Every finding on record at Woodstock Valley Health and Rehabilitation

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision, monitoring, use of safety devices, and fully implement their smoking policy to ensure safety for two of 16 current residents, resident #10 (R10) and R11. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity were lowered to a level 2, isolated. Also, the facility staff failed to provide interventions for adequate supervision for one of 16 residents in the survey sample, Resident #7. The findings include:1. For R10, the facility staff failed to provide a smoking apron and monitor to ensure a cigarette lighter was not kept on his person. R10 was admitted to the facility with diagnosis that included but not limited to nicotine dependence. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 07/23/2025, R10 scored 9 (nine) out of 15 on the BIMS (brief interview for mental status), indicating the R10 was moderately impaired of cognition for making daily decisions. On 09/23/2025 at approximately 10:18 a.m. an observation of R10 was conducted on the locked Dogwood unit. R10 was in a wheelchair, carrying a “Fanny Pak” and observed going outside to the enclosed patio area on the locked Dogwood unit independently. Further observations revealed R10 removing a lighter from the “Fanny Pak, lighting a cigarette, then lighting R11's cigarette. Further observations failed to evidence cigarette butt receptacles on the patio area and a smoking apron for R10. The facility's “Smoking Evaluation” dated 04/10/2025 for R10 documented in part, “Does resident smoke? Yes. Has fine motor skills needed to securely hold cigarette Yes. Observations: 1. Resident is able to communicate why oxygen must be removed prior to going to the smoking area? Yes. 2. Resident is able to communicate the risks associated with smoking. Yes. 3. Resident does not allow ashes or lit material to fall while smoking, inhaling, or holding smoking item? Yes. 4. Resident does not endanger self or others while smoking, (i.e. burn furniture, wheelchair, clothing, skin, self, or others). Yes. 5. Resident smokes only in designated area? Yes. 6. Resident is able to extinguish cigarette safely when finished smoking. Yes. Resident is determined to be: Safe Smoker. Comments/Adaptive equipment needed (if applicable): Utilize an apron while smoking.” The comprehensive care plan for R10 dated 07/19/2023 documented in part, “Focus. Mr. [NAME] is a smoker. Date Initiated: 07/19/2023.” Under “Interventions” it documented in part, “Observe clothing, use smoking apron and skin for signs of cigarette burns. Date Initiated: 07/19/2023; Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 07/19/2023.” On 09/23/2025 at approximately 10:25 a.m. an interview was conducted with R10 in his room. When asked where he obtained the lighter he used to light his and R11's cigarettes, R10 stated the light was in his “Fanny Pak” and that he has it all the time. R10 then opened the “Fanny Pak” and showed the surveyor the cigarette lighter. On 9/23/25 at 3:16 p.m., an interview was conducted with CNA #1 who stated that the smoking at the facility was supervised by staff. She stated that there were designated times, and they were posted at the nurse's station and were the same on both units. She stated that activities normally came over to get the locked unit residents at the smoking times and took the residents over to the other unit for smoke breaks but if they did not come over, the unit CNAs took them out. CNA #1 stated that they kept cigarettes at the desk and the residents came and asked and then went out with them. She stated that everything tobacco related was stored in a drawer behind the nurse's station on the locked unit but it did not have a lock on it. CNA #1 stated that there were only two smokers on their unit currently. CNA #1 stated that R11 was not a smoker but went outside in the courtyard and picked up cigarette butts. CNA #1 stated that R11 would pick them up, not knowing who's they were and smoke them, always asked everyone for cigarettes and lighters. CNA #1 stated that R10 was out in the courtyard this morning with R11 and would provide cigarettes to R11 at times. She stated that R10 would sometimes hide cigarettes, and they were supposed to report them to activities, and they were supposed to confiscate them. CNA #1 stated that she did not give R10 the cigarette he smoked this morning, and she was not sure where R11 got her cigarette from. She stated that they allowed residents to smoke over on the locked unit but did not have any ashtrays to dispose of the cigarette butts, so they threw them on the ground. She stated that they tried to watch R11 to make sure she did not bring the cigarette butts back in the facility, but she probably was. CNA #1 stated that they had a list of residents who required smoking aprons on the other unit. She stated that the residents on the locked unit were allowed to go out to the courtyard as they pleased but were not allowed to smoke whenever they wanted. She stated that they will try to go out to smoke every hour but had to smoke at the designated times with staff supervising them. The facility's smoking sign listing smoking times and location documented, “Woodstock Valley Health & (and) Rehab (Rehabilitation). Smoking Times for Rosewood Courtyard ONLY. O600 (6:00 a.m.), 10:00 a.m., 1:30 p.m., 4:00 p.m., 8:00 p.m.” A review of the facility's smoking policy documented in part, “The Center will have safety equipment available in designated smoking areas including smoking blankets, smoking aprons, a fire extinguisher, and non-combustible self-closing ashtrays, the center will establish and post designated smoking areas and times. Further review of the policy failed to evidence the secured storage of smoking implements, supervision and safety of residents who smoke on the locked unit. On 9/23/25 at 5:15 p.m. ASM (administrative staff member) #1, the executive director, ASM #2, director of nursing, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, ASM #10, traveling director of nursing, LPN (licensed practical nurse) #1, staff development coordinator, LPN #2, unit manager, and OSM (other staff member) #9, regional director of human resources and staffing, were made aware of the observations on the Dogwood unit and were notified of immediate jeopardy (IJ) and substandard quality of care. The facility presented the following IJ plan which was accepted on 09/23/2025 at 9:26 p.m. “Woodstock Valley Health and Rehabilitation 9/23/2025. The following plan is being submitted in response to the Immediate Jeopardy citation at F689 for non-compliance with the facility's smoking policy, the lack of supervision, and the lack of smoking safety interventions, all facility residents are likely at risk for serious injury, serious harm, serious impairment or death. Rooms of Resident #10 and Resident #11 have been searched and they no longer have any smoking materials. The responsible party for both Resident #10 and Resident #11 were notified of the incidents on 9/23/2025. The current smoking area on the locked dogwood unit is no longer designated as a smoking area. Current residents will have their rooms searched with their permission to identify any smoking materials. If smoking materials are found, they will be removed and placed in a secured storage container maintained on Rosewood unit. If resident refuses to have their rooms searched, the facility will respect their decision and will have increased supervision to observe for any signs of them having smoking materials [i.e. smell of smoke, burns in clothing, etc.]. A locked container of all smoking materials, identified as belonging to which resident, will be maintained in a locked medication room on Rosewood unit. The activity staff or charge nurse for Rosewood unit will have access to the keys of the locked container. Current residents will be re-educated on the facility smoking policy. Any resident who desires to smoke will be provided with a written copy of the smoking policy and will be asked to sign the policy. If the resident is unable to sign the policy the resident's responsible party will be contacted and educated on the facility policy. The signed smoking policy by residents or documentation of responsible party education will be documented in the resident's medical record. Residents will only be allowed to smoke in the designated smoking area located in the Rosewood courtyard off the dining room equipped with smoking blankets, smoking aprons, fire extinguisher, and non-combustible self-closing ashtrays at designated smoking times. Current residents who desire to smoke will have their charts reviewed to ensure that the smoking assessment is current and accurately reflects any assistance/supervision and/or protective devices for safe smoking. The residents who desire to smoke will have their care plans reviewed to ensure that the care plan accurately reflects the assistance/supervision and safe smoking devices needed by the residents. All current staff, including contract staff, will be re-educated on the smoking policy and will be educated on their responsibility of what to do when they observe a resident not following the smoking policy, prior to working their next assigned shift. A designated person will be assigned to monitor the doorway leading to the courtyard on the locked Dogwood unit to ensure that if any resident exits into the courtyard they will not smoke. This was initiated 9/23/2025 at approximately 1815 and remains in place until the screamer alarm is installed. Monitoring § The Executive Director or designee will make visual observations of the smoking times on Rosewood 2x daily x 2 weeks and then 3x/week x 4 weeks, to ensure that residents are being supervised and using protective devices for safe smoking. If variances are observed, immediate correction will be made and assigned staff for supervision will be counseled in accordance with facility protocol. § The Executive Director or designee will make daily observations of the courtyard on the locked Dogwood unit x 2 weeks and then 3x/week x 4 weeks to ensure there are no residents smoking or evidence that someone has been smoking in the non-smoking area. § Findings of the daily observations will be monitored weekly by the RVPO or RDCS weekly x 6 weeks. The Executive Director or designee will re-educate any resident who has been observed not following the smoking policy and discharge notice may be given for repeated non-compliance. Findings of the above audits will be reported to the QAPI Committee for additional oversight. Compliance Date: 9/24/2025 @ noon.” On 9/24/25, the survey team performed the following actions to verify that the removal plan had been fully implemented: *Verified the following parts of the removal plan by paper review, with no concerns noted: - Review of the education sign-in sheets for all current facility and contract staff. - Reviewed list of current residents who smoked. - Reviewed medical records of residents who smoke to verify a signed copy of the facility's smoking policy and current smoking assessment. -Reviewed resident's current smoking assessment to verify accurately it reflects any assistance/supervision and/or protective devices for safe smoking. -Reviewed the comprehensive care plan of current residents who smoke to verify that the care plan accurately reflects the assistance/supervision and safe smoking devices needed by the residents. *Verified by observation, with no concerns noted: - Smoking area on the locked Dogwood unit verified was no longer designated as a smoking area. - Rosewood courtyard off the dining room was verified to be equipped with smoking blankets, smoking aprons, fire extinguisher, and non-combustible self-closing ashtrays, present at designated smoking times. - Residents smoking during a designated smoking time, under staff supervision, and with the use of smoking safety interventions. *Verfied Staff Education by staff interviews of Nurses, CNAs, and ancillary staff, demonstrating knowledge compliant with smoking policies and procedures that promoted safety for all residents, with no concerns noted: After review of findings with state agency, it was confirmed that the removal plan had been fully implemented by the facility. On 09/24/2025 at 2:00 p.m., ASM #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, was informed that the removal plan had been verified and the IJ had been abated. No further information was provided prior to exit. 2. For R11, the facility staff failed to provide supervision, a smoking apron and monitor to ensure cigarettes were not kept on her person. R11 was admitted to the facility with diagnosis that included but not limited to dementia (1) and hearing loss. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 08/23/2025, R11 scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating the R11 was severely impaired of cognition for making daily decisions. On 09/23/2025 at approximately 9:53 a.m. an observation of R11 was conducted on the locked unit. R11 was observed in the dayroom sitting in a rocking chair with an unlit cigarette in her right hand up to her mouth. At approximately 9:55 a.m. continued observations of R11 revealed she was holding a plastic cup in her lap. Upon closer observation of the contents of the plastic cup revealed two, unlit, partially smoked cigarettes. At approximately 10:18 a.m. an observation revealed R11 going outside to the enclosed patio area independently followed by R10. Further observations revealed CNA (certified nursing assistant) #1 going out to the patio area after R11 had gone out. Observations also revealed R10 taking a cigarette lighter from his “Fanny Pak”, lighting R10's cigarette while CNA #1 was standing and talking to R10 and R11. Further observations failed to evidence cigarette butt receptacles on the patio area and smoking aprons for R11. On 9/23/25 at 11:28 a.m. Resident #11 (R11) was observed outside in the courtyard sitting in a chair with a walker and personal belongings in front of her. R11 took a partially smoked cigarette out of a bag with personal belongings and began peeling off the paper from the cigarette and throwing it onto the sidewalk. At 11:29 a.m., a staff member went outside to speak with the resident but did not take the cigarette. At 11:33 a.m., another staff member was observed to take the cigarette from R11. At 11:36 a.m., Resident #10 (R10) was observed outside, at 11:37 a.m., R10 was observed taking a cigarette out and lighting it with a lighter that was on his person. R11 ambulated with her rolling walker over to R10 who proceeded to light a cigarette for her. Both residents proceeded to smoke unsupervised with no staff present in the courtyard area. R11 was observed lighting a second partially smoked cigarette with the first cigarette and then proceeded to throw the first cigarette butt behind her into a mulched area with fallen dried leaves present. R11 proceeded to smoke some of the second cigarette and extinguish it into a plastic spoon and store the partially smoked cigarette into the storage pocket of the rolling walker with overflowing personal belongings. Further observations failed to evidence cigarette butt receptacles on the patio area and smoking aprons for R10 and R11. The comprehensive care plan for R11 dated 08/20/2024 documented in part, “Focus. (R11) is an unsafe smoker. Date Initiated: 08/20/2024.” Under “Interventions” it documented in part, “Her smoking supplies are stored with staff in a lock box. Date Initiated: 08/20/2024, She requires a smoking apron while smoking. Date Initiated: 08/20/2024, She requires direct SUPERVISION while smoking. Date Initiated: 08/20/2024.” The facility's “Smoking Evaluation” dated 06/19/2025 for R11 documented in part, “Does resident smoke? Yes. Observations: 1. Resident is able to communicate why oxygen must be removed prior to going to the smoking area? No. 2. Resident is able to communicate the risks associated with smoking. Yes. 3. Resident does not allow ashes or lit material to fall while smoking, inhaling, or holding smoking item? No. 4. Resident does not endanger self or others while smoking, (ie burn furniture, wheelchair, clothing, skin, self, or others). No. 5. Resident smokes only in designated area? No. 6. Resident is able to extinguish cigarette safely when finished smoking. No. Resident is determined to be: Unsafe Smoker. Comments/Adaptive equipment needed (if applicable): Direct supervision at all times and smoking apron.” On 09/23/2025 at approximately 3:45 p.m. an interview was attempted with R10 regarding how she obtained cigarettes. Due to R10's low cognition and hearing difficulty, R10 could not adequately hear and comprehend the questions. On 9/23/25 at 3:16 p.m., an interview was conducted with CNA #1 who stated that the smoking at the facility was supervised by staff. She stated that there were designated times, and they were posted at the nurse's station and were the same on both units. She stated that activities normally came over to get the locked unit residents at the smoking times and took the residents over to the other unit for smoke breaks but if they did not come over, the unit CNAs took them out. CNA #1 stated that they kept cigarettes at the desk and the residents came and asked and then went out with them. She stated that everything tobacco related was stored in a drawer behind the nurse's station on the locked unit but it did not have a lock on it. CNA #1 stated that there were only two smokers on their unit currently. CNA #1 stated that R11 was not a smoker but went outside in the courtyard and picked up cigarette butts. CNA #1 stated that R11 would pick them up, not knowing who's they were and smoke them, always asked everyone for cigarettes and lighters. CNA #1 stated that R10 was out in the courtyard this morning with R11 and would provide cigarettes to R11 at times. She stated that R10 would sometimes hide cigarettes, and they were supposed to report them to activities, and they were supposed to confiscate them. CNA #1 stated that she did not give R10 the cigarette he smoked this morning, and she was not sure where R11 got her cigarette from. She stated that they allowed residents to smoke over on the locked unit but did not have any ashtrays to dispose of the cigarette butts, so they threw them on the ground. She stated that they tried to watch R11 to make sure she did not bring the cigarette butts back in the facility, but she probably was. CNA #1 stated that they had a list of residents who required smoking aprons on the other unit. She stated that the residents on the locked unit were allowed to go out to the courtyard as they pleased but were not allowed to smoke whenever they wanted. She stated that they will try to go out to smoke every hour but had to smoke at the designated times with staff supervising them. The facility's smoking sign listing smoking times and location documented, “Woodstock Valley Health & (and) Rehab (Rehabilitation). Smoking Times for Rosewood Courtyard ONLY. O600 (6:00 a.m.), 10:00 a.m., 1:30 p.m., 4:00 p.m., 8:00 p.m.” A review of the facility's smoking policy documented in part, “The Center will have safety equipment available in designated smoking areas including smoking blankets, smoking aprons, a fire extinguisher, and non-combustible self-closing ashtrays, the center will establish and post designated smoking areas and times. Further review of the policy failed to evidence the secured storage of smoking implements, supervision and safety of residents who smoke on the locked unit. On 9/23/25 at 5:15 p.m. ASM (administrative staff member) #1, the executive director, ASM #2, director of nursing, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, ASM #10, traveling director of nursing, LPN (licensed practical nurse) #1, staff development coordinator, LPN #2, unit manager, and OSM (other staff member) #9, regional director of human resources and staffing, were made aware of the observations on the Dogwood unit and were notified of immediate jeopardy (IJ) and substandard quality of care. The facility presented the following IJ plan which was accepted on 09/23/2025 at 9:26 p.m. “Woodstock Valley Health and Rehabilitation 9/23/2025. The following plan is being submitted in response to the Immediate Jeopardy citation at F689 for non-compliance with the facility's smoking policy, the lack of supervision, and the lack of smoking safety interventions, all facility residents are likely at risk for serious injury, serious harm, serious impairment or death. Rooms of Resident #10 and Resident #11 have been searched and they no longer have any smoking materials. The responsible party for both Resident #10 and Resident #11 were notified of the incidents on 9/23/2025. The current smoking area on the locked dogwood unit is no longer designated as a smoking area. Current residents will have their rooms searched with their permission to identify any smoking materials. If smoking materials are found, they will be removed and placed in a secured storage container maintained on Rosewood unit. If resident refuses to have their rooms searched, the facility will respect their decision and will have increased supervision to observe for any signs of them having smoking materials [i.e. smell of smoke, burns in clothing, etc.]. A locked container of all smoking materials, identified as belonging to which resident, will be maintained in a locked medication room on Rosewood unit. The activity staff or charge nurse for Rosewood unit will have access to the keys of the locked container. Current residents will be re-educated on the facility smoking policy. Any resident who desires to smoke will be provided with a written copy of the smoking policy and will be asked to sign the policy. If the resident is unable to sign the policy the resident's responsible party will be contacted and educated on the facility policy. The signed smoking policy by residents or documentation of responsible party education will be documented in the resident's medical record. Residents will only be allowed to smoke in the designated smoking area located in the Rosewood courtyard off the dining room equipped with smoking blankets, smoking aprons, fire extinguisher, and non-combustible self-closing ashtrays at designated smoking times. Current residents who desire to smoke will have their charts reviewed to ensure that the smoking assessment is current and accurately reflects any assistance/supervision and/or protective devices for safe smoking. The residents who desire to smoke will have their care plans reviewed to ensure that the care plan accurately reflects the assistance/supervision and safe smoking devices needed by the residents. All current staff, including contract staff, will be re-educated on the smoking policy and will be educated on their responsibility of what to do when they observe a resident not following the smoking policy, prior to working their next assigned shift. A designated person will be assigned to monitor the doorway leading to the courtyard on the locked Dogwood unit to ensure that if any resident exits into the courtyard they will not smoke. This was initiated 9/23/2025 at approximately 1815 and remains in place until the screamer alarm is installed. Monitoring § The Executive Director or designee will make visual observations of the smoking times on Rosewood 2x daily x 2 weeks and then 3x/week x 4 weeks, to ensure that residents are being supervised and using protective devices for safe smoking. If variances are observed, immediate correction will be made and assigned staff for supervision will be counseled in accordance with facility protocol. § The Executive Director or designee will make daily observations of the courtyard on the locked Dogwood unit x 2 weeks and then 3x/week x 4 weeks to ensure there are no residents smoking or evidence that someone has been smoking in the non-smoking area. § Findings of the daily observations will be monitored weekly by the RVPO or RDCS weekly x 6 weeks. The Executive Director or designee will re-educate any resident who has been observed not following the smoking policy and discharge notice may be given for repeated non-compliance. Findings of the above audits will be reported to the QAPI Committee for additional oversight. Compliance Date: 9/24/2025 @ noon.” On 09/24/2025 the survey team, through observations, interviews and documentation review, verified the removal plan had been fully implemented by the facility. On 09/24/2025 at 2:00 p.m., ASM #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, was informed the removal plan had been verified and the IJ had been abated. No further information was provided prior to exit. References: (1) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 3. For Resident #7 (R7), a resident assessed as being at risk of elopement, the facility staff failed to maintain interventions to promote adequate supervision. A review of R7's clinical record revealed a nurse's note dated 2/2/25 that documented, [R7's name redacted] found on grounds of facility attempting to go to the store to buy a lighter. Housekeeping manager returned resident to this facility. [R7's name redacted] eloped out of the building and this is an issue because he must have codes to the doors. [R7's name redacted] was a resident on Alzheimer's unit in the past and monitored for elopement risk. An elopement risk evaluation dated 2/2/25 documented R7 was at risk for elopement. The evaluation further documented that R7 was cognitively impaired, independently mobile, had poor decision-making skills, demonstrated exit seeking behaviors, wandered oblivious to safety needs, had a history of elopement, and had the ability to exit the facility. A review of R7's physician's orders revealed an order dated 2/3/25 for a WanderGuard (a bracelet and door controller system used to prevent at-risk residents from exiting the facility) to be applied to the resident's ankle and checked every shift R7's comprehensive care plan dated 2/2/25 documented, [R7's name redacted] is an elopement risk r/t [related to] impairment in cognitive functions and awareness: attempted to leave facility. The interventions included: 2/3/25-Assess for elopement risk. 2/3/25-Monitor location every 15 minutes (resolved/discontinued on 2/4/25). 2/4/25-Wanderguard placement every shift (resolved/discontinued on 2/6/25). Further review of R7's clinical record failed to reveal any further elopement risk evaluation since 2/2/25, revealed the physician's order for a WanderGuard was discontinued on 2/6/25, and failed to reveal any documentation why the WanderGuard was discontinued or documentation of any further interventions to prevent elopement. On 9/23/25 at 2:09 p.m., an observation of R7 was conducted. The resident was observed ambulating with a walker in the hall and was not wearing a WanderGuard. Also, the resident's room was not located on the locked Alzheimer's unit. On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated if a resident is at risk for elopement, the nurse should discuss this with the physician, social services, administrator, and minimum data set coordinator to determine if the resident is suitable for a WanderGuard and update the resident's care plan. LPN #2 stated an additional elopement risk assessment should be done before discontinuing an elopement intervention such as a WanderGuard to make sure the resident truly is no longer at risk for elopement. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. The facility policy titled, Elopements and Wandering Residents documented, 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. The IDT (Interdisciplinary Team) will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. No further information was presented prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 16 residents in the survey sample, Resident #2, was free from mental abuse resulting in psychosocial harm on 3/29/25. The findings include: For Resident #2 (R2) the facility staff failed to ensure the resident was free from mental and verbal abuse resulting in psychosocial harm when the facility staff threatened to have the resident sent out of the facility with a temporary detention order.The resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to: diabetes, obesity, high blood pressure, sleep terrors, insomnia, depressive disorder, anxiety disorder, osteoarthritis, post-traumatic stress disorder, and pain.On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/3/25, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section E - Behavior, the resident was not coded as having any behaviors during the lookback period.The MDS assessment, a quarterly assessment, with an ARD of 1/17/25, completed prior to 3/29/25, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. In Section E - Behavior, the resident was coded as having verbal behavioral symptom directed towards others four to six days of the lookback period but not daily.The nurse's note dated 3/29/25 at 3:29 p.m. documented, Resident has been agitated and verbally inappropriate to staff this shift. Resident came up to med (medication) cart crying and stated that she was going through withdrawal, and she felt like she was dying and couldn't do this anymore. DON (director of nursing), NP (nurse practitioner), Police and EMS (emergency medical services) notified. Resident refused to cooperate with all party's (sic) involved.The physician order dated 3/5/25, documented, Fentanyl Transdermal Patch (1) 72 Hours 75 MCG/HR (micrograms per hour); apply 1 patch every 3 days for chronic pain replace after 3 days and remove per schedule. The March 2025 MAR (medication administration record) documented the above order. The MAR documented the medication was administered on 3/17/25. For 3/20/25 it was documented the patch was removed but for the administration it was documented a 9 which indicates, Other/See Nurse Notes. For 3/23/25, there were 9 document for the removal and administration of the Fentanyl. For 3/26/25, there was a 9 documented for the removal and administration of the Fentanyl.The nurse's note dated 3/20/25 at 3:36 p.m. documented in part, Fentanyl.none acaaiable (sic)(applicable), np (nurse practitioner) to write script.The nurse's note dated 3/23/25 at 5:04 p.m. documented in part, Fentanyl .dc/d (discontinued) new order placed.There was no nurse's note dated 3/26/25 related to the Fentanyl.The narcotic sign-off sheet dated 3/4/25, documented the administration of the Fentanyl patch on 3/17/25. The narcotic sheet was dated 3/29/25, documented the administration of the Fentanyl on 3/29/25. There was no record of administration of Fentanyl on a narcotic sheet between 3/17/25 and 3/29/25, a period of 12 days.The Clinical Opioid Withdrawal Score (COWS) dated 3/29/25 at 6:10 p.m., documented the resident scored a 0 on the assessment. A score greater than eight requires treatment in the emergency room.The nurse's note dated 3/29/25 at 7:33 p.m. documented, LATE ENTRY: Resident in NAD/[NAME] (no acute distress/no acute respiratory distress). Sitting in w/c (wheelchair) conversing other residents. Vital signs obtained. 100/64 (blood pressure), 80 (heart rate), 98.1 (temperature), 96% (oxygen saturation rate) RA (room air), 16 (respirations) even and unlabored, 0/10 (no pain on a scale of 0 - 10 ten being the worse pain ever in) pain. Resident assessed for Opiate withdrawal (COWS). Residents (sic) total score = 0. She is cooperative with assessment. Affect congruent.The social services note dated, 3/29/25 at 8:00 p.m. documented, LATE ENTRY: f/u (follow up) with resident after recent incident. Resident says she is fine but not happy. Offered AG (assisted living) grant and let her know it is an option to be in an assisted living vs (versus) nursing home. She stated she 'will think about it.The comprehensive care plan dated, 8/2/24, and revised on 11/6/24, documented in part, Focus: (R2) reports episodes of having night terrors. Interventions: Administer medications per order. Observe for objective and subjective for increase in night terrors and report to MD/NP (medical doctor/nurse practitioner). Psych (psychological) consult as needed. 4/4/25 - Focus: (R2) has the potential for altered psychosocial well-being r/t PTSD. She has voiced c/o night terrors r/t (related to) traumatic hospitalization resulting in coma. She is followed by house psych and (name of community service board - CCB) outside of the facility. She has exercised her right to not allow facility to have visit notes and information from the CCB. Interventions: Counseling as indicated. If conflict arises, remove resident to calm quiet place and allow resident to vent. Non-pharmacological interventions such as cognitive stimulation, music therapy, outdoor activities, meaningful activities per resident preference. Social services to follow up with resident r/t incident to ensure no lingering effects. 8/22/24 - Focus: (R2) has behaviors of making false accusations, calls 911, makes comments about suicide and suicidal ideations to manipulate her family and staff, throw/drop food trays, tells others not to eat their food, tells others to not be nice to staff and other residents, refusal of medications, threatens staff not to have their jobs. Interventions: Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate locations as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.The facility synopsis of event dated 4/3/25, documented in part, Resident stated to ombudsman she felt intimidated and threatened by employee.The facility synopsis of event dated 4/10/25 documented, Final (facility synopsis of event) for allegation of abuse. (R2) is a [AGE] year-old female, who was admitted to (name of facility) on 7/11/24. Her diagnoses include but are not limited to: COPD (chronic obstructive pulmonary disorder), chronic respiratory failure, H/O (history of) suicidal ideation, CVA (cerebral vascular accident) (stroke), restless leg syndrome, major moderate depressive disorder, PTSD (post traumatic stress disorder), major depressive disorder and generalized anxiety disorder. She uses a wheelchair of mobility, and her BIMS score is 15. It was reported that (R2) on March 29th, the Director of Nursing (ASM -administrative staff member #3), was intimidating and threatening to her. (R2) needed her fentanyl patch to be replaced and was complaining of being in pain and experiencing withdrawal symptoms. During the discussion, (R2)'s behaviors escalated, and EMS and the local police department were notified due to the complaints. While the police and EMS were at the facility, an ECO (emergency containment order) was discussed between (ASM #3) and the police. (R2) heard this conversation and reported that she felt scared and felt (ASM #3) was making false allegations against her. (R2) did not want to leave the facility due to the fear of losing her rights. The police asked (R2) if she wanted to go to the hospital for an evaluation, (R2) refused, and the police and EMS left the facility. (ASM #3) was suspended effective immediately pending this investigation. Staff interviews conducted and statements received from (ASM #3), (ASM #8, the PA - physician assistant), (OSM - other staff member #2), the staffing coordinator, (ASM #5) psychiatrist; and (LPN -licensed practical nurse #4). Statement was received from (R2). Interviewed other residents with a BIMS score of 8 or higher to determine if resident had experienced any abuse or felt unsafe in the facility - none were identified. There were no other residents involved in this incident. This investigation will be unsubstantiated as the statement received from the staff and (R2) are contradicting (sic). (R2) will be monitored weekly x4 for any signs of psychosocial distress by the facility social worker and findings will be documented in the resident's medical record. Any new grievance from (R2) will be comprehensively investigated. The facility team will continue to work collaboratively with APS (adult protective services) and the Ombudsman, both of whom have been involved with this investigation.The Ombudsman Report dated 4/29/25 documented in part, Escalation/Mental Abuse per APS assessment and definition: The DON reportedly aggressively ripped the resident's personal signs from her door, without her consent (according to resident and other staff present), while the police were present in the resident's room. This escalation served to agitate the resident and exacerbate her PTSD symptoms related to medical treatment, causing mental anguish. Resident Rights Violations: Residents have the right to complain. When this resident complained, rightfully, about not receiving her medication in a timely manner, the DON and Provider (ASM #8) moved to discuss an ECO for her despite the medication being on its way to the facility. Both the resident's complaint and any withdrawal symptoms could have been easily handled by getting an emergency prescription to (name of pharmacy) for the resident's medication and administering said medication. There was no need to escalate this matter and in doing so the resident was punished for exercising her right to complain. Additionally, the rationale for this DON's behavior, from her own statement, is based on the resident making reports to other organizations against the facility, making this action appear to be a retaliation. (quotes from the regulations). Residents have the right to informed consent. At no time was this resident given the option to decide how she wanted the issue addressed before EMS/police were called. The DON did not assess the resident, nor did she have a conversation with several other staff about the resident without ever actually speaking to the resident directly. She presented 'facts' about the resident to the provider and psychiatrist without ever assessing the resident directly. Every staff member who interacted directly with the resident that day reported her behavior to be well within her baseline, which the DON would have know if she had taken time to speak with the resident and the staff who were present with her during her complaints.(quotes from the regulations) Residents have the right to refuse care or treatment. The DON's statement also claims that the resident threatened anyone who tried to remove her patch. The resident has the right to maintain bodily autonomy and refuse care or treatment of any kind, including removing a patch that no longer had any medication in it and was not harming her in any way. Additionally, the resident refused transport to the hospital, and instead of honoring this request he Provider and DON moved forward with discussions of an ECO to force her into this decision even though EMS deemed her capable of making rational decisions at the time of her refusal. (quotes from the regulations). Residents have the right to be assessed by skilled medical professionals. In her own statement, the DON stated that the resident's 'bipolar disorder (DON is NOT a mental health practitioner of any kind) would result in 'rapid mood changes,' using this rationale to continue pursuing drastic measures against a resident who had been assessed and was found to not be reactive or out of control. This is not accurate to bipolar disorder and is a harmful assumption to make without a licensed mental health professional assessing the resident in person and making such a claim. Additionally, this resident has not been diagnoses with bipolar disorder and her chart was not consulted to determine her current diagnoses. (quotes from the regulations). Residents have the right to be treated with dignity and respect. This resident was not spoken to by this staff member or the provider until the police were already present in her room. The resident does not recall this DON ever introducing herself to her prior to entering her room with officers, and the DON reported to APS and myself that she felt bad that 'this is how they met for the first time.' Additionally, the DON removed the resident's personal signs from her door without her permission, and they were not an immediate harm to anyone. This bot violated her right to maintain her personal possessions and escalated the mental anguish of the resident during this interaction . (quotes from regulations). Residents have the right to person-centered care. This requires all staff to address each resident individually, according to their needs and preferences. This resident has a history of medical abuse and PTSD, which would indicate the need for calm, clear interactions where she had agency to decide what treatment she would like to pursue. This did not happen. (quotes from the regulations).The facility final synopsis of event dated, 5/7/29, documented, Final (synopsis of event) for allegation of abuse sent 4/10/25 regarding resident (R2). This report serves as an addendum to final FRI for allegation of abuse sent on 4/10/25 regarding resident (R2). Based on the facility's further investigation, it was determined that the root cause of the behavior exhibited on 3/29/25 by (R2) could have been due to the Fentanyl patch not being administered as ordered. The Fentanyl patch is documented as not available on 3/20 and 3/23. This trigger was not recognized or de-escalated by the DON or PA on 3/29/25 resulting in a call to the EMS/police for an ECO. The Fentanyl patch is documented as administered on 3/29 and has been administered timely I April and May. (R2) also has orders for Oxycodone 10 mg 1 tab (tablet) every 4 hrs. (hours) for chronic severe pain while awake and receives routinely every 4 hrs. As a result of the facility's continued investigation and the report received from the Ombudsman on 4/29/25, the facility substantiates that (R2)'s rights were violated and the allegation of neglect regarding timely medication administration was substantiated. Based on the actions that represent a concern for resident rights, the DON (ASM #3)'s employment was terminated on 5/1/25. (license #xxxxxxxxx). The provider group (name of PA's employer) was given a 30-day termination notice on 4/1/25. The facility administrator (ASM #1) was educated on investigation and responding to incidents and received a written counseling regarding conducting timely and comprehensive investigations and responding to incidents on 5/6/25. An audit of all residents on pain medication to ensure meds are available was completed on 5/7/25. Any concerns identified were immediately addressed. The facility identified opportunity for improvement in the following areas and has initiated education on the following topics: Virginia resident rights, HIPPA (health insurance portability act) compliance, Code of Ethics, De-escalation techniques, Responding to need of TDO (temporary detaining order)/ECO, Grievance, Abuse, Neglect, Exploitation and Misappropriation, Mandated reporter, Medication unavailable, Completing a comprehensive investigation to include FRI, Investigating and Responding to Incidents. (R2) has been assessed by her new provider on 5/6/25 with no new concerns identified. (R2) was interviewed by (ASM #2), the DON on 5/3/25 and states that she is in good spirits with no complaints of pain. (R2)'s care plan has been updated to include behavioral/PTSD triggers, behavior monitoring, and resident specific non-pharmacological interventions to minimize triggers. Social Services will follow with resident weekly for 4 weeks to provide psycho-social support and follow-up with any concerns. The facility is working in collaboration with APS (adult protective services) and the Ombudsman to ensure compliance with resident rights. The facility has implemented a process for additional oversight through QAPI (quality assurance plan improvement) to ensure that all allegations regarding care and resident rights are thoroughly investigated with appropriate interventions in place.The physician assistant notes dated 3/29/25, documented in part, Patient was seen today as she is in need of a refill for her fentanyl patches. She has been threatening staff all morning with calls to the state, replace, etc. Pending other current potential legal issues with (R2), a referral to pain management will be considered. Negative for nausea, vomiting, diarrhea, fever, chills, shortness of breath, chest pain.Review of systems: Psychiatric: Normal affect is appropriate. There is no agitation.The psychiatry initial consult dated, 5/22/25, documented in part, She reports a history of abuse, including a verified case involving Adult Protective Services (APS). She experiences night terrors related to her coma and nightmares stemming from the abuse incident. She feels that she has been mistreated and ignored by some staff members, leading to a lack of trust in her care providers. Despite these challenges, she is an advocate for herself and others, working with outside sources to improve conditions.An interview was conducted with R2 on 9/23/25 at 10:00 a.m. The resident stated on 3/29/25 she was feeling not well, sick to her stomach and had diarrhea. She stated her daughter had come in on 3/28/25 and looked at her pain patch (fentanyl) and it was dated 3/17/25. The next morning, she said she started complaining about her pain patch having not been changed as ordered. She stated she told the DON that she needed her pain patch, and the solution was to get a prescription to (local pharmacy) and get it delivered. The DON told the resident that We don't do that. She told the DON that yes, they can do that. The resident explained to the DON that that has been done in the past. R2 stated she went back down the hallway to her room. R2 stated the DON was yelling at her for taking videos of people and violating HIPPA. She thought her glucose monitor was a bodycam. The resident gave the DON the finger and yelled (explicative). The next thing the resident could recall was the police came to her and said she was being hostile. The police asked her if she understood why they were there. The police followed her everywhere she went in the facility. At first the resident was told they were going to ECO her and then changed it to a TDO. The psychiatrist that they called stated she was in a manic phase of her Bipolar disease. R2 stated she doesn't have a diagnosis of bipolar disorder. R2 stated she has PTSD related to being in a coma in 2013. She stated she was embarrassed as there were multiple people in the hallways, staff members, residents, housekeeping and activities. There were multiple kinds of people from different departments. The nurses and aides were watching them watch her. R2 stated she felt like she was dying inside, she felt so sick. R2 stated if the DON had listened to her, she would have understood what the real situation was. R2 stated the DON never wrote anything down and no medical personnel ever assessed her. The rescue squad, when they arrived, did my vital signs. They kept on telling her she was going to be taken TDO. R2 stated they were going to take her to a detox place. They caused this to her, not me being detoxed. She stated the DON had only been here for nine to ten days. R2 stated no one saw the DON oriented to any of the residents. The police told her that she was not appropriate for a TDO, but the DON kept on pressing the issue. The police left. The police told her to stay in her room until they got this figured out. R2 stated she felt the DON was on a power trip. R2 stated she felt the DON should have been more educated on who she was dealing with. (LPN #1) and (LPN #2) came in and did an assessment of her, they talked to her. (LPN #1) got her pain patch and an hour later she wasn't sick anymore. R2 stated she was so scared, they would put her away someplace beyond her control and have no choice in what she was doing, losing her rights. She stated she was petrified. R2 stated the event has left a lasting impression on her. If she sees police officers in the building, she feels like they are coming for her, and her heart starts racing. Her night terrors are about police taking her away and herself and her family don't know where she is. She had trust issues with medical people before but now her trust in medical people is down to nothing. She stated she does have a few people here that she does trust.On 9/23/25 at 12:25 p.m., an interview was conducted with ASM (administrative staff member) #3 (the medical director). ASM #3 stated symptoms of Fentanyl withdrawal could include tachycardia (an increased heart rate), agitation, itching, and seizures if the patient is on a pretty high dose of the medication.An interview was conducted with OSM (other staff member) #1, the social worker, on 9/24/25 at approximately at 9:30 a.m. OSM #1 stated on 3/29/25 she was not here at the time of the incident but (LPN #1 called her and stated the DON and (ASM #8, PA) was trying to TDO (R2). (LPN #1) explained to her that the resident was upset about her medications. I came in to check on her psychosocial wellbeing. OSM#1 stated she sat with the resident in the courtyard. The resident explained to OSM #1 and LPN #1 what was going on, she was in tears and was visibly upset. OSM #1 stated they comforted the resident and made sure she was okay. OSM #1 and LPN #1 explained to the resident they couldn't send her out by TDO because the resident was upset about her medications. When asked if she was made aware of an allegation of abuse, what steps should be taken, OSM #1 stated first is to separate the resident and/or staff member involved. The report it immediately to the DON and (ASM #1), the executive director. The executive director would need to report to the state and start an investigation.An interview was conducted with ASM #4, the former DON, on 9/24/25 at 10:22 a.m. ASM #4 stated she had only been the DON for a short period of time. The supervisor on duty called her and sent her picture of the signs the resident was posting on her door, person and wheelchair. The supervisor on duty stated the resident was complaining of withdrawal symptoms and posting signs that her rights were being violated, the food is bad, and she was not getting her medications. The resident was saying she didn't get her Fentanyl as ordered. ASM #4 stated she was not aware of any concern of the resident not getting her medications. ASM #4 stated she did not know (R2). ASM #4 contacted (ASM #8). The nurse on duty (LPN #4), spoke with ASM #8 and explained that (R2) was complaining of withdrawal symptoms. ASM #4 stated there was apparently a problem with ASM #8's electronic prescription processing and ASM #8 told ASM #4 that she thought the problem was taken care of. ASM #8 sent another order to the pharmacy. ASM #4 stated she called the pharmacy and they didn't have the prescription from ASM #8. ASM #4 stated when she spoke with ASM #8 they both agreed that if the resident was in withdrawal, then the resident's needs could not be met at the facility and the resident needed to be transferred out to the hospital. ASM #4 stated that R2 was still complaining so she called EMS and explained the situation. Dispatch for EMS sent police to accompany EMS in this situation. R2 refused to go. ASM #4 spoke with the police officer, and he stated he was well versed with R2. The police officer told ASM #4 that the resident has the right to refuse to go to the hospital. ASM #4 stated that she and the EMS waited around the corner while the police officer went to talk to R2. ASM #4 stated she entered the resident's room and introduced herself while the officer was in the room. ASM #4 stated she did not request the police. ASM #4 stated that upon entrance to the resident's room the resident asked if she had her pain patch. ASM #4 stated the resident was hostile and stating that she was in withdrawal. ASM #4 stated the resident refused any vital signs be taken. The resident refused to let anyone touch her until they put her patch on. ASM #4 stated she wanted to accurately take care of her symptoms and send the resident out to the emergency room. ASM #4 stated she did look at the patch on the resident and explained it should have been taken off a few days before. ASM #4 stated the resident clenched her fist at her and told ASM #4 that is she came any closer, but the police officer was able to calm the resident down. ASM #4 stated she stepped out of the resident's room. The police said they would have to get her detained in order to get her out of the facility. ASM #4 stated EMS came to her and stated that the resident is alert and oriented and has made the decision to refuse to go to the hospital. ASM #4 stated she spoke with the police officer and ASM #8 and ASM #8 stated she didn't think the resident needed to be sent out via a TDO. ASM #4 stated she contacted ASM #11, the interim chief nursing officer. ASM #11 instructed ASM #4 to get a psychiatrist to do a virtual assessment of the resident. ASM #4 stated she spoke with ASM #5, the psychiatrist, and he stated he didn't need to do a virtual assessment as he knew the resident well. He told ASM #4 that he knew the resident and the resident had bipolar disorder and was in a manic episode. ASM #4 stated she instructed LPN #1 to set up the virtual assessment. ASM #4 stated she was not a doctor and could not diagnose a resident. ASM #4 stated that ASM #8 was not comfortable in pursuing a TDO. ASM #4 stated by 6:00 p.m. the resident had calmed down. ASM #4 stated she had gone to the police station and spoke with the non-emergency phone line and wanted information of how to do a TDO if needed through the night. The police department stated the facility would have to go before the magistrate in the morning to [NAME]. When asked if she raised her voice at the resident, ASM #4 stated no, she was very nice to her. ASM #4 stated she explained to the resident that she understood that the resident was videotaping other residents and the current situation, and she explained to the resident that that was a HIPPA violation. When asked if she removed the resident's handmade signs off the door or walls, ASM #4 stated she did remove them as they were a health department violation due to infection control concerns.An interview was conducted with LPN #1, the staff development coordinator, on 9/24/25 at 11:47 a.m. LPN #1 stated she was not in the building at same time as ASM #4, they were sort of in passing. She stated her assessment of R2 revealed the resident was very upset about her Fentanyl patch. The patch on the resident was dated 3/17/25. LPN #1 stated she explained to ASM #4 that they could get the medications from the local pharmacy, as they have done in the past. LPN #1 stated most of her information was from the resident and she needed to report it to ASM #1, the executive director and ASM #6, the vice president of operations.An interview was conducted with LPN #4, the nurse caring for the resident on 3/29/25, on 9/24/25 at 1:03 p.m. LPN #4 stated R2 was upset about her Fentanyl patch. LPN #4 stated she doesn't normally work that hall very often. LPN #4 stated the resident refused to take off the old patch until the new one was applied. She stated at one point the resident was threatening someone but wasn't sure who it was. LPN #4 stated they contacted the physician assistant, and she came in. ASM #8 ordered the Fentanyl patch. LPN #4 stated she was on the phone with the pharmacy when the police and EMS came, she had no idea who called them. LPN #4 stated she went to the resident's room. She observed ASM #4 and the resident in a kind of an argument. She stated R2 was calm during the whole thing. ASM #4 was trying to get the resident to go to the hospital, but the resident refused to go. R2 was saying she was going through withdrawal as she didn't have her patch. ASM #4 stated the facility was not capable of handling a resident going through withdrawal. LPN #4 stated the police stated the resident didn't have to go. ASM #4 did not agree with that. LPN #4 stated that ASM #4 just wouldn't let it go. LPN #4 stated at some point, a TDO was mentioned, she wasn't sure who brought that up. She stated that R2 wasn't being a harm to herself or others. The resident wasn't yelling or anything like that. The resident didn't want to go to the hospital and just wanted her Fentanyl patch. The resident had posters on her door and clothing stating that she was being mistreated and wasn't getting her medications. ASM #4 ripped the signs off the door. LPN #4 stated she didn't hear ASM #4 ask permission to remove them off the door, stating it was a fire hazard. She further stated that ASM #4 just wouldn't let it go. The police told ASM #4 to go somewhere else as she was making the situation worse and not better. After that, ASM #4 left. LPN #4 stated R2 was fine after everything settled down.An interview was conducted with ASM # 5, the psychiatrist, on 9/24/25 at 2:47 p.m. He recalled receiving a call from ASM #4. He stated he knew the resident and she was difficult at time and had ongoing behavior related to not being satisfied with her care. He stated she can get agitated, but she is not psychotic or has any psychiatric condition. ASM #5 stated he told ASM #4 that if the resident was out of control and a danger to herself or others, then a TDO was appropriate but if she wasn't then a TDO was not needed.An interview was conducted with ASM #1, the executive director, on 9/24/25 at 2:53 p.m. ASM #1 stated she was not in the building on 3/29/25. She stated that when the Ombudsman came to her and stated that the R2 stated her rights were violated. ASM #1 stated that ASM #4 was the aggressor in this situation. ASM #4 had threatened to TDO the resident. The police and EMS were involved. The day after the incident she received calls from her boss asking about the commotion over the weekend. She spoke with R2, and resident informed her that the police were there on 3/29/25 and ASM #4 was trying to TDO her. The resident informed ASM #1 that she could hear the conversation between the police and ASM #4 and her anxiety and PTSD were affected. It was only after the Ombudsman's visit and report that the investigation was reopened. ASM #4 was suspended, brought back for a short period of time and then terminated on the grounds of violation of resident rights and mental abuse.An interview was conducted on 9/24/25 at 3:09 p.m. with ASM #6, the vice president of operations. ASM #6 stated she was not in the building at the time of the incident. She stated when Ombudsman's report came, we investigated it further and found that the conclusion was that there was a concern for violating R2 rights and neglect. When asked if psychosocial harm was found, ASM #6 stated, It could have been also.An interview was conducted with ASM #7, the psychiatric nurse practitioner, that saw the resident on 5/22/25. ASM #7 reviewed her notes and stated the resident told her about the case with APS and it was when the facility tried to TDO her. The resident explained to her that she was afraid of police coming into the building after the 3/29/25 incident.The facility policy, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physic

