the right drug, the right dose, nor the right time to give it. She said she was trying to help the LVN who was nervous and had a lot going on. During an interview on 06/11/2025 at 08:00, the DON said RN A should not have given a medication that she had not personally obtained, checked, and prepared. The DON said she expected the nurses to administer medications in a safe manner. A review of the facility's policy titled Medication Administration indicated the following: Procedure: Always follow five rights: Right medication, Right resident, Right time, Right amount, Right route. 1, Check physician's order for directions on Medication Administration Record (MAR). 2, Check label on medication and compare to the order on the medication administration record. 3. Check for allergies. 4. Wash hands 5. Put on gloves, if necessary. 6. Explain procedure to resident.

Based on interview and record review, the facility failed to ensure the residents received mail for 11 of 11 residents reviewed for rights to forms of communication. (Resident #s #16, #18, #29, #33, #47, #57, #72, #75, #86, #89 and #91). The facility did not deliver mail to Residents #16, #18, #29, #33, #47, #57, #72, #75, #86, #89 and #91, on Saturdays. This failure could place the residents at risk of not receiving mail in a timely manner and a diminished quality of life. During interview, residents #16, #18, #33, #47, #57, #72, #75, #86 and #91 said mail is delivered on Saturday but the Saturday mail is not delivered until Monday. Resident #72 said he delivered the mail, Monday through Friday. He said the mail is provided to him and he delivered the mail to each house that had mail. He said the weekend receptionist locked the Saturday mail up in the administration building and it is not provided to him until Monday, for delivery. During interview on 05/15/2024, at 11:06 AM, on-duty Receptionist - A, said her work schedule was Monday through Friday, 8:00AM to 5:00PM. She said she handled the mail Monday through Friday. She said she would sort the mail, separating the business office mail from the resident mail. She said she would place the resident mail in the tray for the Activity Director to pick up and if the resident had a package, she would place it on the standing rack. She said occasionally she has worked the weekend. She said she would handle any mail delivered on Saturday, the same way, and the mail would be picked up on Monday by the Activity Director. During interview, on 05/15/24 at 1:39 PM, weekend Receptionist - B, said her work schedule was Saturday and Sunday. That her hours varied sometime , but for the most part, her hours were 7:30 AM to 4:30 PM, or later, depending on if the residents had an activity. She said she handled the weekend mail and when it was delivered, she would sort it, place the business office mail in its tray and place the residents mail in its tray. She said the residents mail was usually held over until Monday unless a resident decided to come check for mail or a package that he or she was expecting. She said she would place packages for the residents on the metal rack near her desk. During interview on 05/15/24 at 2:08 PM, the Administrator said mail is delivered to the front desk, Monday through Friday and handled by Receptionist - A, who sort the mail and then set it aside to be picked up and delivered to the residents. The Administrator did not say specifically how the weekend mail was handled. She said, residents can call or come to the front desk to check and see if they have received a package, as many residents order things on Amazon; delivered by Fed-X or UPS. Review of a policy Titled: Resident Rights, dated October 2022: i) indicated, the resident has a right to send and receive unopened mail, and to receive letters, packages and other material delivered to the facility for the resident .

Based on interview and record review, the facility failed to ensure residents were informed orally, of their rights, for 7 of 11 residents interviewed during a group meeting. (Resident #s #16, #18, #29, #33, #47, #72, and #75). Residents #16, #18, #29, #33, #47, #72, and #75 were not provided on going communication of their rights orally, during their stay in the facility. This failure could place the residents at risk of a decreased quality of life, decreased awareness of their right and decreased execution of their rights. Findings include: Record review of monthly resident council meeting minutes, on 05/14/2024 at 10:00AM, revealed resident rights were not reviewed or discussed over the past five months; April, March, February and January 2024 and December 2023. During interview on 05/14/2024 at 10:00AM, Residents #16, #18, #29, #33, #47, #72 and #75 said, the Activity Director had not reviewed or explained resident rights to them, nor had the Administrator. During interview on 05/14/2024 at 10:55AM, the Activity Director said he has not reviewed the resident rights with the residents at the resident council meetings. He said they receive them at admission, and he has given them printed copies, but he has not reviewed and explained them to the residents. During interview on 05/15/2024 at 2:09 PM, the Administrator said, the resident receives a copy of the resident rights at admission, in their admission packet. She said, if an issue comes up, when she attends the resident council meetings, she will explain that issue, as it pertains to that issue, but she has not reviewed or explained the list of resident rights with the residents. Review of a document titled Resident Right, with a revised date of October 2022 , reflected Purpose: To ensure the facility will inform the resident both orally and in writing in a language that the resident understands . Procedure: 2 Information about resident rights and responsibilities will be given to the resident both orally and in writing.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 20 resident reviewed for accidents. (Resident #1 and Resident #2) The facility failed to provide adequate supervision which resulted in Resident #1 spilling hot coffee on himself and obtained 2nd degree burn to right thigh that measured 27cm x 20cm x 0.1cm; 540cm of surface area. The facility did not provide adequate supervision while transporting Resident #2 in the facility van which resulted in Resident #2 obtained wedge compression fracture mid thoracic spine. An IJ was identified on 05/06/24. The IJ template was provided to the facility on [DATE] at 5:56pm. While the IJ was removed on 05/08/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk for serious injury and accidents. Findings included: 1)Record review of Resident #1's face sheet, printed on 5/4/24, indicated he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses including muscle weakness (a lack of muscle strength), tremors (an unintentional and uncontrolled rhythmic muscle movement of one or more parts of the body), PTSD (a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety), and Type 2 diabetes with chronic kidney disease (a chronic condition that happens when you have persistently high blood sugar levels), polyneuropathy (affects the peripheral nerves, which are the nerves that control the movement of the arms and legs) and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the revised care plan initiated on 3/5/24 indicated the following: Focus - Resident #1 was at risk for complications due to coffee burn to right thigh and abdomen. Goal: Resident will have no complications through the review period. Interventions: Allow time for hot liquids to cool down some before consuming, at his request, Apron to be provided while hot liquids are consumed, encourage fluid intake and to take slow sips of hot liquids, Resident provided with a Spill-proof coffee cup, Resident to be verbally informed when hot liquids are being provided, and Treatment with Silvadene as ordered. Record review of Resident #1's quarterly MDS dated [DATE] indicated he had difficulty communicating some words or finishing thoughts but is able if prompted and usually understands others. Resident #1 had a BIMS score of 11, which indicated he had moderately impaired cognition. Section GG - Indicated Resident #1 had the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident. Record review of the complaint and incident intake worksheet in TULIP created on 3/5/24 on Resident #1 indicated: Date and time of the incident 3/2/24 at 8:00am; Date facility first learned of incident 3/2/24 at 1:30pm. Immediate action taken to protect client: reading of temperatures for coffee was obtained. Narrative of the incident: resident received a 2nd-degree coffee burn to his right thigh; treatment was provided. After an assessment by the Wound Nurse on 3/5/24, it was determined to send the resident out for further treatment. Record review of Resident #1's provider investigation report dated 3/12/24 revealed Description of the Allegation: Resident #1 spilled coffee on his leg, did not report to staff until several hours later. Description of injury: 2nd degree burn to right thigh, 27cm x 20 cm x 0.1cm; 540cm of surface area. Investigation Summary: On March 2, 2024, at 2:30pm, Resident #1 reported to the Charge Nurse that he had spilled coffee on his right thigh that morning. Resident #1 stated that he did not tell anyone earlier because he was not worried about it. Upon assessment a reddened area was noted to Resident #1's right thigh. Skin was intact. Resident #1 did not complain of pain to area. Nurse Practitioner was contacted and ordered Silvadene cream to the area. During staff interviews, staff stated that Resident #1's coffee cup did not have a lid that morning. CNA's stated that they had seen the coffee spill on the floor around him but did not observe the spill on his clothes due to he was wearing denim jeans. Resident #1 has a history of tremors with decreased range of motion to both arms. Resident #1 had been provided with a cup with a lid but refused to use the lid. On 3/5/24 at 10:20am, Resident #1's skin was evaluated by the ADON and the wound care nurse. Resident #1's right thigh had developed weeping blisters and the skin had begun to peel. The Nurse Practitioner was updated, and an order was received to send Resident #1 to the ER for further evaluation and treatment. Record review of the wound doctor's report dated 3/8/24 indicated Resident #1 had a burn wound of the right thigh full thickness. Wound Size (L x W x D): 27 x 20x 0.1cm. Dressing Treatment Plan: Collagen sheet apply once daily for 30days. Secondary dressing: Gauze Island with bandage apply once daily for 30days. During an attempted interview on 5/5/24 at 1:25 p.m., Resident #1 was in his room napping in his wheelchair right in front of his television, he did not answer questions asked. During an interview on 5/5/24 at 1:38 p.m., CNA J said she worked the 7am to 3pm shift and on 3/2/24 the morning of the incident with Resident #1 she went to work early a little after 6am and Resident #1 was at the table finishing breakfast and she cleaned up spilt coffee from the floor. She said Resident #1 was wearing dark colored pants so she could not tell at that time he spilt his coffee on himself. CNA J said she asked Resident #1 if he was alright and in a harsh tone Resident #1 replied I'm okay, give me some more coffee. She said later that morning, she was doing patient care and that was when she discovered a large red mark on his right thigh. CNA J said she asked Resident #1 what happened and that was when he told her he spilt his coffee. She said she finished patient care and immediately notified LVN K. CNA J said prior to the coffee incident with Resident #1, facility did not have the plastic lids to put on the coffee cups, since the incident they were to now put the lids on all coffee cups before giving to the residents. During an interview on 5/5/24 at 2:01 p.m., LVN K said he was working as Resident #1's charge nurse the morning of the incident. He said CNA J reported to him about Resident #1's right thigh coffee burn. He said he went to assess Resident #1, documented it on his chart, and notified NP and family. LVN K said he recalled Resident #1's thigh pink in color whenever he initially looked at Resident #1's thigh and Resident #1 told him he spilt his coffee. LVN K said prior to Resident #1's coffee burn incident residents were able to use self-dispensing canister to pour their own coffee and they were not using the white plastic lids for the coffee cups. He said since the coffee burn incident staff were to temp the coffee prior and staff was now pouring all coffee for the residents and putting the white plastic lids on all cups prior to giving to the residents. During an observation on 5/6/24 at 5:50 p.m., the DON took measurements of Resident #1's thigh with measuring tape; the visible red burn scar was 18 cm x 6.5 cm. Record review of the revised hot liquid safety policy dated March 2024 revealed the following: Policy: Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. Procedure: 1.Hot liquids can cause scalding and burns. The degree of injury depends on the temperature, the amount of skin exposed, and the duration of exposure. Refer to the table attached to this policy for an illustration of the time required for a burn to occur at various temperatures. 2.The temperatures of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches an appropriate temperature. 3.Residents are assessed for their ability to handle containers and consume hot liquids. This includes but is not limited to residents with cognitive loss, vision issues, loss of hearing, weakness of upper extremities and/or tremors. 4.Residents with difficulties will receive appropriate supervision or use of assistive devices in order to consume hot liquids. Interventions will be individualized and noted on the resident's plan of care. Interventions include, but are not limited to: a. Wide based cups b. Cups with lids and handles c. Limit Styrofoam cups to residents with no difficulties d. Aprons e. Disallow hot liquids while lying in bed. f. Therapy Referrals 5. Staff shall respond immediately to spills or other accidents with hot liquids to minimize the risk for burns. Wet clothing should be immediately removed, and cool compress applied to affected area. Follow procedures regarding incidents/accidents should anyone experience exposure to hot liquids. 6. Monitor residents for at least 24 hours following exposure to hot liquids, as redness or blisters may not appear initially. 7. General safety precautions when serving hot liquids include, but are not limited to: A .Make sure resident is alert and in proper position to consume hot liquids. b.Use cups, mugs, or other containers that are appropriate for hot beverages. c. Do not overfill containers. d. Regulate temperature of hot liquids to which residents have direct access. e. Place filled containers directly on table. Do not hand them directly to residents. f. Keep hot liquids away from edges of the table. g. Do not refill containers while the resident is holding the container. h. Provide supervision as needed. 2) Record review of Resident #2's face sheet, printed on 5/4/24, indicated he was a [AGE] year-old male who admitted on [DATE] with diagnoses including hypertension (blood pressure that is higher than normal), Type 2 diabetes(a chronic condition that happens when you have persistently high blood sugar levels), low back pain( A common, painful condition affecting the lower portion of the spine), and back spasm (sudden tightness and pain in your back muscles). Record review of Resident #2's revised care plan dated 4/22/24 revealed Focus: Resident #2 at risk for complications and pain due to T-7 fracture (Tylenol #4). Goal: Resident #2 will not have any complications related to the fracture. Interventions/Tasks: Appointment with Neuro, Routine Pain Assessments, Wear brace as ordered until follow up appointment. Record review of Resident #2's Quarterly MDS dated [DATE] indicated he had clear comprehension and made himself understood. Resident #2 had a BIMS score of 15, which indicated he was cognitively intact. Record review of Resident #2's incident report dated 4/1/24 completed by LVN C revealed the incident location: Out of Facility / During Transport; Nursing Description: Transportation driver came to RN supervisor and stated that when she took off from a red light she looked up in the mirror and seen resident's legs in the air. She had the rider go check him and she pulled over as fast as she could and they assisted the resident upright and secured wheelchair properly before proceeding to doctor appointment. Resident Description: Resident stated that the transportation staff hadn't strapped him in properly on the van. No Injuries Observed Post Incident. Notes: per resident and transportation staff he hit his back and right shoulder. No discoloration noted at this time. Record review of the complaint and incident intake worksheet in TULIP created on 4/3/24 indicated: Date and time of the incident 4/1/2024 at 2:15pm; Dated facility first learned of incident 4/1/2024 4:00pm. Immediate action taken to protect client: Investigate Bus/Driver taken out of transport service pending safety investigation of staff and bus, Send patient for additional diagnostic testing. Narrative of the incident: During a transport to a physician appointment on April 1, 2024, Resident #2 was riding in the facility bus and while enroute the wheelchair tilted backwards causing Resident #2 to fall to the floor of the bus. On April 2, 2024, he complained of pain , X rays were obtained and showed a fracture to his mid thoracic vertebrae. Physician notified and new orders for orthopedic consult received. Actions and Notifications: Facility bus has been taken out of use for transports and is being inspected for safety standards. Investigation /interview with multiple staff members to determine the root cause of the incident. Transports have been suspended for the staff involved pending safety analysis of both Driver/vehicles. Physician notified. Resident is his own Responsible party. Record review of Resident #2's Progress notes indicated the following: -On 4/1/24 at 2:00pm; completed by LVN C: Resident #2 is leaving via facility transportation at this time to go to an eye appointment. - At 5:15pm; completed by LVN C: Resident #2 asked nurse if he had any discoloration on his back or right shoulder. LVN C nurse did not see any discoloration. A few minutes later a member of transportation went to LVN C and stated that Resident #2 had fallen into his chair when boarding the van. Resident #2 stated that the transportation staff did not strap him in properly on the van. Assessed Resident #2's skin and started neuroes. RN supervisor and NP notified. Resident is his own RP. -On 4/2/24 at 9:01am; completed by LVN D: Resident #2 reported to LVN D that he has neck pain, right shoulder pain, and right rib pain and states it is from when he fell in transportation bus yesterday. Notified NP and received an order for right shoulder x-ray, c spine, rib series and skull series. -At 9:08am; x-ray orders called in. -At 2:00pm; Resident #2 was administered Tramadol 50mg pain medication due to Resident #2 requested for pain to neck, right shoulder and right rib pain. -At 4:09pm; completed by the Social Worker: Visited Resident #2 to check on him. Resident #2 reported that he was in an accident on the bus where he fell backwards in his chair going to an appointment. Resident #2 stated that he did not unlock his brakes on his wheelchair. This social worker validated Resident #2. Resident #2 was pleasant but said that he was in pain. Nurse aware. -At 4:47pm; completed by LVN C: Per NP refer to orthopedics for wedge compression fracture mid thoracic spine for possible kyphoplasty. Informed RN supervisor of x-ray findings and new order. -On 4/3/24 at 10:14am; completed by RN E: Administered tramadol 50mg for pain to right upper back. - at 2:36pm; new from DON to send Resident #2 to the ER via EMS for spinal Xray to confirm fracture. Resident #2 who is his own RP notified. -At 3:12pm; completed by PTA F: in preparation for gait training nurse came in and informed this therapist and Resident #2 that the x-ray showed possible spinal fracture and Resident #2 is going to ER via Ems. Resident #2 had stated he was sore from the incident but that he wanted to go sit on the porch. Therapist was unaware that x-ray had been ordered or administered. -At 3:38pm; completed by DON: Due to Resident #2 recent fall and mobile x-ray determined fracture of mid-thoracic spine, the NP was notified. The resident was sent to the ER for further evaluation. -On 4/4/24 at 9:02am; completed by RN E: Resident #2 returned to facility via EMS, resident was transferred to bed by EMS personnel, Resident #2 had a brace on there is no order on removal. Resident #2 stated they didn't tell him if could sleep in it or take it off, Resident #2 was dx with Compression fracture of T7 Vertebra, Chronic bilateral low back pain without sciatica and Hyperglycemia due to Diabetes Mellitus. CT of Cervical spine, Head, Lumbar Spine and Thoracic Spine without contrast without contrast and Chest Xray 1 view was performed. CBC with auth diff and BMP was also done. Results was not sent with resident. Resident #2 reports pain of 9/10 to back BP 115/75 hr 55 temp 98.2, O2 sat 93 RR20. NO new orders, RN Sup and NP notified of resident's return. -At 9:34am; Administered tramadol 50mg for pain to right upper back. - At 1:02pm; Follow-up Pain Scale was: 5 PRN Administration was: Ineffective. - At 1:04pm; Administered tramadol 50mg for pain to midback. - At 1:15pm; completed by RN Supervisor G: Resident #2's pain level has increased due T7 compression fracture and Tramadol is not controlling the pain. NP informed and new order for Tylenol #3 1 Q 4 hr PRN received. Order entered, pharmacy notified, and CN informed. CN to inform resident.- at 9:45pm; completed by RN E: Administered and was effective. -at 10:56pm; completed by RN E: new order from RN Sup per NP for Tylenol #3 1 tab Q 4 hrs Order entered, resident. Who is his own RP notified. -On 4/5/24 at 1:06pm; completed by RN H: Acetaminophen-Codeine Tablet 300-30 MG Give 1 tablet by mouth every 4 hours as needed for Mild / Moderate Pain Acetaminophen Warning: Do not Exceed 3GM (3,000mg)of acetaminophen total from all sources in 24hr period. Resident #2 c/o pain to back of 7.5-8/10, was wearing back brace. Oriented to new pain medication, voiced understanding and stated he would contact staff for assistance with adls if needed. -At 2:54pm; Follow-up Pain Scale was: 3, PRN Administration was: Effective but Resident #2 stated pain continues but had decreased. -At 3:36pm; Resident #2 expressed anxiety r/t recent compression fracture diagnosis and accompanying movement restrictions. Denied need for PRN anxiety medication but voices understanding that it is available if needed. Questions answered as needed and resident reassured that staff would be there to assist with adls or any tasks he may need. Resident #2 voiced that eased anxiety. Resident #2 voiced understanding of education regarding movement restrictions and back brace given by therapy. New PRN pain medication administered this shift per orders as needed, education provided at time of administration and resident voiced understanding. Medication was effective in lowering pain level. Call light and desired belongings within reach. -At 5:13pm; completed by Director of Rehab: Resident #2 had a back brace that is to be worn at all times when out of bed. He is not to twist, bend/reach to floor level or lift anything over 3lbs. -On 4/5/24 at 9:00pm; completed by LVN C: ECA at bedside with this nurse to help assist with turning due to recent back injury. -On 4/6/24 at 7:29am; Completed by LVN D: Per Director of Therapy regarding showers- usually a person can't shower until cleared by a doctor. If Resident #2 choose to shower, he would have to do so with the brace on. Normally should be done before bed so it can hang to dry overnight. Notified Resident #2 and he verbalized understanding at that time. -At 7:30pm; Completed by LVN D: Administered Acetaminophen-Codeine Tablet 300-30 MG, Resident #2 requested for back pain. - At 9:55pm; Completed by LVN C: back pain r/t T7 compression fracture. -On 4/7/24 at 6:49am; Completed by LVN D: Resident #2 stated that his overall back pain was at a 7/10 at that time. Resident #2 declined pain med at that time. -At 9:00am; Completed by LVN D: Administered Acetaminophen-Codeine Tablet 300-30 MG, Resident #2 requested for back pain. -At 11:30am; Completed by LVN D: PRN T#3 administered at 0900 that morning was effective per resident. Resident #2 back brace applied and transferred to a back supporting chart in his room with 2 staff members assisted. Resident #2 stated he wanted to remain in chair until after his son left from visiting. Educated resident on using call light, placed within reach, when assistance was needed. -On 4/8/24 at 9:45am; Completed by LVN D: Administered Acetaminophen-Codeine Tablet 300-30 MG, Resident #2 requested for back pain. -On 4/9/24 at 10:39am; Completed by RN E: Administered tramadol 50mg for pain to upper back. -On 4/10/24 at 1:48pm; Completed by LVN D: Administered Acetaminophen-Codeine Tablet 300-30 MG, Resident #2 requested for back pain at a 7/10 while sitting on side of bed. -At 1:49pm; Completed by LVN D: Administered Ativan 0.5mg tablets, due to Resident #2 requested for increased anxiety at this moment due to sitting upright with back brace on. --At 3:08pm; Completed by NP: Chief Complaint: Resident #2 presents with back pain related to a recent T7 compression fracture. History of Present Illness: The patient reports that his pain is an 8 out of 10 without the prescribed pain medication, Tylenol number three, which is ordered every four hours as needed. He stated that the pain reduces to a 5 out of 10 after taking the medication, indicating ineffective pain relief. He has a follow-up appointment scheduled with a neurosurgeon. Relevant Symptoms and Experiences: Resident #2 has severe COPD and is currently on continuous oxygen therapy with a BiPAP at night. He was experiencing bilateral lower extremity edema, rated as plus two, and his LASIX dosage was recently increased to 40 milligrams POQ day to address that issue. He was wearing a back brace due to the compression fracture. - General: Patient is alert and oriented x3, pleasant, with clear speech. - Musculoskeletal: Wearing a back brace due to T7 compression fracture. No swelling in bilateral upper extremities. Plus two edema in bilateral lower extremities. Assessment & Plan: 1. T7 compression fracture - Continue wearing back brace for support and stabilization - Follow-up with neurosurgeon as scheduled - Monitor pain levels and effectiveness of current pain management 2. Inadequate pain relief - Continue Tylenol #3 every 4 hours as needed - Consider discussing alternative or additional pain management options with the neurosurgeon during follow-up -On 4/11/24 at 9:19am; Completed by Social Worker: This social worker stopped by to visit the veteran. Resident #2 stated that he was still in pain. Resident #2 reported that he was nervous to see the neurosurgeon. -At 10:55am; Completed by LVN D: Administered Acetaminophen-Codeine Tablet 300-30 MG, Resident #2 requested for back pain. -At 7:00pm; Completed by: LVN C: Administered Acetaminophen-Codeine for pain r/t compression fracture of the T7 vertebrae. During an interview on 5/5/24 at 10:07 a.m., with the Administrator and Regional Clinical Consultant. The Administrator said she first learned of the van incident during morning meetings the following morning on 4/2/24, but incident was told differently as if Resident #2 fell while transporting and loading onto the van because that was how the original incident report was documented. She said she did not hear of how the actual van incident occurred and about the fracture until late 4/3/24 whenever the x-ray results came back. The Regional Consultant said she found out about the van incident around 11:00am on 4/3/24. She said she would have expected for Driver B to not touch Resident #2 and to immediately call the DON, or RN Supervisor immediately after the incident occurred and to then call 911 for EMS to check out resident and for them to transport Resident #2 to the hospital. She said CNAs were not qualified to assess residents, it would have to be a nurse or EMS staff. The Regional Clinical Consultant said since the van incident she developed a Facility Transportation policy dated April 2024 on what to do in event of any issues that involved a resident tripping, falling, or becoming unsecured or any other situation that may cause an injury to anyone during transportation. During an observation and interview on 5/5/24 at 12:56pm revealed Resident #2 was in his room sitting in a chair wearing a full coverage back brace. Resident #2 said on the day of the incident, he had an eye appointment and was going by facility van. He said as the van driver approached the railroad track his wheelchair started tilting backwards, and as the driver gassed the van to go over the track his wheelchair flipped back and he was looking at the roof of the van. Resident #2 said everything happened so fast and he was shocked by what had happened. He said the driver and the helper untangled him from the belt strap and helped him off the floor. Resident #2 said the driver offered to take him to the emergency room but since he had already missed a previous eye appointment, he did not want to miss another eye appointment. Resident #2 said having vision issues was scary and serious, so all he could think about at the time was not missing another eye appointment. He said he did think his wheelchair was properly strapped in because he had ridden on the facility van in the past and he had not had that issue before. Resident #2 said he had not been back on the facility van since the incident and said he did not know how he would feel once he was back in the van and he possibly could have anxiety once he looked at the back of the driver seat as a reaction to the incident. He said he wanted to know if the driver had been retrained, did the facility figure out what went wrong, if the facility van was adequate and had this happened before. Resident #2 said he needed answers to those questions before he felt safe riding on the van again. He said his back hurts daily and was able to manage the pain with pain medication. He said the pain was most severe whenever he moved. During an interview on 5/6/24 at 12:06pm, Driver B said she had been a van driver for about four years, and this was her first incident with a wheelchair flipping over during transport. She said on the day of the incident, they were running behind for Resident #2's eye appointment due to staff did not have him up and ready. She said she loaded Resident #2 onto the van and strapped down Resident #2's wheelchair. Driver B said as she was driving up to a railroad track, she could see in her rearview mirror Resident #2's wheelchair slightly tilting back, but as she went across the railroad track, she looked up at her rearview mirror again and could see Resident #2's feet in the air. She said she had to pull over out the way of traffic to help with Resident #2. Driver B said Resident #2 was lying on his back with portable oxygen tank wedge between the floor of the van and the back of the wheelchair and Resident #2 on his back on top of the oxygen tank. She said Resident #2 repeatedly said his head was hurting, she said she did not ask for location of head pain and assumed it was the back of Resident #2's head because that was the part he hit during the incident. She said she unstrapped Resident #2 and proceeded to get Resident #2 up onto all fours, and he was in that position for a few minutes trying to catch his breath and he continued complaining that his head was hurting. Driver B demonstrated all fours as being on hands and knees. She said after a few minutes herself and the helper moved Resident #2 from on all fours to sitting on the side of the van and at that time he was still catching his breath, he was wearing oxygen tubing and complained of head hurting. Driver B said she asked Resident #2 if he was okay and offered to take Resident #2 to the emergency room , but he declined and insisted on going to the eye appointment. Driver B said the only phone call she made at that time was to the eye doctors to verify it was okay for Resident #2 to still come since he was so late for the appointment, and she was informed they would still see him. Driver B said prior to incident she had been trained on how to properly secure a wheelchair but had not been trained in the case of a wheelchair flipping over. Driver B said after she returned Resident #2 back to the facility, she notified a RN Supervisor and Resident #2's charge nurse about the incident. During an observation on 5/6/24 at 11:51a.m., Driver B demonstrated how to load and unload a Resident on the van. One of the straps used to secure the wheelchair would not catch and made the chair feel loose. Observation of a total of 17 straps on the van used to secure residents in wheelchair for transporting, showed 5 of the 17 straps were not functioning correctly. During an interview on 5/6/24 at 12:38pm LVN B said she worked as Resident #2's charge nurse on 4/2/24 during the 7am to 3pm shift, which was the following day after the incident. She said during her rounds Resident #2 complained of pain to several parts of his body and that was unlike him because he rarely complained of pain prior to incident. She said Resident #2 told her the van driver did not strap him in good and his wheelchair had flipped over the previous day in the van on his way to an eye appointment. LVN B said she had not been informed during rounds, and she checked Resident #2's chart to see what had been done regarding the incident, and she did not see anything on his chart other than a statement that Resident #2 asking the LVN C if he had any bruises to his back. LVN B said at that point she notified the NP and ordered an x-ray. She said during her shift Resident #2 appeared tensed and was lying in bed complaining of pain. LVN B said x-rays were done during her shift, and the results came back after her shift, during the 3p to 11p shift. She said she completed a grievance/concern form on behalf of Resident #2 regarding the incident he told her. Record review of the grievance/concern form dated 4/2/24 completed by LVN B on Resident #2 revealed Concern: Wheelchair was not properly secured by driver of facility transport vehicle. After going over railroad tracks Resident #2 was thrown out of the wheelchair onto the floor of vehicle. Being on the floor caused shortness of breath and anxiety to worsen as well as pain from impact with floor. Action Recommended: Driver to round and secure residents then escort to round and double check. Record review of the employee counseling form dated 4/5/24 and completed on 4/8/24 indicated Driver B received a written counseling. Employer Statement: On 4/1/24 during a transport to an appointment, a resident tipped over backwards in his wheelchair and landed on his back in the bus. This incident would not have occurred if the wheelchair had been properly secured. As the driver of the vehicle, Driver B was responsible for ensuring that the residents were secured in place for a safe transport. Performance Expectation: As listed on the driver job description, Driver B was expected to provide safe and timely transportation of residents on both a scheduled an as needed basis. Record review of the facility transportation policy dated April 2024 revealed .9. Wheelchair residents will utilize vehicle lift according to manufacturer instructions. Wheelchairs will be secured per manufacturer instructions. 10. Prior to moving vehicle, driver will personally assure that all riders have been safely secured . 12. In the event of any issue that involves a resident tripping, falling, or becoming unsecured or any other situation that may cause an injury to anyone during transportation, including any vehicle accident, the following procedures will be followed. a) The van will immediately moved to the nearest safe location off the road and emergency flashers are to be turned on. b) The resident or injured person should not be moved. c) The Nursing Supervisor is to be contacted immediately, director of nursing, and/or administrator. d) In the event of an injury or accident 911 is to be called and EMS and/or police to respond as indicated to evaluate the situation. e) Obtain in writing all details of incident, time, locations, and all persons in the vehicle. f) Prior to moving the transportation vehicle driver must ensure all persons are safe. g) Any time an incident occurs during transport that results in wheelchair tipping in any direction or a resident landing on floor of van, EMS is to be called. Resident is to be evaluated at emergency room . Under no circumstances is the resident to continue to be transported by facility vehicle. h) Upon learning of any incident regarding more that basic first aid from bumping against the

Based on interview and record review the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 20 residents (Resident #2) reviewed for clinical records in that. -RN Supervisor G changed contents entered on Resident #2's risk management (incident report). This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication, a delay in services or a potential decline in resident 's health. Findings included: Record review of Resident #2's face sheet, printed on 5/4/24, indicated he was a [AGE] year-old male who admitted on [DATE] with diagnoses including hypertension (blood pressure that is higher than normal), Type 2 diabetes(a chronic condition that happens when you have persistently high blood sugar levels), low back pain( A common, painful condition affecting the lower portion of the spine), and back spasm (sudden tightness and pain in your back muscles). Record review of Resident #2's Progress notes indicated the following: -On 4/1/24 at 2:00pm; completed by LVN C: Resident #2 is leaving via facility transportation at this time to go to an eye appointment. - At 5:15pm; completed by LVN C: Resident #2 asked nurse if he had any discoloration on his back or right shoulder. LVN C nurse did not see any discoloration. A few minutes later a member of transportation went to LVN C and stated that Resident #2 had fallen into his chair when boarding the van. Resident #2 stated that the transportation staff did not strap him in properly on the van. Assessed Resident #2's skin and started neuroes. RN supervisor and NP notified. Resident is his own RP. Record review of Resident #2's incident report dated 4/1/24 completed by LVN C revealed the incident location: Out of Facility / During Transport; Nursing Description: Transportation driver came to RN supervisor and stated that when she took off from a red light she looked up in the mirror and seen resident's legs in the air. She had the rider go check him and she pulled over as fast as she could and they assisted the resident upright and secured wheelchair properly before proceeding to doctor appointment. Resident Description: Resident stated that the transportation staff hadn't strapped him in properly on the van. No Injuries Observed Post Incident. Notes: per resident and transportation staff he hit his back and right shoulder. No discoloration noted at this time. During an interview on 5/6/24 at 10:46 a.m., RN Supervisor G said she normally made corrections to the risk management (incident reports) because that was what she was taught to do by another staff who no longer worked there. She said on 4/1/24 Driver B had come to her about the incident on the van with Resident #2 and she instructed for Driver B to notify LVN C which was Resident #2's charge nurse at the time. RN Supervisor G said on the following day which was 4/2/24 during the clinical morning meeting the team was reviewing Resident #2's risk management and she had to step out so she missed it and had she not missed Resident #2's risk management she could had corrected it at that time, but it was not until 4/3/24 the previous DON went to her about Resident #2's x-ray results and she read over the Nursing description section and it was incorrect. She said LVN C documented Resident #2 had fall during transporting onto the van and she knew that was not what Driver B had told her happened on 4/1/24, so she reentered and corrected the Detail section only to reflect the actual incident of what Driver B had told her. RN Supervisor G said the original note was deleted from risk management once she went back in and made her edits, but the progress note entered by LVN C was what the risk management originally had before she made her changes. Record review of a written statement from RN Supervisor G dated 4/4/24 revealed she was asked .if it was normal to edit another nurse documentation and RN Supervisor G replied was and still is whenever she became ADON the DON at the time trained her and had her check and correct risk managements (incident reports) every morning before clinical meeting. The corrections were generally grammar/spelling related or if she had questions about how something happened, she would call the nurse that opened the risk and then add what they told her. IF they put the skin tear on the right leg but it was really on the left leg, she would correct that. She Never corrected vital signs or pain assessments. If there were names of other residents or staff, she would remove the names and use room numbers or position titles. If there were injuries and they were noted on one page but not on the next she would add it to the second page. If check boxes were not marked that should be then she would add them. The editing was not to change what the nurses said happened, it was to complete and make the risk management paint the correct picture of the incident. She had opened risk managements for charge nurses so that it would put a time stamp on when incident happened, and they would edit and complete it. It was not always just one person working on a risk management and it was not always the person that originally opened it completing anything on it at all. So no, she never thought of editing a risk management wrongful. During an interview on 5/5/24 at 10:07 a.m., with the Administrator and Regional Clinical Consultant. The Administrator said she first learned of the van incident during morning meetings the following morning on 4/2/24, but incident was told differently as if Resident #2 fell while transporting and loading onto the van because that was how the original incident report was documented. She said she did not hear of how the actual van incident occurred and about the fracture until late 4/3/24 whenever the x-ray results came back. The Regional Consultant said she found out about the van incident around 11:00am on 4/3/24. The Administrator said whenever she went to work on 4/4/24 to review the incident report it had been changed and that to reflect Resident #2 wheelchair flipped back when going over a railroad track. The Administrator said on 4/2/24 during clinical morning meetings if she had seen that she would have handle the incident differently and called it in sooner. The Administrator and Regional Clinical Consultant both said they were not aware and did not know a staff could go back in and make changes to the risk management (incident reports) and there was no way of knowing if the document had been edited or changed because unlike a progress note, risk management does not make a strikeout mark indicating edits. They said no staff should be going back into records and making changes without reflecting that changes or edits had been done. During an attempted telephone interview on 5/6/24 at 12:37 p.m., LVN C, was unreachable, a voice message was left; however, there was no return call received. Record review of in-service and signature sheet dated 4/4/24 for RN Supervisor G completed by Regional Clinical Consultant revealed Education on prohibiting change in content entered on risk management. If information is incorrect, you must strike out and restart a new one. Record review of medical records policy dated October 2021 revealed Purpose: The medical record shall contain a representation of the experiences of the resident and include information to provide a picture of the resident's status through complete documentation. Procedure: 1) Licensed staff and interdisciplinary team members shall document observation and services provided in the resident's medical record in accordance with state law. 2) Documentation shall be completed at the time of service, but no later than the shift in which the documentation or care service occurred. 3) When documentation occurs after the fact and outside of the acceptable time limits, the entry shall clearly be indicated as late entry.

