Every finding on record at Worcester Rehabilitation & Health Care Center

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had an unwitnessed fall and an episode of emesis (vomiting) during the 11:00 P.M. to 07:00 A.M. shift, and then experienced a decline in condition, the Facility failed to ensure nursing notified the Provider in a timely manner, as required.Findings include: Review of the Facility's policy titled, Acute Condition: Significant Change, dated April 2015 indicated: - The nurse will notify the residents' attending physician or physician on call when there has been a significant change in the resident's condition. Resident #1 was admitted to the Facility in July 2024, diagnoses included diabetes, difficulty walking, sleep apnea and schizoaffective disorder. Review of the Facility's Investigation Report, dated 9/22/25, indicated that Resident #1 was found by Nursing staff on the floor of his/her room lying in emesis at approximately 2:00 A.M., was assessed by Nurse #1 and found to be at his/her baseline with no complaints of pain and was placed back into bed. The Report further indicated that Resident #1 had a decline in his/her condition in the morning when Nurse #1 assessed him/her and he/she was non-rousable but breathing. During a telephone interview on 10/21/25 at 1:30 P.M., Certified Nurse Aide (CNA) # 2 said on 9/22/25, around 6:00 A.M., Resident #1 had told her he/she was not feeling well, wasn't his/her usual self, was weak, and that she reported what Resident #1 said to the Nurse.During a telephone interview on 10/21/25 at 11:38 A.M., Nurse #1 said that on 9/22/25 around 2:00 A.M., CNA staff called her into Resident #1's room and he/she was on the floor by the bathroom lying on his/her side in emesis. Nurse #1 said she assessed Resident #1, found him/her at baseline, with no complaints of pain and he/she denied hitting his/her head. Nurse #1 said since the fall was unwitnessed, she started the Neurological Documentation Record per facility protocol. Nurse #1 said at 8:00 A.M., she re-assessed Resident #1, he/she was unrousable and breathing. Nurse #1 said she continued to monitor Resident #1 and said she notified the Nursing Supervisor around 9:00 A.M., who at that time did an assessment of Resident #1 and notified the Provider, who provided orders to send him/her to the Hospital Emergency Department (ED). Nurse #1 said she did not notify Resident #1's Provider or the On-Call Provider of his/her condition change in the morning or of the previous night's fall with emesis and she should have. Review of the Neurological Documentation Flow Sheet dated 9/22/25, indicated Resident #1 became lethargic and unrousable at approximately 8:00 A.M.Review of Resident #1's medical record indicated there was no documentation to support nursing notified the Provider timely on 9/22/25 of his/her fall and episode of vomiting [that had occurred around 2:00 A.M. during the overnight shift]. There was no documentation to support nursing notified the Provider after CNA #2 reported Resident #1 complaints of not feeling well and not feeling like him/herself to Nurse #1 around 6:00 A.M., or of the decline in his/her condition noted by Nurse #1 around 8:00 A.M., when the Provider was not notified until around 9:00 A.M., by the Nursing Supervisor. During a telephone interview on 10/21/25 at 11:13 A.M., the Nurse Practitioner (NP) said she was notified by nursing staff around 9:00 A.M., on 9/22/25 that Resident #1 had a fall during the overnight night shift, that he/she slipped on his/her own vomit and had a change in condition. The NP said she gave orders to send him/her to the Hospital Emergency Department. The NP said there is an On -Call Provider on overnight until 08:00 A.M., and that the nursing staff should have called the On- Call Provider. During an interview on 10/21/25 at 10:34 A.M., the Nursing Supervisor said she was notified by Nurse #1 at approximately 9:00 A.M. on 9/22/25 that Resident #1 had an episode of emesis with an unwitnessed fall during the night and had a decline in condition in the morning and said she (Nursing Supervisor) called the Provider and received an order to send him/her to the Hospital ED. During a telephone interview on 10/21/25 at 2:00 P.M., the Director of Nursing (DON) said there was no documentation to support that Nurse #1 notified the On-Call Provider during the overnight shift to report that Resident #1 had an unwitnessed fall, emesis and a decline in condition in a timely manner. The DON said that it is the facility's expectation that nursing staff assess for acute changes in the resident's condition, notify the resident's Provider, and the DON and in this case, it was not done. On 10/21/25, the Facility presented the Surveyor with a Plan of Correction with an effective date of 10/01/25, that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A. Resident #1 no longer resides at the facility. B. On 9/22/25, a Facility wide audit was initiated by the Nursing Administration on residents with acute condition changes to ensure Facility policy was followed. C. Starting on 9/22/25, audits were conducted daily by the DON/designee with a 30 day lookback period on documentation to ensure that the provider had been notified of any residents with changes in condition, and will be reviewed at the daily morning report until substantial compliance is met and the results of the audits will be reviewed at the next monthly QAPI meeting. D. On 9/22/25, education of Nursing and Certified Nurse Aide (CNA) staff was initiated by the Director of Nurses on the Change in Condition Policy. E. On 9/27/25, a Quality Assurance Performance Improvement (QAPI) meeting was conducted, concern areas discussed included: immediate response and ongoing monitoring plan to sustain compliance with Facility Policy on Acute Condition Changes-Clinical Protocol, and results of the Audits. F. On 10/01/25, the Facility completed the Education of all nursing staff on the facility protocol and process (per policy) when a resident has a change in condition. G. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on observations, interviews, and record review, the facility failed to provide appropriate access to the call light for one Resident (#88) out of a total sample size of 27 residents. Specifically, for Resident #88, the facility staff failed to place the Resident's call light within his/her reach, putting Resident #88 at risk of falls, and being unable to request staff assistance when needed. Findings include: Review of the facility policy titled Resident's Rights, undated, indicated Residents have the right: -To have [their] personal preferences reasonably accommodated. -To have all reasonable requests responded to promptly. Review of the facility policy titled, Call Lights; Use Of, dated April 2015, indicated: -All facility resident/patients will have a call light or alternative communication device within his/her reach when unattended. -Answer all call lights, promptly whether or not you are assigned to the resident/patient. -Answer all call lights, in a prompt, calm, courteous manner. -When providing care to residents/patients be sure to position the call light conveniently, telling/showing the resident/patient where the call light is located. -Orient all new residents/patients to the call light at the bedside as well as the call light in the bathroom, and shower/tub rooms. Resident #88 was admitted to the facility in April 2025, with diagnoses including abnormalities of gait and mobility, weakness, and Hypertension (HTN). Review of the Minimum Data Set (MDS) Assessment, dated 4/15/25, indicated Resident #88: -was cognitively intact as evidenced by a Brief Interview f or Mental Status (BIMS) score of 15 out of a possible score of 15. -was understood by others and understand others. -has adequate hearing, adequate vision, and clear speech. Review of Resident #88's Comprehensive Person-Centered Care Plan, initiated 4/11/25 and revised 5/1/25, indicated the Resident was at risk for falls with an intervention to have the call light within reach. On 5/14/25 at 8:27 A.M., the surveyor observed Resident #88 lying in bed in his/her bedroom. The surveyor observed the call light hanging on the wall on the left side of the Resident's bed and out of reach of the Resident. the surveyor further observed Resident #88 was alone in his/her bedroom with no evidence of a roommate. During an interview on 5/14/25 at 12:32 P.M., Resident #88 said that he/she needed a call light so he/she can call for staff help if needed. The surveyor observed the Resident was alone in his/her room, with the call light hanging on the wall, out of reach of the Resident who was lying in bed. Resident #88 said he/she uses the call light to get assistance from staff when needed. Resident #88 said he/she was unable to locate the call light at this time. The surveyor and the Resident observed the call light hanging on the wall to the left of the Resident. Resident #88 said that he/she was unable to reach the call light on the wall while lying in bed, if he/she needed to call staff for assistance. On 5/14/25 from 12:30 P.M. through 12:50 P.M., the surveyor observed a staff member enter Resident #88's room and exit the room with the Resident's lunch tray in the staff member hands. The surveyor returned to the Resident's room and observed that the call light was hanging on the wall behind the head of the Resident's bed, away from the Resident, and not within the Resident's reach. On 5/14/25 at 1:15 P.M., the surveyor and Certified Nurses Aide (CNA) #1 entered Resident #88's room and reviewed the placement of Resident #88's call light in his/her bedroom which remained hanging on the wall behind the head of the Resident's bed. CNA #1 said that the call light should have been within Resident #88's reach to ensure that the Resident can use the call light to call for staff assistance. CNA #1 further said that ensuring that the call light was within the Resident 's reach was important so Resident #88 could call for assistance if needed to ensure safety. CNA #1 also said that Resident #88 was able to utilize a call light to call for staff assistance, if the call light was within the Resident's reach. During an interview on 5/14/25 at 1:43 P.M., the Director of Nursing (DON) said that the expectation for CNA's was that call lights were always placed within the Resident's reach after care and each time staff enter or leave the room to provide assistance for the residents. The DON further said that the nursing staff should ensure that all residents had access to their call lights. The DON said call lights should be within reach of the residents to ensure the residents safety and ability to access staff in order to have their needs met.

Based on record review, and interviews, the facility failed to ensure that one Resident (#103) out of a total sample of 27 residents, with limited range of motion (ROM) received appropriate care and services to maintain and/or improve their mobility function. Specifically, the facility staff failed to implement a functional mobility program to have staff walk with Resident #103 as recommended by PT (Physical Therapy) upon discharge from skilled services, which resulted in an avoidable reduction in ROM and mobility for the Resident. Findings include: Resident #103 was admitted to the facility in January 2025 with diagnoses including Type II Diabetes with diabetic neuropathy, Myasthenia Gravis without acute exacerbation, and difficulty walking. Review of the Minimum Data Set (MDS) assessment, dated 4/10/25, indicated Resident #103: -was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of a possible 15. -had lower extremity impairments on both sides, utilized a wheelchair, and walking had not been attempted due to medical condition or safety concerns during the lookback period. -received Physical and Occupational Therapies during the assessment period. On 5/13/25 at 11:26 A.M., the surveyor observed Resident #103 in bed and dressed for the day. During an interview at the time, Resident #103 said that he/she was having some swelling to his/her legs and that staff were supposed to walk with him/her daily. Resident #103 further said that he/she had been discharged from rehabilitation services about two weeks prior with the plan for staff to walk with him/her daily. On 5/14/25 at 10:30 A.M., the surveyor observed Resident #103 reclining in bed with the head of the bed elevated. During an interview at the time, Resident #103 said that he/she witnessed a conversation while he/she was on services with Physical Therapy, between a Physical Therapist (PT) and a Certified Nurses Aide (CNA) where the PT staff educated the CNA about walking with the Resident daily. Resident #103 said that he/she did not walk to the bathroom at this time, he/she utilized a brief instead of the toilet, and that staff do not walk with him/her to the bathroom. Resident #103 said that no staff have walked with him/her since he/she was discharged from rehabilitation services. Review of Resident #103's Order Summary Report Active Orders as of 4/1/25, indicated the following Physician's orders: -PT Physical Therapy 3x/wk for 4 weeks for LE (lower extremity) therex (therapeutic exercise), theract (therapeutic activity), gait, NMR (neuromuscular re-education), Pt/staff education and safety, initiated 2/20/25. Review of Resident #103's Physical Therapy Treatment Encounter Notes indicated the following: -4/24/25: Gait training on unit with Contact Guard Assist/Stand By Assist, 300 feet. Inservice on ambulation on unit with 1st shift CNA's with rollator. -4/28/25: Completed functional mobility training with Contact Guard Assist, sit to stand and transfers with rollator use. Contact Guard Assist for gait training on the unit. Staff in-service completed. [Resident] is communicated on Discharge, in agreement. Review of Resident #103's Physical Therapy Discharge summary, dated [DATE], indicated the following: -Dates of service: 2/17/25 - 4/28/25 -[Resident] was seen for skilled PT to address strength, balance, and mobility deficits. -[Resident] requires Contact Guard Assist/Stand By Assist for safe sit to stand, transfers, and gait training with rollator use. -Staff in-service completed on ambulation. -[Resident] and Caregiver training: safe transfers and gait. -Prognosis to Maintain Current Level of Function = good with staff follow through. -Discharge Recommendations: Out of Bed and ambulation. Review of the Inservice Training document, dated 4/24/25, indicated: -Rehabilitation Services presented education for Resident #103's walking on the unit. -[Resident] to walk on unit with rollator with gait belt 300 feet or as tolerated holding onto belt or standby assist for safety with verbal cues for upright posture. -4 CNA's and one unidentified staff, including CNA #2, signed and dated the education form on 4/24/25. Review of Resident #103's CNA Care Card dated 4/1/25, indicated Not Applicable relative to the Resident's transfer needs or walking any distance. Review of Resident #103's CNA Documentation Survey Report for April 2025 and May 2025 failed to indicate that the Resident was transferred to the toilet, walked on any uneven surfaces, or walked a specific distance from 4/28/25 through 5/14/25. Review of Resident #103's Nursing Progress Notes failed to indicate any documentation of the Resident being offered to walk with staff or that a plan of care was updated for staff to walk with the Resident. During an interview on 5/14/25 at 10:57 A.M., CNA #2 said that she knew Resident #103 well and that the Resident was not safe to walk with her at this time. CNA #2 said that the Resident is not able to walk to the bathroom now. CNA #2 said that typically therapy staff make recommendations so that a Resident can walk with staff and if CNA #2 had questions, she would feel comfortable speaking with the Rehabilitation Staff for clarification. CNA #2 said that if staff walk with a resident, such as if a resident walked to the toilet, it would be documented in the resident's record. CNA #2 said that she did not recall participating in any in-service or education relative to Resident #103 walking recently, but she had in the past. During an interview on 5/14/25 at 2:13 P.M., Rehabilitation Staff Member #1 said that when a resident is discharged from Rehabilitation Services with a walking plan, it would be considered a functional mobility plan. Rehabilitation Staff Member #1 further said rehab staff would do caregiver education to staff about the resident's level of functioning and maximum ability to perform tasks. The surveyor and Rehabilitation Staff Member #1 reviewed the In-Service Form dated 4/24/25, and Rehabilitation Staff Member #1 said the form was evidence of education provided to staff for Resident #103's functional mobility program. During an interview on 5/14/25 at 3:13 P.M., Rehabilitation Staff Member #2 said that she was the Physical Therapist who worked with Resident #103 and completed his/her discharge from rehabilitation services. Rehabilitation Staff #2 said that at the time of discharge on [DATE], Resident #103 was able to transfer and was walking at a Contact Guard level. Rehabilitation Staff #2 said that an in-service and education was provided to nursing staff. Rehabilitation Staff #2 said the Resident needed encouragement, was able to make his/her needs known, expressed understanding of the rehabilitation plan, and he/she had been able to ambulate with a rollator and walk between 150 - 300 feet at time of discharge. The surveyor and Rehabilitation Staff #2 reviewed the In-Service documentation and Rehabilitation Staff #2 said that a Physical Therapy Assistant (PTA) had provided the education to nursing staff on 4/24/25, and the form was how that education was documented. During an interview on 5/15/25 at 1:29 P.M., the Director of Nursing (DON) said that a resident's Care Card is how a resident's level of functioning and care plan is communicated to the nursing staff and would indicate if a resident walked with assistance by staff. The DON further said that when staff education was provided on 4/24/25, Resident #103's Care Card should have been updated so that the Resident could have walked with staff assistance as recommended by Physical Therapy, but the Resident had not been walked as recommended.

Based on interview, and record review, the facility failed to ensure that assistive devices to maintain vision were acquired for one Resident (#118) out of a total sample of 27 residents. Specifically, for Resident #118, the facility failed to ensure that a prescription for necessary glasses was filled, as recommended by the Optometrist (Eye Doctor). Findings include: Review of the facility policy titled Consultant Services, dated April 2015, indicated: -[The facility] will identify and facilitate consultant services to meet the resident's needs, to ensure optimum care for each resident/patient through consultant services. -The charge nurse will notify the attending physician of findings and he/she can then order the specific treatments as outlined by the consultant. -A consultant's report or some form of documentation pertaining to the results will be retained in the clinical record. Resident #118 was admitted to the facility in January 2024, with diagnoses including Paranoid Schizophrenia, Type 2 Diabetes without complications, and Essential (primary) Hypertension. Review of the Resident's clinical record included evidence of the appointment of a Legal Guardian, dated 6/21/23. Further review of the Resident's clinical record included a consent for an Eye Care Consultation, signed by the Resident's Guardian on 3/21/24. Review of the Eye Care Consultation report dated 10/17/24, indicated: -Pt (patient) reports blurry vision in the distance. -Personal Ocular History .myopia (near sightedness); Diabetes Type 2, without complications, retinopathy, hypertensive, history of wearing soft CLs (contact lenses). -Visual acuity uncorrected right 20/40, left 20/25. -No Glasses. -Assessment: >Diabetes Type 2, without complications, both eyes, >retinopathy, hypertensive, mild, both eyes, >Myopia, both eyes. -Recommendations: New Glasses Recommended, to be delivered upon approval. -Plan: Monitor blood sugars, Monitor Blood Pressure, New distance glasses. -Action Required by Nursing Home Staff: Glasses required, encourage part-time use for distance, New order for glasses. -The Consultation Report included a prescription for eyeglasses, dated 10/17/24 that expires on 10/17/26. Review of the Resident's Progress Notes included a Social Service Note dated 10/23/24, which indicated: -Resident is UTD (up to date) with routine eye/dental care. -Team to follow-up with recommendation for part-time glasses. Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #118: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 possible points. -did not have any eye glasses. Review of the Physician's orders for Resident #118 included: -Yearly eye examination -Reason: Diabetes Mellitus, dated 5/9/25. During an interview on 5/13/25 at 9:52 A.M., Resident #118 said that he/she needed glasses for distance, but did not have any eye glasses. During an interview on 5/19/25 at 1:33 P.M., the Director of Nursing (DON) said that the staff should have followed up on the recommendation made by the eye doctor to fill the prescription for eyeglasses last October but the staff had not done so. The DON said that it was the Unit Managers' responsibility to review the Consultants' Notes and notify the Doctor of recommendations for follow through. The DON was unable to provide evidence that any facility staff had followed through on the recommendation for Resident #118 to get the needed prescription eye glasses.

Based on observation, record review, and interview, the facility failed to provide peripherally inserted central catheter (PICC: flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV]) care and services in accordance with professional standards of practice and plan of care for one Resident (#137) of two applicable residents receiving IV treatment via PICC, out of a total sample of 27 residents. Specifically, for Resident #137, the facility staff failed to measure the external length of the PICC weekly, as ordered by the Physician to prevent the risk of inadvertent PICC migration and catheter related complications. Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Edition, dated 2021, included the following for documentation relative to PICC line migration and dressing changes: -Use a sterile measuring tape or incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter has not migrated. -Measure upper arm circumference when clinically indicated to assess for the presence of edema and deep vein thrombosis (DVT: blood clot in a deep vein), take the measurement four inches (10 centimeters) above the antecubital fossa (area of transition between the forearm and upper arm) and compare this measurement to the baseline. Review of the facility policy, titled Midline/Extended Dwell Catheter Needleless Connector Change, effective January 2022, indicated: -Needleless connector will be changed according to the IV therapy order: upon admission, at least every seven days and as needed for any complications. Review of the facility policy for Midline/Extended Dwell Catheter Dressing Change, dated January 2022, indicated: -To provide specific intervals and technique for midline or extended dwell catheter dressing changes. -The IV therapy order for care and maintenance is required - dressing changes will occur according to the intravenous (IV) Order Form -If the catheter migrates out during the dressing change DO NOT re-insert the migrated catheter. -With each assessment of the Vascular Access Devices (VAD), presence of the following at a minimum should be included: >External catheter length. Review of the ProCare Infusion Therapy Order Forms, dated 3/25/25 and 4/24/25, for a vascular PICC indicated the following considerations for catheter care: -Document catheter length and external catheter length. -Document baseline arm circumference and as needed. -Document external catheter length weekly with dressing change and as needed. Resident #137 was admitted to the facility in March 2025 with diagnoses including acute and subacute endocarditis and severe sepsis with septic shock. Review of Resident #137's Comprehensive Care Plan, last revised 4/17/25, indicated: -receiving IV therapy for endocarditis and was receiving antibiotics. -An intervention to change IV tubing per policy and as needed. -IV as ordered. Review of the Minimum Data Set (MDS) assessment, dated 4/25/25, indicated Resident #137: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 points. -was receiving IV antibiotic medication. -had a central line in place. Review of Resident #137's May 2025 Physician's orders indicated: -measure external catheter length on admission, weekly with dressing change and as needed, every day shift every Wednesday for maintenance, dated 4/24/25. Review of Resident #137's April 2025 and May 2025 Treatment Administration Records (TARs) indicated the Resident's PICC line dressing was changed but the external length of the catheter was not documented on: -4/3/25 -5/7/25 -5/14/25 Further review of the April 2025 and May 2025 TARs indicated that the PICC line dressing had not been changed, nor the external length of the catheter measured on 4/30/25. During an interview on 5/13/25 at 8:59 A.M., Resident #137 said that his/her PICC line dressing had only been changed once since he/she was admitted to the facility in March 2025. During an interview on 5/15/25 at 11:13 A.M., the Director of Nursing (DON) said that for Resident #137, the weekly measurements for the PICC line were not being done but they should have been. The DON also said that it is important to check the measurements weekly to ensure that the PICC line did not migrate and cause medical complications to the Resident.

Based on record review, and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#30) out of a total sample of 27 residents. Specifically, the facility failed to ensure that Resident #30 received follow-up Behavioral Health Services after recommendations for continued psychiatric follow-up visits were made by the Provider for a Resident with known mental illness, who demonstrated behaviors, was prescribed psychotropic medications, and who required emergency mental health evaluation for suicidal ideation (SI). Findings include: Review of the facility policy titled Consultant Services, dated April 2015, indicated: -The facility routinely uses their own consultants in the following specialty areas - psychiatry, dental, optometry, and podiatry. -Once the consultant is identified by the Physician . the staff will call the consultant to notify him/her of the request and document response in the medical record. -A consultant's report or some form of documentation pertaining to results will be retained in the clinical record. Resident #30 was admitted to the facility in April 2025 with diagnoses including Post Traumatic Stress Disorder (PTSD), Schizoaffective Disorder, bi-polar type, Borderline Personality Disorder, Depressive Disorder, and Generalized Anxiety Disorder. Review of Resident #30's Progress Notes included a Clinician Progress Note dated 4/17/25, which indicated: -The Resident was recently admitted to the hospital for suicidal ideation and exacerbation of bi-polar symptoms. -Plans include ongoing psychiatric management. -Will benefit from psychiatric follow-up in house. Review of the most recent Minimum Data Set (MDS) Assessment, dated 4/23/25, indicated Resident #30: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points. -reported he/she had little interest or pleasure in doing things and feeling down or depressed for two to six days during the MDS two-week look back period. -had verbal behaviors, other behavioral symptoms and rejected care for one to three days during the MDS seven-day look back period. -received antipsychotic and antidepressant medication. Review of Resident #30's clinical record indicated: -Request for Service Form signed by the Resident on 4/17/25, for Behavioral Health Services. -A Nursing Progress Note dated 4/19/25, that indicated the Resident discharged from the facility Against Medical Advice (AMA) and called his/her own ambulance for pick up (Director of Nursing [DON] and Nurse Practitioner[NP] notified). -A Nursing Progress Note dated 4/20/25, that indicated the Resident had returned to the facility from the hospital after evaluation for suicidal ideation. -Physician's order for psychiatric consultation and treatment as indicated, order date 4/20/25. -Care plan for Alteration in Mood exhibited by signs and symptoms of depression and anxiety with an intervention to refer to psychiatric services as needed. -Care plan for a History of Trauma with the potential for re-traumatization by triggers that include talking about his/her past history, with an intervention to refer the Resident for psychiatric services for added support as needed. During an interview on 5/13/25 at 9:06 A.M., Resident #30 said that he/she wanted to see a Specialist from the Psychiatric Consultant Team and that he/she had not seen one since he/she has been in the facility. Review of Resident #30's clinical record failed to indicate that the Resident had been seen by the facility's Consultant Psychiatric Services to date. During an interview on 5/14/25 at 12:37 P.M., Social Worker (SW) #1 said that Resident #30 should have been referred to the Consultant Psychiatric Team, but the Resident had not been referred. During an interview on 5/14/25 at 12:57 P.M., the Medical Records Staff said that all new residents should be referred to for Behavioral Health Services upon admission to the facility. The Medical Records Staff also said that Resident #30 should have been referred for Behavioral Health follow up, but had not been referred.

Based on record review, and interviews, the facility failed to maintain accurate records of controlled substances (drugs or chemicals that the government regulates for its manufacture, possession, and use, that are classified into schedules based on their potential for abuse) for one Unit (5th Floor) out of four units reviewed. Specifically, for the 5th Floor Unit, the facility staff failed to maintain accurate documentation in the Controlled Substance Register (Narcotic Book), relative to the recording of prescription numbers and receipt dates being recorded on the individual pages when a new controlled medication was entered into the Register or the information for a medication was transferred from one page to another. Findings include: Review of the facility policy titled Narcotics (Massachusetts & Rhode Island), dated April 2015, included: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling and record keeping in the facility, in accordance with Federal and State laws and regulations and require narcotic book documentation as follows. -Pages: <Head top of each page - Use blue/black ink. <Prescription number and date of prescription. <Indicate if medication is new, from e-Kit, or transferred on right upper page. <Prescription number needed to be check[ed] each time [a new] card [was] received. Update as needed. This number changes periodically after a certain number of refills, for non C-II narcotics. -Transfer from one page to another: <At top right of new page, indicate page transferred from . <Head new page completely. -Receiving Narcotics: <Log in Narcotic Book. <If new, head top of page completely . <If previous order, check prescription number and update if needed. -Auditing <The Narcotic Book should be audited on a consistent basis. On 5/14/25 at 10:33 A.M., the surveyor and Nurse #1 reviewed the Controlled Substance Log on the 5th Floor Unit. Review of the Controlled Substance Log failed to provide evidence that the headings of each page were completed with prescription numbers, fill dates, and transfer page numbers. Nurse #1 said that when there was a change of page for a medication in the Controlled Substance Log, the Nurse must fill out the heading on the new page with the page number the medication was transferred from, the prescription number, and the filled on date. The surveyor and Nurse #1 reviewed the Control Log pages where a transfer to another page had occurred and none of the headings reviewed had been filled out for prescription number, and date that the prescription had been filled. Nurse #1 said that the headings should have been completely filled in with prescription numbers, filled on dates, and pages numbers but they had not been completed. During an interview on 5/14/25 at 2:11 P.M., the Director of Nursing (DON) said when controlled medications were received from the pharmacy the prescription number and date filled were logged into the Controlled Medication Log. The DON said that when the page number was changed in the Controlled Medication Log, the prescription number and date filled must be transferred to the new page. The DON said that the headings of each page in the Controlled Medication Log should be complete to include the prescription number and date the prescription was filled.

Based on interview, and record review, the facility failed to ensure that one Resident (#133) out of a total sample of 27 residents, was afforded the ability to review/sign documents pertaining to his/her medical care. Specifically, the facility failed to ensure that Resident #133, who was identified as his/her own person and was able to make his/her own decisions, was able to review and sign documentation relative to Advanced Directives (life sustaining measures that can be taken when a person's heart stops or they fail to breathe on their own), psychotropic medication, vaccination education, and ancillary services that could be provided while at the facility. Findings include: Review of the facility document titled, admission Procedure, last reviewed April 2005, indicated: -Prior to or upon admission the Admissions Coordinator will provide each resident and/or responsible party with written information regarding the resident's rights under state law to make decisions regarding his or her medical care, including the right to accept or refuse treatment and to formulate advance directives. -The advance directive status of each resident will be reviewed at their resident care conference. -In the event that the resident has not executed an advanced directive, and the Interdisciplinary Team (IDT) along with the resident's physician determine that the resident is capable of executing an advance directive (i.e. is no longer incapacitated), the social worker will provide the resident with this information. -This will be documented in the resident's medical record. Resident #133 was admitted to the facility in February 2025 with diagnoses including hemiplegia and gastrostomy (G-tube). Review of the Resident's clinical record included the following: -Request for Services Form for consent or declination for audiology (hearing services), eye care, podiatry (foot care services), dental, and Behavioral Health, which was completed, all services were requested and the consent was signed by the Resident's Representative on 2/25/25. -Resident admission Vaccination Education Form for the Influenza, Pneumococcal Conjugate and COVID-19 vaccines, all vaccines were declined and signed by the Resident's Representative on 2/25/25. -Informed Consent Forms for the administration of psychotropic medication were signed by the Resident's Representative on 2/24/25. -MOLST (Medial Orders for Life Sustaining Treatment) Form completed and signed by the Resident's Representative on 2/25/25. Further review of Resident #133's clinical record indicated that Resident #133's Healthcare Proxy (HCP) was not invoked (put into effect, was not dependent on a designated person to make medical and health care decisions) by the Physician/Medical Provider since his/her admission to the facility. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #133: -has a mild cognitive impairment as evidenced a Brief Interview of Mental Status (BIMS) score of 11 out of 15. -understood and does speak English as well as Spanish. Review of Resident #133's Social Service Interim Progress Note dated 3/11/25, indicated the Resident: -had a care plan conference on 3/11/25, -was seen by the facility's psychiatric team with no new recommendations, and -the HCP understood that the Resident had not been invoked. During an interview on 5/14/25 at 12:44 P.M., Social Worker (SW) #1 said that upon the Resident's admission she had confirmed with the hospital that Resident #133's HCP had not been activated and that he/she had the capacity for informed medical decision making. SW #1 also said that the MOLST Form and Consent Forms should not have been signed by the Resident's HCP on admission, but should have been signed by the Resident, but they were not signed by the Resident. During an interview on 5/14/25 at 4:51 P.M., the Assistant Director of Nursing (ADNS) said that the facility should have had Resident #133 sign all of his/her consents upon admission, but they had not done so.

Based on interviews, and record reviews, the facility failed to maintain a complete and accurate clinical record for one Resident (#133) out of a total sample of 27 residents. Specifically, for Resident #133, the facility failed to accurately document the daily total amount of administered enteral feeding. Findings include: Review of the facility policy titled Enteral Feeding, dated April 2015, indicated: -Check physician order for formula, rate and water flushes. -Document procedure in the resident's medical record. -Record intake, flush and free water volume administered. Review of the facility policy titled Nursing Documentation, dated February 2016, indicated: -The licensed nursing personnel documents information related to the resident's condition and care provided in the resident's medical record. -Notes should be clear, concise, and not subject to misinterpretation. -Treatments: the type and resident/patient response. Resident #133 was admitted to the facility in February 2025 with diagnoses including hemiplegia and gastrostomy. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #133: -has a mild cognitive impairment as evidenced a Brief Interview of Mental Status (BIMS) score of 11 out of 15. -has a gastrostomy. Review of Resident #133's Care Plans, last revised 3/19/25, indicated that the Resident had a gastric feeding tube because of a diagnosis of Cerebrovascular Accident (CVA). Review of the May 2025 Physician's orders indicated: -Enteral feed order two times a day for nutrition, Administer Glucerna 1.5 calorie at 100 milliliters (ml) an hour for 14 hours (6:00 P.M. to 8:00 A.M.) via feed pump. Flush with 30 ml free water before and after cycle, start date 2/25/25. -Change G-Tube (gastrostomy tube) feeding system every 24 hours (bag, tubing and syringe), start date 2/25/25. Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) for April 2025 and May 2025 failed to indicate the total amount of enteral formula that Resident #133 was administered daily. During an interview on 5/15/25 at 11:27 A.M., the Dietician said that the facility staff should have documented Resident #133's enteral fluid intake so that she knows how much the Resident was consuming daily but the staff had not accurately documented the enteral fluid intake. During an interview on 5/15/25 at 11:53 A.M., the Assistant Director of Nursing (ADNS) said that the facility staff had not been documenting Resident #133's total enteral fluid intake but they should have been. The ADNS was also unable to locate evidence that the Resident's daily intake was being documented elsewhere in the Resident's clinical record.