Based on staff interview, and facility document review, the facility staff failed to ensure the required QAPI (Quality Assurance and Performance Improvement) committee members attended for three of three quarterly meeting reviews, (October 2024 through December 2024, January 2025 through March 2025, and April 2025 through June 2025). The findings include:The facility staff failed to ensure an Infection Preventionist attended QAPI meetings from October 2024 through June 2025. A review of QAPI meeting sign-in sheets for October 2024 through June 2025 failed to reveal the signature of an Infection Preventionist. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated an infection preventionist is supposed to attend the QAPI meetings and she could not show an infection preventionist attended the QAPI meetings from October 2025 through June 2025. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. 1. The facility policy titled, Quality Assurance and Performance Improvement (QAPI) documented, The QAA Committee shall be interdisciplinary and shall:a. Consist at a minimum of: i. The Infection Preventionist.b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. No further information was presented prior to exit.

Based on staff interview, and facility document review, the facility staff failed to provide evidence of an updated hospital transfer agreement for one of one agreement reviewed, potentially affecting all residents, a census of 86. The findings include:The facility staff failed to provide an updated hospital transfer agreement. A review of the hospital transfer agreement revealed there was no current contractual agreement with the hospital. The agreement was between the hospital and the name of the previous owner of the facility, a company no longer in existence. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated that when the new company began ownership of the facility (June 2025), she had to reach out to all vendors, write up new contracts, send the contracts to the new company's legal team for review, send the contracts back to the vendors for changes, then send the contracts back to the new company's legal team. ASM #1 stated the new company bought approximately 48 or 49 facilities and this has been a slow process. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. No further information was presented prior to exit.

Based on staff interview, and facility document review, the facility staff failed to meet RN (registered nurse) requirements for 16 of 31 days reviewed. The findings include:1. The facility staff failed to provide RN coverage for eight consecutive hours a day on 8/25/25, 8/30/25, 8/31/25, 9/13/25, and 9/14/25. A review of nursing schedules revealed there was no RN coverage for eight consecutive hours on 8/25/25, 8/30/25, 8/31/25, 9/13/25, and 9/14/25. On 9/25/25 at 1:45 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated there had not been eight consecutive hours of RN coverage in the facility and there was only one other RN besides her working at the facility. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. The facility policy titled, Nursing Services-Registered Nurse (RN) documented, The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week. No further information was presented prior to exit. 2. The facility staff failed to ensure the Director of Nursing did not serve as a charge nurse on 8/25/25, 8/27/25, 8/29/25, 9/2/25, 9/8/25, 9/9/25, 9/10/25, 9/11/25, 9/12/25, 9/15/25, 9/19/25, and 9/20/25. A review of the nursing schedules revealed the Director of Nursing served as a charge nurse on 8/25/25, 8/27/25, 8/29/25, 9/2/25, 9/8/25, 9/9/25, 9/10/25, 9/11/25, 9/12/25, 9/15/25, 9/19/25, and 9/20/25. A review of nurse staffing postings revealed the resident census on all of those dates was greater than 60 residents. On 9/25/25 at 1:45 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she was told she was not supposed to work as a nurse on the floor unless there was a crisis, but if we don't have any other choice then we don't have a choice. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern.The facility policy titled, Nursing Services-Registered Nurse (RN) documented, The Director of Nursing may serve as a charge nurse only when the facility has average daily occupancy of 60 or fewer residents. No further information was presented prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a pressure injury for two of 16 residents in the survey sample, Residents #3 and #6.The findings include:1) For Resident #3 (R3), the facility staff failed to provide treatments to pressure injuries (1) as ordered during dates in January and February of 2025.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/28/2025, the resident was assessed as having three Stage 3 pressure injuries and two Stage 2 pressure injuries that were present on admission.Review of the eTAR (electronic treatment administration record) for R3 dated 1/1/25-1/31/25 failed to evidence treatments completed on the following dates:Clean all wounds on buttocks with wound cleanser, apply skin prep to outer edges of wounds. Soak gauze in Dakin's solution, put gauze into wounds, squeeze out excess liquid, cover with foam dressings every day shift every 3 day(s). On 1/27/25 the eTAR was observed to be blank.Review of the eTAR for R3 dated 2/1/25-2/28/25 failed to evidence treatments completed on the following dates:Gentamicin Sulfate External Ointment 0.1 % (Gentamicin Sulfate (Topical)) Apply to sacrum, L + R ischium topically one time a day for pseudomonas infection for 2 Weeks. On 2/4/25, 2/6/25, and 2/7/25. The dates were observed to be blank.Wound care for left ischium, right ischium, sacrum. Cleanse with wound cleanser, pat dry. Apply gentamicin 0.1% ointment to wound bed, then apply calcium alginate to wound bed. Cover with foam dressing QD (every day) and change PRN (as needed) for saturation/soilage every day shift. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank.Wound care order for left heel Cleanse with wound cleanser, apply calcium alginate, cover with foam dressing QD every day shift for Wound Care. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank.Wound care order for right heel Cleanse with wound cleanser, pat dry, apply skin prep QD. Offload with boot or heelz up pillow one time a day. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank. The comprehensive care plan for R3 documented in part, [Name of R3] has pressure injury to left ischium r/t decreased mobility, occasional bladder incontinence, history of radiation and chemotherapy r/t rectal cancer, poor nutrition, Non-compliance with treatment and regimen. Date Initiated: 02/03/2025. The clinical record failed to evidence documentation regarding the missed treatments on the dates listed above in January and February of 2025.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that treatments were evidenced as completed by documentation in the eTAR.On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern.No further information was provided prior to exit.Reference:(1) A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm.2) For Resident #6 (R6), the facility staff failed to provide treatments for a pressure injury on multiple dates in July, August and September 2025 and failed to complete weekly assessments that included measurement and description of wound progress.On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 8/13/25, the resident was assessed as having one unstageable pressure injury that was not present on admission or reentry.A weekly skin integrity review for R6 dated 4/9/2025 documented intact skin.A weekly skin integrity review for R6 dated 4/18/2025 documented in part, .coccyx- open area on coccyx found by CNA (certified nursing assistant) staff member.A wound physician summary for R6 dated 4/22/2025 documented in part, .Patient is seen for evaluation and management of wound(s)/skin. Staff noticed an open area at pt's buttock area and have been placing a dry dressing on the area. Pt has a hx (history) of stage 2 PI (pressure injury) to her left buttock along with previous trauma to the area. Left Buttock: (+) partial thickness ulceration that measures 1.0 x 0.5 x 0.2 cm. Wound base 100% pink/red moist tissue. reopened stage 2 PI Contributing factors to dx: poor mobility, incontinence, previous trauma to area, age, muscle weakness, previous stage 2 PI to left buttock Wound care to left buttock as follows: Cleanse with wound cleanser or NS (normal saline), pat dry. Apply zinc Q (every) shift.A wound physician summary for R6 dated 5/20/2025 documented in part, .Left buttock (+) partial thickness ulceration that measures 0.5 x 0.5 x 0.1 cm. Wound base 100% pink/red moist tissue. Edges adherent to wound base.A pressure ulcer wound round assessment for R6 dated 8/4/2025 documented in part, Units of measure: centimeters. Site: Coccyx; Type: Pressure; Length: 1.5; Width 1.5; Depth 0.3; Stage: unstageable. Wound bed: slough; Color: yellow; wound edges: rolled. Continue treatment as ordered.A wound physician summary for R6 dated 9/18/2025 documented in part, .Stage 4 Pressure Wound Sacrum Full Thickness. Wound Size (LxWxD) (length by width by depth): 1x1x1.2cm.Granulation tissue: 100% . Healing Potential: Good. Estimated Time to Heal: 2-4 months.Approach: Off-loading.Review of the clinical record documented skin assessments documenting presence of the wound and continued wound treatments but failed to evidence weekly measurements of the pressure injury including width, length, depth, type of tissue and exudate described between the measurements obtained on 5/20/25 and 8/4/25.Review of the eTAR (electronic treatment record) for R6 dated 7/1/25-7/31/25 failed to evidence treatments completed to the coccyx pressure injury on 7/3/25, 7/21/25, 7/22/25, 7/23/25, 7/24/25 and 7/25/25. The dates were observed to be blank.Review of the eTAR for R6 dated 8/1/25-8/31/25 failed to evidence treatment completed to the coccyx pressure injury on 8/23/25. The date was observed to be blank.Review of the eTAR for R6 dated 9/1/25-9/30/25 failed to evidence treatments completed to the coccyx pressure injury on 9/5/25 and 9/20/25. The dates were observed to be blank.The clinical record failed to evidence documentation regarding the missed treatments on the dates listed above in July, August and September of 2025. The comprehensive care plan for R6 documented in part, [Name of R6] has unstageable pressure injury to the coccyx r/t (related to) poor mobility, incontinence. Date Initiated: 08/14/2019. Under Interventions it documented in part, Administer treatments as ordered and monitor for effectiveness. Date Initiated: 05/14/2025. Assess/record/monitor wound healing. Date Initiated: 05/14/2025. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Date Initiated: 05/14/2025.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that treatments were evidenced as completed by documentation in the eTAR. She stated that the facility formerly had a wound care nurse practitioner who came in weekly and assessed residents pressure injuries, measuring them and adjusting treatments as needed but they did not come there any longer. She stated that she had been on night shift and was not sure of the current process but if a new wound was reported to her she asked a nurse trained in wounds to measure it and referred it to the physician for treatment. On 9/24/2025 at 4:56 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that the former assistant director of nursing used to keep a log sheet where she tracked pressure injuries and measured them weekly but had stepped down from the position. She stated that there was an assessment that they could complete in the electronic medical record to record their assessments but there had been a lapse due to the assistant director stepping down, and the wound nurse practitioner leaving. She stated that she could say that after the assistant director of nursing stepped down there was a period when there was a gap in tracking and measuring but they had a new doctor who started last week to assist them. ASM #2 stated that R6 was non-compliant with repositioning and tended to lay flat on her back or on the left side. On 9/25/2025 at 4:58 p.m., ASM #1, the administrator, was made aware of the concern.No further information was provided prior to exit.