Based on interview and record review the facility failed to promptly notify the ordering physician or NP of laboratory results that fell outside the clinical ranges in accordance with facility policies and procedures for notification for 1 of 4 residents reviewed for labs. The facility received lab results for Resident #1's labs on 12/14/23 which indicated his potassium was low. The requesting physician and the NP were not notified. This failure could place residents at risk of delayed treatment/intervention and decline in health. Findings Included: Record review of Resident #1's face sheet dated 1/4/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, high blood pressure, dementia, and mixed high cholesterol. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he was moderately cognitively impaired. The MDS indicated he was independent with all ADLs. Record review of Resident #1's Labs dated 12/9/23 indicated his potassium was 3.2 (normal range 3.5- 4.9) Record Review of Resident #1's physician's order from an outside provider (in the facility computer system) dated 12/7/23 indicated repeat BMP on 12/14/23 for a diagnosis of Hypokalemia (low potassium). Please fax the results to number provided. Record review of a nursing note dated 12/11/23 indicated the family member wanted a copy of Labs drawn at the hospital to be sent to the facility NP for review. There were no new orders at this time. The BMP (Basic Metabolic Panel) was due to be rechecked on 12/14/23 per orders from the hospital. Record review of labs dated 12/14/23 indicated Resident #1's potassium was low at 3.3 (range 3.5 to 4.9) there was no indication they were received or signed off on until 12/21/23. Record review of Resident #1's nursing notes from 12/14/23 to 12/19/23 revealed there was no mention in the nursing notes of the 12/14/23 labs being sent to NP or faxed to the physician requesting the redrawn lab. Record review of the facility root cause analysis dated 1/3/24 (received on 1/4/24 at 2:40 p.m.) indicated Resident #1 had a TURP (surgery used to treat urinary problems that are caused by an enlarged prostate.) surgery scheduled for 12/20/23. The Resident attended a pre-surgery appointment on 12/7/23, and pre-surgical baseline labs were drawn. At that time the surgeon did not order a potassium supplement for this current level of 3.2 potassium level. However, he did request that the potassium level be redrawn on 12/4/23. On 12/11/23 Resident #1's labs were reviewed by the NP. There were no new orders but to continue with the redraw for labs on 12/14/23. On 12/14/23 Resident #1's labs were drawn, and his potassium was 3.3. The lessons learned was all abnormal lab values are to be reported to the NP by phone and documented. The Nurse supervisor will monitor resident with labs pending and if the resident becomes symptomatic. Nursing staff would be educated on the lessons learned. During an interview on 1/4/23 at 12:30 p.m. the Administrator and DON said they could not provide any information that the NP was notified of Resident #1's lab on 12/14/23 with low potassium. During an interview on 1/4/24 at 1:30 p.m. LVN A said that she did not know the Resident #1 had low potassium. She said no one informed her and she did not know anything about Resident #1's labs. During an interview on 1/4/24 At 1:58 p.m. an interview with NP said that she looked at the original labs from the neurologist from 12/9/23. She said she remembered Resident #1's potassium level was 3.2. She said he was scheduled for repeat labs on 12/14/23 and she was fine with that recommendation. The NP said could not confirm that she received the labs for 12/14/23. She did not remember seeing the follow up labs before the resident was discharged . She said the potassium levels are not critical until they are under 3.0. She said if she had seen the labs, she would likely have ordered a repeat, as she did not want to put residents on a supplement until a pattern was established of low potassium labs or the labs were critical. During an interview on 1/4/24 at 3:55 p.m. RN B said she was not aware Resident #1 had low potassium and she was not aware of any labs. Record review of the facility Laboratory Services policy last revised in October 2012 indicated Laboratory services will be performed as ordered by the physician. Record review of the facility Change in Condition Notification policy indicated the Resident's attending physician and representative would be notified of change in resident condition. Situations which would require a change in medication or treatment regimen such as abnormal lab values.

Based on observation, interview, and record review the facility failed to ensure each resident environment remained free of accident hazards as possible and the resident received adequate supervision to prevent accidents for 1 of 6 residents reviewed for accidents. (Resident #2) The facility failed to put interventions in place to prevent accidents regarding Resident #2 that had a history of self-injurious behaviors. Resident #2 tried to harm himself by placing a call light cord around his neck twice on [DATE]. The resident also had a history of throwing himself out of his wheelchair in attempts to himself. The facility failed to ensure: Resident #2's room was free of all harmful items including the call light cord. Resident #2 was provided observation and other interventions to ensure he did not harm himself. Resident #2 was provided with appropriate interventions to prevent or improve his behaviors. The facility failed to ensure care plan interventions were implemented. They failed to notify the physician when the resident exhibited self-injurious behavior. They failed to follow their policy on suicide precautions protocol. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 6:30 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems This failure placed residents at risk for hazards due to lack of adequate supervision with the potential for serious injury and death. Findings included: Record review of Resident #2's face sheet with no date indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were unsteadiness on feet, muscle weakness, personal history of psychological trauma, diabetes, major depression, and PTSD. Record review of Resident #2's quarterly MDS dated [DATE] indicated he had moderate cognitive impairment. He required extensive assistance of two people for transfers and bed mobility. Resident #2 used a wheelchair for ambulation. Record review of Resident #2's care plan dated [DATE] indicted a Focus area of depression. The Goal was the Resident #2 would be free of signs and symptoms of depression. Some of the interventions were contact social services as needed, medications as ordered, observe for change in mental status, observe for signs and symptoms of depression and psychiatric consult as needed. A Focused area of difficulty in psychosocial adjustments related to admission to the facility. One of the interventions was to observe for signs and symptoms of difficulties in psychosocial adjustment, such as decreased socialization, sad mood, verbalized wanted to go home. A Focus area of resident had falls. A fall [DATE] indicated sent to the ER for psychiatric evaluation. A fall [DATE] therapy to screen and treat if indicated. A fall [DATE] anticipate resident needs for transfers, snacks, and toileting. A Focus area of at risk for excessive bruising /bleeding related to aspirin and Plavix use. Some of the interventions were to handle resident gently and observe for signs of bruising. A focused area of the resident required assistance with activities of daily living. Some of the interventions. Were the resident required. Extensive assist of two staff for bed mobility dressing, personal hygiene, toilet use, incontinent care, and transfers. The resident required one person assist of the staff for locomotion around the unit. A Focus area of depression and PTSD. The Resident hallucinated from the war and nightmares. One of the interventions were a psychiatric consult as needed. A Focused area identified on [DATE] indicated the resident has a history of suicide attempts. Referred to inpatient psychiatric services remove any items that could be used to harm from the resident reach such as cords, bags, sharp objects, a safety assessment to be completed by clinical staff upon return of the resident from the hospital. Interventions noted on [DATE] were to ensure the resident had a cow bell or other means of communication if the call light is removed dated and notify the physician as and staff to complete 15-minute checks on Resident daily. During an interview on [DATE] at 12:15p.m. the DON said saw the safety assessment mentioned on the care plan for Resident #2. She said that was not something that nurses did; it may be something the SW completed. She also said she reviewed the care plan for Resident #2 and saw the 15 minutes checks. She said they should still be going on because there was no assessment that said otherwise. However, the Resident #2 was not being monitored. The DON said the SW had monitoring sheets of 15-minute checks done on [DATE] and [DATE]. She said she could not remember what she had done on [DATE] to ensure Resident #2 was safe. She said because at that time she was the only one here and she was over my head. The DON said the Administrator was at conference, ADON, nurse supervisor, and staff development nurse all out with Covid. She said the NP was not notified until the next day and she was not aware of any other residents exhibited suicidal behaviors. She said she did not remember saying anything about making Resident #2 a DNR. The DON said she was not aware of the recommendations made on [DATE] from the psychologist for Resident #2 and they were not done. During an interview on [DATE] at 11:22 a.m. the MDS Coordinator said she put a different care plan intervention in place every time Resident #2 had a fall. He had 4 falls since [DATE]. She said when he came back from the hospital, he had some medical changes and now is not as independent as he once was. She said he was noted to be throwing himself on the floor on [DATE]. She said on [DATE] he said he did not know how he got on the floor. She said the resident is on Paxil and aspirin and they do weekly skin assessments to ensure he had no bruising. She said she had put one of interventions for the suicide was to complete a safety assessment. She said that was nursing 101. She said all they had to do was make sure the room was safe, remove any objects that could cause harm. She said she was just made aware today that the call light cord was still in the room. She said the 15-minute checks intervention was to be removed after the resident and his environment were deemed safe. She said she had no idea that was not completed. Record review of Resident #2's computerized physician orders indicated an order dated [DATE] for Plavix tablet 75 mg (blood thinner) and Aspirin EC 81 mg. An order dated [DATE] indicated refer to counseling services for evaluation and treatment related to depression. An order dated [DATE] for physical therapy to evaluate and treat for therapeutic exercises, therapeutic activities, neuromuscular, reeducation, wheelchair management and modalities. Record review of Resident #2's Psychosocial assessment dated [DATE] indicated this resident was referred with a diagnoses of major depressive disorder, and posttraumatic stress disorder with decreased motivation and elevated anxiety. The resident said he preferred to be alone and called himself an isolate. He had no interest in hobbies or in church before his placement. He tended to avoid the other residents and had no interest in them. His responses supported the inference that he had the capacity for reasoning. The treatment plan was Resident #2 was recommended for psychotherapy with emphasis on redefining grief and loss, anticipating a lengthy period of trust building. Recommended the following for provider prescribing psychotropic medications. Mood or behavioral changes noted by staff be made know to the physician on a timely basis. Recommended therapy to be executed in weekly encounters. Completed by Psychologist contracted by the facility. Record review of Resident #2's nurses note dated [DATE] at 10:29 a.m. indicated was called to Resident # 2 and he was lying on the floor on his right side with head toward the TV. Resident #2 was attempting to self-transfer from the wheelchair to the bed when he fell . He was assisted by three staff members off the floor, and he denied abdominal pain. Written by RN D. Record review of Resident #2's incident report dated [DATE] at 11:00 a.m. indicated. The writer entered the room around 11:00 a.m. the resident was lying in bed with the call light cord wrapped around his nek. This writer removed the call light cord from around his neck and gave him the call light button. He again wrapped the call light cord to his neck. When the write tried to remove the cord form his neck, the resident grabbed my had trying not to let me remove the cord. The writer was able to remove the cord from his neck and put the cord out of his reach. The resident said, I will not be here long. The DON was notified. Immediate Action taken: the writer removed the call light cord from his neck nd put the cord out of his reach and the DON was notified. He was oriented to person, situation, and place. The form was signed by LVN A on [DATE] the form indicated the DON was notified on [DATE] at 11:00 a.m. The NP and responsible party were notified on [DATE] at 11:00 a.m. Completed by LVN A Record review of a Suicide Risk Screen Tool with no date indicated Resident #2 had thoughts of wishing he was dead, his family would be better off without him, thoughts of killing his self and he tried to kill his self. The resident stated he had attempted to end his life twice. His first attempt was wrapping his bed cord around his neck and his second was trying to turn his wheelchair over and hit his head. The resident stated these attempts were yesterday [DATE]. The resident denied wanting to kill himself today. The patient required a brief suicide safety assessment to determine if a full mental health evaluation is needed. Completed by the SW. Record review of Resident #2's 1 (one) hour monitoring tool indicated he was monitored every hour from 11 a.m. on [DATE] to 11:00 a.m. on [DATE]. The monitoring tool was not located in the computer file. They were provided on [DATE] at 1:30 p.m. by the SW Record review of social services note dated [DATE] at 3:53 p.m. indicated SW was just informed by clinical staff that Resident #2 had made two attempts to kill himself yesterday. The SW immediately went to Resident #2 's room to perform a suicide screening. Resident #2 to stated that he did try to kill himself two times yesterday once by wrapping the called light cord around his neck to hang himself. He said in the other attempt was he was trying to turn over his wheelchair to hit his head on the floor. Resident #2 had been isolating the past two weeks and had been experiencing an increase in depressive symptoms. The resident stated he ws not currently suicidal but is open to hospitalization . SW faxed Resident #2 clinical information's to the behavioral hospital awaiting update on admission for inpatient psychiatric services, the social worker will also contact Resident #2's family with an update. Signed by the SW. Record review of Resident #2's nursing note dated [DATE] at 4:19 p.m. entitled late entry for a note dated [DATE] at 11:00 a.m. This writer entered Resident #2's room around 11 to take vitals and blood pressure blood glucose. The resident was lying in bed with a cord wrapped around his neck. This writer removed the cord from his neck and gave him the call button. He again wrapped the call light cord to his neck. When this writer tried to remove the cord from around his neck, there is a grabbed my hand, trying not to let me remove the cord. This writer was able to remove the cord from his neck and put the cord out of his reach. The DON was notified signed by LVN A. Record review of Resident #2's nursing note dated [DATE] at 5:14 p.m. indicated the resident was denied admission to the behavioral hospital. He will be sent to the local hospital for a psychiatric evaluation due to suicidal ideations in attempted suicide on yesterday by wrapping the quarter round is neck. The social worker currently contacting the staff at the local hospital to give report and discuss a need for immediate and urgent, psychiatric evaluation and placement, the resident had admitted to being suicidal in both attempts and wanted help. The resident is willing and agreeable with inpatient treatment currently. Record review of Resident #2's hospital psychiatric consult dated [DATE] at 10:36 p.m. indicated Resident #2 presented to the ER with a history of depression, schizophrenia presenting following a suicide attempt he has extensive medical history with severe debility and neurocognitive deficits. It is difficult to perform a complete psychiatric eval, given his memory impairments and aphasia. He did report depressive symptoms along with his suicide attempt yesterday in the contacts of recent family stressors. It seemed many of the symptoms had been ongoing for some time. His chart showed he was only taking Zoloft 50 mg and he denied taking any other psychiatric medications recently. Finding placement for him will likely take some time since he is completely dependent upon staff for ADLs. We will continue to monitor him and monitor his progress daily disposition given intimate risk outside of a secure environment. Recommended inpatient psychiatric admission once medically cleared. It was reported the resident was transferred from the nursing home after attempting suicide by wrapping a cord around his neck and falling from his wheelchair. The patient does not deny that he was did that thing. He said he was a suicidal but stated he is no longer having suicidal ideations now. He reported that he wanted to hurt himself because he was tired of sitting around and doing nothing all day. He stated that he had these thoughts recently for recurrently for several years, but he could not say exactly how long. The resident said he had no previous suicide attempts and stated he would not try. If he returned home, and he reported auditory hallucinations. He reported that these hallucinations revolve around light at the end of the tunnel, but they did not tell him to harm his himself. He has had recent stressors of his family member taking his money. The resident reported occasional hopelessness, and he reported auditory hallucinations 2 to 3 times a month regarding going down a tunnel but is unable to elaborate. He also reported visual hallucinations of his deceased mom for the past [AGE] years he denied these hallucinations as being distressful and stated they are not related to his attempt. He said he was diagnosed with schizophrenia three years ago and said the voices started after he had a heart attack. The resident had three suicide attempts. His suicidal screen indicated that he was a high risk for suicide. His judgment was poor. He is unable to perform self-care and ADLs without assistance. His insight was in poor condition, his coping skills and reasoning reasons for continuing living comments. The patient is cooperative on exam but can become irritable when discussing his life at the nursing home. Given the patient age and some inconsistencies in his history and personal information between the patient in the nursing home, raising suspicion of the contributory factors from possible dementia there is a high suspicion of depressive origins due to the patient's history of major depressive disorder, decreased concentration, suicidal ideation/attempts, hallucinations, raise, concerns of depression, with psychotic features. The resident was placed on suicide precautions. Record review of Resident #2's history and physical dated [DATE] at 2:53 p.m. indicated that a psychiatric consult was performed on the patient while he was in the emergency roiagnom on ,d+[DATE] /23 with repeat visits by the inpatient psychiatric team on [DATE] and [DATE]. It was recommended inpatient psychiatric admission for the patient when medically cleared. He was admitted today into inpatient due to mental status and for emerging atrial fibrillation. Geriatric psychiatric unit here at the hospital is unable to take the patient due to his condition. Record review of a nursing note dated [DATE] at 1:27 PM. Indicated Resident #2 remained in the ER at the local hospital at this time. The staff at the hospital currently trying to find placement for him due to active hallucinations and suicidal ideations, as well as multiple attempted suicides. The ER staff have not been able to place this resident due to physical/medical limitations of mobility. The medical records from the ER stay were obtained as well as his current face sheet, medication list, and previous records have been provided to the VA land board representative to assist with placement for the resident as well. Per the ER staff the resident is calm and compliant at this time and he admitted , his attempts, and he continued to want help with the issues and will sign a voluntary for inpatient psychiatric treatment. Signed by RN D Record review of Resident #2's nursing note dated [DATE] at 10:00 a.m. indicated the RN called a local hospital and spoke with a nurse who reported on yesterday they were still waiting on psychiatric placement for Resident #2 however, had medical episode, and then he was admitted medically at the hospital the admitting MD included suicidal ideations in his diagnosis and he will be seen by psychiatric services during his admission. At this time, it is expected to be a 3-to-5-day admission due to the onset of arrhythmia( improper beating of the heart). Signed by RN D Record review of Resident #2 's nurses note dated [DATE] at 10:02 a.m. indicated a report received from the doctor at the local hospital physician said that the psychiatrist has signed off on the residence discharge and it will take a few days to weeks for the resident to return to baseline. They feel medical status was related to dementia and delirium, causing suicidal ideations. The resident has been on one-to-one observation the doctor recommended returning to the home facility for removal of potential harmful items no access to linens, at risk items, and frequent checks every 2-to-3-hour checks. The resident continued Zoloft, Abilify discontinued, potassium and magnesium a little low so supplement, recommend it with repeat lab in one week. The DON was notified and approved the return of the Resident with Resident up a wheelchair without one-to-one supervision, the hospital to arrange transport. Signed by RN H Record review of Resident #2 's nurses note dated [DATE] at 1:10 p.m. indicated the resident retuned to the facility from the hospital. Signed by LVN A Record review of Resident #2 's nurses note dated [DATE] indicated the resident was found unresponsive and sent to the hospital. Signed by LVN Z Record review of Resident #2 's nurses note dated [DATE] at 9:46 p.m. indicated the resident retuned to the facility due to a diagnosis of acute encephalopathy(functional alteration of mental status due to systemic factors). At 11:37 p.m. the resident was placed on suicide protocol of every 15 min checks. Signed by RN Record review of Resident #2 's nurses note dated [DATE] at 3:38 p.m. indicated frequent visual checks done and monitor for suicidal thoughts and behaviors. (last mention of suicidal monitoring) signed LVN A Record review of Resident #2's 15-minute monitoring sheets from [DATE] starting at 9:45 p.m. to [DATE] at 8:00 p.m. Record review of Resident #2's incident report dated [DATE] at 4:00 p.m. indicated the DON was called by the charge nurse to report Resident #2 had fallen. The resident was lying on the floor in his room with his head towards the floor and the feet toward the bed. On the floor was the resident's remote control and a water bottle. The resident stated that he lost his balance and fell out of the wheelchair attempting to pick up his tv remote off the floor. A head-to-toe assessment was conducted with no injuries noted, the resident was assisted off the floor into bed, initiated neuro checks, and notified responsible party of fall with no injuries. Record review of Resident #2's incident report dated [DATE] at 3:00 p.m. indicated the was called to the room with Resident #2 lying on the floor next to the bed. Ensure they initiated the facility policy of suicide precautions, the resident said he was getting up. The resident was assessed, and neuros and vital signs taken. Record review of Resident #2's a Fall Risk Screen dated [DATE] at 1:46 p.m. indicated the resident had falls on [DATE] and [DATE] and was identified as high risk for falls. The comments were Resident #2 did not know his limitations Record review of Resident #2's Post Fall Assessment form with a lock date of [DATE] at 4:10 p.m. Record review of Resident#2's fall on [DATE] at 1:00 p.m. The resident said he didn't know how it happened. He was getting up from the wheelchair, he received a skin tear to the left elbow and the nurse practitioner was notified and the responsible party. The care plan review indicated it was an intentional fall due to being mad at family interventions and recommendations. Post fall was one hour observation checks initiated on [DATE] into monitor for signs and symptoms of hallucinations and flashbacks initiate Q1 hour observation sheet the potential interventions were assistive, mobile device, wheelchair, positioning/seating device, elevation, evaluation of footwear, elevation of hide the bed, change in footwear, nightlight, bed in lowest position, recline chair, mechanical lift for transfer, toileting, schedule, therapy , safety cues, reinforce reminders, assistive devices within reach, signage, stop sign, evaluate timing of medication's, occupational therapy, daily nap, restorative program, psychiatric evaluation, medical evaluation, anti-tippers, pain assessment, body pillows for positioning, wider mattress, drop seat in wheelchair, anti-roll back brakes, wheelchair, break, extensions with tops, painted orange for additional visual cues, medication review, and evaluate activity program and encourage participation. The care plan had been updated and addendum indicated. Risk factors included multiple recent and previous falls, current flashbacks/hallucinations, previous intentional falls due to suicidal ideations, and anger towards family. During the IDT review, it was determined that the root cause of the fall was due to flashbacks/intentional falling to the anger with the family member. Resident number two admitted throwing himself on the floor due to anger and admitted to having current flashbacks to war/hallucinations, intervention/care plans, updated and documented above. Record review of Resident #2 's nurses note dated [DATE] at 10:34 a.m. indicated it was reported to this RN the resident fall on [DATE] was most likely purposeful due to anger and another attempt to harm himself. This resident spoke with his family member just prior to his fall. The family member said they were not coming to visit that day. The resident was very angry and upset. This resident has also stated in the past that he throws himself from his wheelchair on purpose to inflict harm on himself. The fall occurred immediately after he spoke to the family member. It was his third fall within this past week. The resident told the SW he was not trying to hurt himself. However, her had a smirk on his face and laughed during the evaluation. A cowbell was placed in the resident's room for use as a call light system. Th maintenance was contacted to assist staff in making the room safe and safely removed the old call light. Signed by RN D. Record review of Resident #2's social service note created on [DATE] at 11:07 a.m. titles late entry for [DATE] at 10:03 a.m. indicated the SW spoke with Resident #2 to inquire on whether his recent falls were an attempt for self-harm or [NAME] as the resident has historically caused falls as an attempt to self-harm. Resident #2 stated he did not try to hurt himself. He denied having any suicidal indication. The resident stated, I am in a better mindset. SW encouraged the resident to let staff know if his mental health starts to decline. The SW will continue to monitor the resident for behaviors. Signed by the SW Record review of Resident #2's social services note dated [DATE] at 11:21 a.m. indicated Resident to be evaluate for counseling though the VA on [DATE] at 9:00 a.m. During an interview on [DATE] at 2:00 p.m. the SW said on [DATE] she was told by multiple staff that on Monday, [DATE] Resident #2 wrapped a cord around his neck and said he wanted to die. The SW said she was off on [DATE] but when she returned to work on [DATE] the only thing that was said about Resident #2 in the morning meeting was the DON said to look at making him a DNR. The SW said an ECA reported to RN D that Resident #2 had tried to kill himself the day before, and they got sent him out to the hospital. She said there were issues with care dynamic with his family member a few months ago, he got really depressed. She said she did a referral for psychological services at that time. The SW said she asked Resident #2 today if he was suicidal and he was very sarcastic, but said no. He went to the hospital but was not admitted to the Behavioral health due to physical and medical issues. She said he received weekly counseling, but she did not know how that was going. During an interview on [DATE] at 2:35 p.m. with RN D said Resident #2 had two suicide attempts on Monday, [DATE]. They were not informed about the suicide. The only thing that was brought up in the Morning meeting regarding Resident #2 was the DON wanted to make him a DNR. She said the DON was aware of the attempted suicide and did not put any interventions into place. She said LVN A was the nurse that was on duty on [DATE]. RN D said LVN A did not complete a nursing note or incident report until instructed to do so on [DATE]. RN D said LVN A said Resident #2 wrapped the call light cord around his neck, and she told the DON. She said LVN A said she was not given any instruction of what to do or how to procced with Resident #2. RN D said she called the SW on [DATE], and she came and did a suicide screen. She said the SW contacted the Behavior Health Hospital and Resident #2 was sent to the local hospital for a medical clearance to be admitted to the Behavior Health unit. RN D said on today [DATE] they removed all sharps from his room. She said they gave Resident #2 a call bell and moved the call light out of his reach. She said she had requested help from Maintenance to remove Resident #2's call light cord from the room, they had tried to remove the call light but was unable to without it continuously beeping. She said maintenance told her to push the reset button and did not come and remove the call light cord. She said she had told him his directions did not work. RN D said Resident#2 was agitated today because were trying to remove things from his room. She said he had been depressed for a while. She said he is often depressed around Christmas because he lost several family members around Christmas. RN D said she had gotten reports that Resident #2 was depressed, and they got counseling for him. She said she did not know exactly what lead to the attempt on [DATE]. RN D said Resident #2 often gets upset with the family member and acted out. She said Resident # 2 had put himself on the floor on yesterday per staff reports after having an issue with the family member. RN D said they asked him today if he wanted to hurt himself, he said no but was sarcastic with his remark. During an interview on [DATE] at 2:50 a.m. LVN E said he had worked at the facility for 1 year. He said Resident #2 had moments that he appeared depressed. He said he had not voiced any suicidal thoughts to him. He said he thought part of his problems with his falls was he did not know his limitations. During an interview and observation on [DATE] at 2:55 p.m. observation of Resident #2 showed him in bed and the bed was at waist height, there was a mat on the floor. Resident #2 said he did not want to die. He said that he wrapped the cord around his neck to prove to them that he could do it. He could not explain what he meant by them. He answered questions with appropriate answers and facial expressions. Observation of the room showed the call light was present. It was behind the bed; however, Resident #2 had a grabber on his table that would assist him to reach it. There was also a long cord connected to the electric lift over the bed the cord was between 6 to 9 feet long plugged into the wall by his bed. He said he was not throwing his self on the floor to hurt his self. Resident #2 said he just fell , and he did not know why. Said he was not feeling well, he was eating okay, and sleeping okay. He said he did not like to attend activities he was a loner and mostly liked to stay to himself. He said had his tv and his computer. He said he was depressed sometimes and would like to have someone to talk to about his issues. The resident said he had not talked to a counselor but would like to. During an interview on [DATE] at 3:10 p.m. ECA F said she was not here when Resident #2 put the cord around his neck. She said Resident #2 had put himself on the floor a few times. He would get mad with his family member either they would not come to visit, not answer the phone or something that would make him mad. She said on yesterday the family member would not answer the phone, or said something he did not like, and he wound up on the floor. She said he had just gone into his room. He was barley in the door, and he was on the floor. ECA F said Resident #2 had temper tantrums when did not get his way. She said Resident #2 did say he did not want to be here on occasion. She said he cannot stand up and he is a Hoyer lift transfer. She said Resident #2 puts his bed up high even when we tell him to keep it low. ECA F said Resident #2 had a fall mat on the floor, in July he told me he would not be here long. She said they moved all his sharps and things in the bathroom, and Resident #2 cannot get them without assistance. She said they gave him a call bell if he needs anything, but the call light is still in the room. During an interview on [DATE] at 3:20 p.m. ESA L said Resident #2 had not told her he wanted to die. She said sometimes he said he want to go, get out of here, and he talked of going home to Arkansas or Oklahoma. She said the normal behavior for Resident #2 was agitated. he will throw cups and tables. ECA L said for last two months he had been a little nicer, spend most time in the room. She said they told her he had a cord around his neck, but did not see it. During an interview on [DATE]at 3:24 p.m. ECA R said she worked here one year and said that Resident #2 was lonely. She said his family member used come a lot but does not anymore. She said he got mad at the family member and would be depressed. She said when he is depressed, he just looks sad and disconnected from everything. ECA R said Resident #2 did not interact much with the others, but he did show some difference in his moods. She said she was told in July Resident # 2 wrapped the cord around his neck, but he said nothing to her about wanting to die. ECA R said Resident #2 did throw temper tantrums and would throw his self out of chair at times. ECA R said she did not know if he was just angry or trying to hurt himself for attention. She said when asked how did you fall or why did you fall Resident #2 would say thing like I just fell . During an interview on [DATE] at 4:05 p.m. the Maintenance Director said he was informed this morning that they wanted to remove the call light in Resident #2's room. He told whoever called him what to do to remove it. He said they called him about it still ringing when the cord was removed. He told them to just press reset button. He had not gone to check it out and he had not sent any of his guys to look at the issue. He said he did not know if the call light was still there or not. <br [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure each resident received necessary behavioral health care services to maintain the highest practicable mental and psychosocial wellbeing for 1 of 6 residents reviewed for behavioral services. (Resident #2) The facility failed to: Ensure psychological services were provided as ordered by the physician Intervene and provide safety measures on [DATE] when Resident #2 tried to kill himself. He wrapped a call light cord around his neck twice and threw himself from the wheelchair. Ensure they initiated the facility policy on Suicide Precautions. Have a interventions and a system in place to monitor Resident #2's behaviors when he began to exhibit harmful behaviors of throwing his self on the floor. Ensure Resident #2's care plan interventions were followed such as continued 15-minute morning, a safety assessment. Ensure the physician was aware of his self-injurious behaviors. Ensure the call light cord was removed and out of his reach after the resident used it twice by wrapping it around his neck. It was removed on [DATE] after surveyor intervention. Facility failed to put interventions in place after the resident returned from the hospital to address his behavioral health needs. An Immediate Jeopardy (IJ) situation was identified on [DATE] p.m. While the IJ was removed on [DATE] at 6:30 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for lack of behavioral health services with the potential for serious injury and death. Findings included: Record review of Resident #2's face sheet with no date indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were unsteadiness on feet, muscle weakness, personal history of psychological trauma, diabetes, major depression, and PTSD. Record review of Resident #2's quarterly MDS dated [DATE] indicated he had moderate cognitive impairment. He required extensive assistance of two people for transfers and bed mobility. Resident #2 used a wheelchair for ambulation. Record review of Resident #2's care plan dated [DATE] indicted a Focus area of depression. The Goal was the Resident #2 would be free of signs and symptoms of depression. Some of the interventions were contact social services as needed, medications as ordered, observe for change in mental status, observe for signs and symptoms of depression and psychiatric consult as needed. A Focused area of difficulty in psychosocial adjustments related to admission to the facility. One of the interventions was to observe for signs and symptoms of difficulties in psychosocial adjustment, such as decreased socialization, sad mood, verbalized wanted to go home. A Focus area of resident had falls. A fall [DATE] indicated sent to the ER for psychiatric evaluation. A fall [DATE] therapy to screen and treat if indicated. A fall [DATE] anticipate resident needs for transfers, snacks, and toileting. A Focus area of at risk for excessive bruising /bleeding related to aspirin and Plavix use. Some of the interventions were to handle resident gently and observe for signs of bruising. A focused area of the resident required assistance with activities of daily living. Some of the interventions. Were the resident required. Extensive assist of two staff for bed mobility dressing, personal hygiene, toilet use, incontinent care, and transfers. The resident required one person assist of the staff for locomotion around the unit. A Focus area of depression and PTSD. The Resident hallucinated from the war and nightmares. One of the interventions were a psychiatric consult as needed. A Focused area identified on [DATE] indicated the resident has a history of suicide attempts. Referred to inpatient psychiatric services remove any items that could be used to harm from the resident reach such as cords, bags, sharp objects, a safety assessment to be completed by clinical staff upon return of the resident from the hospital. Interventions noted on [DATE] were to ensure the resident had a cow bell or other means of communication if the call light is removed dated and notify the physician as and staff to complete 15-minute checks on Resident daily. During an interview on [DATE] at 12:15p.m. the DON said saw the safety assessment mentioned on the care plan for Resident #2. She said that was not something that nurses did; it may be something the SW completed. She also said she reviewed the care plan for Resident #2 and saw the 15 minutes checks. She said they should still be going on because there was no assessment that said otherwise. However, the Resident #2 was not being monitored. The DON said the SW had monitoring sheets of 15-minute checks done on [DATE] and [DATE]. She said she could not remember what she had done on [DATE] to ensure Resident #2 was safe. She said because at that time she was the only one here and she was over my head. The DON said the Administrator was at conference, ADON, nurse supervisor, and staff development nurse all out with Covid. She said the NP was not notified until the next day and she was not aware of any other residents exhibited suicidal behaviors. She said she did not remember saying anything about making Resident #2 a DNR. The DON said she was not aware of the recommendations made on [DATE] from the psychologist for Resident #2 and they were not done. During an interview on [DATE] at 11:22 a.m. the MDS Coordinator said she put a different care plan intervention in place every time Resident #2 had a fall. He had 4 falls since [DATE]. She said when he came back from the hospital, he had some medical changes and now is not as independent as he once was. She said he was noted to be throwing himself on the floor on [DATE]. She said on [DATE] he said he did not know how he got on the floor. She said the resident is on Paxil and aspirin and they do weekly skin assessments to ensure he had no bruising. She said she had put one of interventions for the suicide was to complete a safety assessment. She said that was nursing 101. She said all they had to do was make sure the room was safe, remove any objects that could cause harm. She said she was just made aware today that the call light cord was still in the room. She said the 15-minute checks intervention was to be removed after the resident and his environment were deemed safe. She said she had no idea that was not completed. Record review of Resident #2's computerized physician orders indicated an order dated [DATE] for Plavix tablet 75 mg (blood thinner) and Aspirin EC 81 mg. An order dated [DATE] indicated refer to counseling services for evaluation and treatment related to depression. An order dated [DATE] for physical therapy to evaluate and treat for therapeutic exercises, therapeutic activities, neuromuscular, reeducation, wheelchair management and modalities. Record review of Resident #2's Psychosocial assessment dated [DATE] indicated this resident was referred with a diagnoses of major depressive disorder, and posttraumatic stress disorder with decreased motivation and elevated anxiety. The resident said he preferred to be alone and called himself an isolate. He had no interest in hobbies or in church before his placement. He tended to avoid the other residents and had no interest in them. His responses supported the inference that he had the capacity for reasoning. The treatment plan was Resident #2 was recommended for psychotherapy with emphasis on redefining grief and loss, anticipating a lengthy period of trust building. Recommended the following for provider prescribing psychotropic medications. Mood or behavioral changes noted by staff be made know to the physician on a timely basis. Recommended therapy to be executed in weekly encounters. Completed by Psychologist contracted by the facility. Record review of Resident #2's nurses note dated [DATE] at 10:29 a.m. indicated was called to Resident # 2 and he was lying on the floor on his right side with head toward the TV. Resident #2 was attempting to self-transfer from the wheelchair to the bed when he fell . He was assisted by three staff members off the floor, and he denied abdominal pain. Written by RN D. Record review of Resident #2's incident report dated [DATE] at 11:00 a.m. indicated. The writer entered the room around 11:00 a.m. the resident was lying in bed with the call light cord wrapped around his nek. This writer removed the call light cord from around his neck and gave him the call light button. He again wrapped the call light cord to his neck. When the write tried to remove the cord form his neck, the resident grabbed my had trying not to let me remove the cord. The writer was able to remove the cord from his neck and put the cord out of his reach. The resident said, I will not be here long. The DON was notified. Immediate Action taken: the writer removed the call light cord from his neck nd put the cord out of his reach and the DON was notified. He was oriented to person, situation, and place. The form was signed by LVN A on [DATE] the form indicated the DON was notified on [DATE] at 11:00 a.m. The NP and responsible party were notified on [DATE] at 11:00 a.m. Completed by LVN A Record review of a Suicide Risk Screen Tool with no date indicated Resident #2 had thoughts of wishing he was dead, his family would be better off without him, thoughts of killing his self and he tried to kill his self. The resident stated he had attempted to end his life twice. His first attempt was wrapping his bed cord around his neck and his second was trying to turn his wheelchair over and hit his head. The resident stated these attempts were yesterday [DATE]. The resident denied wanting to kill himself today. The patient required a brief suicide safety assessment to determine if a full mental health evaluation is needed. Completed by the SW. Record review of Resident #2's 1 (one) hour monitoring tool indicated he was monitored every hour from 11 a.m. on [DATE] to 11:00 a.m. on [DATE]. The monitoring tool was not located in the computer file. They were provided on [DATE] at 1:30 p.m. by the SW Record review of social services note dated [DATE] at 3:53 p.m. indicated SW was just informed by clinical staff that Resident #2 had made two attempts to kill himself yesterday. The SW immediately went to Resident #2 's room to perform a suicide screening. Resident #2 to stated that he did try to kill himself two times yesterday once by wrapping the called light cord around his neck to hang himself. He said in the other attempt was he was trying to turn over his wheelchair to hit his head on the floor. Resident #2 had been isolating the past two weeks and had been experiencing an increase in depressive symptoms. The resident stated he ws not currently suicidal but is open to hospitalization . SW faxed Resident #2 clinical information's to the behavioral hospital awaiting update on admission for inpatient psychiatric services, the social worker will also contact Resident #2's family with an update. Signed by the SW. Record review of Resident #2's nursing note dated [DATE] at 4:19 p.m. entitled late entry for a note dated [DATE] at 11:00 a.m. This writer entered Resident #2's room around 11 to take vitals and blood pressure blood glucose. The resident was lying in bed with a cord wrapped around his neck. This writer removed the cord from his neck and gave him the call button. He again wrapped the call light cord to his neck. When this writer tried to remove the cord from around his neck, there is a grabbed my hand, trying not to let me remove the cord. This writer was able to remove the cord from his neck and put the cord out of his reach. The DON was notified signed by LVN A. Record review of Resident #2's nursing note dated [DATE] at 5:14 p.m. indicated the resident was denied admission to the behavioral hospital. He will be sent to the local hospital for a psychiatric evaluation due to suicidal ideations in attempted suicide on yesterday by wrapping the quarter round is neck. The social worker currently contacting the staff at the local hospital to give report and discuss a need for immediate and urgent, psychiatric evaluation and placement, the resident had admitted to being suicidal in both attempts and wanted help. The resident is willing and agreeable with inpatient treatment currently. Record review of Resident #2's hospital psychiatric consult dated [DATE] at 10:36 p.m. indicated Resident #2 presented to the ER with a history of depression, schizophrenia presenting following a suicide attempt he has extensive medical history with severe debility and neurocognitive deficits. It is difficult to perform a complete psychiatric eval, given his memory impairments and aphasia. He did report depressive symptoms along with his suicide attempt yesterday in the contacts of recent family stressors. It seemed many of the symptoms had been ongoing for some time. His chart showed he was only taking Zoloft 50 mg and he denied taking any other psychiatric medications recently. Finding placement for him will likely take some time since he is completely dependent upon staff for ADLs. We will continue to monitor him and monitor his progress daily disposition given intimate risk outside of a secure environment. Recommended inpatient psychiatric admission once medically cleared. It was reported the resident was transferred from the nursing home after attempting suicide by wrapping a cord around his neck and falling from his wheelchair. The patient does not deny that he was did that thing. He said he was a suicidal but stated he is no longer having suicidal ideations now. He reported that he wanted to hurt himself because he was tired of sitting around and doing nothing all day. He stated that he had these thoughts recently for recurrently for several years, but he could not say exactly how long. The resident said he had no previous suicide attempts and stated he would not try. If he returned home, and he reported auditory hallucinations. He reported that these hallucinations revolve around light at the end of the tunnel, but they did not tell him to harm his himself. He has had recent stressors of his family member taking his money. The resident reported occasional hopelessness, and he reported auditory hallucinations 2 to 3 times a month regarding going down a tunnel but is unable to elaborate. He also reported visual hallucinations of his deceased mom for the past [AGE] years he denied these hallucinations as being distressful and stated they are not related to his attempt. He said he was diagnosed with schizophrenia three years ago and said the voices started after he had a heart attack. The resident had three suicide attempts. His suicidal screen indicated that he was a high risk for suicide. His judgment was poor. He is unable to perform self-care and ADLs without assistance. His insight was in poor condition, his coping skills and reasoning reasons for continuing living comments. The patient is cooperative on exam but can become irritable when discussing his life at the nursing home. Given the patient age and some inconsistencies in his history and personal information between the patient in the nursing home, raising suspicion of the contributory factors from possible dementia there is a high suspicion of depressive origins due to the patient's history of major depressive disorder, decreased concentration, suicidal ideation/attempts, hallucinations, raise, concerns of depression, with psychotic features. The resident was placed on suicide precautions. Record review of Resident #2's history and physical dated [DATE] at 2:53 p.m. indicated that a psychiatric consult was performed on the patient while he was in the emergency roiagnom on ,d+[DATE] /23 with repeat visits by the inpatient psychiatric team on [DATE] and [DATE]. It was recommended inpatient psychiatric admission for the patient when medically cleared. He was admitted today into inpatient due to mental status and for emerging atrial fibrillation. Geriatric psychiatric unit here at the hospital is unable to take the patient due to his condition. Record review of a nursing note dated [DATE] at 1:27 PM. Indicated Resident #2 remained in the ER at the local hospital at this time. The staff at the hospital currently trying to find placement for him due to active hallucinations and suicidal ideations, as well as multiple attempted suicides. The ER staff have not been able to place this resident due to physical/medical limitations of mobility. The medical records from the ER stay were obtained as well as his current face sheet, medication list, and previous records have been provided to the VA land board representative to assist with placement for the resident as well. Per the ER staff the resident is calm and compliant at this time and he admitted , his attempts, and he continued to want help with the issues and will sign a voluntary for inpatient psychiatric treatment. Signed by RN D Record review of Resident #2's nursing note dated [DATE] at 10:00 a.m. indicated the RN called a local hospital and spoke with a nurse who reported on yesterday they were still waiting on psychiatric placement for Resident #2 however, had medical episode, and then he was admitted medically at the hospital the admitting MD included suicidal ideations in his diagnosis and he will be seen by psychiatric services during his admission. At this time, it is expected to be a 3-to-5-day admission due to the onset of arrhythmia( improper beating of the heart). Signed by RN D Record review of Resident #2 's nurses note dated [DATE] at 10:02 a.m. indicated a report received from the doctor at the local hospital physician said that the psychiatrist has signed off on the residence discharge and it will take a few days to weeks for the resident to return to baseline. They feel medical status was related to dementia and delirium, causing suicidal ideations. The resident has been on one-to-one observation the doctor recommended returning to the home facility for removal of potential harmful items no access to linens, at risk items, and frequent checks every 2-to-3-hour checks. The resident continued Zoloft, Abilify discontinued, potassium and magnesium a little low so supplement, recommend it with repeat lab in one week. The DON was notified and approved the return of the Resident with Resident up a wheelchair without one-to-one supervision, the hospital to arrange transport. Signed by RN H Record review of Resident #2 's nurses note dated [DATE] at 1:10 p.m. indicated the resident retuned to the facility from the hospital. Signed by LVN A Record review of Resident #2 's nurses note dated [DATE] indicated the resident was found unresponsive and sent to the hospital. Signed by LVN Z Record review of Resident #2 's nurses note dated [DATE] at 9:46 p.m. indicated the resident retuned to the facility due to a diagnosis of acute encephalopathy(functional alteration of mental status due to systemic factors). At 11:37 p.m. the resident was placed on suicide protocol of every 15 min checks. Signed by RN Record review of Resident #2 's nurses note dated [DATE] at 3:38 p.m. indicated frequent visual checks done and monitor for suicidal thoughts and behaviors. (last mention of suicidal monitoring) signed LVN A Record review of Resident #2's 15-minute monitoring sheets from [DATE] starting at 9:45 p.m. to [DATE] at 8:00 p.m. Record review of Resident #2's incident report dated [DATE] at 4:00 p.m. indicated the DON was called by the charge nurse to report Resident #2 had fallen. The resident was lying on the floor in his room with his head towards the floor and the feet toward the bed. On the floor was the resident's remote control and a water bottle. The resident stated that he lost his balance and fell out of the wheelchair attempting to pick up his tv remote off the floor. A head-to-toe assessment was conducted with no injuries noted, the resident was assisted off the floor into bed, initiated neuro checks, and notified responsible party of fall with no injuries. Record review of Resident #2's incident report dated [DATE] at 3:00 p.m. indicated the was called to the room with Resident #2 lying on the floor next to the bed. Ensure they initiated the facility policy of suicide precautions, the resident said he was getting up. The resident was assessed, and neuros and vital signs taken. Record review of Resident #2's a Fall Risk Screen dated [DATE] at 1:46 p.m. indicated the resident had falls on [DATE] and [DATE] and was identified as high risk for falls. The comments were Resident #2 did not know his limitations Record review of Resident #2's Post Fall Assessment form with a lock date of [DATE] at 4:10 p.m. Record review of Resident#2's fall on [DATE] at 1:00 p.m. The resident said he didn't know how it happened. He was getting up from the wheelchair, he received a skin tear to the left elbow and the nurse practitioner was notified and the responsible party. The care plan review indicated it was an intentional fall due to being mad at family interventions and recommendations. Post fall was one hour observation checks initiated on [DATE] into monitor for signs and symptoms of hallucinations and flashbacks initiate Q1 hour observation sheet the potential interventions were assistive, mobile device, wheelchair, positioning/seating device, elevation, evaluation of footwear, elevation of hide the bed, change in footwear, nightlight, bed in lowest position, recline chair, mechanical lift for transfer, toileting, schedule, therapy , safety cues, reinforce reminders, assistive devices within reach, signage, stop sign, evaluate timing of medication's, occupational therapy, daily nap, restorative program, psychiatric evaluation, medical evaluation, anti-tippers, pain assessment, body pillows for positioning, wider mattress, drop seat in wheelchair, anti-roll back brakes, wheelchair, break, extensions with tops, painted orange for additional visual cues, medication review, and evaluate activity program and encourage participation. The care plan had been updated and addendum indicated. Risk factors included multiple recent and previous falls, current flashbacks/hallucinations, previous intentional falls due to suicidal ideations, and anger towards family. During the IDT review, it was determined that the root cause of the fall was due to flashbacks/intentional falling to the anger with the family member. Resident number two admitted throwing himself on the floor due to anger and admitted to having current flashbacks to war/hallucinations, intervention/care plans, updated and documented above. Record review of Resident #2 's nurses note dated [DATE] at 10:34 a.m. indicated it was reported to this RN the resident fall on [DATE] was most likely purposeful due to anger and another attempt to harm himself. This resident spoke with his family member just prior to his fall. The family member said they were not coming to visit that day. The resident was very angry and upset. This resident has also stated in the past that he throws himself from his wheelchair on purpose to inflict harm on himself. The fall occurred immediately after he spoke to the family member. It was his third fall within this past week. The resident told the SW he was not trying to hurt himself. However, her had a smirk on his face and laughed during the evaluation. A cowbell was placed in the resident's room for use as a call light system. Th maintenance was contacted to assist staff in making the room safe and safely removed the old call light. Signed by RN D. Record review of Resident #2's social service note created on [DATE] at 11:07 a.m. titles late entry for [DATE] at 10:03 a.m. indicated the SW spoke with Resident #2 to inquire on whether his recent falls were an attempt for self-harm or [NAME] as the resident has historically caused falls as an attempt to self-harm. Resident #2 stated he did not try to hurt himself. He denied having any suicidal indication. The resident stated, I am in a better mindset. SW encouraged the resident to let staff know if his mental health starts to decline. The SW will continue to monitor the resident for behaviors. Signed by the SW Record review of Resident #2's social services note dated [DATE] at 11:21 a.m. indicated Resident to be evaluate for counseling though the VA on [DATE] at 9:00 a.m. During an interview on [DATE] at 2:00 p.m. the SW said on [DATE] she was told by multiple staff that on Monday, [DATE] Resident #2 wrapped a cord around his neck and said he wanted to die. The SW said she was off on [DATE] but when she returned to work on [DATE] the only thing that was said about Resident #2 in the morning meeting was the DON said to look at making him a DNR. The SW said an ECA reported to RN D that Resident #2 had tried to kill himself the day before, and they got sent him out to the hospital. She said there were issues with care dynamic with his family member a few months ago, he got really depressed. She said she did a referral for psychological services at that time. The SW said she asked Resident #2 today if he was suicidal and he was very sarcastic, but said no. He went to the hospital but was not admitted to the Behavioral health due to physical and medical issues. She said he received weekly counseling, but she did not know how that was going. During an interview on [DATE] at 2:35 p.m. with RN D said Resident #2 had two suicide attempts on Monday, [DATE]. They were not informed about the suicide. The only thing that was brought up in the Morning meeting regarding Resident #2 was the DON wanted to make him a DNR. She said the DON was aware of the attempted suicide and did not put any interventions into place. She said LVN A was the nurse that was on duty on [DATE]. RN D said LVN A did not complete a nursing note or incident report until instructed to do so on [DATE]. RN D said LVN A said Resident #2 wrapped the call light cord around his neck, and she told the DON. She said LVN A said she was not given any instruction of what to do or how to procced with Resident #2. RN D said she called the SW on [DATE], and she came and did a suicide screen. She said the SW contacted the Behavior Health Hospital and Resident #2 was sent to the local hospital for a medical clearance to be admitted to the Behavior Health unit. RN D said on today [DATE] they removed all sharps from his room. She said they gave Resident #2 a call bell and moved the call light out of his reach. She said she had requested help from Maintenance to remove Resident #2's call light cord from the room, they had tried to remove the call light but was unable to without it continuously beeping. She said maintenance told her to push the reset button and did not come and remove the call light cord. She said she had told him his directions did not work. RN D said Resident#2 was agitated today because were trying to remove things from his room. She said he had been depressed for a while. She said he is often depressed around Christmas because he lost several family members around Christmas. RN D said she had gotten reports that Resident #2 was depressed, and they got counseling for him. She said she did not know exactly what lead to the attempt on [DATE]. RN D said Resident #2 often gets upset with the family member and acted out. She said Resident # 2 had put himself on the floor on yesterday per staff reports after having an issue with the family member. RN D said they asked him today if he wanted to hurt himself, he said no but was sarcastic with his remark. During an interview on [DATE] at 2:50 a.m. LVN E said he had worked at the facility for 1 year. He said Resident #2 had moments that he appeared depressed. He said he had not voiced any suicidal thoughts to him. He said he thought part of his problems with his falls was he did not know his limitations. During an interview and observation on [DATE] at 2:55 p.m. observation of Resident #2 showed him in bed and the bed was at waist height, there was a mat on the floor. Resident #2 said he did not want to die. He said that he wrapped the cord around his neck to prove to them that he could do it. He could not explain what he meant by them. He answered questions with appropriate answers and facial expressions. Observation of the room showed the call light was present. It was behind the bed; however, Resident #2 had a grabber on his table that would assist him to reach it. There was also a long cord connected to the electric lift over the bed the cord was between 6 to 9 feet long plugged into the wall by his bed. He said he was not throwing his self on the floor to hurt his self. Resident #2 said he just fell , and he did not know why. Said he was not feeling well, he was eating okay, and sleeping okay. He said he did not like to attend activities he was a loner and mostly liked to stay to himself. He said had his tv and his computer. He said he was depressed sometimes and would like to have someone to talk to about his issues. The resident said he had not talked to a counselor but would like to. During an interview on [DATE] at 3:10 p.m. ECA F said she was not here when Resident #2 put the cord around his neck. She said Resident #2 had put himself on the floor a few times. He would get mad with his family member either they would not come to visit, not answer the phone or something that would make him mad. She said on yesterday the family member would not answer the phone, or said something he did not like, and he wound up on the floor. She said he had just gone into his room. He was barley in the door, and he was on the floor. ECA F said Resident #2 had temper tantrums when did not get his way. She said Resident #2 did say he did not want to be here on occasion. She said he cannot stand up and he is a Hoyer lift transfer. She said Resident #2 puts his bed up high even when we tell him to keep it low. ECA F said Resident #2 had a fall mat on the floor, in July he told me he would not be here long. She said they moved all his sharps and things in the bathroom, and Resident #2 cannot get them without assistance. She said they gave him a call bell if he needs anything, but the call light is still in the room. During an interview on [DATE] at 3:20 p.m. ESA L said Resident #2 had not told her he wanted to die. She said sometimes he said he want to go, get out of here, and he talked of going home to Arkansas or Oklahoma. She said the normal behavior for Resident #2 was agitated. he will throw cups and tables. ECA L said for last two months he had been a little nicer, spend most time in the room. During an interview on [DATE]at 3:24 p.m. ECA R said she worked here one year and said that Resident #2 was lonely. She said his family member used come a lot but does not anymore. She said he got mad at the family member and would be depressed. She said when he is depressed, he just looks sad and disconnected from everything. ECA R said Resident #2 did not interact much with the others, but he did show some difference in his moods. She said she was told in July Resident # 2 wrapped the cord around his neck, but he said nothing to her about wanting to die. ECA R said Resident #2 did throw temper tantrums and would throw his self out of chair at times. ECA R said she did not know if he was just angry or trying to hurt himself for attention. She said when asked how did you fall or why did you fall Resident #2 would say thing like I just fell . During an interview on [DATE] at 4:05 p.m. the Maintenance Director said he was informed this morning that they wanted to remove the call light in Resident #2's room. He told whoever called him what to do to remove it. He said they called him about it still ringing when the cord was removed. He told them to just press reset button. He had not gone to check it out and he had not sent any of his guys to look at the issue. He said he did not