Based on observations, and interviews, the facility failed to maintain appropriate hygiene practices while serving meals in the dining room, on one Unit (1st Floor) out of four Units observed. Specifically, the facility failed to ensure that staff distributing food during the lunch meal on the 1st Floor dining room performed appropriate hand hygiene during the meal service to prevent contamination and the spread of foodborne illnesses. Findings include: Review of the facility policy titled Hand Hygiene, April 2015, indicated: -To protect residents/patient from health care associated infections. >Equipment: -Soap. -Warm running water. -Paper towels. >Hand Sanitizing: -Alcohol-based hand rub. Dining Service Staff Training, Revised May 2015, indicated but was not limited to: >Poor personal hygiene and cross contamination. >The key to serving safe food is to handle it safely. Remember that hand washing is the single most important measure to prevent food borne illness. Review of the facility Dietary Department Guidelines, undated, included but was not limited to: -The facility must distribute food under sanitary conditions. -Dietary employees will comply with all basic personal health requirements. -All dietary department workers must observe good personal hygiene. -Handwashing sinks will be available, and all employees will be required to wash hands on entering the dietary department and as frequently as needed between tasks. On 5/15/25 at 12:18 P.M., during a dining observation in the 1st Floor Unit dining room, the surveyor observed the following: -9 Staff members were in the dining room assisting with meal service. Staff observed included -1 Medical Record personnel (MR), 3 Activity Assistants (AA), 5 Dietary Aides. -A drink station including coffee, pitchers of juices, water, sealed juices, carbonated beverages, coffee mugs, and glasses stored in a metal container on top of ice. -The beverage cart was observed positioned next to the exit door in the dining room. -Two alcohol-based hand hygiene dispensers were observed fixed on the wall, a sink with soap, paper towels, and a trash container were located at the back of the dining room. -Resident meals were plated from the steam table by the cook onto resident plates at the back of the dining room. The cook was observed wearing gloves and a hair restraint. -2 Dietary Aides were at the steam table placing meals, meal tickets, and utensils on resident meal trays. -3 additional Dietary Aides were observed standing in the dining room. - AA#1, AA#2, AA#3, and 1 Medical Record Personnel were serving meal trays to residents seated at the tables. -Drinks were being served to the residents from the drink station by AA #1, AA #2, and AA #3 in between serving residents with meals. -AA #1 and AA #2 were observed to clear the used utensils, plates, and cups on two tables, wiped the tables with a paper towel, and placed the dirty plates, cups, and tableware in the dirty bins positioned on the right side of the dining room with ungloved hands and did not perform hand hygiene after handling the dirty dishware. -AA#1 and AA #2 were observed to return to the steam table and continued serving other residents meal items with no hand hygiene performed after the tables were cleaned and dirty dishware handled with ungloved hands. -AA#1, AA#2, and AA#3 were observed pouring and serving beverages, clearing plates, cups, and other dirty utensils from the tables with no hand hygiene performed between serving beverages to the residents and handling dirty dishware. -1 Dietary Aide entered the dining room and placed a container on the table positioned next to the steam table with individual ice cream covered in the container with ice underneath the ice cream. -The surveyor observed AA #1, AA #2, and AA #3 approach the container with the ice cream, open the container, removed ice creams and served residents the ice creams without performing hand hygiene first. During an interview on 5/15/25 at 12:50 P.M., Medical Record Personnel (MR) #1 said that she had been educating all the Activity Assistants during lunch services that it was important for all staff to perform hand hygiene during dining service. MR #1 further said that all the Activity Assistant staff members were aware of the importance of sanitizing their hands in between serving residents. Medical Record #1 also said that all the Activity Assistants were educated not to clean dirty tables or handle any dirty plates from residents while dining service was in process, until the meals service was completed. During an interview on 5/15/25 at 1:40 P.M., the Director of Nursing (DON) said that the expectation for all staff, including nursing and activity assistants, during dining services was that all staff are to sanitize their hands in between serving the meals to residents. The DON said that the dining room on the 1st Floor has alcohol base hand sanitizer on the wall and a sink with soap and paper towels for staff use. The DON also said that when staff remove dirty plates and tables in the dining room during meal service, staff should use gloves, clean the table, then remove the gloves, and perform hand hygiene after removing their gloves. The DON further said that performing hand hygiene during meals was important to prevent infection control and spreading germs to residents. During an interview on 5/16/25 at 8:20 A.M., the Infection Preventionist (IP) said that all staff members regardless of their discipline and/or department within the facility were trained on hand hygiene upon hire. The IP also said there was an ongoing education on hand hygiene and all staff were trained again during the annual training. The IP further said that all three Activity Assistant staff members in the dining room during the lunch meal services were new hires who had been trained in hand hygiene during meals and coffee activities upon hire. The IP said that performing hand hygiene in between serving residents is important to prevent the spread of germs to other residents.

Based on observations, records reviewed and interviews, the Facility failed to ensure they maintained an effective pest control program, when from the end of May 2024 to the beginning of August 2024, despite having a known active, ongoing infestation of mice and German Cockroaches (one of the most stubborn and difficult species to eliminate) in several resident care areas of the Facility, Pest Control Service visits and treatments were not conducted at the Facility during that time. Findings include: The Facility was unable to provide the surveyors with any policies related to the maintenance of a clean, homelike environment or pest control. Review of the Pest Control Service Reports indicated visits to the Facility were made on the following dates: 05/02/24, 05/16/24, 08/06/24, 08/23/24, 09/03/24, 09/17/24 and 10/01/24 (date of survey). Review of the Pest Control Service Report, dated 05/02/24, indicated the following: -five dead mice were found in the kitchen food preparation area -three dead mice were found in the kitchen stove/oven line. Review of the Pest Control Service Report, dated 05/16/24, indicated the following: -10 live German Cockroaches were found in the bathrooms (location not specified). -two dead mice were found in the bathrooms (location not specified). -four dead mice were found in the kitchen food preparation area -four dead mice were found in the kitchen stove/oven line. There were no Pest Control Service visits conducted from 05/16/24 through 08/06/24 despite the Facility having an on-going, active infestation of mice and a newly identified problem with cockroaches. Review of the Pest Control Service visit on 08/23/24 indicated the following: -four dead mice found in the kitchen food preparation area -four dead mice found in the kitchen stove/oven line. Review of the Pest Control Service visit on 09/17/24 indicated the following: -14 dead German cockroaches found in the bathrooms (location not specified). -3 dead mice found in the bathrooms (location not specified). -2 dead mice found in the kitchen food preparation area. During an environmental tour of Unit 5 on 10/01/24, Surveyor #1 observed the following: - 7:50 A.M., room [ROOM NUMBER], Non-Sampled (NS) Resident #10 showed the surveyor a Mouse and Insect Glue Board and said that Maintenance gave this to him/her to catch the numerous mice that have been in his/her room. NS Resident #10 said he/she was not comfortable torturing the mice and wished the facility would take care of this problem once and for all. - 8:59 A.M., room [ROOM NUMBER], NS Resident #14 said he/she sees both mice and cockroaches in his/her room and that it made him/her uncomfortable. During an environmental tour of Unit 4 on 10/01/24, Surveyor #1 observed the following: - 3:09 P.M., room [ROOM NUMBER] - small black gnat-like flying insects throughout the room, nearer Bed A, a small, approximately one-half-inch sized orange colored, six-legged insect crawling on the wall, a larger approximately one inch sized, orange colored, six-legged insect with antennae crawling on the wall next to the call light housing. - 3:30 P.M., room [ROOM NUMBER] - a large, approximately two-inch-long orange colored six-legged insect with antennae crawling on the floor next to the wall between the bathroom and Bed A. - 3:42 P.M., room [ROOM NUMBER] - numerous small black gnat-like flying insects throughout the entire room. During an environmental tour of Unit 2 on 10/01/24, Surveyor #2 observed the following: -8:10 A.M., room [ROOM NUMBER] B, mice droppings inside of NS Resident #2's top drawer of both his/her bedside table and bureau, and ripped edges along the bottom of a cloth bag which held snacks, next to NS Resident #2's bed. NS Resident #2 said he/she had seen more than 50 mice in his/her room within the last year, and presented a tally sheet of mice caught, and said the mice situation was only getting worse. NS Resident #2 said the ripped edges on the cloth bags were from mice trying to bite through them to get to the food. -8:30 A.M., room [ROOM NUMBER] B, NS Resident #4 said he/she had mice in the room nightly. During an environmental tour of Unit 2 on 10/02/24, Surveyor #2 observed the following: -2:10 P.M., room [ROOM NUMBER] B, NS Resident #7 said the Facility had a lot of mice and cockroaches and when he/she turned on the bathroom light at night, he/she would see cockroaches scatter. NS Resident #7 said the cockroaches come out of there like crazy and pointed to the heater in his/her room that was detached from the wall, causing a space between the wall and the heater. -10:15 A.M., room [ROOM NUMBER] A, NS Resident #8 said there were too many mice in the Facility and the cockroaches came out of the wall vents in his/her room. NS Resident #8 shook his/her picture frames and clock which were all on the wall, and said cockroaches came out from behind them at night. During an environmental tour of Unit 3, on 10/01/24, Surveyor #2 observed the following: -8:40 A.M., room [ROOM NUMBER] A, several small black gnat-like bugs flying around the bedside table area. During an environmental tour of Unit 3, on 10/02/24, Surveyor #2 observed the following: -10:40 A.M., room [ROOM NUMBER] A, a dead brownish insect with several legs on Resident #2's closet floor. Resident #2 said there was a cockroach in his/her pile of linen a few days prior. Resident #2 said he/she heard rats in the ceiling at night. During an observation of the main kitchen dish room on 10/02/24 at 8:30 A.M., Surveyor #1 observed several small black gnat-like flying insects hovering over the floor drain and a large amount of small black gnat-like flying insects surrounding the area underneath the sink centered around the garbage disposal, as well as flying around throughout the dish room. During an interview on 10/02/24 at 8:40 A.M., the Food Service Director (FSD) said he was aware of the flying insects around the dish room, and he thought the exterminator was aware of them, as well. During an interview on 10/02/24 at 9:11 A.M., the Administrator, Surveyor #1 asked the Administrator if he was aware of the flying insect problem both in the kitchen and on the nursing units, and if the exterminator was addressing this problem. Initially, the Administrator said that the exterminator was treating for the flying insects, however Surveyor #1 referred him to the most recent exterminator report, that they had provided to the surveyors, which only addressed mice and roaches. The Administrator then said the exterminator was not aware of the flying insects, therefore they were not treating the infestation. Surveyor #1 and Surveyor #2 informed the Administrator of the multiple observations of flying insects on the nursing units and the Administrator said residents have complained to him about fruit flies and he said his response to them was to make sure they did not keep food, specifically fruit in their rooms. The Surveyors asked the Administrator if he was certain the flying insects were fruit flies and not drain flies, as they were observed congregating around the drains in the kitchen. The Administrator said he did not know. Immediately following the interview, Surveyor #1 and the Administrator went to the dish room and observed a small number of small, black gnat-like flying insects hovering over the floor drain and a large amount of small, black gnat-like flying insects flying around the garbage disposal under the sink and all around the sink area, in general. The Administrator then said the insect problem in the dish room was bad. During a follow-up observation and interview with the FSD on 10/02/24 at 9:45 A.M., Surveyor #1 observed numerous small black gnat-like flying insects all around the dish room. The FSD said when the exterminator visited, the exterminator did not seek him out to provide any information as to what their findings were and what their recommendations might have been, and that the exterminator reports directly to the Plant Manager. The FSD said he attended Quality Assurance and Performance Improvement (QAPI) meetings monthly and while pest control is discussed at each meeting, he said there was nothing discussed specifically relative to the kitchen, just an overall general report that pest control is being addressed. The FSD said he was not aware of the most recent report that identified how many and where any dead mice were found in the kitchen and was not aware that the exterminator was not treating the flying insects in the kitchen. 37086 During a group interview on 10/02/24 at 1:15 P.M. with the Administrator, Director of Housekeeping, and the Plant Manager, the Director of Housekeeping said he was responsible for the pest control in the Facility. The Director of Housekeeping said he accompanied the exterminator when they came in and he did not know why the exterminator did not make visits to the Facility in June or July 2024. The Director of Housekeeping said he did not do much with the end of visit reports the exterminator provided and said What else can I do? I just keep cleaning. The Administrator said he was unaware that the Pest Control Services did not make visits to the Facility in July and August 2024 and said they were supposed to come to the Facility at least monthly. The Administrator said the Facility needed to do more to combat the pest problems.

Based on observations and interviews for four out of four resident units, the Facility failed to ensure they provided a functional Resident Call/Communication System which relayed to the cell directly to staff or a centralized staff work area, that allowed residents residing on the units, to call for staff assistance. Findings include: Review of the Facility policy titled, Call Light Use of, dated April 2015 indicated but was not limited to: - All [name of company] Health Care Systems residents/patients will have a call light or alternative communication device within his/her reach when unattended. - Report any defective call lights in the maintenance log. - If the call light is unable to be repaired immediately provide an alternative communication method. Review of the safe/clean/comfortable/home-like environment/call light audit provided to the Surveyors completed by the Plant Manager on 10/1/24 (on the date of the survey) indicated the following: - All call lights on Unit 2 were not working. - 24 call lights on Unit 3 were not working. - 38 call lights on Unit 4 were not working. - 3 call lights on Unit 5 were not working. During a tour of Unit 5 on 10/01/24 at 7:50 A.M., Surveyor #1 observed the following: - room [ROOM NUMBER]-A - Call light device missing the button that activated the system, there was no hand bell in the room - room [ROOM NUMBER]-B- Call light not functioning, there was no hand bell in the room. - room [ROOM NUMBER]- Emergency call light in the bathroom did not have a pull chain to activate the system. During an observation and interview on 10/01/24 at 9:24 A.M., with Certified Nurse Aide (CNA) #1 and Maintenance Worker #1 (on Unit #4), Surveyor #1 attempted to activate the call system by pressing the call button for room [ROOM NUMBER]-A. Surveyor #1 observed that a light appeared on the panel behind the bed where the call light was plugged in, however the light above the door on the outside of the room did not illuminate. Surveyor #1 then attempted to activate the call system by pressing the call button for room [ROOM NUMBER]-B. Surveyor #1 observed there was no light on the wall panel behind the bed or out in the hallway above the door to the room. Surveyor #1 then went to the Nurse's station to look for a panel or system that would alert staff to where a call light had been activated, however the system was shut down. CNA #1 said staff would know if a resident activated the call system because there would be a beeping sound, the light outside the room would illuminate and it would appear on the computer at the Nurse's station. CNA #1 then proceeded to the Nurse's station to show Surveyor #1 the computer that would identify which room initiated the call system, however the computer was not functioning and CNA #1 requested Maintenance Worker #1's assistance. Maintenance Worker #1 found that the cable was disconnected from the monitor under the desk, reconnected it and was able to show Surveyor #1 the display. At that time, Maintenance Worker #1 then went into room [ROOM NUMBER]-B and attempted to activate the call system. Surveyor #1 and Maintenance Worker #1 both observed that the panel behind the bed did not light up, nor did the light outside above the resident's door. Maintenance Worker #1 said he did not think that any call lights on Unit 4 worked properly and did not work for some time. Surveyor #1 and Maintenance Worker #1 then went to room [ROOM NUMBER]-A and attempted to activate the call system and observed the panel behind the bed lit up, however the light outside above the resident's door did not, but the light above room [ROOM NUMBER] (which they had not activated) did illuminate. Maintenance Worker #1 said that was a problem. During an interview on 10/01/24 at 9:45 A.M., Nurse #2 said if the resident in room [ROOM NUMBER]-A rang for help, care could be delayed because staff would respond to room [ROOM NUMBER] because that would be the light staff would see to respond to, which was the wrong room. Nurse #2 also said she could not hear an audible bell when we activated the call system in room [ROOM NUMBER]-A. During an environmental tour of Unit 4 on 10/01/24 at 3:00 P.M., Surveyor #1 observed the following: - room [ROOM NUMBER]-B - Call light did not work. Non-Sampled (NS) Resident # 13 said if he/she needed a nurse, he/she just went into the hall and called for one and that he/she did not have a hand bell. - room [ROOM NUMBER]-A and 403-B - call light did not work - room [ROOM NUMBER]-A and 406-B - call light did not work - room [ROOM NUMBER]-A and 408-B - call light did not work - room [ROOM NUMBER]-A - call light did not work, hand bell on nightstand did not have a striker inside. - room [ROOM NUMBER]-B - there was no call light connected to the wall panel at all. NS Resident #12 said he/she had no idea where it was, that he/she was not given a hand bell and when he/she needed help, he/she yelled for it. - room [ROOM NUMBER]-A - call light did not work. 37086 During an environmental tour on Unit 2 on 10/01/24 at 7:53 A.M., Surveyor #2 observed: -Non-functioning call light system for the entire unit. During an environmental tour on Unit 3 on 10/01/24 at 8:40 A.M., Surveyor #2 observed: -No call lights ringing and several resident rooms with non-functional call lights. -During an interview on 10/01/24 at 8:10 A.M., NS Resident #2 said his/her call light did not work, that he/she had a hand bell which did not work either and if he/she needed staff assistance he/she would go to the hallway and call for help. -During an interview on 10/01/24 at 8:24 A.M., NS Resident #3 said his/her call light did not work and if he/she needed staff assistance he/she would get out of bed and find a staff member to help him/her. -During an interview on 10/01/24 at 8:40 A.M., NS Resident #5 said his/her call light did not work and he/she had to use the hand bell when he/she needed staff assistance. -During an interview on 10/01/24 at 2:07 P.M., NS Resident #6 said his/her call light did not work and he/she would yell out when he/she needed assistance from staff. -During an interview on 10/01/24 at 2:10 P.M., NS Resident #7 said his/her call light did not work and if he/she needed something from staff he/she would leave his/her room to find help. During a group interview on 10/02/24 at 1:20 P.M., with the Administrator, the Plant Manager and the Director of Housekeeping, the Surveyors asked about their non-functioning call light system which has been a known issues since before March 2024. The Administrator said they had received a quote for replacement and the company required a 50 percent down payment. Surveyor #1 asked about their previous plan of correction to replace the system completely with a quote in March 2024 and inquired why the call light system was still non-functional. The Administrator shrugged his shoulders and said they had just received a new quote. The Administrator said the call lights were a real problem for the Facility and had been an on-going issue sometimes they work, sometimes they do not. The Administrator said that not all residents with a non-functional call light had a hand bell to use because the hand bells were easily broken and in constant need of replacement. The Administrator said the entire call light system for Units 2, 3 and 4 were in need of replacement.

Based on records reviewed, interviews, and observations, the Facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was comprehensive, ensured the residents' environment was maintained to promote a clean, safe, homelike environment, and was focused on indicators of quality of life for residents in the facility. Findings include: Review of the Facility's QAPI Policy, dated April 2015, indicated the following: -Policy-The Facility will have effective QAPI programs to improve the quality of life, and quality of care and services delivered. -When fully implemented, the QAPI program should address all systems of care and management practices, and should always include clinical care, quality of life, and resident choice. -The Facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. -The Facility uses a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized and delivered. Review of the June 2024 QAPI Meeting Minutes indicated the following information was submitted from the Department Heads: -Housekeeping and Laundry: Keeping track of mice sightings. Pest control comes monthly. -Plant: Working on the mouse problem, pest control comes regularly. Call lights have been serviced but [reports of non-working call lights] are on-going. Review of July 2024 QAPI Meeting Minutes indicated the following information was submitted from the Department Heads: -Housekeeping and Laundry: Keeping track of mice sightings. Pest control comes monthly. -Plant: Working on the mouse problem, pest control comes regularly. Review of the August 2024 QAPI Meeting Minutes indicated the following was submitted from the Department Heads: -Housekeeping and Laundry: Keeping track of mice sightings. Pest control came in July. -Nursing: Call lights on Unit 2 and Unit 4 are not working and we are waiting for [the company] to pay the bill to have them fixed. Review of a QAPI plan specific to insects and rodents, dated 08/29/24, indicated the following: -The Problem: Residents collecting items that attract bugs and rodents. -The Goal: Remove food trash contraband from resident bedside tables. -Action Steps: Inspect and remove any food trash contraband from bedside tables. -Responsible Person: Director of Housekeeping -Estimated Completion Date: Ongoing. Review of the previous six months of Pest Control Services, provided by the Facility, indicated Pest Control Services were at the Facility on the following dates: -05/02/24, 05/16/24, 08/06/24, 08/23/24, 09/03/24, 09/17/24 and 10/01/24 (date of survey). Pest Control Service visits were not conducted at the Facility during the months of June 2024 and July 2024, despite QAPI meeting minutes which indicated the Pest Control Service visits were done monthly. Review of the Facility's Audit, titled Safe/Clean/Comfortable/Homelike Environment/Call Light Audit, dated 10/01/24, included the following: -Unit 2 -18 out of 18 resident rooms had no working call lights. -Unit 3-12 out 19 resident rooms had no working call lights. -Unit 4-20 out of 20 resident rooms had no working call lights. -Unit 5-3 out of 19 resident rooms had no working call lights. Despite the Facility having identified the non-functional call bell system months prior, the issues had not yet been resolved at the time of this survey. During a telephone interview on 10/04/24 at 12:00 P.M., the Administrator said more work needed to be done to combat the pest infestations. The Administrator said the QAPI for pest control should have been more detailed to determine its effectiveness. The Administrator said the call lights had been an on-going issue and should have already been fixed.

Based on observations and interviews, for four out of four nursing units Nourishment Kitchens and in the facility's main kitchen, specifically the dish room, the Facility failed to ensured they maintained a sanitary environment related to food storage/preparation, which placed all residents at risk for food-borne illness. Findings include: Review of the Facility Policy titled, Cleaning Procedures, Revised 05/12 indicated: - All areas of the Dietary Department will be cleaned on a regular schedule. Review of the Facility Dietary Department Guidelines, undated, indicated but was not limited to: - All food preparation equipment, dishes and utensils must be maintained in a clean, sanitary and safe manner and used and repaired according to manufacturer's recommendations. - All food items should be labeled and dated . Review of the Facility Policy titled, Personal Food Policy, dated 04/28/19 indicated but was not limited to: - All personal food items brought into the facility must be in airtight packaging or covered storage containers to keep bacteria out. - The staff person receiving the personal food shall label the container with the date it was brought into the facility (or date of preparation, if known) and the name of the Resident receiving it. - No personal food may be brought to the facility kitchen. - Any perishable items that are found outside of the refrigerator or unlabeled shall be discarded unless it can be verified that the food has not been out for more than two hours. On 10/01/24 at 9:00 A.M., Surveyor #2 observed the following in the Nourishment kitchen on Unit 3: - Peeling wallpaper behind the microwave area. The edges of the peeled wallpaper were brown and thick. - The corner crease of the wallpaper between the counter and the cabinets had a brown stain from the bottom of the cabinet to the top of the counter. - The wallpaper was separated at the seams under the hand sanitizer pump station with heavily gray stained wallpaper adjacent to the sanitizer pump. - There was a large flap of peeling wallpaper under the counter, near the trash bin. The backside of the peeled wallpaper had black specks and brown stains. The wall had large gray stains. - The kick-plate under the cabinets was separated from the cabinet, creating a one-half inch space. - The ceiling tiles in the corner of the room were not flush, creating a visible space between the ceiling tile and the wall. - A large brownish gray stain covered two ceiling tiles over the counter top. - A large grayish brown stain went from the ceiling down the corner of the wall. - The light fixture contained debris and dead insects. - The corner pieces of wallpaper from the top of the cabinet to the ceiling were peeling off. On 10/01/24 at 2:22 P.M., Surveyor #2 observed the following in the Nourishment kitchen on Unit 2: - Three ceiling tiles above the alcove next to the countertop had large brown stains. - The bottom half of the wall behind the door had large areas of cracked spackle. - The corner of the floor behind the door contained a thick, black pile of dirt. - A large area of wallpaper along the wall was peeling along the seam, with the seam edges stained black. On 10/02/24 at 10:15 A.M., Surveyor #1 observed the following in the Nourishment Kitchen on Unit 4: - Refrigerator - Bottom shelf contained a plastic beverage cup and plastic bowl of fruit in a plastic bag, unlabeled and undated. -There was a plastic container of assorted food and bowl of food loosely covered with torn aluminum foil inside a plastic bag, unlabeled and undated. - Top shelf had a plastic container with an orange lid containing unidentified food, unlabeled and undated. - Inside door had a white plastic squeeze bottle with a reddish/pink residue on the top and around the neck of the bottle, with an unidentified (unlabelled) reddish pink liquid inside the bottle. - Microwave - inside top of unit was worn away with patches of a black, crusty substance that when touched, fell on to the glass turntable below. - Counter top area, there was a bag of various items, including a bottle of prescription medication, Styrofoam cup with tea bags unlabeled and undated, and an empty plastic beverage cup with white lid containing pink stains and brown specks. - Cabinet contained an opened, unlabeled and undated bottle of chili sauce, and an opened unlabeled and undated container of peanut butter. - Wall above cabinet had peeling, torn wallpaper stained yellow adjacent to the ceiling, and wallpaper was also torn and peeling adjacent to the cabinet below with edge lifted creating a gap along the right side of the cabinet. - Ceiling tile adjacent to the wall, was lifted creating a one-half inch gap on the wall above the cabinet. - Under the sink there were large black stains, and gaps between the linoleum were laden with thick black substance, one tile was broken with diagonal open space stained black, one tile was broken with two circular areas missing stained brown, and the wall above the floor had dark gray and brown streaks. - Wall surrounding the trash bin was stained with a pink substance, with pink drip marks extending to the vinyl baseboard above the floor. - Floor surrounding the trash bin had black and rust colored crusty stains extending from the entry to the kitchen, around the edge of the trash bin and extending around the corner to the refrigerator area. On 10/02/24 at 10:55 A.M., Surveyor #1 observed the following in the Nourishment Kitchen on Unit 5: - Utensil drawer had sticky brown-black stains along the top lip of drawer, inside the front wall of drawer and on the drawer base and there was a plastic spoon lying on top of the sticky substance. - Microwave inside top of unit had peeling plastic, brownish gray and rust specks with three circular rusty areas that dropped particles onto the turntable when touched. The turntable contained sticky brown stains and had a translucent sticky substance with black specks. During an interview on 10/02/24 at 10:30 A.M., CNA #2 said all food stored in the Nourishment Kitchen needed to be labeled with a resident's name and dated when the food was brought into the facility. CNA #2 also said there should not be staff items such as medications and tea bags stored in the Nourishment kitchen. With Surveyor #1, CNA #2 viewed the inside top of the microwave, she said [NAME], the particles could drop into the resident's food and make them sick. During an interview on 10/02/24 at 11:15 A.M., CNA #4 said the inside top of the microwave was dirty and rusty, and particles from the top could fall into resident's food. CNA #4 also said that both the turntable and utensil drawer were dirty and needed to be cleaned. During an interview on 10/02/24 at 11:24 A.M., the Director of Housekeeping said the microwaves on Unit 4 and 5 needed to be replaced. The Director of Housekeeping said that the housekeeping staff were responsible for the overall cleanliness of the Nourishment Kitchens which included refrigerators, freezers, counters, floors, walls, drawers, and cabinets and that both Unit 4 and Unit 5 Nourishment kitchens needed a thorough cleaning. During a group interview on 10/02/24 at 1:20 P.M., with the Administrator, Director of Housekeeping and Plant Manager after viewing photos the surveyors provided of their findings, the Administrator said he would not expect the wall on the Unit 2 Nourishment kitchen to look like that, and the Director of Housekeeping said the Unit 2 ceiling tiles needed to be replaced. During an observation of the Main Kitchen dish room on 10/02/24 at 8:30 A.M., Surveyor #1 noted a foul odor emanating throughout the room, there was an industrial fan blowing, flying insects could be seen hovering over the floor drain and around the garbage disposal under the sink, there was an adherent, thick, black substance along the top right edge of the garbage disposal, two red buckets with standing water underneath the garbage disposal, and black crumbs and assorted debris around the floors perimeter of the entire room, including underneath the dishwasher. During an interview at 8:40 A.M., the Food Service Director (FSD) said the foul odor was likely due to the drains and pipes in the dish room remaining stagnant for a couple of months due to the dishwasher being out of service. During a follow up observation and interview with the FSD on 10/02/24 at 9:45 A.M., Surveyor #1 observed multiple flying insects within the dish room. When it was brought to the attention of the FSD that a Dietary Aide had been observed earlier today by Surveyor #1 and the Administrator, sanitizing a meal cart in the dish room, the FSD said the Dietary Aide should not have been cleaning the meal cart in the dish room given the current insect infestation because of the risk of the insects getting into the food. In addition, the FSD said he was aware the dish room was unsanitary and required thorough cleaning and that Maintenance needed to fix the leaks under the garbage disposal. During an observation and interview on 10/02/24 at 9:11 A.M., the Administrator said he was not sure of the exact date the dishwasher stopped working, but said that it should be ready for use today after the company came to provide the appropriate sanitizing chemicals. Immediately after the interview, the Administrator and Surveyor #1 together observed the dish room. A dietary aide was inside the dish room cleaning and sanitizing a meal cart readying it for the residents' lunch meal to be transported upstairs to the Nursing units. There were a couple small, black flying insects hovering around the floor drain and a large number (too numerous to count) flying around under the sink and around the garbage disposal. The Administrator said the insect problem was bad in the dish room as well as the odor, and before the dishwasher was put back into service the dish room required a thorough cleaning and should not have been this dirty.