Based on facility staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure medications were available for administration for two of 16 residents in the survey sample, Residents #3 and #7.The findings include:1) For Resident #3 (R3), the facility staff failed to ensure medications were available for administration during dates in February and March of 2025. Review of the eMAR (electronic medication administration record) for R3 dated 2/1/25-2/28/25 failed to evidence administration of the following medication on the dates listed below: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG (milligram)/50ML (milliliter)-% (Daptomycin-Sodium Chloride) Use 500 mg intravenously in the morning related to Sepsis, Unspecified Organism. On 2/9/25 and 2/21/25. (antibiotic to treat infection) (1). The eMAR for 2/9/25 was observed to be blank and 2/21/25 eMAR progress note documented “ordered call to pharmacy.” Epoetin Alfa-epbx Injection Solution 40000 UNIT/ML (Epoetin Alfa-epbx) Inject 1 ml subcutaneously one time a day every Fri for Anemia of Chronic disease. (to treat anemia) (2) On 2/14/25. The eMAR progress note documented “Not available in omni cell, awaiting from pharmacy.” Pregabalin Oral Capsule 25 MG (Pregabalin) Give 25 mg by mouth every morning and at bedtime related to pain in unspecified joint. (to treat pain) (3) Not administered on the 6:00 a.m. doses on 2/1-2/4/25, 2/6/25, 2/7/25, and 2/20/25 and the 9:00 p.m. doses on 2/1, 2/3, 2/5-2/9/25. The eMAR progress notes on 2/1/25, 2/4/25, 2/6/25, 2/7/25, 2/9/25 documented, “on order”, 2/2/25- “ordered”, 2/3/25- “script needs to be wrote”, 2/8/25- “not available at this time” and 2/20/25- “new order wrote, has not arrived.” Review of the eMAR for R3 dated 3/1/25-3/31/25 failed to evidence administration of the following medication on the dates listed below: Pregabalin Oral Capsule 300 MG (Pregabalin) Give 1 capsule by mouth every morning and at bedtime for neuropathy. On 3/8/25 at 9:00 a.m. The eMAR progress note documented, “on order.” On 3/20/25 at 9:00 p.m., the eMAR progress note documented, “ordered.” On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that medications were evidenced as given by documentation in the eMAR. She stated that if a medication was not available on the medication cart they checked the Omnicell (in house medication) stock and if not there they called the pharmacy to see when it would be available. She stated that they were supposed to notify the physician when a medication was not given to let them know when the medication was going to be delivered and follow their instructions. The facility policy “Medication Administration” dated 6/1/2025 documented in part, “Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection… Policy Explanation and Compliance Guidelines: Administer medication as ordered in accordance with manufacturer specifications .” On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern. No further information was provided prior to exit. Reference: (1) Daptomycin Injection: MedlinePlus Drug Information (2) Epoetin Alfa, Injection: MedlinePlus Drug Information (3) Pregabalin: MedlinePlus Drug Information 2. For Resident #7 (R7), the facility staff failed to ensure the medications Ziprasidone and Flomax were available for administration on multiple dates July 2025 through September 2025. A review of R7's clinical record revealed the following physician's orders: 3/14/25-Ziprasidone 60mg (milligrams). One capsule by mouth every morning and at bedtime for schizophrenia. 5/6/25-Flomax 0.4mg. One capsule by mouth once a day for enlargement of the prostate gland. A review of R7's MARs (medication administration records) for July 2025 through September 2025 failed to reveal evidence the morning dose of Ziprasidone was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, and 8/11/25, failed to reveal evidence the bedtime dose of Ziprasidone was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, 7/28/25, 9/15/25, 9/16/25, 9/17/25, and 9/18/25, and failed to reveal evidence the daily dose of Flomax was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, 7/27/25, and 8/11/25. On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses evidence the administration of medications by documenting the medications were administered on the MAR. On 9/25/25 at 3:51 p.m., another interview was conducted with LPN #2. LPN #2 stated that if a medication is not available in the medication cart, the nurse should obtain the medication from the Omnicell (a machine containing various medications) if the medication is available there or contact the pharmacy if the medication is not available in the Omnicell. A review of the Omnicell list revealed Ziprasidone and Flomax were not available in the Omnicell. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview and facility document review, facility staff failed to provide residents with the correct amount of food according to the facility's menu in one of one facility kitchens. The findings include:On 09/22/2025 at approximately 2:00 p.m. an observation in the facility's kitchen revealed OSM (other staff member) #10, acting dietary manager plating Caesar salad into bowls using a beige/ off-white handle scoop. Further observations revealed OSM #10 placing one scoop of salad into each bowl. At approximately 4:24 p.m. an observation of the facility's kitchen tray line revealed the cook plating food for the resident's dinner. Observations of the serving utensils being used by the cook to plate the food revealed he was using a grey handle scoop for serving lasagna, and a red handle scoop for sliced carrots. Continued observations revealed the cook placed one scoop of lasagna, carrots on the resident's dinner plates and one bowl of Caesar salad on each meal tray. The facility's menu for dinner on 09/22/2025 documented in part, Monday. Entree. Lasagna w/ (with) meat sauce 1 (one) square. Caesar Salad 1 Cup. Sliced Carrots 1/2 (half) Cup.The facility's Production Count dated Monday-9/22/2025 documented in part, Lasagna w/MeatSauce 8 Oz (eight ounces), Caesar Salad 1 Cup, Sliced Carrots 1/2 Cup. The kitchen's Disher Size reference sheet documented in part, SCOOP NO. (number) MENU OZ VOLUME#4 8 Oz 1 Cup#8 4 Oz 1/2 Cup#10 3 Oz 3/8 (three-eighth) Cup#16 2Oz 1/4 (quarter) Cup On 09/25/2025 at approximately 1:10 p.m. an interview was conducted with OSM #11, district manager for dietary. When asked about the serving sizes of the grey, red and beige/ off-white handle scoops, OSM #11 showed the surveyor the scoops and stated the that the grey handle scoop holds four ounces, the red handle scoop holds two ounces and the beige/ off-white handle scoop holds three ounces. After informed of the observation of the serving utensils/scoops being used for food portions as stated above for the resident's dinner on 09/22/2025 OSM #11 stated the cook should have referenced the Production Sheet and check for the correct serving utensil/scoop to serve the correct portions of food. When asked if residents received the correct amount of food for dinner on 09/22/2025 she stated no. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on observations, staff interview, clinical record review and facility document review, facility staff failed implement the comprehensive care plan for six of 16 current residents in the survey sample, Residents #10 (R10), R11, #7, #2, #3 and #6. The findings include:1. For R10, facility staff failed to provide a smoking apron while smoking a cigarette on the locked Dogwood unit. R10 was admitted to the facility with diagnosis that included but not limited to nicotine dependence. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 07/23/2025, R10 scored 9 (nine) out of 15 on the BIMS (brief interview for mental status), indicating the R10 was moderately impaired of cognition for making daily decisions. On 09/23/2025 at approximately 10:18 a.m. an observation of R10 was conducted on the locked Dogwood unit. R10 was in a wheelchair, carrying a “Fanny Pak” and observed going outside to the enclosed patio area on the locked Dogwood unit independently. Further observations revealed R10 removing a lighter from the “Fanny Pak”, lighting a cigarette then lighting R11's cigarette. Further observations failed to evidence R10 with a smoking apron while smoking a cigarette. At 11:36 a.m., Resident #10 (R10) was observed outside, at 11:37 a.m., R10 was observed taking a cigarette out and lighting it with a lighter that was on his person. R10 proceeded to smoke unsupervised with no staff present in the courtyard area. Further observations failed to evidence a smoking apron for R10. The facility's “Smoking Evaluation” dated 04/10/2025 for R10 documented in part, “Comments/Adaptive equipment needed (if applicable): Utilize an apron while smoking.” The comprehensive care plan for R10 dated 07/19/2023 documented in part, “Focus. Mr. [NAME] is a smoker. Date Initiated: 07/19/2023.” Under “Interventions” it documented in part, “Observe clothing, use smoking apron and skin for signs of cigarette burns. Date Initiated: 07/19/2023.” On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the purpose of the care plan was to make sure they had a generalized location to show how to take care of residents that they were not familiar with. She stated that they implemented the care plan by looking at it and making sure any changes were communicated to the CNAs (certified nursing assistants) as they were noted or communicated to them. The facility's policy “Comprehensive Care Plans” documented in part, “It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 2. For R11, facility staff failed to provide a smoking apron and direct supervision while smoking a cigarette on the locked Dogwood unit. R11 was admitted to the facility with diagnosis that included but not limited to dementia (1) and hearing loss. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 08/23/2025, R11 scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating the R11 was severely impaired of cognition for making daily decisions. On 09/23/2025 at approximately 9:53 a.m. an observation of R11 was conducted on the locked Dogwood unit. R11 was observed in the dayroom sitting in a rocking chair with an unlit cigarette in her right hand up to her mouth. At approximately 10:18 a.m. an observation revealed R11 going outside to the enclosed patio area on the locked Dogwood unit independently followed by R10. Observations also revealed R10 taking a cigarette lighter from his “Fanny Pak”, lighting R10's cigarette while CNA #1 was standing and talking to R10 and R11. Further observations failed to evidence a smoking apron for R11. On 9/23/25 at 11:28 a.m. Resident #11 (R11) was observed outside in the courtyard sitting in a chair with a walker and personal belongings in front of her. At 11:36 a.m., R10 was observed outside, at 11:37 a.m., R10 was observed taking a cigarette out and lighting it with a lighter that was on his person. R11 ambulated with her rolling walker over to R10 who proceeded to light a cigarette for her. R11 proceeded to smoke unsupervised with no staff present in the courtyard area. R11 was observed lighting a second partially smoked cigarette with the first cigarette. R11 proceeded to smoke some of the second cigarette and extinguish it into a plastic spoon and store the partially smoked cigarette into the storage pocket of the rolling walker. Further observations failed to evidence a smoking apron for R11. The comprehensive care plan for R11 dated 08/20/2024 documented in part, “Focus. (R11) is an unsafe smoker. Date Initiated: 08/20/2024.” Under “Interventions” it documented in part, “She requires a smoking apron while smoking. Date Initiated: 08/20/2024, She requires direct SUPERVISION while smoking. Date Initiated: 08/20/2024.” On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 3. For Resident #7 (R7), the facility staff failed to implement the resident's comprehensive care plan for antipsychotic medication administration. R7's comprehensive care plan dated 4/25/24 documented, (R7) is on antipsychotic therapy r/t (related to) Undifferentiated Schizophrenia. Administer antipsychotic medications as ordered by physician. A review of R7's clinical record revealed a physician's order dated 3/14/25 for Ziprasidone (an antipsychotic medication) 60mg (milligrams). One capsule by mouth every morning and at bedtime for schizophrenia. A review of R7's MARs (medication administration records) for July 2025 through September 2025 failed to reveal evidence the morning dose of Ziprasidone was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, and 8/11/25, and failed to reveal evidence the bedtime dose of Ziprasidone was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, 7/28/25, 9/15/25, 9/16/25, 9/17/25, and 9/18/25. On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the purpose of the care plan is to make sure staff have a generalized location of where they are able to go, look, and learn how to take care of residents if they are not familiar with the residents. LPN #2 stated nurses evidence the administration of medications by documenting the medications were administered on the MAR. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. No further information was presented prior to exit. 4a. For Resident #2 (R2), the facility staff failed to implement the care plan for the administration of medications. The comprehensive care plan dated, 7/23/24, documented in part, “Focus: (R2) has hypertension. Interventions: Give anti-hypertensive medications as ordered. Focus: (R2) has altered cardiovascular status r/t (relate to) HTN, HLD (high blood pressure and hyperlipidemia). Focus: (R2) has Diabetes Mellitus. Interventions: Diabetes medications as ordered by doctor. Focus: (R2) has constipation. Focus: (R2) is on pain medication therapy r/t chronic arthritis. Interventions: Administer ANALGESIC medications as ordered by physician. Focus: (R2) is on antiplatelet therapy r/t cerebrovascular disease. Interventions: Administer antiplatelet medications as ordered by physician. Focus: (R2) has potential for pain r/t arthritis, right wrist pain/muscle spasms, migraine. Interventions: Administer analgesia as per orders.” The physician order dated 7/30/25, documented: 1. Atorvastatin Calcium Oral Tablet (1) 80 MG (milligrams); Give 80 mg by mouth at bedtime related to hyperlipidemia. 2. Clopidogrel Bisulfate Oral Tablet (2) 75 MG; Give 75 mg by mouth at bedtime related to Personal history of transient ischemic attach (TIA) and cerebral infarction without residual deficit. 3. Edarbyclor Oral Tablet (3) 40-25 MG; Give 1 tablet by mouth at bedtime related to essential hypertension (high blood pressure). 4. Miralax Oral Powder (4) 17GM (grams)/scoop; Give 1 scoop by mouth one time a day for constipation. 5. Gabapentin Oral Capsule (7) 300 MG; Give 2 capsules by mouth every 12 hours for neuropathy related to type 2 diabetes mellitus with other diabetic neuropathy. 6. Insulin Lispro Injection Solution (9) inject as per sliding scale: if 151-200 = 4 units; 201-250 = 6 units; 251 -300 = 8 units; 301-350 = 10 units; 351-400 = 12 units, over 400 call MD, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with other diabetic neurological complications. Review of the Medication Administration Record (MAR) for September 2025 documented the above order. On 9/17/25 and 9/18/25 at the 9:00 p.m. doses of the above medication orders, the MAR was blank. Review of the nurse's notes for 9/17/25 and 9/18/25, failed to evidence documentation related to the medications not being administered. An interview was conducted with LPN (licensed practical nurse) #1 on 9/24/25 at 11:47 a.m. LPN #1 stated the purpose of the care plan is it is how we are going to care for the resident and it should be followed. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References: 1. Atorvastatin is also used to decrease the amount of fatty substances such as low-density lipoprotein (LDL) cholesterol ('bad cholesterol') and triglycerides in the blood and to increase the amount of high-density lipoprotein (HDL) cholesterol ('good cholesterol') in the blood. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a60004.html 2. Clopidogrel is used alone or with aspirin to prevent serious or life-threatening problems with the heart and blood vessels in people who have had a stroke, heart attack, or severe chest pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601040.html 3. Edarbyclor is used alone or in combination with other medications to treat high blood pressure. This information was obtained from the following website: https://medlineplus.gov/druginfo /meds/a611028.html 4. Miralax is used to treat occasional constipation. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a603032 5. Gabapentin capsules, tablets, and oral solution are also used to relieve the pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/ a694007.html 6. Insulin lispro injection products are also used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) who need insulin to control their diabetes. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697021 4b. For Resident #2 (R2), the facility staff failed to implement the comprehensive care plan for the administration of a wound treatment. The comprehensive care plan dated, 8/13/25, documented in part, “Focus: has a surgical wound of the abd (abdomen) from debridement and irrigation of abd tissue r/t (related to) necrotizing fasciitis. Interventions: Administer treatments as ordered.” The physician order dated, 8/31/25, documented, “Cleanse ABD (abdominal) wound with wound cleanser, apply hydrofera blue and dry drsg (dressing) every three days at bedtime every 3 days for wound care.” The September 2025 Treatment Administration Record (TAR) documented the above order. The TAR documented the treatment was administered on 9/6/25 and 9/9/25. On 9/12/25 a “9” was documented. For 9/15/25, 9/18/25 and 9/21/25, the box where the nurse documents the treatment having been done was blank. The nurse's note dated 9/12/25 at 11:09 p.m. documented in part, “Patient wants treatment done tomorrow after she gets a shower.” There was no further documentation on the TAR or nurse's notes that the treatment was done on 9/13/25. Further review of the nurse's notes failed to evidence any documentation for 9/15/25, 9/18/25 or 9/21/25. An interview was conducted with LPN (licensed practical nurse) #1 on 9/24/25 at 11:47 a.m. LPN #1 stated the purpose of the care plan is it is how we are going to care for the resident and it should be followed. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References: 1. Hydrofera Blue® creates a multifaceted, non-toxic environment for wound healing. Hydrofera Blue's unique capillary action continuously pulls harmful bacteria- laden slough, exudate, and debris away from the wound bed. This information was obtained from the following website: https://hydrofera.com/why-blue/ 5) For Resident #3 (R3), the facility staff failed to A) implement the comprehensive care plan to administer medication as ordered during dates in February and April of 2025 and B) to provide treatments to pressure injuries as ordered during dates in January and February of 2025. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/28/2025, the resident was assessed as receiving medications including insulin, antibiotic, diuretic, opioid, antiplatelet and hypoglycemic medication. Section M documented R3 having three Stage 3 pressure injuries and two Stage 2 pressure injuries that were present on admission. A) The comprehensive care plan for R3 documented in part, “[Name of R3] has impaired cognitive function and/or impaired thought processes r/t (related to) recent hospitalization for sepsis, metabolic encephalopathy. Date Initiated: 02/03/2025.” Under “Interventions” it documented in part, “… Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/03/2025…” “[Name of R3] has potential for fluid deficit r/t Diuretic use, Poor intake. Date Initiated: 02/03/2025.” Under “Interventions” it documented in part, “Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/03/2025…” “[Name of R3] has Diabetes Mellitus. Date Initiated: 02/03/2025.” Under “Interventions” it documented in part, “…Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Date Initiated: 02/03/2025…” “[Name of R3] has anemia r/t iron deficiency. Date Initiated: 02/03/2025.” Under “Interventions” it documented in part, “…Give medications as ordered. Monitor for side effects, effectiveness. Date Initiated: 02/03/2025…” Review of the eMAR (electronic medication administration record) for R3 dated 2/1/25-2/28/25 failed to evidence administration of the following medication on the dates listed below: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG (milligram)/50ML (milliliter)-% (Daptomycin-Sodium Chloride) Use 500 mg intravenously in the morning related to Sepsis, Unspecified Organism. On 2/9/25 and 2/21/25. The eMAR for 2/9/25 was observed to be blank and 2/21/25 eMAR progress note documented “ordered call to pharmacy.” Epoetin Alfa-epbx Injection Solution 40000 UNIT/ML (Epoetin Alfa-epbx) Inject 1 ml subcutaneously one time a day every Fri for Anemia of Chronic disease. On 2/14/25. The eMAR progress note documented “Not available in omni cell, awaiting from pharmacy. Gabapentin Oral Capsule 100 MG (Gabapentin) Give 4 capsule by mouth in the morning for Neuropathy related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. Take 2 capsules twice daily. On 2/22/25, 2/23/25 and 2/24/25. The eMAR progress note dated 2/22/25 documented “on order”, 2/23/25 “pharmacy to send” and 2/24/25 “pharmacy contacted.” Gabapentin Oral Capsule 100 MG (Gabapentin) Give 8 capsule by mouth at bedtime for neuropathy. On 2/21/25, 2/22/25 and 2/23/25. The eMAR progress note dated 2/21/25 and 2/22/25 documented “on order.” The eMAR progress note dated 2/23/25 documented “pharmacy to send.” Neurontin Oral Capsule 400 MG (Gabapentin) Give 2 capsule by mouth every morning and at bedtime for neuropathy. On 2/27/25. The eMAR progress note dated 2/27/25 documented “on order.” Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 8 unit subcutaneously in the morning related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. On 2/9/25, the eMAR was observed to be blank. Review of the eMAR for R3 dated 4/1/25-4/30/25 failed to evidence administration of the following medication on the dates listed below: Spironolactone Oral Tablet 25 MG (Spironolactone) Give 1 tablet by mouth in the morning every Mon, Wed, Fri for Heart Failure. (to treat fluid retention) (8) On 4/4/25 and 4/7/25 the eMAR progress notes documented, “ordered.” It failed to evidence notification of the physician of the medication not being administered. On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the purpose of the care plan was to make sure they had a generalized location to show how to take care of residents that they were not familiar with. She stated that they implemented the care plan by looking at it and making sure any changes were communicated to the CNAs (certified nursing assistants) as they were noted or communicated to them. LPN #2 stated that medications were evidenced as given by documentation in the eMAR and if medication was not available on the medication cart they checked the Omnicell stock and if not there they called the pharmacy to see when it would be available. B) The comprehensive care plan for R3 documented in part, “[Name of R3] has pressure injury to left ischium r/t decreased mobility, occasional bladder incontinence, history of radiation and chemotherapy r/t rectal cancer, poor nutrition, Non-compliance with treatment and regimen. Date Initiated: 02/03/2025.” Under “Interventions” it documented in part, “Administer treatments as ordered and monitor for effectiveness. Date Initiated: 02/03/2025…” Review of the eTAR (electronic treatment administration record) for R3 dated 1/1/25-1/31/25 failed to evidence treatments completed on the following dates: Clean all wounds on buttocks with wound cleanser, apply skin prep to outer edges of wounds. Soak gauze in Dakin's solution, put gauze into wounds, squeeze out excess liquid, cover with foam dressings every day shift every 3 day(s). On 1/27/25 the eTAR was observed to be blank. Review of the eTAR for R3 dated 2/1/25-2/28/25 failed to evidence treatments completed on the following dates: Gentamicin Sulfate External Ointment 0.1 % (Gentamicin Sulfate (Topical)) Apply to sacrum, L + R ischium topically one time a day for pseudomonas infection for 2 Weeks. On 2/4/25, 2/6/25, and 2/7/25. The dates were observed to be blank. Wound care for left ischium, right ischium, sacrum. Cleanse with wound cleanser, pat dry. Apply gentamicin 0.1% ointment to wound bed, then apply calcium alginate to wound bed. Cover with foam dressing QD (every day) and change PRN (as needed) for saturation/soilage every day shift. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank. Wound care order for left heel Cleanse with wound cleanser, apply calcium alginate, cover with foam dressing QD every day shift for Wound Care. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank. Wound care order for right heel Cleanse with wound cleanser, pat dry, apply skin prep QD. OFFLOAD with boot or heelz up pillow one time a day. On 2/4/25, 2/6/25, 2/7/25, 2/13/25, and 2/17/25 the eTAR was observed to be blank. The clinical record failed to evidence documentation regarding the missed treatments on the dates listed above in January and February of 2025. On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the purpose of the care plan was to make sure they had a generalized location to show how to take care of residents that they were not familiar with. She stated that they implemented the care plan by looking at it and making sure any changes were communicated to the CNAs (certified nursing assistants) as they were noted or communicated to them. LPN #2 stated that treatments were evidenced as completed by documentation in the eTAR. On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern. No further information was provided prior to exit. 6) For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan to provide treatments for a pressure injury on multiple dates in July, August and September 2025 and failed to complete weekly assessments that included measurement and description of wound progress. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 8/13/25, the resident was assessed as having one unstageable pressure injury that was not present on admission or reentry. The comprehensive care plan for R6 documented in part, “[Name of R6] has unstageable pressure injury to the coccyx r/t (related to) poor mobility, incontinence. Date Initiated: 08/14/2019.” Under “Interventions” it documented in part, “Administer treatments as ordered and monitor for effectiveness. Date Initiated: 05/14/2025. Assess/record/monitor wound healing. Date Initiated: 05/14/2025… Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Date Initiated: 05/14/2025.” Review of the clinical record documented skin assessments documenting presence of the wound and continued wound treatments but failed to evidence weekly measurements of the pressure injury including width, length, depth, type of tissue and exudate described. Review of the eTAR (electronic treatment record) for R6 dated 7/1/25-7/31/25 failed to evidence treatments completed to the coccyx pressure injury on 7/3/25, 7/21/25, 7/22/25, 7/23/25, 7/24/25 and 7/25/25. The dates were observed to be blank. Review of the eTAR for R6 dated 8/1/25-8/31/25 failed to evidence treatment completed to the coccyx pressure injury on 8/23/25. The date was observed to be blank. Review of the eTAR for R6 dated 9/1/25-9/30/25 failed to evidence treatments completed to the coccyx pressure injury on 9/5/25 and 9/20/25. The dates were observed to be blank. The clinical record failed to evidence documentation regarding the missed treatments on the dates listed above in July, August and September of 2025. On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the purpose of the care plan was to make sure they had a generalized location to show how to take care of residents that they were not familiar with. She stated that they implemented the care plan by looking at it and making sure any changes were communicated to the CNAs (certified nursing assistants) as they were noted or communicated to them. LPN #2 stated that treatments were evidenced as completed by documentation in the eTAR. She stated that the facility formerly had a wound care nurse practitioner who came in weekly and assessed residents pressure injuries, measuring them and adjusting treatments as needed but they did not come there any longer. She stated that she had been on night shift and was not sure of the current process but if a new wound was reported to her she asked a nurse trained in wounds to measure it and referred it to the physician for treatment. On 9/24/2025 at 4:56 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that the former assistant director of nursing used to keep a log sheet where she tracked pressure injuries and measured them weekly but had stepped down from the position. She stated that there was an assessment that they could complete in the electronic medical record to record their assessments but there had been a lapse due to the assistant director stepping down, and the wound nurse practitioner leaving. She stated that she could say that after the assistant director of nursing stepped down there was a period when there was a gap in tracking and measuring but they had a new doctor who started last week to assist them. ASM #2 stated that R6 was non-compliant with repositioning and tended to lay flat on her back or on the left side. On 9/25/2025 at 4:58 p.m., ASM #1, the administrator, was made aware of the concern. No further information was provided prior to exit.