Based on interview and record review the facility failed to ensure a resident had the right personal privacy and confidentiality of his medical records for 1 of 4 residents reviewed for confidentiality (Resident #1.) The DON used Resident #1's computer access code to obtain his medical records without his permission. This caused the resident to be angry and paranoid. This facility failure caused the resident emotional distress. Findings included: Record review of Resident #1's face sheet with no date indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses of urinary tract infection, diabetes, schizoaffective disorder (Mental health diagnosis with a combination of schizophrenia and mood disorders), bipolar disorder Mental disorder with extreme mood swings), major depressive disorder ( persistent feeling of sadness and loss of interest), and post-traumatic stress disorder( mental disorder resulting from a traumatic event which causes extreme feeling of stress, fear, anxiety, and nervousness). Record review of Resident #1's annual MDS dated [DATE] indicated he had no cognitive impairment. The assessment indicated he was independent with all ADLS and used an electric wheelchair for mobility. Record review of Resident #1's care plan dated 6/18/21 indicated he had a Focus area of complications related to history of psychotropic medications due to bipolar disorder, schizoaffective disorder, major depression, and PTSD. The Goal was for the Resident to be free from signs and symptoms of depression. Some of the interventions were to notify the SW as needed, observe for change in mental status, and observe for signs and symptoms of depression. During an interview on 8/28/23 at 1:25 p.m. Resident #1 said he was upset because the DON violated his HIPAA (rights that protect his personal information) rights. She asked him to give her the paperwork they gave him at his hospital discharge. He had given her those papers and attached to that paperwork was his log in information to access his computer chart from the hospital. He said the DON had used that information and logged into his account and got copies of his records. He did not give her permission to do so. He said when he had tried to log into the account, he was unable to access the account. That was when he learned she had used his information, because the account indicated it was activated and he had not done so. He said she did not tell him she had used his information because the account was already activated. It was only after he complained that she came to him with the Administrator and apologized. He said it irritated him that someone would use his information without asking. He did not know who she had given his medical records to, but he did not appreciate it one bit. She apologized only after she got caught. He said the incident made him mad and he had problems with his anger due to having PTSD. He said it also made him paranoid because he could not figure out who she gave his information to or why. During an interview on 8/28/23 at 5:04 p.m. the DON said Resident #1 gave her paperwork that the hospital had given him for his discharge. The DON said on that paperwork was an access code for Resident #1's MyChart (electronic record.) She said he did not ask him if she could use the access code information. She just set up the account and got copies of his records. The DON said the only thing the hospital sent was his discharge papers and nothing else. She said they had attempted to contact hospital 3 times for additional records, and they did not send anything. The DON said Resident #1 returned with an access code and that is what she used. She said Resident #1 knew that she had used the code only after she had used it. The DON said she had assisted Resident #1 with getting his passcode changed and set up his account so he could access it himself. During an interview on 8/28/23 at 5:30 p.m. the Administrator said she was aware of the issue with Resident #1's records. She had gone with the DON as a witness that he was informed his access code was used and the DON apologized for using his information without permission. During an interview on 8/29/23 at 2:00 p.m. the SW said Resident #1 had received his discharge paperwork from the hospital on 8/24/23. He was upset that the DON was able to access his online hospital records. She said Resident #1 was trying to get into his chart but could not because the account had already been activated. The SW said she knew the DON and Administrator had apologized to him. Record review of the facility Resident Rights Policy dated October 2022 indicated the resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment, written and telephone communications. The resident has the right to secure confidential personal and medical records. The resident has the right to refuse the release of personal and medical records Record review of a Privacy Acknowledgment and Non-Disclosure Agreement indicted the facility is committed to protecting the privacy of all its Residents and protecting the confidentiality of their health care information. While with Residents at the facility, I realize that I may have access to or become aware of confidential resident medical information, whether or not I am directly involved in providing care to the resident. I understand that I must keep this information in the strictest of confidence. As a condition of my employment at that facility, I agree that i: will not examine, use or disclose confidential resident medical information except as needed to perform the duties of my job. Signed by the DON on 5/3/23

Based on interview, and record review the facility failed to ensure allegations of abuse, and neglect were reported within 24 hours to the state agency for 1 of 6 residents reviewed for abuse (Resident #2.) Resident #2 attempted to commit suicide on 7/24/23 with a contributing factor of the facility failing to ensure he received counseling. The facility did not report the incident of possible serious bodily harm with the risk of death to the state agency. This failure caused the allegation to go unreported and could result in other instances of abuse or neglect not being reported. Findings included. Record review of Resident #2's face sheet with no date indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were unsteadiness on feet, muscle weakness, personal history of psychological trauma, diabetes, major depression, and PTSD. Record review of Resident #2's quarterly MDS dated [DATE] indicated he had moderate cognitive impairment. He required extensive assistance of two people for transfers and bed mobility. Resident #2 used a wheelchair for ambulation. Record review of Resident #2's care plan dated 9/8/22 indicted a Focus area of depression. The Goal was the Resident #2 would be free of signs and symptoms of depression. Some of the interventions were contact social services as needed, medications as ordered, observe for change in mental status, observe for signs and symptoms of depression and psychiatric consult as needed. A Focused area of difficulty in psychosocial adjustments related to admission to the facility. One of the interventions weas to observe for signs and symptoms of difficulties in psychosocial adjustment, such as decreased socialization, sad mood, verbalized wanted to go home. A Focus area of resident had falls. A fall 7/24/23 indicated sent to the ER for psychiatric evaluation. A fall 8/22/23 therapy to screen and treat if indicated. A fall 8/25/23 anticipate resident needs for transfers, snacks, and toileting. A Focus area of at risk for excessive bruising /bleeding related to aspirin and Plavix use. Some of the interventions were to handle resident gently and observe for signs of bruising. A focused area of the resident required assistance with activities of daily living. Some of the interventions. Were the resident required. Extensive assist of two staff for bed mobility dressing, personal hygiene, toilet use, incontinent care, and transfers. The resident required one person assist of the staff for locomotion around the unit. A Focus area of depression and PTSD. The Resident hallucinated from the war and nightmares. One of the interventions were a psychiatric consult as needed. A Focused area identified on 7/25/23 indicated the resident has a history of suicide attempts. referred to inpatient psychiatric services remove any items that could be used to harm from the resident reach such as cords, bags, sharp objects, a safety assessment to be completed by clinical staff upon return of the resident from the hospital. Interventions noted on 8/28/23 were to ensure the resident had a cow bell or other means of communication if the call light is removed dated and notify the physician as and staff to complete 15-minute checks on Resident daily. Record review of Resident #2's computerized physician orders indicated an order dated 9/16/22 for Plavix tablet 75 mg (blood thinner) and Aspirin EC 81 mg. An order dated 6/7/23 indicated refer to counseling services for evaluation and treatment related to depression. An order dated 8/15/23for physical therapy to evaluate and treat for therapeutic exercises, therapeutic activities, neuromuscular, reeducation, wheelchair management and modalities. Record review of Resident #2's Psychosocial assessment dated [DATE] indicated this resident was referred with diagnoses of major depressive disorder, and posttraumatic stress disorder with decreased motivation and elevated anxiety. The resident said he preferred to be alone and called himself an isolate. He had no interest in hobbies or in church before his placement. He tended to avoid the other residents and had no interest in them. His responses supported the inference that he had the capacity for reasoning. The treatment plan was Resident #2 was recommended for psychotherapy with emphasis on redefining grief and loss, anticipating a lengthy period of trust building. Recommended the following for provider prescribing psychotropic medications. Mood or behavioral changes noted by staff be made known to the physician on a timely basis. Recommended therapy to be executed in weekly encounters. Record review of Resident #2's nurses note dated 07/24/23 at 10:29 a.m. indicated staff was called to Resident # 2 room and he was lying on the floor on his right side with head toward the TV. Resident #2 was attempting to self-transfer from the wheelchair to the bed when he fell . He was assisted by three staff members off the floor, and he denied abdominal pain. Written by RN D. Record review of Resident #2's incident report dated 7/24/23 at 11:00 a.m. indicated: The writer entered the room around 11:00 a.m. the resident was lying in bed with the call light cord wrapped around his nek. This writer removed the call light cord from around his neck and gave him the call light button. He again wrapped the call light cord to his neck. When the writer tried to remove the cord from his neck, the resident grabbed my had trying not to let me remove the cord. The writer was able to remove the cord from his neck and put the cord out of his reach. The resident said, I will not be here long. The DON was notified. Immediate Action taken: the writer removed the call light cord from his neck and put the cord out of his reach and the DON was notified. He was oriented to person, situation, and place. The form was signed by LVN A on 7/25/23 the form indicated the DON was notified on 7/24/23 at 11:00 a.m. The NP and responsible party were notified on 7/25/23 at 11:00 a.m. completed by LVN A. Record review of a Suicide Risk Screen Tool with no date indicated Resident #2 had thoughts of wishing he was dead, his family would be better off without him, thoughts of killing his self and he tried to kill his self. The resident stated he had attempted to end his life twice. His first attempt was wrapping his bed cord around his neck and his second was trying to turn his wheelchair over and hit his head. The resident stated these attempts were yesterday 7/24/23. The resident denied wanting to kill himself today. The patient required a brief suicide safety assessment to determine if a full mental health evaluation is needed. Completed by the SW. Record review of Resident #2's 1(one) hour monitoring tool indicated he was monitored every hour from 11 a.m. on 7/24/23 to 11:00 a.m. on 7/25/23. The monitoring tool was not located in the computer file. They were provided on 8/29/23 at 1:30 p.m. by SW Record review of Resident #2's nursing note dated 7/25/23 at 4:19 p.m. entitled late entry for a note dated 7/24/23 at 11:00 a.m. This writer entered Resident #2's room around 11 to take vitals and blood pressure blood glucose. The resident was lying in bed with a cord wrapped around his neck. This writer removed the cord from his neck and gave him the call button. He again wrapped the call light cord to his neck. When this writer tried to remove the cord from around his neck, then her grabbed my hand, trying to prevent me from removing the cord. This writer was able to remove the cord from his neck and put the cord out of his reach. The DON was notified. Signed by LVN A. Record review of social services note dated 7/25/23 at 3:53 p.m. indicated SW was just informed by clinical staff that Resident #2 had made two attempts to kill himself yesterday. The SW immediately went to Resident #2 's room to perform a suicide screening. Resident #2 stated that he did try to kill himself two times yesterday once by wrapping the called light cord around his neck to hang himself. He said in the other attempt was he was trying to turn over his wheelchair to hit his head on the floor. Resident #2 had been isolating the past two weeks and had been experiencing an increase in depressive symptoms. The resident stated he ws not currently suicidal but is open to hospitalization . The SW faxed Resident #2 clinical information's to the behavioral hospital awaiting update on admission for inpatient psychiatric services, the social worker will also contact Resident #2's family with an update. Signed by SW Record review of Resident #2's nursing note dated 7/25/23 at 5:14 p.m. indicated the resident was denied admission to the behavioral hospital. He will be sent to the local hospital for a psychiatric evaluation due to suicidal ideations and attempted suicide on yesterday by wrapping the quarter round is neck. The social worker currently contacting the staff at the local hospital to give report and discuss a need for immediate and urgent, psychiatric evaluation and placement, the resident had admitted to being suicidal in both attempts and wanted help. The resident is willing and agreeable with inpatient treatment currently. Written by RN D During an interview and record review on 8/28/23 at 5:04 p.m. the DON said Resident #2 tried to commit suicide on 7/24/23 someone had informed her, but she did not recall what had occurred after that. The DON said she had looked at Reportable incident triage form that was dated 2017 and it had attempted suicide listed as one of the things to report. The Administrator was out at that time, and she had not reported the incident. During an interview on 8/28/23 at 5:30 p.m. the Administrator the facility Abuse Coordinator said she was at a conference the week of 7/24/23 and was not aware of the incident until she returned the following week. She had not reported the incident to the state agency she did not think it was reportable. During an interview on 8/28/23 at. 6:30 p.m. DON and Administrator were informed of concerns with Resident #2. The Administrator said she was confused about the whole issue. The DON said she understood, Resident #2 had tried to commit suicide and they had basically done nothing. During an interview on 8/29/23 at 1:07 p.m. the SW said Resident #2 had an appointment on 6/29/23 for counseling but he did not attend the appointment apparently there was a problem with his payer source. She said he did not have Medicaid part B and his payer source would not pay for the counseling. She thought he was being seen by counseling weekly, but he was not. She said she was not made aware of the payer source issue until yesterday. Record review of the facility policy on abuse dated October 2022 indicated each resident had the right to be free from abuse. One of the categories of abuse was Deprivation of goods and services that are necessary to attain or maintain physical, mental, or psychosocial wellbeing. Staff has the knowledge and ability to provide care and services, but choose not to do so, or acknowledge the request for assistance from a resident which result in care deficits to a resident. Another category of abuse was Serious bodily injury is an injury involving substantial risk of death, involving protracted loss or impairment of the duction of the body requiring medical intervention such as hospitalization , or physical rehabilitation. The policy indicated any allegation of abuse will be immediately reported to the facility Administrator. The facility will designate an Abuse Prevention Coordinator responsible for reporting allegations of abuse to the state agency.