Based on observations (which included taking photographs), interviews and records reviewed, for four of four resident units, the facility failed to ensure it provided a safe, clean, comfortable and homelike environment for it's residents, when during the course of the survey observations conducted in common areas, resident rooms, and resident care areas, there was obvious signs of various stages of disrepair, aging and unclean conditions, on flooring, walls, ceilings and windows, all of which were in areas accessed and utilized by residents in their daily lives, and were either unsafe, in need of immediate repair and/or created potentially hazardous conditions, none of which supported that a homelike environment was being provided for facility residents. Findings include: The Facility was unable to provide the surveyors with any policies related to the maintenance of a clean, homelike environment or pest control. During an environmental tour of Unit 5 on 10/01/24 at 7:50 A.M., Surveyor #1 observed the following: Wall between main elevators on Unit 5 had black streaks, gouges and chipped/peeling paint, and the vinyl baseboard was stained with black streaks. room [ROOM NUMBER] - Bathroom light did not turn on with wall switch and there was exposed spackle under bathroom sink. Bed A -wall adjacent to the bathroom was heavily damaged with gouges and chipped paint. -Vinyl baseboard around perimeter of room was pulling away from the wall exposing black, grimy wall underneath, and instead of being secured with adhesive, it was secured by nails which created multiple gaps between the nails where wall underneath was exposed. -Built up brownish-rust colored grime on floor behind the room's main entry door. -Vertical crack leaving a gap in wall along entry wall. -Window drape liners were shredded and shedding white fibers when moved. -Exposed round head and flat head screws were in the wall. -Section of baseboard heater was missing in the bathroom exposing a sharp top edge. room [ROOM NUMBER] - Large patch and numerous smaller patches of rust and chipped paint along top of floor heating/air conditioning unit and wall mounted heating/air conditioning unit. -Area of grime/rust all along the floor underneath and on the floor heating/air conditioning unit. -Exposed metal hanging brackets on wall above heating/air conditioning unit. room [ROOM NUMBER] - Bed B -dresser was missing drawer handle on bottom right-hand draw. -Exposed metal hanging brackets on the wall. Bed A - had an exposed flat head screw in wall above the dresser. room [ROOM NUMBER] - Bathroom with exposed spackle on the wall above the baseboard heater. -Plywood that covered the bathtub with puddle of liquid on it. -Entry wall to room was badly damaged with gouges, stains, black streaks and damaged spackle. -Exposed flat head screws protruded from the wall above the television. room [ROOM NUMBER] - Closet with damaged/missing slats. room [ROOM NUMBER] - Entry door to the room with chipped paint exposing pink color underneath. -Bathroom baseboard heater was rusty and coming apart. Bed A - wall between bathroom and bed badly damaged, gouged with black streaks, chipping, and exposed spackle. -Window blinds were broken. -Heating/air conditioning unit front cover panel was disconnected from unit. -Wall behind the television had an unpainted outline of the former television wall mount and damaged wall/wallpaper. room [ROOM NUMBER]- Bed A - wall between bathroom and the bed was heavily damaged and gouged with black streaks and exposed spackle. Bed B - wall contained an exposed, protruding flat head screw that protruded from the wall, which was heavily damaged with gouges and exposed spackle. -The top portion of the vinyl baseboard was pulling away from wall creating a gap. room [ROOM NUMBER] - Front of heater/air conditioning panel was disconnected/unsecured. -Exposed round head screw protruded from the wall. room [ROOM NUMBER] - Walls in the room were gouged/damaged with exposed spackle, front of heater/air conditioning panel was disconnected/unsecured. room [ROOM NUMBER] - Broken window blinds, with missing slats. -Non-Sampled (NS) Resident #11 said the broken blinds with missing slats created a glare for him/her, so he/she made his/her own valances which were hanging sideways from the corner from the left-hand window. -The wall surrounding the emergency call light housing was damaged with drywall anchors exposed and chipped paint. room [ROOM NUMBER] - There were two pink basins with standing water under the sink, as well as a puddle of water on the floor next to the basins in the bathroom and the toilet that did not flush effectively. Non-sampled Resident #10 said the bathroom sink leaked, filling one basin per day, and he/she said he/she kept the second basin as a back-up. NS Resident #10 said the sink had been leaking for weeks and he/she had told facility staff, but nobody had come to repair the leak. In addition, NS Resident #10 demonstrated to Surveyor #1 that the toilet does not flush effectively, by placing a piece of toilet paper in the bowl. After he/she flushed the toilet three times, the toilet paper remained in the bowl. -The wall that separated the bathroom from Bed A and door jamb was heavily chipped, contained exposed spackle, and had black scrape marks extending the length of the wall. -There was broken linoleum tile exposing brown flooring underneath approximately eight inches long by two inches wide and adjacent linoleum tile was cracked. -There were missing slats and a missing knob on the closet, as well as a rusty heater in the bathroom. room [ROOM NUMBER] - Emergency call light housing was hanging out of the wall, attached only by electrical wire inside the wall, there was exposed spackle on walls and adhesive Command strips were stuck in various places on the wall. room [ROOM NUMBER]- Bed A- wall between bathroom and the bed was heavily damaged with chips, black scrape marks, cracks, and the corner edge of the wall contained a gap extending up the wall from the baseboard approximately two feet in height. -There were exposed roundhead screws that protruded from the wall. -The floor transition between the bathroom tile and linoleum in the room entrance was heavily soiled with a thick black substance. -The bathroom door jamb was damaged. room [ROOM NUMBER] -Bed A wall was soiled with brownish, red splatters and drip marks. -Blank wall plate (a protective plate used to cover electrical hazards) had the bottom right corner missing exposing electrical box underneath. -The wall over the heating unit had chipped and peeling paint. During an environmental tour of Unit 4 on 10/01/24 at 2:57 P.M., Surveyor #1 observed the following: room [ROOM NUMBER] - Dresser missing top right-hand drawer. The drawer was located in the bathroom on the plywood covered bathtub with a metal drawer track resting inside the drawer. -Heater/air conditioning unit was loose/pulling away from wall. room [ROOM NUMBER] - Broken closet door louvers/slats. room [ROOM NUMBER] - Bed B wall was damaged and the wall alongside left window had peeling paint, spackle and torn wallpaper on top edge. -There were no screens in the windows and drape liners were shredded and torn. room [ROOM NUMBER] - Bathroom ceiling had brown water stains surrounding ceiling vent. -Persistent water damage was present as evidenced by layers of spackle surrounding vent and brown water stains bleeding through repaired areas. -Lower portion of wall next to the bed was gouged with chipped paint and there was an oval shaped hole in linoleum next to bed. -Wall behind the bed was severely damaged with alternating areas of chipped, peeling paint, there was a thick gray-blue substance on the wall and there was exposed spackle. -Nightstand had drawers that did not align, leaving a large gap above the top drawer. Bed B's footboard was removed from the bed and leaning against dresser. -There were various insects in the room (round black bugs and long, orange-colored bugs). -Windows lacked screens, drapes on the right hand window only secured on the right side causing them to droop. -Adhesive Command strips were adhered to the wall. -Exposed round head screws protruded from the wall, and vinyl baseboard was peeling off the wall next to the room entrance. room [ROOM NUMBER] - Bathroom heater/baseboard had peeling paint, jagged edges with rust exposed and missing end cap. -Bathroom walls with chipped and peeling paint. -Wall at the entry to the room had gouges, black streaks and chipped paint. -Windows were without screens. -Vinyl baseboard was missing along lower edges of the wall exposing broken plaster/drywall and a hole in the wall. room [ROOM NUMBER] - Bed B television was mounted behind the bed. NS Resident #12 said the television has never worked since he/she has been there, and he/she did not know why it was mounted where he/she could not view it. -The floor in front of heating/air conditioner unit was stained yellow, top of heating/air conditioner unit was covered in rust along the air ducts and windows had no screens. -There were no knobs on the closet doors. -The light over the bed did not have a pull chain to turn on the light. -There were screw holes in the walls. -The corners of floors in room contained a built up debris. Bed A -there was stained black linoleum behind the nightstand, and there was an alive, orange-colored insect crawling on the floor. -The toilet in the bathroom was missing a bolt, the toilet itself was loose and therefore not secured to the floor properly. The mirror in the bathroom was hanging crooked with the right-hand side much lower than the left side. -The bathroom wall was damaged and had peeling paint and the bathroom floor tiles were stained black. -The baseboard heater contained exposed rust, peeling paint and was missing an end-cap. room [ROOM NUMBER] - Windows were without screens. -There was a raised area of cracked linoleum 12 inches from the back wall of the room approximately 30 inches across and one inch wide with a crumbly brown substance exposed within the crack. -A padded fall mat (used to protect residents in the event of a fall) next to the bed, the vinyl edges were peeling away from the foam. -There was a broken metal handle on the top drawer of the nightstand containing a rough edge. -There was an electrical outlet without a cover and an exposed round head screw extending from the wall. room [ROOM NUMBER] - Bed A -call bell cord was laden with black grime. 37086 During an environmental tour on Unit 2 on 10/01/24 , Surveyor #2 observed the following: -room [ROOM NUMBER]- Bathroom ceiling was peeling around the vent, which was surrounded with unfinished spackle. -room [ROOM NUMBER]- Light fixture upon entry to the resident room with a yellow stain and dead insects inside of the fixture. -room [ROOM NUMBER]- Bathroom ceiling with large area of unfinished spackle, and a large brownish stain with gouged area adjacent to the ceiling vent. -room [ROOM NUMBER]- Window blinds with brown stains. -The heating unit was pulling away from the wall, leaving a jagged edge along the wall and a space between the wall and the heating unit. -The base of the heating unit had a jagged edge along the floor and was not firmly attached to the wall. -The back of the toilet had a pool of brown liquid surrounding the base of the pipe which connected the toilet to the wall. During an environmental tour on Unit 2 on 10/02/24, Surveyor #2 observed the following: -room [ROOM NUMBER]- The bathroom door kick-plate had black gouges and the bottom corner was peeling away from the door, leaving a jagged edge between the door and the plate. -The exposed corner of the wooden bathroom door was blackened. -The resident's closet doors had large scratches with chipped paint going across the bottom of both doors. -room [ROOM NUMBER]- Bed A ceiling tile had a large brownish, gray stain. The ceiling tile next to it was not flush to the drop grid suspension, leaving a space between the ceiling and the drop grid suspension. During an environmental tour on Unit 3 on 10/01/24, Surveyor #2 observed the following: -room [ROOM NUMBER]- Bed A floor had large dark areas of grime and was very sticky when standing or walking on it. -There was no threshold (transition) between the bathroom floor and flooring in the room. -The wall and bathroom door frame were separated from each other, creating a space between the wall and the frame. -The bathroom ceiling had a large, gouged area on the ceiling adjacent to the ceiling vent. -room [ROOM NUMBER]- Light fixture upon entry to the resident room had a large brown stain with dead insects inside of the fixture. -room [ROOM NUMBER]- Bathroom ceiling had a large hole, hanging piece of plaster, and unfinished spackle around the ceiling vent. Several pieces of the bathroom ceiling material had fallen onto the bathroom floor. -The baseboard heater in the bathroom had rust on the top and a broken cover. -room [ROOM NUMBER]- Bathroom ceiling had scattered brownish stains. Unfinished spackle surrounded the ceiling vent. -Residents' clothes were hung along the shower curtain pole under the ceiling which was in disrepair. -room [ROOM NUMBER]- Bathroom ceiling had brownish stains and unfinished, peeling spackle surrounding the ceiling vent. During an environmental tour on Unit 3 on 10/02/24, Surveyor #2 observed the following: -room [ROOM NUMBER]- Ceiling tile adjacent to the window had a large brown stain. -Bed A -ceiling tile had several circular stains, the center was dark brown, and the periphery was gray stained. -The ceiling tile across from Bed A had a brown circular stain in the bottom left corner. -The wall along the entry to the room had a large gouge that went across half the wall, adjacent to the vent on the lower portion of the wall. -The bathroom door had multiple large, deep gouges along the kick-plate, and the door jamb had gouges and missing pieces of plaster on both sides. -The ceiling on the inside of the resident's closet had a hole, approximately two inches wide, that went around the base of the sprinkler head. -There was a dead, brownish colored insect on the closet floor. -The handrail in the hallway next to the elevator was broken off, leaving a jagged edge on either side. -The walls next to the elevator were gouged and dirty. During a group interview on 10/02/24 at 1:25 P.M., with the Administrator, Director of Housekeeping and the Plant Manager, they said the following. The Administrator said he did not do environmental rounds with the Plant Manager or the Director of Housekeeping, but said if he noticed any issues of concern or things that required repairs, he would reach out to either the Plant Manager or the Director of Housekeeping. The Administrator said he did not keep written logs of any requests he had made related to the Facility's environmental needs. Surveyor #1 and Surveyor #2 reviewed their findings from their environmental tours, including sharing showing them the photos that were taken of each concern area. After reviewing all the photos, Surveyor #1 and Surveyor #2 asked the Administrator, Plant Manager and the Director of Housekeeping if they provided a safe, clean, homelike environment for the Residents. The Administrator said, we could do better and the Plant Manager shook his head and said no.

Based on records reviewed and interviews, the Facility failed to ensure that resident grievances related to services provided by the Dietary Department, including reports of cold food, were addressed and resolved by the Facility in a timely manner, when review of the last two months of Resident Council Meeting minutes, and interviews with residents, indicated there were still ongoing and unresolved resident concerns. Findings include: Review of the Facility's Policy for Resident Council, with a revision date of October 2015, indicated the following: Policy: -The Recreation Department will provide support and assistance in the formation of a Resident Council. The residents will have an opportunity to express their concerns or grievances, contribute ideas and make recommendations regarding the operation of the home. Procedure: -Notify Department Heads in writing of concerns that come up during the meeting. -Retain a copy of the resolution that addresses each concern. Report submitted by the Facility via the Health Care Facility Reported System (HCFRS), dated 08/15/24, indicated the Facility's dishwasher was no longer functioning, a new dishwasher had been delivered and was waiting installation. The Report included the Facility's plan to wash, rinse, and sanitize the dishes in the interim. On 10/01/24 the surveyor obtained written permission from the Resident Council President to review the Resident Council Meeting Minutes from the previous three months. Review of the Facility's Resident Council Meeting Minutes, dated 08/22/24, indicated five residents attended the meeting and under the Realm of Food Services the Minutes indicated that residents stated the food was cold. Further review of the Minutes indicated the concerns were forwarded to the Food Service Director (FSD). Review of the Resident Council Concern Follow-Up Form, dated 08/22/24, indicated the residents stated the food was cold, the FSD responded that the new dishwasher would be installed in the next few weeks, dietary would serve food as hot as possible and meal trays would be passed quickly. The Form included a resolution date of 08/22/24 and was signed by the FSD and Administrator. Review of the Facility's Resident Council Meeting Minutes, dated 09/19/24, indicated seven residents attended the meeting and under the Realm of Food Services the Minutes indicated that the residents stated the food was cold. Further review of the Minutes indicated the concerns were forwarded to the FSD. Review of the Resident Council Concern Follow-up Form, dated 09/19/24, indicated the residents complained the food was cold at dinner, the FSD responded that the dishwasher was currently being installed and the dietary staff were serving the residents meals on Styrofoam and once the dishwasher was installed, they would go back to serving the meals on regular plates. The Form included a resolution date of 09/19/24 and was signed by the FSD and Administrator. On 10/01/24 at 7:53 A.M., Surveyor #2 observed the breakfast meal on Unit 3. The meals were served on and covered with, Styrofoam plates. During interviews on 10/01/24 at 7:53 A.M., 8:59 A.M. and 10/02/24 at 10:15 A.M. and 10:28 A.M. with Non-sampled Resident's #2, #3, #7, #8, #9 and Resident #2 regarding the food served at the facility, they said hot food items were usually cold and that meals had been served on Styrofoam for the last few months. During an interview on 10/02/24 at 4:41 P.M., the Food Service Director (FSD) said he had received complaints of cold food through the Resident Council and said the cold food concern would be resolved once the new dishwasher was installed. The FSD said he did not do any test meal trays or change any protocols in an effort to resolve the residents' concern of cold food. During a telephone interview on 10/04/24 at 12:00 P.M., the Administrator said he had received the Resident Council Follow-Up forms in August and September 2024 and was aware residents had stated the food was often cold. The Administrator said he had not anticipated that the new dishwasher would take so long to install and that the installation had been delayed because it required a custom fit. The Administrator said they had tried to use regular plates and wash them after each meal but it was a daunting, unsustainable task, so they went back to serving all resident meals on Styrofoam plates.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), who was assessed to be at risk for nutritional decline secondary to wound healing needs, anemia, multiple food allergies, multiple food preferences, and who had planned weight loss goals, the Facility failed to ensure Resident #2's nutritional status including body weight, were accurately assessed and monitored appropriately by nursing and per facility policy, as a result Resident #2 experienced an undesired weight gain in three months. Findings include: Review of the Facility Policy titled Weights, dated 08/2015, indicated the following: -Newly admitted residents are weighed weekly for four weeks and monthly thereafter. -All weight loss/gain of five pounds on a resident weighing 100 lbs. or more requires a reweigh for verification. -Weights are documented in the resident's medical record. -If a significant weight loss/gain is identified (greater than 5% in 30 days or 10% in 6 months), the Interdisciplinary Team, Dietician, Physician and Family are notified. Resident #2 was admitted to the Facility in July 2024, diagnoses included status post left below the knee amputation and iron deficiency anemia. Review of Resident #2's Nutritional Assessment, dated 07/11/24, indicated Resident #2 weighed 150 lbs. Review of Resident #2's Nutrition Care Plan, dated 07/11/24, indicated Resident #2 was at risk for nutritional decline related to a recent below the knee amputation, anemia, multiple food allergies, multiple food preferences, dislike of protein sources and hyperlipidemia (abnormally high amounts of fat in the blood). The care plan goals included for Resident #2 to maintain a stable weight without significant changes and (achieve) a 5% weight loss of body weight (8 lbs.). The Care Plan included the following interventions: -Notify the Registered Dietician (RD), family and physician of significant weight changes -Obtain weights as ordered and record Review of Resident #2's Treatment Administration Record (TAR) for the months of July and August 2024 indicated he/she had a physician's order to obtain his/her weight on admission and for four consecutive weeks post admission then reassess every Monday for four weeks. The TARs indicated that although Resident #2's weight was recorded on 07/08/24, no weights were entered on 07/15/24, 07/22/24, 07/29/24, or during the month of August 2024. Review of Resident #2's TAR for the month of September 2024, indicated there was no physician's order to obtain weights, despite the Facility's policy of obtaining monthly weights for all residents unless otherwise indicated. Review of the Dietician's Progress Note, dated 09/25/24, indicated Resident #2 reported to the Registered Dietician (RD) that he/she gained weight since admission. The Note indicated Resident #2 expressed a desire to lose weight and the RD reviewed basic meal and snack planning with a goal for gradual weight loss. During an interview on 10/02/24 at 9:33 A.M., the Registered Dietician (RD) said she was notified by Resident #2 that he/she requested to be seen, because Resident #2 felt he/she had gained weight. The RD said she requested staff to obtain Resident #2's weight that day (09/25/24) and that was when his/her significant weight gain of nearly 40 lbs. was identified. The RD said it was the Facility's policy to obtain a resident's weight on admission, then weekly thereafter for four weeks, then monthly unless otherwise indicated. The RD said she did not know why staff had not obtained Resident #2's weights as ordered. The RD said that once Resident #2's significant weight gain was identified, she provided him/her with education for healthy choices of meals and snacks. The RD said she checked the electronic medical record for identified weight triggers (gains or losses), but only the weights that were obtained and recorded would register. Review of Resident #2's weight record indicated the following: 07/05/24- 150 lbs. 07/08/24- 150 lbs. 09/25/24- 184.6 lbs. 10/01/24- 188 lbs. During an interview on 10/02/24 at 10:28 A.M., Resident #2 said he/she had gained almost 40 lbs. since his/her admission to the Facility, that he/she had never weighed that much in his/her whole life and he/she was unhappy with the weight gain. During an interview on 10/02/24 at 3:39 P.M., Unit Manager #2 said it was the Facility's policy to obtain a resident's weight on admission to the Facility, then weekly for four weeks, then monthly thereafter unless otherwise indicated. Unit Manager #2 said the resident weights were kept on a form on the resident unit, that the Certified Nurse Aides (CNAs) were responsible to obtain and record the resident's weight and then nursing was responsible to enter the weight into the resident's electronic medical record (EMR). Unit Manager #2 said that because Unit 3 was busy, either he, or the Assistant Director of Nurses (ADON) would enter the weights into each resident's EMR, not the charge nurse. Unit Manager #2 reviewed Resident #2's Treatment Administration Records for the months of July, August, and September 2024 and said he did not know why Resident #2's weights were not obtained, as ordered. Unit Manager #2 said there should have been a physician's order to obtain Resident #2's weights monthly as of September 2024. Unit Manager #2 said part of the problem may have been how nursing entered the physician's orders into the EMR upon Resident #2's admission to the Facility. Unit Manager #2 said for any resident weights with a discrepancy of less than or greater than 5 lbs., the Registered Dietician and Physician were to be notified. During an interview on 10/02/24 at 4:24 P.M., the Director of Nurses (DON) said it was her expectation that resident's weights were obtained by staff as ordered by the physician. The DON said she did not know the weights for Resident #2 were not obtained as ordered and they needed to do better.

Based on observations and interview, for one of four resident units (Unit 3) the Facility failed to ensure the handrail in the corridor between the Nurse's Station and the Nourishment Kitchen, was secured to the wall. Finding include: During an environmental tour on 10/02/24 at 12:10 P.M., Surveyor #2 observed the handrail in the corridor on Unit 3, between the Nurses Station and Nourishment kitchen was loose and unattached from the wall, which created a gap between the end of the railing and the wall, posing a potential safety hazard to residents. During an interview on 10/02/24 at 1:25 P.M. the Administrator said all handrails should be secured to the wall.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was at risk for developing Diabetes-related foot complications, with physician's orders for diabetic foot care, the Facility failed to ensure Resident #1 received proper care and treatment to maintain good foot health. Findings include: Review of the Facility policy titled, Diabetic Foot Care, dated June 2015 indicated but was not limited to: - Diabetic foot care is provided by qualified nursing staff. Foot condition is noted and changes reported as warranted. - Nurse to contact physician for podiatry consult regarding trimming of nails. - Podiatry will be scheduled to trim toenails. - Report any irregularities to charge nurse. - Document all appropriate information in medical record including foot assessment. - Assessment will be completed on admission and with routine skin assessment. - Any pertinent findings should be reported to physician and/or appropriate practitioner. Resident #1 was admitted to the facility in April 2019 with diagnoses including Type 2 Diabetes and Dementia. During a telephone interview on 09/27/24 at 1:40 P.M., Witness #1 said Witness #2 contacted him and sent a video Witness #2 recorded at the facility of Resident #1's feet and said Resident #1's toenails looked like vulture's claws. Witness #1 said Resident #1's toenails were long, discolored, and curled over the tops of his/her toes. Witness #1 also said family had been in to visit Resident #1 previously, but he/she always had socks and shoes on so they would not have noticed if his/her toenails were overgrown. Witness #1 said Resident #1 required help from staff for everything except for eating and was unable to put his/her own socks on because he/she was unable to dress him/herself. Witness #1 said Resident #1 was always very particular about his/her appearance, never had any problems with his/her feet and would be very upset if he/she realized what his/her feet looked like. During a telephone interview on 09/27/24 at 3:30 P.M., Witness #2 said during a visit on 05/14/24, Resident #1 wanted to rest in bed, so he tried to make Resident #1 comfortable by removing his/her socks, and it was then he noticed the toenails on both of his/her feet were so long, they had grown far beyond the tips of his/her toes, were curling downward and sideways towards his/her pinky toe. Witness #2 said he told a Nurse (exact name unknown), and said the Nurse acted like she had no idea Resident #1's nails were that long, and did not offer any resolution at that time. Witness #2 said that as far as he knew, the Facility staff did not do anything about this until Witness #1 contacted the facility five to six weeks ago. Witness #2 said he was never made aware that the Resident had repeatedly refused any type of foot care and had he known, he would have tried to intervene in some way. Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #1 required maximum assistance from staff members with all his/her activities of daily living (ADLs) except for eating and ambulation and that the Resident was severely cognitively impaired. Review of Resident #1's ADL Care Plan, reviewed with the most recent Quarterly MDS Assessment, indicated that Resident had an ADL Deficit related to Dementia with behavioral disturbance, required assistance with bathing, grooming, and toileting and could be combative with care. Review of Resident #1's Care Plan related to non-compliance, reviewed with the most recent Quarterly MDS Assessment, indicated the Resident became very combative due to Dementia with behavioral disturbance. Resident #1's The Care Plan also indicated to inform the Resident about risks of non-compliance and to discuss with Resident his/her objections, reasons, fears, and ideas. Review of Resident #1's Behavior Care Plan, reviewed with the most recent Quarterly MDS Assessment indicated the Resident was verbally abusive and physically abusive/combative with care. The Care Plan also indicated redirecting the Resident with food and activities when agitated, explaining to the Resident why his/her behavior is unacceptable, to identify stressors that may be contributing to his/her inappropriate behavior. Review of Resident #1's Diabetes Care Plan, reviewed with the most recent Quarterly MDS Assessment, indicated the Resident required diabetic foot care and Podiatry consult, as ordered. Review of an e-mail, dated 10/01/24 at 6:05 P.M., (provided by Social Worker #1), addressed to Social Worker #1 from the contracted agency that provided Podiatry care to the Facility indicated their electronic medical record system only went back to October 2021 and any documentation related to Resident #1 refusing foot care was no longer available. The e-mail further said Resident #1 was placed on the Do Not Treat for Podiatry list on 10/02/21 due to repeated refusals. Review of the contracted Podiatrist Visit Summary, dated 09/03/24 indicated Resident #1 was on the schedule to be treated, however was not treated with the reason documented as being No Time. During an observation and interview on 10/01/24 at 11:30 A.M., Certified Nurse Aide (CNA) 1, along with Surveyor #1, approached Resident #1 while he/she was lying in bed under the covers. CNA #1 asked Resident #1 if he/she would allow us to look at his/her feet. Resident #1 did not respond verbally; however, he/she maintained eye contact with CNA #1. CNA #1 then removed the Resident's covers and explained what she was going to do. Resident #1 started to move away slightly; however, CNA #1 then offered him/her a package of cookies. CNA #1 said Resident #1 can be resistant to care; however, he/she usually responds well and allowed care if offered a snack. Resident #1 happily took the cookies and began eating them while allowing CNA #1 to remove his/her socks and position and handle his/her feet to allow Surveyor #1 to observe the condition of them. Resident #1 tolerated CNA #1's handling and positioning of his/her feet to allow the surveyor to assess their condition very well, the whole time enjoying his/her cookies. Resident #1 allowed CNA #1 to then re-apply his/her socks and covers with no resistance or combativeness. CNA #1 said Resident 1 had Diabetes and diabetic foot care should be provided daily to the him/her. During an interview on 10/01/24 at 2:30 P.M., Unit Manager #1 said Resident #1 required assistance from staff for all personal care, had Diabetes and required diabetic foot care to be performed by the Nurse every evening (3:00 P.M. - 11:00 P.M.) shift. Unit Manager #1 said after the nurse performed diabetic foot care, they were supposed sign it off on the Treatment Administration Record (TAR). Unit Manager #1 said Resident #1 could be resistant to care but staff attempted to redirect his/her behavior and said snacks helped to calm Resident #1 down. Unit Manager #1 said that the contracted Podiatrist attempted several times to provide foot care to Resident #1 in the past, however after Resident #1 refused multiple times, he/she was removed from their list. Unit Manager #1 said she had recently learned from the Facility's Medical Records Coordinator when she reached out to and requested Resident #1 be placed on the Podiatry list, that he/she had refused care. Unit Manager #1 further said these refusals occurred prior to her working at the facility which was almost two years ago. Surveyor #1 asked Unit Manager #1 if she knew how long Resident #1 had gone without having his/her nails cut and Unit Manager #1 said she did not know. Unit Manager #1 said that because nurses were not allowed to cut toenails at the facility, they referred residents' foot care to the contracted Podiatrist. Unit Manager #1 said staff should have been notifying Resident #1's representative, the Nurse Practitioner and/or Physician if Resident #1 refused treatment as well as document the refusals in a Progress Note, and then said she did not know if any of them had ever been notified that Resident #1 had refused foot care. During an interview on 10/02/24 at 11:40 A.M., Nurse #1 said she knew Resident #1 and was not aware he/she had excessively long toenails. Surveyor #1 asked Nurse #1 who was responsible for performing diabetic foot care and how often it should be completed. Nurse #1 said both the CNAs and Nurses provided diabetic foot care weekly on residents' shower days. Nurse #1 said that diabetic foot care included looking at the resident's feet, making sure the feet were clean and dry and if they found something like thick calluses or wounds, they notified the Nurse Practitioner. Nurse #1 said that Nurses were not allowed to cut residents' toenails and if they noticed they were long, they put the resident on the list for the Podiatrist to visit. Surveyor #1 reviewed the e-mail from the contracted Podiatrist provided by the Facility's Social Worker that indicated Resident #1 was placed on the contracted Podiatrist Do Not Treat list effective 10/02/21 due to Resident #1 refusing care and asked Nurse #1 what happened when a resident repeatedly refuses care. Nurse #1 said the Resident's Representative, the Physician and/or the Nurse Practitioner were to be notified, and the Nurse was supposed to write a Progress Note to document the refusals. Nurse #1 said if Resident #1 refused to have his/her toenails cut, nursing staff should have attempted different interventions for him/her to accept care and that Resident #1 should not have gone months without foot care, especially since he/she had Diabetes. Nurse #1 further said to the best of her knowledge, she had never contacted Resident #1's representative or Nurse Practitioner to notify them of Resident #1 refusing foot care. During an interview on 10/02/24 at 12:16 P.M., CNA #2 said she regularly cared for Resident #1 and that Resident #1 required assistance from staff for bathing/showering, dressing, and incontinent care. CNA #2 said that she cleaned, dried and moisturized Resident #1's feet well and did this either in the shower room or in the Resident's room. CNA #2 said she recalled Resident #1's toenails to be very long and curled over the tops of his/her toes, but CNAs were not allowed to cut toenails, so she informed the Nurse, but did not recall which one. CNA #2 said Resident #1 tried to refuse care because he/she did not understand what was being done to him/her, but if she simply explained to Resident #1 what she was doing, he/she allowed her to provide care. CNA #2 said that Resident #1's behaviors of refusing care did not include physical violence such as kicking or hitting and that he/she would just stiffen up and try to physically pull away from the staff member. During a telephone interview on 10/03/24 at 4:33 P.M., CNA #3 said she knew Resident #1 and that Resident #1 required assistance of staff for all his/her personal care. CNA #3 said that Resident #1 could be resistant to care occasionally and that sometimes two CNAs had to provide care to Resident #1. CNA #3 said when Resident #1 refused care, he/she would try to get up and move out of the caregivers' reach and sometimes put his/her hands up to attempt to push caregivers away but would never yell, hit or kick the caregivers. CNA #3 said that when Resident #1 started to behave in this way, she would just try to talk to the him/her. CNA #3 said she would tell Resident #1 she needed to do something, and explain to him/her why, and Resident #1 would then accept the care. CNA #3 said that CNAs were not allowed to cut residents' toenails, but if she noticed they were long, she always let the Nurse know so they could get the resident on the Podiatry list. Review of Resident #1's Podiatrist Progress Note dated 09/16/24 indicated the following: - Reason for visit: Initial exam; Atherosclerosis (build-up of fats, cholesterol and other substances in and on the artery walls which can obstruct blood flow) of the extremities with increased risk of infection, Onychomycosis (a nail fungus that causes thickened, brittle, crumbly or ragged nails), - Progress Note: Initial exam and evaluation performed, reviewed chart and medical history, debrided nails (a procedure that removes diseased or infected tissue from nail bed and surrounding area) to patient's tolerance. - Non-professional treatment is hazardous to the patient. - Nail thickness is four millimeters, reduced to two millimeters after procedure. - Trimmed calluses x 4 to patient's tolerance without incident During a telephone interview on 10/03/24 at 10:20 A.M., the Podiatrist said he saw Resident #1 on 09/16/24 because he was told by facility staff that somebody filed a complaint regarding the condition of Resident #1's feet. The Podiatrist said Resident #1's toenails had already been trimmed before his visit, however the Resident had significant callous formation on both feet. The Podiatrist said he knew Resident #1's nails were not cut by a Podiatrist because if they had, that person would have also addressed the thick calluses present on the his/her feet. Surveyor #1 asked the Podiatrist what he meant in his progress note that indicated, Non-Professional treatment is hazardous for the patient. The Podiatrist said Resident #1 had Diabetes and because of this, he/she would be at a very high risk for diabetic-related complications such as increased risk of infection, slow healing and chronic wounds that could result in amputation of the toes or feet. The Podiatrist said that often a well-meaning person may accidentally nick or cut a toe while trimming a resident's toenails or filing calluses which could introduce bacteria into the area, which could then cause an infection, and it was important that Diabetics receive meticulous foot care and maintenance. The Podiatrist said that when he provided care to Resident #1, the Nurse was present and he/she very accepting of care and not combative or resistant. During an interview on 10/02/24 at 1:00 P.M., the Administrator said the issue of Resident #1's toenails was brought to his attention in August 2024 via a telephone call from Resident #1's family member. The Administrator said that he assessed the Resident's toenails and found them to be very long, thick and scaly and he cut them immediately. The Administrator said Resident #1's toenails were so long and thick they required the use of large nail clippers to cut them effectively. Prior to the Administrator cutting the Resident's toenails, the Administrator said Unit Manager #1 told him that Resident #1 was combative with care, however he said he found that Resident #1 was not combative at all when he cut his/her nails. Surveyor #1 asked the Administrator how long it had been since Resident #1's toenails had been cut and the Administrator said he could not speculate on the amount of time that had passed. The Administrator said there was no documentation in Resident #1's medical record to support that Resident #1 had refused foot care multiple times, that the contracted Podiatrist ceased visiting the Resident due to multiple refusals and or that Resident #1's Representative had been notified of the Resident's refusals. The Administrator said he, himself failed to document the foot care he provided to the Resident in his/her medical record. During an interview on 10/02/24 at 3:15 P.M., the Director of Nurses (DON) said that Nurses were allowed to cut residents' toenails, however if a resident had Diabetes, they should be referred to the contracted Podiatrist for care. The DON said that Nurses were responsible for performing diabetic foot care and were to document this on the Treatment Administration Record (TAR). The DON said if Resident #1 repeatedly refused care, staff should have re-approached him/her and attempted to come up with interventions that would allow staff to complete the necessary care. The DON said that if Resident #1 repeatedly refused care, the Nurse should have notified the Resident's Representative, the Nurse Practitioner and/or Physician and documented the refusal in a Progress Note. Surveyor #1 asked the DON if a resident should go for months without foot care and the DON said they should not. During a follow-up interview on 10/02/24 at 4:36 P.M., the DON said she reviewed Resident #1's medical record, which included his/her Care Plans and Progress Notes and was unable to find any documentation to support that Resident #1 repeatedly refused foot care, or that his/her Representative, Nurse Practitioner and/or Physician were notified of Resident #1's refusals of foot care. The DON said there were not personalized interventions on Resident #1's care plan related to ADL care, Diabetic foot care or Behaviors. .