Based on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of two facility units, Rosewood Unit. The findings include:On 09/22/2025 at approximately 5:45 p.m., a test tray consisting of lasagna with meat sauce, sliced carrots, green beans and mash potatoes were placed on a food cart in the facility's kitchen and sent to the Rosewood Unit of the facility. The cart was followed by the surveyor, OSM (other staff member) #11, district manager for dietary. At approximately 6:05 p.m., the last dinner tray was served to a resident on the Rosewood Unit and OSM #11 was asked to remove cover from the test plate then proceeded to take the temperatures of the food. Two surveyors observed OSM #11 obtaining the food temperatures of the test tray. The lasagna with meat sauce was 127-degrees F (Fahrenheit), the green beans were 117-degrees F, sliced carrots were 113-degrees F and the potatoes were 112-degrees F. The test tray was sampled by two surveyors, OSM #11 for appropriate holding temperatures and palatable taste. When asked to describe the taste of the food OSM #11 stated the food could have been warmer. After tasting all the food on the test tray OSM #11 was asked if the food was palatable. She stated the food was not palatable and should have been 130-degree F. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on resident interview, staff interview and facility document review, facility staff failed to provide HS (hours of sleep) snacks on two of two resident units, Dogwood and Rosewood units. The findings include:The facility's Meal Delivery Schedule documented in part, Breakfast (7:30 a.m.)-8:00 (a.m.)). Rosewood (unit) 8:00. Dinner 4:30 (p.m.)-5:15 (p.m.). Rosewood 5:15. According to the Meal Delivery Schedule there are 14 hours and 15 minutes between the last full evening meal and the first full meal of the next day. On 09/24/2025 at approximately 10:40 a.m. an interview was conducted with Resident #2 (R2), resident council president for the Rosewood unit, about snacks being provided to resident during the night shift. She stated that the residents are not offered snacks and that the resident council had never agreed to allow up to 16 hours to elapse between a substantial evening meal and breakfast the following day. On 09/24/2025 at approximately 10:50 a.m. an interview was conducted with R16, resident council president for the Dogwood unit, about snacks being provided to resident during the night shift. She stated that the residents are not offered snacks and that the resident council had never agreed to allow up to 16 hours to elapse between a substantial evening meal and breakfast the following day On 09/24/2025 at approximately 4:35 p.m. an interview was conducted with CNA (certified nursing assistant) #2 regarding snacks being provided to residents during the night shift. CNA #2 stated that in March and April 2025 she worked on the 7:00 p.m. to 7:00 a.m. shift and that snacks were not consistently provided to the residents because there were not enough staff. On 09/25/2025 at approximately 1:30 p.m. an interview was conducted with OSM #11, district manager for dietary , regarding HS snacks for residents. She stated the HS snacks consisted of sandwiches, cookies, crackers and drinks provided by the dietary department and sent to the nurse's stations at 7:00 p.m. each evening. She further stated that it was the responsibility of the nursing staff to pass on the snacks to the residents. OSM #11 also stated that she received pictures form OSM #12, the facility's dietary account manager, showing the HS snacks from previous evenings were not passed on to residents and she had an email from OSM #12 regarding concerns of the snack not being passed on to the residents. The email dated 08/14/2025 at 9:07 a.m. from OSM #12 to OSM #11 documented in part, .So the snacks are being given out. The CNAS (certified nursing assistants) and residents are still coming to get milk because it is not being given out. I did send (Name of Administrative staff Member #1) a text message of pictures to show her. In the stand up she told me she received them and told me she would address it but said nothing at the stand up meeting. But we are doing our part for once and they are not doing theirs. On 09/25/2025 an attempt to interview OSM #12 was unsuccessful due to her being out on leave. On 09/25/2025 at approximately 2:22 p.m. an interview was conducted with ASM #1, executive director regarding HS snacks. She stated that she did recall the messages from OSM #12 and purchased two new snack carts for each unit in August (2025). She also stated that she informed the nursing managers, LPN (licensed practical nurse) #1 and ASM #2 regarding residents not receiving the HS snacks. ASM #1 stated the nurse managers were to educate the nurses and CNAs who work on the 3:00 p.m.-11:00 p.m. shift about passing HS snacks to residents. On 09/25/2025 at approximately 3:00 p.m. an interview was conducted with ASM #2 regarding residents receiving HS snacks. She stated that it was hit or miss that the residents received the HS snacks. She further stated that she did not recall the conversation with ASM #1. On 09/25/2025 at approximately 4:20 p.m. an interview was conducted with LPN #1. She stated she did not recall the conversation with ASM #1 regarding the HS snacks. She further stated that the facility's was not bringing the snacks to the unit. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on observations and staff interviews, the facility staff failed to serve food in a sanitary manner in one of one facility kitchens. The findings include:On 09/22/2025 at approximately 5:30 p.m. an observation in the facility kitchen revealed OSM (other staff member) #10, acting dietary manager and OSM #11 , district manager for dietary, hand drying 20 resident meal trays, placing them on the tray line. Continuing observation revealed kitchen staff at the tray line, sliding the meal trays down the tray line, placing resident's meals on the tray and placing the tray in the food carts to be taken to the unit floors. On 09/25/2025 at approximately 1:30 p.m. an interview was conducted with OSM #11. When informed of the observation as stated above OSM #11 stated that the meal trays should have been air dried to prevent contamination. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, and facility document review, the facility staff failed to provide evidence of an updated contract with an outside provider for one of eight contracts reviewed, potentially affecting seven residents who received respiratory equipment services. The findings include:The facility staff failed to provide an updated contract for respiratory equipment. A review of facility contracts with outside service providers revealed there was no current contractual agreement with the respiratory equipment provider. The contract was between the outside provider and the name of the previous owner of the facility, a company no longer in existence. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated that when the new company began ownership of the facility (June 2025), she had to reach out to all vendors, write up new contracts, send the contracts to the new company's legal team for review, send the contracts back to the vendors for changes, then send the contracts back to the new company's legal team. ASM #1 stated the new company bought approximately 48 or 49 facilities and this has been a slow process. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to maintain a clean, comfortable, and homelike environment for one of 16 residents in the survey sample, Resident #7, three of three reusable bed pads observed in the laundry room, and in six of 27 resident rooms observed. The findings include:1. For Resident #7 (R7), the facility staff failed to maintain a blanket on the resident's bed in a clean and homelike manner. On multiple dates, a brown stain was observed on the blanket. Also, on 9/24/25, stains were observed on three of three washed bed pads in the laundry room. On 9/22/25 at 3:34 p.m., 9/23/25 at 8:02 a.m., 9/23/25 at 3:16 p.m., and 9/24/25 at 9:01 a.m., an observation of R7's room was conducted. A white blanket was observed on the resident's bed and contained a large brown oval stain (approximately ten inches in diameter) on the left lower corner. On 9/24/25 at 4:44 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated bed linens should be changed on shower days and as needed. CNA #2 stated a lot of facility linens are stained, even when they are washed and clean. At this time, three washed and dried reusable bed pads were observed with CNA #2 in the laundry room. All three bed pads contained large light brown and yellow stains. On 9/24/25 at 5:53 p.m., an observation of the three bed pads was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated the bed pads were not clean, comfortable, or homelike, and should not be in use. On 9/25/25 at 1:38 p.m., an interview was conducted with OSM (other staff member) #3 (the account manager of environmental services). OSM #3 stated she used to have an overstock of linens in the past when the contracted environmental services company ordered linens, and the stained linens would have been thrown in the trash. OSM #3 stated the facility now orders linens and there have been issues with getting linens. OSM #3 also stated she has had issues with adding bleach to the washing machines and a representative from the washing machine company has had to come in and adjust the machines. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. The facility policy titled, Safe and Homelike Environment documented, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible .3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 4. The facility will provide and maintain bed and bath linens that are clean and in good condition. No further information was presented prior to exit. 2a. Facility staff failed to maintain the privacy curtains in a clean and sanitary manner in resident rooms 311, 313 and 338. On 09/23/2025 at approximately 9:45 a.m., observations of resident rooms [ROOM NUMBER] revealed the privacy curtains between the A-side and B-side of the rooms were dirty and stained. On 09/24/2025 at approximately 9:40 a.m., observations of resident room numbers 313, 311, and 338 revealed the privacy curtains between the A-side and B-side of the rooms were dirty and stained. On 09/24/2025 at approximately 2:35 p.m. an interview was conducted with OSM (other staff member) #3, account manager for environmental services. When asked about cleaning resident's privacy curtains she stated that all the privacy curtains in the resident's room are pulled down and cleaned once a month for every resident room and when they are dirty or soiled. She stated that the residents' privacy curtains are checked for cleanliness by the housekeepers during the daily cleaning and if the curtains are soiled or dirty, they are taken down and laundered. She also stated that any staff member can notify housekeeping if they find a resident's privacy curtain is dirty or soiled. At approximately 2:45 p.m. an observation of the privacy curtains between the A-side and B-side of the room in resident rooms [ROOM NUMBER] with OSM #3. She agreed with the findings of the privacy curtains described above and stated that the curtains needed to be taken down and cleaned and did not present a homelike environment. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 2b. Facility staff failed to maintain resident room [ROOM NUMBER] in a clean and sanitary manner. On 09/23/2024 at approximately 9:45 a.m., an observation of resident room [ROOM NUMBER] revealed food debris and spill stains next to and under the beds on the A-side and B-side of the room. On 09/24/2024 at approximately 9:40 a.m., an observation of resident room [ROOM NUMBER] revealed food debris and spill stains next to and under the beds on the A-side and B-side of the room. On 09/24/2025 at approximately 2:35 p.m. an interview was conducted with OSM (other staff member) #3, account manager for environmental services. When asked to describe the procedure housekeepers follow for daily cleaning of resident's room she stated that basic cleaning is done daily. She also stated the housekeeper starts in the resident's room with emptying the resident's trash, wiping down all surfaces, walls, dusting, wiping down the bathroom, dust mopping then damp mopping the bathroom and resident's room. At approximately 2:50 p.m. an observation of resident room [ROOM NUMBER] was conducted with OSM #3. Upon entering the resident room and describing the observations conducted on 09/23/2024 and 09/24/2025 as described above, she agreed with the observations and stated that she was aware of the condition of the room and stated that it was unacceptable and did not present a homelike environment. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 2c. Facility staff failed to maintain resident rooms [ROOM NUMBERS] in good repair. On 09/23/2024 at approximately 9:45 a.m. an observation of resident room [ROOM NUMBER] was conducted. An observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high. Observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high. On 09/23/2024 at approximately 9:45 a.m., an observation of resident room [ROOM NUMBER] revealed a gouged, unpainted plaster patch on the lower portion of the wall between the resident's dresser and the bathroom door covering an area approximately two feet wide by 18 inches high. On 09/24/2024 at approximately 9:40 a.m., an observation of resident room [ROOM NUMBER] was conducted. An observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high. Observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high. On 09/24/2024 at approximately 9:40 a.m., an observation of resident room [ROOM NUMBER] revealed a gouged , unpainted plaster patch on the lower portion of the wall between the resident's dresser and the bathroom door covering an area approximately two feet wide by 18 inches high. On 09/24/2025 at approximately 2:35 p.m. an interview was conducted with OSM #4, plant operator and maintenance director. When asked to describe the procedure for keeping resident rooms in good repair he stated that staff will usually tell him when something needs to be fixed in a resident's room. He also stated that each nurse's has maintenance request log that staff fill in when something in a resident's room in in need of repair. He stated he does walk-throughs checking resident rooms for repairs but that it is inconsistent. At approximately 2:55 p.m. an observation of resident rooms [ROOM NUMBERS] was conducted with OSM #4. He agreed with the findings as stated above and stated the rooms needed repair and it did not present a homelike environment. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, and facility document review, the facility staff failed to complete an annual performance review for four of five CNA (certified nursing assistant) reviews. The findings include:For CNA #3, CNA #4, CNA #5, and CNA #6, the facility staff failed to complete an annual performance review. CNA #3 was hired on 8/22/23. CNA #3's most recent performance review was completed on 8/27/24.CNA #4 was hired on 6/13/23. CNA #4's most recent performance review was completed on 7/23/24.CNA #5 was hired on 7/20/21. CNA #5's most recent performance review was completed on 7/22/24.CNA #6 was hired on 2/15/23. CNA #6's most recent performance review was completed on 7/31/24. On 9/25/25 at 1:45 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she did not know who was responsible for ensuring the completion of CNA performance reviews because she had only been the director of nursing since April 2025 and had never been a director of nursing before then. ASM #2 stated she assumed CNA performance reviews should be completed every year based on the CNA's hire date. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. The facility policy titled, Nurse Aide Training Program documented, 2.b. It is the responsibility of the employee to attend/complete mandatory in-service trainings to maintain employment status with the facility. A review of the employee's attendance/completion records shall be performed at least annually, such as at time of performance review. No further information was presented prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to administer medications and treatment per the physician's orders for three of 16 residents in the survey sample, Residents #3, #2 and #7.The findings include:1) For Resident #3 (R3), the facility staff failed to administer medication as ordered during dates in February and April of 2025. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/28/2025, the resident was assessed as receiving medications including insulin, antibiotic, diuretic, opioid, antiplatelet and hypoglycemic medication. Review of the eMAR (electronic medication administration record) for R3 dated 2/1/25-2/28/25 failed to evidence administration of the following medication on the dates listed below: Gabapentin Oral Capsule 100 MG (Gabapentin) Give 4 capsule by mouth in the morning for Neuropathy related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. (to treat seizures/nerve pain) (1). Take 2 capsules twice daily. On 2/22/25, 2/23/25 and 2/24/25. The eMAR progress note dated 2/22/25 documented “on order”, 2/23/25 documented “pharmacy to send” and 2/24/25 documented “pharmacy contacted.” Gabapentin Oral Capsule 100 MG (Gabapentin) Give 8 capsule by mouth at bedtime for neuropathy. On 2/21/25, 2/22/25 and 2/23/25. The eMAR progress note dated 2/21/25 and 2/22/25 documented “on order.” The eMAR progress note dated 2/23/25 documented “pharmacy to send.” Neurontin Oral Capsule 400 MG (Gabapentin) Give 2 capsule by mouth every morning and at bedtime for neuropathy. On 2/27/25., the eMAR progress note documented “on order.” Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 8 unit subcutaneously in the morning related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. (to treat diabetes) (2). On 2/9/25, the eMAR was observed to be blank. Review of the eMAR for R3 dated 4/1/25-4/30/25 failed to evidence administration of the following medication on the dates listed below: Spironolactone Oral Tablet 25 MG (Spironolactone) Give 1 tablet by mouth in the morning every Mon, Wed, Fri for Heart Failure. (to treat fluid retention) (3) On 4/4/25 and 4/7/25 the eMAR progress notes documented, “ordered.” On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that medications were evidenced as given by documentation in the eMAR and if medication was not available on the medication cart they checked the Omnicell stock (in house stocked medication) to see if the medication was in there for them to pull out and administer. Review of the facility provided Omnicell inventory list dated 9/23/25, documented Gabapentin 100mg stocked with a par level of 10 capsules, Gabapentin 400mg stocked with a par level of 10 capsules, Lantus Solostar 100 unit/ml stocked with a par level of two vials, and Spironolactone 25mg stocked with a par level of 10 tablets. The facility policy “Medication Administration” dated 6/1/2025 documented in part, “Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection… Policy Explanation and Compliance Guidelines: Administer medication as ordered in accordance with manufacturer specifications .” On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern. No further information was provided prior to exit. Reference: (1) Gabapentin: MedlinePlus Drug Information (2) Insulin Glargine (rDNA origin) Injection: MedlinePlus Drug Information (3) Spironolactone: MedlinePlus Drug Information 2a. For Resident #2 (R2), the facility staff failed to administer multiple medications on 9/17/25 and 9/18/25. An interview was conducted with R2 on 9/23/25 at 10:00 a.m. R2 stated she did not get her medications as ordered. The physician order dated 7/30/25, documented: 1. Atorvastatin Calcium Oral Tablet (1) 80 MG (milligrams); Give 80 mg by mouth at bedtime related to hyperlipidemia. 2. Clopidogrel Bisulfate Oral Tablet (2) 75 MG; Give 75 mg by mouth at bedtime related to Personal history of transient ischemic attach (TIA) and cerebral infarction without residual deficit. 3. Edarbyclor Oral Tablet (3) 40-25 MG; Give 1 tablet by mouth at bedtime related to essential hypertension (high blood pressure). 4. Miralax Oral Powder (4) 17GM (grams)/scoop; Give 1 scoop by mouth one time a day for constipation. 5. Mirapex Oral Tablet (5) 1 MG; Give 1 mg by mouth at bedtime related to restless legs syndrome. 6. Montelukast Sodium Oral Tablet (6) 10 MG; Give 10 mg by mouth at bedtime related to chronic obstructive pulmonary disease. 7. Gabapentin Oral Capsule (7) 300 MG; Give 2 capsules by mouth every 12 hours for neuropathy related to type 2 diabetes mellitus with other diabetic neuropathy. 8. Magnesium Oxide Oral Tablet (8) 400 MG; Give 400 mg by mouth every 12 hours for supplement. 9. Insulin Lispro Injection Solution (9) inject as per sliding scale: if 151-200 = 4 units; 201-250 = 6 units; 251 -300 = 8 units; 301-350 = 10 units; 351-400 = 12 units, over 400 call MD, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with other diabetic neurological complications. Review of the Medication Administration Record (MAR) for September 2025 documented the above order. On 9/17/25 and 9/18/25 at the 9:00 p.m. doses of the above medication orders, the MAR was blank. Review of the nurse's notes for 9/17/25 and 9/18/25, failed to evidence documentation related to the medications not being administered. The comprehensive care plan dated, 7/23/24, documented in part, “Focus: (R2) has hypertension. Interventions: Give anti-hypertensive medications as ordered. Focus: (R2) has altered cardiovascular status r/t (relate to) HTN, HLD (high blood pressure and hyperlipidemia). Focus: (R2) has Diabetes Mellitus. Interventions: Diabetes medications as ordered by doctor. Focus: (R2) has constipation. Focus: (R2) is on pain medication therapy r/t chronic arthritis. Interventions: Administer ANALGESIC medications as ordered by physician. Focus: (R2) is on antiplatelet therapy r/t cerebrovascular disease. Interventions: Administer antiplatelet medications as ordered by physician. Focus: (R2) has potential for pain r/t arthritis, right wrist pain/muscle spasms, migraine. Interventions: Administer analgesia as per orders.” An interview was conducted with LPN (licensed practical nurse) #1 on 9/24/25 at 11:47 a.m. LPN #1 stated nurse evidence she's given a medication by checking it off on the MAR. The above MAR was reviewed with LPN #1. She stated it isn't documented as given. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References: 1. Atorvastatin is also used to decrease the amount of fatty substances such as low-density lipoprotein (LDL) cholesterol ('bad cholesterol') and triglycerides in the blood and to increase the amount of high-density lipoprotein (HDL) cholesterol ('good cholesterol') in the blood. This information was obtained from the following website: : https://medlineplus.gov/druginfo/meds/a60004.html 2. Clopidogrel is used alone or with aspirin to prevent serious or life-threatening problems with the heart and blood vessels in people who have had a stroke, heart attack, or severe chest pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601040.html 3. Edarbyclor is used alone or in combination with other medications to treat high blood pressure. This information was obtained from the following website: https://medlineplus.gov/druginfo /meds/a611028.html. 4. Miralax is used to treat occasional constipation. This information was obtained from the following website: https://medlineplus.gov/druginfo/med s/a603032.html 5. Pramipexole (Mirapex) is also used to treat restless legs syndrome. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds /a697029.html 6. Montelukast is used to prevent wheezing, difficulty breathing, chest tightness, and coughing caused by asthma. This information was obtained from the following website: https://medlineplus.gov/druginfo /meds/a600014.html 7. Gabapentin capsules, tablets, and oral solution are also used to relieve the pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/ a694007.html. 8. Magnesium oxide also is used as a dietary supplement when the amount of magnesium in the diet is not enough. This information was obtained from the following website: https://medlineplus.gov/druginfo /meds/a601074.html. 9. Insulin lispro injection products are also used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) who need insulin to control their diabetes. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697021 2b. For Resident #2 (R2), the facility staff failed to administer wound treatments to an abdominal wound between 9/9/25 and 9/23/25. An interview was conducted with R2 on 9/23/25 at 10:00 a.m. The resident stated that her current wound dressing is supposed to be every three days. It hasn't been done on many occasions. The physician order dated, 8/31/25, documented, “Cleanse ABD (abdominal) wound with wound cleanser, apply hydrofera blue and dry drsg (dressing) every three days at bedtime every 3 days for wound care.” The September 2025 Treatment Administration Record (TAR) documented the above order. The TAR documented the treatment was administered on 9/6/25 and 9/9/25. On 9/12/25 a “9” was documented. For 9/15/25, 9/18/25 and 9/21/25, the box where the nurse documents the treatment having been done was blank. The nurse's note dated 9/12/25 at 11:09 p.m. documented in part, “Patient wants treatment done tomorrow after she gets a shower.” There was no further documentation on the TAR or nurse's notes that the treatment was done on 9/13/25. Further review of the nurse's notes failed to evidence any documentation for 9/15/25, 9/18/25 or 9/21/25. The comprehensive care plan dated, 8/13/25, documented in part, “Focus: has a surgical wound of the abd (abdomen) from debridement and irrigation of abd tissue r/t (related to) necrotizing fasciitis. Interventions: Administer treatments as ordered.” An interview was conducted with LPN (licensed practical nurse) #1 on 9/24/25 at 11:47 a.m. LPN #1 stated nurse evidence she's completed a treatment by checking it off on the TAR. The above TAR was reviewed with LPN #1. She stated it isn't documented as completed. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References: 1. Hydrofera Blue® creates a multifaceted, non-toxic environment for wound healing. Hydrofera Blue's unique capillary action continuously pulls harmful bacteria- laden slough, exudate, and debris away from the wound bed. This information was obtained from the following website: https://hydrofera.com/why-blue/ 3. For Resident #7 (R7), the facility staff failed to administer the medication melatonin on multiple dates in July 2025 and September 2025. A review of R7's clinical record revealed a physician's order dated 3/5/25 for melatonin 5mg (milligrams). Two tablets by mouth at bedtime for insomnia. A review of R7's July 2025 and September 2025 MARs (medication administration records) failed to reveal evidence that melatonin was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/25/25, 7/26/25, 7/28/25, 9/15/25, 9/16/25, 9/17/25, and 9/18/25 (as evidenced by blank spaces on the MARs). A review of the in-house over-the-counter medication supply list revealed melatonin 5mg tablets were available in the facility. On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses evidence the administration of medications by documenting the medications were administered on the MAR. On 9/25/25 at 3:51 p.m., another interview was conducted with LPN #2. LPN #2 stated that if a medication is not available in the medication cart, the nurse should obtain the medication from the facility stock of over-the-counter medications or Omnicell (a machine containing various medications) if the medication is available there. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. No further information was presented prior to exit.

Based on resident interview, staff interview and facility document review, the facility staff failed to maintain sufficient nursing staff to meet the resident's needs for two of two resident units, Dogwood and Rosewood units. The findings include:The facility staff failed to maintain sufficient nursing staff to provide HS (hours of sleep) snacks to residents. The Facility Assessment Tool dated 06/01/2025 documented in part, Staffing plan. Position: Nurse aides - Distribution adjusted based on resident activities and care needs per shift. Total Number Needed or Average or Range: 6-8 (six to eight) CNAs (certified nursing assistants) day shift, 4-6 (four to six) CNAs evening / nights. The facility's As worked schedules for nursing staff on the Dogwood Unit dated 06//2024 through 06/30/2025 documented one CNA (certified nursing assistant) during the 3:00 p.m. to 11:00 p.m. shift on 06/07/2025 with a facility census of 77, and 06/14/2025 with a facility census of 77; one CNA for four hours during the 3:00 p.m. to 11:00 p.m. shift on 06/04/2025 with a facility census of 76, 06/06/2025 with a facility census of 76, 06/08/2025 with a facility census of 78, 06/11/2025 with a facility census of 77, 06/13/2025 with a facility census of 79 and on 06/24/2025 with a facility census of 71. The facility's As worked schedules for nursing staff on the Rosewood Unit dated 06//2024 through 06/30/2025 documented one CNA during the 3:00 p.m. to 11:00 p.m. shift on 06/01/2025 with a facility census of 78 and on 06/08/2025 with a facility census of 78. On 09/24/2025 at approximately 10:40 a.m. an interview was conducted with Resident #2 (R2), resident council president for the Rosewood unit, with a BIMs (Brief Interview for Mental Status) of 15, being cognitively intact for making daily decisions, about snacks being provided to resident during the night shift. She stated that the residents are not offered snacks. On 09/24/2025 at approximately 10:50 a.m. an interview was conducted with R16, resident council president for the Dogwood unit, with a BIMs of 15, being cognitively intact for making daily decisions, about snacks being provided to resident during the night shift. She stated that the residents are not offered snacks. On 09/24/2025 at approximately 2:15 p.m., a telephone interview was conducted with OSM (other staff member) #2, former staffing coordinator. When asked about the number of CNAs needed for the Dogwood and Rosewood units during the 3:00 p.m. to 11:00 p.m. (3-11) shift she stated she would try to get three CNAs but usually had two CNAs for each unit during the 3-11 shift. When asked to describe the procedure she followed if there were not enough staff she stated she would reach out to staff to work another shift or call staff to 0see if they could come in and work. When asked about utilizing agency nursing staff she stated that corporate did not allowed her to use agency staff. On 09/24/2025 at approximately 4:35 p.m. an interview was conducted with CNA (certified nursing assistant) #2 regarding snacks being provided to residents during the night shift. CNA #2 stated that in March and April 2025 she worked on the 7:00 p.m. to 7:00 a.m. shift and that snacks were not consistently provided to the residents because there were not enough staff. On 09/25/2025 at approximately 1:30 p.m. an interview was conducted with OSM #11, district manager for dietary , regarding HS snacks for residents. She stated the HS snacks consisted of sandwiches, cookies, crackers and drinks provided by the dietary department and sent to the nurse's stations at 7:00 p.m. each evening. She further stated that it was the responsibility of the nursing staff to pass on the snacks to the residents. On 09/25/2025 at approximately 3:00 p.m. an interview was conducted with ASM #2 regarding residents receiving HS snacks. She stated that it was hit or miss that the residents received the HS snacks. On 09/25/2025 at approximately 3:15 p.m. an interview was conducted with CNA #7 regarding staffing during the 3:00 p.m. to 11:00 p.m. shift. She stated that there are times when she is the only CNA working on a unit for two to three hours. On 09/25/2025 at approximately 3:20 p.m. an interview was conducted with OSM #8, staffing coordinator for sister facility. After reviewing the As Worked schedule for the dates listed above, she agreed that the facility was short staffed on the 3-11 shift for the dates listed above. The facility's policy Nursing Services and sufficient Staff documented in part, Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines: 3. The facility is required to provide licensed nursing staff 24 hours a day (except when waived), along with other nursing personnel, including but not limited to nurse aides. 5. Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

For Resident #2 (R2), the facility staff failed to administer pain medications per the physician order to manage the resident's pain. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/3/25, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. An interview was conducted with R2 on 9/23/25 at 10:00 a.m. R2 stated on 3/29/25, she was going into withdrawal symptoms related to not getting her pain patch (Fentanyl - an opioid used to treat severe pain) (1) as prescribed. She stated she was sick to her stomach, diarrhea and just didn't feel well. She stated her daughter had been in the facility on 3/28/25 and noticed that her pain patch was dated 3/17/25. R2 stated that it has happened again that she didn't get her patch as prescribed. The physician order dated 3/5/25, documented, Fentanyl Transdermal Patch 72 Hours 75 MCG/HR (micrograms per hour); apply 1 patch every 3 days for chronic pain replace after 3 days and remove per schedule. The March 2025 MAR (medication administration record) documented the above order. The MAR documented the medication was administered on 3/17/25. For 3/20/25 it was documented the patch was removed but for the administration it was documented a 9 which indicates, Other/See Nurse Notes. For 3/23/25, there were 9 document for the removal and administration of the Fentanyl. For 3/26/25, there was a 9 documented for the removal and administration of the Fentanyl. The nurse's note dated 3/20/25 at 3:36 p.m. documented in part, Fentanyl.none acaaiable (sic)(available), np (nurse practitioner) to write script. The nurse's note dated 3/23/25 at 5:04 p.m. documented in part, Fentanyl .dc/d (discontinued) new order placed. There was no nurse's note dated 3/26/25 related to the Fentanyl. The narcotic sign-off sheet dated 3/4/25, documented the administration of the Fentanyl patch on 3/17/25. The narcotic sheet was dated 3/29/25, documented the administration of the Fentanyl on 3/29/25. There was no record of administration of Fentanyl on a narcotic sheet between 3/17/25 and 3/29/25, a period of 12 days. The physician order dated, 8/15/25, documented, Fentanyl Transdermal Patch 72-hour 25 MCG/HR; apply 1 patch transdermally every 72 hours for chronic pain for 21 days and remove per schedule. The September 2025 MAR documented the above order. The last documented dose of Fentanyl administration was on 9/2/25. For the scheduled dose for 9/5/25, the box was blank. Review of the nurse's note failed to evidence documentation related to the Fentanyl on 9/5/25. The physician order dated, 9/9/25, documented, Fentanyl Transdermal Patch 72-Hour 25 MCG/HR; apply 1 patch transdermally one time a day every 3 day(s) for pain and remove per schedule. The September 2025 MAR documented the above order. On 9/9/25, a 9 was documented in the box for administration.The nurse's note dated 9/9/25 at 10:15 a.m. documented, Was applied yesterday. Review of the narcotic sing-off sheets dated 8/22/25, documented the Fentanyl was administered on 9/2/25 and 9/12/25. The narcotic sign-off sheet dated 9/8/25, documented the Fentanyl was administered on 9/8/25 and 9/15/25. This indicates the resident received the patch on 9/2/25, no patch was administered on 9/5/25. Fentanyl was administered on 9/8/25, no administration, per the physician order on 9/11/25, and then administered on 9/12/25. The resident missed two doses, one on 9/5/25 and 9/11/25, going six days between doses. The comprehensive care plan dated, 11/6/24, documented in part, Focus: (R2) is on pain medication therapy r/t (related to) chronic arthritis. Interventions: Administer ANALGESIC medication as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift). On 9/23/25 at 12:25 p.m., an interview was conducted with ASM (administrative staff member) #3 (the medical director). ASM #3 stated symptoms of Fentanyl withdrawal could include tachycardia (an increased heart rate), agitation, itching, and seizures if the patient is on a pretty high dose of the medication.An interview was conducted with LPN (licensed practical nurse) #1 on 9/24/25 at 11:47 a.m. LPN #1 stated nurse evidence she's given a medication by checking it off on the MAR. The above MARs, narcotic sheet and nurse's notes were reviewed with LPN #1. She verified that the resident did not receive her Fentanyl patch for 12 days in March and missed doses of Fentanyl in September per the documentation. The facility policy, Pain Management documented in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References:. 1. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601202.html