Based on record review and interview the facility failed to develop and implement a baseline care plan which includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 resident (Resident #300) reviewed for baseline care plans. The facility did not develop a baseline care plan for Resident #300. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings included: Record Review of Resident #300's admission record revealed an admitted [DATE] with a principal diagnosis: Benign Prostatic hyperplasia with lower Urinary tract symptoms, personal History of Urinary tract infections, Acute Kidney Injury. Record review of Resident #300's MDS assessment dated [DATE] revealed a BIMS Summary Score of 00 (severely impaired cognition). Record review of Resident #300's medical record revealed Resident #300 did not have a Baseline care plan. During an interview on 3/21/2023 at 1:55 PM., the MDS Coordinator, stated Resident #300's Base Line care plan was not done and stated she would check with the DON to make sure it was not completed. During an interview on 3/21/2023 at 2:10 PM, the MDS Coordinator states she checked with the DON and was confirmed that the Base Line care plan was not done, when asked who was responsible for doing that care plan, she said the Admission RN During an interview on 3/22/2023 at 10:45AM. the DON stated Resident #300's Base Line Care Plan was not done, and should have been done within 24 hours of admission, she said the Resident #300 was admitted on a Sunday and the RN supervisor was to do the Admission Care Plan, then the DON said she went on vacation and did not follow up on care plans. She was asked how you normally catch this, the DON said she has a check list to check that nursing has entered their plan. Record review of the facility's policy titled Base Line Care Plans dated November 2017 revealed: BASELINE CARE PLAN POLICY DATED: NOVEMBER 2017 Policy: The facility will develop and implement a baseline care plan for each resident in order to provide effective and person-centered care of the resident. Responsibility: Licensed Nurse Purpose: To provide an interdisciplinary resident centered care plan to meet the initial needs of the resident involving the resident and/or representative. Procedure: 1. The baseline care plan will: a. Be developed within 24 hours of the residents' s admission b. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: i. Initial goals based on admission orders ii. Physicians orders iii. Dietary orders iv. Therapy services v. Social Services vi. PASARR recommendation, if applicable 2. The facility must provide the resident and/or their representative with a copy of the baseline care plan that includes but is not limited to: a. The initial goals of the resident b. A copy of the resident's medications, dietary orders and other services or treatments to be administered. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility d. Any updated information based on the details of the comprehensive care plan, as necessary.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 resident (Resident #300) reviewed for care plans in that: Residents #300 care plans did not implement a person-centered individualized care plan in that: a. Resident #300 diagnosis of Acute Kidney Disease was not addressed in the care plan. b. Resident #300 received pain medications with pain not addressed in the care plan. c. Resident #300's diagnosis of Urinary Tract Infection was not addressed in the care plan. d. Resident #300's care plan did not address the use of Foley Catheter. e. Resident #300's care plan did not address Benign Prostatic hyperplasia This failure could place resident at risk of receiving inadequate interventions not individualized to their care needs. Findings included: During an interview on 3/22/2023 at 10:45AM. the DON stated Resident #300's Comprehensive Care Plan was not done and should have been done within 24 hours of admission, she said the Resident #300 was admitted on a Sunday and the RN supervisor was to do the Care Plan, then the DON said she went on vacation and did not follow up on care plansto see if Care plans were done nor updated. She was asked how you normally catch this, the DON said she has a check list to check that nursing has entered their plan and she failed to follow up. The DON said this was bottom line her responsibility to make sure this was completed. Record Review of Resident #300's admission record revealed an admitted [DATE] with a principal diagnoses of: Benign Prostatic hyperplasia with lower Urinary tract symptoms, personal History of Urinary tract infections, and Acute Kidney Injury. Record review of Resident #300's MDS assessment dated [DATE] revealed a BIMS Summary Score of 00 (severely impaired cognition). Record review of Resident #300's medical record revealed Resident #300 did not have a Comprehensive care plan. Record Review of the facillity: BASELINE CARE PLAN POLICY DATED: NOVEMBER 2017 Policy: The facility will develop and implement a baseline care plan for each resident in order to provide effective and person-centered care of the resident. Responsibility: Licensed Nurse Purpose: To provide an interdisciplinary resident centered care plan to meet the initial needs of the resident involving the resident and/or representative. Procedure: 1. The baseline care plan will: a. Be developed within 24 hours of the residents' s admission b. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: i. Initial goals based on admission orders ii. Physicians orders iii. Dietary orders iv. Therapy services v. Social Services vi. PASARR recommendation, if applicable 2. The facility must provide the resident and/or their representative with a copy of the baseline care plan that includes but is not limited to: a. The initial goals of the resident b. A copy of the resident's medications, dietary orders and other services or treatments to be administered. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility d. Any updated information based on the details of the comprehensive care plan, as necessary. Record review of the facility's policy titled Comprehensive Care Plans dated June 2019 revealed: Care Plan Comprehensive Policy: 1. To develop a comprehensive resident person centered care plan. Responsibility: Licensed Nurses. Purpose: To develop an interdisciplinary resident centered comprehensive care plan to meet the individual needs of each resident. Procedure: 1. An interdisciplinary team develops and maintains a comprehensive care plan for each resident 2. The comprehensive care plan has been designed to: a. Identify care needs that include resident's strengths, history, and preferences b. Incorporate risk factors c. Establish goals in measurable outcomes d. Include individualized approaches to meet residents' goals 3. The resident comprehensive care plan is developed within seven (7) days after the completion of the MDS assessment. New residents will have a comprehensive care plan within seven (7) days after the completions of the MDS assessment, not to exceed (21) days from the date of admission a. Care plans are revised as changes are indicated b. Review of the care plan is made with each comprehensive and quarterly assessment. 4. The facility supports the residents' right to be informed of and participate in their care plan with the resident and/or representative.

Based on interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance unless the resident's clinical condition demonstrated that this was not possible, or the resident's preferences indicated otherwise for 1 of 5 Residents (Resident #1) reviewed for nutritional status. The facility did not develop and implement interventions to address Resident #1's decrease in appetite and intake and actual weight loss. The facility did not develop and implement interventions to address Resident #1's increased need for assistance with eating. The facility did not monitor Resident #1's hydration or develop and implement interventions for ensuring Resident #1's hydration when he was identified as experiencing impaired intake. The facility did not consider contributing factors to Resident #1's weight loss and ADL function including newly prescribed [CONDITION(S)] medications, adjustment to placement and behavioral changes. The facility did not notify the primary care provider or the dietician regarding Resident #1's continued weight loss. The facility did not provide nutritional supplements as ordered. Resident #1 had significant weight loss of 25.6 pounds in 30 days. A negative 17 percent of his body mass index. An Immediate Jeopardy (IJ) situation was identified on 4/5/22 at 9:47 a.m. While the IJ was removed on 4/6/22 at 5:45 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of not receiving necessary treatment and care which could result in decline in health, significant weight loss which could manifest into other health complications. Findings included: Record review of an Admission Record Resident Information Sheet indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS, dated [DATE], indicated his BIMS score was 9 (8-12 moderately impaired cognition). Resident #1's behaviors indicated the resident had behaviors of wandering daily. The potential indicator of [CONDITION(S)] was none. The functional status listed for bed mobility and transfer between surfaces was supervision with set up help only. Dressing limited assistant with one person assist. Eating was independent with set up help only. Toilet use and personal hygiene was limited assist with one person assist. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care Plan dated 2/18/22 revealed a focus area was at risk for weight loss related to dementia. Some of the interventions were dietitian to evaluate nutritional status as needed, follow the facility weight loss protocol, allow resident time to feed self, dietician to evaluate nutritional status as need, offer food alternatives as needed and provide verbal encouragement with meals. A focus area was Activities of Daily Living. One of the interventions was the resident required supervision and set up with meals(no updates after 2/18/22.) A focus area indicated Resident #1 had anxiety and agitation and could be combative and was on psychoactive medications of [MEDICATION(S)] (antipsychotic medication) and [MEDICATION(S)]. (Benzodiazepine anticonvulsants). Some of the interventions were to document target behaviors, notify physician as needed, and psychiatric consults as need. The care plan did not indicate it was updated to reflect Resident #1 was experiencing actual weight loss and include any additional interventions related to the resident's ongoing weight loss. The care plan did not indicate Resident #1 was being monitored for hydration on interventions to ensure hydration. The care plan did not address possible adverse side effects of [CONDITION(S)] medications and their effect on the Resident #1's ability to feed himself, appetite and mental status. Review of Resident #1's clinical record showed a UA dated 2/9/22, it was negative for a [CONDITION(S)]. The UA was the only lab provided when labs were requested. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no other lab orders noted. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurse's notes indicated [MEDICATION(S)] 2mg intramuscular was ordered on 2/23/22. Review of nurses notes also indicated [MEDICATION(S)] was increased to 100 mg two times daily on 2/24/22. The computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Tablet 50 mg give 1 tablet by mouth one time a day related to PBFAD effective date 3/3/22. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Tablet 50 mg give 1 tablet by mouth one time a day related to PBFAD effective date 3/3/22. Record review of the Physician indicated Resident #1 was to receive [MEDICATION(S)] Tablet 0.5 mg give 1 table by mouth every 8 hours as needed for increased agitation and anxiety with no stop date with an effective date of 3/8/22 -after hospitalization . Record review of computerized physician orders, dated 3/15/22, indicated: The Diet order Summary: Regular diet with finger food texture active dated 3/3/22. (Dietician recommended on 2/21/22) Carnation instant Breakfast two times a day for decreased appetite on hold from 3/4/22 to 3/9/22. Magic Cup two times a day give with lunch and dinner meals on hold (no documented reason for the hold) from 3/4/22 to 3/11/22. Monthly weights in the morning starting on the 5th of the month and ending on the 5th every month. Dated 2/2/22 with a start date of 2/5/22. May open/crush medications as allowed by pharmacist directive guidelines, may give in food and or liquids. Review of Resident #1's clinical record revealed the only lab present was a UA dated 2/9/22. Record review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (no mention of Boost on the physician orders) Resident #1 received Boost one time on 2/26 and two times on 2/27/22. The February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Then placed on hold from 2/26/22- 2/28/22. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated ice cream was given two times on 3/1/22 and 3/2/22. The March MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The March MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (no documented reason for the hold). The record review revealed Resident #1 received some type of supplements form 2/23/22 through 3/3/22. Record review of Resident #1's Weights and Vitals Summary, dated 3/15/22, indicated the following: The Resident Was 66 inches tall. On 2/7/22 weight 143.6 lbs. On 2/16/22 weight 134.6 lbs. On 2/23/22 weight 128.2 lbs. On 3/4/22 weight 118 lbs. (re- weigh) The Summary indicated the DON requested a Re Weigh on 3/4/22. (25.6 Pounds loss) On 3/9/22 weight 119.2 lbs. (the resident was discharged on [DATE] to hospital.) Resident #1 lost 24.5 pounds at negative 17.8 percent weight loss. (to receive the percentage of weight loss, divide the amount of weight loss by the starting weight, and multiply by 100.) Record review of a nutritional assessment, dated 2/21/22, indicated Resident #1 had significant weight loss of negative 6.3% in nine days. His appetite was listed as fair, no problems chewing, no problem swallowing, and no problems with liquid. He required no assistance with eating. The dietitian's assessment note indicated the resident was admitted to the facility on [DATE]. The resident was exit seeking and had lost a significant amount of weight since his admission. The resident walked around the facility often and may not be sitting down to eat meals. The resident was likely not meeting needs at this time as evidenced by weight loss. Recommended to add finger foods to all trays as possible; the goal was to maintain weight at less than 5% with a good oral intake of greater than 75%; will continue to monitor, signed by the Dietician. Review of ADL sheets indicated Resident #1 was admitted on [DATE] most days he ate 75 to 100 percent until about 2/10/22. Review of February 2022 ADL sheet for eating and assistance with eating indicated Resident #1 ate: Breakfast at 9 a.m. On February 12, 13, 14, 17, 20, 21, 23, 25, 26, 27, and 28 ate 26 to 50 percent On February 15, 16, 18,19, 22, and 24 he ate 76-100 percent Lunch at 1 p.m. On February 12, 13, he ate 76-100 percent The rest of the days he ate 51-75 except on 27 he ate 76 to 100 percent Dinner at 6 p.m. On February 12, 13, and 14 blanks On February 15 and 16 he ate 51-75 percent On February 17 and 18 he ate 26-50 percent On February 19 he refused On February 20 he ate 26-50 percent substitute offered and he ate 25 percent On February 21 he refused On February 22 he ate 26-50 percent substitute offered and he ate 25 percent On February 23 ate 26- 50 percent refused supplement On February 24 refused to eat and refused supplement On February 25 ate 76-100 percent On February 26 refused to eat and refused supplement On February 27 ate 76- 100 percent On February 28 ate 51- 75 percent Review of Resident # 1's ADL sheet for requiring assistance with eating for February 2022: Review of the ADL sheets indicated around 2/18/22 the resident started to require assistance with for breakfast and lunch. The sheet indicated he did not receive assistance except on 2/20/22 he was listed as limited assist with one person. However, one of the aides that filled out the form with eating assistance was (CAC) CNA A filled in the breakfast and dinner activity and need for assistance ADL sheet. During an interview on 3/16/22 at 12:12 p.m. CNA A said the documentation was not right. She said she did not know the computer system well. She put 0 -1 independent with supervision. She said he required assistance most days. The other staff indicated for most days at dinner he was total dependent or required extensive assist of one person with meals for the later part of the month in February. Review of March 2022 -ADL Sheet indicated: Breakfast at 9 a.m. March 1, he at 0-25 percent March 2,3, 4, he ate 51- 75 percent March 5 blank, On March 6, 26-50 percent substitute offered, and he consumed 75 percent On March 7, 26-50 percent substitute offered, and he consumed 50 percent On March 8 -hospitalized Lunch at 1 p.m. On March 1 refused but at 50 percent of a substitute On March 2, he ate 51 to 75 percent On March 3 and 4, he ate 26-50 percent and 50 percent of a substitute On March 5, blank On March 6, and 7, he ate 51-75 percent Dinner at 6 p.m. On March 1, refused On March 2, refused On March 3, he ate 51-75 percent On March 4, refused On March 5, refused On March 6, he ate 25-50 percent On March 7, he refused but did eat 25 percent of a substitute Review of Resident #1's March eating with assistance: indicated one of the aides that assisted with eating (CAC) CNA A filled in the breakfast and lunch activity or need for assistance ADL sheet. She signed 5 of the 7 days. She said it was not right. She said she did not know the computer system well. She put 0 -1 independent with supervision. The other staff indicated for most days at dinner he was total dependent or required extensive assist of one person with meals for March. There was no documentation found on the ADL sheets or anywhere else in his record that mentioned hydration for Resident #1. Record review of nursing notes indicated the following: -On 2/8/22 at 11:14 a.m. observed resident in dining room eating breakfast socializing with other residents. No complaints Signed by LVN K. -On 2/22/22 at 10:48 p.m. Resident had 50 percent of dinner, encouraged to take ice-cream as well, but took only half. -On 2/25/22 at 1:47 p.m. new order for Carnation Breakfast for decrease in appetite two times a day. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . -On 2/25/22 at 9:16 p.m. at dinner time the resident ate 100 percent and was cooperative after given as needed [MEDICATION(S)]. Initial dose of [MEDICATION(S)] 20 mg given earlier with no adverse reaction noted. No adverse reaction noted as well to increase dose of [MEDICATION(S)], in bed at this time, eyes closed and resting quietly. -On 2/26/22 at 9:53 p.m. at the earlier part of this shift Resident started to undress self and had his mattress inverted about 7:00 p.m. -redirection done PRN [MEDICATION(S)] given as was effective. Carnation instant breakfast not in yet. Ensure given and he took it all. -On 2/26/22 at 10:37 p.m. noted a new order for Boost 2 times a day until Carnation instant Breakfast Available. -On 3/3/22 at 9:30 a.m. new recommendation from Dietitian to add finger foods to all trays as possible. Signed by RN F. -On 3/3/22 at 10:41 a.m. responsible party met with [RN H] in house to discuss concerns with resident's weight loss and medications. The RN voiced concerns to the NP. Received new order to start magic cups with lunch and dinner instead of ice cream cups related to weight loss. New order to give [MEDICATION(S)] 50 mg in a.m. and 100 mg every evening for better quality of life and therapeutic effects. Signed by RN H. -On 3/8/22 at 5:00 a.m. summoned to resident room per Aide related to Residents feeling warm upon entering the room. The resident was laying in right lateral position with eyes closed resident was hard to arouse but moved slightly when move, vital signs- blood pressure 96 / 56 heart notify 120, respiration 30, temperature 99.6, oxygen saturation 88-93 at room air. Notified emergency services, at 5:17 a.m. notified responsible party in regards of changing condition and being sent to the hospital on 3/8/22. Signed by RN F. -On 3/8/22 at 2:28 p.m. (after resident hospitalization ) the RN spoke to the nurse practitioner regarding resident taking [MEDICATION(S)] 1 mg. The resident appeared overly sedated after taking this dose and may need a reduction. Receive a new order to decrease [MEDICATION(S)] to 0.5 every eight hours as needed. Re-evaluate if new orders received from the hospital. Signed by RN H. Record review of a Hospital History and Physical, dated 3/8/22 at 9:50 a.m., indicated Resident # 1's Assessment and Plan identified the principal problem for hospital admission as [CONDITION(S)] (the bodies extreme response to an infection) with acute [CONDITION(S)] without septic shock. The active problems were acute metabolic [CONDITION(S)] (a problem in the brain caused by a chemical imbalance in the blood), acute kidney injury (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days.), [CONDITION(S)] (too much sodium in the blood), acute urinary tract infection, elevated liver function test and abnormal CT of the head. The patient's Sodium level was 171 (two common causes insufficient fluid intake and too much water loss) and the sodium level was likely to explain the patient's mental status changes, the lack of nutrition was concerning. The patient presented with an altered mental status. Per the nursing facility the patient has gotten gradually more lethargic and had less by mouth intake over the last several days. Review of the Hospital Labs dated 3/8/22 showed a Comprehensive Metabolic Panel (measures 14 different substances in the blood. It provides important information about your body's chemical balance and metabolism. Metabolism is the process of how the body uses food and energy.) results: Sodium level 171 (range 133-145) (High Sodium, [CONDITION(S)] involves dehydration which can have many causes such as not drinking enough water) Chloride 141 (range 96-108) High levels of Chloride may indicate dehydration BUN (blood urea nitrogen) 109 (range 8-23) High levels mean you kidneys are not working Creatinine (a waste product that comes from the normal wear and tear on muscles of the body) 3 (range 0.6-1.3) Can indicate the kidneys are not working which could be from dehydration. [MEDICATION(S)] (protein made by your body)2.7 (range3.4-4.8) GFR (glomerular filtration rate-how much blood your kidneys filter each minute)18 (Kidney Damage (severe decreased in GFR 15-19) Record review of Dietician note for Resident #1 dated 3/9/22 at 12:53 p.m. (after hospitalization ) weight loss follow up revealed the current body weight was 118 pounds, Body Mass Index 19 - at risk for age. The resident has lost negative 17.8% in 30 days. His by mouth intake poor- variable average 50% per nurses note. Pertinent medications were multivitamins, fish oil, no updated labs, no skin breakdown noted. The resident had magic cups two times a day and carnation instant breakfast every day ordered. The resident had a finger food diet ordered. The resident may not be meeting needs at this time as evidenced by poor intake and weight loss. The MD to consider appetite stimulant goal was to maintenance weight loss of less than 5% and a good by mouth intake of more than 75 percent, signed by the Dietician. Record review of a discharge summary, dated 3/14/22, indicated Resident #1 was sent to the hospital on 3/8/22 due to increased altered mental status and abnormal vital signs. The family discharged the resident from the facility. During a telephone interview with a family member on 3/15/22 at 9:34 a.m. they said Resident #1 had a complete physical on 1/18/22 prior to admission to the facility, and everything looked good. He was admitted to the facility on [DATE]. Resident #1 was very fit for his age; he could do 60 pushups. Prior to coming to the facility, he was independent, he dressed himself and took his own showers. Resident #1 did not want to be there, he tried to escape every way he could. He tried to climb the fence several times, and he would pull off his clothes. The family member said LVN I said Resident #1 was eating but he was not eating a lot. He started sleeping through lunch. The family member said the facility drugged him up. Another family member tried to feed him a day or two before hospitalization . It took her 45 minutes to feed him pinches off a muffin and some milk. Resident #1 would put his thumbs on his lips like a small child. The family member said he told the head nurse (RN H) he wanted Resident #1's medications cut down. He does not know if she did it or not. Resident #1 was still in the hospital, on a feeding tube, and had a drainage tube for his gall bladder. They did not know if he is going to live or not. During an interview on 3/15/22 at 10:28 a.m. CNA A said Resident #1 was an active person (moving around, independent, athletic.) When he first came to the facility, he did not require assistance with eating or dressing. He had a decline but did not like to be fed. He would not let staff assist him. He would refuse to drink sometimes. She said later, Resident #1 would sit, sleep, and eat. They gave him medications to keep him calm. He was still combative prior to hospitalization but did require more assistance. During an interview on 3/15/22 at 10:36 a.m. with CNA E, she said when Resident #1 first arrived at the facility, he was combative (hitting and resistant) and wanted to leave. He would fight but required assistance with eating. He did not like for staff to feed him so he was given finger foods that he could eat on by his himself. During an interview on 3/15/22 at 10:58 a.m., LVN K said on 3/7/22 Resident #1 had a change in condition, he was less active, and more sedated. She said he was still combative, but she noted a change. He was not eating. She said she let RN H Supervisor know and the NP. She told RN H to let the DON know to come and assess the resident because he was different. Before 3/7/22, the last time she saw him, he crawled around on the floor and was more active. This time he was combative but in more of a leave me alone kind of way. On Sunday 3/6/22 he was in bed but appeared to be more combative. He got prn [MEDICATION(S)] quite often. During an interview on 3/15/22 at 11:10 a.m., CNA C said she worked with Resident #1. A few days before hospitalization Resident #1 appeared kind of sedated and tired compared to his usual self. During an interview on 3/15/22 at 11:13 a.m., LVN I said she was able to give Resident #1 his medications by crushing them and put them in his pudding or ice cream. LVN I said the resident had behaviors and tried to run away, he was forgetful and combative, he was placed on medications of [MEDICATION(S)] and Klonipin to help with those symptoms. She did not think he was hallucinating or delusional. He had a lot of other behaviors. She said he got [MEDICATION(S)] quite often to calm down. She said 3/4/22 was the last day she worked prior to his going to the hospital. LVN I said on that day he sat at the table confused, but staff fed him ice cream. She said he was his normal self but needed assistance with eating. He could not hold a cup he used both hands. During an interview on 3/15/22 at 2:05 p.m., the DON said the reason Resident # 1 was on [MEDICATION(S)] was because of his behaviors. He was combative, took his clothes off, urinated on the floor, and climbed fences. The DON said she was the person that monitored the weights. He had some weight loss, they prescribed carnation instant breakfast, ice cream and magic cup. The magic cup was placed on hold because they did not have any in stock. During an interview on 3/15/22 at 2:17 p.m., RN H said she saw Resident #1 the day before he went to the hospital. She said LVN K informed her on 3/7/22, he was not eating and was spitting out his medications. RN H said that was not anything new, she did not do any follow up and she told LVN K to let the NP know. She said by looking at him she could not tell he lost weight. She said they had ordered a magic cup and finger food. She never talked to the dietician. He had ice cream which was given by LVN I. The ice cream did not have many calories, so they switched to the magic cup. RN H said she did have a meeting with the resident's family member on 3/3/22 and the family member was concerned about Resident #1 losing weight and he seemed more lethargic. She said it was after family intervention that the facility discussed the Magic cup and to lower his medications. She stated Resident #1 was a lot more active on admission. She said part of his inactivity was due to the medications he took. The last time she saw him he was sitting at the table and the staff were trying to get him to eat and drink, when he was admitted he was independent with eating. During an interview on 3/15/22 at 2:58 p.m. RN G said she was the supervisor, on 3/7/22 she remembered Resident #1 ate poorly at supper. She stated she crushed his medications to get him to take the medications. He did drink but held the cup with two hands. His condition had changed, and he was more sedated. The last time she saw him he was crawling around on the floor. She had seen him on one occasion trying to climb the fence so, his condition had declined. During an interview on 3/15/22 at 3:15 p.m., CNA B said the last few days prior to hospitalization Resident #1 needed assistance with eating. He would sit around and sleep. His would open his eyes, but he was still somewhat combative. Sometimes he would eat and drink, it depended on how he felt. During an interview on 3/16/22 at 6:43 a.m., RN F said she usually worked with the residents. They were short staffed on the night of 3/7/22-3/8/22. She said she received information in report that Resident #1 had a gradual decline. She said an aide went in to change him and he was hard to arose. She had concerns about his low BP and high respirations and pulse. She sent him to the hospital early morning on 3/8/22. During an interview and record review on 3/16/22 at 10:10 a.m., the DON said Resident #1's weights were concerning to her, he refused meals. On 3/12/22 the family told her the hospital had concerns about Resident #1's dehydration and weight loss. She said she investigated information while she was on the phone, only regarding the family concerns. Her plan was when Resident #1 returned from the hospital she would have started him on [MEDICATION(S)] (appetite stimulant). The family discharged the resident on 3/14/22. The DON said she never talked to the doctor and she never assessed Resident #1 herself. She was not aware he had a change in condition. She was informed they sent him out to the hospital. She was aware of the family discussion on 3/3/22 about weight loss and the family felt Resident #1 was sedated. The DON said she did not consider the antipsychotic medications could have contributed to his change in eating hobbits. During an interview on 3/16/22 at 12:12 p.m., CNA J said when Resident # 1 first came, he was athletic, and he could use his arms and raise his whole body out of the chair. He was transferred to the locked unit because of his elopement attempts. Resident # 1 was mostly independent with his ADLs. She said you could tell by looking at him, he had lost weight. She stated he would not eat. CNA J said the day before he went out to the hospital, he was still trying to fight. He appeared tired and sleepy. She said she was with LVN K when she tried to give him his meds. He was still strong he hit the cup and knocked it across the room. She said they tied to give him a magic cup and some milk, he accepted a little. She said you could see a decline. She said when she left at 3:00 p.m. on 3/7/22, he was in the bed asleep. During an interview on 3/16/22 at 12:20 p.m., CNA A said the closer to Resident #1s hospitalization he required more assistance with everything. Sometimes he would let them help him. He had a hard time feeding himself. He would allow them to put the food on the spoon and let him put the spoon to his mouth. CNA A said she had filled out the information on the computer about his meals and the assistance required. However, she was not sure if she did it accurately. Resident #1 did require assistance with eating for about a week or two prior to hospitalization . During an interview on 3/16/22 at 4:05 p.m. The dietician said she never had a conversation with the DON about Resident #1 losing weight. She knew the facility staff completed some diet changes because the Dietary Manager informed her about the finger foods, the carnation instant breakfast, and the magic cups. The Dietician said it would be good to know what was going on so she could prepare interventions for weight loss. Her last visit to the facility was 2/21/22 when she completed a nutritional assessment on Resident #1. She said her last note written was on 3/9/22, was because she had reviewed the chart. She noted from his chart review Resident #1 had lost weight and was not eating. The Dietician said she was not provided any information from anyone at the facility; she did her own investigation into a resident's status. During an interview on 3/18/22 at 2:30 p.m., the DON said they tried to redirect Resident #1 and it was not effective. That was the only intervention they tried before placing him on medications. She did not recall recommending a psychological consult and could not find documentation that one was requested. The DON did not provide an explanation as to why the physician or dietician were not notified. She just said she did not notify the physician or the dietician regarding Resident #1 not eating or his weight loss. During an interview on 3/18/22 at 4:10 p.m., the NP said she remembered Resident #1. She got calls about him 3 to 4 times a week if not every day regarding his behaviors. She had put him on an initial does of [MEDICATION(S)] 50 mg, two times a day. It did not seem to calm him down. So, she increased the dose to 100 mg two times daily. The NP said she was never informed Resident #1 was not eating and losing weight. If she had known she would have ordered an appetite stimulant. During an interview on 3/21/22 at 9:08 a.m. with the DM, she said when Resident #1 was first admitted he constantly walked. She thought he was losing weight because he never sat down. The Dietician put him on finger foods, a sandwich, or for breakfast a sausage biscuit. The Aides were concerned Resident #1 would not sit. They gave him some medications and he was not wandering as much. He started to need assistance with meals. She thought he was placed on some supplements. They had Quality of Care meeting every week. He was on weekly weights. Resident #1 lost 14 pounds in a week. His weight loss was a concern. During an interview on 3/21/22 at 10:00 a.m., the DON said they did not conduct and IDT meeting regarding Resident #1 losing weight or his behaviors. They did conduct an IDT meeting about his fall on 2/8/22. During an interview on 4/4/22 at 1:10 p.m. Resident #1's family member said Resident #1 lived with them prior to residing at the facility. Resident#1 was 86-years-old but strong. He could do 60 pushups at a time on his knuckles. He could do pull ups on a pull up bar. He said his father had sundowners (a state of confusion occurring in the late afternoon and spanning into the night.) and had some behaviors and confusion, especially at night. He was never violent, and he did not believe half the things the facility said Resident #1 was doing. The family member said he talked to his nurse, LVN I, about 5 days prior to 3/3/22. He said they went to the facility on 3 occasions to see Resident #1 and he was in the bed asleep. He was so sleep they could not wake him up. They were told he had just received his medications on those occasions. He said he had asked LVN I to reduce the medications and make sure he did not sleep through meals. LVN I said she would but did n