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for the administration of Suboxone (a narcotic medication used for the maintenance of opioid dependence), the Facility failed to ensure nursing notified Resident #1's Physician when his/her medication was unavailable to be administered in accordance with his/her Physician orders, as a result Resident #1 did not receive his/her scheduled doses for five days (missing a total of 15 doses). Findings include: Review of the accessdata.fda.gov website related to Suboxone, indicated the following: -The medication contains buprenorphine, a partial opioid agonist (produces a similar response to the intended chemical and receptor), and naxolone, an opioid antagonist (stops the receptor from producing a response), and is indicated for the maintenance of opioid dependence. -When discontinuing treatment, gradually taper to avoid signs and symptoms of withdrawal. Review of the Report submitted by the Facility, via the Health Care Facility Reporting System (HCFRS), dated 05/03/24, indicated that Resident #1 was admitted to the Facility in April 2024, and had not received his/her Physician ordered Suboxone until 05/01/24 (missing a total of 15 doses). Resident #1 was admitted to the Facility in April 2024, diagnosis included history of cocaine use disorder (in remission). Review of Resident #1's Physician's Orders, dated 04/25/24, indicated he/she was to receive Suboxone Sublingual (under the tongue) Film 8-2 milligrams (mg) one film sublingually three times a day (8:00 A.M., 2:00 P.M. and 8:00 P.M.) related to substance abuse. Review of Resident #1's Medication Administration Record (MAR), for the month of April 2024, indicated that Resident #1's Suboxone was not administered by nursing on the following dates, and that on each of the dates the MAR were initialed and signed off by nursing with charting code 9, which indicated to see the Nurse's Notes: -04/26/24 at 2:00 P.M. -04/27/24 at 2:00 P.M. -04/28/24 at 8:00 A.M. and 2:00 P.M. -04/29/24 at 8:00 A.M., 2:00 P.M. and 8:00 P.M. -04/30/24 at 8:00 A.M., 2:00 P.M. and 8:00 P.M. Review of Resident #1's Nurse Progress Notes, dated 04/28/24, 04/29/24 and 04/30/24, all indicated his/her Suboxone was unavailable. The Notes indicated that despite nursing use chart code 9 on 04/26/24 and 04/27/24 (see Nurses Note), there was no nursing documentation specific to the administration of Suboxone on those dates. Further review of Resident #1's Medical Record indicated there was no documentation to support that upon Resident #1's admission to the Facility, or before 04/30/24, of nursing staff ever having notified the Physician that Resident #1 had not received his/her Suboxone as ordered, or to request that the Physician send a prescription for the Suboxone to the pharmacy. During a telephone interview on 05/16/24 at 1:32 P.M., the Pharmacy Manager said the pharmacy required a prescription for Suboxone before the medication could be dispensed and the first prescription for Resident #1's Suboxone was received on 04/30/24. Review of the Controlled Substance Log (a book used by nursing to keep an accurate count of all narcotics and to record administration of narcotics), indicated the first entry for receipt of Resident #1's Suboxone (30 films) was on 05/01/24. During an interview on 05/15/24 at 12:22 P.M., Nurse #1 said that he was on duty and cared for Resident #1 on 04/26/24 during the 7:00 A.M. through 3:00 P.M. shift and also administered his/her 2:00 P.M. scheduled medications on 04/27/24. Nurse #1 said that Resident #1's Suboxone was unavailable. Nurse #1 said he did not notify the Physician that Resident #1 had not received the Suboxone as ordered and that the Suboxone was unavailable. During an interview on 05/15/24 at 3:34 P.M., Nurse #2 said that she was on duty and cared for Resident #1 on 04/26/24 and 04/27/24 during the 3:00 P.M. through 11:00 P.M. shift. Nurse #2 said Resident #1's Suboxone was unavailable. Nurse #2 said that she told her nursing supervisor that the medication was unavailable, but that she (Nurse #2) did not notify the Physician. During a telephone interview on 05/15/24 at 1:14 P.M., the Nursing Supervisor said that she was on duty on 04/27/24 and 04/28/24, and had not administered Suboxone to Resident #1 because it was unavailable. The Nursing Supervisor said she probably got side-tracked and forgot to follow-up, that she should have called Resident #1's provider to request a prescription for his/her Suboxone to be faxed to the pharmacy and to notify the provider that Resident #1 had not received his/her Suboxone as ordered. Review of Resident #1's Nurse Progress Notes, indicated on 04/28/24 at 8:27 A.M. and 3:17 P.M., and on 04/29/24 at 2:32 P.M., Nurse #4 entered that Resident #1's Suboxone was ordered but not yet received. During an interview on 05/15/24 at 12:01 P.M., Nurse #4 said that she was on duty and assigned to Resident #1 on 04/28/24 and 04/29/24 during the 7:00 A.M. through 3:00 P.M. shift. Nurse #4 said Resident #1's Suboxone was unavailable. Nurse #4 said she had heard from other nursing staff (exact names unknown) that Resident #1's Suboxone was on order. Nurse #4 said she did not notify Resident #1's provider that he/she had not received the scheduled Suboxone doses or that he/she needed a prescription for Suboxone to be sent to the Pharmacy. During an interview on 05/15/24 at 11:38 A.M., the Nurse Practitioner (NP) said that she was in to see Resident #1 at the Facility on 04/28/24 and nursing staff did not tell her that Resident #1 needed a prescription for his/her Suboxone or that Resident #1 had not received any doses of his/her Suboxone since admission. The NP said that once she was notified by nursing that Resident #1 needed a prescription (04/30/24), she sent it to the pharmacy, the NP said it had been several days and doses of the Suboxone that Resident #1 had not received as ordered. The NP said that as a general rule, not even one dose of Suboxone should be missed. During a telephone interview on 05/16/24 at 11:45 A.M., the Director of Nurses (DON) said that nursing should have notified Resident #1's provider immediately when Resident #1's Suboxone was not administered as ordered and when it was identified by nursing that Resident #1 did not have any Suboxone available. The DON said the Facility did not have a specific policy for Physician notification related to medications being unavailable or not administered because it was a basic standard of nursing practice.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had limited mobility, and preferred to stay in bed, the Facility failed to ensure he/she was provided with adequate preventative measures to maintain his/her safety in an effort to prevent incidents/accidents resulting in serious injury, when he/she sustained burns from food that had been reheated in the microwave by staff. On 09/01/23, Resident #1 asked a staff member to reheat his/her soup, after the staff member reheated the soup in the microwave, she did not check the temperature of the soup, per facility guidelines, before bringing it back to Resident #1. The soup spilled onto Resident #1, and he/she sustained second degree (partial thickness, involves both the first and second layer of skin and appears red, blistered, and maybe swollen or painful) burns to the left side of his/her neck and shoulder extending to his/her left upper back, he/she required treatments and monitoring of the burn areas by nursing. Findings include: Review of the Facility's protocol titled Guidelines for Reheating of Food in the Microwave indicated once heated per Reheating chart, place thermometer in the center of the food item. Review of the American Burn Association Scald Injury Prevention Guide, dated 2017, indicated older adults are in a higher risk for burns and injuries. Older adults have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize the hot liquid is too hot until the injury has occurred. Resident #1 was admitted to the Facility in May 2021, diagnoses included spinal stenosis, sciatica, type 2 diabetes, obesity, and personality disorder. Review of Resident #1's Plan of Care related to Activities of Daily Living (ADL's), indicated he/she required set up assistance with meals and was independent with eating. Review of Resident #1's Plan of Care related to Functional Mobility, indicated he/she required extensive assistance of two staff for positioning and was totally dependent with the use of a mechanical lift and two staff members for transfers. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 08/18/23, indicated he/she required supervision and set up for eating. Review of the Report submitted by the Facility in the Health Care Facility Reporting System (HCFRS), dated 09/02/23, indicated Resident #1 was in bed, had been eating a cup of soup that a CNA had reheated and when he/she took a bite, the noodles were too hot, he/she dropped the noodles and lost control of the cup. The Report indicated the cup of soup dropped (and the contents spilled) onto (the left side) Resident #1's neck, shoulder and back. The Report indicated the Nurse Supervisor assessed Resident #1 and saw blistering and redness. Review of the Facility's Internal Investigation Report, dated 09/01/23, indicated that the skin around (the left side)Resident #1's neck area was reddened and peeled with a fluid filled blister measuring 1.5 centimeters (cm) x 1 cm. The Report indicated Resident # 1's description of the incident indicated he/she was drinking the soup, when it spilled around his/her neck area. Review of Certified Nurse Aide (CNA) #1's written Witness Statement (included in the Investigation Report), dated 09/01/23, indicated that Resident #1 requested that she warm his/her soup and she heated it for 30 seconds. The Statement indicated Resident #1 said it wasn't warm enough and she reheated the soup a second time, for 30 seconds more. CNA #1's Statement did not indicate whether or not she checked the temperature of the soup with a thermometer, (per facility policy) either of the times she reheated the soup, as required. During an interview on 09/27/23 at 3:40 P.M., Certified Nurse Aide (CNA) #1 said that on 09/01/23, she went into Resident #1's room because of a request to reheat his/her soup. CNA #1 said she reheated the soup in the microwave for 30 seconds, took it back to Resident #1, and he/she said it's not warm enough. CNA #1 said she reheated a second time for 30 seconds and took it back to Resident #1. CNA #1 said she did not use the thermometer either time when she reheated the soup. CNA #1 said she tested the temperature by pouring some soup on the back of her hand and thought it felt ok. Review of Resident #1's Hospital Discharge Summary, dated 09/02/23, indicated that the residents left anterior and left posterior neck were noted with superficial partial and deep partial thickness second degree burns. The Summary indicated treatment instructions were to wash area daily with soap and water and follow up with primary care physician in 3 days. Review of Resident #1's Weekly Skin Audit, dated 09/02/23, indicated that his/her front left shoulder had 50 percent of skin with blisters, and he/she had red areas on his/her upper chest, lower jaw, and left side of the neck. Review of Resident #1's Wound Physician Evaluation, dated 09/06/23, indicated he/she had a left upper shoulder full thickness burn measuring 6.5 x 5 x 0.1 cm, a lower face full thickness burn measuring 14 x 5 x 0.1 cm, a proximal upper chest full thickness burn measuring 6.5 x 5 x 0.1 cm, and a left lateral neck full thickness burn measuring 6.5 x 5 x 0.1 cm. The Wound Evaluation indicated that the primary dressing treatment as ordered by Physician was to apply Silver Sulfadiazine cream once daily for 30 days, and Xeroform gauze, apply once daily for 30 days and a secondary dressing to be applied to burn wounds on upper chest, left lateral neck, and left upper shoulder. The Evaluation indicated an additional dressing treatment was ordered to apply Silver Sulfadiazine twice daily for 15 days for the burn on Resident #1's lower face. Review of Resident #1's Wound Physician Evaluation, dated 09/13/23, indicated Resident #1 was not seen due to a non-wound-related hospitalization since last visit. During an interview on 09/27/23 at 1:17 P. M., the Food Service Director (FSD) said that the temperature guidelines for reheating food are posted in the kitchenettes on each unit near the microwave and thermometers are there as well. The FSD said it has always been the practice of the facility for staff to follow the guidelines and use thermometers to ensure the food temperature is reheated to 155 degrees. During an interview on 09/27/23 at 1:43 P.M., the Staff Development Coordinator (SDC) said the CNA who reheated Resident #1's soup in the microwave, did not follow facility guidelines when she did not use the thermometer to check the temperature after she reheated it. The SDC said it is the Facility's expectations that the CNA's and Nurses follow the reheating guidelines and checking the temperature of the food with the thermometer. During an interview on 09/27/23 at 3:27 P.M., the Nursing Supervisor said it is the Facility's expectations that the CNA's and Nurses follow reheating guidelines and are checking the temperature of the food with the thermometer. The Nursing Supervisor said she did not know if CNA #1 used the thermometer to check Resident#1's soup after reheating it twice. The Nursing Supervisor said the incident happened around 10:00 P.M, and when she assessed Resident #1, his/her skin was red/peeling, and a blister was noted on the left side of his/her neck. The Nursing Supervisor said Resident #1 refused to go to the Hospital Emergency Department that night, so she obtained orders from the on-call provider for Silvadene cream. During an interview on 09/27/23 at 3:01 P.M., the Director of Nurses (DON) said when CNA #1 reheated Resident #1's soup, she had not followed facility guidelines when she did not use a thermometer to check the temperature of the soup after reheating it in the microwave. The DON said it is the Facility's expectations that the CNA's and Nurses follow reheating guidelines and check the temperature of reheated food items with the thermometer. During an interview on 09/27/23 at 2:02 P.M., the Regional Nurse said an audit was conducted on 09/02/23 and all units had the reheating instructions and thermometers near the microwave. The Regional Nurse said she interviewed CNA #1, who said the second time she reheated the soup, she did not take the temperature with a thermometer. On 9/27/23, the Facility presented the Surveyor with a Plan of Correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A. On 9/01/23, Resident #1 was immediately assessed by nursing after the incident, who recommended that he/she go to the Hospital Emergency Department for evaluation and treatment as needed, but he/she refused. The Nursing Supervisor obtained orders for Silvadene cream. B. On 9/01/23, The Nursing Supervisor immediately initiated education with nursing staff on all units, to cease microwave use at that time. C. On 9/02/23, a Facility wide audit was completed by the Director of Nursing and Regional Nurse to ensure all kitchenettes had the Facility Reheating Guidelines and thermometers. Signs were re-posted for related to instructions for heating meals for resident to include temperature reading from the licensed staff on the unit. D. On 9/02/23, the Director of Nursing and the Regional Nurse ensured the process on the 4th floor unit was changed with a second temperature check required by a licensed nurse before serving reheated food to all residents. E. On 9/06/23, the Director of Nursing completed the Education of all nursing staff on the facility's reheating meals guidelines, and temperature checks. F. Starting effective 9/02/23- the Director of Nursing and/or his/her designee are responsible to ensure compliance by conducting weekly audits of the education of staff, with reheating food per facility guidance policy. The audits will be completed weekly for four weeks or until substantial compliance is achieved. The results of the audits will be brought to monthly QAPI meeting, for a minimum of three months. G. During the September 2023 Quality Assurance Performance Improvement (QAPI), the Committee discussed Resident #1's burn incident and as well as the results of the Audits completed thus far by the Director of Nursing. H. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the Facility failed to ensure Resident #1 was free from physical abuse when, on 6/08/23 around 11:30 P.M., Security Guard #1 used physical force to put and hold Resident #1 down on the floor. Findings include: Review of the Facility Abuse, Neglect and Exploitation Policy, implemented 2/2023, indicated that it was the policy of the 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. Review of Resident #1's clinical record indicated that he/she was admitted to the Facility during December 2022 and his/her diagnoses included alcoholic cirrhosis, congestive heart failure, chronic obstructive pulmonary disease and adjustment disorder with depressed mood. Review of Resident #1's most recent Quarterly Minimum Data Set Assessment, completed 6/05/23, indicated that he/she ambulated with supervision and his/her cognitive patterns were intact. During an interview on 7/17/23 at 1:15 P.M., Resident #1 said that Security Guard #1 tackled him/her and put him/her onto the floor. Resident #1 said that Security Guard #1 held him/her on the floor for about two minutes before letting him/her get up. Resident #1 said that he/she was not injured when Security Guard #1 tackled him/her and held him/her on the floor, but said that he/she was sore following the incident. During an interview on 7/17/23 at 4:12 P.M., the Assistant Director of Nurses said that on 6/16/23 Resident #1 told her that he/she had a problem with Security Guard #1 several days ago (later determined to an incident that occurred on 6/08/23). The Assistant Director of Nurses said Resident #1 told her he/she was unable to recall the specific day and said Security Guard #1 tackled him/her and held him/her on the floor. The Assistant Director of Nurses said that Resident #1 told her that since the incident with Security Guard #1, he/she had been experiencing lower back pain. During an interview on 7/17/23 at 3:02 P.M., Security Guard #1 said that staff members called him to Resident #1's unit on 6/08/23 when Resident #1 was arguing with staff members. Security Guard #1 said that when he responded to Resident #1's unit, Resident #1 fought with him so he put Resident #1 into a headlock and put him/her onto the floor. Security Guard #1 said that he held Resident #1 on the floor for one to two minutes while Resident #1 called him names and tried to put his/her hands on his face. Security Guard #1 said when he let Resident #1 get up off the floor, Resident #1 stood up on his/her own with no issue and then he took Resident #1 to his/her room. During an interview on 7/24/23 at 2:12 P.M., the Director of Security said that he reviewed the video surveillance camera footage from 6/08/23 around 11:30 P.M. which depicted an incident between Resident #1 and Security Guard #1. The Director of Security said that the video footage showed the incident from an angle above and outside the elevator. The Director of Security said that although the video surveillance camera footage did not depict the entire interaction between Resident #1 and Security Guard #1, said he could see them tumble to the floor outside of the elevator. The Director of Security said that Security Guard #1 sat on top of Resident #1 for about two minutes while Resident #1 struggled to get up off the floor. The Director of Security said that Facility Security Staff were instructed to be hands off with residents at all times and Security Guard #1 should not have put his hands on Resident #1, caused or contributed to his/her fall to the floor or sat on him/her to keep him/her on the floor. On 7/17/23 the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A) Resident #1 was assessed by the Assistant Director of Nursing on 6/16/23 and determined to have no bruises, redness or open areas related to the incident with Security Guard #1. The Physician/nurse practitioner were notified of Resident #1's allegation and his/her complaint of related pain since the incident. B) The Director of Security placed Security Guard #1 on suspension on 6/16/23 pending an investigation of Resident #1's allegation and the Facility terminated Security Guard #1 on 6/22/23. C) Between 6/16/23 and 6/20/23, the Regional Clinical Specialist reviewed all grievances submitted to the Facility during May and June 2023 and the Progress Notes of all Facility residents between 5/15/23 and 6/23/23 and determined there had been no unreported, documented incidents indicative of resident abuse. D) Between 6/17/23 and 6/30/23, the Facility Social Worker interviewed three residents from each floor weekly regarding experiences of resident safety interventions by Facility security staff members without concerning findings. E) On 6/17/23 and on-going, the Facility interdisciplinary team initiated heightened focus on reviews of all incidents of resident aggression during daily interdisciplinary (morning) meetings. F) On 6/17/23 and on-going, the Facility Regional Clinical Specialist initiated review of all incident reports for timeliness of reporting to Facility leadership. G) Between 6/19/23 and 6/23/23, all Facility staff received training from the Facility Director of Nursing or designee on the Facility Resident Abuse Policies and Procedures and the Facility Code Orange Policy (resident behavioral incidents). H) Between 6/19/23 and 6/21/23, all Facility security staff received training on de-escalation techniques by the Facility substance use disorders counselor. I) On 6/16/23, the Administrator, Regional Clinical Specialist and Social Worker initiated a Quality Improvement Plan (QAPI) to address resident abuse to be reviewed during the June and July 2023 QAPI meetings. J) The Administrator and/or his/her designee are responsible for overall compliance.