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to notify the emergency contact of changes in condition and the physician of medications not administered for two of 16 residents in the survey sample, Residents #3 and #4.The findings include:1) For Resident #3 (R3), the facility staff failed to A) notify the physician of medications not administered or held during dates in February, March and April of 2025 and B) notify the emergency contact of changes in condition on 3/10/2025 and 4/8/2025.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/28/2025, the resident was assessed as being moderately impaired for making daily decisions. The assessment documented R3 receiving medications including insulin, antibiotic, diuretic, opioid, antiplatelet and hypoglycemic medication.The resident admission demographic information documented R3 being their own responsible party and having two family members as emergency contacts.A) Review of the eMAR (electronic medication administration record) for R3 dated 2/1/25-2/28/25 failed to evidence administration of the following medication on the dates listed below:Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG (milligram)/50ML (milliliter)-% (Daptomycin-Sodium Chloride) Use 500 mg intravenously in the morning related to Sepsis, Unspecified Organism. On 2/9/25 and 2/21/25. (antibiotic to treat infection) (1). The eMAR for 2/9/25 was observed to be blank and 2/21/25 eMAR progress note documented ordered call to pharmacy. It failed to evidence notification of the physician of the medication not being administered.Epoetin Alfa-epbx Injection Solution 40000 UNIT/ML (Epoetin Alfa-epbx) Inject 1 ml subcutaneously one time a day every Fri for Anemia of Chronic disease. (to treat anemia) (2) On 2/14/25. The eMAR progress note documented Not available in omni cell, awaiting from pharmacy. It failed to evidence notification of the physician of the medication not being administered.Gabapentin Oral Capsule 100 MG (Gabapentin) Give 4 capsule by mouth in the morning for Neuropathy related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. (to treat seizure/diabetic neuropathy) (3) Take 2 capsules twice daily. On 2/22/25, 2/23/25 and 2/24/25. The eMAR progress note dated 2/22/25 documented on order, 2/23/25 pharmacy to send and 2/24/25 pharmacy contacted. It failed to evidence notification of the physician of the medication not being administered.Gabapentin Oral Capsule 100 MG (Gabapentin) Give 8 capsule by mouth at bedtime for neuropathy. On 2/21/25, 2/22/25 and 2/23/25. The eMAR progress note dated 2/21/25 and 2/22/25 documented on order. The eMAR progress note dated 2/23/25 documented pharmacy to send. It failed to evidence notification of the physician of the medication not being administered.Neurontin Oral Capsule 400 MG (Gabapentin) Give 2 capsule by mouth every morning and at bedtime for neuropathy. On 2/27/25. The eMAR progress note dated 2/27/25 documented on order. It failed to evidence notification of the physician of the medication not being administered.Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 8 unit subcutaneously in the morning related to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. (to treat diabetes) (4) On 2/9/25, the eMAR was observed to be blank.Pregabalin Oral Capsule 25 MG (Pregabalin) Give 25 mg by mouth every morning and at bedtime related to pain in unspecified joint. (to treat pain) (5) The 6:00 a.m. doses on 2/1-2/4/25, 2/6/25, 2/7/25, and 2/20/25 and the 9:00 p.m. doses on 2/1, 2/3, 2/5-2/9/25. The eMAR progress notes documented 2/1/25, 2/4/25, 2/6/25, 2/7/25, 2/9/25- on order, 2/2/25- ordered, 2/3/25- script needs to be wrote, 2/8/25- not available at this time and 2/20/25- new order wrote, has not arrived. It failed to evidence notification of the physician of the medication not being administered.Review of the eMAR for R3 dated 3/1/25-3/31/25 failed to evidence administration of the following medication on the dates listed below:Pregabalin Oral Capsule 300 MG (Pregabalin) Give 1 capsule by mouth every morning and at bedtime for neuropathy. On 3/8/25 at 9:00 a.m. The eMAR progress note documented, on order. On 3/20/25 at 9:00 p.m., the eMAR progress note documented, ordered. It failed to evidence notification of the physician of the medication not being administered.Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for Heart Failure. (to treat heart failure and high blood pressure) (6) On 3/30/25 at 5:00 p.m. the eMAR documented a code 7, the eMAR chart codes documented 7=sleeping. It failed to evidence notification of the physician of the medication not being administered.Entresto Oral Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day for DMT2 (diabetes mellitus type 2). (to treat heart failure) (7) On 3/30/25 at 5:00 p.m. the eMAR documented a code 7, the eMAR chart codes documented 7=sleeping. It failed to evidence notification of the physician of the medication not being administered.Review of the eMAR for R3 dated 4/1/25-4/30/25 failed to evidence administration of the following medication on the dates listed below:Spironolactone Oral Tablet 25 MG (Spironolactone) Give 1 tablet by mouth in the morning every Mon, Wed, Fri for Heart Failure. (to treat fluid retention) (8) On 4/4/25 and 4/7/25 the eMAR progress notes documented, ordered. It failed to evidence notification of the physician of the medication not being administered.Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for Heart Failure. On 4/7/25 at 5:00 p.m. the eMAR progress note documented BP (blood pressure) was 96/67. The progress note failed to evidence notification of the physician of the low blood pressure and held medications.Entresto Oral Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day for CHF. On 4/7/25 at 5:00 p.m., the eMAR progress note documented low BP. The progress note failed to evidence notification of the physician of the low blood pressure and held medications.The physician orders for R3 documented the medications list above and orders for the following:Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for Heart Failure. Start Date: 03/20/2025.Entresto Oral Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day for DMT2. Start Date: 03/21/2025.The physician orders failed to evidence parameters for holding the Carvedilol or Entresto or an order to hold medications when sleeping.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that medications were evidenced as given by documentation in the eMAR. She stated that if a medication was not available on the medication cart they checked the Omnicell stock and if not there they called the pharmacy to see when it would be available. She stated that they were supposed to notify the physician when a medication was not given to let them know when the medication was going to be delivered and follow their instructions. LPN #2 stated that if a medication had parameters for holding them it would be documented in the medication order itself which instructed them when to hold the medication. She stated that if they felt that the blood pressure was too low to administer a medication and they did not have parameters in the physician orders they would call the physician and let them know that it was held and document it in the eMAR notes. LPN #2 stated that if a resident was sleeping when she came in with their medications she would come back at the end of her med pass to try again. She stated that for medications like Entresto and Coreg she would wake the resident up because they were important unless there was a physician order to hold them when sleeping. B) A Change in Condition (SBAR) (situation, background, assessment, recommendation) assessment for R3 dated 3/10/2025 documented in part, .The change in condition, symptoms, or signs observed and evaluated is/are: Res (resident) was lethargic, had labored breathing, confusion, sats (saturations) were in the 70s. This started on: 03/10/2025. Mental Status Evaluation (compared to baseline; check all changes that you observe) Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse), increased confusion or disorientation. Respiratory Evaluation: Abnormal lung sounds (rales, rhonchi, wheezing), cough, labored or rapid breathing, shortness of breath, other respiratory changes (describe), Describe cough: productive; Describe other: low O2 (oxygen) sats (saturation). Recommendation of Primary Clinician (if any): start O2, abx (antibiotic), and DuoNeb (nebulizer treatment). Name of Family/Health Care Agent Notified: res own RP (responsible party).A Change in Condition (SBAR) assessment for R3 dated 4/8/2025 documented in part, .The change in condition, symptoms, or signs observed and evaluated is/are: Resident sounds gurgled when talking, breathing is labored, pale in color. This started on: 04/08/2025. Caregiver reported to this nurse that he was pale in color and sounded gurgled when talking. She went to get PA, this nurse went to residents room he was pale in color and having a hard time breathing, started on 3l of oxygen, physician arrived assessed resident and told us to call 911. Name of Family/Health Care Agent Notified: res own RP (responsible party).The clinical record for R3 failed to evidence notification of the next of kin for the changes in condition on 3/10/25 and 4/8/25.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that when a resident has a change in condition they documented everything on the change in condition form and sent the resident to the hospital as needed. She stated that even if the resident was their own responsible party if there was an emergency, they contacted the next of kin to notify them what was happening and documented that in the medical record. LPN #2 stated that if the resident was having an emergency and a change in condition they may not be able to understand what was happening and the family needed to know. The facility policy Notification of Changes dated 6/1/2025 documented in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: . Circumstances that require a need to alter treatment. Additional considerations: Competent individuals: The facility must still contact the resident's physician and notify resident's representative, if known. A family that wishes to be informed would designate a member to receive calls. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern.No further information was provided prior to exit.Reference:(1) Daptomycin Injection: MedlinePlus Drug Information(2) Epoetin Alfa, Injection: MedlinePlus Drug Information(3) Gabapentin: MedlinePlus Drug Information(4) Insulin Glargine (rDNA origin) Injection: MedlinePlus Drug Information(5) Pregabalin: MedlinePlus Drug Information(6) Carvedilol: MedlinePlus Drug Information(7) Valsartan and Sacubitril: MedlinePlus Drug Information(8) Spironolactone: MedlinePlus Drug Information2) For Resident #4 (R4), the facility staff failed to notify the next of kin of a change in condition on 7/8/2024.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/29/2024, the resident was assessed as being cognitively intact for making daily decisions. The assessment documented no wandering behaviors and no wander/elopement alarm use.The resident admission demographic information documented R4 being their own responsible party with contact information listed for their spouse under contacts.A Change in Condition assessment for R4 dated 7/8/2024 documented in part, .The change in condition, symptoms, or signs observed and evaluated is/are: Resident found outside facility across from facility. This started on: 7/8/2024. Resident found outside building across the street, he stated he could not find the bathroom. Resident returned inside with staff, skin check completed, wander guard applied, and safety checks initiated. Recommendations of Primary Clinician (if any): Wanderguard. Name of Family/Health Care Agent Notified: Resident is his own RP (responsible party).The progress notes for R4 documented in part, 07/08/2024 03:47 Note Text: Resident caught outside of the front parking lot by a staff member. Resident was walked back. [Name of staff member] notified to care plan for a wander guard.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that when a resident has a change in condition they documented everything on the change in condition form and notified the physician and responsible party. She stated that even if the resident was their own responsible party if there was an emergency, they contacted the next of kin to notify them what was happening and documented that in the medical record. LPN #2 stated that if the resident was having an emergency and a change in condition they may not be able to understand what was happening and the family needed to know. She reviewed the documentation for R4 and stated that the next of kin for R4 should have been made aware of the elopement and wander guard because at the time of the elopement and need for a wander guard she would question if they would be able to be their responsible party.On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern.No further information was provided prior to exit.

Based on observation, staff interview and clinical record review, it was determined that facility staff failed to promote a resident's dignity for one of 16 current residents in the survey sample, Residents #8 (R8). The findings include:For R8, facility staff stood while providing feeding assistance. R8 was admitted to the facility with diagnoses that included but were not limited to swallowing difficulties. On the most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 08/13/2025, R8 scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating R8 was severely impaired of cognition for making daily decisions. GG0130 Self-Care coded R8 as being dependent for eating. 09/23/2025 at approximately 8:08 a.m., an observation revealed R9 in bed being fed by CNA (certified nursing assistant) #2. Further observations revealed CNA #2 standing next to the bed while feeding R8. Observation of R9's meal tray revealed food was p[placed in bowls. The comprehensive care plan for R8 dated 10/29/2018 documented in part, Focus. (R8) has an ADL self-care performance deficit r/t (related to) Vascular dementia (1), history of CVA (cerebral vascular accident) (2), and impaired cognition. Date Initiated: 10/29/2018. Under Interventions it documented in part, EATING: (R8) is dependent on staff for feeding Date Initiated: 10/29/2018. On 09/24/2025 at approximately 4:35 p.m. an interview was conducted with CNA (certified nursing assistant) #2. When asked to describe how she positioned herself when she fed R8 on 09/23/2025 during breakfast CNA #2 stated she was standing next to R8 while feeding her. She further stated that it was not dignified to be standing while assisting a resident with eating/feeding. The facility's policy Resident Rights documented in part, 4. Respect and dignity. The resident has a right to be treated with respect and dignity, including: c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References:(1) A gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. Vascular dementia (VaD) is caused by a series of small strokes over a long period. This information was obtained from the website: https://medlineplus.gov/ency/article/000746.htm.(2) A stroke. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm.

5. For Resident #61 (R61), the facility staff failed to assess the resident to safely leave the facility unsupervised in the community. The resident signed themselves out of the facility unsupervised on 15 occasions. R61 was admitted to the facility with diagnoses that included but were not limited to COPD (chronic obstructive pulmonary disease) (1), unspecified dementia (2), and major depressive disorder (3). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/30/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented no wandering or behaviors observed. Section GG documented R61 able to ambulate 150 feet independently. The assessment failed to assess R61's ability to maneuver steps or curbs while in the community. The Release of Responsibility for Leave of Absence document for R61 documented the resident signing themselves out on the following dates 8/8, 8/19, 10/3, 10/5, 12/24, 3/5, 3/14, twice on 3/15, twice on 3/24, three times on 5/12, and 5/18. (The year was not documented on all dates). The current physician orders for R61 documented in part the following psychotropic medications ordered, - Amitriptyline HCL (4) oral tablet 50 mg (milligram) Give 1 tablet by mouth at bedtime for depression. Order Date: 07/28/2022. - Buspirone HCL (5) oral tablet 5 mg Give 1 tablet by mouth every 8 hours related to anxiety disorder, unspecified. Order Date: 05/19/2024. - Donepezil HCl (6) tablet 10 mg Give 1 tablet by mouth at bedtime for dementia. Order Date: 06/08/2022. - Lorazepam (7) oral tablet 1 mg Give 1 mg by mouth at bedtime for anxiety. Order Date: 01/16/2024. - Trazodone HCL (8) tablet 50 mg Give 1.5 tablet by mouth at bedtime for depression. Order Date: 02/10/2023. The physician orders failed to evidence an order for R61 to be allowed to leave the facility unsupervised to the community. The progress notes for R61 documented in part, - 5/11/2024 12:24 Resident takes other residents things without asking. This writer found six cigarettes and a lighter in her room this morning. Resident has a nicotine patch on and has been educated multiple time she can't smoke with the patch on . yet resident continues to sneak cigarettes. Will talk to mngt (management) Monday. Review of R61's clinical record documented an elopement risk evaluation dated 8/10/2023 which documented no risk for elopement. The assessment failed to evidence an assessment of the residents ability to safely leave the facility unsupervised in the community. A BIMS assessment dated [DATE] documented R61 being cognitively intact. The assessment failed to evidence the residents ability to safely leave the facility unsupervised in the community. The comprehensive care plan for R61 documented in part, [Name of R61] has impaired cognitive function r/t (related to) dementia. Date Initiated: 06/16/2022. The care plan further documented, [Name of R61] has behaviors of stealing other resident's and staff belongings, and leaving building without signing out, going through linen cart and going into ice cart after being educated on infection control policies. Date Initiated: 01/04/2023. On 5/21/2024 at 8:42 a.m., an interview was conducted with R61 in their room. R61 stated that there were days that they left the facility to go to the dollar store and grocery store. R61 stated that they walked to the front entrance to meet the bus and it carried them to the store where they bought what they needed and then they rode the bus back to the facility. R61 stated that they signed a paper at the nurses station when they left the building and told the nurse where they were going. R61 stated that the facility had put a bracelet on them the night before and told them that the state wanted them to track where they were and they did not think it was right and it went against their religious beliefs so they had taken it off. R61 ended the interview at that time. On 5/20/2024 at approximately 5:12 p.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that in order for a resident to independently leave the facility, the resident should not be at risk for wandering, be alert and oriented times four (to person, place, time and situation), be aware of their own safety, and sign out. RN #3 further stated that there was not a specific assessment regarding a resident's ability to safely and independently leave the facility. On 5/20/2024 at 5:41 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator, ASM #4, the director of sales and marketing, ASM #5, the regional director of clinical services, and ASM #6, the vice president of operations. ASM #1 stated an elopement risk assessment was completed for residents and if residents were not at risk for elopement, were alert and oriented, and know what was going on, they had the right to sign themselves out and could leave the facility. ASM #5 stated that she did not think the elopement risk assessment addressed safety, but would look into it. ASM #5 stated that the staff also looked at the residents' BIMS score and whether the resident was alert and oriented. ASM #5 was not able to describe how the BIMS assessment correlated to a residents' function at a higher level of safety awareness but stated she would find out. ASM #1, ASM #4, ASM #5, and ASM #6 were made aware of the concern for immediate jeopardy at that time. A bcat (brief cognitive assessment tool) was completed for R61 on 5/20/2024 by OSM (other staff member) #3, occupational therapist. The assessment documented a score of 23, out of a possible 50, indicating R61 presented with moderate to severe dementia. The therapy screen attached documented in part, . Comments (optional): Screen specific for cognitive using BCAT score: 23/50. Eval (evaluation) orders requested: None . On 5/21/2024 at 9:44 a.m., an interview was conducted with OSM #3, occupational therapist. OSM #3 stated the bcat was a measure of cognitive function that broke down different categories like verbal recall and executive functioning. OSM #3 stated R61's bcat score showed that they were in the dementia category. He stated that R61 was not on current therapy caseload so the only assessment completed for them was the bcat. He stated that he did not perform an assessment of R61's physical ability to leave the facility as ambulation was typically handled by physical therapy. He stated that his understanding was that administration wanted him to assess the residents requested for their cognitive ability to be safe to leave the facility alone. He stated that based on R61's bcat score he was torn to make a decision and there were different types of tests that could be done. He stated that the physical assessment still needed to be completed for R61 to make the final decision. On 5/21/2024 at 10:15 a.m., an interview was conducted with RN #1. RN #1 stated she did not have a definitive answer to say how the staff assess residents to determine if they could safely and independently leave the facility unsupervised. RN #1 stated that she had not personally seen R61 leave the facility but felt that the resident was not completely alert and oriented. She stated that if R61 left the facility unsupervised they could forget where they were going and forget how to get back and feared that R61 would take anything that anyone would offer them. She stated that R61 had a habit of stealing things that did not belong to them and snuck cigarettes into their room. She stated that there was a risk of R61 getting burned, causing a fire, getting on the bus and getting lost, getting dehydrated, falling or getting abducted. RN #1 stated there was about an 80 percent likelihood that R61 would sustain serious harm, serious injury, or a serious adverse outcome while out in the community unsupervised and it was just a matter of time. On 5/21/2024 at 10:31 a.m., ASM #1 stated that on 5/20/2024, R61 was given cognitive and physical function tests to determine if the resident could safely and independently leave the facility unsupervised. ASM #1 stated R61's mind was not as good as it should be but physically the resident was okay. ASM #1 stated R61 had not been deemed to safely and independently leave the facility unsupervised. On 5/21/2024 at 11:00 a.m., an interview was conducted with ASM #3, the nurse practitioner. ASM #3 stated that the company allows some residents to go out and take trips by themselves but she had never assessed a resident to determine if the resident could safely and independently leave the facility unsupervised. No further information was provided prior to exit. Reference: (1) chronic obstructive pulmonary disease (COPD) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. (2) dementia A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. (3) major depressive disorder Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm. (4) Amitriptyline is used to treat symptoms of depression. Amitriptyline is in a class of medications called tricyclic antidepressants. It works by increasing the amounts of certain natural substances in the brain that are needed to maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682388.html#why (5) Buspirone is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety. Buspirone is in a class of medications called anxiolytics. It works by changing the amounts of certain natural substances in the brain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a688005.html#why (6) Donepezil is used to treat dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and may cause changes in mood and personality) in people who have Alzheimer's disease (AD; a brain disease that slowly destroys the memory and the ability to think, learn, communicate and handle daily activities). Donepezil is in a class of medications called cholinesterase inhibitors. It improves mental function (such as memory, attention, the ability to interact with others, speak, think clearly, and perform regular daily activities) by increasing the amount of a certain naturally occurring substance in the brain. Donepezil may improve the ability to think and remember or slow the loss of these abilities in people who have AD. However, donepezil will not cure AD or prevent the loss of mental abilities at some time in the future. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a697032.html#why (7) Lorazepam is used to relieve anxiety. Lorazepam is also used to treat insomnia caused by anxiety or temporary situational stress. Lorazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682053.html#why (8) Trazodone is used to treat depression. Trazodone is in a class of medications called serotonin modulators. It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681038.html#why 6. For Resident #47 (R47), the facility staff failed to address and/or reevaluate the plan of care after falls on 3/11/24 and 3/25/24. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 4/14/2024, the resident was assessed as being severely impaired for making daily decisions. The assessment documented R47 having two falls without injury since the previous assessment. The clinical record for R47 documented in part, - A Change in Condition dated 3/11/2024 documenting in part, .Found lying on right side of bed on the floor. No injuries. VS (vital signs) attempted several times but resident was combative, slapping and scratched this writer . Primary Care Clinician Notified: [Name of nurse practitioner] 03/11/2024 08:30 . Name of Family/Health Care Agent Notified: No family to contact . - A Change in Condition dated 3/25/2024 documenting in part, .Resident found lying on the floor to the left of her bed. No injuries noted. Resident hitting, pinching and spitting at staff while attempting to put her back to bed. Resident assisted to WC (wheelchair) . Primary Care Clinician Notified: [Name of nurse practitioner] 03/25/2024 10:00 . Name of Family/Health Care Agent Notified: No family to call . - A Change in Condition dated 3/25/2024 documenting in part, .Slid self out of WC onto floor right after being sat at nurses station post fall in resident room. No injuries noted . Primary Care Clinician Notified: [Name of nurse practitioner] 03/25/2024 10:00 . Name of Family/Health Care Agent Notified: No family to call . The comprehensive care plan for R47 documented in part, [Name of R47] is at risk for falls r/t (related to) dementia, confusion, deconditioning, gait/balance problems, unaware of safety needs. Date Initiated: 01/08/2024. Revision on: 01/10/2024. The comprehensive care plan failed to evidence a review or revision after the falls on 3/11/2024 and 3/25/2024. The clinical record failed to evidence fall investigation or a review of the plan of care after the falls on 3/11/2024 and 3/25/2024. On 5/21/2024 at approximately 10:00 a.m., a request was made to ASM (administrative staff member) #1, the administrator, for the fall investigations for the falls on 3/11/2024 and 3/25/2024, none were provided. On 5/21/2024 at 3:55 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that when a resident had a fall the staff should review the current fall interventions in place and initiate a new intervention if deemed necessary, review the medications for possible contributing causes, provide frequent rounding and review the falls. She stated that the nurse was responsible for making the decision on adding any intervention and updating the care plan but they had not being doing it consistently. She stated that the care plan should at least be reviewed and a fall risk assessment completed. On 5/22/2024 at 9:13 a.m., an interview was conducted with LPN (licensed practical nurse) #6, MDS coordinator. LPN #6 stated that after a fall the care plan was reviewed and revised as needed. She stated that falls were discussed daily in the team meeting and nursing did a risk assessment to determine potential contributing factors of the falls so new interventions could be put into place. On 5/23/2024 at approximately 3:15 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations and OSM (other staff member) #11, the director of social services were made aware of the findings. No further information was obtained prior to exit. 7. For Resident #25 (R25), the facility staff failed to implement interventions to prevent future injuries after experiencing a fall on 1/29/24. On 4/15/24, R25 experienced a fall and was transferred to the hospital for evaluation and treatment of an injury he sustained in a fall that evening. R25 was admitted to the facility with diagnoses including cerebral palsy and quadriplegia. A review of R25's clinical record reveals he experienced a fall on 1/29/24. A review of R25's care plan dated 5/15/24 (including a history of revisions for the past year) revealed no evidence of review or revision after the fall on 1/29/24. A review of R25's progress notes revealed the following: 4/15/24 at 6:01 p.m. This Writer was walking passed (sic) resident room and saw him sitting in his wc (wheelchair. Approximately 10 minutes later this writer was going up the hall to help another resident and he was found lying on the floor on his abdomen with his head to the right side of bodynet to his bed. He had a laceration to his scalp and a towel was placed on the floor mat .Resident does have contractures to his bles (bilateral lower extremities. This writer tried to touch his left shoulder and he cried out in pain. Resident was not moved at this time and 911 was called .Resident transferred to [name of local hospital] for evaluation of fall/laceration. 4/15/24 at 11:30 p.m. Resident returned to facility via stretcher .Dx (diagnosis): Ground level fall, abrasion of scalp. No distress noted. A review of the emergency room record for R25 dated 4/15/24 revealed, in part: EMS (emergency medical service) reports nursing home believes he slid out of his wheelchair, abrasion noted to the occipital scalp. No evidence of additional traumatic injury. CT (computed tomography) negative. Laceration/abrasion not requiring repair. On 5/15/24 at 1:33 p.m., RN (registered nurse) #1 was interviewed. When asked the process to be followed after a resident falls, she stated the staff should attempt to find out how the resident fell. She stated the electronic medical record has specific post-fall documentation that need to be completed. She stated the care plan should be reviewed, and new interventions should be put in place to prevent injuries from future falls. On 5/15/24 at 3:23 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated after a resident falls, the team reviews all falls the next morning in the clinical meeting. This meeting addresses all aspects of the fall, including how and where it occurred, and new interventions that should go on the resident's care plan. On 5/22/24 at 5:10 p.m., ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. No further information was provided prior to exit. 3. For Resident #58 (R58), the facility staff failed to thoroughly assess the resident to determine if the resident could safely and independently leave the facility unsupervised. The resident left the facility unsupervised on multiple occasions. R58 was admitted to the facility on [DATE]. R58's diagnoses included but were not limited to cerebral palsy (1), suicidal ideations, bipolar disorder (2), epilepsy (3), muscle weakness, and a history of falling. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/15/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section GG documented R58 used a wheelchair and/or scooter. A review of R58's clinical record revealed the following current physician's orders for psychotropic medications: 5/25/23-divalproex sodium (4) 250 mg (milligrams), three tablets two times a day for depression. 5/25/23-sertraline (5) 100 mg, one tablet once a day for depression. 6/21/23-trazodone (6) 50 mg at bedtime for insomnia. 4/5/24-risperdal (7) 0.5 mg two times a day for agitation/aggressive behaviors. 2/7/24-buspirone (8) 10 mg, one tablet two times a day for depression/anxiety. Further review of R58's clinical record revealed a physician's order dated 5/26/23 that documented, May go out on LOA (leave of absence) with meds. The order did not specify if R58 could safely and independently leave the facility unsupervised. A nurse's note dated 5/26/23 documented, Resident propelling in w/c (wheelchair), up and down hallways. He stated he was his own POA (power of attorney), and he wanted to get out of the facility to go explore [NAME]. Was informed he could not go outside on his own. A nurse's note dated 5/27/23 documented, This patient went to [NAME] to buy tobacco products. The sheriff's office called this facility due to a passerby spotting patient. This nurse took the phone call. Patient confirmed to be a patient of our facility. Once patient returned to facility, patient stated that he had forgotten to notify staff of his LOA (leave of absence) due to being new to the facility and being new to facility protocols. A nurse's note dated 5/30/23 documented, Resident verbally expressed desire to go out by himself. Resident was educated about ShenGo (public bus) availability. Resident was educated on safety and DON (director of nursing), NP (nurse practitioner), and his Nurse expressed concerns about him going out on his own. Resident is his own RP (responsible party) and makes his own decisions; he reminded DON of this. Resident said 'I know how to cross the street. Look who you are talking to. I am (name) and I do this all the time.' Resident signed himself out and went to [NAME]; he said, 'I will be back.' DON offered for one of us to go shopping for him, he refused. Nurse, NP aware. A nurse's note dated 6/7/23 documented, Resident went to [NAME] last pm, This morning a [sic] empty bottle of [NAME] Bootlegger was found on the front porch in the mulch, this is some type of alcohol beverage sold at the [NAME] store. Resident denied that he had drank it. Educated on the effects of alcohol with the medications that he is taking. NP made aware of findings. Will monitor resident for any concerns. An elopement risk evaluation signed by a nurse on 6/21/23 documented R58 was cognitively impaired, independently mobile, had poor decision-making skills, demonstrated exit seeking behaviors, wandered oblivious to safety needs, had a history of elopement, had the ability to exit the facility and was at risk for elopement. The evaluation failed to document an assessment to determine if R58 could safely and independently leave the facility unsupervised. A nurse's note dated 7/13/23 documented, Resident was going to go out for a stroll and was struggling to get around and brought back in by an employee after dispatch called reporting he was falling out of the chair. A nurse's note dated 9/27/23 documented, Staff went to change and assist resident to bed for the night. Patient reeked of alcohol had urinated on himself in the wheelchair, slurred speech, unable to assist staff to help him into bed. Patient stated to staff I have only been drinking mt dew. Three 24oz cans of 8% alcohol found in resident's room. Educated resident on the interactions that could occur with mixing alcohol with his medication. 2 staff assisted resident into bed changed his clothes and brief placed pillows under sheet to help assist resident from rolling out of bed, fall mat placed on the floor and bed put in low position. Administrator contacted about behavior. A nurse's note dated 10/14/23 documented, On 10-13-2023 resident was in bed at 7pm told nurse he wasnt [sic] feeling well and he thought he might have a seizure, nurse told him to stay in bed so he would be safe if he had a seizure, VSS (vital signs stable) WNL (within normal limits), no s/s (signs or symptoms) of seizure activity noted, nurses on north hall were giving report at the nursing station, this nurse saw the resident up in his wheelchair propelling self-down hall towards the front lobby, this nurse got a call from the rescue squad saying that the resident called 911 and wanted to go to the ER (emergency room), went to ER and told the DR (doctor) in the ER that he took 11-12 hits off a CBD (cannabidiol) vape pen and thought he was overdosing, no new orders, ER gave him a packed lunch and sent him back at 10pm, resident went to bed no further issues noted, call bell in reach. A nurse's note dated 5/2/24 documented, Resident checked himself out this am to go to the store he came back and appeared to be intoxicated unable to raise his head and slurred speech resident put back to bed at his requested [sic] np ware [sic]. A nurse's note dated 5/2/24 documented, Resident left the building without signing out and went to pizza [NAME]. A nurse's note dated 5/3/24 documented, Resident left the building without signing himself out and it was reported by the activities director that when he came back into the building his breath smelled of alcohol and he appears to have slurred speech and unable to hold his head up. A nurse's note dated 5/3/24 documented, Resident noted to be in another resident's [sic] conversing with resident and leaning heavily to the left with difficulty sitting erect. There is a noted odor of alcohol when the resident converses with this nurse. This nurse also noted alcoholic beverage 'Four Loko Sour Apple' on residents' [sic] lap. Resident reports to this nurse the 'Four Loko' is his. He reports he has already consumed #2 cans. Vitals obtained: 120/78 (blood pressure), 82 (pulse), 98.8 (temperature), 97% (oxygen level) RA (room air), 16 even and unlabored (respirations). NP notified. T/O (Telephone Order) Monitor resident. ED (Executive Director) aware. DON aware. Nursing will continue to monitor. A note signed by an advanced practice registered nurse dated 5/6/24 documented, PCC (name of computer system containing R58's clinical record) does report h/o (history of) suicidal ideations with comment of rolling into traffic in his wheelchair .PCC reports seen in ER on [DATE] for illict [sic] drug OD (overdose) when he was out of facility over the weekend . Further review of nurses' notes for the duration of R58's stay revealed documentation that R58 had presented with seizures, multiple falls, and suicidal ideations while at the facility. Further review of R58's clinical record failed to reveal an assessment to determine if the resident could safely and independently leave the facility unsupervised. A release of responsibility for leave or absence form revealed R58 signed out on 12/25, 3/1, 3/17, 3/24/24, 4/5, 4/11, 4/15, 4/28, 5/2, 5/8, 5/10, 5/11, 5/13, 5/17, and 5/18 (the year was not documented on all dates except for 3/24/24). On 5/20/24 at 5:08 p.m., R58 was observed in a manual wheelchair on the facility front porch and an interview was conducted with the resident. R58 stated he goes out of the facility by himself and leaves the property pretty much every day. R58 stated he has to sign out before he leaves, and he goes to places such as the tobacco shop and up the hill where the fast-food restaurants are. R58 stated he doesn't always wheel himself in the wheelchair when he is off the property. R58 stated that sometimes, people he doesn't know stop and assist him. On 5/20/24 at approximately 5:12 p.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that in order for a resident to independently leave the facility, the resident should not be at risk for wandering, be alert and oriented times four, be aware of their own safety, and sign out. RN #3 further stated that there was not a specific assessment regarding a resident's ability to safely and independently leave the facility. On 5/20/24 at 5:41 p.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator), ASM #4 (the director of sales and marketing), ASM #5 (the regional director of clinical services), and ASM #6 (the vice president of operations). ASM #1 stated an elopement risk assessment is completed for residents and if residents are not at risk for elopement, are alert and oriented, and know what is going on, then they need to sign themselves out and can leave the facility. ASM #5 stated she did not think the elopement risk assessment addressed safety, but she would have to look at it. ASM #5 stated staff also look at residents' BIMS and if residents are alert and oriented. ASM #5 was not able to describe how the BIMS correlates to residents' function at a higher level of safety awareness but stated she would find out. ASM #1, ASM #4, ASM #5, and ASM #6 were made aware of the above concern and immediate jeopardy. A bcat (brief cognitive assessment tool) was completed for R58 on 5/20/24. The assessment documented a score of 40, out of a possible 50, indicating R58 presented with mild cognitive impairment. An occupational therapy treatment note dated 5/20/24 documented, Pt (Patient) seen to assess use of manual wc (wheelchair) outdoors. Pt able to manipulate wc to access sidewalks and ramps. Pt had difficulty on downhill sidewalk due to sidewalk tilting side to side as well as slanted down hill. Pt able to manage using BUE (bilateral upper extremities) to propel wc up hill towards the facility. Pt able to access ramp at front of facility after crossing the street . On 5/21/24 at 9:44 a.m., an interview was conducted with OSM (other staff member) #3 (the occupational therapist who documented the 5/20/24 assessments). OSM #3 stated the bcat is a measure of cognitive function that breaks down different categories like verbal recall and executive functioning. OSM #3 stated R58's bcat score was almost perfect and R58 did pretty good on the immediate recall portion of the bcat but had poor scores on the portions of visuospatial, memory of objects, and executive functioning. OSM #3 stated R58 has gone to Walmart and [NAME] by himself and has been found in the middle of the street. OSM #3 stated he completed an assessment of R58 in the wheelchair outside of the facility. OSM #3 stated during the assessment, R58 went down the hill and up the hill towards the hospital (adjacent to the facility property), R58 propelled up the street, but did not cross a street. OSM #3 stated physically, R58 could complete most of his assessment but sometimes R58 is under the influence of alcohol and marijuana gummies, and this delays his functioning. OSM #3 stated R58 enjoys people helping him, gets strangers to push him, and asks strangers for money. OSM #3 stated there were instances where R58 had been observed out in the middle of the road. OSM #3 stated there was no issue if R58 goes to the end of the road, but the resident is going farther. On 5/21/24 at 10:15 a.m., an interview was conducted with RN #1. RN #1 stated she didn't really have a definitive answer how staff assess residents to determine if they can safely and independently leave the facility unsupervised. RN #1 stated R58 is alert, oriented, and able to make his own decisions so to her knowledge, as long as he signs out, the staff doesn't have a say in where the resident goes. RN #1 stated R58 had gotten kicked out of [NAME] because he steals, and one time, a CNA (certified nursing assistant) had to walk from the facility to 7-11 to assist R58 because he got stuck. RN #1 further stated that R58 goes to the dollar store on the other side of town, and she could not tell the number of times people from the community have brought the resident back to the facility. In regard to the risks R58 faces while out in the community unsupervised, RN #1 stated R58 could get abducted, could break a bone because of a fall, could sustain a heat stroke, could sustain sunburn, could have a seizure, or could become dehydrated. RN #1 stated R58 has been seen out in the middle of the road in the community and obtains alcohol, vape pens and marijuana while out in the community. RN #1 stated there was a 90 percent likelihood that R58 would sustain serious harm, serious injury, or a serious adverse outcome while out in the community unsupervised and it was just a