Based on interview and record review the facility failed to ensure residents who have not used [CONDITION(S)] drugs are not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed (Resident #1) The facility failed to implement non-pharmacological interventions before placing Resident #1 on [CONDITION(S)] medications when he began experiencing adjustment difficulties and exhibiting behaviors The facility failed to monitor, identify and act upon adverse consequences of [CONDITION(S)] medication when Resident #1 experienced unplanned weight loss, decline in ADL functions, dehydration, sedation, lethargy and mental changes. The facility failed to assess Resident # 1 for any medical, physical, or psychological causes of distress prior to initiating [CONDITION(S)] medications. The facility failed to document a clinical rational for the use of [CONDITION(S)] medications for Resident #1. Resident #1 had a 25.6 pound weight loss weight loss in 30 days and was admitted to the hospital with diagnoses of [CONDITION(S)]-the bodies extreme response to infection, metabolic [CONDITION(S)]- a problem in the brain caused by chemical imbalance in the blood, and [CONDITION(S)]-too much sodium in the blood. These failures could place residents at risk for receiving unnecessary [CONDITION(S)] medications leading to decline in functional status, nutritional status, mental status and death. An Immediate Jeopardy (IJ) situation was identified on 4/5/22 at 9:47 a.m. While the IJ was removed on 4/6/22 at 5:45 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk receiving unnecessary medications which could result in decline in health, which could manifest into other health complications. Findings included: Record review of an Admission Record Resident Information Sheet indicated Resident #1 was an [AGE] year-old male admitted on [DATE] with diagnoses which included malignant neoplasm of prostate ([CONDITION(S)]), [CONDITION(S)] (high cholesterol), dementia (mental process disorder affecting memory, personality, and reasoning) without behavioral disturbance, atherosclerosis of coronary artery (plaque in the walls of blood vessels) bypass and low back pain. An additional diagnosis was added on 2/11//22 of Psychological and behavioral factors associated with disorders or diseases classified elsewhere. Record review of a diagnosis audit report indicated Resident #1 was given a diagnosis on 2/11/22 of Psychological and Behavioral Factors Associated with Disorders or Diseases Classified Elsewhere. The diagnosis details indicated it was not an acceptable primary diagnosis. Record review of Resident #1's MDS, dated [DATE], indicated his BIMS (Brief Interview for Mental Status) score was 9 (a score of 8-12 moderately cognitive impairment.) The Preferences for Customary Routine and Activities had received shower, snacks between meals, staying up past 8 p.m. and a place to lock belongings. Resident #1's Behaviors indicated the resident had behaviors of wandering daily. The Potential indicator of [CONDITION(S)] was none. The Functional status listed for bed mobility and transfer between surfaced was supervision with set up help only. Dressing limited assistant with one person assist. Eating was independent with set up help only. Toilet use and personal hygiene was limited assist with one person assist. His active diagnoses were cancer, coronary Artery Disease, [CONDITION(S)], and Non- Alzheimer's Dementia. Record review of Resident #1's Care Plan, indicated he had a focus area of adjustment related to admission to the facility, dated 2/2/22. The goals were difficulties in psychological adjustment through next review date. The interventions were to observe for signs and symptoms of difficulties in psychological adjustment, decrease socialization, sad moods, and verbalized wants to go home. A Focus area was also at risk for increased confusion, dated 2/2/22. The intervention was to encourage and assist resident to be among others and involved in activities for mental stimulation and diversion. Notify the physician as needed, observe for changes in mental status, observe for side effects of medications, provide choice for resident and use diversional activities as needed. A Focus area was listed as a risk for exit seeking behaviors as evidenced by wandering the facility unaccompanied and he wears a wander guard, dated 2/18/22. The intervention was to attempt diversional activities as needed. A Focus area was at risk for weight loss related to dementia, dated 2/18/22. Some of the interventions were dietitian to evaluate nutritional status as needed and follow the facility weight loss protocol. A Focus area was activities of daily living. One of the interventions was the resident required supervision and set up with meals dated to 2/18/22. A Focus area indicated Resident #1 had anxiety and agitation and could be combative and he was taking psychoactive medications of [MEDICATION(S)] and Konopin, dated 2/18/22. The care plan did not include what interventions should be implemented if signs and symptoms of difficulties in psychological adjustment, decrease in socialization, sad moods and verbalized wants to go home were observed. The care plan did not indicate any non-pharmacological interventions for Resident #1 when he experienced anxiety and agitation and combative behavior. Record review of Resident #1's consent form (with the facilities name and the physician's name) for antipsychotic or neuroleptic medication treatment form indicated: I believe the individual has the following psychiatric condition or maladaptive behavior. Psychosocial and Behavioral Factors Associated with Disorders or Disease Classification Classified Elsewhere. My diagnosis is based on the following dominant characteristics exhibited by this individual uncontrollable anger and irrational thinking. The following course of therapy with antipsychotic or neuroleptic medications is proposed with the following medications dosage and frequency, [MEDICATION(S)] 50 milligrams one by mouth two times a day. The risk and benefits in my clinical opinion the probable clinically significant side effects and risk of the proposed treatment with antipsychotic or neuroleptic medications are indicated: Serious side effects include restlessness, constant need to move, shakiness, tremor, and mental mood changes such as increased anxiety depression thoughts of suicide. Difficulty swallowing, Constipation, persistent abdominal pain, persistent nausea vomiting, loss of appetite, yellowing eyes or skin, interrupted breathing during sleep and trouble urinating. The need for and benefit of this proposed treatment and antipsychotic or neuroleptic medications is indicated: [MEDICATION(S)] is used to treat certain mental mood conditions such as [CONDITION(S)] [CONDITION(S)] disorder, certain episodes of [CONDITION(S)], or depression associated with [CONDITION(S)] disorder. (the resident did not have any of these diagnoses) [MEDICATION(S)] is known to be an antipsychotic atypical type it works to restore the balance in certain natural substances neurotransmitters in the brain. This medication can decrease hallucinations improve your concentration it helps you to think more clearly and positively about yourself feel less nervous and take more active part in everyday life. It may also improve your mood sleep appetite energy level. [MEDICATION(S)] can help prevent severe mood swings and decrease how often mood swings occur. It was digitally signed by the physician on 2/14/22. The consent form indicated a phone consent was received by Resident #1's Power of Attorney on 2/2/22 from the RN who also digitally signed the form on 2/14/22. According to the National Alliance on Mental Illness (web page 3/22/22) [MEDICATION(S)] carried a Black Box Warning- a Black box warnings are the most serious warnings the FDA issues. They warn doctors and patients about serious or life-threatening adverse drug reactions. Antipsychotics earned black box warning because they are associated with increased rates of stroke and death in older adults with dementia. Review of Resident #1's clinical record showed a UA dated 2/9/22, it was negative for a [CONDITION(S)]. The UA was the only lab provided when labs were requested. Review of the physician orders indicated Admission labs for base line CBC, CMP, PSA, Lipids, and BMP and then routine labs annually. There were no other lab orders noted. Review of physician order dated 2/11/22 indicated [MEDICATION(S)] 1mg give by mouth every 8 hours as need for anxiety- additional information alert black box warning noted in the order. Review of physician order dated 2/13/22 indicated [MEDICATION(S)] 50 mg by mouth two time a day-for anxiety and or agitation related to PBFAD additional information alert black box warning noted in the order. Review of physician orders indicated [MEDICATION(S)] 20mg one time daily for PBFAD effective date 2/24/22. Review of nurse's notes indicated [MEDICATION(S)] 2mg intramuscular was ordered on 2/23/22. Review of nurses notes also indicated [MEDICATION(S)] was increased to 100 mg two times daily on 2/24/22. The computerized physician order did not reveal this information. There were no individual order was provided after request. Record review of the February 2022 Medication Administration Record indicated [MEDICATION(S)] 0.5 mg given by mouth two times a day for (PBFAD) with a start date of 2/11/22 and end date of 2/13/22. The MAR indicted the resident received [MEDICATION(S)] two times on 2/12/22 and one time on 2/13/22. Record review of the February 2022 MAR indicated Resident #1 received [MEDICATION(S)] 1 mg by mouth as need for increased anxiety and exit seeking behaviors related to (PBFAD) on the following days: -On 2/11/22 at 2:30 p.m. -On 2/13/22 at 12:39 a.m. and 5:33 p.m. -On 2/14/22 at 8:36 a.m. and 3:53 p.m. -On 2/18/22 at 11:24 a.m. and 10:45 p.m. -On 2/19/22 8:40 a.m. and 3:50 p.m. -On 2/20/22 at 4:30 p.m. -On 2/21/22 at 5:55 p.m. -On 2/22/22 at 4:44 p.m. -On 2/23/22 at 11:27 a.m. -On 2/24/22 6:19 p.m. -On 2/25/22 at 9:00 a.m. and 4:25 p.m. -On 2/26/22 at 8:20 a.m. and 7:00 p.m. -On 2/27/22 at 7:00 a.m. and 5:24 p.m. -On 2/28/22 at 7:30 a.m. and 5:35 p.m. Record review of the February 2022 MAR indicated [MEDICATION(S)] 50 mg to be given one table by mouth two times a day for anxiety and agitation related to (PBFAD) with a start dated of 2/14/22 and hold until 2/15/22 with an end date of 2/24/22. The MAR indicated Resident #1 received [MEDICATION(S)] 50 mg two times a day on 2/16/22 through 2/23/22 and one time on 2/24/22. Record review of the February 2022 MAR indicated [MEDICATION(S)] 100 mg to be given one table by mouth two times a day related to (PBFAD) with a start dated of 2/24/22 and an end date of 3/3/22. The MAR indicated the resident received [MEDICATION(S)] 100 mg one time on 2/24/22 and two times on 2/25/22, 2/26/22, 2/27/22 and 2/28/22. Review of physician orders indicated [MEDICATION(S)] Tablet 100 mg give 1 tablet by mouth one time a day related to PBFAD. [MEDICATION(S)] Tablet 50 mg give 1 tablet by mouth one time a day related to PBFAD effective date 3/3/22. Review of physician orders indicated [MEDICATION(S)] Tablet 50 mg give 1 tablet by mouth one time a day related to PBFAD. [MEDICATION(S)] Tablet 50 mg give 1 tablet by mouth one time a day related to PBFAD effective date 3/3/22. Record review of the Physician indicated Resident #1 was to receive [MEDICATION(S)] Tablet 0.5 mg give 1 table by mouth every 8 hours as needed for increased agitation and anxiety with no stop date with an effective date of 3/8/22 -after hospitalization . Record review of the March 2022 MAR indicated [MEDICATION(S)] 100 mg tablet was given 03/03/22 through 3/7/22. [MEDICATION(S)] 50 mg was given in the morning from 3/4/22 and 3/5/22 the resident refused on 3/6/22 and 3/7/22. [MEDICATION(S)] 100 mg 1 tablet by mouth two times a day related to PBFAD with a start dated of 2/24/22 and a discontinue date of 3/3/22. [MEDICATION(S)] 1 mg give one tablet by mouth every 8 hours as needs for increased agitation, anxiety, and exit seeking behaviors related to PBFAD. The record indicated the resident received the [MEDICATION(S)] 1 mg on the following days: -On 3/1/22 at 5:44 p.m. -On 3/2/22 at 7:30 a.m. and 5:24 p.m. -On 3/3/22 at 7:04 p.m. -On 3/5/2 at 4:59 p.m. -On 3/6/22 at 5:16 p.m. Review of Resident #1's anti-psychotic behavior side Effect Tracking sheet for February and March 2022 indicated behaviors for medications could be sedation/drowsiness, appetite changes, constipation/[CONDITION(S)]. The forms had checks that the medications [MEDICATION(S)] and [MEDICATION(S)] were administered. Review of the forms did not indicate any behaviors of drowsiness, or appetite changes. Review of an in service dated 3/15/22 indicated nurses were educated on the administration of PRN antipsychotic medications, the behaviors must be charted to justify the administration of medications. Was the behavior observed? What behavior was demonstrated by the resident to justify the medications? (hitting, kicking, screaming, pinching, biting, refusal of care, or delusional behaviors, etc. These notes are very important. Record review of Resident #1's Weights and Vitals Summary, dated 3/15/22, indicated the following: The Resident Was 66 inches tall. On 2/7/22 weight 143.6 lbs. On 2/16/22 weight 134.6 lbs. On 2/23/22 weight 128.2 lbs. On 3/4/22 weight 118 lbs. (re- weigh) The Summary indicated the DON requested a Re Weigh on 3/4/22. (25.6 Pounds loss) On 3/9/22 weight 119.2 lbs. (the resident was discharged on [DATE] to hospital.) Resident #1 lost 24.5 pounds at negative 17.8 percent weight loss. (to receive the percentage of weight loss, divide the amount of weight loss by the starting weight, and multiply by 100.) Review of the ADL sheets indicated around 2/18/22 the resident started to require assistance with for breakfast and lunch. The sheet indicated he did not receive assistance except on 2/20/22 he was listed as limited assist with one person. However, one of the aides that filled out the form with eating assistance was (CAC) CNA A filled in the breakfast and dinner activity and need for assistance ADL sheet. During an interview on 3/16/22 at 12:12 p.m. CNA A said the documentation was not right. She said she did not know the computer system well. She put 0 -1 independent with supervision. She said he required assistance most days. The other staff indicated for most days at dinner he was total dependent or required extensive assist of one person with meals for the later part of the month in February. Review of March 2022 -ADL Sheet indicated: Breakfast at 9 a.m. March 1, he at 0-25 percent March 2,3, 4, he ate 51- 75 percent March 5 blank, On March 6, 26-50 percent substitute offered, and he consumed 75 percent On March 7, 26-50 percent substitute offered, and he consumed 50 percent On March 8 -hospitalized Lunch at 1 p.m. On March 1 refused but at 50 percent of a substitute On March 2, he ate 51 to 75 percent On March 3 and 4, he ate 26-50 percent and 50 percent of a substitute On March 5, blank On March 6, and 7, he ate 51-75 percent Dinner at 6 p.m. On March 1, refused On March 2, refused On March 3, he ate 51-75 percent On March 4, refused On March 5, refused On March 6, he ate 25-50 percent On March 7, he refused but did eat 25 percent of a substitute Review of Resident #1's March eating with assistance: indicated one of the aides that assisted with eating (CAC) CNA A filled in the breakfast and lunch activity or need for assistance ADL sheet. She signed 5 of the 7 days. She said it was not right. She said she did not know the computer system well. She put 0 -1 independent with supervision. The other staff indicated for most days at dinner he was total dependent or required extensive assist of one person with meals for March. There was no documentation found on the ADL sheets or anywhere else in his record that mentioned hydration for Resident #1. Record review of Resident # 1's nursing notes indicated the following: -On 2/11/22 at 10:00 a.m. the Resident was outside trying to climb the fence; would not listen to aides they were trying to redirect him. RN Supervisor was notified, and she came and assessed the resident. Talked him into coming inside. Th NP was informed received a new order for [MEDICATION(S)] 0.5 mg two times a day and [MEDICATION(S)] 1mg as needed every 8 hours. -On 2/11/22 at 2:30 p.m. [MEDICATION(S)] 1 mg give 1 tablet by mouth every 8 hours as need for increased anxiety/exit seeking behaviors related to PBFAD. -On 2/13/22 at 12:39 a.m. as needed Klonipin given for agitation, wandering halls, and exit seeking behaviors. [Resident #1] took all his clothes off, urinated all through his bedroom, took mattress of the bed, took foot board off and pushed into the end under the bed, very agitated, Medication was ineffective. Notified RN and NP -On 2/13/22 at 10:06 a.m. Received clarification from NP to continue the as needed [MEDICATION(S)] order written but discontinue the scheduled [MEDICATION(S)] order related to new order for [MEDICATION(S)] since [MEDICATION(S)] appears to be ineffective. -On 2/15/22 at 11:32 a.m. started on [MEDICATION(S)] 50 mg two times a day. Resident was really sleepy this morning. -On 2/16/22 at 1:15 p.m. the Resident was agitated and anxious this morning before the morning dose of [MEDICATION(S)], after the dose of [MEDICATION(S)] was given the resident was calmer and more relaxed. -On 2/18/22 at 11:24 a.m. aide saw Resident attempting to climb the fence. The Aide was able to redirect the resident back into the facility. He was given 1 mg of [MEDICATION(S)] due to increased anxiety behaviors. -On 2/18/22 at 5:50 p.m. resident agitated, ripped part of the electrical plate off the wall, redirected with some effectiveness, will continue to monitor. -On 2/23 22 at 1:12 p.m. aide said Resident crawling on the floor taking off his clothes in front of staff other Residents. New order for [MEDICATION(S)] 0.5 mg, one time only he refused. An order received at 1:32 [MEDICATION(S)] 2 mg IM x one dose. At 3:22 p.m. [MEDICATION(S)] administered. -On 2/24/22 at 9:21 p.m. new order to increase [MEDICATION(S)] to 100 mg bid and start [MEDICATION(S)] 20 mg. -On 2/25/22 at 5:49 a.m. increase [MEDICATION(S)] tablet 50 mg to [MEDICATION(S)] 100 mg two times a day. -On 2/25/22 at 9:16 p.m. at dinner time the resident ate 100 percent and was cooperative after given as needed [MEDICATION(S)]. Initial dose of [MEDICATION(S)] 20 mg given earlier with no adverse reaction noted. No adverse reaction noted as well to increase dose of [MEDICATION(S)], in bed at this time, eyes closed and resting quietly. -On 2/28/22 at 2:22p.m. resident still needing [MEDICATION(S)] for anxiety and agitation. -On 3/3/22 at 10:41 a.m. responsible party met with [RN H] in house to discuss concerns with resident's . medications. The RN voiced concerns to the NP . New order to give [MEDICATION(S)] 50 mg in a.m. and 100 mg every evening for better quality of life and therapeutic effects. -On 3/3/22 at 8:40 p.m. the resident refused medications, waited for an hour and he still refused. He was asked if he wanted pudding. He nodded yes. When the nurse was giving the medications with pudding. He pushed the nurse's hand and medications and pudding sprayed on the floor and the bed. The resident did not say anything. -On 3/5/22 at 1:52 p.m. The resident has slept off and on this shift. He is awake currently. -On 3/7/22 at 2:51 p.m. resident refused vital signs the resident is being combative hitting staff oncoming nurse aware. -On 3/8/22 at 5:00 a.m. summoned to resident room per aide related to residents feeling warm upon entering the room. The resident was laying in right lateral position with eyes closed resident was hard to arouse but moved slightly when move, vital signs- blood pressure 96 / 56 heart notify120, respiration 30, temperature 99.6, oxygen saturation 88-93 at room air. Notified emergency services, at 5:17 a.m. notified responsible party in regards of changing condition and being sent to the hospital on 3/8/22. -On 3/8/22 at 2:28 p.m. (after resident hospitalization ) the RN spoke to the nurse practitioner regarding resident taking [MEDICATION(S)] 1 mg. The resident appeared overly sedated after taking this dose and may need a reduction. Receive a new order to decrease [MEDICATION(S)] to 0.5 every eight hours as needed. Re-evaluate if new orders received from the hospital. Record review of Dietician note for Resident #1 dated 3/9/22 at 12:53 p.m. (after hospitalization ) weight loss follow up revealed the current body weight was 118 pounds, Body Mass Index 19 - at risk for age. The resident has lost negative 17.8% in 30 days. His by mouth intake poor- variable average 50% per nurses note. Pertinent medications were multivitamins, fish oil, no updated labs, no skin breakdown noted. The resident had magic cups two times a day and carnation instant breakfast every day ordered. The resident had a finger food diet ordered. The resident may not be meeting needs at this time as evidenced by poor intake and weight loss. The MD to consider appetite stimulant goal was to maintenance weight loss of less than 5% and a good by mouth intake of more than 75 percent, signed by the Dietician. Record review of a discharge summary, dated 3/14/22, indicated Resident #1 was sent to the hospital on 3/8/22 due to increased altered mental status and abnormal vital signs. The family discharged the resident from the facility on 3/13/22. Record review of a Hospital History and Physical, dated 3/8/22 at 9:50 a.m., indicated Resident # 1's Assessment and Plan identified the principal problem for hospital admission as [CONDITION(S)] (the bodies extreme response to an infection) with acute [CONDITION(S)] without septic shock. The active problems were acute metabolic [CONDITION(S)] (a problem in the brain caused by a chemical imbalance in the blood), acute kidney injury (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days.), [CONDITION(S)] (too much sodium in the blood), acute urinary tract infection, elevated liver function test and abnormal CT of the head. The patient's sodium level is 171 and the sodium level is likely to explain the patient's mental status changes, the lack of nutrition is concerning. The patient presented with an altered mental status. Per the nursing facility the patient has gotten gradually more lethargic and had less by mouth intake over the last several days. Review of the Hospital Labs dated 3/8/22 showed a Comprehensive Metabolic Panel (measures 14 different substances in your blood. It provides important information about your body's chemical balance and metabolism. Metabolism is the process of how the body uses food and energy.) results: Sodium level 171 (range 133-145) (High Sodium, [CONDITION(S)] involves dehydration which can have many causes such as not drinking enough water. Chloride 141 (range 96-108) High levels of Chloride may indicate dehydration BUN (blood urea nitrogen) 109 (range 8-23) High levels mean you kidneys are not working Creatinine (a waste product that comes from the normal wear and tear on muscles of the body) 3 (range 0.6-1.3) Can indicate the kidneys are not working which could be from dehydration. [MEDICATION(S)] (protein made by your body)2.7 (range3.4-4.8) GFR (glomerular filtration rate-how much blood your kidneys filter each minute)18 (Kidney Damage (severe decreased in GFR 15-19) During a telephone interview with a family member on 3/15/22 at 9:34 a.m. they said Resident #1 had a complete physical on 1/18/22 prior to admission to the facility, and everything looked good. He was admitted to the facility on [DATE]. Resident #1 was very fit for his age; he could do 60 pushups at a time. Prior to coming to the facility, he was independent, he dressed himself and took his own showers. Resident #1 did not want to be there, he tried to escape every way he could. He tried to climb the fence several times, and he would pull off his clothes. The family member said LVN I said Resident #1 was eating but he was not eating a lot. He started sleeping through lunch. The family member said the facility drugged him up. Another family member tried to feed him a day or two before hospitalization . It took her 45 minutes to feed him pinches off a muffin and some milk. Resident #1 would put his thumbs on his lips like a small child. The family member said he told the head nurse (RN H) he wanted Resident #1's medications cut down and they needed to do something about his weight. He does not know if she did it or not. Resident #1 was still in the hospital, on a feeding tube, and had a drainage tube for his gall bladder. They did not know if he is going to live or not. During an interview on 3/15/22 at 10:28 a.m. CNA A said Resident #1 was an active person. He would take his clothes off, use the bathroom anywhere, BM or urine. When he first came, he did not require assistance with eating or dressing. He had a decline but did not like to be fed. He would not let them assist him. He would refuse to drink sometimes. She said later Resident #1 would sit, sleep, and eat. They gave him medications to keep him calm. He was still combative prior to hospitalization but did require more assistance. During an interview on 3/15/22 at 10:58 a.m., LVN K said on 3/7/22 Resident #1 had a change in condition. She said he was still combative, but she noticed a change. He was less active and more sedated. He was not eating. She said she let RN H Supervisor know and the NP. She told RN H and let the DON know to come and assess him because he was different. Before 3/7/22 the last time she saw him he was crawling around on the floor and more active. This time he was combative but in more of a leave me alone kind of way. On Sunday 3/6/7 he was in bed but appeared to be more combative. He got [MEDICATION(S)] quite often he also got a one-time dose of [MEDICATION(S)]. During an interview on 3/15/22 at 11:10 a.m. CNA C said she worked with Resident #1. A few days before hospitalization . Resident #1 appeared sedated and real tired compared to his usual self. During an interview on 3/15/22 at 11:13 a.m., LVN I said she was able to give Resident #1 his medications by crushing them and putting them in pudding or ice cream. LVN I said the resident had behaviors of trying to run away. He was forgetful and combative. He was placed on medications of [MEDICATION(S)] and Klonipin to help with those symptoms. She did not think he was hallucinating or delusional. He had a lot of other behaviors. She said he got [MEDICATION(S)] quite often to calm down. She said 3/4/22 was the last day she worked prior to his going to the hospital. During an interview on 3/15/22 at 12:15 p.m. the Assistant to Activities said prior to going to the hospital Resident #1 was not very active, for a few days. He was up but mostly just sitting around. He did not participate in her actives even when he was doing good. During an interview on 3/15/22 at 2:05 p.m. the DON said the reason Resident # 1 was on [MEDICATION(S)] was because of his behaviors. He was combative, took his clothes off, urinated in the floor, and climbed fences. The DON said the antipsychotic [MEDICATION(S)] was used to address the behaviors the resident exhibited. The DON said Resident #1 had a diagnosis of PBFAD that indicated it was fine to give him an antipsychotic. During an interview on 3/15/22 at 2:17 p.m., RN H said she saw Resident #1 the day before he went to the hospital. She said LVN K informed her on 3/7/22, he was not eating and was spitting out his medications. RN H said that was not anything new, she did not do any follow up. She told LVN K to let the NP know. RN H said she did have a meeting with the family member 3/3/22 and they were concerned about Resident #1 losing weight and he seemed more lethargic. She said yes it was after family intervention that they discussed the Magic cup and to lower his medications. She admitted Resident #1 to the facility on [DATE], and he was a lot more active on admission. She said part of his inactivity was due to the medications he was taking. The last time she saw him he was sitting at the table and the staff were trying to get him to eat and drink. She said he was prescribed [MEDICATION(S)] 100 mg two times a day and Resident #1 had a problem being sleepy all the time. They reduced the [MEDICATION(S)] to 50 mg. He was initially started on [MEDICATION(S)] on 2/11/22 his primary diagnosis was Unspecified Dementia. He was admitted on [DATE] received the PBFAD diagnosis on 2/11/11. During an interview o 3/15/22 at 2:58 p.m., RN G said Resident #1's condition had changed, he was more sedated. During an interview on 3/15/22 at 3:15 p.m., CNA B said a few days prior the Resident #1 's hospitalization he needed assistance with eating. He would sit around and sleep His would open his eyes, but he was still somewhat combative. Sometimes he would eat and drink, it depended on how he felt. During an interview on 3/16/22 at 6:43 a.m., RN F said she usually did not work with the residents. They were short staffed on the night of 3/7-3/8/22. She said she received information in report that Resident #1 had a gradual decline. She said an aide went in to change him and he was hard to arose. She had concerns about his low BP and high respirations and pulse. She sent him to the hospital early in the morning on 3/8/22. During an interview on 3/16/22 at 10:10 a.m. the DON said the family felt Resident #1 was sedated. She said there was no problem with the resident's medications, [MEDICATION(S)] or Klonipin. The diagnosis sheet indicated the diagnosis of PBFAD was not an applicable primary diagnosis. The DON said the PBFAD was not his primary diagnosis, that was all that indicated. On 3/18/22 at 2:30 p.m. DON said the only intervention they tried was to redirect Resident #1 but was not effective. She did not recall recommending a psychological consult and could not find documentation that one was requested. During an telephone interview on 3/18/22 at 4:10 p.m. the NP said she remembered Resident #1. She got calls about his behaviors 3 to 4 times a week if not every day. She had put him on an initial does of [MEDICATION(S)] 50 mg, two times a day. It did not seem to calm him down. So, she increased the dose to 100 mg two times daily. She said she had recommended he receive inpatient treatment but did not remember why her orders were not followed. (the ADM, cooperate nurse and DON all denied that happened they were present during the call.) Record review of the National Alliance of Mental Illness revealed [MEDICATION(S)] ([MEDICATION(S)]) is used to treat symptoms of hallucination, delusions, disorganized thinking, loss of desire to be around people, trouble speaking, and lack of motivation. It is used to treat Symptoms of [CONDITION(S)] and [CONDITION(S)] disorder. During an interview on 4/4/22 at 1:10 p.m. Resident #1's family member said Resident #1 lived with them prior to residing at the facility. Resident #1 was 86-years-old but strong. He could do 60 pushups at a time on his knuckles. He could do pull ups on a pull up bar. He said Resident #1 had sundowners( a state of confusion occurring in the late afternoon and spanning into the night) and had some behaviors and confusion, especially at night. He was never violent, and he did not believe half the things the facility said Resident #1 was doing. The family member said he talked to his nurse LVN I about 5 days prior to 3/3/22. He said they went to the facility on 3 occasions to see Resident #1 and he was in the bed asleep. He was so slee