Based on records reviewed, review of facility surveillance camera footage, and interviews, for one of three sampled residents (Resident #1) who had a history of being homeless, required hospitalization after sustaining a Traumatic Brain Injury (TBI) due to a fall, and had a Temporary Guardianship in place, the Facility failed to ensure he/she was assessed for risk of elopement and that he/she was provided with adequate supervision to maintain his/her safety to prevent an incident of elopement, when he/she was able to walk out of and away the facility past multiple staff members who were assigned to monitor visitors and residents entering and leaving through the front entrance of the facility. On 11/27/22, at approximately 12:30 P.M., Resident #1 left his/her unit by getting on the elevator across from the nursing station and did so unnoticed by staff members that were in the area at that time. Resident #1 exited the elevator on the first floor, made his/her way to the main lobby, and despite facility policy that all visitors must stop at the reception desk to sign in and out of the facility, Resident #1 was able to walk undetected past the receptionist and a security guard, who were assigned to and stationed in the front lobby, and made his/her way out the front door. Resident #1 exited the facility to the outside patio smoking area located at the front of building, where several residents were attending a scheduled supervised smoking break, which was being supervised by another security guard and the smoking attendant. Resident #1 stood outside against one of the patio railings for several minutes, and although both staff members recall seeing Resident #1 outside that day, neither of them approached or questioned him/her. Resident #1 walked down the front stairs, stopped looked back at staff briefly, and then walked away from the facility. Resident #1 was not noted to be missing by staff until 4:00 P.M., (three and a half hours later). Resident #1's whereabouts are still unknown. Findings include: The Facility's Policy, Elopement, dated 7/2015, indicated that all residents are screened for risk of elopement on admission by the Licensed Nurse. The policy defined elopement as the ability of a resident who is not capable of protecting himself/herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. The Facility's Policy, Leave of Absence (LOA), dated 12/2015, indicated that a physician's order is required for a resident LOA. When the resident is their own responsible person, they may go on LOA unattended. When the resident is not their own responsible person, a responsible person is required to attend the LOA. Residents and responsible persons are required to sign out/in on the LOA log. The Facility's Policy, Visitors Policy, undated, indicated that all visitors must enter the facility through the main entrance. All visitors must register their name, the name of the resident they are visiting and the time of day they enter and leave the facility. The Policy indicated that the guest register is located at the reception desk. The Policy indicated that Visitor badges will be provided to guests by the receptionist and must be worn during the visit, and that visitors may be asked to provide identification. Review of the report submitted by the facility via the Health Care Facility Reporting System (HCFRS), dated 11/29/22, indicated that on 11/27/22 at 4:00 P.M. the nursing supervisor noted that Resident #1 was not in his/her room, was not on his/her unit, Doctor Hunt (facility's missing resident protocol) search was initiated, calls were placed to local hospital emergency departments and Resident #1 had not checked in there, local police, the Nurse Practitioner, his/her Guardian, and facility administrative staff were notified. Police arrived to the facility at 5:30 P.M., report given, Resident #1 has no family contact, is homeless, and does not have an address at this time. The Report indicated Resident #1 had recently been admitted to the facility after an acute hospitalization after he/she had a fall down 14 stairs, with resulting subdural hematoma (bleeding, collection of blood associated with a traumatic brain injury) was without consciousness, and had hemorrhagic contusions with scattered focal fractures. Resident #1 was admitted to the facility in November 2022, diagnoses included traumatic subdural hemorrhage/hematoma (head injury strong enough to burst blood vessels) with resulting cerebral infarct (ischemic stroke) and expressive aphasia (affects speech, as well as writing and understanding spoken/written language), right sided skull and facial fractures, Substance Use Disorder (SUD, related to alcohol abuse) and history of homelessness. Review of Resident #1's Hospital Discharge Summary, dated 11/23/22, indicated that during his/her hospital admission, he/she was determined to be incapacitated and the hospital sought and obtained a court order for Temporary Guardianship. Review of Resident #1's Temporary Guardianship, dated 11/16/22 indicated the resident had acute care needs that required immediate attention, therefore the Guardian was authorized to admit Resident #1 to a nursing facility, apply for health insurance benefits, obtain financial information and authorize an antipsychotic medication treatment plan. The Temporary Guardianship is in place for a period of 90 days, through 2/15/23. Review of Resident #1's Nursing Admission assessment dated [DATE] at 5:40 P.M. indicated he/she was alert to person, but not to place or time. Further review of Resident #1's Nursing Admission Assessment indicated that (despite facility policy that all residents will be assessed upon admission) an Elopement Risk Assessment was not completed upon admission for Resident #1 at any time during his/her admission. Review of Resident #1's Certified Nurse Aide (CNA) Resident Care Card, undated, indicated Resident #1 required continual supervision with ambulation. During an interview on 12/12/22 at 12:37 P.M., Nurse #2 said she completed Resident #1's admission assessments but said she did not complete an Elopement Risk Assessment for him/her on the day of admission. Nurse #2 said an Elopement Assessment should be completed within 1 to 2 days of a resident's admission. During an interview on 12/06/22, the Director of Nursing said Elopement Risk Assessments are to be completed on admission by the admitting nurse. During an interview on 12/07/22 at 9:15 A.M., the Regional Social Worker (SW) said facility policy is that all new admissions are reviewed the next business day at morning meeting. The SW said for new admissions they would review the hospital transfer documentation, and an incapacitated resident would be identified on admission. During an interview on 12/06/22 at 11:48 A.M., the SUD (Substance Use Disorders) Councilor said he had not met Resident #1 due to the Holiday. The SUD Councilor said the admitting Nurse completes the initial SUD/ETOH (alcohol) assessment, and that they look for behaviors in the discharge paperwork that could be a red flag. The SUD Councilor said he likes to assess SUD residents within 48 hours of admission, but that Resident #1 had eloped prior to him being able to complete the assessment. There was no documentation to support an Elopement Risk assessment was ever completed by the facility for Resident #1, who still had a Temporary Guardianship in place due to incapacity related to his/her TBI, who was homeless with no known address, and had no involvement or contact with family for support in the community. Review of Resident #1's Nursing Progress Note dated, 11/27/22 at 4:00 P.M., indicated Resident #1 was not in his/her room and that Doctor Hunt (facility's missing resident protocol) was initiated. The Note indicated the Administrator, Director of Nurses, Guardian, Police and local hospitals were notified of the missing resident. During the dates of survey, the surveyors made the following observations of the facility's main entrance, lobby area, and outdoor smoking area (patio) that is directly off the main entrance. The lobby was observed to be approximately 12 feet (ft) x 12 ft, and was a very small, enclosed area, so anyone coming and going through the lobby, including in or out the front door, would be seen by staff seated in the lobby. There is a Security Guard desk equipped with a security camera monitor, and another desk adjacent to the Security Guard for the Receptionist, where visitors and vendors are instructed to stop to sign in and out of the facility. There was another door a few feet away from the Reception Desk that enters onto the first floor. There are no resident rooms on the first floor. The elevators on the first floor are located beyond the lobby area down a hallway and are not in view of staff stationed in the lobby. Review of surveillance camera video footage provided by the facility, indicated the timeline and sequence of Resident #1's elopement on 11/27/22 were as follows: -12:31 P.M., Resident #1 comes out of his/her room into the hallway on the 5th Floor and makes his/her way to the area close to the nursing station. Resident #1 is dressed in a long-sleeved shirt and khaki pants, and places a suit jacket on a chair in the hallway. A nurse and a certified nurse aide (CNA) can be seen in the area around the nursing station, but do not appear to notice or acknowledge Resident #1's presence. Resident #1 has full view and easy access to the unit two elevators that are now in front of him/her. A food truck had also been delivered and left on the unit, and obscures the 5th floor unit camera's view of the elevators. -12:32 P.M., Resident #1 walks toward the elevators, then turns back toward the chair where he/she left the jacket, he/she picks it up, and then walks in a hurried manner towards the elevators. Resident #1 is no longer in view of the 5th floor camera at this point. The next time surveillance camera footage (no time stamp available) shows Resident #1 as he/she is exiting the building through the main entrance front door that leads directly to the designated smoking area in the front of the building. Resident #1 can be seen dressed in a long sleeve shirt, khaki pants, sneakers, with his/her right hand in his/her suit jacket pocket, he/she was not observed to be on a cell phone at that time. Once Resident #1 exited the elevator on the 1st floor and made his/her way down the hallway to get to the lobby, once in the lobby he/she would have to walk past the receptionist and the security guard stationed in the front lobby in order to get to and go out through the main entrance. Surveillance camera footage then shows Resident #1 as he/she walks over to the exterior main entrance stairs and leans against the railing. There is another resident in view of the camera sitting to the left of where Resident #1 was standing at the top of the stairs. Resident #1 walks down the stairs, stops, and while facing the street, he/she appears to be looking for something in his/her clothing. Resident #1 pulls out a cell phone from the left back pocket of his/her pants and then appears to be speaking on the phone. Resident #1 proceeds to walk over a grassy area next to the stairs while holding the phone in his/her right hand and then steps onto the sidewalk. Resident #1 can be seen on the camera footage running away from the facility. -12:37 P.M., Resident #1 can be seen on another external facility surveillance camera walking on the sidewalk, away from the facility with his/her cell phone in his/her right hand holding it to his/her right ear. - 12:39 P.M. is the last time Resident #1 is seen on surveillance camera footage, he/she is walking down the hill away from the facility and looking at his/her cell phone. Review of the surveillance camera footage from 12:33 P.M. to 12:39 P.M., indicated that the Smoking Attendant and Security Guard, assigned to supervise the residents attending the 12:30 P.M. to 1:15 P.M., scheduled smoking break do not come into the view of the cameras, so their exact locations or what they are doing on the patio are not captured or recorded. Surveillance camera footage was reviewed multiple times by the surveyors, and there was no surveillance camera footage that showed or supported that Resident #1 was ever approached, questioned, or stopped by staff members at any point on the day he/she eloped from the facility. During an interview on 12/07/22 at 11:37 A.M., Security Guard (SG) #2 said he was on duty 11/27/22 for the day shift. Security Guard #2 said he could not recall if he was stationed in the lobby area or out in the smoking area during the smoking break that started at 12:30 P.M. SG #2 said prior to Resident #1's elopement that day, the LOA Book had not been updated regularly. SG #2 said on 11/27/22, he did see, but did not recognize the person (Resident #1) leaving the facility as a resident. SG #2 said he can only assume that the person (Resident #1) appeared to be a visitor when he/she left the facility, but said he did not observe the person (Resident #1) sign in or out with the receptionist. SG #2 and said although he saw him/her, said he did not stop the person (Resident #1) to question him/her, but should have. During an interview on 12/07/22 at 11:10 A.M., Security Guard (SG) #1 said she was on duty 11/27/22 during the day shift, and was assigned to cover the front lobby area. SG #1 said all visitors are required to stop at the reception desk in the lobby to sign in/out and receive a visitor sticker upon entering. SG #1 said she did not see Resident #1 enter the building or sign in as a visitor that day. SG #1 said although she was assigned to cover the lobby that day, said she did not see Resident #1 leave the facility that day. Although SG #2 said he assumed the person (Resident #1) he observed on 11/27/22 out in the smoking area and then leaving facility grounds during the smoking break was a visitor, there was also no documentation to support that the person (Resident #1) signed into the visitor log or was stopped in the lobby by staff to sign out of the facility that day, as a visitor. During an interview 12/07/22 at 3:20 P.M., Nurse #1 said she was the Nursing Supervisor on duty 11/26/22 and 11/27/22. Nurse #1 said she had met Resident #1 on 11/26/22, he/she was quiet and kept to him/herself. Nurse #1 said on 11/27/22, she worked as a staff nurse on Resident #1's unit and after completing her medication pass on the day shift, she did rounds on the unit before going to another floor for the next shift. Nurse #1 said that was when she noticed Resident #1 was not in his/her room and asked other staff members if they had seen him/her. Nurse #1 said they started looking throughout the unit, including in the closets, and community rooms without success. Nurse #1 said Security was notified and they said they had not seen Resident #1. Nurse #1 said other residents reported to staff that they had seen Resident #1 outside in the smoking area talking on the phone. Nurse #1 said Dr Hunt was initiated at 4:00 P.M. The Administrator, Director of Nurses, the physician, local Police and Resident #1's Guardian were notified. Nurse #1 said Resident #1 was still missing when she completed her shift at 11:00 P.M. During an interview on 12/07/22 at 3:02 P.M., The Smoking Aide said she was working on 11/27/22, and did see a person (later identified to be Resident #1) in a suit jacket standing near the stairs talking on the phone, but said she did not know he/she was a resident. Smoking Aide said she was only responsible to supervise residents who are out there to smoke. During an interview on 12/06/22 at 9:30 A.M., the Administrator said that Resident #1 was admitted to the facility 11/23/22 and eloped on 11/27/22 at 12:30 P.M. The Administrator said they reviewed the surveillance camera video footage to determine how Resident #1 managed to elope that day. The Administrator said watching the video of the incident, Resident #1 presented like a visitor when exiting the facility. The Administrator said there was a receptionist and a security guard assigned to and stationed in the lobby on 11/27/22 at the time of Resident #1's elopement. The Administrator said Resident #1 should have been stopped by the receptionist or security guard before exiting the facility, as a resident or visitor, according to facility policy. On 12/07/22 the facility provided the surveyors with an acceptable plan of correction that addressed the identified area of concern. The plan of correction included the following: A. 11/27/22, Facility and ground search conducted for Resident #1, local police, hospitals, and Temporary Guardian notified. B. 11/28/22, Facility initiated Nursing Rounds, all nurses must conduct a room by room search at the start of each shift and ensure they have visual contact with all residents they are assigned to care for. C. 11/27/22 and 11/28/22, Nursing Supervisors and Nursing Management staff completed audits on all resident records to ensure Elopement Risk Assessments were completed and accurate. D. 11/28/22 through 11/30/22, Nursing Supervisors and Nursing Management completed resident record audits to ensure baseline care plans were in place, and that comprehensive care plans were updated as needed. E. 11/27/22 and 11/28/22, Nursing Supervisors and Nursing Management staff reviewed care plans and care cards for all residents assessed for and identified as being at risk for elopement and were updated as needed. F. 11/28/22 and 11/29/22, Administrative staff provided education and training to Receptionist(s), and staff assigned as smoking attendant regarding visitations, elopements, and supervision of residents. G. 11/27/22, immediate change,Security Guards, Receptionist, and Smoking Attendants to review Elopement Book at the start of each shift for any updates. H. 11/27/22 through 11/30/22, Staff Education Coordinator (SDC) and Management reviewed the Elopement Policy, which included the 5 Eyes of Elopement with all staff and immediate actions to be taken by staff in the event of a missing resident. SDC provided staff education related to Identifying resident risky behaviors for elopement is key. I. 11/28/22 through 11/30/22, Staff Education Coordinator and Nursing Management team completed education for nursing staff on identifying, reporting, and documenting when a resident exhibits risky behavior, which included observations and a list of potentially risky behaviors. J. 11/28/22 through 11/30/22, Staff Education Coordinator and Nursing Management team provided education to nursing staff regarding reviewing and being aware of changes in residents plans of care, safety measures, and K. 11/30/22, Main Entrance Security Change, a new keypad lock installed on front door, anyone wishing to enter or exit the facility (residents, staff, visitors) can only do so by first being screened by security guards. Security Guards are assigned to the facility 24/7. L. Facility QAPI Committee meeting to include and continue to review concerns identified related to resident safety, security, elopement risks, and resident assessments. M. The Administrator, Director of Nursing, and/or their designees will be responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a permanent Guardianship in place and therefore was not his/her own responsible person, the Facility failed to ensure their policy for residents requiring accompaniment to appointments was implemented and followed, so that Resident #1 was provided with adequate supervision during an appointment outside of the Facility. On [DATE], Resident #1 left the Facility transported to a medical appointment by a chair van service, without an escort to accompany and stay with him//her while he/she was at an outside appointment. While at the appointment, Resident #1 left the appointment by him/herself and has not been located since. Findings include: The Facility's Policy, titled, Accompaniment of Residents to Scheduled Appointments, dated ,d+[DATE], indicated: -The Facility would attempt to maintain resident's safety on appointments scheduled by the Facility which occur outside of the Facility. -If the resident is not deemed safe and competent to attend the appointment alone the Facility will assist in providing accompaniment. -The resident's responsible party will be contacted to determine if they would like to accompany the resident to the scheduled appointment. -The responsible party may also chose an alternate party to accompany the resident who is not employed by the Facility. -In the event that no responsible party not employed by the Facility is able to accompany the resident, the Facility will provide accompaniment to the scheduled appointment. The Facility's Policy, titled, Elopement, dated ,d+[DATE], indicated elopement was defined as the ability of a resident who is not capable of protecting him/herself from harm to successfully leave the Facility unsupervised and unnoticed and who may enter into harm's way. The Facility's Investigation Report, undated, indicated that on [DATE], Resident #1 was heard saying goodbye and I'm going home after my appointment to other residents as he/she was getting ready to leave the Facility to attend a Physician's appointment. The Report indicated Nurse #1 checked with the Director of Social Services, who said Resident #1 was not prepared for discharge. The Report indicated Resident #1 was sent to the outside appointment without a staff member to escort him/her, and he/she eloped from the appointment. Resident #1 was admitted to the Facility in [DATE], diagnoses included [CONDITION(S)], alcohol and substance abuse, heart failure, and dementia. Review of the Speech Therapy Evaluation and Plan of Treatment, dated [DATE], indicated Resident #1 exhibited cognitive deficits with orientation, reasoning, and had delayed recall and safety issues. Review of the Montreal Cognitive Assessment (MoCA), dated [DATE], indicated Resident #1 scored 13 out of 30, indicating that Resident #1 was cognitively impaired. Review of Resident #1's Behavior Care Plan, dated [DATE], Activities of Daily Living Care Plan, dated as revised [DATE], Cognition Care Plan, dated as revised [DATE], Functional Mobility Care Plan, dated as revised [DATE], and Communication Care Plan, dated as revised [DATE], all indicated he/she had deficits related to impaired cognition from dementia. Review of Resident #1's Potential for Discharge Care Plan, dated [DATE], and his/her Advanced Directives Care Plan, dated [DATE], indicated he/she had an emergency Guardian in place, which was due for court review on [DATE]. Review of the Order Appointing Temporary Guardian for an Incapacitated Person, dated [DATE], indicated a court appointed temporary Guardianship for Resident #1, which included authorization to admit him/her to a nursing facility, the temporary Guardianship would expire on [DATE], and a hearing would be held on [DATE] to determine ongoing Guardianship. Review of the Electronic Mail (Email), sent from the Guardian's Office to the Director of Social Services, dated [DATE], indicated the Director of Social Services was provided a copy of Resident #1's Decree and Order of Appointment of Guardian for an Incapacitated Person, dated [DATE]. The Decree and Order of Appointment of Guardian for an Incapacitated Person, dated [DATE], indicated it was for permanent court ordered Guardianship for Resident #1, which included Guardianship over his/her person and authorization to admit him/her to a nursing Facility. However, review of Resident #1's Medical Record indicated there was no documentation to support that the Decree and Order of Appointment of Guardianship for an Incapacitated Person, dated [DATE], was placed in his/her Medical Record. Review of the Social Services Note, dated [DATE], indicated Nurse #1 told the Director of Social Services that Resident #1 was observed saying goodbye and had packed his/her belongings, as though he/she was being discharged following an outside appointment, and Nurse #1 had asked if he/she had a discharge planned for that day. The Note indicated the Director of Social Services told Nurse #1 that Resident #1 did not have a planned discharge, and that he/she had a Guardianship in place. The Note indicated the Director of Social Services called the Guardian and made her aware that Resident #1 had verbalized that he/she was not returning from the appointment, and that Resident #1's Guardian said she was still working on finding housing. Review of the Nursing Progress Note, dated, [DATE], indicated Resident #1 did not return from his/her outside appointment, and that the transportation company called the Facility to notify them that they were informed by the medical office staff that Resident #1 had left the appointment 10 minutes before they arrived. Review of the Orders Administration Note (nursing documentation related to medication administration), dated [DATE], indicated Resident #1 eloped from an outside appointment. During interview on [DATE] at 11:02 A.M., the Director of Social Services said Resident #1 was admitted to the Facility with a temporary Guardianship in place, which expired on [DATE]. The Director of Social Services said she was notified a few weeks later that Resident #1's Guardianship had been made permanent on [DATE], and said she had a copy of it in a folder in her office, but had not updated the nursing department or filed the updated Guardianship in his/her medical record. The Director of Social Services said that on [DATE], Nurse #1 told her that Resident #1 was observed saying goodbye to peers and staff and asked her if there was a plan to discharge him/her after his/her scheduled doctor's appointment. The Director of Social Services said she told Nurse #1 there was not a discharge plan in place, and that Resident #1 had a Guardianship. The Director of Social Services said she asked Nurse #1 if Resident #1 had an escort, and that Nurse #1 said a staff member was waiting with him/her outside for transportation to arrive. The Director of Social Services said she then called Resident #1's Guardian to inform her of Resident #1's intent to leave, and said the Guardian told her she was still working on finding appropriate housing for him/her. The Director of Social Services said she went outside to speak to Resident #1, but he/she had already left for the appointment. The Director of Social Services said she assumed a staff member had escorted Resident #1 to the appointment, but said she did not clarify if Resident #1 was provided with an escort to the appointment. The Director of Social Services said any resident with a Guardianship in place needs to have an escort to any outside appointment. During interview on [DATE] at 12:48 P.M., Nurse #1 said that on [DATE], she was working on the opposite side of the same unit where Resident #1 lived. Nurse #1 said she overheard Resident #1 saying goodbye to other residents as he/she was leaving the unit to go to an outside Physician's appointment, and said she called the Director of Social Services to ask if he/she was being discharged . Nurse #1 said the Director of Social Services said there was no plan to discharge Resident #1 that day. Nurse #1 said Resident #1 was already outside waiting for transportation when she spoke to the Director of Social Services, said she did not know if he/she had an escort to the Physician's appointment, and said the Director of Social Services did not ask if he/she had an escort. During interview on [DATE] at 2:54 P.M., Resident #1's Guardian said she was not notified of his/her outside appointment until [DATE] (the day of the appointment), and said the Facility should have sent an escort with Resident #1 to his/her appointment. During interview on [DATE] at 12:01 P.M., the Director of Nurses said that if nursing staff had known Resident #1 had a Guardianship, he/she would have had a staff escort to his/her appointment, and said any resident with a Guardianship in place needs to have an escort to any outside appointment. The Director of Nurses said, Resident #1's location was still unknown.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when on [DATE], his/her temporary Guardianship expired and became a permanent Guardianship, the Director of Social Services, who was made aware of the change, failed to update Resident #1's medical record with the new Guardianship paperwork. As a result, on [DATE], Resident #1, who was not his/her own responsible person, left the Facility without an escort, was transported to a medical appointment by a chair van service, and while at the appointment, Resident #1 eloped and has not been located since. Findings include: The Facility's Policy, titled, Medical Record Policy and Procedure, Authorization and Release Element, dated [DATE], indicated the medical record was defined as the collection of information concerning the resident and their health care that was created and maintained in the regular course of business, and may include records maintained in an electronic system. The Policy indicated the medical record would include legal forms, including Guardianships. The Facility's Investigation Report, undated, indicated that on [DATE], Resident #1 was heard saying goodbye and I'm going home after my appointment to other residents as he/she was getting ready to leave the Facility to attend a Physician's appointment. Nurse #1 checked with the Director of Social Services, who said Resident #1 was not prepared for discharge. Resident #1 was sent to the outside appointment without a staff member to escort him/her, and eloped from the appointment. Resident #1 was admitted to the Facility in [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Order Appointing Temporary Guardian for an Incapacitated Person, dated [DATE], indicated a court appointed temporary Guardianship for Resident #1, which included authorization to admit him/her to a nursing facility, the temporary Guardianship would expire on [DATE], and a hearing would be held on [DATE] to determine ongoing Guardianship. Review of the Electronic Mail (Email), sent from the Guardian's Office to the Director of Social Services, dated [DATE], indicated the Director of Social Services was provided a copy of Resident #1's Decree and Order of Appointment of Guardian for an Incapacitated Person, dated [DATE]. The Decree and Order of Appointment of Guardian for an Incapacitated Person, dated [DATE], indicated it was a permanent court ordered Guardianship for Resident #1, which included Guardianship over his/her person and authorization to admit him/her to a nursing facility. Review of Resident #1's Medical Record indicated there was no documentation to support that the Decree and Order of Appointment of Guardianship for an Incapacitated Person, dated, [DATE], was placed in his/her medical record. Review of Resident #1's Behavior Care Plan, dated [DATE], Activities of Daily Living Care Plan, dated as revised [DATE], Cognition Care Plan, dated as revised [DATE], Functional Mobility Care Plan, dated as revised [DATE], and Communication Care Plan, dated as revised [DATE], indicated he/she had deficits related to impaired cognition from dementia. Review of Resident #1's Potential for Discharge Care Plan, dated [DATE], and his/her Advanced Directives Care Plan, dated [DATE], indicated he/she had an emergency Guardian in place, which was due for court review on [DATE]. Review of the Nursing Progress Note, dated, [DATE], indicated Resident #1 did not return from his/her outside appointment, and that the transportation company called the Facility to notify them that they were informed by the medical office staff that Resident #1 had left the appointment 10 minutes before they arrived to transport him/her back to the Facility. Review of the Orders Administration Note (nursing documentation related to medication administration), dated [DATE], indicated, Resident #1 eloped from an outside appointment. During interview on [DATE] at 11:02 A.M., the Director of Social Services said Resident #1 was admitted to the Facility with a temporary Guardianship in place, which expired on [DATE]. The Director of Social Services said she was notified a few weeks later that the Guardianship was made permanent on [DATE], and said she had a copy of it in a folder in her office, but had not updated the nursing department or filed the updated Guardianship in his/her medical record, but should have done so. During interview on [DATE] at 12:01 P.M., the Director of Nurses said that on [DATE], the nursing staff were not aware that Resident #1 had a Guardianship in place, that nursing would have gotten the information for the medical record. The DON said that if nursing staff knew Resident #1 had a Guardianship in place, an escort would have been sent with him/her to the appointment. The Director of Nurses said Resident #1's location was still unknown.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who were assessed to be at risk for elopement, were severely cognitively impaired, and resided on a secure unit, the Facility failed to maintain Resident #1's and Resident #2's safety and ensure adequate supervision was provided during scheduled resident smoke breaks in the Facility's designated smoking area, which is an open, unsecured patio in the front of the Facility with direct access to the street via a set of stairs, as a result both residents eloped from the smoking area, and one resident remains missing. - On 10/18/21 at approximately 11:55 A.M., while attending a staff supervised outdoor smoking break activity in the Facility's designated smoking area located on the open, unsecured patio area at the front of the building (with direct access to the street from the patio stairs), Resident #1 with a known history of prior elopements, eloped from the Facility's designated smoking area unbeknownst to staff, and has not been found. - On 10/15/21 at 8:09 P.M. (three days prior to Resident #1's elopement), while attending a staff supervised outdoor smoking break activity in the Facility's designated smoking area located on the open, unsecured patio area at the front of the building (with direct access to the street from the patio stairs), Resident #2 eloped from the Facility's designated smoking area unbeknownst to staff . On 10/15/21 at approximately 10:45 P.M. (2.5 hours after he/she had eloped), a Family Member called the Facility and informed staff that Resident #2 arrived at his/her Family's residence (approximately 46 miles from the Facility). - On 10/21/21, (which was six days after Resident #2's elopement and three days after Resident #1's elopement), during the Survey, the Facility reported that although video surveillance equipment installed in the designated smoking area on the patio at the front of the building was active and functioning at the time of both elopements, the Facility had not reviewed the surveillance footage (as part of their investigation) to determined how Resident #2 had eloped, in an effort to potentially prevent other residents, including Resident #1 (who remains missing) from eloping. Refer to F656 and F684 Findings include: Review of the Facility Policy titled, Elopement, dated 7/2015, indicated the Facility strives to promote resident safety by maintaining a process to screen all residents for risk of elopement, implement preventive strategies for residents identified at risk, institute measures for resident identification at the time admission and conduct missing resident procedures, as warranted. 1. Review of Resident #1's Hospital Admission Report, dated 9/09/21, (prior to admission to the Facility) indicated he/she presented to the Emergency Department with acute mental status changes and a witnessed [CONDITION(S)]. The Report indicated he/she was found to have had a [MEDICATION(S)] (an opioid drug) overdose, which was responsive to [MEDICATION(S)] (a reversal agent for opioid overdose). The Report indicated Resident #1 remained confused and was admitted for placement, as his/her family is unable to take care of him/her and he/she was deemed unsafe to discharge to the streets. The Hospital Admission History indicated that during Resident #1's January 2020 admission to the Hospital, he/she required 24/7 supervision and was discharged to a Nursing Home, from which he/she later eloped. Review of Resident #1's Medical Record indicated that his/her diagnoses included Dementia with opioid and [CONDITION(S)]. The Record indicated that during his/her admission to this Facility in 7/2021, while at an appointment at an outside Physician's office, Resident #1 eloped. Review of Resident #1's Nursing Admission Note, dated 10/01/21, indicated upon admission from the Hospital, Resident #1 was admitted to a Secured Unit. Review of Resident #1's Elopement and Wandering Assessment, dated on 10/01/21, indicated that Resident #1 was at risk for wandering and elopement. Review of the Facility's Health Care Proxy Form, dated 10/05/21, indicated it was determined that Resident #1 lacked the capacity to make health care decisions due to a cognitive deficits caused by dementia. Review of Resident #1's Care Plan titled Behavior Problem concern, dated as initiated 10/04/21, indicated that Resident #1 was at risk to try to leave the nursing facility, that he/she expressed the desire to go home and moved about the unit with no rational purpose. The Care Plan goal was that Resident #1 would not leave the Facility unescorted. Resident #1's Behavior Problem Care Plan interventions included the following: - Encourage participation in positive meaningful diversional activity programs of choice. - Establish and maintain daily routine to meet physical needs. - If he/she is seen at an exit, encourage him/her to come with staff. Further review of Resident #1's Care Plans indicated there was no documentation to support that additional interventions were developed or implemented related to Resident #1's tendency to wander without purpose or his/her risk for elopement when it came to Resident #1 requiring supervision in the designated smoking area. Review of Resident #1's Admission Minimum Data Set Assessment (MDS), dated [DATE], indicated that his/her cognition was severely impaired, his/her mood was depressed or hopeless, and that he/she had behaviors of verbal symptoms directed toward others. The MDS indicated Resident #1 required supervision with ambulation, and he/she wandered one to three days out of the seven-day assessment period. The MDS indicated Resident #1's wandering placed him/her at a significant risk of getting to a potentially dangerous place and compared to prior assessments, his/her wandering had become worse. Review of the Nursing Progress Note, dated 10/08/21, indicated Resident #1 was agitated walking from his/her room to the nurse's station, stating, who the [OBSCENITY] took my hat? The Note indicated the nurse helped him/her look for the hat which was found inside one of the drawers in his/her room and, he/she was medicated with [MEDICATION(S)] 25 milligrams (mg) (an anti-psychotic medication) with positive effect. Review of the Nursing Progress Note, dated 10/09/21, indicated Resident #1 was agitated and was medicated with [MEDICATION(S)] 25 mg for agitation. Review of the Nursing Progress Note, dated 10/18/21 at 12:45 P.M., indicated that at approximately 12:45 P.M., the nurse was notified by staff that the food on Resident #1's lunch tray had not been eaten. The Note indicated an elopement code (a emergency protocol for elopement) was initiated. The Note indicated Resident #1 was not found within the Facility or the surrounding area. The Administrator, the Physician, the Healthcare Agent, and the Police were notified of the elopement. Review of the Police Report, dated 10/18/21 at 1:16 P.M., indicated that the Facility notified the Police Department that Resident #1, a cognitively impaired resident, had walked away from the Facility during a morning smoking break. Review of the Facility's Elopement Investigation, dated 10/18/21, indicated that the staff were not aware that Resident #1 had eloped until his/her lunch tray was left untouched, approximately one hour after he/she had eloped from the outdoor smoking break. Further review of the Investigation indicated the description of the elopement circumstances was left blank. Additionally there was no documentation to support that corrective actions were implemented or that environmental safety checks were conducted, in an effort to prevent the potential for other resident elopements. Review of Resident #1's Medical Record and during an interview on 10/22/21 at 3:20 P.M., the Acting Director of Nursing said that it had been four days since Resident #1 had eloped and said he/she had still not been found. On 10/21/21 at 12:15 P.M., the Surveyor with the Assistant Administrator (for the first time) watched the outdoor video surveillance footage of the 11:00 A.M. to 12:00 P.M. smoking break for resident who resided on the secured unit, and were in the designated smoking area, the open, unsecured patio area, at the front of the building. In the video, Resident #1 can be seen looking around, then stands up from his/her chair and walks in the direction of the staircase. Resident #1 then leaves the Facility grounds unsupervised on 10/18/21 at 11:55 A.M., according to the video time stamped recording. Review of Nurse #1's written Witness Statement, dated 10/18/21, indicated prior to Resident #1's elopement, she observed that he/she had been wandering the hallway stating he/she wanted to get some money and wanted staff to call his/her Family Member. The Statement indicated Nurse #1 reported that Resident #1 was last seen at the Nurses' Station wandering (exact time not indicated). Review of the Ambassadors written Witness Statement, dated 10/21/21, indicated on 10/18/21, during the secured unit smoke break between the times of 10:00 A.M. and 11:20 A.M., Resident #1 said he/she needed to go to the bank to get money. The Statement indicated the Ambassador told Resident #1 that she would find out how he/she could get money, then she went to lunch and later learned he/she had eloped. Review of Certified Nurse Aide (CNA) #1's, CNA #2's, and CNA #3's written Witness Statements (who were responsible for the supervision and transportation of residents to and from the smoking area), dated 10/18/21, indicated that neither of these three CNA's brought Resident #1 back to the secured unit. During an interview on 10/21/21 at 3:15 P.M., with CNA #1 and at 4:34 P.M. with CNA #2 , and on 10/22/21 at 1:22 P.M. with CNA #3, the CNA's said they had brought residents to the smoking area in groups of three, but all three CNA's said they did not bring Resident #1 back to the unit on 10/18/21 during the 11:00 A.M. to 12:00 P.M. smoking break. The CNA's said the process of bringing residents back to the secured unit was not organized. CNA #1 and CNA #2 said there was no system to track and confirm that individual residents had been returned safely to the unit, and that there was no mechanism to count and match the number of those who left the secured unit with the number of those who returned. During observations on 10/21/21, the Surveyor observed the following: - Designated smoking area is a concrete patio in the front of building, it is an open, unsecured area, there are several seating areas with tables and chairs on both sides of the patio, with a small set of stairs to the front of the patio that exit to the sidewalk and away from the Facility. - 9:54 A.M. six residents from the third floor unit were out on a smoke break, and were being supervised by Security Guard #2, who was also responsible for counting, documenting and distributing cigarettes, while trying to supervise the residents. - 3:40 P.M. five residents from the third floor unit were out on a smoke break, and were being supervised by the Smoking Attendant, who was also responsible for counting, documenting, and distributing cigarettes while trying to supervise the residents. During both observations the surveyor also observed two doors in the patio area, these doors lead to the heating and air conditioning mechanical equipment that were in an enclosed fenced area, one of the doors were unlocked, leaving this area unsecured and accessible by residents. During an interview on 10/22/21 at 10:35 A.M., the Director of Maintenance said one of the doors that exited the Smoking Area lead to an enclosed fenced area for the HVAC (Heating Ventilation Air Conditioning) system, which was left unlocked by the maintenance staff and should have been kept locked. During an interview on 10/21/21 at 3:16 P.M., with Security Guard #1, at 3:25 P.M. with CNA#1, and at 3:40 P.M., with the Smoking Attendant, they each said they could not adequately supervise the residents in the smoking area while counting and distributing smoking material. During an interview at 9:55 A.M. on 10/21/21 with the Assistant Administrator, said there are usually two staff members outdoors at all the resident smoke breaks for supervision, but said when she looked outdoors to the smoking area today (10/21/21), said there was only Security Guard #2 supervising the residents, as well as distributing and counting cigarettes with the six residents. During an interview on 10/21/21 with the Assistant Administrator at 9:55 A.M. and the Acting Director of Nurses at 10:15 A.M., both said the Facility has outdoor video surveillance 24/7, but said the video surveillance footage of Resident #2's elopement (three days ago) and Resident #1's elopement (six days ago) had not been viewed by anyone in Administration until this Survey. During an interview at 10:15 A.M. on 10/21/21, the Acting Director of Nurses (DON) said there always needs to be two staff members to supervise the smoking breaks for safety, with residents from all the units (but 20 minutes earlier, there had been only one person, Security Guard #2). The Acting DON also said that Facility Administration had not yet reviewed the video surveillance footage of the elopements. During an environmental tour of the Smoking Area, at 3:40 P.M. on 10/21/21, with Security Guard #1 and Security Guard #2, both said one of the doors in the smoking area (that went into the enclosed are with the mechanical equipment) had been left unlocked and should have been secured. Security Guard #1 said Resident #1 probably stayed hidden in the enclosed area behind the door until everyone went indoors, and then came out and left the Facility. As of 10/27/21, Resident #1 was still reported as missing. 2. Review of Resident #2's Medical Record indicated that his/her medical history included toxic metabolic [CONDITION(S)] (a dysfunction within the brain caused by chemical imbalance in the blood) with alcohol withdrawal prior to admission, a history of opioid abuse, and [CONDITION(S)] illness. Review of Resident #2's Elopement and Wandering Assessment, dated on 10/07/21, indicated that Resident #2 was at risk for elopement. Review of the Facility's Bed Change List, indicated Resident #2 was admitted to an unsecured (open) unit on 10/07/21 at 7:50 P.M. and he/she had a bed change to the secured unit on 10/8/21 at 4:35 P.M. Review of the Nursing Progress Note dated 10/08/21, indicated Resident #2 had intermittent confusion. Review of Resident #2's Care Plan titled Behavior Problem, dated as initiated 10/11/21, indicated that Resident #2 was at risk for elopement and that he/she had tried to leave the Facility. The Care Plan indicated the goal was that Resident #2 would not leave the Facility unescorted. Resident #2's Behavior Problem Care Plan interventions included the following: - Encourage participation in positive meaningful diversional activity programs of choice. - Establish and maintain daily routine to meet physical needs. - If he/she is seen at an exit, encourage him/her to come with staff. - Moved to the secured unit. - Provide picture identification and description of resident to office staff located near the exits. Further review of Resident #2's Care Plans indicated there was no documentation to support that additional interventions were developed or implemented related to his/her risk for elopement when it came to Resident #2 requiring supervision in the designated smoking area. Review of the Physician's Order, dated 10/12/21, indicated Resident #2's Health Care Proxy had been invoked due to cognitive impairment. Review of Resident #2's Admission MDS, dated [DATE], indicated that he/she was severely cognitively impaired, had behavior symptoms that were not directed toward others, he/she required supervision with ambulation, and wandered daily during the seven-day assessment period. The MDS indicated Resident #2's wandering placed him/her at a significant risk of getting into a potentially dangerous place and compared to prior assessments, his/her wandering was worse. Review of the Nursing Progress Note, dated 10/14/21, indicated Resident #2 continued to wander in the hallway, into other residents' rooms and closets, that he/she was redirected with poor effect and yelled when he/she was redirected. Review of the Nursing Progress Note, dated 10/15/21 at 10:40 P.M., indicated the Nursing Supervisor was informed that Resident #2 could not be found on the Secured Unit. Review of the Facility's Investigation, dated 10/15/21, indicated that Resident #2 went missing from the Facility on 10/15/21 at 8:45 P.M., that he/she was confused, has mental illness, he/she requires supervision and verbal cues. The Investigation indicated during the secured units smoke break at approximately 7:15 P.M., Resident #2 was seen in the outdoor smoking area for his/her evening smoke but was never seen returning to the secured unit. An Elopement Code was called and staff were unable to locate Resident #2. Further review of the Investigation indicated there was no documentation to support an environmental safety check was conducted. Review of the Police Report, dated 10/15/21 at 9:11 P.M., indicated a Police Officer was dispatched to the Facility for a report that Resident #2 was missing from the Facility and was last seen in the outdoor smoking area between 8:15 P.M. and 8:45 P.M. Review of the Nursing Progress Note, dated 10/15/21, indicated that the Facility received a telephone call from Resident #2's invoked Healthcare Agent (HCA) at approximately 10:45 P.M. (over 2.5 hours after his/her elopement) who said that Resident #2 had appeared at the HCA's home, and the HCA sent him/her to the Hospital Emergency Department for an evaluation. During an interview on 10/27/21 at 1:20 P.M., the Nurse Practitioner said she performed the psychiatric exam on Resident #2 on 10/13/21, and diagnosed him/her as being in an acute hypomanic (condition in which person displays revved up energy or activity level, mood or behavior) state with delusions (false beliefs), and ordered [MEDICATION(S)] (a mood stabilizing medication), with the expectation that it would have been administered on the day it was ordered, 10/13/21. The Nurse Practitioner said a resident with hypomania is at an increased risk for elopement without mood stabilizing medications. Review of the Psychiatric Nurse Practitioner Note, dated 10/13/21 at 10:33 A.M., indicated that staff reported that Resident #2 had not slept in more than three days, that he/she had been wandering in the hallways, was impulsive and difficult to re-direct. The Note indicated Resident #2 was talking excessively, had no inhibitions and was delusional. The Note indicated Resident #2 was in a hypomanic state, a mood stabilizer was needed, and to administer [MEDICATION(S)] 250 milligrams (mg) twice a day for hypomania. Review of Resident #2's Physician's Orders indicated there was no documentation to support that the Nurse Practitioners recommendation was followed up on, or that his/her Physician's orders included an order for the administration of [MEDICATION(S)] 250 mg twice a day for the treatment of hypomania, (prior to his/her elopement on 10/15/21 at 8:09 P.M.). Review of Resident #2's Medication Administration Record (MAR), dated 10/13/21 through 10/15/21, indicated there was no documentation to support he/she had a Physician's order for [MEDICATION(S)] 250 mg twice a day. During an interview on 10/27/21 at 11:50 A.M., Nurse #1 said that while Resident #2 was hypomanic two days prior to his/her elopement, no additional mood stabilizing medications were administered. Nurse #1 said Resident #2 started receiving [MEDICATION(S)] on 10/19/21, four days after his/her return to the Facility. Nurse #1 said while Resident #2 was hypomanic, there was no additional supervision provided for the designated outdoor smoking area. During an interview on 10/21/21 at 10:15 A.M., the Acting Director of Nurses (DON) said Resident #2's unit was changed from an unsecured (open) unit to a secured unit because he/she was an elopement risk. The Acting DON said Resident #2 verbalized that he/she wanted to leave the Facility and go to his/her Family residence. The Acting DON said while on the secured unit, Resident #1 was wandering on the unit and trying to escape. During an interview on 10/27/21 at 1:35 P.M., the Administrator and the DON said they were not aware of Resident #2's acute hypomanic state, or that the condition increased the risk of his/her elopement. The Administrator and DON said they were not aware that Resident #2 had not been administered the mood stabilizing medication until seven days after they had been recommended by the Psychiatric Nurse Practitioner. On 10/21/21 at 12:15 P.M., the Surveyor and the Assistant Administrator (for the first time) watched the outdoor video surveillance footage from 10/15/21 of the 7:15 P.M. to 8:15 P.M. smoking break for the secured unit, in the outdoor smoking area. In the video, Resident #2 can be seen looking around, then walking away from the smoking area, down the front steps, and then leaving the Facility grounds in darkness, unsupervised at 8:09 P.M., according to the video time stamped recording. The Smoking Attendant's Witness Statement, dated 10/15/21, indicated prior to Resident #2's elopement, he (Smoking Attendant) was handing out cigarettes and writing in the smoking book, and did not see many of the residents go back into the building after their smoke break, because he was busy handing out cigarettes. During an interview at 4:50 P.M. on 10/21/21, the Smoking Attendant said on 10/15/21, when Resident #2 had eloped from the smoking group, two CNA's were transporting other residents back to the secured unit. The Smoking Attendant said that he could not adequately supervise the residents while counting and distributing cigarettes. The Smoking Attendant said at one point he was the only person supervising the residents on 10/15/21, in the smoking area. The Smoking Attendant said although Security Guard #3 who is extremely observant and works hard to ensure that residents don't elope, usually helps to supervise resident in the smoking area, said Security Guard #3 was also assigned to perform other duties at the same time he was assigned to the smoking detail, making it impossible for him to adequately help supervise the residents with the him (Smoking Attendant). Review of the Hospital Emergency Department Note, dated 10/16/21 at 10:55 A.M., indicated Resident #2 had a history of [CONDITION(S)] and presented with a request for medical clearance for detoxification. The Note indicated Resident #2 said his/her last alcoholic drink was this morning. The Note indicated [CONDITION(S)] was a chronic problem for him/her and Resident #2 was medically cleared for detoxification at this time. During an interview on 10:15 A.M. on 10/21/21, the Acting DON said on return to the Facility, Resident #2 was put on 1:1 supervision (one staff member with Resident #2 for constant supervision). However, review of Resident #2's updated Care Plan indicated, it did not include 1:1 supervision as a safety intervention. The Acting DON said no other additional safety interventions related to the designated smoke break area were put in place by the Facility related to the potential for the other residents at risk for elopement, during their smoking breaks (Resident #1 eloped three days later on 10/18/21 and is still missing).