2. For Resident #85 (R85), the facility staff failed to initiate treatment for pressure injuries in a timely manner. R85 was admitted to the facility on [DATE]. A weekly skin integrity review dated 5/10/24 documented R85 presented with the following pressure injuries: -an unstageable pressure injury (1) on the right elbow. -an unstageable pressure injury on the coccyx. -an unstageable pressure injury on the right buttock. -a stage three pressure injury (1) on the left buttock. Further review of R85's clinical record revealed treatment for the right elbow, coccyx, and right buttock was not initiated until 5/11/24 and treatment for the left buttocks was not initiated until 5/15/24. The physician's orders were: -5/11/24-cleanse right elbow eschar (dead skin tissue) with normal saline and cover with a dry dressing every Tuesday, Thursday, and Saturday. -5/11/24-cleanse sacrum (coccyx) with wound cleanser, pat dry, pack with 2x2 gauze moistened with 1/4 strength Dakin's (wound cleanser) and cover with dry dressing every Tuesday, Thursday, and Saturday. -5/11/24- cleanse right upper buttock wound with wound cleanser, pat dry, moisten gauze with 1/4 strength Dakin's and cover with dry dressing every Tuesday, Thursday, and Saturday. -5/15/24- cleanse left buttocks with wound cleanser, pat dry, moisten gauze with 1/4 strength Dakin's and cover with a dry dressing every Tuesday, Thursday, and Saturday. On 5/21/24 at 4:01 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that when a resident is admitted , he or she should have a skin assessment within 24 hours of admission and treatment for pressure injuries should be implemented right aware when the wounds are found. RN #4 stated the nurses should place a treatment order in the computer system based on the facility standing orders and she texts the wound care nurse practitioner for orders. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5 (the regional director of clinical services) were made aware of the above concern. Reference: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to assess, monitor and/or implement treatment for pressure injuries for two of 43 residents in the survey sample, Residents #45 and #85. For Resident #45, the facility staff failed to implement treatment for a pressure injury (1) and the wound became larger in size, thus causing harm to the resident. The findings include: 1.a. For Resident #45 (R45), the facility staff failed to implement treatments for a pressure injury on the left lateral thigh. The Admission/readmission Data Collection form dated 5/1/2024, documented in part, Skin: Left thigh (rear) Pressure injury 04/28/24. The Braden Scale for Predicting Pressure Sore Risk, dated 5/1/24, documented the resident scored a 16. A score of 16 indicated the resident was at risk for developing pressure injuries/sores. Review of the physician orders failed to evidence an order for the treatment of the left thigh pressure injury. The Weekly Skin Integrity Review dated, 5/14/24, documented in part, Left thigh (rear) lateral abrasion 4x3x0 (centimeters). The wound care specialist notes dated 5/15/24, documented in part, Staff noticed 2 open areas, one on pt's (patient's) left lateral thigh they think from transfer with a Hoyer due to pad rubbing .PLAN: Left lateral thigh (+) partial thickness ulceration that measures 4.0 x 3.0 x 0.2 cm. Wound base 100% pale pink moist tissue with bioform before debridement, 100% pink/red moist tissue after. Edges adherent to wound base, scant non-odorous serous drainage, peri wound without erythema, no induration or cellulitis. Patient does demonstrate evidence of pain when area is palpated, subsides with care .Wound to left lateral thigh as follows: Cleanse with wound cleanser or NS (normal saline), pat dry. Apply xeroform to wound bed. (TX (treatment) for moist wound healing and/or autolytic debridement). Cover with dry dressing. Change dressing QD (every day) and as needed for saturation or soilage. Review of the physician orders and the TAR (treatment administration record) failed to evidence the above treatment orders had been implemented. Observation was made of R45 with the wound care specialist, administrative staff member (ASM) #7 on 5/22/24 at 8:43 a.m. ASM #7 stated there was no dressing in place on the left lateral thigh and the wound was weeping onto the wheelchair. The wound measured 5.0 x 6.0 x 0.2 cm. When asked if the wound got worse since the previously week because there was no treatment order in place for this wound, ASM #7 stated, absolutely. Review of the resident's care plan failed to evidence documentation for pressure injuries. An interview was conducted with RN (registered nurse) #4 on 5/21/24 at 3:55 p.m. The thigh wound was found on 5/14/24 and the wound care specialist saw the resident on 5/15/24 and made recommendations for treatment to the thigh wound. When asked how those orders get put into the medical record, RN #4 stated she puts them in. Informed RN #4 that there were no treatment orders in place for the thigh wound. RN #4 was asked if she was the only one putting in orders, RN #4 stated, generally. The facility policy, Skin and Wound, documented in part, Policy: To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries. Process: Pressure Injury Prevention: 1. Residents's skin will be evaluated upon admission/readmission and documented in the medical record. 2. Braden Risk Evaluation will be completed upon admission/readmission, weekly for 4 weeks, quarterly and with a signbificant change in condition. 3. Nurse to complete skin evaluation weekly and prior to transfer/discharge and doucment in the medical record. 4. CNA (certified nursing assistant) to complete skin observations and report changes to Nurse. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM (other staff member) #11, the director of social services were made aware of the concern for harm on 5/22/24 at 5:15 p.m. No further information was provided prior to exit. 1.b. For Resident #45, the facility staff failed to implement the wound care specialist recommendations for treatment in a timely manner for the right upper back wound. There was a delay of four days to implement the treatment. The Admission/readmission Data Collection form dated 5/1/2024, failed to evidence documentation of the right upper back wound. The Weekly Skin Integrity dated 5/14/24 documented in part, Site: right upper back stage 3 (2) PI (pressure injury) 5x10x0.2 Notes: Wound care currently seeing weekly. Device associated PI. There were no weekly skin assessments completed between 5/1/24 and 5/14/24. The Pressure Ulcer Wound Rounds dated, 5/15/24, documented in part, Right upper back, pressure: length 5 cm.; width 10 cm., depth 0.2 cm. Stage III (3). The wound care specialist notes dated 5/15/24, documented in part, Staff noticed 2 open areas .a wound at pt's right upper back they think is from the back of his wheelchair .Right upper back (+) full thickness ulceration that measures 5.0 x 10.0 x 0.2 cm. Wound base 20% intact, 40% granular, 40% thin slough before debridement, 20% intact, 60% granular, 20% thin adherent slough after. Edges adherent to wound base, moderate non-odorous serous drainage, peri wound without erythema, no induration or cellulitis. Patient does demonstrate evidence of pain when area is palpated, subsides with care Wound care to right upper back as follows: Cleanse with normal saline or wound cleanser, pat dry. Apply alginate to wound bed. cover with foam dressing. (tx for moist wound healing and/or autolytic debridement). Change dressing every day and as needed for saturation or soilage. Observation was made of R45 with the wound care specialist, (ASM) #7 on 5/22/24 at 8:43 a.m. The right upper back wound measured 2 cm. x 10 cm. x 0.2 cm. ASM #7 stated that the wound did improve as demonstrated by a decrease in area. The physician orders dated 5/19/24, four days after the wound specialist treated the resident, documented, Cleanse area to right upper back with normal saline or wound cleanser, pat dry. Apply calcium alginate to wound bed, cover with foam dressing (tx for moist wound healing and/or autolytic debridement). change dressing every day and as needed for saturation or soilage one time a day for wound care. Review of the May 2024 TAR documented the above order as starting on 5/19/24. Review of the comprehensive care plan failed to evidence documentation of the right upper back wound or pressure wounds. An interview was conducted with RN (registered nurse) #4 on 5/21/24 at 3:55 p.m. The upper back wound was found on 5/14/24 and the wound care specialist saw the resident on 5/15/24 and made recommendations for treatment to the upper back wound. When asked how those orders get put into the medical record, RN #4 stated she puts them in. Informed RN #4 that the order did not get put into the physician orders until 5/19/24. When asked why they didn't get put into place, RN #4 stated, she was on the medication cart. ASM #1, the administrator, ASM #5, the regional director of clinical services, ASM #6, the vice president of operations, and OSM (other staff member) #11, the director of social services, were made aware of the above concern on 5/22/24 at 5:15 p.m. No further information was provided prior to exit. References: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/. (2) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/.

Based on observation, staff interview, facility document review, clinical record review, and during the course of a complaint investigation, it was determined that the facility staff failed to provide behavioral health services such as conducting individualized assessments and person centered planning, related to residents who demonstrated or expressed suicidal ideation, for six of 41 residents in the survey sample, Resident #230, Resident #59, Resident #20, Resident #24, Resident #61 and Resident #13. On 8/25/21, Resident #230 expressed thoughts of self- injury documented on the MDS-Section D-Letter I., and was not further assessed by facility staff. Safety interventions and behavioral health services were not put in place. On 8/31/21, Resident #230 was found by staff at approximately 3: 00 a.m., with a call bell cord wrapped around his neck, self-injurious behavior that is likely to cause serious injury, harm, impairment, or death to the resident, resulting in transportation to the emergency room for further evaluation. The hospital documented the resident was being discharged back to the facility with a safety plan; however, there was no documented plan in place upon the resident's return to the facility, and no care plan addressing suicidal ideation developed until 9/2/21. On 10/21/21 at 1:10 PM a request was made to ASM (administrative staff member) #1, the executive director for a list of residents receiving psychiatric services, and a list of residents who had expressed thoughts of self- injury documented on the MDS-Section D-Letter I. Seven other residents were identified by the facility as having been assessed on the MDS-Section D-Letter I., as having expressed thoughts of self- injury. Five of the seven, (Residents # 59, 20, 24 61 and 13), had no further immediate assessments, safety interventions and /or behavioral health services provided resulting in the findings of Immediate Jeopardy on 10/21/21 at 4:28 p.m. The IJ was abated on 10/22/2021 at 6:37 p.m. and lowered to an E. The findings include: 1. Resident #230 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a five day Medicare assessment with an ARD (assessment reference date) of 8/26/21, coded Resident #230 as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating Resident #230 was cognitively intact. A review of MDS Section D-Mood-letter I: Thoughts that you would be better off dead or of hurting yourself in some way coded Resident #230 as Yes for these questions and coded the frequency of symptoms for the resident as 2-6 days. Resident #230 was reviewed as part of a complaint regarding a concern of attempted suicide. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Psychology as needed. Further review of Resident #230's clinical record failed to reveal any evidence psychiatric consults or services were provided. A review of Resident #230's clinical record failed to evidence the development of a baseline care plan to address psychosocial needs and mood, including thoughts of self injury/suicide. On 9/2/21, the comprehensive care plan documented in part, FOCUS-Resident is at risk for a decline in mood related to medical condition and current living arrangements. INTERVENTIONS-Arrange for psych [psychiatric] consult follow up as indicated. A review of the nursing progress notes documented in part the following: - 8/24/21 at 1:11 PM, Level of consciousness noted as oriented to person oriented to place oriented to time. Mood status is happy pleasant smiling. Behavioral problems are not noted. - 8/25/21 at 4:27 PM, Level of consciousness noted as oriented to person. Mood status is angry negative statements fidgety. Behavioral problems are not noted. 8/27/21 at 8:49 AM, Level of consciousness noted as oriented to person oriented to place oriented to time. Mood status is depressed happy pleasant smiling negative statements flat affect. Behavioral problems are not noted. A review of the social services progress note dated 8/27/21 at 2:54 PM, documented in part, Resident answered yes to thoughts of hurting himself. Asked resident is [Sic.] he had any plans of hurting himself he stated he was in a bad mood the day of PHQ9 interview. A facility hospital transfer form dated 8/31/21 at 2:58 AM, documented in part, Suicide attempt. Reason for transfer: Resident was found with light cord wrapped around his neck and when asked what he was doing he stated, 'trying to f .[expletive] hand (Sic. [hang]) myself'. The hospital emergency department physician history and physical exam dated 8/31/21 at 3:55 AM, documented in part, Chief complaint: Psychiatric evaluation. Context: Resident is an [AGE] year old male who presents from nursing home because of suicidal ideations. The patient apparently is upset with the nursing home and upset with his medical care to the point that he states he would like to be put out of his misery. He asked one of the nurses if they could shoot him. He also tried to wrap a small piece of string around his neck. The patient tells me that he would like to be put out of is misery. Review of Systems: Psychiatric/Behavioral: positive for suicidal ideas. Neuro/Psych: Normal affect and agitated mood. Patient is alert, and oriented to person place and circumstance. Critical Care: Differential diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital emergency department nursing note dated 8/31/21, documented in part, Disposition: Case discussed with patient, daughter and physician. Plan of Care: discharge with safety plan. A nursing home nurses progress noted dated 8/31/21 at 4:24 PM, documented in part, Patient returned from the hospital on stretcher accompanied by 2 EMT [emergency medical technicians], patient returned with no new order, all morning meds [medications] was administered at the hospital, new catheter and wound dress done while at the hospital. Vital signs: blood pressure 145/83, respirations 16, pulse 76, temperature 97.6. Patient continues to be monitored for suicidal idea. Patient was able to participate in Physical therapy activity. Currently in bed resting. A review of Resident #230's medical record failed to evidence that a safety plan was initiated for the resident upon return to the facility. On 10/20/21 at 4:05 PM, an interview was conducted with OSM (other staff member) #4, the social services manager. When asked about the discharge plan for Resident #230, OSM #4 stated, We had a pre-discharge meeting. It was not a care plan meeting. The resident was to be discharged on Tuesday 9/7. The daughter decided to take the resident home on 9/3/21, a Friday at 6:42 PM. An interview was conducted on 10/21/21 at 2:46 PM with Resident #230's daughter. When asked about the discharge date for her father, Resident #230's daughter stated, After his suicide attempt, I could not leave him in the facility over another weekend. I met with the social worker and she took notes on all kinds of scrap pieces of paper. I talked with the administrator about taking my dad home and he told me 'we really dropped the ball on this one including administration'. The administrator said they would release my dad with their wound vacuum since they had dropped the ball. I could not wait to get him out of there before something else happened to him. An interview was conducted on 10/20/21 at 1:15 PM with ASM (administrative staff member) #2, the director of clinical services [director of nursing]. When asked what actions would be done if a resident answered yes to thoughts that they would be better off dead, or of hurting themselves in some way, ASM #2 stated, We would remove everything out of room that they could do harm, give them plastic silverware, paper plates or Styrofoam containers for food. We would take away anything that could be wrapped around his neck. We would put them on 1:1. If situation escalated, we would send them out to the hospital. We would document behaviors and pass all this information on in report. When asked if she remembered the suicidal attempt by Resident #230, ASM #2 stated, No, I was moving from another part of the state and don't remember being informed. An interview was conducted on 10/20/21 at 2:55 PM, with OSM (other staff member) #4, the social services manager. When asked what process occurs when a resident answers yes to thoughts that they would be better off dead, or of hurting themselves in some way, OSM #4 stated, I wasn't aware of the answer until 8/27. I would call the director of clinical services and alert them. I ask the resident if they have a plan in place and notify the nurse. We would not leave the resident alone and would pull any items from the room the resident could harm themselves with. On 10/25/21 at 3:57 PM, another interview was conducted with OSM (other staff member) #4, the social services manager. When asked the about the process followed if a resident verbalized thoughts of self-harm, prior to education last week, OSM #4 stated, Prior to education last week, I would just inform the MDS coordinator and the nursing director. Now we stay with the resident and do not leave them. Before last week, normally I would follow up immediately and leave a note immediately. When asked where this information was documented and evidenced, OSM #4 stated, For Resident #230, I don't have any documentation or evidence. An interview was conducted on 10/21/21 at 6:47 AM with LPN (licensed practical nurse) #8. When asked if she remembered Resident #230, she asked to pull up his picture and then LPN #8 stated, Yes, I remember caring for him. When asked if she had been informed that he had verbalized thoughts of harm to himself, LPN #8 stated, No, I never knew that he was a risk to himself and that there was behavior issues. When asked what actions would be taken if a resident verbalized thoughts of harm to himself, LPN #8 stated, I would have them 1:1 and document it, inform the physician, nursing leaders, and family. An interview was conducted on 10/21/21 at 7:27 AM with LPN #5. When asked if she remembered Resident #230, LPN #5 stated, Yes I remember the resident and there was an issue where they sent him out to the hospital because I think he had a cord tied around his neck. I do not remember that he was put on 1:1. Normally our protocol is to put them on 1:1. When asked what interventions were put in place upon his return from the hospital, LPN #5 stated, I don't believe anything new was put in place. An interview was conducted by phone on 10/21/21 at 8:48 AM with LPN #9, the nurse on duty 8/31/21, night shift with Resident #230. When asked to describe the situation, LPN #9 stated, I found him [Resident #230] at about 3:00 AM. He knew what he was doing and he had the cord wrapped around his neck. I did my protocol. I had the CNA (certified nursing assistant) sit outside of his door and monitor him. I put him on frequent checks. Notified the nurse practitioner, the administrator and the nursing director. We were changing nursing directors I think at that time. I know the DON [director of nursing] and the administrator knew because they came in and talked with me the next day. When asked if she had been informed the resident had verbalized thoughts of harming himself, LPN #9 stated, No, I knew nothing about that before this situation, this took me by surprise. I did not know he was at risk. An interview was conducted on 10/21/21 at 10:20 AM with ASM #6, the nurse practitioner. When asked if she was informed that Resident #230 had verbalized thoughts of harming himself, ASM #6 stated, No, I did not know beforehand that he had suicidal tendency. There would have been orders to have him taken to the hospital if needed and seen by psychiatry. A second interview was conducted 10/21/21 at 12:11 PM, with Resident #230's daughter. When asked if her father had any history of self-harm or verbalizing thoughts of self-harm, the Resident #230's daughter stated, No, he has never tried to harm himself. That morning (8/31/21), the facility had my phone number wrong and my nephew had to call me to inform me that had taken my dad to the emergency room . When I went into see him, my dad said, Sis, I was in pain for two days and I couldn't sleep. So I see that cord and said I can wrap this cord around my neck and turn over in bed a few times it just might get tight enough. It's better than being here in this place. An interview was conducted on 10/21/21 at 1:09 PM with ASM #1, the administrator. When asked what he remembered about Resident #230's suicide attempt, ASM #1 stated, I would have to go back and look, but I remember being told that the cord was laying across his neck, not wrapped around his neck. When ASM #1 was informed of the interview conducted with the night nurse and that her recollection and the documentation in the medical record were consistent and documented, Resident was found with light cord wrapped around his neck and when asked what he was doing he stated, 'trying to f .[expletive] hand (Sic. [hang]) myself'. ASM #1 stated, I don't remember that. When asked if any interventions were initiated upon Resident #230's return from the emergency department and if an investigation had been initiated, ASM #1 stated, I don't think so. A review of the facility's Resident Expressing Suicidal Ideations policy dated 8/2017, documented in part, To ensure the safety of any resident that expresses the desire to harm themselves. The Director of Clinical Services and the Executive Director are to be notified immediately of any resident that expresses the desire to harm themselves. Once a resident expresses the desire to harm themselves, staff to do the following: staff to remain with resident until a physician or a qualified psychologist evaluates the resident and documents that the resident is not suicidal or at risk of harming self-OR until the resident is transferred to a higher level of care, the nurse to be notified immediately, the nurse to notify the physician and responsible party of the resident's condition, the nurse to notify the Director of Clinical Services and the Executive Director, the nurse to prepare the resident for transfer and ensure a safe transfer to the emergency room if ordered. A review of the facility's Mental Health Referrals policy dated 11/2014, documented in part, Mental Health referrals will be utilized by the facility when a resident's behavior and affect appears disturbed or indicates distress. Resident's behavior and affect are observed by nursing home staff members and documented in the resident's chart. A list of any other residents who had verbalized self-injury was requested from ASM [administrative staff member) #1, the administrator, on 10/2/21 at approximately 1:01 p.m. On 10/21/21 at 2:15 p.m., ASM #1 provided a resident list based on MDS-Section D-Letter I Thoughts that you would be better off dead, or of hurting yourself in some way; that were coded as 'yes'. This list contained seven additional residents. The survey team reviewed the records of these additional seven residents, (Resident #'s 10, 50, 59, 20, 24, 61 and 13). The resident record review revealed five of the seven (Resident #'s 59, 20, 24, 61 and 13), failed to evidence any implementation of further assessments, safety interventions, and behavioral health services for these additional five residents with documented 'yes' answers to the MDS question about being better off dead or of hurting themselves. This resulted in a likely situation for serious psychosocial harm, serious injury, serious harm, serious impairment, or death to occur. On 10/21/21 at 3:41 PM, the Long Term Care supervisor, was notified of the facility's failure to implement immediate further assessments, safety interventions, and behavioral health services for these additional five residents as documented above. The Long Term Care supervisor consulted with three additional Long Term Care supervisors and the Division director and the team was notified of immediate jeopardy findings. On 10/21/21 at 4:28 PM, the survey team met with the executive director, director of clinical services and the vice president of operations, and informed them of the concern for Immediate Jeopardy. On 10/21/21, the facility submitted the following plan of correction that was accepted at approximately 8:05 p.m. 1. Resident #230 triggered for self-injury on the PHQ-9 completed on August 25, 2021. The resident was found with his call bell around his neck on 8/31/21 and was sent to the emergency room . The facility failed to implement behavioral health services for Residents #230, #61, #50, #59, #24, #10, #13, and #20. On October 21, 2021, it was identified residents #61, #50, #59, #24, #10, #13, and #20 triggered for self-injury on the PHQ-9. Resident #230 was discharged on [DATE]. Residents #61, #50, #59, #24, #10, #13, and #20 had call bells removed from their room, plastic silverware implemented until assessed by a Registered Nurse on 10/21/21. 2. The Director of Nursing (DON) or designee will complete PHQ-9 for all residents with BIM score of 8 and above. Residents with a BIMS of 7 or below will have nursing and social services documentation reviewed for the last 30 days for thoughts of self-injury or other present symptoms. Residents identified with feelings of self-injury as recorded on PHQ-9 or through documentation review will have MD/NP/RP notification and appropriate interventions in place and plan of care updated. MD/NP will be consulted on appropriate immediate interventions until psych [psychiatric] services can be rendered in house or transferred to a higher level of care as appropriate. Plan of care will be updated by licensed nurse. 3. Regional Vice President of Operations/Regional Director of Clinical Services will re-educate Social Services Director, MDS Coordinators, and Nurse Management on policy and procedures related to completing PHQ-9 per the RAI Manual Guidelines and correctly identifying thoughts of self-injury and policy for addressing change in condition. Correctly identifying thoughts of self-injury include a resident verbalizing the following: 1. Feeling bad about yourself - or that you are a failure or have let yourself or your family down 2. Thoughts that you would be better off dead, or of hurting yourself in some way. Addressing a change in condition is done by identifying a resident's change in their physical, mental, or psychosocial status. DON [director of nursing] or designee will re-educate all staff on identifying changes in psychosocial behavior. Staff education to include identifying a resident expressing the desire to harm themselves and completing the following: 1. Staff to remain with resident until a physician or a qualified psychologist evaluates the resident and documents that the resident is not suicidal or at risk of harming self or until the resident is transferred to a higher level of care. 2. The nurse to be notified immediately 3. The nurse to notify the physician and responsible party of the resident's condition. 4. The nurse to notify the Director of Clinical Services and the Executive Director 5. The nurse to prepare the resident for transfer and ensure a safe transfer to the emergency room if ordered. No staff will be allowed to work until education is completed. IDT [interdisciplinary team] will review 24 hour report and nurse notes of residents triggering for self-injury and any other symptom presence during the morning clinical meeting to ensure appropriate interventions are in place, MD/NP/RP [medical doctor/nurse practitioner/ responsible party] notification and care plans reflect appropriate interventions. DON/designee to review completed PHQ-9's to identify residents who may have triggered for self-injury during morning clinical meeting Monday through Friday. Weekend staff identifying residents who express the desire to harm themselves will follow the suicidal ideation policy. This will be an ongoing intervention. 4. DON to report findings from QI [quality improvement] monitoring at the QI committee meeting monthly for 12 months for further compliance and/or revision. 5. Date of compliance 10/22/21 at 3:00pm. On 10/23/21 from 8:00 AM-10:00 AM, the facility plan of correction was verified onsite by the following: 1. Review of the all resident's PHQ-9 and/or documentation of MD/NP/RP notification and appropriate interventions. 2. Review of all psychiatric evaluations of residents who were identified as wanting to harm themselves as coded on the PHQ-9. 3. Review of all resident care plans that required a revision/update regarding psychiatric services. 4. Review of all credible evidence for training provided, education content and staff sign in sheets for all shifts and staff. 5. Interviews, in-person and telephone, with numerous facility staff, including contract staff, from varying shifts and disciplines in regard to identifying changes in resident's psychosocial behavior or expressing the desire to harm themselves and the steps they need to follow: a. Staff to remain with resident until a physician or a qualified psychologist evaluates the resident and documents that the resident is not suicidal or at risk of harming self or until the resident is transferred to a higher level of care. b. The nurse to be notified immediately c. The nurse to notify the physician and responsible party of the resident's condition. d. The nurse to notify the Director of Clinical Services and the Executive Director e. The nurse to prepare the resident for transfer and ensure a safe transfer to the emergency room if ordered. In addition to the seven resident's originally identified, the facility identified three additional residents as wanting to harm themselves. These residents were also included in the verification review. All ten resident were evaluated by psychiatric services and deemed safe before the immediate jeopardy abatement on 10/22/21 at 6:37 PM. No further information was provided prior to exit. 2. The facility staff failed to assess and implement a plan of care for Resident #59 who stated he had thoughts that he would be better off dead, or of hurting himself in some way on a quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 9/29/21. The facility staff failed to evidence that behavioral health services were offered to Resident #59 between 9/29/21 and 10/21/21. Resident #59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (3) The most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 9/29/21, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of MDS Section D-Mood-letter I: Thoughts that you would be better off dead, or of hurting yourself in some way coded the resident as Yes and frequency of symptoms coded the resident as 2-6 days. A review of the comprehensive care plan dated 7/8/21, documented in part, FOCUS-Resident has a decline in mood problem related to terminal prognosis. INTERVENTIONS-Behavioral health consults as needed. Seen by psych [psychiatric] services (initiated 10/22/21). Facility/hospice staff to provide emotional support as needed. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A past order had a discontinuation date of 1/30/21. A review of the social services progress note dated 9/29/21 at 11:07 AM, documented in part, On PHQ9 resident answered yes to thoughts about being dead/harming self, he stated that he has no plan in place and the thoughts come and go. There was no evidence in the medical record of additional monitoring or notification of nursing. There was no evidence of removing items from the resident's room or psychiatric consult for Resident #59, prior to identification of immediate jeopardy on 10/21/21, as documented above. On 10/21/21 at 4:28 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services and ASM #3, the regional vice president of operations were informed of the Immediate Jeopardy findings at this time. A review of the resident safety check form dated 10/21/21 3:00 PM through 10/21/21 6:45 PM documented every 15 minute checks. On 10/21/21 at 5:10 PM an interview was conducted with Resident #59. When asked if he remembered being asked about thoughts of self-harm, Resident #59 stated, Yes, I remember the conversation and remember saying that. Nothing else has been done, I have not talked with anyone. A review of the nurse practitioner progress note dated 10/22/21 at 10:30 AM, documented in part, Suicide screening: Psychiatric: Insight: good judgement. Mental status: confused and abnormal affect, hallucinations. Orientation: not oriented to time, place and person. Memory: recent memory abnormal and remote memory abnormal. Patient with no voiced suicidal ideations or thoughts per staff. Psych [psychiatric] to evaluate patient as well. On 10/25/21 at 3:57 PM, an interview was conducted with OSM (other staff member) #4, the social services manager. When asked to provide any information regarding notification to the Director of Clinical Services regarding Resident #59's assessed thoughts of self-harm, OSM #4 stated, I'm not sure, I will have to check and get back with you. When asked about the process staff follows if a resident verbalized thoughts of self-harm, prior to education last week, OSM #4 stated, Prior to education last week, I would just inform the MDS coordinator and the nursing director. Now we stay with the resident and don't leave them. Before last week, normally I would follow up immediately and leave a note immediately. On 10/25/21 at 4:06 PM, an interview was conducted with ASM (administrative staff member) #2, the director of clinical services [director of nursing]. When asked the process followed if the mood assessment identifies thoughts of self-harm, ASM #2 stated, Normally the social services manager reports it to me prior to education last week. When asked what the revised process included, ASM #2 stated, We assess the resident and put them on every 15 minute checks until the physician can see them. If suicidal, take call bell out of room and put them on 1:1. This process was started last week. We had someone in social services that was not reporting this information to us. That person is no longer here. Since, I have been here (8/26/21 as interim, 9/16/21 as permanent), I have never had anyone report a resident with thoughts of self-harm to me. On 10/26/21 at 8:25 AM, OSM #4 provided email dated 9/29/21 at 8:05 AM to the ASM (administrative staff member) #2, the director of clinical services, which documented in part, Resident #59 also answered yes to having thoughts about hurting himself or being better off dead but stated he had no plan in place. He seems very depressed now that he is in isolation, more so then before, seems to have a hard time understanding why he is in quarantine. No further information was provided prior to exit. References: (1) Diabetes mellitus inability of insulin to function normally in the body. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 160. (2) [CONDITION(S)] 'COPD' (chronic non-reversible lung disease. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 120. (3) Chronic respiratory failure (chronic inability of the heart and lungs to maintain and adequate level of gas exchange. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 502. 3. The facility staff failed to assess and implement a plan of care for Resident #20 who stated he had thoughts that he would be better off dead, or of hurting himself in some way on a quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 8/19/21. The facility staff failed to evidence that behavioral health services were offered to Resident #20 between 8/19/21 and 10/21/21. Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 8/19/21, coded Resident #20 as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of MDS Section D-Mood-letter I: Thoughts that you would be better off dead, or of hurting yourself in some way coded Resident #20 he resident as Yes and frequency of symptoms coded the resident as 2-6 days. A review of the comprehensive care plan dated 8/23/21, documented in part, FOCUS-Potential for psychosocial well-being. INTERVENTIONS-Observe for psychosocial and mental status changes. Document and social work report as indicated. Provide emotional support and allow residents to express feelings, fears and concerns. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Psychology as needed. A review of the MDS coordinator note dated 8/23/21 at 1:17 PM, documented in part, MDS 8/13 Mood interviews. Mood is fluctuating daily. Recent SCIC (significant change in condition) due to coming off hospice. There was no evidence in the medical record of additional monitoring or notification of nursing regarding Resident #20's 8/19/21, assessment for thoughts of being better off dead, or of hurting yourself in some way . There was no documented evidence of removing items from the resident's room or of psychiatric consult, prior to the identification of immediate jeopardy on 10/21/21, as documented above. On 10/21/21 at 4:28 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services and ASM #3, the regional vice president of operations were informed of the Immediate Jeopardy findings at this time. A review of the resident safety check form dated 10/21/21 11:00 PM through 10/22/21 11:45 AM documented every 15 minute checks. On 10/21/21 at 5:00 PM, an interview was attempted with Resident #20, but was not completed. A review of the nurse practitioner progress note dated 10/22/21 at 12:00 PM, documented in part, Suicide screening: Psychiatric: Insight: poor insight. Mental status: lethargic, confused and abnormal affect, hallucinations. Orientation: not oriented to time, place and person. Memory: recent memory abnormal and remote memory abnormal. Patient does not answer questions or respond to provider, staff report no suicidal ideations or thoughts. Psych [psychiatric] to evaluate patient as well. On 10/25/21 at 3:57 PM, an interview was conducted with OSM (other staff member) #4, the social services manager. OSM #4 was asked to provide any informa [TRUNCATED]