Based on interview and record review the facility failed to ensure residents who have not used [CONDITION(S)] drugs are not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed (Resident #1) 1. The facility failed to try other interventions before placing Resident #1 on psychoactive medications. 2. The facility failed to identify adverse consequeses of the medications such as unplaned weight loss, decline in ADL fuctions, dehydration, subdued, sedated, lethargic, and mental status changes. These failures could place residents at risk for receiving psychoactive medications instead of other interventions to reduce their behaviors. Findings include: Record review of an Admission Record Resident Information Sheet indicated Resident #1 was an [AGE] year-old male admitted on [DATE] with diagnoses which included malignant neoplasm of prostate ([CONDITION(S)]), [CONDITION(S)] (high cholesterol), dementia (mental process disorder affecting memory, personality, and reasoning) without behavioral disturbance, atherosclerosis of coronary artery (plaque in the walls of blood vessels) bypass and low back pain. An additional diagnosis was added on 2/11//22 of Psychological and behavioral factors associated with disorders or diseases classified elsewhere. Record review of a diagnosis audit report indicated Resident #1 was given a diagnosis on 2/11/22 of Psychological and Behavioral Factors Associated with Disorders or Diseases Classified Elsewhere. The diagnosis details indicated it was not an acceptable primary diagnosis. Record review of Resident #1's MDS, dated [DATE], indicated his BIMS (Brief Interview for Mental Status) score was 9 ( a score of 8-12 moderately cognitive impairment.) The Preferences for Customary Routine and Activities had received shower, snacks between meals, staying up past 8 p.m. and a place to lock belongings. Resident #1's Behaviors indicated the resident had behaviors of wandering daily. The Potential indicator of [CONDITION(S)] was none. The Functional status listed for bed mobility and transfer between surfaced was supervision with set up help only. Dressing limited assistant with one person assist. Eating was independent with set up help only. Toilet use and personal hygiene was limited assist with one person assist. His active dwas Non- Alzheimer's Dementia. Record review of Resident #1's Care Plan, indicated he had a focus area of adjustment related to admission to the facility, dated 2/2/22. The goals were difficulties in psychological adjustment through next review date. The interventions were to observe for signs and symptoms of difficulties in psychological adjustment, decrease socialization, sad moods, and verbalized wants to go home. A Focus area was also a risk for increased confusion, dated 2/2/22. The intervention was to encourage and assist resident to be among others and involved in activities for mental stimulation and diversion. A Focus area was listed as a risk for exit seeking behaviors as evidenced by wandering the facility unaccompanied and he wears a wander guard, dated 2/18/22. The intervention were to attempt diversional activities as needed. A Focus area was at risk for weight loss related to dementia, dated 2/18/22. Some of the interventions were dietitian to evaluate nutritional status as needed and follow the facility weight loss protocol. A Focus area was activities of daily living. One of the interventions was the resident required supervision and set up with meals dated to 2/18/22. A Focus area indicated Resident #1 had anxiety and agitation and could be combative and he is taking psychoactive medications of [MEDICATION(S)] and Konopin, dated 2/18/22. Record review of Resident #1's consent form (with the facilities name and the physician's name) for antipsychotic or neuroleptic medication treatment form indicated: I believe the individual has the following psychiatric condition or maladaptive behavior. Psychosocial and Behavioral Factors Associated with Disorders or Disease Classification Classified Elsewhere. My diagnosis is based on the following dominant characteristics exhibited by this individual uncontrollable anger and irrational thinking. The following course of therapy with antipsychotic or neuroleptic medications is proposed with the following medications dosage and frequency, [MEDICATION(S)] 50 milligrams one by mouth two times a day. The risk and benefits in my clinical opinion the probable clinically significant side effects and risk of the proposed treatment with antipsychotic or neuroleptic medications are indicated: Serious side effects include restlessness, constant need to move, shakiness, tremor, and mental mood changes such as increased anxiety depression thoughts of suicide. Difficulty swallowing, Constipation, persistent abdominal pain, persistent nausea vomiting, loss of appetite, yellowing eyes or skin, interrupted breathing during sleep and trouble urinating. The need for and benefit of this proposed treatment and antipsychotic or neuroleptic medications is indicated: [MEDICATION(S)] is used to treat certain mental mood conditions such as [CONDITION(S)] [CONDITION(S)] disorder, certain episodes of [CONDITION(S)], or depression associated with [CONDITION(S)] disorder. (the resident did not have any of these diagnoses) [MEDICATION(S)] is known to be an antipsychotic atypical type it works to restore the balance in certain natural substances neurotransmitters in the brain. This medication can decrease hallucinations improve your concentration it helps you to think more clearly and positively about yourself feel less nervous and take more active part in everyday life. It may also improve your mood sleep appetite energy level. [MEDICATION(S)] can help prevent severe mood swings and decrease how often mood swings occur. It was digitally signed by the physician on 2/14/22 The consent form indicated a phone consent was received by Resident #1's Power of Attorney on 2/2/22 from the RN who also digitally signed the form on 2/14/22. According to the National Alliance on Mental Illness [MEDICATION(S)] carried a Black Box Warning- a Black box warnings are the most serious warnings the FDA issues. They warn doctors and patients about serious or life-threatening adverse drug reactions. Antipsychotics earned black box warning because they are associated with increased rates of stroke and death in older adults with dementia. Record review of the Physician orders, dated 3/15/22, indicated Resident #1 received [MEDICATION(S)] Tablet 0.5 mg give 1 table by mouth every 8 hours as needed for increased agitation and anxiety. [MEDICATION(S)] Tablet 100 mg give 1 tablet by mouth one time a day related to PBFAD. [MEDICATION(S)] Tablet 50 mg give 1 tablet by mouth one time a day related to PBFAD. Record review of the February Medication Administration Record indicated [MEDICATION(S)] 0.5 mg given by mouth two times a day for (PBFAD) with a start date of 2/11/22 and end date of 2/13/22. The MAR indicted the resident received [MEDICATION(S)] two times on 2/12/22 and one time on 2/13/22. Record review of the February MAR indicated Resident #1 received [MEDICATION(S)] 1 mg by mouth as need for increased anxiety and exit seeking behaviors related to (PBFAD) on the following days: -On 2/11/22 at 2:30 p.m. -On 2/13/22 at 12:39 a.m. and 5:33 p.m. -On 2/14/22 at 8:36 a.m. and 3:53 p.m. -On 2/18/22 at 11:24 a.m. and 10:45 p.m. -On 2/19/22 8:40 a.m. and 3:50 p.m. -On 2/20/22 at 4:30 p.m. -On 2/21/22 at 5:55 p.m. -On 2/22/22 at 4:44 p.m. -On 2/23/22 at 11:27n a.m. -On 2/24/22 6:19 p.m. -On 2/25/22 at 9:00 a.m. and 4:25 p.m. -On 2/26/22 at 8:20 a.m. and 7:00 p.m. -On 2/27/22 at 7:00 a.m. and 5:24 p.m. -On 2/28/22 at 7:30 a.m. and 5:35 p.m. Record review of the February 2020 MAR indicated [MEDICATION(S)] 50 mg to be given one table by mouth two times a day for anxiety and agitation related to (PBFAD) with a start dated of 2/14/22 and hold until 2/15/22 with an end date of 2/24/22. The MAR indicated Resident #1 received [MEDICATION(S)] 50 mg two times a day on 2/16/22 through 2/23/22 and one time on 2/24/22. Record review of the February 2022 MAR indicated [MEDICATION(S)] 100 mg to be given one table by mouth two times a day related to (PBFAD) with a start dated of 2/24/22 and an end date of 3/3/22. The MAR indicated the resident received [MEDICATION(S)] 100 mg one time on 2/24/22 and two times on 2/25/22, 2/26/22, 2/27/22 and 2/28/22. Record review of the March MAR indicated [MEDICATION(S)] 100 mg tablet was given 03/03/22 through 3/7/22. [MEDICATION(S)] 50 mg was given in the morning from 3/4/22 and 3/5/22 the resident refused on 3/6/22 and 3/7/22. [MEDICATION(S)] 100 mg 1 tablet by mouth two times a day related to PBFAD with a start dated of 2/24/22 and a discontinue date of 3/3/22. [MEDICATION(S)] 1 mg give one tablet by mouth every 8 hours as needs for increased agitation, anxiety, and exit seeking behaviors related to PBFAD. The record indicated the resident received the [MEDICATION(S)] 1 mg on the following days: -On 3/1/22 at 5:44 p.m. -On 3/2/22 at 7:30 a.m. and 5:24 p.m. -On 3/3/22 at 7:04 p.m. -On 3/5/2 at 4:59 p.m. -On 3/6/22 at 5:16 p.m. Record review of Resident # 1's nursing notes indicated the following: -On 2/11/22 at 10:00 a.m. the Resident was outside trying to climb the fence; would not listen to aides they were trying to redirect him. RN Supervisor was notified, and she came and assessed the resident. Talked him into coming inside. Th NP was informed received a new order for [MEDICATION(S)] 0.5 mg two times a day and [MEDICATION(S)] 1mg as needed every 8 hours. -On 2/11/22 at 2:30 p.m. [MEDICATION(S)] 1 mg give 1 tablet by mouth every 8 hours as need for increased anxiety/exit seeking behaviors related to PBFAD. -On 2/13/22 at 12:39 a.m. as needed Klonipin given for agitation, wandering halls, and exit seeking behaviors. [Resident #1] took all his clothes off, urinated all through his bedroom, took mattress of the bed, took foot board off and pushed in into the and under the bed, very agitated, Medication was ineffective. Notified RN and NP -On 2/13/22 at 10: 06 a.m. Received clarification from NP to continue the as needed [MEDICATION(S)] order written but discontinue the scheduled [MEDICATION(S)] order related to new order for [MEDICATION(S)] since [MEDICATION(S)] appears to be ineffective. -On 2/15/22 at 11:32 a.m. started on [MEDICATION(S)] 50 mg two times a day. Resident was really sleepy this morning. -On 2/16/22 at 1:15 p.m. the Resident was agitated and anxious this morning before the morning dose of [MEDICATION(S)], after the dose of [MEDICATION(S)] was given the resident was calmer and more relaxed. -On 2/18/22 at 11:24 a.m. aide saw Resident attempting to climb the fence. The Aide was able to redirect the resident back into the facility. He was given 1 mg of [MEDICATION(S)] due to increased anxiety behaviors. -On 2/18/22 at 5:50 p.m. resident agitated, ripped part of the electrical plate off the wall, redirected with some effectiveness, will continue to monitor. -On 2/23 22 at 1:12 p.m. aide said Resident crawling on the floor taking off his clothes in front of staff other Residents. New order for [MEDICATION(S)] 0.5 mg, one time only he refused. An order received at 1:32 [MEDICATION(S)] 2 mg IM x one dose. At 3:22 p.m. [MEDICATION(S)] administered. -On 2/24/22 at 9:21 p.m. new order to increase [MEDICATION(S)] to 100 mg bid and start [MEDICATION(S)] 20 mg. -On 2/25/22 at 5:49 a.m. increase [MEDICATION(S)] tablet 50 mg to [MEDICATION(S)] 100 mg two times a day. -On 2/25/22 at 9:16 p.m. at dinner time the resident ate 100 percent and was cooperative after given as needed [MEDICATION(S)]. Initial dose of [MEDICATION(S)] 20 mg given earlier with no adverse reaction noted. No adverse reaction noted as well to increase dose of [MEDICATION(S)], in bed at this time, eyes closed and resting quietly. -On 2/28/22 at 2:22p.m. resident still needing [MEDICATION(S)] for anxiety and agitation. -On 3/3/22 at 10:41 a.m. responsible party met with [RN H] in house to discuss concerns with resident's . medications. The RN voiced concerns to the NP . New order to give [MEDICATION(S)] 50 mg in a.m. and 100 mg every evening for better quality of life and therapeutic effects. -On 3/3/22 at 8:40 p.m. the resident refused medications, waited for an hour and he still refused. He was asked if he wanted pudding. He nodded yes. When the nurse was giving the medications with pudding. He pushed the nurse's hand and medications and pudding sprayed on the floor and the bed. The resident did not say anything. -On 3/5/22 at 1:52 p.m. The resident has slept off and on this shift. He is awake currently. -On 3/7/22 at 2:51 p.m. resident refused vital signs the resident is being combative hitting staff oncoming nurse aware. -On 3/8/22 at 5:00 a.m. summoned to resident room per aide related to residents feeling warm upon entering the room. The resident was laying in right lateral position with eyes closed resident was hard to arouse but moved slightly when move, vital signs- blood pressure 96 / 56 heart notify120, respiration 30, temperature 99.6, oxygen saturation 88-93 at room air. Notified emergency services, at 5:17 a.m. notified responsible party in regards of changing condition and being sent to the hospital on 3/8/22. -On 3/8/22 at 2:28 p.m. (after resident hospitalization ) the RN spoke to the nurse practitioner regarding resident taking [MEDICATION(S)] 1 mg. The resident appeared overly sedated after taking this dose and may need a reduction. Receive a new order to decrease [MEDICATION(S)] to 0.5 every eight hours as needed. Re-evaluate if new orders received from the hospital. Record review of a discharge summary, dated 3/14/22, indicated Resident #1 was sent to the hospital on 3/8/22 due to increased altered mental status and abnormal vital signs. The family discharged the resident from the facility on 3/13/22. Record review of a Hospital History and Physical, dated 3/8/22 at 9:50 a.m., indicated Resident # 1's Assessment and Plan identified the principal problem for hospital admission as [CONDITION(S)] (the bodies extreme response to an infection) with acute [CONDITION(S)] with out septic shock. The active problems were acute metabolic [CONDITION(S)] (a problem in the brain caused by a chemical imbalance in the blood), acute kidney injury (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days.), [CONDITION(S)] (too much sodium in the blood), acute urinary tract infection, elevated liver function test and abnormal CT of the head. The patient's sodium level is 171 and the sodium level is likely to explain the patient's mental status changes, the lack of nutrition is concerning. The patient presented with an altered mental status. Per the nursing facility the patient has gotten gradually more lethargic and had less by mouth intake over the last several days. During a telephone interview with a family member on 3/15/22 at 9:34 a.m. they said Resident #1 had a complete physical on 1/18/22 prior to admission to the facility, and everything looked good. He was admitted to the facility on [DATE]. Resident #1 was very fit for his age; he could do 60 pushups. Prior to coming to the facility, he was independent, he dressed himself and took his own showers. Resident #1 did not want to be there, he tried to escape every way he could. He tried to climb the fence several times, and he would pull off his clothes. The family member said LVN I said Resident #1 was eating but he was not eating a lot. He started sleeping through lunch. The family member said the facility drugged him up. Another family member tried to feed him a day or two before hospitalization . It took her 45 minutes to feed him pinches off a muffin and some milk. Resident #1 would put his thumbs on his lips like a small child. The family member said he told the head nurse (RN H) he wanted Resident #1's medications cut down. He does not know if she did it or not. Resident #1 was still in the hospital, on a feeding tube, and had a drainage tube for his gall bladder. They did not know if he is going to live or not. During an interview on 3/15/22 at 10:28 a.m. CNA A said Resident #1 was an active person. He would take his clothes off, use the bathroom anywhere, BM or urine. When he first came, he did not require assistance with eating or dressing. He had a decline but did not like to be fed. He would not let them assist him. He would refuse to drink sometimes. She said later Resident #1 would sit, sleep, and eat. They gave him medications to keep him calm. He was still combative prior to hospitalization but did require more assistance. During an interview on 3/15/22 at 10:58 a.m., LVN K said on 3/7/22 Resident #1 had a change in condition. She said he was still combative, but she noticed a change. He was less active and more sedated. He was not eating. She said she let RN H Supervisor know and the NP. She told RN H and let the DON know to come and assess him because he was different. Before 3/7/22 the last time she saw him he was crawling around on the floor and more active. This time he was combative but in more of a leave me alone kind of way. On Sunday 3/6/7 he was in bed but appeared to be more combative. He got [MEDICATION(S)] quite often he also got a one-time dose of [MEDICATION(S)]. During an interview on 3/15/22 at 11:10a.m. CNA C said she worked with Resident #1. A few days before hospitalization . Resident #1 appeared sedated and real tired compared to his usual self. During an interview on 3/15/22 at 11:13 a.m., LVN I said she was able to give Resident #1 his medications by crushing them and putting them in pudding or ice cream. LVN I said the resident had behaviors of trying to run away. He was forgetful and combative. He was placed on medications of [MEDICATION(S)] and Klonipin to help with those symptoms. She did not think he was hallucinating or delusional. He had a lot of other behaviors. She said he got [MEDICATION(S)] quite often to calm down. She said 3/4/22 was the last day she worked prior to his going to the hospital. During an interview on 3/15/22 at 12:15 p.m. the Assistant to Activities said prior to going to the hospital Resident #1 was not very active, for a few days. He was up but mostly just sitting around. He did not participate in her actives even when he was doing good. During an interview on 3/15/22 at 2:05 p.m. the DON said the reason Resident # 1 was on [MEDICATION(S)] was because of his behaviors. He was combative, took his clothes off, urinated in the floor, and climbed fences. The DON said the antipsychotic [MEDICATION(S)] was used to address the behaviors the resident exhibited. The DON said Resident #1 had a diagnosis of PBFAD that indicated it was fine to give him an antipsychotic. During an interview on 3/15/22 at 2:17 p.m., RN H said she saw Resident #1 the day before he went to the hospital. She said LVN K informed her on 3/7/22, he was not eating and was spitting out his medications. RN H said that was not anything new, she did not do any follow up. She told LVN K to let the NP know. RN H said she did have a meeting with the son on 3/3/22 and the son was concerned about Resident #1 losing weight and he seem more lethargic. She said yes it was after family intervention that they discussed the Magic cup and to lower his medications. She admitted Resident #1 to the facility on [DATE], and he was a lot more active on admission. She said part of his inactivity was due to the medications he was taking. The last time she saw him he was sitting at the table and the staff were trying to get him to eat and drink. She said he was prescribed [MEDICATION(S)] 100 mg two times a day and Resident #1 had a problem being sleepy all the time. They reduced the [MEDICATION(S)] to 50 mg. He was initially started on [MEDICATION(S)] on 2/11/22 his primary diagnosis was Unspecified Dementia. He was admitted on [DATE] received the PBFAD diagnosis on 2/11/11. During an interview o 3/15/22 at 2:58 p.m., RN G said she was the supervisor Resident #1's condition had changed, he was more sedated. During an interview on 3/15/22 at 3:15 p.m., CNA B said a few days prior the Resident #1 's hospitalization he needed assistance with eating. He would sit around and slept. His would open his eyes, but he still somewhat combative. Sometimes he would eat and drink, it depended on how he felt. During an interview on 3/16/22 at 6:43 a.m., RN F said she usually did not work with the residents. They were short staffed on the night of 3/7-3/8/22. She said she received information in report Resident #1 had a gradual decline. She said an aide went in to change him and he was hard to arose. She had concerns about his low BP and high respirations and pulse. She sent him to the hospital early morning on 3/8/22. During an interview on 3/16/22 at 10:10 a.m. the DON said the family felt Resident #1 was sedated. She said there was no problem with the resident's medications, [MEDICATION(S)] or Klonipin. The Diagnosis sheet indicated the diagnosis of PBFAD was not an applicable primary diagnosis. The DON said the PBFAD was not his primary diagnosis, that was all that indicated. On 3/18/22 at 2:30 p.m. DON said the only intervention they tried was to redirect Resident #1 but was not effective. She did not recall recommending a psychological consult and could not find documentation that one was requested. During an interview on 3/18/22 at 4:10 p.m. the NP said she remembered Resident #1. She got calls about his behaviors 3 to 4 times a week if not every day. She had put him on an initial does of [MEDICATION(S)] 50 mg, two times a day. It did not seem to calm him down. So, she increased the dose to 100 mg two times daily. She said she had recommended he receive inpatient treatment but did not remember why her orders were not followed. (the ADM, cooperate nurse and DON all denied that happened.) Record review of the National Alliance of Mental Illness revealed [MEDICATION(S)] ([MEDICATION(S)] ) is used to treat symptoms of hallucination, delusions, disorganized thinking, loss of desire to be around people, trouble speaking, and lack of motivation. It is used to treat Symptoms of [CONDITION(S)] and [CONDITION(S)] disorder.

Based on interview and record review the facility failed to ensure a resident whose assessment did not reveal or who did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1) reviewed for behaviors. Facility failed to provide Resident #1 with timely assessments and alternatives to psychotic medications. This failure could place residents at risk for not receiving timely assessments and interventions to prevent behavioral adjustment issues. Findings include: Record review of an Admission Record Resident Information Sheet indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 required a secure locked unit. Related to the resident is at risk for wandering and lacked understanding of safety with a start date of 2/5/22. Record review of Resident #1's MDS, dated [DATE], indicated his BIMS (Brief Interview for Mental Status) score was 9 (8-12 moderately impaired cognition.) Resident #1's behaviors indicated the resident had behaviors of wandering daily. The Potential indicator of [CONDITION(S)] was none. The Functional status listed for bed mobility and transfer between surfaced was supervision with set up help only. Dressing limited assistant with one person assist. Eating was independent with set up help only. Toilet use and personal hygiene was limited assist with one person assist. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Care Area Assessment (CAA) Summary, dated 2/9/22, indicated Activities was identified in both the Care Area triggered and the Care Planning and Decision areas. CAA date was 2/15/22. Record review of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care Plan indicated he had a Focus area of adjustment related to admission to the facility dated 2/2/22. The goals were difficulties in psychological adjustment through next review date. The interventions were to observe for signs and symptoms of difficulties in psychological adjustment, decrease socialization, sad moods, and verbalizes wants to go home. A Focus area was also a risk for increased confusion dated 2/2/22. The intervention was to encourage and assist resident to be among others and involved in activities for mental stimulation and diversion. A Focus area was listed as a risk for exit seeking behaviors as evidenced by wandering the facility unaccompanied and he wears a wander guard dated 2/18/22. The intervention were to attempt diversional activities as needed. A Focus area was at risk for weight loss related to dementia dated 2/18/22. Some of the interventions were dietitian to evaluate nutritional status as needed and follow the facility weight loss protocol. A Focus area was activities of daily living. One of the interventions was the resident required supervision and set up with meals dated to 2/18/22. A Focus area indicated Resident #1 had anxiety and agitation and could be combative and he is taking psychoactive medications of [MEDICATION(S)] and [MEDICATION(S)] dated 2/18/22. The interventions were to document target behaviors, notify physician as needed, psych consults as needed and routine pharmacy audits. There was no Care Plan area found for Activities. Record review of Resident #1's initial Activity Assessment, dated 2/9/22, indicated activity pursuit patterns, the resident liked cards, games, music, walking outdoors, watching TV, watching movies, and parties and social events. The resident was currently interested in walking outdoors, watching TV, watching movies and parties. He liked to participate in scheduled activities in the morning and in the afternoon. He preferred activity setting of his own room or the activity room. He liked to get up when the sun came up and go to bed when the sun went down. He also said he liked to take naps at random times of the day. The Resident Quotes and Adjustment to placement questions were left blank. The Assessment indicated Resident #1's attitude was uncooperative, but he seemed interested in activities in general. The Assessment was signed by the AD on 2/11/22. Record review of Resident # 1's nursing noted indicated the following: -On 2/3/22 at 2:40 p.m. day two a new admit. The resident is very confused on whereabouts. He continues to wander into other rooms. He is constantly walking and looking for his family. The resident can be redirected but it only lasts for a few minutes. His appetite is good. The resident requires no assist with ADLs. He is continent of bowel and bladder and able to feed self. He ambulates independently. Gait steady. -On 2/3/22 at 5:45 p.m. the wander guard alarm sounded. A male staff saw the resident walk out the front door and followed the resident. Attempting several times to give the resident redirection. Which the resident refused; the staff continued to stay with the resident. Housekeeping staff, seeing the situation was able to redirect the resident back inside. The nurse directed to the resident to the recliner in the TV area and covered resident with a blanket. He closed his eyes and relaxed. The nurse notified RN Supervisor and DON. -On 2/4/22 at 12:48 p.m. the resident was moved to the C house (a locked unit.) He was alert confused and ambulating himself without assistance. Signed by RN H. -On 2/4/22 at 10:47 p.m. the resident is ambulatory, friendly to both staff and other residents. He denied pain or discomfort. -On 2/5/22 at 9:42 p.m. at the start of the shift, as staff were going inside C house [Resident #1] just got out through the door quickly, staff including this nurse apprehended him, but he walked fast toward the E and F houses. RN Supervisor was call and came out as well. The nurses were able to talk him back to C house via the back patio. The resident is calm and conversant and confused as usual; noted that his personal alarm is not functioning. Closely monitor. -On 2/6/22 at 10:02 p.m. the resident was noted to walk around and peep outside and would ask staff for a key. Redirection done as needed. No elopement noted. -On 2/8/22 at 11:14 a.m. observed resident in dining room eating breakfast socializing with other residents. No complaints Signed by LVN K -On 2/8/22 at 4:37 p.m. the resident fell trying to get out the door when staff was entering building. The resident is confused at times, unable to explain what happened. Signed RN H -On2/9/22 at 6:51 a.m. Urine collected for a UA (results negative the same date) -On 2/9/22 at 2:00 p.m. the resident was trying to get out the front door as Aide was coming into the house. He grabbed the Aide's wrist hard as he was trying to get out. Signed by LVN I -On 2/10/22 at 8:53 a.m. IDT (interdisciplinary team) note, met to review the resident fall on 2/8/22 put interventions in place redirection and staff educated. -On 2/11/22 at 10:00 a.m. the resident was outside trying to climb the fence; would not listen to aides they were trying to redirect him. RN Supervisor was notified, and she came and assessed the resident. Talked him into coming inside. Th NP was informed received a new order for [MEDICATION(S)] 0.5 mg two times a day and [MEDICATION(S)] 1 mg as needed every 8 hours. Signed By LVN I -On 2/11/22 at 2:30 p.m. [MEDICATION(S)] 1 mg give 1 tablet by mouth every 8 hours as need for increased anxiety/exit seeking behaviors related to PBFAD. Signed by LVN I -On 2/15/22 at 11:32 a.m. Resident started on [MEDICATION(S)] 50 mg two times a day. Resident was really sleepy this morning. -On 2/16/22 at 1:15 p.m. the resident was agitated and anxious this morning before the morning dose of [MEDICATION(S)], after the dose of [MEDICATION(S)] was given the resident was calmer and more relaxed. -On 2/18/22 at 11:24 a.m. the aide saw resident attempting to climb the fence. The aide was able to redirect the resident back into the facility. He was given 1 mg of [MEDICATION(S)] due to increased anxiety behaviors. -On 2/18/22 at 5:50 p.m. Resident agitated, ripped part of the electrical plate off the wall, redirected with some effectiveness, will continue to monitor. -On 2/23 22 at 1:12 p.m. the aide said Resident crawling on the floor taking off his clothes in front of staff and other Residents. New order for [MEDICATION(S)] 0.5 mg, one time only he refused. An order received at 1:32 [MEDICATION(S)]( antipsychotic medication) 2mg IM x one dose. At 3:22 p.m. [MEDICATION(S)] administered. -On 2/24/22 at 9:21 p.m. new order to increase [MEDICATION(S)] to 100 mg bid and start [MEDICATION(S)](anitdepression medication) 20 mg. -On 2/25/22 at 5:49 a.m. increase [MEDICATION(S)] tablet 50 mg to [MEDICATION(S)] 100 mg two times a day. -On 2/25/22 at 9:16 p.m. at dinner time the resident ate 100 percent and was cooperative after given as needed [MEDICATION(S)]. Initial dose of [MEDICATION(S)] 20 mg given earlier with no adverse reaction noted. No adverse reaction noted as well to increase dose of [MEDICATION(S)], in bed at this time, eyes closed and resting quietly. -On 2/28/22 at 2:22p.m. Resident still needing [MEDICATION(S)] for anxiety and agitation. - On 3/3/22 at 10:41 a.m. responsible party met with [RN H] in house to discuss concerns with resident's weight loss and medications. The RN voiced concerns to the NP. Received new order to start magic cups with lunch and dinner instead of ice cream cups related to weight loss. New order to give [MEDICATION(S)] 50 mg in a.m. and 100 mg every evening for better quality of life and therapeutic effects. Signed by RN H. -On 3/3/22 at 8:40 p.m. the resident refused medications, waited for an hour and he still refused. He was asked if he wanted pudding. He nodded yes. When the nurse was giving the medications with pudding. He pushed the nurse's hand and medications and pudding sprayed on the floor and the bed. The resident did not say anything. - -On 3/7/22 at 2:51 p.m. the resident refused vital signs the resident is being combative hitting staff oncoming nurse aware. Signed by LVN K. -On 3/8/22 at 5:00 a.m. summoned to resident room per aide related to residents feeling warm upon entering the room. The resident was laying in right lateral position with eyes closed resident was hard to arouse but moved slightly when moved, vital signs- blood pressure 96 / 56 heart notify 120, respiration 30, temperature 99.6, oxygen saturation 88-93 at room air. Notified emergency services, at 5:17 a.m. notified responsible party in regards of changing condition and being sent to the hospital on 3/8/22. Signed by RN F. -On 3/8/22 at 2:28 p.m. (after resident hospitalization ) the RN spoke to the nurse practitioner regarding resident taking [MEDICATION(S)] 1 mg. The resident appeared overly sedated after taking this dose and may need a reduction. Received a new order to decrease [MEDICATION(S)] to 0.5 mg every eight hours as needed. Re-evaluate if new orders received from the hospital. Signed by RN H. Record review of a discharge summary, dated 3/14/22, indicated Resident #1 was sent to the hospital on 3/8/22 due to increased altered mental status and abnormal vital signs. The family discharged the resident from the facility on 3/14/22. Record review of a Hospital History and Physical, dated 3/8/22 at 9:50 a.m., indicated Resident # 1's Assessment and Plan identified the principal problem for hospital admission as [CONDITION(S)] (the bodies extreme response to an infection) with acute renal failure without septic shock. The active problems were acute metabolic [CONDITION(S)] (a problem in the brain caused by a chemical imbalance in the blood), acute kidney injury (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days.), [CONDITION(S)] (too much sodium in the blood), acute urinary tract infection, elevated liver function test and abnormal CT of the head. The patient's sodium level is 171 ( two common causes insufficient fluid intake and too much water loss) (normal sodium level between 135-145) and the sodium level is likely to explain the patient's mental status changes, the lack of nutrition is concerning. The patient presented with an altered mental status. Per the nursing facility the patient has gotten gradually more lethargic and had less by mouth intake over the last several days. During a telephone interview with a family member on 3/15/22 at 9:34 a.m. they said Resident #1 had a complete physical on 1/18/22 prior to admission to the facility, and everything looked good. He was admitted to the facility on [DATE]. Resident #1 was very fit for his age; he could do 60 pushups. Prior to coming to the facility, he was independent, he dressed himself and took his own showers. Resident #1 did not want to be there, he tried to escape every way he could. He tried to climb the fence several times, and he would pull off his clothes. The family member said LVN I said Resident #1 was eating but he was not eating a lot. He started sleeping through lunch. The family member said the facility drugged him up. Another family member tried to feed him a day or two before hospitalization . It took her 45 minutes to feed him pinches off a muffin and some milk. Resident #1 would put his thumbs on his lips like a small child. The family member said he told the head nurse (RN H) he wanted Resident #1's medications cut down. He does not know if she did it or not. Resident #1 was still in the hospital, on a feeding tube, and had a drainage tube for his gall bladder. They did not know if he is going to live or not. During an interview on 3/15/22 at 10:28 a.m., CNA A said Resident #1 was athletic, and active. He would take his clothes off, use the bathroom anywhere, BM or urine. When he first came, he did not require assistance with eating or dressing. He had a decline but did not like to be fed. He would not let staff assist him. He would refuse to drink sometimes. She said later Resident #1 would sit, sleep, and eat. They gave him medications to keep him calm. He was still combative prior to hospitalization but did require more assistance. During an interview on 3/15/22 at 10:36 a.m. with CNA E she said when Resident #1 first arrived he was combative. He just wanted to leave. He tried to climb the fence. He got up the fence two times. She said he would try to run out the door whenever someone opened it. He was very athletic and getting out was his only focus. When they tried to change him, he would fight. He would pull off his clothes. She said he did calm down, but he was still strong. He would fight but required assistance with eating. He did not like for them to feed him so he was given finger foods he could eat on his own. During an interview on 3/15/22 at 10:58 a.m., LVN K said on 3/7/22 Resident #1 was less active and more sedated. She said he was still combative, but she noted a change. He was not eating. She said she let RN H Supervisor know and the NP. She told RN H and let the DON know to come and assess him because he was different. Before 3/7/22 the last time she saw him he was crawling around on the floor and more active. This time he was combative but in more of a leave me alone kind of way. On Sunday 3/6/22 he was in bed but appeared to be more combative. During an interview on 3/15/22 at 11:10 a.m. CNA C said she worked with Resident #1. A few days before hospitalization Resident #1 appeared kind of sedated and real tired compared to his usual self. During an interview on 3/15/22 at 11:13 a.m., LVN I said Resident #1 had behaviors of trying to run away. He was forgetful and combative. He was placed on medications of [MEDICATION(S)] and Klonipin to help with those symptoms. She did not think he was hallucinating or delusional. He had a lot of other behaviors. She said he got [MEDICATION(S)] quite often to calm down. She said 3/4/22 was the last day she worked prior to his going to the hospital. LVN I said on that day he sat at the table confused, But staff fed him ice cream. She said he was his normal self but needed assistance with eating. He could not hold a cup he used both hands. During an interview on 3/15/22 at 12:15 p.m. the Assistant to Activities said prior to going to the hospital Resident #1 was not very active, for a few days. He was up but mostly just sitting around. He did not participate in her activities even when he was doing good. During an interview on 3/15/22 at 2:05 p.m., the DON said the reason Resident # 1 was on [MEDICATION(S)] was because of his behaviors. He was combative, took his clothes off, urinated on the floor and climbed fences. During an interview on 3/15/22 at 2:17 p.m., RN H said she saw Resident #1 the day before he went to the hospital. She said LVN K informed her on 3/7/22, he was not eating and wasspitting out his medications. RN H said that was not anything new, she did not do any follow up. She told LVN K to let the NP know. She admitted Resident #1, and he was a lot more active on admission. She said part of his inactivity was due to the medications he was taking. The last time she saw him he was sitting at the table and the staff were trying to get him to eat and drink. During an interview o 3/15/22 at 2:58 p.m. RN G said she was the supervisor and the last time she saw him he was crawling around on the floor. She had seen him on one occasion trying to climb the fence so, and stated the resident had declined. During an interview on 3/16/22 at 6:43 a.m., RN F said she usually did work with the residents. They were short staffed on the night of 3/7-3/8/22. She said she received information in report Resident #1 had a gradual decline. She said an aide went in to change him and he was hard to arose. She had concerns about his low BP and high respirations and pulse. She sent him to the hospital early morning on 3/8/22. During an interview and record review on 3/16/22 at 10:10 a.m., the DON said She was not aware he had a change in condition. She was informed they sent him out to the hospital. She was aware of family discussion on 3/3/22 the family felt Resident #1 was sedated. She said there was no problem with the resident's medications, [MEDICATION(S)] or [MEDICATION(S)]. He needed the medications due to his behaviors. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said the PBFAD was not his primary diagnosis, that was all that indicated. He received the [MEDICATION(S)] an [MEDICATION(S)] because of his behaviors. He would try to elope, climb the fence, tear up his room, urinate and BM on the floor, crawl on the floor. He would resist care. The [MEDICATION(S)] and [MEDICATION(S)] calmed him down. During an interview on 3/16 at 12:12 p.m., CNA J said when Resident # 1 first came, and he was athletic he could use his arms and raise his whole body out of the chair. He was transferred to the C House (a locked unit) because of his elopement attempts. Resident # 1 was mostly independent with his ADLs. She said Resident #1 had behaviors of pulling off his clothes. He was stronger than the other residents and aggressive. He would push you through the door to get outside. He would fight or resist. Resident #1 would stand up and have a BM in the floor. He would not use the actual bathroom. She said you could tell by looking at him, he had lost weight. He would not eat. CNA J said the day before he went out to the hospital he was still trying to fight. He appeared tired and sleepy. She said she was with LVN K when she tried to give him his medications. He was still strong he hit the cup and knocked it across the room. She said that he would not eat and tied to give him a magic cup and some milk. She said you could see a decline, but he was still fighting, and she would take him from his room to the dining room and by the time she got there he was already naked. She said that when she left at 3:00 p.m. on 3/7/22, he was in the bed asleep. During an interview on 3/16/22 at 12:20 p.m., CNA A said the closer to Resident #1's hospitalization he required more assistance with everything. Sometimes he would let them help him. He had a hard time feeding himself. He would allow them to put the food on the spoon and let him put the spoon to his mouth. CNA A said she had filled out the information on the computer about his meals and the assistance requires. However, she was not sure if she did it accurately. Resident #1 did require assistance with eating for about a week or two prior to hospitalization . On 3/18/22 at 2:30 p.m., the DON said the only intervention they tried was to redirect Resident #1 but was not effective. She did not recall recommending a psychological consult and could not find documentation that one was requested. During an interview on 3/18/22 at 4:10 p.m. the NP said she remembered Resident #1. She got calls about Resident #1's behaviors 3 to 4 times a week if not every day. She had put him on an initial does of [MEDICATION(S)] 50 mg, two times a day. It did not seem to calm him down. So, she increased the dose to 100 mg two times daily. She said she had recommended he receive inpatient treatment but did not remember why her orders were not followed, (the ADM, cooperate nurse and DON all denied that happened.) During an interview on 3/21/22 at 8:08 a.m., the AD said Resident #1 did not participate in many activities and if he did it was not for long, less than 5 minutes. After review of Resident #1's Care Plan, the AD said she did not generate a Care Plan for him. She was not sure why she did not. The AD said none of the activates she tried with other residents worked for him, such as activity boards, board games or movies. She said he would say those games were childish. The AD said during her initial interview with him and the family. Resident # 1 seemed upset, so she did not ask any detailed questions about the things he liked to do. When she asked him what he wanted to do, he would say he wanted to go home and drink coffee. When he was taken outside when he saw the gate he would attempt to leave. He would become physical when agitated. He would be verbally aggressive and try to hit. When he was climbing the fence once she tried to hold him. The AD said she did not know how far he could have gotten, but he was going up. He was a very active man. He changed after he received the medications. He was different. All he did was set. She said she asked LVN I why he was so sleepy. LVN I said it was because of the medications he received for agitation. LVN I told her he would try to push, fight, or slap at people if they bothered him. He was no longer pacing or walking around that had stopped, he just sat and slept all the time. During an interview on 3/21/22 at 8:39 a.m., the Social Worker said she did not know Resident #1 was an elopement risk when he was admitted . They called her to the house to conduct a BIMs (9) on him because he tried to elope. The facility put a wander guard on him and that was not working, so they moved him to the C house Which was a memory support unit (MSU) -locked unit. She said Resident #1 was an active man, he never sat down, wandered the unit, and walked around. The week before hospitalization he sat at the dining room table with the other guys asleep, sometimes. That was a different behavior from when he first came to the facility and he was constantly on the move. The Social Worker said nurses would let her know if a referral for counseling services was needed. She said she never received a referral for Resident # 1. The Social Worker said they did have some residents on counseling services that had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/21/22 at 9:08 a.m. with the DM she said when Resident #1 was first admitted he constantly walked. She thought he was losing weight because he never sat downThe Aides were concerned that he would not sit. Then they gave him some medications and he was not wandering as much. He started to need assistance with meals. During an interview with on 3/21/22 at 10:00 a.m. the DON said they did not conduct and IDT meeting regarding Resident #1's behaviors.