Based on observations, record review and interviews, the facility failed to obtain psychiatric services for 4 Residents (#3, #76, #25, and #88), out of a total of 37 sampled residents. Findings include: 1. Resident #88 was admitted to the facility in 3/2019 with [DIAGNOSES REDACTED]. Review of Resident #88's most recent quarterly Minimum (MDS) data set [DATE], indicated that he/she had a Brief Interview for Mental Status score of 12 out of a possible 15, which indicated that Resident #25 had moderate cognitive impairment. The Minimum Data Set also indicated that Resident #25 required supervision from staff to complete activities of daily living. The surveyor asked the Director of Nursing and the Corporate Nurse for a policy regarding psychiatric services, and the facility was unable to provide one. Review of Resident #88's medical record indicated the following: *A social service note dated 3/21/19, indicated that Resident #88 was to have psychiatric services while at the facility. The note also indicated that social services will remain available for advocacy and support as needed. * A Nurse Practitioner note dated 3/22/19, which indicated a referral to psychiatric services for anxiety *Nursing notes written on 3/24/19, 3/31/19, 4/2/19, 4/22/19, and 4/25/19, which indicated that Resident #88 experienced an increase in anxiety and required addition/prn [MEDICATION NAME] to reduce anxiety. *A Physician note dated 5/2/19, that indicated the physician had written an order for [REDACTED]. *Care plans initiated on admission that included: - History of depression and risk for alteration in psychosocial well-being - [MEDICAL CONDITION] drug use related to history of depression and suicidal ideation. An intervention dated 3/20/19, was to refer to psych services. - Behavior problem due to history of suicidal ideation and depression - Alteration in mood/behavior due to history of depression and suicidal ideation. An intervention dated 3/21/19, was to refer to psych services. *The medical record failed to indicate a referral to psychiatric services was made after the (MONTH) 2019 recommendation from the nurse practitioner, the 5 instances of Resident #88's increased anxiety, or after the second referral from the Physician for Resident #88 to be seen by psychiatric services. Review of an incident report dated, 5/17/19, indicated that on 5/12/19, Resident #88 was found by a nurse with two cuts on his/her upper left extremity right above the wrist. At the time the nurse was assessing him/her, Resident #88 said that he/she had cut him/herself possibly because of anxiety. This incident occurred 10 days after the physician's second referral for Resident #88 to be seen by psychiatric services. Review of the hospitalization report dated 5/12/19, indicated that Resident #88 said his/her depression had been getting worse and that was the reason for cutting his/her wrists. An additional physician note from the hospital also dated 5/12/19, indicated that Resident #88 said he/she was feeling increasingly depressed and he/she slit his/her wrists in an attempt to kill him/herself. During an interview on 10/28/19 at 9:42 [NAME]M., Social Worker #1 said that she typically handles referrals to psychiatric services. Social Worker #1 said that she was unaware of the referral back in (MONTH) for Resident #88 to be seen by the psychiatrist. Social Worker #1 said that she was the only social worker in the building at the time and the referral must have been missed, confirming that there was a delay in psychiatric services needed. Social Worker #1 was also unable to explain why Resident #88 was not seen by psychiatric services after the physician made the second referral in May, 2019. 2. Resident #25 was admitted to the facility in 5/2019 with [DIAGNOSES REDACTED]. Review of Resident #25's most recent quarterly Minimum (MDS) data set [DATE], revealed that he/she had a Brief Interview for Mental Status score of 9 out of a possible 15, which indicated that Resident #25 had moderate cognitive impairment. The Minimum Data Set also indicated that Resident #25 required minimal assistance from staff to complete activities of daily living. Review of Resident #25's social services note dated 5/18/19, indicated that due to his/her psychiatric history, Resident #25 will be followed by psychiatric services while a patient at the facility. Review of Resident #25's nursing progress notes indicated he/she had 3 resident-to-resident altercations on 5/27/19 and 6/8/19. Review of Resident #25's behavior monitoring sheets for (MONTH) 2019 indicated Resident #25 had 8 occurrences of disruptive-socially inappropriate behavior, 8 occurrences of physically abusive behavior and 20 occurrences of verbally abusing behavior. Review of Resident #25's behavior monitoring sheets for (MONTH) 2019 indicated Resident #25 had 14 occurrences of disruptive-socially inappropriate behavior, 4 occurrences of physically abusive behavior and 14 occurrences of verbally abusing behavior. Review of Resident #25's behavior monitoring sheets for (MONTH) 2019 indicated Resident #25 had 9 occurrences of disruptive-socially inappropriate behavior, 2 occurrences of physically abusive behavior and 12 occurrences of verbally abusing behavior. Review of Resident #25's behavior monitoring sheets for (MONTH) 2019 indicated Resident #25 had 21 occurrences of disruptive-socially inappropriate behavior, 16 occurrences of physically abusive behavior and 35 occurrences of verbally abusing behavior. Review of Resident #25's behavior monitoring sheets for (MONTH) 2019 indicated Resident #25 had 25 occurrences of disruptive-socially inappropriate behavior, 17 occurrences of physically abusive behavior and 32 occurrences of verbally abusing behavior. Review of Resident #25's behavior monitoring sheets for (MONTH) 2019 indicated Resident #25 had 20 occurrences of disruptive-socially inappropriate behavior, 16 occurrences of physically abusive behavior and 29 occurrences of verbally abusing behavior. Review of Resident #25's care plans indicated the following: *A care plan initiated on 7/12/19 for behavior problem related to verbally abusive, disruptive behavior, physically abusive, and socially inappropriate. *A care plan initiated on 7/29/19 for history of substance abuse. The care plan indicated interventions to provide individual/group therapy/psychoeducational groups and to have psych service prn per MD order. *A care plan initiated on 5/27/19 for an alteration in mood. The care plan indicated an intervention to refer to psych services. *A care plan initiated on 7/29/19 for depression. The care plan indicated an intervention for a psych consult/follow-up. *A care plan initiated on 7/29/19 for anxiety. The care plan indicated an intervention for a psych evaluation and follow up as needed for medication management and counseling. *A care plan initiated on 9/16/19 for [MEDICAL CONDITION] drug use. The care plan indicated an intervention for a consult to psych services. Review of Resident #25's active physician's orders [REDACTED]. This order was again revised on 8/6/2019. An additional order was written on 7/30/19, for [MEDICATION NAME] (an anti-anxiety medication) 1 milligram daily. Review of Resident #25's medical record failed to indicate a consent for the [MEDICATION NAME]. Review of Resident #25's medical record failed to indicate a consent for psychiatric services was obtained nor was Resident #25 evaluated by psychiatric services in the facility until 10/17/19. Review of Resident #25's physician progress notes [REDACTED].#25 had been followed by psych services while at the facility. The physician was unavailable at the time of the survey due to being on vacation and could not be asked if she was unaware that at the time this note was written, Resident #25 had not been seen by psychiatric services since admission. During an interview on 10/23/19 at 11:40 [NAME]M., the Nursing Supervisor said that psychiatric services had been delayed because consents were not obtained by the guardian for Resident #25 to be seen by psychiatric services until this month. The Nursing Supervisor said that the process started in August. During an interview on 10/24/19 at 1:2 P.M., Social Worker #2 said she had reached out to Resident #25's Guardian to obtain the consents for psychiatric services and had just now received them back and this was the cause in delay in treatment. Review of the written communication between Social Worker #2 and Resident #25's guardian indicated that Social Worker #2 first asked the guardian for consent for psychiatric services on (MONTH) 16, 2019, after 6 months of documented behavior concerns, 3 months after Resident #25's first resident to resident incident, and 1 month after starting a new anti-anxiety medication. 3. Resident #76 was admitted to the facility in 6/2019 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], Resident #76 scored an 11 out of a possible 15, indicating moderate cognitive impairment. The MDS also indicated that Resident #76 was able to walk and transfer with supervision. Review of Resident #76's nursing progress notes indicated he/she had 3 physical resident-to-resident altercations on 7/21/19, 9/25/19, and 10/7/19. Review of Resident #76's Social Services Summary dated 6/2019, from his/her discharge packet from another facility indicated the following: Behaviors present since admission to the facility include: verbal abuse of staff/peers, socially inappropriate behaviors, wanders into other residents' rooms, and physical aggression towards staff. I would recommend referring Resident #76 to psych services upon admission for ongoing medication management and evaluation as needed. Review of Resident #76's social service note dated 6/18/19, indicated psych services to follow resident. Review of Resident #76's active physician's orders [REDACTED]. Review of Resident #76's physician progress notes [REDACTED]. 6/24/19: A patient with dementia and [MEDICAL CONDITION] and he/she will continue to be a patient here. I will be writing an order for [REDACTED].>9/20/19: Chronic [MEDICAL CONDITION]. Resident #76 will continue psych medications. Resident #76 will be followed by psych service. Resident #76 is on [MEDICATION NAME] (an antipsychotic medication). Review of Resident #76's care plans indicated the following: -An intervention dated 6/14/19 for psych services as needed per Physician order. -An intervention for major [MEDICAL CONDITION] dated 6/17/17: referred to psych services for psych consult and medication review. -An intervention dated 9/26/19 to be followed by psych services for medication, mood, and behaviors. Review of Resident #76's medical record failed to indicate a consent for psychiatric services was obtained nor was Resident #76 evaluated by psychiatric services in the facility. During an interview on 10/28/19 at 10:20 [NAME]M., the Director of Social Services said she had reached out to Resident #76's Guardian on 10/9/19, and his/her Guardian said she would send the psych services forms back. During an interview on 10/28/19 at 10:30 [NAME]M., Resident #76's Guardian said she had not received consent forms for psychiatric services from the facility, but she did want Resident #76 evaluated by psychiatric services in the facility. During an interview on 10/29/19 at 10:23 [NAME]M., the Director of Nursing said Resident #76 had not been evaluated by psychiatric services in the facility since admission. During an interview on 10/29/19 at 12:16 P.M., Social Worker #2 said she had reached out to Resident #76's Guardian, but had not received a response from her. 4. Resident #3 was admitted to the facility in 4/2019 with a [DIAGNOSES REDACTED]. Review of Resident #3's care plan indicated a care plan in effect for Behavior problem related to refusal of care and medications, verbal abuse and disruptive behaviors as evidenced by: yelling, cursing and threatening others, along with refusing care. Review of a nursing note dated 9/16/19 indicated Resident #3 threw all of his/her medications on the floor. After the nurse poured the medications again, Resident #3 took only the [MEDICATION NAME] and threw the rest of the medications on the floor again stating they don't help anyway. Review of the physician's orders [REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #3 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. In addition, Resident #3 exhibited verbal behavioral symptoms and refused care almost daily. Review of Resident #3's medical record indicated an initial psychiatric evaluation was not conducted until 10/18/19, more than a month after the physician's orders [REDACTED].>During an interview conducted on 10/29/19 at 10:12 [NAME]M. with Nursing Supervisor #1, she stated when there is an order for [REDACTED].#1 said she is not sure why this consult occurred so late. \

Based on observations, policy review, record reviews and interviews, the facility failed to keep 3 Residents (#12, #44, and #46) free from accidents and failed to provide supervision for 1 resident (#232) who had a drug overdose and for 1 resident (#22) who was found in possession of drug paraphernalia (#22) out of a total sample of 37 residents. Findings include: 1. For Resident #12, the facility failed to keep him/her free from falls with injury. Resident #12 was admitted in 1/2016 with [DIAGNOSES REDACTED]. On the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #12 scored a 13 out of a possible 15 indicating he/she was cognitively intact. The MDS also indicated Resident #12 required extensive assistance with bed mobility, transferring, and locomotion with a wheelchair; the resident was not able to walk. Further Review of Resident #12's care plans indicated an intervention dated 7/21/19, to have Resident #12's call light within reach. On 10/22/19 at 8:04 [NAME]M., the surveyor observed Resident #12 in bed in his/her room, his/her call light was on the floor out of reach. On 10/24/19 at 8:26 [NAME]M., the surveyor observed Resident #12 in bed in his/her room, his/her call light was on the floor out of reach. Review of Resident #12's Fall Incident Report and Investigation dated 2/3/19, indicated Resident #12 sustained a fall at 12:30 P.M., while attempting to transfer from the wheelchair to his/her bed in his/her room. The fall was unwitnessed. The report indicated the intervention to prevent further occurrence was for staff to assist Resident #12 back to bed directly after meals. Review of Resident #12's care plans failed to indicate an intervention to assist the Resident back to bed directly after meals. Review of Resident #12's Fall Incident Report and Investigation dated 9/25/19 indicated the Resident #12 fell at 10:25 [NAME]M. while transferring him/herself from the wheelchair to his/her bed. The report indicated the Resident's call light was not in reach at the time of the fall. The report indicated the intervention to prevent further occurrence was Resident #12 was re-educated to call for help and assistance. Review of Resident #12's Fall Incident Report and Investigation dated 10/7/19 indicated Resident #12 fell at 12:15 P.M. while transferring him/herself from his/her bed to the wheelchair. The report indicated the intervention to prevent further occurrence was Resident #12 was re-educated to call for help and assistance (an intervention indicated on 9/25/19). Review of Resident #12's Fall Incident Report and Investigation dated 10/19/19 indicated Resident #12 fell on [DATE] at 6:00 P.M. while transferring him/herself from the wheelchair to his/her bed. Resident #12 sustained a laceration on the left side of his/her head. The report indicated Resident #12's call light was not in reach at the time of the fall. The report further indicated the intervention to prevent further occurrence was resident re-educated to call for help and assistance. Review of Resident #12's nursing progress note dated 10/19/19 indicated Resident #12 was sent to the emergency room for further evaluation after the fall on 10/19/19. Review of Resident #12's nursing progress note dated 10/21/19, indicated Resident #12 had returned from the hospital to the facility. It further indicated Resident #12 required 4 staples to close his/her laceration to the left side of his/her head, and he/she had a pelvic fracture and a spinal fracture. Review of Resident #12's After Visit Summary dated 10/19/19 from the hospital indicated Resident #12 had a laceration repair with staples, a worsening of pubic ramous fracture from 10/11/19, a sacral fracture, and a nondisplaced L1-L2 [MEDICATION NAME] process fracture. During an interview on 10/29/19 at 9:31 AM Nurse #7 said after a fall, staff evaluate for pain and injuries but was not able to say how to update a Resident's plan of care. Review of Resident #12's progress notes from 9/2019 or 10/2019 failed to indicate the Resident's plan of care had been reviewed, reassessed, or revised. During an interview on 10/29/19 at 10:20 [NAME]M., the Director of Nursing said Resident #12's plan of care had not been followed after his/her falls. 2. Resident #44 was admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #44 scored a 15 out of 15 on the Brief Interview for Mental Status, which indicated he/she was cognitively intact. The MDS also indicated Resident #44 required extensive assistance with bed mobility, transfers, dressing, hygiene, toileting, and bathing. Review of Resident #44's nursing progress note dated 9/7/19 indicated that Resident #44 fell at 9:45 [NAME]M. in front of the nurses' station. The resident stood up and attempted to sit on wheelchair and fell on the floor onto his/her left side. Review of Resident #44's Fall Incident Report and Investigation dated 9/7/19 indicated the following: -The resident sustained [REDACTED].M. in the hallway next to the nurses' station. -The resident stood up from the wheelchair and attempted to sit back on the wheelchair and fell on the floor. -The intervention to prevent further occurrences was to make a referral for physical therapy for safe rise/transfer to wheelchair. Review of Resident #44's nursing progress notes from 9/2019 and 10/2019 failed to indicate a request for a physical therapy screen or evaluation had been submitted for Resident #44 after his/her fall on 9/7/19. Review of Resident #44's physician's orders [REDACTED]. Further review of Resident #44's medical record failed to indicate a screen or evaluation was submitted or filed in Resident #44's medical record, nor that a physical therapy screen had been performed in 9/2019 or 10/2019. During an interview on 10/28/19 at 12:18 P.M., Occupational Therapist (OT) #1 reviewed the rehabilitation documentation and said Resident #44 had not been on physical therapy's caseload since 2/2019. Review of Resident #44's nursing progress note dated 9/10/19 indicated that Resident #44 fell at 4:00 P.M. in the elevator. Resident #44 stood up and attempted to hit an aide and fell . Resident #44 sustained a skin tear on the left elbow, left arm, and right knee. Review of Resident #44's Fall Incident Report and Investigation dated 9/10/19 indicated the following: -Resident #44 fell on [DATE] at 4 P.M. while attempting to hit an aide. -Resident #44 had been sitting in his/her wheelchair prior to the fall. -Resident #44 sustained skin tears to the left elbow, lower arm, and right knee. -The report failed to indicate an intervention to prevent further occurrence, nor did it indicate if Resident #44's care plan was updated. Review of Resident #44's nursing progress notes dated 10/14/19 indicated the resident was found with blood on the hair when assessed by the Nurse on duty. The Nurse Practitioner gave an order for [REDACTED].#44 returned from the hospital at 11:45 [NAME]M. He/she had 5 staples on his/her scalp wound. Review of Resident #44's Fall Incident Report and Investigation dated 10/14/19 indicated the following: -Resident #44 sustained an unwitnessed fall on 10/14/19 around 6:50 P.M. while transferring him/herself to bed. -Resident #44 was observed to have a head injury and left arm injury after the fall. -Resident #44 was utilizing a wheelchair for mobility. -The intervention to prevent further occurrence was keeping a close eye on Resident #44 The intervention failed to specify a method for increased supervision for Resident #44. The report failed to indicate if the care plan had been updated. Review of Resident #44's fall care plan indicated the following: -The resident was at risk for fall related injury. -An intervention dated 12/1/18 with revision on 12/2/18 for referral for screen and treatment as needed for physical therapy, mental health, and occupational therapy. -The fall care plan failed to indicate any updated interventions following the falls on 9/7/19 or 9/10/19. During an interview on 10/29/19 at 10:20 [NAME]M., the Director of Nursing said that Resident #44's plan of care had not been updated to include interventions to prevent falls. 3. Resident #46 was admitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. On the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #46 scored a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating intact cognition. The MDS dated [DATE] also indicated Resident #46 required supervision with walking and transfers. Review of Resident #46's progress notes dated 10/1/19 indicated following: -The resident was picked up by Emergency Medical Technician's (EMTs) at 2:30 P.M., sent to the hospital for evaluation and treatment, as the resident was noted through media (video camera) review to be burning a towel. -Resident back from hospital, no new orders. Review of Resident #46's psychiatric progress note dated 10/1/19 indicated the resident was evaluated because he/she was observed on camera setting a towel on fire twice. Review of Resident #46's Application Pursuant to Section 12 (a) (psychiatric commitment) dated 10/1/19 indicated the resident attempted to start a fire today twice by lighting a towel on fire. Review of the facility document Investigation Small Fire on 4th Floor Enclosed Porch, undated, indicated the following: -At 7:15 [NAME]M., on 10/1/19 the Administrator was notified by phone that a towel had been on fire on an enclosed porch on the fourth floor of the facility. -At 6:43 [NAME]M. fire was visible in a reflection in the window. Resident #46 left the area within 1 minute of arrival. At 6:46 [NAME]M., fire was no longer visible. Resident #46 entered the area again. Fire was visible again. Resident #46 left the area at 6:49 [NAME]M. -We are quite certain Resident #46 was responsible for the fire. Review of Resident #46's care plans indicated he/she has behaviors of pacing, roaming, and wandering on the unit. Review of Resident #46's Documentation Survey Report for 10/2019 failed to indicate behaviors for fire starting were being monitored or assessed by facility staff, nor were staff monitoring or assessing his behaviors for wandering, pacing, or roaming. During an interview on 10/24/19 at 10:41 [NAME]M., the Director of Nursing said the conclusion was that Resident #46 set fire on the unit on 10/1/19. The Director of Nursing said the staff did not close the door to the porch and the resident accessed the secured area that way. The Director of Nursing said the door has an automatic closer on it now to prevent the residents from accessing that area unsupervised. On 10/25/19 at 1:02 P.M., the surveyor observed the door to the secured porch area on the fourth floor unit propped open by a chair with no staff supervising the area. On 10/28/19 at 1:09 P.M., the surveyor observed the door to the secured porch area on the fourth floor unit propped open by a chair with no staff supervising the area. During an interview on 10/29/19 at 10:20 [NAME]M., the Director of Nursing said the door should be closed when the area is not supervised by staff. 4. For Resident #232, the facility failed to provide supervision after an overdose in the facility. On 10/28/19 at 8:10 [NAME]M., the Director of Nursing reported to the surveyor that Resident #232 overdosed over the past weekend and was sent out to the hospital. Resident #232 was admitted to the facility on in 10/2019 with a [DIAGNOSES REDACTED]. Review of Resident #232's discharge paperwork from the hospital dated 10/27/19, indicated while Resident #232 was hospitalized to be treated for [REDACTED]. Resident #232 was given [MEDICATION NAME] (a medication used to reverse the effects of opioid medications in an emergency situation). Resident #232 was encouraged to stay on the hospital unit to receive the care he/she needed. Review of a nurse's note dated 10/26/19 indicated at 10:25 P.M., during safety rounds, Resident #232 was found unresponsive in his/her bedroom. Resident #232 did not respond to his/her name nor stimuli. [MEDICATION NAME] was administered and the resident gained consciousness shortly. The Nurse Practitioner was called and gave an order to send Resident #232 to the hospital as well as to conduct a room search. No items were found in Resident #232's room. Resident #232 returned to the facility on [DATE] at 2:00 [NAME]M. On 10/28/19 at 10:00 [NAME]M., the surveyor observed Resident #232 getting off the elevator on the 5th floor by himself/herself heading towards his/her room. During an interview with Nurse #3 at that time, Nurse #3 said Resident #232 is on a safety plan because of an overdose. Resident #232 is not suppose to leave the facility without a responsible party and is to have supervised visits. Nurse #3 showed the surveyor a sheet of paper taped at the nurses' station that had residents' names on it and what their safety plans were. The title on the top of the sheet was Safety Plans. Under the category Drug use/Overdose In Facility Indicated Resident #232's name was there. The safety plan was: Therapeutic leaves of absence with responsible party, supervised visits. On 10/28/19 at 10:57 [NAME]M., a call came to the 5th floor nurses' station indicating a taxi had arrived for Resident #232 and another resident. Resident #232 was observed getting in the elevator unsupervised. When asked where Resident #232 was going, Nurse #3 said Resident #232 goes to a clinic to get his/her [MEDICATION NAME]. Nurse #3 said the facility has a bus that takes residents to the clinic, but Resident #232 takes a cab, probably because the bus is full. Nurse #3 said she did not know if Resident #232 was going to be supervised. The facility failed to follow a safety plan for Resident #232. 5. For Resident #22, the facility failed to implement a safety plan after a room search produced drug paraphernalia. Review of the facility's policy titled Room Entry and Search, dated (MONTH) (YEAR) Indicated the following: Policy - The facility staff may enter and search a resident's room if: * There is reason to believe that illegal activity is occurring or has occurred in the room * There is reason to believe that activity which violates the facility's policies is occurring or has occurred in the room *There is reason to believe that activity causing a health and safety threat is occurring or has occurred in the room Procedure: *The resident will be given notice that a room search will be conducted and will be informed of the reason for the search * The resident will be allowed to be present during the search if they so desire * The results of the search will be documented * If the results of the search produce any hazardous items, an individualized plan of care will be developed to determine the frequency of repeat searches to ensure resident safety During an interview with the Substance Use Counselor on 10/23/19 at 3:10 P.M., she stated room searches are conducted when there is a suspicion of illegal activity and a safety plan is put in place immediately after the occurrence. The Substance Use Counselor said Resident #22 was not on a safety plan. On 10/23/19, during an interview with the Director of Nurses, she said a room search was conducted for Resident #22 recently, but was not sure of the date. The Director of Nurses said a nip bottle was found that was transformed into a pipe and it had a brown substance in it. The Director of Nurses said when a room search is conducted, an incident report is filled out and attached is the findings of the room search. The Director of Nurses said that every Monday morning, there is a substance use disorder (SUD) meeting, where residents who are on safety plans are reviewed. The Director of Nurses said she would find the incident report relating to the room search and provide the minutes from SUD meeting. Review of Resident #22's care plans indicated there was no individualized care plan developed to ensure the resident's safety. During further interview with the Director of Nurses on 10/28/19 at 3:08 P.M., she said she was unable to locate an incident report for the room search. In addition, the Director of Nurses provided the minutes to the SUD meetings recently conducted and there was no documentation regarding Resident #22's room search or safety plan.