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed staff failed to provide care and services to promote the highest level of well-being for one of 19 residents in the survey sample, Residents #14. Resident #14 had signed an advance directive stating she wanted all resuscitative efforts to be undertaken for her. In accordance with this advance directive, the physician had written an order that the resident would be a full code. On [DATE], Resident #14 was discovered to be without pulse and without respirations. The facility staff failed to honor the advance directive and failed to follow the physician's order by immediately beginning CPR and calling for emergency medical assistance and Resident #14 expired. The findings include: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), an admission assessment with an assessment reference date of [DATE], Resident #14 was coded as being severely cognitively impaired for making daily decisions, having scored only three out of 15 on the BIMS (brief interview for mental status). A review of the admission nursing assessment dated [DATE] revealed that Resident #14 was alert and oriented to person only. A review of Resident #14's clinical record revealed a page with the title FIRST ALERT. This page contained the following: CODE ALERT: FULL. Further review of the clinical record revealed the document (Name of state) Advance Directive for Health Care. This document stated, in part: I (name Resident #14) willingly and voluntarily make known my wishes in the event that I am incapable of making an informed decision about my health care, as follows: .Section II: My Health Care Instructions .I provide the following instructions in the event my attending physician determines that my death is imminent (very close) and medical treatment will not help me recover .I want all treatments to prolong my life as long as possible within the limits of generally accepted health care standards. I understand that I will receive treatment to relieve pain and make me comfortable. This document listed the names of one individual to serve as primary agent, and another individual to serve as secondary agent. This document was signed by Resident #14 and dated [DATE]. Further review of the clinical record revealed a document with the title Advance Directives Discussion Document. The document stated, in part: Please indicate your wishes regarding the following: Cardiopulmonary Resuscitation (CPR): PROVIDE. Please indicate if you possess any of the following documents or have primary decision-maker. The document contained a check mark beside the categories of advance directive and health care agent. The document continued: I have received a copy of the facility's policies on Advance Directives and have been given a chance to ask questions regarding my rights to make decisions regarding my medical care. I understand that I have the right to refuse or accept medical and/or surgical treatment, and the right to formulate advance directives concerning my health care. Honoring resident choices requires providing appropriate documentation, and I understand that I am responsible for providing the facility with the necessary and/or legal documentation appropriate for Advance Directives. The document was signed by Resident #14 and by the primary agent designated in the Advance Directive for Health Care. A review of the physician's orders for Resident #14 revealed the following order, dated [DATE] and signed by the physician on [DATE]: Code - full. A review of Resident #14's comprehensive care plan dated [DATE] revealed no information related to her advance directive or code status. A review of the nurses' notes for Resident #14 revealed, in part, the following: - [DATE] - [DATE] 7p - 7a (7:00 p.m. on [DATE] through 7:00 a.m. on [DATE]) - Resident resting quietly. (Arrow pointing up) (increased) temp (body temperature). No c/o (complaint of) pain. No SOB (shortness of breath)/cough noted. Call bell in reach. Will cont (continue) to monitor. - @ (at) 130 (1:30 a.m.), CNA (certified nursing assistant) went into take resident's temp and found her with no pulse and not breathing. Blue around lips and nail beds. ADCS (assistant director of clinical services (*note at the time of this incident the current director of clinical services, administrative staff member #2, held the position of assistant director of clinical services) ) and Dr. (doctor) notified. Both of these notes were signed by LPN (licensed practical nurse) #10. - [DATE] 0245 (2:45 a.m.) Pt (patient) without respiration, no apical heart rate present. Pt (patient) expired, pt identified as full code @ this time. 2nd (second) nurse verified. CPR initiated. EMS (emergency medical services) called. MD (medical doctor (physician)) made aware and RP (responsible party). This note was signed by ASM (administrative staff member) #2, the director of clinical services. Further review of the clinical record revealed the following order, dated [DATE] and was signed by ASM #3, the nurse practitioner, on [DATE]: Send to ER (emergency room ) for eval (evaluation) and treat (treatment). A review of the EMS (Emergency Medical Service) record for Resident #14 dated [DATE] revealed, in part, the following: Dispatched to (facility) for a person in [MEDICAL CONDITION]. On scene, in (Resident #14's room number), found a 72 YOF (year old female) lying supine on the bed with staff performing CPR on the pt and was (sic) bagging her with bi-valve mask. Staff was asked if there were a DNR (do not resuscitate) and they advised that she is a full code. Pt was found in [MEDICAL CONDITION] while the nurse was doing rounds. Unknown down time. CPR was started and 911 called. General impression was poor. Pt was unresponsive. Pt was not mobile. Pt was unstable. Pt was logged rolled (sic) onto a backboard and the Lucas device (automatic CPR machine) was place and was initiated to take over CPR. Care was transferred to (name of EMS company). Medical hx (history) was obtained from staff. Pt allergies [REDACTED].Pt had no signs of life. Pt was transported to (name of local hospital) .On arrival to (name of local hospital), pt was still unresponsive and not breathing. A review of the records from the local hospital dated [DATE] revealed, in part, the following: Emergency History and Physical Exam: (Name of Resident #14) is a 72 y.o. (year old) female who presents by EMS. Apparently the patient was found on the floor unresponsive in (sic) cyanotic around at the nursing home .unknown how long she had been down .Differential [DIAGNOSES REDACTED].The patient was pronounced dead at 3:43 a.m. Death certificate completed. Clinical Impression: Dead on arrival. A review of the report sent to the state agency dated [DATE] revealed, in part, the following: (Name of Resident #14) was a [AGE] year old female admitted to this facility on [DATE] .Her advanced directive requested full code status. On [DATE] at 0130 (1:30 a.m.), (Resident #14) presented as unresponsive to the on shift CNA. The CNA reported this to LPN Charge Nurse (name of LPN #10), who noted the resident as having no pulse, no breathing and presenting with blue lips and nail beds. (LPN #10) phoned (ASM #2) and requested that she come to the facility and pronounce death. On arrival, (ASM #2) also noted (Resident #14) to be absent of vital signs; but identified (Resident #14) as a full code and initiated the facility CPR policy and transferred (Resident #14) via EMS to the local emergency department .After facility investigation, neglect has been substantiated. (LPN #10's) employment with this facility has been terminated and required reporting will occur to the Department of Health Professions. A review of the facility's investigation file about this incident revealed the following statement written by LPN #3 and dated [DATE]: On [DATE], (LPN #10) asked me to come and check patient with her. Listened to heart and lungs nothing heard (sic). (LPN #10) was nonchalant with the situation told (sic) me patient had been declining and had hx (history) of CA (cancer). This lead (sic) me to believe that the patient was comfort and expecting to go any time. Further review of the facility's investigation file revealed the following statement written by LPN #10 dated [DATE]: At 0130 (1:30 a.m.) I sent CNA to take temp of resident. Earlier she had a temp of 100.1. CNA called me to the resident's room. Found resident without resp (respirations) and very pale and turning cold. (Resident had been checked on an hour prior.) At this point I called another nurse to listen for heart rate/breath sounds. At this point I texted the ADCS (assistant director of clinical services) and left a message and she returned the called (sic). At this point, I was unaware the resident was a full code. When the ADCS arrived we began CPR and called the squad (EMS). On [DATE] at 1:45 p.m., LPN #5 was interviewed. When asked what she would do if a staff member reported to her that a resident under her care had been found without pulse and without respirations, LPN #5 stated: I would page a code blue. She stated the process is for two nurses to check the resident's chart and clarify the physician's order. If the resident is a full code, somebody starts CPR and somebody else makes the calls and does the paperwork. She stated the facility provides frequent training and code blue drills for the staff. On [DATE] at 2:40 p.m., LPN #4 was interviewed. When asked what she would do if a staff member reported to her that a resident under her care had been found without pulse and without respirations, LPN #4 stated: I would grab the chart to see whether or not they are a DNR. She stated if the resident was not a DNR, she would assess the resident and start CPR if there were no vital signs. She stated she would get other staff members to call the rescue squad, family, and physician. On [DATE] at 3:40 p.m., ASM #3, the nurse practitioner, was interviewed. When asked if a resident has an order to be a full code, and if that resident ceased heart rate and respirations, what should be done, ASM #3 stated: The resident should be coded. ASM #3 stated: The underlying [DIAGNOSES REDACTED]. She added that she is aware that the facility practices this scenario by way of code blue drills frequently. On [DATE] at 7:05 a.m., CNA #1 was interviewed. She stated that she was assigned to Resident #14 on the night of [DATE] through [DATE]. She stated the resident had a fever earlier in the shift, and that LPN #10 had asked her to re-check the resident's temperature. CNA #1 stated when she entered the resident's room, it looked like she was dead. She was gray. She stated she stepped out of the room and called for LPN #10 to come to the room. CNA #1 stated: (LPN #10) never looked at the chart. She immediately yelled for LPN #3 to come and help her. They both went in the room and checked (Resident #14). She stated she remembered the nurses talking to each other about who was on call for the facility to pronounce death, and that neither of them discussed the resident's code status. She stated one of the nurses called ASM #2, the director of clinical services and that it was a good while before ASM #2 arrived at the facility. CNA #1 stated ASM #2 came in and pronounced (Resident #14's death). She stated ASM #2 went to do paperwork at the desk, and discovered that Resident #14 was a full code. CNA #1 stated ASM #2 started CPR and other staff called emergency services. On [DATE] at 7:10 a.m., LPN #3 was interviewed. LPN #3 stated: I was working on my side and (LPN #10) yelled for me to go help her. We went in the room. (Resident #14) was gray and cold. (LPN #10) told me the resident [MEDICAL CONDITION], and had been declining. She told me the resident had basically given up. I thought she was on comfort care. We both assessed her. LPN #3 stated there were no signs of life, and there was no discussion of the resident's code status. LPN #3 stated LPN #10 called ASM #2. ASM #2 arrived at the facility and they started CPR. I really don't know what happened after that because I went back to work on my side. On [DATE] at 7:20 a.m., ASM #2, (the director of clinical services (who at the time of this incident was in the position of assistant director of clinical services)) was interviewed. ASM #2 stated during the early morning hours of [DATE], she received a call from LPN #10. She did not remember the exact time, and stated LPN #10 left a voicemail for her. ASM #2 stated: At some point I woke up and checked the voicemail. I came in, went in the room. I observed (Resident #14) was not breathing, no pulse, and no blood pressure. I went down to the desk and started to write the note and saw the green spine on the chart. ASM #2 stated a green spine indicates that a resident has a physician's order for a full code. She stated when she checked the chart for the physician's order, she discovered that Resident #14 was a full code, and she went and started CPR on her (Resident #14). ASM #2 stated the EMS arrived, took over the CPR and transported the resident to the emergency room . She stated she called ASM #4, the attending physician, later in the morning and told him what had happened. On [DATE] at 7:35 a.m., ASM #4 was interviewed. He stated he did not remember being called by LPN #10 to inform him that Resident #14 had been discovered in her room without signs of life. He stated he remembered ASM #2 calling him later to inform him of what had happened. When asked what process was to be followed when a resident who has a full code order is discovered without signs of life, ASM #4 stated: We should immediately call a code and call 911, and we should immediately begin resuscitative efforts. The administrator and director of nursing at the time of this incident are no longer employed by the facility. On [DATE] at 8:35 a.m., ASM #1, the executive director, and ASM #2 were informed of these concerns. At this time, the survey team informed these staff members of the concern for harm. A review of the facility policy Advance Directives - Nursing revealed, in part, the following: The facility nursing staff will abide by resident advance-directives, if known, and if those directives are not in conflict with Federal and State regulations. Nursing staff must verify medical records to determine whether or not any advance directives have been issued by the resident .Nursing staff must be aware of other advance directives regarding residents' wishes before certain treatments are initiated (i.e. intravenous feeding). Follow these steps in an emergency situation: If a resident stops breathing or there is an absence of pulse or heat beat, staff will check to determine whether a DNR order has been entered. If there is no DNR order, cardiopulmonary resuscitation (CPR) must be administered immediately. Page 'Code Blue' to summon anyone in the facility who has been certified to administer CPR. At the same time, call emergency paramedic support. The attending physician must also be notified. A review of the facility policy Cardiopulmonary Resuscitation (CPR) revealed, in part, the following: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a DNR order. Cardiopulmonary resuscitation is performed only by individuals certified in CPR. All licensed nurses are to maintain certification for CPR. Procedure: In the event of [MEDICAL CONDITION], immediately call for assistance. Two staff members are to verify the current physician order for [REDACTED]. The physician orders CPR to be discontinued. Contact the physician and family. Document the details of occurrence in the medical record using the Code Blue Documentation Form. On [DATE] at 9:10 a.m., ASM #2, the director of clinical services, presented the survey team with a plan of action related to these concerns. The plan was dated [DATE] and documented: - PROBLEM: Code policy and Procedures. Verification of code status of unresponsive patient. Residents right to self-determination, standards of practice. Step 1 - Evaluation of Systems and Immediate Response. Cardiopulmonary Resuscitation was initiated by the Licensed Nurse and EMS was initiated. Employee suspended until investigation can be completed. Verification of the employee having current CPR certification status by DCS (director of clinical services)/Designee. Completion of grievance form by ED/Designee regarding resident rights followed through the grievance process. Verification by DCS/Designee that crash carts/equipment ready and available. How to Identify other Resident at Risk. Social Service/Designee to contact Residents/RP with full code status and verify continued desire for this status. Review by Social Services Director/Designee of current resident records to ensure that documentation is consistent to include most current MD (medical doctor)/Physician's order .and state DNR document. Review of Licensed Nurse files to verify current CPR certification present. ED (executive director)/Designee to review last (5) in-house deaths to ensure proper following of orders and honoring of resident rights with any concerns to be noted on a grievance form and addressed through the grievance process. What measures were put in place to prevent recurrence? Ongoing staff education by the DCS/Designee on green light/red light with focus on bringing the chart to the code and verifying that the code status is honored. Training by the DCS/Designee will also focus on upholding resident rights and following Drs. Orders. (sic) Code blue drills will be conducted by the DCS/Designee and ongoing once a week for three months then monthly. ED/SW (social worker)/Designee will continue weekly code status reviews and ensure that status is reviewed at least quarterly with the Resident/RP. Any potential violation of Resident Rights related to code status will be logged/processed through the grievance process. How to monitor to ensure the problem does not reoccur. ED/DCS (director of clinical services) and SW will complete a weekly review of the code drills, code audits and grievance logs to identify any trends or corrective action needed. An impromptu Quality Assurance Performance Improvement Committee Meeting (QAPI) has been held on [DATE] to review the POC (plan of correction) and corrective measures. QA. Results of weekly reviews will be reported to the monthly QAPI meeting for review and discussion to ensure substantial compliance by [DATE]. The survey team reviewed this plan of action, as well as the credible evidence documenting the implementation of this plan. The survey team identified no concerns related to this implementation. Additionally, the survey team reviewed the CPR licenses of all nursing staff as compared to the as-worked schedules provided by the facility. No concerns were identified related to the facility having CPR-licensed staff on duty at all times in the facility. This citation is cited as past noncompliance. CPR is an emergency procedure for a person whose heart has stopped or is no longer breathing. CPR can maintain circulation and breathing until emergency medical help arrives. This information is taken from the website https://medlineplus.gov/cpr.html