Based on interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance unless the resident's clinical condition demonstrated that this was not possible or the residents preferences indicated otherwise for 1 of 5 Residents (Resident #1) reviewed. 1. The facility failed to ensure Resident #1 received nutritional supplements as ordered. 2. The facility failed to assess Resident #1 when he had a change in behaviors. 3. The facility failed to ensure Resident #1's comprehensive assessment was updated after he had a change in behaviors. 4. The facility failed to consult a Dietitian or a physician for possible interventions regarding Resident #1. 5. The facility failed to ensure Resident #1 did not have significant weight loss. The resident lost 25.8 pounds in 30 days. These failures could place residents at risk for significant weight loss. Findings include: Record review of an Admission Record Resident Information Sheet indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS, dated [DATE], indicated his BIMS score was 9 (8-12 moderately impaired cognition). Resident #1's behaviors indicated the resident had behaviors of wandering daily. The potential indicator of [CONDITION(S)] was none. The functional status listed for bed mobility and transfer between surfaces was supervision with set up help only. Dressing limited assistant with one person assist. Eating was independent with set up help only. Toilet use and personal hygiene was limited assist with one person assist. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care Plan revealed a Focus area was at risk for weight loss related to dementia dated 2/18/22. Some of the interventions were dietitian to evaluate nutritional status as needed and follow the facility weight loss protocol. A focus area was Activities of Daily Living. One of the interventions was the resident required supervision and set up with meals dated to 2/18/22. A focus area indicated Resident #1 had anxiety and agitation and could be combative and was on psychoactive medications of [MEDICATION(S)] and [MEDICATION(S)], dated 2/18/22. Some of the interventions were Document target behaviors, notify physician as needed, psyche consults as need. Record review of computerized physician orders, dated 3/15/22, indicated: The Diet order Summary: Regular diet with finger food texture active dated 3/3/22 Carnation instant Breakfast two times a day for decreased appetite on hold from 3/4/22 to 3/9/22. Magic Cup two times a day give with lunch and dinner meals on hold (no documented reason for the hold) from 3/4/22 to 3/11/22. Monthly weights in the morning starting on the 5th of the month and ending on the 5th every month. Dated 2/2/22 with a start date of 2/5/22. May open/crush medications as allowed by pharmacist directive guidelines, may give in food and or liquids. Record review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (no mention of Boost on the physician orders) Resident #1 received Boost one time on 2/26 and two times on 2/27/22. The February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Then placed on hold from 2/26/22- 2/28/22. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the March MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated ice cream was given two times on 3/1/22 and 3/2/22. The March MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The March MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (no documented reason for the hold) Record review of Resident #1's Weights and Vitals Summary, dated 3/15/22, indicated the following: The Resident Was 66 inches tall. On 2/7/22 weight 143.6 lbs. On 2/16/22 weight 134.6 lbs. On 2/23/22 weight 128.2 lbs. On 3/4/22 weight 118 lbs. (re- weigh) The Summary indicated the DON requested a Re Weigh on 3/4/22. On 3/9/22 weight 119.2 lbs. (the resident was discharged on [DATE]. Resident #1 lost 24.5 pounds at negative 17.8 percent weight loss. (to receive the percentage of weight loss, divide the amount of weight loss by the starting weight, and multiply by 100.) Record review of a nutritional assessment, dated 2/21/22, indicated Resident #1 had significant weight loss of negative 6.3% in nine days. His appetite was listed as fair, no problems chewing, no problem swallowing, and no problems with liquid. He required no assistance with eating. The dietitian's assessment note indicated the resident was admitted to the facility on [DATE]. The resident was exit seeking and had lost a significant amount of weight since his admission. The resident walked around the facility often and may not be sitting down to eat meals. The resident was likely not meeting needs at this time as evidenced by weight loss. Recommended to add finger foods to all trays as possible the goal was to maintain weight at less than 5% with a good oral intake of greater than 75% will continue to monitor, signed by the Dietician. Record review of nursing notes indicated the following: -On 2/8/22 at 11:14 a.m. observed resident in dining room eating breakfast socializing with other residents. No complaints Signed by LVN K. -On 2/22/22 at 10:48 p.m. Resident had 50 percent of dinner, encouraged to take ice-cream as well, but took only half. -On 2/25/22 at 1:47 p.m. new order for Carnation Breakfast for decrease in appetite two times a day. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . -On 2/25/22 at 9:16 p.m. at dinner time the resident ate 100 percent and was cooperative after given as needed [MEDICATION(S)]. Initial dose of [MEDICATION(S)] 20 mg given earlier with no adverse reaction noted. No adverse reaction noted as well to increase dose of [MEDICATION(S)], in bed at this time, eyes closed and resting quietly. -On 2/26/22 at 9:53 p.m. at the earlier part of this shift Resident started to undress self and had his mattress inverted about 7:00 p.m. -redirection done PRN [MEDICATION(S)] given as was effective. Carnation instant breakfast not in yet. Ensure given and he took it all. -On 2/26/22 at 10:37 p.m. noted a new order for Boost 2 times a day until Carnation instant Breakfast Available. -On 3/3/22 at 9:30 a.m. new recommendation from Dietitian to add finger foods to all trays as possible. Signed by RN F. -On 3/3/22 at 10:41 a.m. responsible party met with [RN H] in house to discuss concerns with resident's weight loss and medications. The RN voiced concerns to the NP. Received new order to start magic cups with lunch and dinner instead of ice cream cups related to weight loss. New order to give [MEDICATION(S)] 50 mg in a.m. and 100 mg every evening for better quality of life and therapeutic effects. Signed by RN H. -On 3/8/22 at 5:00 a.m. summoned to resident room per Aide related to Residents feeling warm upon entering the room. The resident was laying in right lateral position with eyes closed resident was hard to arouse but moved slightly when move, vital signs- blood pressure 96 / 56 heart notify 120, respiration 30, temperature 99.6, oxygen saturation 88-93 at room air. Notified emergency services, at 5:17 a.m. notified responsible party in regards of changing condition and being sent to the hospital on 3/8/22. Signed by RN F. -On 3/8/22 at 2:28 p.m. (after resident hospitalization ) the RN spoke to the nurse practitioner regarding resident taking [MEDICATION(S)] 1 mg. The resident appeared overly sedated after taking this dose and may need a reduction. Receive a new order to decrease [MEDICATION(S)] to 0.5 every eight hours as needed. Re-evaluate if new orders received from the hospital. Signed by RN H. Record review of a Hospital History and Physical, dated 3/8/22 at 9:50 a.m., indicated Resident # 1's Assessment and Plan identified the principal problem for hospital admission as [CONDITION(S)] (the bodies extreme response to an infection) with acute [CONDITION(S)] without septic shock. The active problems were acute metabolic [CONDITION(S)] (a problem in the brain caused by a chemical imbalance in the blood), acute kidney injury (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days.), [CONDITION(S)] (too much sodium in the blood), acute urinary tract infection, elevated liver function test and abnormal CT of the head. The patient's Sodium level was 171( two common causes insufficient fluid intake and too much water loss) and the sodium level was likely to explain the patient's mental status changes, the lack of nutrition was concerning. The patient presented with an altered mental status. Per the nursing facility the patient has gotten gradually more lethargic and had less by mouth intake over the last several days. Record review of Dietician note for Resident #1 dated 3/9/22 at 12:53 p.m. (after hospitalization ) weight loss follow up revealed the current body weight was 118 pounds, Body Mass Index 19 - at risk for age. The resident has lost negative 17.8% in 30 days. His by mouth intake poor- variable average 50% per nurses note. Pertinent medications were multivitamins, fish oil, no updated labs, no skin breakdown noted. The resident had magic cups two times a day and carnation instant breakfast every day ordered. The resident had a finger food diet ordered. The resident may not be meeting needs at this time as evidenced by poor intake and weight loss. The Dietitian to change diet from finger food texture to texture as tolerated with finger foods in addition directions. The MD to consider appetite stimulant goal was to maintenance weight loss of less than 5% and a good by mouth intake of more than 75 percent, signed by the Dietician. Record review of a discharge summary, dated 3/14/22, indicated Resident #1 was sent to the hospital on 3/8/22 due to increased altered mental status and abnormal vital signs. The family discharged the resident from the facility. During a telephone interview with a family member on 3/15/22 at 9:34 a.m. they said Resident #1 had a complete physical on 1/18/22 prior to admission to the facility, and everything looked good. He was admitted to the facility on [DATE]. Resident #1 was very fit for his age; he could do 60 pushups. Prior to coming to the facility, he was independent, he dressed himself and took his own showers. Resident #1 did not want to be there, he tried to escape every way he could. He tried to climb the fence several times, and he would pull off his clothes. The family member said LVN I said Resident #1 was eating but he was not eating a lot. He started sleeping through lunch. The family member said the facility drugged him up. Another family member tried to feed him a day or two before hospitalization . It took her 45 minutes to feed him pinches off a muffin and some milk. Resident #1 would put his thumbs on his lips like a small child. The family member said he told the head nurse (RN H) he wanted Resident #1's medications cut down. He does not know if she did it or not. Resident #1 was still in the hospital, on a feeding tube, and had a drainage tube for his gall bladder. They did not know if he is going to live or not. During an interview on 3/15/22 at 10:28 a.m. CNA A said Resident #1 was an active person (moving around, independent, athletic.) When he first came to the facility, he did not require assistance with eating or dressing. He had a decline but did not like to be fed. He would not let staff assist him. He would refuse to drink sometimes. She said later , Resident #1 would sit, sleep, and eat. They gave him medications to keep him calm. He was still combative prior to hospitalization but did require more assistance. During an interview on 3/15/22 at 10:36 a.m. with CNA E, she said when Resident #1 first arrived at the facility, he was combative (hitting and resistant) and wanted to leave. He would fight but required assistance with eating. He did not like for staff to feed him so he was given finger foods that he could eat on by his self. During an interview on 3/15/22 at 10:58 a.m., LVN K said on 3/7/22 Resident #1 had a change in condition, he was less active, and more sedated. She said he was still combative, but she noted a change. He was not eating. She said she let RN H Supervisor know and the NP. She told RN H and let the DON know to come and assess the resident because he was different. Before 3/7/22, the last time she saw him, he crawled around on the floor and was more active. This time he was combative but in more of a leave me alone kind of way. On Sunday 3/6/22 he was in bed but appeared to be more combative. He got [MEDICATION(S)] quite often. During an interview on 3/15/22 at 11:10 a.m., CNA C said she worked with Resident #1. A few days before hospitalization Resident #1 appeared kind of sedated and tired compared to his usual self. During an interview on 3/15/22 at 11:13 a.m., LVN I said she was able to give Resident #1 his medications by crushing them and put them in his pudding or ice cream. LVN I said the resident had behaviors and tried to run away, he was forgetful and combative, he was placed on medications of [MEDICATION(S)] and Klonipin to help with those symptoms. She did not think he was hallucinating or delusional. He had a lot of other behaviors. She said he got [MEDICATION(S)] quite often to calm down. She said 3/4/22 was the last day she worked prior to his going to the hospital. LVN I said on that day he sat at the table confused, but staff fed him ice cream. She said he was his normal self but needed assistance with eating. He could not hold a cup he used both hands. During an interview on 3/15/22 at 2:05 p.m., the DON said the reason Resident # 1 was on [MEDICATION(S)] was because of his behaviors. He was combative, took his clothes off, urinated on the floor, and climbed fences. The DON said she was the person that monitored the weights. He had some weight loss, they prescribed carnation instant breakfast, ice cream and magic cup. The magic cup was placed on hold because they did not have any in stock. During an interview on 3/15/22 at 2:17 p.m., RN H said she saw Resident #1 the day before he went to the hospital. She said LVN K informed her on 3/7/22, he was not eating and was spitting out his medications. RN H said that was not anything new, she did not do any follow up and she told LVN K to let the NP know. She said by looking at him she could not tell he lost weight. She said they had ordered a magic cup and finger food. She never talked to the dietician. He had ice cream which was given by LVN I. The ice cream did not have many calories, so they switched to the magic cup. RN H said she did have a meeting with the residents family member on 3/3/22 and the family member was concerned about Resident #1 losing weight and he seemed more lethargic. She said it was after family intervention that the facility discussed the Magic cup and to lower his medications. She stated Resident #1 was a lot more active on admission. She said part of his inactivity was due to the medications he took. The last time she saw him he was sitting at the table and the staff were trying to get him to eat and drink, when he was admitted he was independent with eating. During an interview on 3/15/22 at 2:58 p.m. RN G said she was the supervisor, on 3/7/22 she remembered Resident #1 ate poorly at supper. She stated she had to crush his medications to get him to take the medications. He did drink but held the cup with two hands. His condition had changed, and he was more sedated. The last time she saw him he was crawling around on the floor. She had seen him on one occasion trying to climb the fence so, his condition had declined. During an interview on 3/15/22 at 3:15 p.m., CNA B said the last few days prior Resident #1 needed assistance with eating. He would sit around and sleep. His would open his eyes, but he was still somewhat combative. Sometimes he would eat and drink, it depended on how he felt. During an interview on 3/16/22 at 6:43 a.m., RN F said she usually worked with the residents. They were short staffed on the night of 3/7/22-3/8/22. She said she received information in report that Resident #1 had a gradual decline. She said an aide went in to change him and he was hard to arose. She had concerns about his low BP and high respirations and pulse. She sent him to the hospital early morning on 3/8/22. During an interview and record review on 3/16/22 at 10:10 a.m., the DON said Resident #1's weights were concerning to her, he refused meals. On 3/12/22 Resident #1's family member called and said the hospital accused them of abuse regarding Resident #1. The family was told due to his dehydration and weight loss the facility neglected him. She said she investigated information while she was on the phone, only regarding the family concerns. Her plan was when Resident #1 returned from the hospital she would have started him on [MEDICATION(S)] (appetite stimulant). The family discharged the resident on 3/14/22. The DON said she never talked to the doctor and she never assessed Resident #1 herself. She was not aware he had a change in condition. She was informed they sent him out to the hospital. She was aware of the family discussion on 3/3/22 about weight loss and the family felt Resident #1 was sedated. During an interview on 3/16/22 at 12:12 p.m., CNA J said when Resident # 1 first came, he was athletic, and he could use his arms and raise his whole body out of the chair. He was transferred to the locked unit because of his elopement attempts. Resident # 1 was mostly independent with his ADLs. She said you could tell by looking at him, he had lost weight. She stated he would not eat. CNA J said the day before he went out to the hospital, he was still trying to fight. He appeared tired and sleepy. She said she was with LVN K when she tried to give him his meds. He was still strong he hit the cup and knocked it across the room. She said they tied to give him a magic cup and some milk, he accepted a little. She said you could see a decline. She said when she left at 3:00p.m. on 3/7/22, he was in the bed asleep. During an interview on 3/16/22 at 12:20 p.m., CNA A said the closer to Resident #1s hospitalization he required more assistance with everything. Sometimes he would let them help him. He had a hard time feeding himself. He would allow them to put the food on the spoon and let him put the spoon to his mouth. CNA A said she had filled out the information on the computer about his meals and the assistance required. However, she was not sure if she did it accurately. Resident #1 did require assistance with eating for about a week or two prior to hospitalization . During an interview on 3/16/22 at 4:05 p.m. The dietician said she never had a conversation with the DON about Resident #1 losing weight. She knew the facility staff completed some diet changes because the Dietary Manager informed her about the finger foods, the carnation instant breakfast, and the magic cups. The Dietician said would be good to know what was going on so she could prepare. Her last visit to the facility was 2/21/22 when she completed a nutritional assessment on Resident #1. She said her last note written was on 3/9/22, was because she had reviewed the chart. She noted from his chart review Resident #1 had lost weight and was not eating. The Dietician said she was not provided any information from anyone at the facility; she did her own investigation into a resident's status. During an interview on 3/18/22 at 2:30 p.m., the DON said they tried to redirect Resident #1 and it was not effective. That was the only intervention they tried before placing him on medications. She did not recall recommending a psychological consult and could not find documentation that one was requested. The DON did not provide an explanation as to why the physician or dietician were not notified. She just said she did notify the physician or the dietician regarding Resident #1 not eating or his weight loss. During an interview on 3/18/22 at 4:10 p.m., the NP said she remembered Resident #1. She got calls about him 3 to 4 times a week if not every day regarding his behaviors. She had put him on an initial does of [MEDICATION(S)] 50 mg, two times a day. It did not seem to calm him down. So, she increased the dose to 100 mg two times daily. The NP said she was never informed Resident #1 was not eating and losing weight. If she had known she would have ordered an appetite stimulant. During an interview on 3/21/22 at 9:08 a.m. with the DM, she said when Resident #1 was first admitted he constantly walked. She thought he was losing weight because he never sat down. The Dietician put him on finger foods, a sandwich, or for breakfast a sausage biscuit. The Aides were concerned Resident #1 would not sit. They gave him some medications and he was not wandering as much. He started to need assistance with meals. She thought he was placed on some supplements. They had Quality of Care meeting every week. He was on weekly weights. Resident #1 lost 14 pounds in a week. During an interview on 3/21/22 at 10:00 a.m., the DON said they did not conduct and IDT meeting regarding Resident #1 losing weight or his behaviors. They did conduct an IDT meeting about his fall on 2/8/22. Record review of a facility Weight Loss/Gain (Significant) policy, revised October 2012, indicated The Policy - Resident experiencing undesirable weight loss will receive appropriate interventions and a systematic monitoring. The Significant Weight Loss protocol is implemented when a resident has a weight loss of greater than 5 percent in 30 days, 7.5 percent in 90 days and 10 percent in 18- days. The responsibility is to the licensed nurse. The purpose is to identify residents with significant weight loss. The Procedure is weight loss of 5 pounds or more to weigh weekly, Notify the MD, RD, DON, and responsible party. May use short term care plan to assist with documentation, review interventions.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents was provided for 1 of 10 residents reviewed for smoking. (Resident #1) The facility did not supervise Resident #1 when he smoked. Resident #1 had a history of [REDACTED]. On 05/06/19, Resident #1 lit a cigarette while wearing oxygen and the oxygen tubing ignited, [MEDICAL CONDITION] his face, ears, necks, chest, and abdomen. An Immediate Jeopardy was identified that existed on 05/06/19. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance on 05/07/19, prior to the beginning of the survey. This failure could place residents at risk of severe injury and/or death. Findings included: A face sheet dated 05/15/19 indicated Resident #1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 had an order starting 03/11/19, for oxygen per nasal cannula at 3-4 liters as needed when oxygen levels were at or below 92%. A smoking screen dated 01/08/19 indicated Resident #1 knew and understood the smoking policies but continued to be non-compliant. Resident #1 continued to go on trails and smoke on property outside of the smoking area and was not compliant with removing his oxygen tubing and turning the oxygen off before smoking. A smoking screen dated 02/16/19 indicated Resident #1 had been educated multiple times and was aware of the dangers of smoking while having oxygen on and the resident continued to be non-compliant. Resident #1 smoked while in his motorized chair all over the campus and did not smoke only in designated areas. An in-service dated 03/05/19 indicated staff were to remove Resident #1's oxygen tubing and oxygen tank from the resident's wheelchair prior to him going outside to smoke. When the resident returned from smoking, staff should reapply the oxygen tank and tubing and turn the oxygen back on. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was able to make his needs known and understood others. He had moderately impaired cognition. He required extensive assistance with bed mobility, dressing, and transfers. He required supervision with locomotion off and on the unit. Resident #1 used a wheelchair for mobility. He was incontinent of bowel and bladder. The MDS indicated the resident was allowed to go outside at will, regardless of his unsafe smoking history. A care plan dated 03/02/19 indicated Resident #1 may experience [MEDICAL CONDITION] exacerbations and staff should teach the resident deep breathing exercise, [MEDICAL CONDITION] nightly as ordered, and give medications as ordered. Resident #1 smoked on a regular basis and interventions included staff were to supervise the resident's smoking during periods of confusion and ensure his oxygen was turned off. Staff were to inform the resident where the designated smoking areas were and remind him of safe smoking practices, including the danger of smoking around oxygen. The resident was to wear a smoking apron. An incident report dated 05/06/19 indicated Resident #1 caught himself on fire while he was outside smoking unsupervised while receiving oxygen. The oxygen caught fire and the resident's face was burned. Resident #1 [MEDICAL CONDITION] his face, behind his ears, and abdomen. The report indicated the resident was alert and had a pain level of 8 out of 10 and was transported to the hospital for evaluation. A hospital history and physical dated 05/06/19 indicated Resident #1 was receiving oxygen via nasal cannula and wearing his oxygen tank, when he lit a cigarette. Resident #1 received [MEDICAL CONDITION] his face and left neck area. Resident #1 said he had a flash burn. Resident #1 was counseled on safety regarding oxygen. A nursing note dated 05/07/19 indicated Resident #1 returned from the hospital at 3:34 p.m., a skin assessment indicated he had second [MEDICAL CONDITION] his face, left ear, left side of his neck, and right upper quadrant. Resident #1 was alert and verbally responsive. The care plan was updated on 05/07/19 and indicated Resident #1 required supervision with smoking and interventions included to remove cannula and oxygen tank from his wheelchair prior to smoking, the resident was not allowed to have cigarettes or a lighter in his room, resident would wear a smoking apron when smoking, the resident could only smoke in designated areas, and the cigarette would be properly disposed of. A smoking screen dated 05/07/19 indicated Resident #1 was non-compliant with the facility smoking policy and was unsafe to smoke without supervision. Resident #1 was to wear a smoking apron when he smoked. A provider investigation report dated 05/09/19 indicated on 05/06/19, Resident #1 confirmed he was smoking in a non-smoking area while receiving oxygen via nasal cannula from an oxygen cannister. The resident lit a cigarette and ignited the nasal cannula. Two maintenance assistants saw Resident #1 on the walking trail and it appeared he was dragging something behind him that was trailing smoke. The maintenance assistants observed flames coming from Resident #1's oxygen tank on the back of his wheelchair. The valve on the oxygen tank was too hot to touch so one of the maintenance assistants removed the oxygen tank from Resident #1's wheelchair. The report indicated Resident #1 had [MEDICAL CONDITION] his left eye, behind his right ear, and upper lip. The oxygen tubing melted in the resident's hair behind his right ear. Small black areas were noted to his left abdomen, left medial abdomen, and left upper chest. Resident #1 was sent to the hospital for evaluation. The report indicated as a result of the incident, the facility adopted a more stringent smoking policy. Staff and residents were in-serviced on the new policy. Responsible parties were notified of the new smoking policy. During an observation and interview on 05/14/19 at 11:43 a.m., Resident #1 was lying in his bed and was wearing oxygen via nasal cannula. He had brownish red scabs to his upper right ear, upper lip, and nose. Resident #1 had yellow slough to his upper lip and left neck. Resident #1 was wearing his oxygen via nasal cannula. His nostrils appeared to have scabbing. Resident #1 said a car caused [MEDICAL CONDITION] he did not remember the smoking incident. He said he no longer smoked, and he had no previous smoking incidents involving oxygen. Resident #1 did not maintain eye contact and went back to sleep during the interview. During an observation and interview on 05/14/19 at 9:08 a.m., there was an intermittent black line several hundred feet long on the walking trail where Resident #1 was found by the maintenance staff when he was on fire. The administrator said it appeared that the black marks were made from Resident #1's oxygen tubing when it was smoking, and the oxygen tubing was dragging behind him on the walkway. During an observation on 05/14/19 at 10:18 a.m., the shirt Resident #1 wore on 05/06/19 during the incident had multiple holes around the neck and chest area of the shirt. The shirt had black and brown areas of discoloration around the holes. The remaining oxygen tubing that Resident #1 was wearing during the incident was completely black and melted. During an interview on 05/14/19 at 9:14 a.m., maintenance assistant A and maintenance assistant B said on 05/06/19 around 1:25 p.m., they were in a resident's home and heard the facility dog barking in the back yard. When they looked outside, they said they saw Resident #1 rolling in his electric wheelchair on the walking trail behind the home and said it looked like he was dragging something behind him. Maintenance assistant A said they went outside and Resident #1's oxygen tank and the tubing connecting the oxygen to the cannula in his nose were on fire. Maintenance assistant B said he removed the oxygen tank and turned off the oxygen. He said they called RN C and notified her what happened. During an interview on 05/14/19 at 11:21 a.m., RN C said she was in her office on 05/06/19 and at 1:29 p.m., she received a call from maintenance assistant B, who told her about the incident regarding Resident #1 and asked her to bring supplies for treating a burn to the walking trail. She said the incident occurred because Resident #1 was smoking with his oxygen on and it caught fire. RN C said she and the treatment nurse arrived at the scene and Resident #1 was sitting in his electric wheelchair and his oxygen tank had been removed. She said Resident #1's face was black under his left eye, left cheek, and his upper lip. She said Resident #1 was alert and refused any type of care. RN C said she called the DON and was notified to send the resident to the hospital. She said EMS arrived and transported Resident #1 to the hospital. During an interview on 05/14/19 at 11:52 a.m., the treatment nurse said she was in the office with RN C on 05/06/19 when RN C got a call from maintenance assistant B. She said RN C told her that Resident #1 was smoking with his oxygen on. The treatment nurse said she and RN C went to the scene and Resident #1 was alert and joking. She said he had [MEDICAL CONDITION] his face, ears, and abdomen. She said she brought supplies and a cool towel but Resident #1 refused treatment. She said Resident #1 was sent to the hospital and returned to the facility the next day with wound care orders. During an interview on 05/14/19 at 9:24 a.m., CNA D said Resident #1 had a history of [REDACTED]. CNA D said Resident #1's responsible party would not buy him cigarettes, so he would smoke cigarettes that he found, or could borrow from other residents. CNA D said Resident #1 had not had his own cigarettes for months. CNA D said Resident #1 would often go outside and tend to his garden or take his electric wheelchair on the walking trail and not tell staff that he was going to smoke. She said if staff knew he was going to smoke, they would remove his oxygen before he smoked. During an interview on 05/14/19 at 9:28 a.m., CNA [NAME] said she worked the day of Resident #1's incident. She said assisted him into his wheelchair and he went outside like he normally did. She said Resident #1 was alert that day and had no confusion. She said when Resident #1 went outside, he did not notify her that he was going to smoke. CNA [NAME] said the residents were allowed to leave the house without notifying staff. She said Resident #1 enjoyed being outside. She said Resident #1 was in the hospital a few months ago and when he returned, his responsible party stopped buying him cigarettes. She said other residents would give Resident #1 cigarettes. CNA [NAME] said Resident #1 was non-compliant about turning off his oxygen before he smoked, but staff would see him outside and turn off his oxygen. During an interview on 05/14/19 at 9:38 a.m., CNA F said Resident #1 did not have any of his own cigarettes in the last few months but would find partially burned cigarettes in the ash trays. She said she caught Resident #1 with a cigarette butt on 05/05/19. CNA F said if Resident #1 notified staff that he was going to smoke, they would turn off and remove his oxygen. She said Resident #1 typically notified staff when he was tending to his plants or was going on the walking trail. She said sometimes Resident #1 left the house without notifying staff. During an interview on 05/14/19 at 9:34 a.m., LVN G said she did not work the day of Resident #1's incident. She said Resident #1 had a history of [REDACTED]. LVN G said Resident #1 did not have his own cigarettes for the last few months. She said staff recently told her Resident #1 was smoking cigarette butts that he found or borrowed cigarettes from other residents. LVN G said when Resident #1 had his own cigarettes, staff would have to turn off his oxygen and remove the oxygen tank when he was smoking because he would forget about the oxygen danger. During an interview on 05/14/19 at 1:53 p.m., PTA H said Resident #1 was on her case load a few months ago. She said Resident #1 sometimes attempted to smoke with his oxygen on. She said she reported it to staff. PTA H said Resident #1 was not safe when he smoked. An MDS dated [DATE] indicated Resident #2 had a BIMS score of 13 which indicated he was cognitively intact. He made his needs known and understood others. During an interview on 05/14/19 at 12:08 p.m., Resident #2 said he gave Resident #1 a cigarette when he asked for one. Resident #2 said he was unaware he was not supposed to give him cigarettes. He said sometimes he saw Resident #1 in his wheelchair, smoking on the walking trail, with his oxygen on. He said Resident #1 found discarded cigarette butts and smoked them. Resident #2 said staff knew what Resident #1 was doing. He said he no longer gave Resident #1 cigarettes. A MDS dated [DATE] indicated Resident #3 had a BIMS score of 12 which indicated he had moderately impaired cognition. He made his needs known and understood others. During an interview on 05/14/19 at 2:07 p.m., Resident #3 said he let Resident #1 borrow cigarettes. He said staff was constantly telling Resident #1 that he could not smoke while he had his oxygen on. Resident #3 said Resident #1 would get on the walking trail and smoke. He said Resident #1 found cigarette butts in the ash trays and smoke them. He said he no longer gave Resident #1 cigarettes. During an interview on 05/14/19 at 3:03 p.m., CNA J said Resident #1 would go out the back door of the house without telling staff he was leaving. She said staff would try to catch him before he left so they could remove his oxygen but sometimes he would slip out and staff did not know he left. CNA J said Resident #1 did not have his own cigarettes for the last few months but would take cigarette butts out of the metal cans outside and smoke them. CNA J said Resident #1 was alert but was confused at times. She said Resident #1 had not smoked since he returned to the facility. During an interview on 05/14/19 at 3:15 p.m., LVN K said Resident #1 was alert but stubborn. She said Resident #1 would go outside with his oxygen on and staff would try to catch him and remove his oxygen. She said sometimes Resident #1 would go outside without staff knowing. LVN K said she was told that Resident #1 picked up cigarette butts and smoked them because he did not have his own cigarettes. She said Resident #1 had a cigarette lighter. She said Resident #1 had not smoked since he returned to the facility and had not been out of his bed. During an interview on 05/15/19 at 9:25 a.m., LVN M said she worked the day of Resident #1's incident and called EMS. She said Resident #1 did not have his own cigarettes for the last 2 months. She said she was told Resident #1 was borrowing cigarettes from other residents and he was digging in the ash trays for cigarette butts to smoke. She said Resident #1 was alert most of the time and sometimes left the house without notifying staff. She said staff would have to catch Resident #1 and turn off his oxygen because he would sometimes forget to turn it off. LVN M said staff notified the nurses that completed the smoking assessments about Resident #1's smoking behaviors. During an interview on 05/15/19 at 9:47 a.m., RN L said she completed Resident #1's smoking assessments on 01/08/19 and 02/16/19. She said she assessed Resident #1 to be an unsafe smoker, but she did not know that he was finding cigarettes to smoke. She said Resident #1 did not have his own cigarettes for months and she was not notified Resident #1 was still smoking until recently. She said before the incident with Resident #1, residents that smoked were able to keep their smoking materials with them and smoked when they wanted. During an interview on 05/14/19 at 3:29 p.m., the DON said she was notified about the incident with Resident #1. She said when she saw Resident #1's face after the incident, it was black from under his eyes to his bottom lip. She said the oxygen tubing was melted in his hair behind his right ear. She said Resident #1's shirt had burn marks. The DON said she asked Resident #1 if he was smoking with his oxygen on and the resident said yes, but he thought he had taken his oxygen off. She said Resident #1 was transported to the hospital at that time for evaluation. The DON said Resident #1 did not have a history of smoking incidents, but after the incident on 5/6/19, she learned that Resident #1 was taking cigarette butts from the ash tray or borrowing cigarettes from other residents. The DON said Resident #1 was told he needed to quit smoking because of his [MEDICAL CONDITION] after an unrelated hospital stay a few months ago, and his responsible party stopped buying him cigarettes at that time. She said Resident #1 had his lighter and would go on the walking trail to smoke. The DON said before the incident, the residents could keep their smoking materials with them and smoked when they wanted. She said on 05/06/19, they revised the smoking policy, took up and secured all the residents' smoking materials, moved the designated smoking area, and in-serviced all staff and residents that smoked. She said residents that smoked signed the new smoking policy and if the residents did not abide by the new smoking, they would be issued a discharge notice. She said staff were in-serviced to be more alert to where the residents were and to notify the administrator if any residents were seen going through ash trays. She said new ashtrays were ordered that had long necks and made it more difficult for a resident to get to the cigarette butts. She said ashtrays would be cleaned out after each smoke break. During an interview on 05/14/19 at 9:08 a.m., the administrator said he interviewed Resident #1 when he returned to the facility. He said Resident #1 admitted that he was smoking with his oxygen on, but he would not say where he got his cigarette. The administrator said Resident #1 said one of his friends may have given him a cigarette or he could have found a cigarette in the butt can. He said he notified Resident #1 of the new smoking policy and that all smoking materials would be locked up in the nursing office. He notified Resident #1 that all smoking would be supervised at a scheduled time. The administrator said Resident #1 voiced understanding and signed the new smoking policy. The administrator said he was not aware that Resident #1 had been borrowing cigarettes and finding cigarette butts to smoke until after the incident occurred on 05/06/19. He said he expected staff to notify him if Resident #1 was continuing to smoke. He said he held a meeting with the residents that smoked and informed them of the new smoking policies and the residents signed the new policy. A smoking policy last revised 06/20/18 indicated residents were permitted to smoke only in designated areas. He said residents would be screened upon admission, quarterly, and with a change of condition, and if the screen showed safety concerns, the resident was required to have staff/family supervision when smoking. He said all residents' smoking materials would be left with the nurse when not in use, and smoking was prohibited anywhere that oxygen was used or stored, and all residents that used oxygen must have a nurse or care attendant turn off the oxygen and remove their nasal cannulas before smoking. This failure contributed to Resident #1's facial and [MEDICAL CONDITION] a hospital visit after he caught fire, due to inadequate supervision while the resident continued unsafe smoking practices. An Immediate Jeopardy (IJ) was determined to have existed from 05/06/19 to 05/07/19 The IJ was removed on 5/7/19 after the facility implemented a new more stringent smoking policy which required all residents to surrender their smoking materials to the nurses, and increased staff supervision for smoke breaks. The facility remained out of compliance at isolated actual harm. The facility took the following actions to correct the non-compliance on 05/07/19: An updated smoking policy dated 05/06/19 indicated residents would receive smoking assessments upon admission, quarterly, and with a significant change in condition. Residents were permitted to smoke only in designated areas. No smoking materials could be kept with the resident or in the resident's room. Smoking materials would be stored in a secured location. A staff member would supervise resident smoking. Residents that used oxygen must have the nurse turn off the oxygen, remove tank and cannula before proceeding to smoking area. Residents, visitors, or staff were not allowed to give or sell smoking materials to residents. An in-service dated 05/06/19 indicated staff were in-serviced on not allowing residents to smoke while using oxygen. All oxygen tanks and tubes were to be removed from the resident while they smoke. All residents that smoked would be supervised and the scheduled smoke times would be followed. Residents' smoking materials would be kept locked in the nursing office. Residents that required a smoking apron must wear it while smoking. Resident families must give smoking materials to the nurse to lock up. Smoking blankets and fire extinguishers were available at designated smoking areas. Staff, visitors and other residents were not allowed to share smoking materials. On 05/15/19, the surveyor confirmed correction of the non-compliance by: The staff development RN in-serviced staff on 05/06/19 to ensure all residents would be supervised when smoking; all smoking material would be kept locked in the nursing office; specified times were to be followed for supervised smoking; smoking would be only in designated areas; no residents should smoke while any resident was using oxygen; staff must stay with residents while they smoke; staff should light resident's cigarette and not give the lighter to the resident; if a resident was assessed to need a smoking apron, they could not smoke with wearing a smoking apron; families were not to give smoking materials to residents; residents could not keep smoking materials that they bought while on outings; smoking blankets and fire extinguishers were available, staff, visitors, and residents were not to share their smoking materials; and any infractions were to be reported immediately to the RN supervisor. Observations on 05/14/19 and 05/15/19 revealed designated smoking areas were in the breezeway between houses. The smoking areas each included a fire extinguisher, a fire blanket (to smother fires), and a metal receptacle with a lid. The metal receptacle lid had a label that said, cigarette butts only no trash. Residents were smoking in the designated smoking areas. A staff was monitoring the residents during the entire smoke break. Staff handed each resident a cigarette and lit the cigarette for the resident. Staff took the cigarette butts and placed them in the metal receptacle and offered the residents a second cigarette. Residents appeared to handle cigarettes safely and abided to the new smoking policy. Observations on 05/14/19 revealed resident smoking material was secured in the nursing office. Six nurses and seven CNAs were interviewed and said they received training on 05/06/19 prior to the surveyor's entrance regarding the revised smoking policy, keeping smoking materials locked up, supervising scheduled smoke breaks, and smoking in designated areas. Seven residents were interviewed and said they were notified about the revised smoking policy, the designated smoking area, supervised scheduled smoke breaks, and keeping all smoking materials secured in the nursing office. Review of ten resident charts indicated new smoking assessments were completed on 05/07/19. Residents that smoked signed the revised smoking policy.