Based on records reviewed and interviews, for seven of 28 sampled residents (Resident #7,#29, #67, #80, #107, #108 and #109), the facility failed to: prevent accidents including a foot fracture sustained as the result of a fall; identify, evaluate and analyze hazards and risks, including repeated drug overdoses, reports of the ingestion of substances provided by visitors or other residents, reports of medication sharing or selling, and drug trafficking; failed to implement, monitor the effectiveness of, and modify interventions to reduce the risk of overdoses; and, ensure medications were not left unattended and accessible to residents. Findings include: 1. Resident #7 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the Facility's Internal Investigation, dated [DATE], indicated that on [DATE], Resident #7 was treated in the hospital for an opiate overdose which required [MEDICATION NAME] (a medication used to temporarily reverse the effects of opioid medications in an emergency situation, which has no effect on non-opioid medications). The Investigation indicated that Resident #7 said he/she snorted heroin. Review of the Facility's Internal Investigation, dated [DATE], indicated that Resident #7 became unresponsive during a smoking break, was treated with [MEDICATION NAME], and was transferred to the hospital. The Investigation indicated that at the hospital, Resident #7 was diagnosed with [REDACTED]. Review of Resident #7's Substance Abuse Assessment, dated [DATE], indicated that he/she had a history of [REDACTED]. Review of the Facility's Internal Investigation, dated [DATE], indicated that Resident #7 was found unresponsive, was administered [MEDICATION NAME], and was transferred to the hospital after reportedly overdosing. The Investigation included hospital documentation, which indicated that Resident #7 was diagnosed with [REDACTED]. Review of Resident #7's APRN (Advanced Practice Registered Nurse) Note, dated [DATE], indicated that Resident #7 had orders for the administration of [MEDICATION NAME] (an opioid pain medication) twice a day and every four hours as needed (PRN). The Note indicated that the Nurse Practitioner (NP) explained to Resident #7 that he/she could not use illicit drugs while on [MEDICATION NAME] or pain medications. Review of the Facility's Internal Investigation, dated [DATE], indicated that Resident #7 was found lethargic (sluggish) and difficult to arouse, and had three [MEDICATION NAME] pills in his/her possession. The Investigation indicated that Resident #7 was treated at the hospital, where his/her [DIAGNOSES REDACTED]. Review of Resident #7's Hospital Transfer Summary, dated [DATE], indicated that on [DATE], there was a concern for possible overdose on drugs which did not belong to him/her. The Surveyor interviewed the Director of Nurses (DON) at multiple times throughout the dates of survey. The DON said she did not conduct an investigation into why Resident #7 had [MEDICATION NAME] pills in his/her possession on [DATE], or how he/she obtained the pills. Review of the Facility's Internal Investigation, dated [DATE], indicated that on [DATE], Resident #7 was transferred to the hospital due to increased confusion and difficulty breathing. The Investigation indicated that Resident #7's lethargy responded to [MEDICATION NAME], and was likely due to an opioid/heroin overdose. Review of Resident #7's Nurse's Progress Note, dated [DATE], indicated that he/she was very lethargic, hard to arouse, and had slow breathing. The Note indicated that Resident #7 was transferred to the hospital. Review of Resident #7's Hospital Discharge Summary, dated [DATE], indicated that Resident #7 was administered [MEDICATION NAME] for a suspected overdose, with a positive effect. The Summary indicated that Resident #7 overdosed on heroin, and that Resident #7 had a friend who delivered the heroin to him/her at the Facility. There was no documentation at the time of survey to support that the Facility: reviewed Resident #7's narcotic/opiate overdoses on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] to determine how he/she obtained the narcotics/heroin/opiates; or, conducted an investigation to determine how Resident #7 obtained the three [MEDICATION NAME] tablets found in his/her possession on [DATE], despite hospital documentation that there was a concern Resident #7 had overdosed on drugs that did not belong to him/her. 2. Resident #29 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #29's Social Service Interim Progress Note, dated [DATE], indicated that Director of Social Services #1 was informed by another, unnamed, resident that Resident #29 had taken some drugs from another resident. The Note indicated that Resident #29 exhibited a decrease in mental status and was transferred to the Emergency Department (ED) for evaluation. Review of Resident #29's ED Provider Notes, dated [DATE], indicated that he/she presented with an altered mental status and that Facility staff was concerned he/she received some kind of narcotic during a visit with a friend. The Notes indicated that Resident #29 admitted to taking some kind of narcotic on that date, and was diagnosed with [REDACTED]. Review of Resident #29's Hospital Discharge Summary, dated [DATE], indicated that he/she said he/she took pills given to him/her by a friend, and indicated that Resident #29 told Facility staff that he/she took heroin brought to him/her by a friend. Review of Resident #29's Nurse's Progress Note, dated [DATE], indicated that Resident #29 was found in his/her room with another resident (identified as Resident #7). The Note indicated that Resident #7 was found unresponsive, and Resident #29 was alert but disoriented. The Note indicated that Resident #29 was transferred to the Hospital for evaluation. Review of Resident #29's Social Service Interim Progress Note, dated [DATE], indicated that both Resident #7 and Resident #29 were found passed out and not responsive to verbal or physical stimuli. The Note indicated that one dose of [MEDICATION NAME] was administered to Resident #29 for suspected drug/opiate overdose. The Note indicated that a plastic straw and top knot from a corner bag (both consistent with drug paraphernalia) were found on the floor near Resident #29. Review of the Facility's Internal Investigation, dated [DATE], indicated that it included a Statement completed by the NP. The NP's Statement indicated that Resident #29 was lethargic and later found to be unresponsive in the wheelchair, and that [MEDICATION NAME] was administered. Review of Resident #29's Nurse's Progress Note, dated [DATE], indicated that a Certified Nurse Aide (CNA) observed Resident #29 in his/her room with an unidentified substance in his/her hand. The Note indicated that the security officer was notified and went to Resident #29's room. The Note indicated that the security officer reported that Resident #29 handed him two bags of heroin. The Note indicated that the Administrator, DON, and NP were notified. Review of Resident #29's Social Service Interim Progress Note, dated [DATE], indicated that he/she had a recent history of spending his/her money on illicit substances, such as heroin, and sharing the heroin with other residents, which lead to overdose. Review of Resident #29's Nurse's Progress Note, dated [DATE] at 11:59 P.M., indicated that Resident #29 and another resident (identified as Resident #7) were found sniffing an unknown substance. The Note indicated that a white substance and three [MEDICATION NAME] were found. The Note indicated that Resident #29 was transferred to the Hospital for an evaluation. Review of Resident #29's ED Provider Notes, dated [DATE], indicated that he/she reported that he/she took his/her roommate's [MEDICATION NAME]. Review of Resident #29's Nurse's Progress Note, dated [DATE], indicated that Resident #29 was found by maintenance staff dozing off, unsteady and confused. The Note indicated that on assessment by nursing, Resident was diaphoretic and unable to respond appropriately. The Note indicated that drug paraphernalia was found during a search of Resident #29's room, and that Resident #29 was transferred to the hospital for evaluation. Review of Resident #29's Hospital Transfer Summary, dated [DATE], indicated that Resident #29's toxicology screen was positive for opiates. The Surveyor interviewed Director of Social Services #2 at 4:20 P.M. on [DATE]. Director of Social Services #2 said she did not recall the incident from [DATE] in which Resident #29 was in possession of drug paraphernalia or suspected to have used illicit substance(s). The Surveyor interviewed the Medical Director at 10:48 on [DATE]. The Medical Director said she was aware of Resident #29's drug use in the facility, including his/her hospitalization s for overdoses. There was no documentation at the time of survey to support that the Facility: reviewed Resident #29's opiate overdose on [DATE] to determine how he/she obtained the opiates; conducted an investigation to determine how Resident #29 came into the possession of drug paraphernalia, heroin, and/or [MEDICATION NAME] on [DATE], [DATE], [DATE], and [DATE]; reviewed Resident #29's reported ingestion of his/her roommate's [MEDICATION NAME] on [DATE]; and, reviewed the incidents from [DATE] and [DATE] in which Resident #29 and Resident #7 were found together, unresponsive and in possession of drugs and drug paraphernalia. 3. Resident #67 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #67's Social Service Interim Progress Note, dated [DATE], indicated that a code was called after he/she was found unresponsive at the nurses' station. The Note indicated that Resident #67 became responsive after the administration of two doses of [MEDICATION NAME]. The Note indicated that Resident #67 said he/she used [MEDICATION NAME] that was given to him by another resident at the Facility. Review of the Facility's Internal Investigation, dated [DATE], indicated that Resident #67 was treated at the hospital for an opioid overdose. Review of Resident #67's Nurse's Progress Note, dated [DATE] at 10.47 P.M., indicated that at approximately 10:20 P.M., he/she was unresponsive, extremely diaphoretic (sweating heavily), and had a thready pulse (scarcely noticeable, rapid pulse). The Note indicated that Resident #67 became responsive after the administration of two doses of [MEDICATION NAME]. Review of Resident #67's Emergency Department Provider Notes, dated [DATE], indicated that he/she was evaluated for a suspect heroin overdose. Review of Resident #67's Nurse's Progress Note, dated [DATE], indicated that at approximately 8:30 P.M., he/she was unresponsive, had little response to two doses of [MEDICATION NAME], and was transferred to the hospital. Review of Resident #67's Hospital Notes, dated [DATE] and [DATE], indicated that he/she presented with his/her fifth overdose after using some form of an opiate. The Notes indicated that Resident #67 admitted to cocaine use, which was confirmed by positive toxicology testing. There was no documentation at the time of survey to support that the Facility investigated Resident #67's suspected or confirmed incidents of substance abuse on [DATE], [DATE], and [DATE] to determine how he/she obtained the substances to ensure the safety of residents at the Facility. 4. Resident #80 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A. Review of Resident #80's Minimum Data Set (MDS), dated [DATE], indicated that he/she had no cognitive impairment, and required the extensive assistance of two or more persons with bed mobility and toileting needs. The Surveyor interviewed Resident #80 at 8:37 A.M. on [DATE]. Resident #80 said that a few months prior to the date of interview, exact date unknown, he/she fell out of bed during the provision of care. Resident #80 said he/she required the assistance of two persons with care at the time of the incident. Resident #80 said Certified Nurse Aide (CNA) #7 provided care to him/her without the assistance of a second person on the date of the incident. Resident #80 said CNA #7 asked him/her to roll over so that CNA #7 could provide incontinence care. Resident #80 said CNA #7 pushed him/her as he/she rolled over to his/her side, and he/she rolled off of the bed and onto the floor. Resident #80 said he/she landed on the floor between the bed and the wall, struck his/her head on the floor, and immediately felt pain when his/her right foot got caught between the floor and the bed. Resident #80 said it took the assistance of several staff persons to get him/her up off of the floor and back into bed. Review of the Facility's Internal Investigation, dated [DATE], indicated that Resident #80 fell out of bed during the provision of care by CNA #7. The Investigation indicated that Resident #80 sustained lacerations to his/her left back, right buttock area, and left thigh, and a closed fracture (a fracture that does not penetrate the skin) of the second metatarsal (a long bone in the foot) of the right foot. The Investigation indicated that recommendations were made for Resident #80 to wear a short air cast (a device used to immobilize fractures from the base toes to just below the knee, severe regional sprains, and torn ankle ligaments). The Investigation indicated that CNA #7 failed to follow Resident #80's plan of care when she provided care to him/her without the assistance of a second person. Review of CNA #7's written statement, dated [DATE], indicated that she provided care to Resident #80 without the assistance of a second person because one person was on break and another staff person was assisting another resident. There was no documentation at the time of survey to support that the Facility ensured that CNA #7 provided care to Resident #80 on [DATE], in accordance with his/her plan of care. B. Review of Resident #80's Nurse's Progress Note, dated [DATE], indicated that Resident #80 requested [MEDICATION NAME] (a controlled substance used to treat headaches). The Note indicated that Resident #80 took the medication and then gave the medication to another resident. The Note indicated that the medication was retrieved from the other resident's pocket. Review of Resident #80's Nurse's Progress Note, dated [DATE], indicated that Resident #80 was educated on the dangers of sharing or giving prescribed medications to other residents. The DON said she did not investigate that on [DATE], staff witnessed Resident #80 give his/her [MEDICATION NAME] to another resident of the Facility. There was no documentation at the time of survey to support that the Facility reviewed Resident #80's incident of providing his/her pain medication to another resident on [DATE] to determine any potential impact on the health and safety of Resident #80 and other residents. 5. Resident #107 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A. Review of Resident #107's Nurse's Progress Note, dated [DATE], indicated that a hollowed-out pen (often used in the ingestion or inhalation of illicit substances) and cigarettes were found during a search of Resident #107's room. Review of Resident #107's Individual Assessment/Therapy/Collateral Progress Note from the Facility's substance abuse services provider, dated [DATE], indicated that there was a suspicion of substance use because Resident #107 appeared intoxicated. There was no documentation at the time of survey to support that Resident #107's apparent intoxication on [DATE] was communicated to the Facility's nursing staff. Review of Resident #107's Nurse's Progress Note, dated [DATE] at 10:32 A.M., indicated that a search of Resident #107's room yielded two lighters, three small broken glass tubes with a dark residue inside, multiple small pieces of broken glass tube, a piece of wire which appeared to be an open paper clip, one small baggie containing a fine green substance, one bunch of a browning substance which appeared to be charred, one inner pen which appeared to be melted/charred, and one small empty bag with the residue of a fine substance (all items consistent with drugs and drug paraphernalia). Review of Resident #107's Notice of Intent Not to Readmit Resident Following hospitalization or Other Medical Leave of Absence from the Facility with Less than 30 Days' Notice (Expedited Appeal), dated [DATE], indicated that he/she was issued the notice due to endangerment of the health and safety of residents at the Facility. Review of Resident #107's physician progress notes [REDACTED].#107's room. The Note indicated that Resident #107 was issued a discharge notice and a notice not to readmit him/her because he/she was harming everybody's safety at the Facility. The Note indicated that Resident #107 would continue to use drugs in the Facility, which jeopardized everyone else's health. The Medical Director said she wrote the physician progress notes [REDACTED].#107's substance use and keep other residents safe by offering Resident #107 services, which he/she refused. The Medical Director said Resident #107 could not be discharged to another setting because he/she had burned all of his/her bridges, or words to that effect, at other facilities. The Medical Director did not know if interventions were put into place by the Facility to keep other residents safe in the setting of Resident #107's continued drug use. Review of Resident #107's physician progress notes [REDACTED].#107 would not go back to using cocaine or heroin. There was no documentation at the time of survey to support that the Facility evaluated and analyzed Resident #107's known or suspected substance use and/or possession of drug paraphernalia on [DATE], [DATE], and [DATE]; or, developed interventions to keep Resident #107 and other residents safe in the setting of Resident #107's ongoing substance use. B. Review of Resident #107's physician progress notes [REDACTED]. Review of Resident #107's Aftercare Planning Service Note from the Facility's substance abuse services provider, dated [DATE], indicated that he/she continued to use controlled substances and sell cocaine. There was no documentation to indicate that there were any interventions to ensure the safety of Resident #107 in the setting of his/her documented substance use. Review of Resident #107's Social Service Interim Progress Note, dated [DATE], indicated that Resident #107 was reported to have been selling/dealing cocaine to other residents in the Facility. The Note indicated that Resident #107 was issues a 30-Day Notice of Intent to Discharge due to his/her drug selling behaviors. The DON said she was aware of Resident #107's reported drug trafficking in the Facility. The DON said she received reports that Resident #107 was buying drugs for other residents in the Facility, and said that Resident #107 was found with drugs and drug paraphernalia in his/her possession. The DON said the Facility tried to manage Resident #107's substance use and drug trafficking behaviors by offering him/her substance abuse services. The DON said Resident #107 would participate in substance abuse services for a short time, and then refuse to participate further. There was no documentation at the time of survey to support that the Facility evaluated and analyzed reports of Resident #107 trafficking drugs to other residents of the facility, implemented interventions to reduce the risk of drug trafficking; or, monitored the effectiveness of any interventions and modified them as necessary. C. Review of Resident #107's Fall Risk Assessment, dated [DATE], indicated that he/she was at risk for falls. Review of Resident #107's physician progress notes [REDACTED]. Review of Resident #107's Nurse's Progress Notes, dated [DATE], [DATE], and [DATE] indicated that Resident #107 sustained falls. Review of Resident #107's Progress Notes, dated [DATE] and [DATE], indicated that Resident #107 required assistance to get back to the Facility from leaves of absence because the battery in his/her electric wheelchair had died and he/she had no means to communicate his/her need for assistance with Facility staff. Review of Resident #107's Nurse's Progress Notes, dated [DATE], indicated that Resident #107 was last seen in the Facility at approximately 5:00 P.M. on [DATE], was located by the Police Department approximately 12 hours later approximately a quarter-mile from the Facility, and was transported to the hospital. Review of Resident #107's ED Records, dated [DATE], indicated that Resident #107 presented with an altered mental status, was profoundly hypothermic (low body temperature) with a temperature of 84 degrees Fahrenheit (normal adult body temperature is 97 to 99 degrees Fahrenheit), and bradycardic (low heart rate; normal resting heart rate for adults is 60 to 100 beats per minute (bpm)) with a rate of 50 bpm. The Records indicated that Resident #107 was in the possession of a crack pipe and said that he/she smoked crack but could not recall at what time. The Records indicated that Resident#107 tested positive for cocaine, and was hospitalized for [REDACTED]. Review of Resident #107's Nurse's Progress Notes, dated [DATE] and [DATE], indicated that Resident #107 required assistance to get back to the Facility from leaves of absence because the battery in his/her electric wheelchair had died and he/she had no means to communicate his/her need for assistance with Facility staff. Review of Resident #107's Social Service Interim Progress Note, dated [DATE], indicated that Resident #107 was not able to define safe leaving times with his/her electric wheelchair. The Note was dated for more than four months after Resident #107's first reported incident of being on a leave of absence in which the battery for his/her wheelchair died . Review of the Facility's Internal Investigation indicated that it included a Care Plan for Resident #107's extended leaves of absence from the Facility, both dated [DATE], which was not included in Resident #107's clinical record when reviewed by the Surveyor throughout the dates of survey, and was therefore not accessible to Facility staff. There was no documentation at the time of survey to support that the Facility evaluated Resident #107's safety and judgment regarding use of his/her electric wheelchair outside of the Facility, in the setting of multiple falls out of the wheelchair and extended leaves of absence from the Facility. 6. Resident #108 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #108's Nurse's Progress Notes, dated [DATE], indicated that his/her room was searched after the smell of smoke was noted in his/her room. The Notes indicated that Resident #108 was found in possession of multiple small plastic bags (consistent with drug paraphernalia), a glass smoking device/crack pipe, cigarettes, lighters, and brownish/white substances (consistent with drugs). Review of the Facility's Internal Investigation, dated [DATE], indicated that a crack pipe with drug in it was found during the search of Resident #108's room. The Investigation also indicated that Resident #108's significant other brought him/her drugs at the Facility. Review of Resident #108's Care Plan for substance abuse behaviors, initiated on [DATE], indicated that he/she was referred to the substance abuse counselor on [DATE]. Review of Resident #108's Substance Abuse Assessment, dated [DATE], indicated that his/her behaviors since admission to the Facility had indicated drug use, and that there was a suspicion that his/her significant other was bringing him/her drugs. The Assessment indicated that Resident #108 wanted to continue to smoke crack and use heroin, with no desire to make changes. Review of Resident #108's Nurse's Progress Note, dated [DATE], indicated that a staff person from the substance abuse services provider reported that Resident #108 said he/she was going to start selling crack in the Facility. Review of Resident #108's Social Services Interim Progress Note, dated [DATE] at 3:59 P.M., indicated that Resident #108 had been observed and in possession of illicit substances/drug trafficking in the Facility. The DON said Resident #108's significant other was caught on security cameras trafficking illicit substances in the Facility on several occasions, and ultimately was trespassed from the Facility. The DON said she did not know if Resident #108 also trafficked drugs within the Facility. Review of Resident #108's Social Services Interim Progress Note, dated [DATE], indicated that on the prior evening, Resident #108 was observed placing a baggie into his/her clothing. The Note indicated that a search of Resident #108's room was conducted, and a white paper with ashes was found in the bathroom and a plastic baggie was in the toilet. Review of Resident #108's hospital documentation, dated [DATE], indicated that his/her toxicology screen was presumptive (initial report) positive for cocaine. There was no documentation at the time of survey to support that the Facility: reviewed Resident #108's possession of suspected drugs and/or drug paraphernalia on [DATE], [DATE] and [DATE] to determine how he/she obtained the narcotics/heroin/opiates; or, conducted an investigation into reports on [DATE] and [DATE] that Resident #108 was trafficking drugs at the Facility. 7. Resident #109 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the Facility's Internal Investigation, dated [DATE], indicated that Resident #109 reported that Nurse #15 was selling [MEDICATION NAME] and [MEDICATION NAME] (a narcotic pain medication made up of [MEDICATION NAME] (Tylenol) and [MEDICATION NAME]) pills to himself/herself and other residents of the Facility. The Investigation also indicated that Director of Social Services #1 interviewed two residents, who wished to remain anonymous and who reported that they had heard of a Facility employee selling pills in the Facility. The Investigation indicated that the two anonymous residents declined to identify the Facility employee. The DON said she did not investigate the allegations made by the two residents that Facility staff was selling pills to residents. The DON said that because the two residents wished to remain anonymous, she did not interview them about their allegations because she did not know who they were. The DON said she also did not know who the staff person was that allegedly sold the pills to residents, because she did not interview the two residents, and said that it was possible the staff person still worked at the Facility. There was no documentation at the time of survey to support that the Facility investigated allegations of Facility staff selling pills to residents, to identify the staff person allegedly responsible and to protect residents from having access to substances. 8. The Surveyor interviewed Resident #79 at 4:33 P.M. on [DATE]. Resident #79 said that it was impossible for residents with substance abuse issues to stay sober at the Facility. Resident #79 said that despite personal risk to his/her safety, he/she repeatedly notified staff, including nurses, CNAs and Director of Social Services #2, of specific incidents of illicit substance use at the Facility. Resident #79 said Facility staff was not responsive to his/her reports of drug use and selling and said nothing was done, or words to that effect. Resident #79 said that the Facility had numerous security cameras, but that residents who wanted to use illicit substances shared information on where the cameras' blind spots were, and used those spots to their advantage. 9. The Surveyor interviewed Nurse #14 at 2:07 P.M. on [DATE]. Nurse #14 said staff knew which residents used illicit substances, but could not do much about the substance use as the residents would become angry, violent, and would threaten staff. Nurse #14 said some residents and staff reported being fearful of the residents that used substances. 10. The Surveyor interviewed Security Officer #1 at 11:30 A.M. on [DATE]. Security Officer #1 reported that he and Nurse #15 observed a resident, who he was only able to identify by a first name, injecting an unknown substance into his/her Peripherally Inserted Central Catheter (PICC; a type of IV access that can be used for a prolonged period of time) in the bathroom. Security Officer #1 said that it appeared the resident had already injected most of the contents of the syringe into his/her PICC. Security Officer #1 said he and Nurse #15 made the same observation with the same resident, two days in a row, exact dates unknown. The Surveyor interviewed Nurse #15 at 12:46 P.M. on [DATE]. Nurse #15 said she did not recall the specific incidents reported by Security Officer #1, but said she had transferred residents to the hospital for evaluation after incidents of suspected drug use. 11. At 8:15 A.M. on [DATE], the Surveyor and Medical Records Staff #1 entered the third floor nursing station. The Surveyor observed that the only person behind the nursing station was the Administrator, who left after a couple of minutes. The Surveyor observed an unlocked medication cart which had two full blister packs (medication cards in which multiple tablets or pills are contained within individual bubbles, which are then popped when the medication is to be administered) lying directly on the top of the medication cart, in view of anyone looking into the nursing station. One pack contained Quetiapine ([MEDICATION NAME]; an antipsychotic medication) for administration to Resident #18, and the other pack contained Duloxetine ([MEDICATION NAME]; an antidepressant medication) for administration to Resident #25. The Surveyor interviewed Nurse #4 at 8:20 A.M. on [DATE]. Nurse #4 said she had just arrived to work and had no knowledge of the medication cart. The Surveyor then observed Nurse #4 leaving the nursing station, without securing the unlocked medication cart or the blister packs lying on top of it. The Surveyor interviewed Nurse #7 at 8:30 A.M. on [DATE]. Nurse #7 said Nurse #8 worked the 11:00 P.M. to 7:00 A.M. shift and must have left the medication cart as it was observed by the Surveyor. The Surveyor interviewed Unit Manager #1 at 8:40 A.M. on [DATE]. Unit Manager #1 said the medication cart should have been locked, with the two blister packs of medication containing Quetiapine and Duloxetine secured inside the locked cart.