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to preserve a resident's right to execute an advance directive regarding steps to be followed in the event she became without heartbeat and not breathing in the facility. Resident #14 had signed an advance directive stating she wanted all resuscitative efforts to be undertaken for her. In accordance with this advance directive, the physician had written an order that the resident would be a full code. On [DATE], Resident #14 was discovered to be without pulse and without respirations. The facility staff failed to honor the advance directive and follow the physician's order by immediately beginning CPR and calling for emergency medical assistance, and Resident #14 subsequently expired. The findings include: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), an admission assessment with an assessment reference date of [DATE], Resident #14 was coded as being severely cognitively impaired for making daily decisions, having scored only three out of 15 on the BIMS (brief interview for mental status). A review of the admission nursing assessment dated [DATE] revealed that Resident #14 was alert and oriented to person only. A review of Resident #14's clinical record revealed a page with the title FIRST ALERT. This page contained the following: CODE ALERT: FULL. Further review of the clinical record revealed the document (Name of state) Advance Directive for Health Care. This document stated, in part: I (name Resident #14) willingly and voluntarily make known my wishes in the event that I am incapable of making an informed decision about my health care, as follows: .Section II: My Health Care Instructions .I provide the following instructions in the event my attending physician determines that my death is imminent (very close) and medical treatment will not help me recover .I want all treatments to prolong my life as long as possible within the limits of generally accepted health care standards. I understand that I will receive treatment to relieve pain and make me comfortable. This document listed the names of one individual to serve as primary agent, and another individual to serve as secondary agent. This document was signed by Resident #14 and dated [DATE]. Further review of the clinical record revealed a document with the title Advance Directives Discussion Document. The document stated, in part: Please indicate your wishes regarding the following: Cardiopulmonary Resuscitation (CPR): PROVIDE. Please indicate if you possess any of the following documents or have primary decision-maker. The document contained a check mark beside the categories of advance directive and health care agent. The document continued: I have received a copy of the facility's policies on Advance Directives and have been given a chance to ask questions regarding my rights to make decisions regarding my medical care. I understand that I have the right to refuse or accept medical and/or surgical treatment, and the right to formulate advance directives concerning my health care. Honoring resident choices requires providing appropriate documentation, and I understand that I am responsible for providing the facility with the necessary and/or legal documentation appropriate for Advance Directives. The document was signed by Resident #14 and by the primary agent designated in the Advance Directive for Health Care. A review of the physician's orders for Resident #14 revealed the following order, dated [DATE] and signed by the physician on [DATE]: Code - full. A review of Resident #14's comprehensive care plan dated [DATE] revealed no information related to her advance directive or code status. A review of the nurses' notes for Resident #14 revealed, in part, the following: - [DATE] - [DATE] 7p - 7a (7:00 p.m. on [DATE] through 7:00 a.m. on [DATE]) - Resident resting quietly. (Arrow pointing up) (increased) temp (body temperature). No c/o (complaint of) pain. No SOB (shortness of breath)/cough noted. Call bell in reach. Will cont (continue) to monitor. - @ (at) 130 (1:30 a.m.), CNA (certified nursing assistant) went into take resident's temp and found her with no pulse and not breathing. Blue around lips and nail beds. ADCS (assistant director of clinical services (*note at the time of this incident the current director of clinical services, administrative staff member #2, held the position of assistant director of clinical services) ) and Dr. (doctor) notified. Both of these notes were signed by LPN (licensed practical nurse) #10. - [DATE] 0245 (2:45 a.m.) Pt (patient) without respiration, no apical heart rate present. Pt (patient) expired, pt identified as full code @ this time. 2nd (second) nurse verified. CPR initiated. EMS (emergency medical services) called. MD (medical doctor (physician)) made aware and RP (responsible party). This note was signed by ASM (administrative staff member) #2, the director of clinical services. Further review of the clinical record revealed the following order, dated [DATE] and was signed by ASM #3, the nurse practitioner, on [DATE]: Send to ER (emergency room ) for eval (evaluation) and treat (treatment). A review of the EMS (Emergency Medical Service) record for Resident #14 dated [DATE] revealed, in part, the following: Dispatched to (facility) for a person in [MEDICAL CONDITION]. On scene, in (Resident #14's room number), found a 72 YOF (year old female) lying supine on the bed with staff performing CPR on the pt and was (sic) bagging her with bi-valve mask. Staff was asked if there were a DNR (do not resuscitate) and they advised that she is a full code. Pt was found in [MEDICAL CONDITION] while the nurse was doing rounds. Unknown down time. CPR was started and 911 called. General impression was poor. Pt was unresponsive. Pt was not mobile. Pt was unstable. Pt was logged rolled (sic) onto a backboard and the Lucas device (automatic CPR machine) was place and was initiated to take over CPR. Care was transferred to (name of EMS company). Medical hx (history) was obtained from staff. Pt allergies [REDACTED].Pt had no signs of life. Pt was transported to (name of local hospital) .On arrival to (name of local hospital), pt was still unresponsive and not breathing. A review of the records from the local hospital dated [DATE] revealed, in part, the following: Emergency History and Physical Exam: (Name of Resident #14) is a 72 y.o. (year old) female who presents by EMS. Apparently the patient was found on the floor unresponsive in (sic) cyanotic around at the nursing home .unknown how long she had been down .Differential [DIAGNOSES REDACTED].The patient was pronounced dead at 3:43 a.m. Death certificate completed. Clinical Impression: Dead on arrival. A review of the report sent to the state agency dated [DATE] revealed, in part, the following: (Name of Resident #14) was a [AGE] year old female admitted to this facility on [DATE] .Her advanced directive requested full code status. On [DATE] at 0130 (1:30 a.m.), (Resident #14) presented as unresponsive to the on shift CNA. The CNA reported this to LPN Charge Nurse (name of LPN #10), who noted the resident as having no pulse, no breathing and presenting with blue lips and nail beds. (LPN #10) phoned (ASM #2) and requested that she come to the facility and pronounce death. On arrival, (ASM #2) also noted (Resident #14) to be absent of vital signs; but identified (Resident #14) as a full code and initiated the facility CPR policy and transferred (Resident #14) via EMS to the local emergency department .After facility investigation, neglect has been substantiated. (LPN #10's) employment with this facility has been terminated and required reporting will occur to the Department of Health Professions. A review of the facility's investigation file about this incident revealed the following statement written by LPN #3 and dated [DATE]: On [DATE], (LPN #10) asked me to come and check patient with her. Listened to heart and lungs nothing heard (sic). (LPN #10) was nonchalant with the situation told (sic) me patient had been declining and had hx (history) of CA (cancer). This lead (sic) me to believe that the patient was comfort and expecting to go any time. Further review of the facility's investigation file revealed the following statement written by LPN #10 dated [DATE]: At 0130 (1:30 a.m.) I sent CNA to take temp of resident. Earlier she had a temp of 100.1. CNA called me to the resident's room. Found resident without resp (respirations) and very pale and turning cold. (Resident had been checked on an hour prior.) At this point I called another nurse to listen for heart rate/breath sounds. At this point I texted the ADCS (assistant director of clinical services) and left a message and she returned the called (sic). At this point, I was unaware the resident was a full code. When the ADCS arrived we began CPR and called the squad (EMS). On [DATE] at 1:45 p.m., LPN #5 was interviewed. When asked what she would do if a staff member reported to her that a resident under her care had been found without pulse and without respirations, LPN #5 stated: I would page a code blue. She stated the process is for two nurses to check the resident's chart and clarify the physician's order. If the resident is a full code, somebody starts CPR and somebody else makes the calls and does the paperwork. She stated the facility provides frequent training and code blue drills for the staff. On [DATE] at 2:40 p.m., LPN #4 was interviewed. When asked what she would do if a staff member reported to her that a resident under her care had been found without pulse and without respirations, LPN #4 stated: I would grab the chart to see whether or not they are a DNR. She stated if the resident was not a DNR, she would assess the resident and start CPR if there were no vital signs. She stated she would get other staff members to call the rescue squad, family, and physician. On [DATE] at 3:40 p.m., ASM #3, the nurse practitioner, was interviewed. When asked if a resident has an order to be a full code, and if that resident ceased heart rate and respirations, what should be done, ASM #3 stated: The resident should be coded. ASM #3 stated: The underlying [DIAGNOSES REDACTED]. She added that she is aware that the facility practices this scenario by way of code blue drills frequently. On [DATE] at 7:05 a.m., CNA #1 was interviewed. She stated that she was assigned to Resident #14 on the night of [DATE] through [DATE]. She stated the resident had a fever earlier in the shift, and that LPN #10 had asked her to re-check the resident's temperature. CNA #1 stated when she entered the resident's room, it looked like she was dead. She was gray. She stated she stepped out of the room and called for LPN #10 to come to the room. CNA #1 stated: (LPN #10) never looked at the chart. She immediately yelled for LPN #3 to come and help her. They both went in the room and checked (Resident #14). She stated she remembered the nurses talking to each other about who was on call for the facility to pronounce death, and that neither of them discussed the resident's code status. She stated one of the nurses called ASM #2, the director of clinical services and that it was a good while before ASM #2 arrived at the facility. CNA #1 stated ASM #2 came in and pronounced (Resident #14's death). She stated ASM #2 went to do paperwork at the desk, and discovered that Resident #14 was a full code. CNA #1 stated ASM #2 started CPR and other staff called emergency services. On [DATE] at 7:10 a.m., LPN #3 was interviewed. LPN #3 stated: I was working on my side and (LPN #10) yelled for me to go help her. We went in the room. (Resident #14) was gray and cold. (LPN #10) told me the resident [MEDICAL CONDITION], and had been declining. She told me the resident had basically given up. I thought she was on comfort care. We both assessed her. LPN #3 stated there were no signs of life, and there was no discussion of the resident's code status. LPN #3 stated LPN #10 called ASM #2. ASM #2 arrived at the facility and they started CPR. I really don't know what happened after that because I went back to work on my side. On [DATE] at 7:20 a.m., ASM #2, (the director of clinical services (who at the time of this incident was in the position of assistant director of clinical services)) was interviewed. ASM #2 stated during the early morning hours of [DATE], she received a call from LPN #10. She did not remember the exact time, and stated LPN #10 left a voicemail for her. ASM #2 stated: At some point I woke up and checked the voicemail. I came in, went in the room. I observed (Resident #14) was not breathing, no pulse, and no blood pressure. I went down to the desk and started to write the note and saw the green spine on the chart. ASM #2 stated a green spine indicates that a resident has a physician's order for a full code. She stated when she checked the chart for the physician's order, she discovered that Resident #14 was a full code, and she went and started CPR on her (Resident #14). ASM #2 stated the EMS arrived, took over the CPR and transported the resident to the emergency room . She stated she called ASM #4, the attending physician, later in the morning and told him what had happened. On [DATE] at 7:35 a.m., ASM #4 was interviewed. He stated he did not remember being called by LPN #10 to inform him that Resident #14 had been discovered in her room without signs of life. He stated he remembered ASM #2 calling him later to inform him of what had happened. When asked what process was to be followed when a resident who has a full code order is discovered without signs of life, ASM #4 stated: We should immediately call a code and call 911, and we should immediately begin resuscitative efforts. The administrator and director of nursing at the time of this incident are no longer employed by the facility. On [DATE] at 8:35 a.m., ASM #1, the executive director, and ASM #2 were informed of these concerns. At this time, the survey team informed these staff members of the concern for harm. A review of the facility policy Advance Directives - Nursing revealed, in part, the following: The facility nursing staff will abide by resident advance-directives, if known, and if those directives are not in conflict with Federal and State regulations. Nursing staff must verify medical records to determine whether or not any advance directives have been issued by the resident .Nursing staff must be aware of other advance directives regarding residents' wishes before certain treatments are initiated (i.e. intravenous feeding). Follow these steps in an emergency situation: If a resident stops breathing or there is an absence of pulse or heat beat, staff will check to determine whether a DNR order has been entered. If there is no DNR order, cardiopulmonary resuscitation (CPR) must be administered immediately. Page 'Code Blue' to summon anyone in the facility who has been certified to administer CPR. At the same time, call emergency paramedic support. The attending physician must also be notified. A review of the facility policy Cardiopulmonary Resuscitation (CPR) revealed, in part, the following: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a DNR order. Cardiopulmonary resuscitation is performed only by individuals certified in CPR. All licensed nurses are to maintain certification for CPR. Procedure: In the event of [MEDICAL CONDITION], immediately call for assistance. Two staff members are to verify the current physician order for [REDACTED]. The physician orders CPR to be discontinued. Contact the physician and family. Document the details of occurrence in the medical record using the Code Blue Documentation Form. On [DATE] at 9:10 a.m., ASM #2, the director of clinical services, presented the survey team with a plan of action related to these concerns. The plan was dated [DATE] and documented: - PROBLEM: Code policy and Procedures. Verification of code status of unresponsive patient. Residents right to self-determination, standards of practice. Step 1 - Evaluation of Systems and Immediate Response. Cardiopulmonary Resuscitation was initiated by the Licensed Nurse and EMS was initiated. Employee suspended until investigation can be completed. Verification of the employee having current CPR certification status by DCS (director of clinical services)/Designee. Completion of grievance form by ED/Designee regarding resident rights followed through the grievance process. Verification by DCS/Designee that crash carts/equipment ready and available. How to Identify other Resident at Risk. Social Service/Designee to contact Residents/RP with full code status and verify continued desire for this status. Review by Social Services Director/Designee of current resident records to ensure that documentation is consistent to include most current MD (medical doctor)/Physician's order .and state DNR document. Review of Licensed Nurse files to verify current CPR certification present. ED (executive director)/Designee to review last (5) in-house deaths to ensure proper following of orders and honoring of resident rights with any concerns to be noted on a grievance form and addressed through the grievance process. What measures were put in place to prevent recurrence? Ongoing staff education by the DCS/Designee on green light/red light with focus on bringing the chart to the code and verifying that the code status is honored. Training by the DCS/Designee will also focus on upholding resident rights and following Drs. Orders. (sic) Code blue drills will be conducted by the DCS/Designee and ongoing once a week for three months then monthly. ED/SW (social worker)/Designee will continue weekly code status reviews and ensure that status is reviewed at least quarterly with the Resident/RP. Any potential violation of Resident Rights related to code status will be logged/processed through the grievance process. How to monitor to ensure the problem does not reoccur. ED/DCS (director of clinical services) and SW will complete a weekly review of the code drills, code audits and grievance logs to identify any trends or corrective action needed. An impromptu Quality Assurance Performance Improvement Committee Meeting (QAPI) has been held on [DATE] to review the POC (plan of correction) and corrective measures. QA. Results of weekly reviews will be reported to the monthly QAPI meeting for review and discussion to ensure substantial compliance by [DATE]. The survey team reviewed this plan of action, as well as the credible evidence documenting the implementation of this plan. The survey team identified no concerns related to this implementation. Additionally, the survey team reviewed the CPR licenses of all nursing staff as compared to the as-worked schedules provided by the facility. No concerns were identified related to the facility having CPR-licensed staff on duty at all times in the facility. This citation is cited as past noncompliance. CPR is an emergency procedure for a person whose heart has stopped or is no longer breathing. CPR can maintain circulation and breathing until emergency medical help arrives. This information is taken from the website https://medlineplus.gov/cpr.html

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to assess and implement interventions for the prevention and treatment of [REDACTED].#7. There were no assessments for ten days following the development of a newly acquired stage II pressure sore on Resident #7's left buttock. The sore was then found necrotic, odorous, with drainage and increased size. After identification of the deteriorated wound, physician treatment to the necrotic pressure sore was delayed for three days due to lack of notification to the physician. Resident #7, assessed to require staff assistance for bed mobility, had no effective interventions implemented upon admission to protect his feet/heels. Eight days after admission the resident developed pressure sores on both of his heels. The findings include: The National Pressure Ulcer Advisory Panel (NPUAP) provides the following definition and staging system for use as a reference in describing the characteristics of pressure ulcers. The NPUAP defines a pressure ulcer as a "...localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear." (1) NPUAP defines pressure ulcer stages as follows. Stage I: "Non-blanchable redness of intact skin...Intact skin with non-blanchable [DIAGNOSES REDACTED] of a localized area usually over a bony prominence... Stage II: Partial thickness skin loss or blister...Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister... Stage III: Full thickness skin loss (fat visible)...Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunneling. Stage IV: Full thickness tissue loss (muscle/bone visible)...Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown... Full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed...Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV..." Suspected Deep Tissue Injury-depth unknown...Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear...The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue... (1) Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission minimum data set ((MDS) dated [DATE] assessed Resident #7 as having severely impaired cognitive skills for decision making. This MDS assessed Resident #7 as totally dependent upon two people for bed mobility, limited range of motion of his lower extremities on one side and as incontinent of bowel/bladder. 1a.) Resident #7's admission nursing assessment dated [DATE] documented the resident was admitted with no pressure sores on his buttocks. This assessment documented the resident only had a scabbed sore on his right outer ankle and was assessed as "at risk" for pressure sore development. The admission nursing note dated 7/19/12 stated, "...Buttocks slight pink..." Nursing notes dated 7/30/12 documented Resident #7 developed a stage II pressure sore on his left buttock measuring 3 cm (centimeters) by 2 cm (length by width). A physician's orders [REDACTED]. Treatment records for July 2012 and August 2012 documented the dressing was changed to Resident #7's left buttock pressure sore on 7/30/12, 7/31/12, 8/2/12, 8/4/12, 8/5/12, 8/8/12, 8/9/12, 8/10/12 and 8/11/12. [MEDICATION NAME] is a brand name foam dressing used for pressure sore treatment "that absorbs exudate and maintains a moist wound environment." (4) The clinical record, including nursing notes and pressure ulcer assessment sheets, included no further assessments or mention of Resident #7's left buttock pressure sore until 8/10/12 when the wound was assessed to be necrotic, with foul odor, drainage and increased in size. The dressing to the left buttock pressure sore was changed six times from the initial assessment on 7/30/12 until 8/10/12. There were no documented assessments of the pressure sore associated with these dressing changes and no changes in treatment to the wound. A nursing note dated 8/10/12 at 2:35 p.m. documented, "Assessed wounds this am. Sacral wound measures 4 x 6 (and) is necrotic. Covered (with) [MEDICATION NAME] (after) cleaning (with) wound cleanser. note left for MD (physician) to assess on rounds, air mattress in place..." There was no immediate notification to the resident's physician about the deteriorated condition of the pressure sore. The resident's physician was not made aware of the deteriorated, necrotic condition of the pressure sore until three days later on 8/13/12. The physician assessed the resident's wound on 8/13/12 and at that time discontinued the [MEDICATION NAME] dressing treatment and prescribed Santyl ointment to be applied with a gauze dressing twice per day. The Drug Information Handbook of Nursing 8th Edition on page 301 describes Santyl as an ointment used to promote debridement of necrotic tissue in skin ulcers. (3) Resident #7's pressure ulcer record documented the following assessments of the left buttock pressure sore. 7/30/12 - stage II, 3 cm x 2 cm (length by width), no odor, no drainage 8/10/12 - unstageable, 4 cm x 6 cm, foul odor, scant drainage, tissue type "eschar" 8/15/12 - unstageable, 7 cm x 2.3 cm, foul odor, yellow/green drainage, tissue type "moist eschar The physician's progress note dated 8/13/12 stated, "large sacral decub...unable to stage...start Santyl (check) weekly..." On 8/21/12 at 4:15 p.m. accompanied by the licensed practical nurse (LPN #5) caring for Resident #7, the left buttock pressure sore was observed. The sore was oval in shape and approximately 3 inches in length by 1 inch width. The wound was completely covered with black, leathery eschar. The eschar was slightly separated along the wound's edge on one end. There was no noticeable wound odor. The skin around the wound was purplish in color. Resident #7's admission care plan dated 7/19/12 documented interventions to prevent skin breakdown as skin care protocol, turn every 2 hours and as needed, and immediately report any redness or skin breakdown to charge nurse. The resident's comprehensive care plan dated 7/30/12 listed the resident developed a pressure sore on his left buttock. The goal listed stated, "pressure ulcer will decrease in size or heal next 90 days." Listed interventions included, "...Document weekly stage, length x width x depth, odor, progress, lack of progress, current treatment...Review @ weekly skin meeting, Consider special supplements...Obtain labs as ordered...Treatment change..." The unstageable, necrotic status of the pressure sore (assessed on 8/10/12) was not added to the care plan until 8/20/12 and stated, "UTS (unable to stage)...eschar, drainage, odor." Added interventions were "Rx (prescription) per order, MD to assess s/s (signs/symptoms) worsening..." On 8/22/12 at 10:45 a.m. the licensed practical nurse unit manager (LPN #2) caring for Resident #7 was interviewed about the deterioration of the left buttock pressure sore, the lack of assessment/monitoring and delayed notification to the physician. LPN #2 stated she could not find any documented assessments of the left buttock pressure sore from 7/30/12 until 8/10/12. LPN #2 stated assessments would have been documented in the nursing notes or on the pressure sore tracking sheet. LPN #2 stated the nurses performing the dressing changes "obviously looked at it (pressure sore)" but they did not document an assessment. LPN #2 stated she did not know when the wound started to deteriorate. LPN #2 stated, "All I can answer, I looked at it on 8/10 (2012)." LPN #2 stated she did not call the doctor when she found the odorous, necrotic status of the sore on 8/10/12 but left a note on a clipboard for the physician. LPN #2 stated when she assessed the sore on 8/10/12, "It (pressure sore) was necrotic. There was odor and the peri-wound (skin surrounding the wound) was pink." LPN #2 stated, "I knew the doctor was coming the next day." LPN #2 stated she was off work the next two days and when she returned to work on 8/13/12 she realized the physician had not assessed the pressure sore. On 8/23/12 at 11:00 a.m. LPN #2 and LPN #5 were interviewed again about any monitoring/assessments of Resident #7's left buttock pressure sore from 7/30/12 until 8/10/12. LPN #2 and LPN #5 stated they did not find any assessments of the wound during this time period. The facility's policy WC-150 titled Identification of "At Risk" and Suggested Interventions stated on page 5 concerning residents with skin breakdown, "Monitor for clinical changes/including further deterioration...Assess for signs/symptoms of infection...Care plan to identify interventions." The National Pressure Ulcer Advisory Panel Quick Reference Guide states on page 9 concerning assessment of pressure sores, "With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications...Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]." (1) These findings were reviewed with the administrator and regional nurse consultant on 8/22/12 at 3:00 p.m. and 8/23/12 at 11:00 a.m. 1b.) Resident #7's admission nursing assessment dated [DATE] documented the resident was admitted to the facility with a scabbed sore on his right outer ankle but no pressure sores or discoloration on his heels. This admission assessment documented the resident was "at risk" for pressure sore development and required assistance for bed mobility. A nursing note dated 7/27/12 documented, "Purple area on heels noted by CNA's, wrote order for skin prep to heels bil (bilateral) q (every) shift 'till purple areas resolved and to have heeleeze (cushion) while in bed...R (right) heel was 2 cm x 1 cm L (left) heel was 5 cm x 3 1/2 cm." Pressure ulcer tracking sheets documented the following assessment of Resident #7's heel sores. Left heel: 7/27/12 - unstageable, 5 cm x 3.5 cm 7/31/12 - unstageable, 5 cm x 5 cm, "purple, suspect underlying tissue damage..." 8/9/12 - unstageable, 4.2 cm x 4 cm, "purple blister..." 8/15/12 - unstageable, 5.5 cm x 6.5 cm, "dark purple/red tissue some fluid." Right heel: 7/27/12 - unstageable, 2 cm x 1 cm 7/31/12 - unstageable, 6 cm x 5 cm, "(increased) size, purple suspect underlying tissue damage..." 8/9/12 - stage II, 3 cm x 4 cm, "clear fluid filled blister" 8/15/12 - stage II, 3.5 cm x 4 cm, "fluid resolved, light brown tissue" A physician's orders [REDACTED]. Treatment was changed on 7/31/12 to include protective dressings to both heels in addition to the skin prep. A specialty air mattress was prescribed on 8/10/12. The resident had no care plan interventions developed or implemented prior to the development of the unstageable/stage II pressure sores on the resident's heels. The physician's admission note dated 7/22/12 stated the resident had a "fixed brace btn (between) legs" but there were no admitting physician's orders [REDACTED]. Resident #7's admission care plan included no interventions for protection of the resident's heels. The admission care plan dated 7/19/12 listed pressure sores/skin care as a problem for Resident #7 with interventions documented as follow skin care protocol, turn every two hours and as needed and immediately report any redness or skin breakdown to the charge nurse. There were no interventions listed concerning positioning or elevation of the resident's legs, feet or heels. The care plan made no mention of a brace in place between the resident's legs or of positioning interventions related to use of the brace or the resident's post surgical status for a [MEDICAL CONDITION]. On 8/23/12 at 8:40 a.m. accompanied by the licensed practical nurse caring for Resident #7 (LPN #5), Resident #7's heels were observed. The entire left heel was covered with a dry, black, circular wound. The black area was approximately the size of a half dollar coin. An approximately 1/2 inch area surrounding the perimeter of the wound was red. There was no drainage observed. The resident's entire right heel was pink, dry with some scaly skin but with no open wound or black tissue. On 8/22/12 at 10:45 a.m. the licensed practical nurse unit manager (LPN #2) was interviewed about any interventions to prevent Resident #7's heel pressure sores. LPN #2 stated, "We repositioned him as best we could with his limitations." When asked about any heel elevation prior to the development of the pressure sores, LPN #2 stated the resident had been treated surgically for a [MEDICAL CONDITION] and they were concerned about using the heeleeze cushion. When asked about any assessment about the resident's positioning/heel protection or the heeleeze cushion, LPN #2 stated, "The heeleeze (cushion) wasn't talked about when he came in." LPN #2 stated the heeleeze cushion was not implemented until 7/27/12 when the resident was assessed with [REDACTED]. LPN #2 stated the main intervention upon admission was turning and positioning. On 8/23/12 at 8:35 a.m. a certified nurses' aide (CNA #2) that cared for Resident #7 since admission was interviewed about any interventions to protect Resident #7's heels. CNA #2 stated the resident had an "abductor" pillow between his legs when he was first admitted to help with positioning due to his [MEDICAL CONDITION]. CNA #2 stated they used pillows under the resident's lower legs "trying to keep the heels off the bed." When asked how the resident's heels became red, CNA #2 stated the pillows did not always keep the heels off the bed surface. CNA #2 stated, "The pillows did not always work. The heels would be up at first but the pillows would 'smoosh' down after awhile. We'd go back to check him and the pillow was squished down." CNA #2 stated, "We tried as best we could." The facility's policy WC-150 titled Identification of "At Risk" and Suggested Interventions stated, "When a skin assessment identifies an individual as 'at risk,' there are certain interventions, which should be done to reduce the risk:.." This policy included as interventions for pressure reduction, "Use mattress overlays, pillow positioning devices, seat/chair pads, specialized beds, protective equipment (e.g.: heel protectors), etc." This policy listed on page 2 as suggested skin protective interventions for those residents at risk, "Provide padding for casts, braces, splints, elbows and heels..." The National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Quick Reference Guide states on pages 14 concerning skin care for pressure ulcer prevention, "Ensure that the heels are free of the surface of the bed...Heel-protection devices should elevate the heel completely (offload them) ..." (2) These findings were reviewed with the administrator and regional nurse consultant on 8/22/12 at 3:00 p.m. and 8/23/12 at 11:00 a.m. (1) European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. treatment of [REDACTED]. Washington DC: National Pressure Ulcer Advisory Panel; 2009. (2) European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of [REDACTED]. Washington DC: National Pressure Ulcer Advisory Panel; 2009. (3) Turkoski, Beatrice B., Brenda R. Lance and Mark F. Bonfiglio. Drug Information Handbook for Nursing 2007. Hudson, Ohio: Lexi-Comp, 2006. (4) [MEDICATION NAME]. Molnlycke Health Care US. 8/24/12. <http://www.molnlycke.com/us>.

Based on observation, staff interview and clinical record review, the facility staff failed to change a pressure sore dressing in a manner to prevent infection for one of 10 residents in the survey sample. During a dressing change, scissors were not cleansed or disinfected prior to cutting a dressing used as packing in Resident #105's pressure sore. The findings include: Resident #105 was admitted to the facility on [DATE] with a re-admission on 5/24/11. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #105 as cognitively intact. The National Pressure Ulcer Advisory Panel (NPUAP) provides the following definition and staging system for use as a reference in describing the characteristics of pressure ulcers. The NPUAP defines a pressure ulcer as a "...localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear." NPUAP defines a stage IV pressure ulcer as, "Full thickness tissue loss (muscle/bone visible)...Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling." (1) Resident #105's clinical record documented the resident was currently being treated for [REDACTED]. A current physician's orders [REDACTED]. Puracol is a brand name collagen dressing used for the treatment of [REDACTED]. On 10/10/12 at 9:30 a.m. with the resident's permission, a dressing change to the resident's pressure sore was observed performed by the licensed practical nurse unit manager (LPN #2). After providing privacy and preparing a clean field for supplies, LPN #2 washed her hands and put on gloves. LPN #2 opened a pack of gauze pads, opened a pack of cotton tipped applicators and then opened a Puracol dressing packet. LPN #2 reached into her uniform pocket, obtained a pair of scissors then cut the Puracol dressing into three strips approximately 1/4 inch wide. LPN #2 did not cleanse or disinfect the scissors in any manner prior to cutting the Puracol dressing. LPN #2 then put the scissors back into her uniform pocket, positioned the resident, removed/discarded the old dressing, washed her hands and put on clean gloves. After cleansing the wound with wound cleanser spray, LPN #2 packed two strips of the cut Puracol dressing into the depth of the wound using a cotton tipped applicator. The wound was then covered with a gauze dressing and the gauze was secured with paper tape. LPN #2 discarded used supplies and washed her hands. Resident #105's pressure sore opening was circular and slightly smaller than a dime. The depth of the wound was not measured but accommodated two strips of the Puracol packing. There was no visible sign of infection in the wound and the resident expressed no pain/discomfort during the dressing change. On 10/10/12 at 10:00 a.m. LPN #2 was interviewed about using scissors from her pocket to cut the dressing that was packed into Resident #105's pressure sore. LPN #2 stated she normally cleaned her scissors with alcohol prior to using them. LPN #2 stated, "I clean them (scissors) every morning before I start work." LPN #2 stated the scissors were in her uniform pocket prior to cutting the Puracol and stated, "I don't use them (scissors) as frequently as some of the others (nurses)." The Lippincott Manual of Nursing Practice Eighth Edition states on page 1035 concerning care of equipment to prevent the transmission of infection, "Reusable equipment must be cleaned and reprocessed appropriately before use for another patient." Page 129 of this reference states concerning completion of wound care, "Discard the disposable items...clean equipment that is to be reused...To prevent transmission of pathogenic organisms. (3) The Nurses' Guide to Clinical Procedures 5th Edition states on pages 14 and 15 concerning principle of medical asepsis, "Spray or wipe sphygmomanometers, thermometers, ECG leads, or similar daily-use items with [MEDICATION NAME] substance between use with different clients." This reference states on page 14 that disinfecting daily use equipment between patients, "Decreases exposure to potentially infectious medium, because these items provide a good medium for organism growth." (4) These findings were reviewed with the administrator, director of nursing and regional director of clinical services on 10/10/12 at 11:00 a.m. (1) European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. treatment of [REDACTED]. Washington DC: National Pressure Ulcer Advisory Panel; 2009. (2) Puracol Plus. Advance Wound & Skin Care. 1998 - 2012. Medline Industries, Inc. 10/11/12. www.medline.com <http://www.medline.com> (3) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Ambler, PA: Lippincott, Williams & Wilkins, 2006. (4) Smith-Temple, Jean and Joyce Young Johnson. Nurses' Guide to Clinical Procedures. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.