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 10 residents reviewed for pain. (Resident #71). The facility did not provide effective pain relief for Resident #71 for over 3 months. Resident #71 was on [MEDICATION NAME] for years. The medication was stopped abruptly resulting in severe withdrawal symptoms when the facility did not follow up when the physician did not send refill triplicates in a timely manner and did not follow up with the pharmacy to receive the [MEDICATION NAME]. This failure could place the 10 residents who resided in K building at risk for not having effective pain control. Findings included: A face sheet dated [DATE] indicated Resident # 71 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Physician orders [REDACTED].# 71 had an order for [REDACTED]. A quarterly MDS assessment dated [DATE] indicated Resident # 71 was cognitively intact and was coded as independent for all her ADLS. She was coded as having pain. A Care Plan dated for [DATE] indicated Resident #71 had pain, depression, anxiety, fall risk, and trouble sleeping. The care plan for pain indicated Resident #71 would be assessed daily with the goal for her to be free of pain. The MARs from [DATE] through [DATE] indicated Resident #71 received Tylenol #3 on an as needed basis from [DATE]. The MARs dated [DATE] indicated Resident #71 received Tylenol #3 as needed as well as the [MEDICATION NAME] 2.5 mg routinely two times daily. The MARs from [DATE] through [DATE] indicated her pain level was above 5 (on a pain scale of 0 - no pain to 10 - worst possible pain) several days a month. The MAR indicated [REDACTED]. The MARs dated October, November, December, and [DATE] indicated Resident #71 had an order for [REDACTED]. The last dose of [MEDICATION NAME] was given [DATE]. A Discontinue Order form dated [DATE] indicated that [MEDICATION NAME] was to be discontinued per Resident #71's family physician. Nursing Progress Notes dated [DATE] at 17:23 indicated in part, Spoke to (Resident # 71's son) regarding the [MEDICATION NAME]. The facility is still waiting for a triplicate for the [MEDICATION NAME], and discussed that the resident has been taking the Tylenol 3 in place. I explained to the family that the insurance will only pay for the 15 days of [MEDICATION NAME] and that the family would be required to make the difference up. I asked the family member if he would rather use Tylenol #3 scheduled since she seems to be controlled with it. Family wanted to discuss this with (Resident # 71) before we discontinue the [MEDICATION NAME]. The Tylenol 3 cannot be scheduled unless pain management schedules the medication or if the resident chooses to discontinue the [MEDICATION NAME]/pain management and (Resident # 71's regular doctor) takes over her care of regarding her pain. This nurse discussed getting another appointment with pain management and a nurse go with the family to the next appointment to clarify the triplicate problem, if this is the route they choose. Family member wants to wait on discontinuing the [MEDICATION NAME] until he speaks with his mother regarding her desires. Family will follow up with facility for direction. Nursing Progress Notes dated [DATE] at 7:15 p.m. indicated Resident #71's follow up blood pressure (BP) was ,[DATE]. Resident # 71 requested that her physician be called to find out why her [MEDICATION NAME] was on hold. The notes indicated the nurse explained to the resident that the [MEDICATION NAME] was on hold per her pain management physician, because they had found pain medication in her system that was not prescribed to her. Nursing Progress Notes dated [DATE] at 5:56 p.m. indicated Resident #71 was complaining of increased pain to her left shoulder, neck, and arm. She was crying and described the pain as sharp and a constant 8 on the pain scale, indicating severe pain. Nursing Progress Notes [DATE] at 08:49 - Late Entry indicated the nurse talked to Resident #71's son about his mother's pain level. Her son wanted to restart her on the [MEDICATION NAME] and agreed to send her to a different pain management doctor. During an observation and interview on [DATE] at 11:24 a.m., Resident #71 was in her room with the door shut sitting on her bed, very tearful. She complained of pain in her legs and said she was not able to sleep for the previous two nights because her pain medication she had now (Tylenol #3) was not taking the pain away. She said she was taking [MEDICATION NAME] for years and recently the facility and the physician, took me off it. I am nearly [AGE] years old and I shouldn't have to suffer. She said when the [MEDICATION NAME] was suddenly stopped in September, she almost died with the withdrawal from the [MEDICATION NAME]. Resident #71 said she had been very nauseous with vomiting and had excruciating pain all over her body. She said she became very anxious and would cry for long intervals because of the pain. She said she had a very bad case of shingles that attacked her ligaments and nerves and left her in extreme pain. She said, I used to take [MEDICATION NAME] and now had to change to Tylenol #3, but it doesn't help. I have [MEDICAL CONDITION] in both legs and pain all over with very painful muscle contractions. Resident # 71 said she had spasms in her legs and she was in terrible pain and could not sleep. According to healthline.com, accessed [DATE]: [MEDICATION NAME] Withdrawal Symptoms and Treatments https://www.healthline.com/health/going-through-[MEDICATION NAME]-withdrawal, accessed [DATE] indicated Symptoms of [MEDICATION NAME] withdrawal, also sometimes referred to as [MEDICATION NAME] detox, typically start to appear approximately ,[DATE] hours after you last took the drug. The detox process is supervised by a physician. The duration of the process varies from person to person, but may last anywhere from ,[DATE] weeks up to 6 months. Signs of withdrawal symptoms include: tiredness, anxiety, restlessness, trouble sleeping, muscle aches and pains, severe nausea, vomiting, cramps, diarrhea, and depression. According to WebMD: [MEDICATION NAME] Withdrawal, accessed [DATE], indicated The doctor will carefully track your body's response to it and adjust your treatment. When it's time to stop taking it, he'll help you stop slowly to prevent withdrawal. During an interview on [DATE] at 12:20 p.m., LVN D said she was unaware that Resident #17 had a history of [REDACTED]. She said Resident #17 complained of pain a lot. During an interview on [DATE] at 2:05 p.m., RN C said Resident #71's [MEDICATION NAME] was discontinued after they were not able to get any more ordered by the pain physician with a hold until medication come in order dated [DATE]. He said Resident #71 appeared to be over sedated, so the physician told him he would not order any more. He said Resident #71 now had Tylenol #3 in the place of the [MEDICATION NAME]. He said Resident #71 was not seeing a pain physician anymore. He said Resident #71 went back to her regular physician and he ordered Tylenol #3 three times daily. RN C said at one time the resident was being administered Tylenol #3 as needed along with the routine [MEDICATION NAME]. He said he did not know why the [MEDICATION NAME] was still on the resident's MAR. A physician Hold Order dated [DATE] for Resident #71 indicated the [MEDICATION NAME] 2.5 mg two times daily was to held until medication arrives. There were no orders to decrease the [MEDICATION NAME] dose to prevent withdrawal symptoms. This order had been coded as H held on [DATE] going forward. A Discontinue Order form dated [DATE] indicated the [MEDICATION NAME] 2.5 mg two times daily was to be discontinued for Resident #71. During an observation and interview on [DATE] at 9:45 a.m., Resident #71 said she was still in pain, with the scale of 0 (no pain) to 10 (worst pain) she said she was Over 10. She was tearful and grimacing, constantly reaching for her legs to rub them. She said she got the pain medication they were giving her (Tylenol #3), but it was not helping to lower the pain. She asked for help in getting something stronger for her pain. During an interview on [DATE] at 10:30 a.m., Resident #71 said she had gone through withdrawals from the sudden stopping [MEDICATION NAME] and, it nearly killed me. I was so sick. I thought I was going to die. Her son concurred with this and said he was very unhappy with the facility and the doctors for putting his mother through the withdrawals and not keeping her out of pain. He said his mother was taking [MEDICATION NAME] for years and seemed to be fairly pain free. During an interview on [DATE] at 11:45 a.m., RN C said he called Resident #71's regular doctor and had orders to increase Tylenol #3 to one four times a day, starting [DATE], until they could get a pain doctor's appointment. RN C said he was not sure if Resident # 71 was having the pain she complained of having. During an interview on [DATE] at 1:40 p.m., the ADON and the corporate nurse said they did not know why Resident #71's [MEDICATION NAME] was still on the MAR. They said she was not getting it. They said they were not aware that Resident #71 was not weaned off the [MEDICATION NAME] and agreed the resident should have been weaned off, not stopped abruptly. During a telephone interview on [DATE] at 4:00 p.m., Resident #71's pain physician (through his nurse) said he did order more [MEDICATION NAME] for Resident #71 because the facility did not let him know when the [MEDICATION NAME] was almost out. He indicated he would have re-ordered the medication by sending triplicate orders to the pharmacy. He indicated he had a problem with the facility sending him requests for triplicate too late and he was not sure the pharmacy was sending the medication on time. During a telephone interview on [DATE] at 04:26 p.m., Resident #71's pain physician's nurse said in [DATE] the pain physician sent in orders for the [MEDICATION NAME] to the facility's preferred pharmacy for a 30 day supply. She said the physician would continue to see Resident #71 if she changed her place of living and her son accompanied her to the office appointments. The nurse said the physician told her they had a history of [REDACTED]. She said the pharmacy only provided 14 days at a time and required another triplicate for the next 14 days. In a call back telephone order, the nurse said the doctor had filled a prescription for 30 days in [DATE] and the pharmacy had sent out a 14 day supply of the medication. She said the physician was not aware Resident #71 had not received the [MEDICATION NAME] since the end of [DATE]. According to the census provided by the Administrator on [DATE], there were 10 residents in Building K.

Based on observation, interview, and record review, the facility did not provide services in accordance with the comprehensive assessment for 1 of 19 residents reviewed for care plan. (Res #8) Resident #8 was readmitted without a pressure ulcer to his coccyx on 5/1/14, but was at high risk for the development of pressure ulcers. He developed a facility-acquired pressure ulcer (Stage III) within a week. The facility did not implement the use of a pressure relief cushion or provide treatments in accordance with the plan of care. This failure placed 6 res with pressure ulcers at risk for deterioration of the wounds. Findings included: Clinical Physician order [REDACTED].#8, readmitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A care plan last revised 05/08/14 indicated staff was to provide Resident #8 with a cushion in his wheelchair while up in chair and to assist the resident with turning and repositioning off of his coccyx to relieve pressure. The most recent MDS assessment dated [DATE] indicated Resident #8 was total dependent with bed mobility and toilet use, was always incontinent of bowel and bladder, and had one Stage III pressure ulcer that was NOT present at the time of his readmission on 5/1/14. During an interview on 1/28/2015 at 9:45 a.m., the DON said Resident #8 returned from the hospital on [DATE] with a pressure ulcer to his heel and on 5/7/2014 the pressure ulcer to his coccyx was discovered. She said it was an in house acquired pressure ulcer. During an observation on 1/27/2015 at 9:40 a.m., Resident #8 had a pressure ulcer to his coccyx the size a little smaller than a quarter. The pressure sore was open through the skin with red and some white tissue beneath. The skin surrounding the wound looked normal. During an interview on 1/27/2015 at 11:00 a.m., CNA Z said she provided incontinent care to Resident #8 at 7:00 a.m. and the resident did not have a duoderm dressing on the pressure ulcer on his coccyx. She did not report this to the nurse. During an interview on 1/27/2015 at 9:40 a.m., hospice CNA JJ said Resident #8 did not have a dressing to his coccyx and had not received treatment to the pressure ulcer on his coccyx for two weeks. During an interview on 1/27/2015 at 10:45 a.m., Charge Nurse NN said no one reported the duoderm dressing was missing from Resident #8 ' s pressure ulcer to his coccyx. She said the DON does the dressing changes and care. She did not know the stage of the pressure ulcer or current treatment. She went to get the information from the computer, then, at 11:15 a.m., she said no one reported the duoderm was missing until surveyor intervention. She said the ulcer was a stage III and the treatment was a duoderm to his coccyx every three days. During an observation on 1/27/2015 at 11:35 a.m., Resident #8 received treatment to his coccyx. The Charge LVN NN cleaned the area with normal saline, initialed and dated the duoderm, and applied duoderm to the pressure ulcer on his coccyx. During an interview on 1/27/2015 at 10:50 a.m., the DON said she does weekly skin assessments, but the charge nurse does the treatments. She said Resident #8 was to have a duoderm to his wound every three days and as needed. She said staff should report to the charge nurse if there was no dressing on the wound. She said the pressure ulcer was unstageable. During an interview on 1/28/2015 at 9:05 a.m., the DON provided the documentation from the routine TAR to compare with the documentation from the prn TAR. She confirmed a treatment was done on 1/23/2015 and the next treatment should have been done 1/26/2015 and there was no recorded documentation the treatment was done on 1/26/2015 or on the 1/27/2015 observed treatment. The Licensed Nurse Administrative Record (TAR) for January 2015 was to change Resident #8 ' s duoderm dressing to his coccyx one time a day every 3 days with a start date of 1/10/15. There were no initials for the 25th, 26th, 27th of January. The record was initialed 1/22/15 and then 1/28/15. The Treatment Administrative Record (PRN TAR) for January 2015 was for a duoderm to be applied to Resident #8 ' s coccyx as needed or every 3 days. The record was last initialed 1/23/15. During an interview on 1/28/2015 at 8:55 a.m., the DON said she did not do resident care plans. She said her CNA should report to the LVN when the dressing was missing and the LVN should follow the order and replace the dressing as needed. During an observation on 01/27/15 at 11:35 a.m., Resident #8 was transferred from his bed to his wheel chair and was sitting in his wheelchair without a cushion. During an observation on 1/28/2015 at 11:35 a.m., Resident #8 ' s wheel chair cushion was on his bedside table in his room and he did not have a cushion in his wheelchair. During an interview on 1/28/2015 at 11:35 a.m., the CNA MM said she had never seen a cushion in Resident #8 ' s wheel chair during the three years she had worked at the facility. She said Resident #8 was placed in the recliner chair in the dayroom and the resident ' s wheel chair was removed and kept out of the resident ' s sight to keep him from getting out of the recliner and into the wheelchair and running into other residents. The CMS Form 672 dated 01/26/15 indicated 6 residents had pressure ulcers.

Based on observation, interview, and record review, the facility failed to implement interventions based on a comprehensive assessment to prevent development and worsening of pressure ulcers for 2 of 5 residents reviewed for pressure ulcers. (Resident #s 14 & 8) Resident #8 was readmitted with a pressure ulcer on his heel, but did not have a pressure ulcer to his coccyx on 5/1/14. He was at high risk for the development of pressure ulcers. He developed a facility-acquired pressure ulcer (Stage III) on his coccyx within a week. The facility did not monitor the use of a pressure relief cushion or provide treatments in accordance with the plan of care. Resident #14 was admitted without pressure ulcers. She developed 2 facility-acquired pressure ulcers. The facility was unaware that the resident had pressure ulcers until 1/28/15. The facility did not accurately assess the resident's skin, correctly reposition and turn the the resident, or provide the meals as ordered. These failures contributed to the development of new pressure ulcers and the worsening of existing pressure ulcers for Residents #s 14 and 8. These failures could place 4 other residents with pressure ulcers at risk for developing new pressure ulcers and decline in existing pressure ulcers. Findings included: 1. Clinical Physician order [REDACTED].#8, readmitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A care plan last revised 05/08/14 indicated staff was to provide Resident #8 with a cushion in his wheelchair while up in chair and to assist the resident with turning and repositioning off of his coccyx to relieve pressure. The most recent MDS assessment dated [DATE] indicated Resident #8 was total dependent with bed mobility and toilet use, was always incontinent of bowel and bladder, and had one Stage III pressure ulcer that was NOT present at the time of his readmission on 5/1/14. During an interview on 1/28/2015 at 9:45 a.m., the DON said Resident #8 returned from the hospital on [DATE] with a pressure ulcer to his heel and on 5/7/2014 the pressure ulcer to his coccyx was discovered. She said it was an in house acquired pressure ulcer. The Weekly Pressure Ulcer QI Log sheets for Resident #8, indicated the following: *01/02/15 - Resident #8 had pressure ulcer to coccyx described as measuring length x width of 2.3 x 1.3 cm and depth of 0.2 cm. *01/09/15 - Resident #8 had pressure ulcer to coccyx described as measuring length x width of 2.5 x 1.5 cm and depth of 1.0 cm. *01/16/15 - Resident #8 had pressure ulcer to coccyx described as measuring length x width of 6.9 x 5.0 cm dark red 2.5 x 1.5 cm open and depth of 1.0 cm. *01/23/15 - Resident #8 had pressure ulcer to coccyx described as measuring length x width of 2.5 x 1.5 cm open and depth of 1.0 cm. During an observation on 1/27/2015 at 9:40 a.m., Resident #8 had a pressure ulcer to his coccyx. IT was a little smaller than a quarter. The pressure sore was open through the skin with red and some white tissue beneath. The skin surrounding the wound looked normal. The Licensed Nurse Administrative Record (TAR) for January 2015 was to change Resident #8 ' s duoderm dressing to his coccyx one time a day every 3 days with a start date of 1/10/15. There were no initials for the 25th, 26th, 27th of January. The record was initialed 1/22/15 and then 1/28/15. During an interview on 1/27/2015 at 11:00 a.m., CNA Z said she provided incontinent care to Resident #8 at 7:00 a.m. and the resident did not have a duoderm dressing on the pressure ulcer on his coccyx. She did not report this to the nurse. During an interview on 1/27/2015 at 9:40 a.m., hospice CNA JJ said Resident #8 did not have a dressing to his coccyx and had not received treatment to the pressure ulcer on his coccyx for two weeks. During an interview on 1/27/2015 at 10:45 a.m., Charge Nurse NN said no one reported the duoderm dressing was missing from Resident #8 ' s pressure ulcer to his coccyx. She said the DON does the dressing changes and care. She did not know the stage of the pressure ulcer or current treatment. She went to get the information from the computer, then, at 11:15 a.m., she said no one reported the duoderm was missing until surveyor intervention. She said the ulcer was a stage III and the treatment was a duoderm to his coccyx every three days. During an observation on 1/27/2015 at 11:35 a.m., Resident #8 received treatment to his coccyx. The Charge LVN NN cleaned the area with normal saline, initialed and dated the duoderm, and applied duoderm to the pressure ulcer on his coccyx. During an interview on 1/27/2015 at 10:50 a.m., the DON said she does weekly skin assessments, but the charge nurse does the treatments. She said Resident #8 was to have a duoderm to his wound every three days and as needed. She said staff should report to the charge nurse if there was no dressing on the wound. She said the pressure ulcer was unstageable. During an interview on 1/28/2015 at 9:05 a.m., the DON provided the documentation from the routine TAR to compare with the documentation from the prn TAR. She said a treatment was done on 1/23/2015 and the next treatment should have been done 1/26/2015 and there was no recorded documentation the treatment was done on 1/26/2015 or on the 1/27/2015 observed treatment. The Treatment Administrative Record (PRN TAR) for January 2015 was for a duoderm to be applied to Resident #8 ' s coccyx as needed or every 3 days. The record was last initialed 1/23/15. During an interview on 1/28/2015 at 8:55 a.m., the DON said she did not do resident care plans. She said her CNA should report to the LVN when the dressing was missing and the LVN should follow the order and replace the dressing as needed. During an observation on 01/27/15 at 11:35 a.m., Resident #8 was transferred from his bed to his wheel chair and was sitting in his wheelchair without a cushion. During an observation on 1/28/2015 at 11:35 a.m., Resident #8 ' s wheel chair cushion was on his bedside table in his room and he did not have a cushion in his wheelchair. During an interview on 1/28/2015 at 11:35 a.m., the CNA MM said she had never seen a cushion in Resident #8 ' s wheel chair during the three years she had worked at the facility. She said Resident #8 was placed in the recliner chair in the dayroom and the resident ' s wheel chair was removed and kept out of the resident ' s sight to keep him from getting out of the recliner and into the wheelchair and running into other residents. 2. MDS dated [DATE] indicated Resident #14, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #14 was totally dependent on staff for bed mobility, eating, dressing, toileting bathing and locomotion. The resident was incontinent of bowel and bladder. The resident had problems in the area of communication with the MDS indicating that she had unclear speech and was only sometimes understood. Resident #14 had no pressure ulcers at the time of this assessment. A pressure ulcer care plan for a (now resolved) deep tissue injury on her heels last revised 11/13/14 indicated staff were to assist Resident #14 with turning/repositioning every two hours and as needed. A Braden scale assessment dated [DATE] indicated Resident #14 was at very high risk for skin breakdown. During an interview on 01/28/2015 at 1028, ECA CC said, the hospice nurse just left at about 0930. She changed her (Resident #14) and bathed her, got her in the geri chair and put her in the TV room. She said they would change her again at about 2pm. The majority of the time she has not " gone " yet. If she is awake she will put her hand on her brief, and that is how we know she needs to be changed During an interview on 01/28/2015 at 1100, RN K said that Resident #14 makes grunts and noises, but no meaningful verbal response. The ECAs talk to her and seem to be able to communicate with her. RN K said a skin assessment is to be completed once a week. RN K said the resident previously had a skin issue with her heels, but they had healed, and there were no other skin issues at this time. RN K said the DON does address and stage pressure ulcers, so when we need her to look at something we enter it into the electronic record and she retrieves it. If it were something that needed to be looked at right away the DON can be reached by phone. A weekly skin assessment by RN K on 1/27/15 indicated the resident was without new skin issues at this time. During an interview on 01/28/15 at 1425 hospice RN L said she was at the facility for a skilled nursing visit. Hospice RN L said Resident #14 ' s skin was assessed with [REDACTED]. Hospice RN L said they coordinate with the aides and the nurse here. The skin assessments that they do are in addition to skin assessments done by the facility. Hospice RN L said that coordination occurs face to face with the nurse at the facility, with our staff daily, contact each other over the phone or email. Hospice RN L said that Resident #14 was not wet or dirty when she saw her. During an interview and record review on 01/28/15 at 1500, hospice RN L approached and said she had provided incorrect information about Resident #14. She said Resident #14 had a stage II pressure ulcer on her coccyx. A hospice nursing note dated 01/22/15 by hospice RN L indicated a stage II pressure ulcer which measured 2cm x 1cm x <0.1cm. The treatment specified was to clean with a wipe and apply skin barrier with each incontinent episode. Hospice RN L said that incontinent checks are every two hours. She said she reported her assessment findings to RN K. During a treatment observation on 01/28/15 at 1520 Resident #14 had reddened areas noted on left buttock, coccyx, and a blanchable red crease under her right buttock. During an interview on 01/28/15 at 1550 RN K said she was working on 1/22/15. They (ECAs) were supposed to check and see if Resident #14 was dry every two hours and barrier cream applied each time she was changed. She said she had not reviewed the hospice chart in a while, and she thought she knew what was going on. The Skilled Nursing Addendum wound care documentation by hospice RN L on 1/28/15 described a stage II wound on Resident #14 ' s left buttock 1.5cm x 0.6cm x <0.1cm; a stage II wound on coccyx 2cm x 1.1cm x <0.1cm; and a reddened blanchable crease under her right buttock. During a continuous observation on 01/28/15 beginning at 1020, Resident #14 was seated in a geri chair. No staff repositioned her until the incontinence and skin check at 1520. A dietary profile dated 1/23/15 indicated that Resident #14 weighed 98 lbs and was at 75% of her Ideal Body Weight. During an observation on 1/27/2015 at 1245 pm, ECA J prepared noon meal for resident #14, which consisted of oatmeal prepared with milk and applesauce with a glass of thickened water and juice. The meal served to other residents included spaghetti with meat sauce, green salad, and garlic bread. During an interview on 1/27/2015 at 2:30 p.m., ECA J said she served oatmeal to resident #14 because " I didn ' t think I could puree today's meal to a safe consistency for the resident. I have tried it before with ground beef and she has a hard time with it. " During an interview on 1/27/15 at 1630 Dietician J said that the expectation would be that a resident on a pureed diet would receive the same menu items as other residents, but they would be pureed. The CMS Form 672 dated 01/26/15 indicated 6 residents had pressure ulcers.