Based on records reviewed and interviews, for eight of 28 sampled residents (Resident #7, #29, #65, #67, #80, #99, #107, and #108), the facility failed to ensure that: staff conducted accurate and timely substance abuse assessments and evaluations; there was a plan in place which included oversight by the Medical Director to ensure the safety of residents in the setting of known incidents of drug trafficking and substance use; residents' clinical record contained accurate information regarding known substance abuse and treatment history; substance abuse services were provided consistent with residents' identified needs; that substance abuse care plans were completed, accessible to staff and reviewed and revised as needed; and, that the facility provided an environment and atmosphere that was conducive to mental and psychosocial well-being of residents with Substance Use Disorders (SUDs). Findings include: - On 08/27/18, the Director of Nurses (DON) provided the Surveyor with a list of residents with known SUD who resided in the Facility, which indicated that approximately 46% of the Facility's population had a known SUD. - The Surveyor interviewed the Medical Director at 10:48 A.M. in 09/05/18. The Medical Director said she was the attending physician for most of the residents at the Facility. The Medical Director said the Facility had a high percentage of residents with SUDs. The Medical Director said that there were limited resources available at the Facility for residents with SUD, and that the Facility was working on having resources in place for staff to be able to care for residents with SUD. - The Surveyor interviewed the Director of Nurses (DON) at 2:30 P.M. on 08/24/18 and at multiple times throughout the dates of survey. The DON said the expectation was that the initial substance abuse assessment was completed within 24 hours of a resident's admission to the Facility. The DON said the Facility did not have a policy and/or procedure on the care and treatment of [REDACTED]. - The Surveyor interviewed the Licensed Alcohol and Drug Counselor (LADC) at 1:50 P.M. on 08/29/18. The LADC said she and her staff provided substance abuse services to the residents of the Facility in conjunction with Facility staff. The LADC said she and her staff were responsible for the completion of assessments, facilitation of groups, individual therapy, and training for staff. The LADC said substance use assessments were completed on any resident with a history of substance abuse, and were separate from the Substance and/or [MEDICAL CONDITION] Evaluation completed by Facility staff. The LADC said assessments were completed within three days of receipt of the referral, and that if assessments could not be completed within those three days, the reason(s) were documented. The LADC said she and her staff also assessed residents following incidents of alleged or confirmed illicit substance use. The LADC said residents who overdosed were seen as soon as possible, otherwise residents were seen usually within three days of alleged or confirmed illicit substance use. The LADC said there were residents who told her that they had concerns about maintaining their sobriety at the Facility because of the availability of illicit substances. The LADC said the Facility had difficulties with drug trafficking. - The Surveyor interviewed Director of Social Services #2 at 10:18 A.M. on 08/28/18 and at multiple times throughout the dates of survey. Director of Social Services #2 said she had located drug paraphernalia during resident room searches such as heroin, crack pipes, lighters, and syringes. Director of Social Services #2 said the Facility did not have admission criteria for admitting residents with SUD. Director of Social Services #2 said the Facility did not admit residents in active withdrawal, but then said there was a resident admitted approximately a week prior and was currently actively withdrawing from illicit drugs. Director of Social Services #2 said there were residents who attended substance use outpatient programs daily, but said that information was not documented in the residents' clinical records and said she was not aware if the Facility communicated incidents of alleged illicit substance use with the residents' substance use outpatient programs. - The Surveyor interviewed the Ombudsman Program Director (OPD) and the Assistant Ombudsman Program Director (AOPD) at 11:08 A.M. on 08/23/18. The OPD and AOPD said residents reported that it was easier to obtain illicit substances inside the Facility than out on the street. The OPD and AOPD said they received concerns from staff about not being provided adequate resources or training to care for residents with SUDs. The OPD and AOPD said they were aware the Administrator and DON had received reports of illicit drug use by residents in the Facility. - The Facility's policy titled Evaluations, Schedule Of, revised (MONTH) (YEAR), indicated that evaluations would be used to aid in the development of resident-centered care plans. The Policy indicated that Substance and/or [MEDICAL CONDITION] evaluations were conducted on admission, re-admission, quarterly, annually, with significant change, and with an acute event of substance or alcohol use. 1. Resident #7 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #7's Substance and/or [MEDICAL CONDITION] Evaluation, completed 02/12/18, indicated that he/she had a history of [REDACTED].#7's known history of psychoactive substance abuse or opioid abuse. Review of the Facility's Internal Investigation, dated 03/31/18, indicated that on 03/30/18, Resident #7 was treated in the hospital for an opiate overdose which required [MEDICATION NAME] (a medication used to temporarily reverse the effects of opioid medications in an emergency situation, which has no effect on non-opioid medications). The Investigation indicated that Resident #7 said he/she snorted heroin. The Investigation included a substance abuse care plan, dated 03/31/18, which was not included in Resident #7's clinical record when reviewed by the Surveyor on multiple dates of survey, and did not include Resident #7's reported history of [MEDICAL CONDITION]. There was no documentation at the time of survey to support that the Facility completed a Substance and/or [MEDICAL CONDITION] Evaluation after Resident #7's opiate overdose on 03/30/18, in accordance with facility policy, or that the Substance Abuse Assessment was completed by the Facility's substance abuse services provider within three days. This was not consistent with information provided by the LADC to the Surveyor during interview. Review of the Facility's Internal Investigation, dated 04/26/18, indicated that Resident #7 became unresponsive during a smoking break, was treated with [MEDICATION NAME], and was transferred to the hospital. The Investigation indicated that at the hospital, Resident #7 was diagnosed with [REDACTED]. Review of Resident #7's Substance Abuse Assessment, dated 05/02/18, indicated that he/she had a history of [REDACTED]. The Assessment included a Substance Abuse Care Plan, dated 05/01/18, which did not include a plan for Resident #7's history of [MEDICAL CONDITION]. There was no documentation at the time of survey to support that the Facility completed a Substance and/or [MEDICAL CONDITION] Evaluation after Resident #7's opiate overdose on 04/26/18, in accordance with facility policy, or that the Substance Abuse Assessment was completed by the Facility's substance abuse services provider within three days. This was not consistent with information provided by the LADC to the Surveyor during interview. Review of Resident #7's Substance and/or [MEDICAL CONDITION] Evaluation, completed 05/19/18, indicated that he/she had a history of [REDACTED].#7's history of [MEDICAL CONDITION]. Review of the Facility's Internal Investigation, dated 05/20/18, indicated that Resident #7 was found unresponsive and reportedly overdosed on drugs. The Investigation indicated that Resident #7 was administered [MEDICATION NAME] and transferred to the hospital, where he/she was diagnosed with [REDACTED]. There was no documentation at the time of survey to support that the Facility completed a Substance and/or [MEDICAL CONDITION] Evaluation after Resident #7's opiate overdose on 05/20/18, in accordance with facility policy, or that the Substance Abuse Assessment was completed by the Facility's substance abuse services provider within three days. This was not consistent with information provided by the LADC to the Surveyor during interview. Review of Resident #7's APRN (Advanced Practice Registered Nurse) Note, dated 06/13/18, indicated that Resident #7 had orders for the administration of [MEDICATION NAME] (an opioid pain medication) twice a day and every four hours as needed (PRN). The Note, signed by the Nurse Practitioner (NP), indicated that he told Resident #7 that he/she could not use illicit drugs while on [MEDICATION NAME] or pain medications. Review of the Facility's Internal Investigation, dated 07/06/18, indicated that Resident #7 was found lethargic (sluggish) and difficult to arouse, and had three [MEDICATION NAME] pills in his/her possession. The Investigation indicated that Resident #7 was treated at the hospital, where his/her [DIAGNOSES REDACTED]. Review of Resident #7's Substance and/or [MEDICAL CONDITION] Evaluation, completed 07/22/18, indicated that he/she had a history of [REDACTED].#7's documented history of [MEDICAL CONDITION] or opioid and heroin abuse. Review of Resident #7's Substance Abuse Assessment, dated 07/27/18, included a substance abuse care plan, undated, which did not include a plan for Resident #7's history of [MEDICAL CONDITION] or heroin abuse. There was no documentation at the time of survey to support that the Facility completed a Substance and/or [MEDICAL CONDITION] Evaluation until 16 days after Resident #7's narcotic overdose on 07/06/18, or that the Substance Abuse Assessment was completed by the Facility's substance abuse services provider within three days. This was not consistent with information provided by the LADC to the Surveyor during interview. Review of the Facility's Internal Investigation, dated 08/16/18, indicated that on 08/04/18, Resident #7 was transferred to the hospital due to increased confusion and difficulty breathing. The Investigation indicated that Resident #7's lethargy responded to [MEDICATION NAME], and was likely due to an opioid/heroin overdose. There was no documentation at the time of survey to support that the Facility completed a Substance and/or [MEDICAL CONDITION] Evaluation after Resident #7's opiate overdose on 08/04/18, in accordance with facility policy, or that the Substance Abuse Assessment was completed by the Facility's substance abuse services provider within three days. This was not consistent with information provided by the LADC to the Surveyor during interview. Review of Resident #7's Nurse's Progress Note, dated 08/28/18, indicated that he/she was very lethargic, hard to arouse, had slow breathing, and was transferred to the hospital. Review of Resident #7's Hospital Discharge Summary, dated 08/31/18, indicated that Resident #7 was administered [MEDICATION NAME] for a suspected overdose, with a positive effect. The Summary indicated that Resident #7 overdosed on heroin, and that Resident #7 said a friend delivered the heroin to him/her at the Facility. Review of Resident #7's clinical record indicated that as of 09/05/18, there was no documentation at the time of survey to support that the Facility completed a Substance and/or [MEDICAL CONDITION] Evaluation or a Substance Abuse Assessment after Resident #7's heroin overdose on 08/28/18, in accordance with Facility policy and information provided to the Surveyor during interviews. There was no documentation at the time of survey to support that the Facility completed assessments after Resident #7's narcotic or opioid overdoses on 03/30/18, 04/26/18, 05/20/18, 07/06/18, 08/04/18 or 08/28/18, in accordance with Facility policy and consistent with information provided by the LADC to the Surveyor during interview, to determine his/her risk for relapse, and what substance use services he/she may require; or, that the Facility had services in place to meet Resident #7's substance use needs. 2. Resident #29 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #29's Social Service Interim Progress Note, dated 04/12/18, indicated that Director of Social Services #1 was informed by another, unnamed, resident that Resident #29 had taken some drugs from another resident and that Resident #29 was transferred to the Emergency Department (ED) for evaluation. Review of Resident #29's ED Provider Notes, dated 04/12/18, indicated that he/she presented with an altered mental status and that Facility staff was concerned he/she received some kind of narcotic during a visit with a friend. The Notes indicated that Resident #29 admitted to taking some kind of narcotic on that date, and that he/she was diagnosed with [REDACTED]. Review of Resident #29's Hospital Discharge Summary, dated 04/28/18, indicated that he/she said he/she took pills given to him/her by a friend, and indicated that Resident #29 told Facility staff that he/she took heroin brought to him/her by a friend. Review of Resident #29's Nurse's Progress Note, dated 05/20/18, indicated that Resident #29 was found in his/her room with another resident (identified as Resident #7). The Note indicated that Resident #7 was found unresponsive, and Resident #29 was alert but disoriented. The Note indicated that Resident #29 was transferred to the Hospital for evaluation. Review of Resident #29's Social Service Interim Progress Note, dated 05/20/18, indicated that both Resident #7 and Resident #29 were found passed out and not responsive to verbal or physical stimuli. The Note indicated that one dose of [MEDICATION NAME] was administered to Resident #29 for suspected drug/opiate overdose, and that a plastic straw and top knot from a corner bag (both consistent with drug paraphernalia) were found on the floor near Resident #29. Review of the Facility's Internal Investigation, dated 05/20/18, indicated that it included a Statement completed by the NP, which indicated that Resident #29 found unresponsive in his/her wheelchair and [MEDICATION NAME] was administered. Review of Resident #29's Nurse's Progress Note, dated 06/11/18, indicated that a Certified Nurse Aide (CNA) observed Resident #29 in his/her room with an unidentified substance in his/her hand. The Note indicated that the security officer was notified and went to Resident #29's room. The Note indicated that the security officer reported that Resident #29 handed him two bags of heroin. The Note indicated that the Administrator, DON, and NP were notified. Review of Resident #29's Social Service Interim Progress Note, dated 07/05/18, indicated that he/she had a recent history of spending his/her money on illicit substances, such as heroin, and sharing the heroin with other residents, which lead to overdose. Review of Resident #29's Nurse's Progress Note, dated 07/06/18 at 11:59 P.M., indicated that Resident #29 and another resident (identified as Resident #7) were found sniffing an unknown substance. The Note indicated that a white substance and three [MEDICATION NAME] were found, and that Resident #29 was transferred to the Hospital for an evaluation. Review of Resident #29's ED Provider Notes, dated 07/06/18, indicated that he/she reported that he/she took his/her roommate's [MEDICATION NAME]. There was no documentation at the time of survey to support that the Facility completed assessments after Resident #29's suspected or confirmed illicit substance use on 04/12/18, 05/20/18, or 07/06/18, in accordance with Facility policy and consistent with information provided by the LADC to the Surveyor during interview. 3. Resident #65 was admitted to the Facility in (MONTH) (YEAR). Review of Resident #65's pre-admission documentation indicated that he/she had a history of [REDACTED]. Review of Resident #65's Substance and/or [MEDICAL CONDITION] Evaluation, dated 04/07/18, indicated that he/she did not have a history of substance use, which was not consistent with his/her pre-admission information. Review of Resident #65's Nurse's Progress Notes, dated 04/13/18, 04/15/18, 04/16/18, 04/17/18, 04/19/18, and 04/22/18, indicated that he/she was medication seeking (a person's manipulative, demanding behaviors in an attempt to obtain medication). Review of Resident #65's physician progress notes [REDACTED]. Review of Resident #65's Medication Management Assessment, dated 05/31/18, indicated that Resident #65 had a history of [REDACTED]. Review of Resident #65's Substance and/or [MEDICAL CONDITION] Evaluation, dated 07/10/18, indicated that he/she did not have a history of substance use, which was not consistent with his/her pre-admission information, or Medication Management assessment dated [DATE]. Review of Resident #65's physician progress notes [REDACTED]. There was no documentation at the time of survey to support that the Facility: referred Resident #65 for assessment by the substance abuse services provider; ensured that assessments accurately documented Resident #65's known history of [MEDICAL CONDITION]; and, assessed Resident #65 after multiple documented incidents of medication seeking behavior to determine the need for substance abuse services. 4. Resident #67 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A. Review of Resident #67's Initial Social Services Summary, dated 10/17/17, indicated that he/she had been using substances for the previous two years. Review of Resident #67's Nurse's Progress Note, dated 11/05/17, indicated that a search of his/her room was conducted due to suspected drug use. Review of Resident #67's Nurse's Progress Note, dated 11/08/17, indicated that he/she returned from the hospital with documentation of a suspected opioid overdose. Review of Resident #67's Social Service Interim Progress Note, dated 03/29/18, indicated that he/she was considering using drugs in response to coming off of [MEDICATION NAME]. The Note did not indicate that it included any interventions or a referral to the Facility's substance abuse services provider. Review of Resident #67's Medication Management Assessment, dated 04/19/18, indicated that he/she was kicked out of his/her [MEDICATION NAME] clinic due to an altercation with staff at the clinic, and indicated that Resident #67 was a high risk for relapse. The Surveyor interviewed the Medical Director at 10:48 A.M. in 09/05/18. The Medical Director said she was Resident #67's attending physician. The Medical Director said Resident #67 was kicked out of his/her [MEDICATION NAME] clinic several months prior to the date of interview for assaulting a security officer. The Medical Director said she did not know where Resident #67 received his/her [MEDICATION NAME] from, or what dose of [MEDICATION NAME] he/she was receiving after being kicked out of the [MEDICATION NAME] clinic. Review of Resident #67's Social Service Interim Progress Note, dated 05/30/18, indicated that he/she was found unresponsive at the nurses' station, and became responsive after the administration of two doses of [MEDICATION NAME]. The Note indicated that Resident #67 said he/she used [MEDICATION NAME] that was given to him by another resident at the Facility. Review of the Facility's Internal Investigation, dated 05/30/18, indicated that Resident #67 was treated at the hospital for an opioid overdose. Review of Resident #67's Nurse's Progress Note, dated 06/01/18 at 10:47 P.M., indicated that at approximately 10:20 P.M., Resident #67 was unresponsive, extremely diaphoretic (sweating heavily), and had a thready pulse (scarcely noticeable, rapid pulse). The Note indicated that Resident #67 became responsive after the administration of two doses of [MEDICATION NAME]. Review of Resident #67's ED Provider Notes, dated 06/01/18, indicated that he/she was evaluated for a suspect heroin overdose. Review of Resident #67's Social Service Interim Progress Note, dated 06/07/18, indicated that on 06/06/18, he/she was observed exchanging money for an unknown item in front of the Facility, and appeared impaired. Review of Resident #67's APRN Note, dated 06/30/18, indicated that he/she was seen for a surgical consult, and that Resident #67 was advised to stop using illicit drugs. Review of Resident #67's Nurse's Progress Note, dated 07/11/18, indicated that at approximately 8:30 P.M., he/she was unresponsive, had little response to two doses of [MEDICATION NAME], and was transferred to the hospital. Review of Resident #67's Hospital Notes, dated 07/11/18 and 07/12/18, indicated that he/she presented with his/her fifth overdose after using some form of an opiate. The Notes indicated that Resident #67 admitted to cocaine use, which was confirmed by positive toxicology testing. Review of Resident #67's Administrator Progress Note, dated 08/20/18, indicated that he/she admitted to using cocaine in the community. Review of Resident #67's Nurse's Progress Note, dated 08/24/18, indicated that a broken small round glass straw with a darkened end, which gave the appearance that the straw was used to smoke a substance, was found in his/her room. Review of Resident #67's Nurse's Progress Note, dated 08/27/18, indicated that he/she reported that he/she started using drugs again. Review of Resident #67's ED Notes Report, dated 08/27/18, indicated that he/she tested positive for cocaine. B. Review of Resident #67's substance abuse history Care Plan, initiated on 10/11/17, indicated that on 05/30/18, he/she was referred for substance abuse services. Review of Resident #67's Individual Assessment/Therapy/Collateral Progress Note, dated 06/21/18, indicated that he/she was not evaluated by the substance abuse services provider for approximately 22 days after the date of the referral. Review of Resident #67's behavioral Care Plan, initiated on 10/16/17, indicated that he/she was referred to substance abuse services on 07/11/18. Review of Resident #67's Substance Abuse Assessment, dated 07/19/18, indicated that he/she was not evaluated by the substance abuse services provider for approximately 8 days after the date of the referral. Review of Resident #67's Administrator Progress Note, dated 08/20/18, indicated that he/she admitted to recent cocaine use in the community. There was no documentation at the time of survey to support that the Facility completed Substance Abuse Assessments or Substance and/or [MEDICAL CONDITION] Evaluations after Resident #67's suspected or confirmed illicit substance use on 11/05/17, 11/08/17, 05/01/18, 05/30/18, 06/01/18, 06/06/18, or 07/11/18, in accordance with Facility policy, information provided by the LADC during interview; or completed in response to documented referrals made to substance abuse services on 05/30/18 and 07/11/18. C. Review of Resident #67's Substance Abuse Assessment, dated 11/30/17, indicated that it was completed more than seven weeks after Resident #67's admission to the Facility. Review of Resident #67's Substance and/or [MEDICAL CONDITION] Evaluations indicated that there were no evaluations completed between 10/11/17 and 04/10/18. There was no documentation at the time of survey to support that the Facility completed Substance Abuse Assessments and/or Substance and/or [MEDICAL CONDITION] Evaluations in accordance with Facility policy and information provided during interviews. D. Review of Resident #67's substance abuse history Care Plan, initiated on 10/11/17, indicated that it did not include documentation regarding his/her suspected or confirmed incidents of substance use on or about 11/08/17, 05/02/18, 06/06/18, 07/11/18, or 08/20/18. Review of Resident #67's behavioral problem Care Plan, initiated on 10/16/17, indicated that it did not include documentation regarding his/her suspected or confirmed incidents of substance use on or about 11/08/17, 05/02/18, 05/30/18, 06/06/18, or 08/20/18 There was no documentation at the time of survey to support that the Facility reviewed and/or revised Resident #67's substance abuse or behavioral problem Care Plans in response to confirmed or suspected incidents of substance use on 11/08/17, 05/02/18, 06/06/18, or 08/20/18. E. Review of Resident #67's Substance Abuse Assessment, dated 11/30/17, indicated that his/her substance use/abuse included prescription pills, heroin, [MEDICATION NAME], Carfentanil (an opioid that is 100 times more potent than the same amount of [MEDICATION NAME], and 5,000 times more potent than a unit of heroin), and nicotine. The Assessment indicated that it did not include documentation regarding Resident #67's suspected or confirmed incidents of substance use on 11/05/17 and 11/08/17. Review of Resident #67's Substance and/or [MEDICAL CONDITION] Evaluation, dated 04/10/18, indicated that he/she had a history of [REDACTED]. The Evaluation indicated that it did not include documentation of Resident #67's history of abuse/use of prescription pills and nicotine, and did not include documentation of Resident #67's suspected use on 11/08/17. Review of Resident #67's Substance and/or [MEDICAL CONDITION] Evaluation, dated 07/09/18, indicated that he/she had a history of [REDACTED]. The Evaluation did not include documentation of Resident #67's history of abuse/use of substances of prescription pills and nicotine, and did not include documentation of Resident #67's suspected or confirmed incidents of substance use on 05/01/18, 05/30/18, 06/01/18, or 06/06/18. There was no documentation at the time of survey to support that Resident #67's substance use assessments and evaluations consistently documented his/her known substance use history, or suspected or confirmed incidents of substance use. 5. Resident #80 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A. Review of Resident #80's Nurse's Progress Note, dated 07/07/18, indicated that Resident #80 requested [MEDICATION NAME] (a controlled substance used to treat headaches). The Note indicated that Resident #80 took the medication and then gave the medication to another resident. The Note indicated that the medication was retrieved from the other resident's pocket by a staff person. The DON said she did not investigate or address the report that on 07/07/18 staff witnessed Resident #80 give his/her [MEDICATION NAME] to another resident of the Facility to determine if interventions were necessary to ensure the safety of Resident #80 and other residents. There was no documentation at the time of survey that the Facility assessed Resident #80 or addressed an incident of medication sharing to determine if interventions were necessary to ensure the safety of Resident #80 and other residents. B, Review of Resident #80's Substance and/or [MEDICAL CONDITION] Evaluations indicated that there were no Evaluations completed between 01/20/18 and 07/22/18, which was not consistent with Facility policy. There was also no documentation at the time of survey to support that a Substance and/or [MEDICAL CONDITION] Evaluation was completed in conjunction with Resident #80's witnessed pill sharing on 07/07/18, in accordance with Facility policy. C. The Surveyor interviewed Resident #80 at 8:37 A.M. and at multiple times throughout the dates of survey. Resident #80 said residents actively used illicit substances in the Facility, which made it very hard for him/her stay sober. Resident #80 said he/she feared for his/her safety and sobriety at the Facility because administration, including the Administrator and DON, were aware of the substance use issues at the Facility and did not do anything about it. 6. Resident #99 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #99's Substance and/or [MEDICAL CONDITION] Evaluation, dated 01/25/18, indicated that he/she had a history of [REDACTED].#99 was likely (8) to seek alternate substance treatment. Review of Resident #99's Initial Social Services Summary, dated 01/30/18, indicated that he/she had a history of [REDACTED]. Review of Resident #99's Substance Abuse Assessment, dated 02/01/18, indicated that his/her substance use/abuse included: alcohol, crack, cocaine, hallucinogens, prescriptions, and heroin. The Assessment indicated that approximately two months prior to the date of the assessment, Resident #99 attempted suicide via overdose. The Substance Abuse Care Plan, dated 02/01/18 and included with the Substance Abuse Assessment, indicated that it did not include Resident #99's known history of [MEDICAL CONDITION]. Review of Resident #99's Nurse's Progress Note, dated 02/13/18, indicated that Resident #99 expressed a plan of suicide via overdose and was transferred to the hospital for evaluation. Review of Resident #99's Patient Progress Note, dated 08/23/18, indicated that he/she attempted suicide via overdose on two separate occasions within four months of his/her admission to the Facility, which was not consistent with the Substance Abuse assessment dated [DATE]. The Note indicated that on one of the occasions, Resident #99 overdosed after injecting heroin. There was no documentation at the time of survey to support that the Facility's substance abuse services provider evaluated Resident #99 after an expressed plan to commit suicide via overdose in (MONTH) (YEAR); or, that the Facility developed a plan to reduce Resident #99's risk of suicide via overdose. 7. Resident #107 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #107's History and Physical (H&P), dated 11/21/17, indicated that he/she used illicit drugs. Review of Resident #107's physician progress notes [REDACTED]. A. Review of Resident #107's Nurse's Progress Note, dated 12/04/17, indicated that a hollowed-out pen (often used in the ingestion of illicit substances) and cigarettes were found during a search of Resident #107's room. Review of Resident #107's Individual Assessment/Therapy/Collateral Progress Note completed by the substance abuse services provider, dated 12/08/17, indicated that no substance use was reported, but that there was a suspicion, and that Resident #107 appeared intoxicated. There was no documentation at the time of survey to support that Resident #107's possible intoxication on 12/08/17 was communicated to Facility staff by the substance abuse services provider, or that any assessment was conducted or interventions implemented specific to the alleged intoxication. Review of Resident #107's Nurse's Progress Note, dated 01/12/18 at 10:32 A.M., indicated that a search of Resident #107's room yielded

Based on records reviewed and interviews, the facility failed to ensure that the Medical Director was involved in the development or implementation of resident care policies and content of staff trainings for the care and treatment for [REDACTED]. Findings include: On 08/27/18, the Director of Nurses (DON) provided the Surveyor with a list of residents with known SUDs who resided in the Facility, which indicated that approximately 46% of the Facility's population had a known SUD. - The Surveyor interviewed the Director of Nurses (DON) at 2:30 P.M. on 08/24/18 and at multiple times throughout the dates of survey. The DON said the Facility did not have any policies and/or procedures on the care and treatment of [REDACTED]. There was no documentation at the time of survey to indicate that the Facility, in coordination with the Medical Director, developed or implemented resident care policies regarding the care and treatment of [REDACTED]. - The Surveyor interviewed the Medical Director at 10:48 A.M. in 09/05/18. The Medical Director said she was the attending physician for almost all of the residents at the Facility. The Medical Director said the Facility had a high percentage of residents with SUDs. The Medical Director said trainings were offered at the Facility regarding SUDs, but said she did not know what the content of those trainings were and did not know if or how the Facility ensured staff competency of the trainings provided.

Based on records reviewed and interviews, for two of 28 sampled residents (Resident #7 and #67), the facility failed to ensure care plans were reviewed and revised in accordance with comprehensive assessments and in response to known incidents of substance use. Findings include: The Surveyor interviewed the Director of Nurses (DON) at multiple times throughout the dates of survey, and at 3:05 P.M. on 09/05/18. The DON said resident care plans were either documented on paper or in the resident's electronic health record. The DON said staff would have to check both the electronic health record and the resident's paper clinical record to review any active care plans. 1. Resident #7 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. - The Facility's Internal Investigation, dated 03/31/18, indicated that Resident #7 was treated in the hospital on [DATE] for an opiate overdose which required [MEDICATION NAME] (a medication used to temporarily reverse the effects of opioid medications in an emergency situation, which has no effect on non-opioid medications). The Investigation indicated that Resident #7 said he/she snorted heroin. The Investigation included a substance abuse care plan, dated 03/31/18, which was not included in Resident #7's paper or electronic clinical record when reviewed by the Surveyor on multiple dates of survey. The Facility's Internal Investigation, dated 04/26/18, indicated that Resident #7 became unresponsive during a smoking break, was treated with [MEDICATION NAME], and was transferred to the hospital. The Investigation indicated that at the hospital, Resident #7 was diagnosed with [REDACTED]. Review of Resident #7's clinical record included a MDS dated [DATE]. There was no documentation at the time of survey to indicate that Resident #7's substance abuse Care Plans were reviewed or revised in conjunction with the MDS dated [DATE], to include Resident #7's known substance use history, his/her opiate overdose on 04/26/18, his/her desire to achieve or maintain sobriety, his/her risk for relapse, or his/her desire to seek treatment for [REDACTED]. - The Facility's Internal Investigation, dated 05/20/18, indicated that Resident #7 was found unresponsive, was administered [MEDICATION NAME], and was transferred to the hospital after reportedly overdosing. The Investigation included hospital documentation which indicated that Resident #7 was diagnosed with [REDACTED]. Review of Resident #7's Individual Assessment/Therapy/Collateral Progress Note, dated 06/06/18, indicated that Resident #7 identified pain as his/her trigger for substance abuse. The Facility's Internal Investigation, dated 07/06/18, indicated that Resident #7 was found lethargic (sluggish) and difficult to arouse, and had three [MEDICATION NAME] (a narcotic pain medication) pills in his/her possession. The Investigation indicated that Resident #7 was treated at the hospital, where his/her [DIAGNOSES REDACTED]. The Facility's Internal Investigation, dated 08/16/18, indicated that on 08/04/18, Resident #7 was transferred to the hospital due to increased confusion and difficulty breathing. The Investigation indicated that Resident #7's lethargy responded to [MEDICATION NAME], and was likely due to an opioid/heroin overdose. Review of Resident #7's clinical record included a MDS dated [DATE]. There was no documentation at the time of survey to indicate that Resident #7's substance abuse Care Plans were reviewed or revised in conjunction with the MDS dated [DATE], to include Resident #7's known substance use history, his/her reported overdoses on 05/20/18, 07/06/18 or 08/04/18, his/her report that substance use was triggered by pain, his/her desire to achieve or maintain sobriety, his/her risk for relapse, or his/her desire to seek treatment for [REDACTED]. 2. Resident #67 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #67's Nurse's Progress Note, dated 11/08/17, indicated that he/she returned from the hospital with documentation of a suspected opioid overdose. Review of Resident #67's Social Service Interim Progress Note, dated 03/29/18, indicated that he/she was considering using drugs due to coming off of [MEDICATION NAME] (a medication used to treat pain and narcotic drug addiction). Review of Resident #67's Medication Management Assessment, dated 04/19/18, indicated that he/she was a high risk for relapse. Review of Resident #67's Social Service Interim Progress Note, dated 05/02/18, indicated that he/she was sent to the hospital after he/she disclosed cocaine use the prior evening to self-medicate his/her depression. Review of Resident #67's Social Service Interim Progress Note, dated 06/07/18, indicated that on 06/06/18, he/she was observed exchanging money for an unknown item in front of the Facility, and appeared impaired. Review of Resident #67's Administrator Progress Note, dated 08/20/18, indicated that he/she admitted to cocaine use in the community. There was no documentation at the time of survey to indicate that Resident #67's substance abuse and/or behavioral problem Care Plans were reviewed or revised in conjunction with the MDSs dated 01/11/18 and 04/12/18, to include Resident #77's desire to achieve or maintain sobriety, his/her risk for relapse, or his/her desire to seek treatment for [REDACTED].#67's confirmed or suspected incidents of substance use on 11/08/17, 05/02/18, 06/06/18, and 08/20/18.

Based on records reviewed and interviews, for one of 28 sampled residents (Resident #7), the facility failed to ensure nursing staff acted in accordance with the resident's expressed written request to withhold cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest. Findings include: The Facility's Cardiopulmonary Resuscitation (CPR) policy, dated (MONTH) (YEAR), indicated that CPR would be initiated when a [MEDICAL CONDITION] occurred, except when the resident had a valid Do Not Resuscitate (DNR) order in place. The Facility's Emergency Nasal [MEDICATION NAME] ([MEDICATION NAME]) Administration policy, dated (MONTH) (YEAR), indicated that in the event of suspected opioid depression, to administer [MEDICATION NAME] prior to the administration of rescue breathing and CPR, if indicated. Resident #7 was admitted to the Facility in (MONTH) (YEAR). Review of Resident #7's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, dated [DATE], indicated that Resident #7 was a DNR in the event of a cardiac or respiratory arrest. Review of Resident #7's advanced directives care plan, initiated [DATE], indicated that Resident #7 wished to be a DNR, and to not administer CPR. Review of the Facility's Internal Investigation, dated [DATE], indicated that it included a written statement signed by Nurse #2. The Statement indicated that Nurse #2 responded to calls for help, and observed Resident #7 unresponsive. The Statement indicated that Nurse #2 told staff to page a Code Blue (an emergency page used to indicate a person is in cardiopulmonary arrest and in need of resuscitative efforts) and 911. The Statement indicated that CPR was initiated on Resident #7, his/her MOLST form was reviewed, and that CPR was stopped once his/her code status was found to be a DNR. Review of a written statement by an unidentified person, dated [DATE], indicated that on [DATE], a CNA announced a Code Blue after she checked on Resident #7 due to requests from unknown persons. The Statement indicated that there was so much confusion, and that no one knew Resident #7's code status. The Statement indicated that the unidentified person initiated CPR on Resident #7, got tired, and requested someone else take over. Review of Resident #7's Nurse's Progress Notes, dated [DATE], indicated that Resident #7 became unresponsive, CPR was initiated, and 911 was called. The Notes indicated that Resident #7's MOLST was checked, and he/she was noted to be a DNR and CPR was stopped. The Notes indicated that Resident #7 was transferred to the hospital, and returned to the Facility the same day. The Surveyor interviewed Nurse #2 at 10:55 A.M. on [DATE]. Nurse #2 said he could not recall who initiated CPR on Resident #7. Nurse #2 said CPR was initiated prior to confirmation of Resident #7's code status, and was stopped once he/she was determined to be a DNR. The Investigation indicated that on [DATE], Resident #7 was treated in the hospital for an opiate overdose which required [MEDICATION NAME] (a medication used to reverse the effects of opioid medications in an emergency situation, which has no effect on non-opioid medications). The Investigation indicated that Resident #7 said he/she snorted heroin. There was no documentation at the time of survey to support that Facility staff withheld CPR in accordance with Resident #7's wishes.

Based on records reviewed and interviews, for one of 28 sampled residents (Resident #6), the facility failed to ensure incontinence care was provided in a private setting. On 05/21/18, staff provided incontinence care to Resident #6 in the hallway of his/her nursing unit, in view of other residents. Findings include: Resident #6 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #6's Minimum Data Set (MDS), dated [DATE], indicated that he/she was severely cognitively impaired, was frequently incontinent of bladder and bowel, and required the extensive assistance of more than two persons for toileting needs. The MDS also indicated that Resident #6's primary language was not English. Review of the Facility's Internal Investigation, dated 05/21/18, indicated that at approximately 7:20 A.M. on that date, Nurse #10 instructed staff to provide incontinence care to Resident #6 in the hallway of his/her nursing unit. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 10:38 A.M. on 09/04/18. CNA #1 said that shortly after the start of the 7:00 A.M. to 3:00 P.M. shift, exact date unknown, Nurse #10 said Resident #6's incontinence brief was wet and he/she needed to be changed now. CNA #1 said that when she tried to tell Nurse #10 that they would take Resident #6 into a room to provide care, Nurse #10 responded that he/she needed to be changed now. CNA #1 said staff told Nurse #10 they would not provide care in the hallway due to dignity issues, and Nurse #10 began yelling at them and told them to change Resident #6 immediately. CNA #1 said she and other staff provided incontinence care to Resident #6 in the hallway because Nurse #10 was so mad and they were afraid of her. CNA #1 said there were other residents in the hallway when staff provided incontinence care to Resident #6. CNA #1 said it was possible the other residents saw Resident #6's exposed buttocks and genitals because there was no way to give Resident #6 any privacy or cover his/her genitals and buttocks during the provision of care in the hallway. Review of the Facility's Internal Investigation, dated 05/21/18, indicated that it included a written statement from CNA #8. The Statement indicated that while Resident #6 was in the hallway, Nurse #10 told her to get an incontinence brief for Resident #6 because he/she needed incontinence care. The Statement indicated that when CNA #8 suggested taking Resident #6 into a room, Nurse #10 said she wanted him/her changed in the hallway with other staff and residents present as her witness that staff from the prior shift had not provided care. Review of the Facility's Internal Investigation, dated 05/21/18, indicated that it included a written statement from Nurse #12. The Statement indicated that Nurse #10 asked staff to change Resident #6's incontinence brief while he/she was in the hallway. The Statement indicated that Nurse #12 asked Nurse #10 to let staff take Resident #6 to his/her room and provide care there. The Statement indicated that Nurse #10 wanted Resident #6's incontinence brief changed right now. The Surveyor interviewed Nurse #10 at 10:07 A.M. on 09/26/18. Nurse #10 said that on the morning of the incident, exact date unknown, she observed Resident #6 walking in the hallway with his/her incontinence brief down at his/her ankles. Nurse #10 said Resident #6's buttocks and genitals were exposed because his/her johnny was too short and only covered down to the lower abdominal area. Nurse #10 said a clean incontinence brief was placed on Resident #6 in the hallway because his/her room was not nearby. Nurse #10 said she could not recall if there were other residents in the hallway. Although Resident #6 could not be interviewed due to cognitive impairment and a language barrier to determine the level of harm experienced by Resident #6, it is presumed that a reasonable person would experience emotional harm if no privacy was given during the provision of incontinence care in a public area, and if one's genitals and buttocks were exposed in the presence of others.

Based on records reviewed and interviews, for two of 28 sampled residents (Residents #80 and #99), the facility failed to ensure that Resident #80 was provided care in accordance with his/her plan of care, and failed to ensure that Resident #99 was free from verbal abuse by staff. Findings include: The Facility's Abuse Prohibition Policy, dated (MONTH) (YEAR), indicated that the facility had the responsibility to ensure that each resident had the right to be free from abuse, mistreatment, neglect, and misappropriation of his or her personal property. 1. Resident #80 was admitted to the Facility in (MONTH) (YEAR). Review of Resident #80's Minimum Data Set (MDS), dated [DATE], indicated that he/she had no cognitive impairment, and required the extensive assistance of two or more persons with bed mobility and toileting needs. The Surveyor interviewed Resident #80 at 8:37 A.M. on 08/23/18. Resident #80 said that a few months prior to the date of interview, exact date unknown, he/she fell out of bed during the provision of care. Resident #80 said he/she required the assistance of two persons with care at the time of the incident. Resident #80 said Certified Nurse Aide (CNA) #7 provided care to him/her without the assistance of a second person on the date of the incident. Resident #80 said CNA #7 asked him/her to roll over so that CNA #7 could provide incontinence care. Resident #80 said CNA #7 pushed him/her as he/she rolled over to his/her side, and he/she rolled off of the bed and onto the floor. Resident #80 said he/she landed on the floor between the bed and the wall, struck his/her head on the floor, and immediately felt pain when his/her right foot got caught between the floor and the bed. Resident #80 said it took the assistance of several staff persons, including PT #1, to get him/her up off of the floor and back into bed. Review of the Facility's Internal Investigation, dated 04/04/18, indicated that Resident #80 fell out of bed during the provision of care by CNA #7. The Investigation indicated that Resident #80 sustained lacerations to his/her left back, right buttock area, and left thigh, and a closed fracture (a fracture that does not penetrate the skin) of the second metatarsal (a long bone in the foot) of the right foot. The Investigation indicated that recommendations were made for Resident #80 to wear a short air cast (a device used to immobilize fractures from the base toes to just below the knee, severe regional sprains, and torn ankle ligaments). The Investigation indicated that CNA #7 failed to follow Resident #80's plan of care when she provided care to him/her without the assistance of a second person. The Surveyor interviewed Physical Therapist (PT) #1 at 2:00 P.M. on 09/13/18. PT #1 said he and Occupational Therapist (OT) #1 responded to a scream for help from Resident #80's room, and observed Resident #80 pinned between the bed and the wall, half kneeling and half on one foot. PT #1 said Resident #80 complained of foot and knee pain. PT #1 said that at the time he and OT #1 entered Resident #80's room, there was only one staff person present, a CNA whose name he could not recall. The Surveyor interviewed OT #1 at 1:15 P.M. on 09/14/18. OT #1 said she and PT #1 responded to Resident #80's room after hearing a scream. OT #1 said she observed that Resident #80 was stuck in-between his/her bed and the wall. OT #1 said Resident #80 was partially under the bed, with his/her right knee on the floor and his/her right ankle lodged under his/her body. OT #1 said that at the time of Resident #80's fall out of bed, exact date unknown, he/she required the assistance of two persons with care. Review of CNA #7's written statement, dated 04/03/18, indicated that she provided care to Resident #80 without the assistance of a second staff person because one staff person was on break and another staff person was assisting another resident. There was no documentation at the time of survey to support that the Facility ensured that CNA #7 provided care to Resident #80 on 04/04/18, in accordance with his/her plan of care. 2. Resident #99 was admitted to the Facility in (MONTH) (YEAR). Review of the Facility's Internal Investigation, dated 04/23/18, indicated that Director of Maintenance #1 reportedly spoke to Resident #99 in a threatening manner, and was terminated due to his conduct. The Investigation indicated that the incident was witnessed by other residents and staff, including the Administrator. The Surveyor interviewed the Administrator at 3:35 P.M. on 09/04/18. The Administrator said he witnessed the incident between Resident #99 and Director of Maintenance #1 in (MONTH) (YEAR), exact date unknown. The Administrator said he heard Resident #99 say that Director of Maintenance #1 threatened him/her. The Administrator said he observed that Director of Maintenance #1 spoke to Resident #99 in a raise, angry tone of voice and appeared agitated. The Administrator said Resident #99 appeared angry, agitated, and definitely upset by the incident. The Administrator said Director of Maintenance #1 was terminated because of his behavior towards Resident #99 on that date. Review of the Facility's Incident Report Form, dated 04/23/18, indicated that the Facility substantiated the allegation of verbal abuse toward Resident #99 by Director of Maintenance #1. There was no documentation at the time of survey to support that the Facility ensured Resident #99 was free from verbal abuse by Director of Maintenance #1 on 04/23/18.

Based on records reviewed, observations, and interviews, for four of 28 sampled residents (Resident #3, #7, #35, and #65), the facility failed to ensure that licensed nursing staff provided care in accordance with professional standards of practice regarding: the withdrawal of cardiopulmonary resuscitation (CPR); accurate transcription of physician's orders [REDACTED]. Findings include: 1. The (YEAR) American Heart Association (AHA) guidelines for CPR indicated that rescuers who start Basic Life Support (BLS; which includes CPR) should continue resuscitation until one of the following occurs: - Restoration of effective, spontaneous circulation; - Care is transferred to a team providing advanced life support (ALS; such as Emergency Medical Technicians (EMTs)); - The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy; or, - Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met. The New England Journal of Medicine (NEJM) article, dated [DATE], indicated that the universal termination of resuscitation guidelines suggest that resuscitation should be terminated if, after at least four 2-minute intervals of CPR, three criteria are met: 1) the arrest was not witnessed by emergency medical services (EMS); 2) there has been no return of spontaneous circulation (ROSC; which include: breathing, coughing, or movement and a palpable (detectible) pulse or a measurable blood pressure); and, 3) no shocks were delivered to stimulate heart activity. The Facility's Cardiopulmonary Resuscitation (CPR) policy, dated (MONTH) (YEAR), indicated that CPR would be initiated when a [MEDICAL CONDITION] occurred, except when the resident had a valid Do Not Resuscitate (DNR) order in place. The Policy indicated that CPR may not be stopped until relieved by the Emergency Medical System (EMS) personnel or a verbal physician order [REDACTED]. Resident #7 was admitted to the Facility in (MONTH) (YEAR). Review of Resident #7's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, dated [DATE], indicated that Resident #7 was a DNR in the event of a cardiac or respiratory arrest. Review of Resident #7's advanced directives care plan, initiated [DATE], indicated that Resident #7 wished to be a DNR, and to not administer CPR. Review of a written statement by an unidentified person, dated [DATE], indicated that on [DATE], a CNA announced a Code Blue after she checked on Resident #7 due to requests from unknown persons. The Statement indicated that there was so much confusion, and that no one knew Resident #7's code status. The Statement indicated that the unidentified person initiated CPR on Resident #7, got tired, and requested someone else take over. Review of the Facility's Internal Investigation, dated [DATE], indicated that it included a written statement signed by Nurse #2. The Statement indicated that Nurse #2 responded to calls for help, and observed Resident #7 unresponsive. The Statement indicated that Nurse #2 told staff to page a Code Blue (an emergency page used to indicate a person is in cardiopulmonary arrest and in need of resuscitative efforts) and 911. The Statement indicated that CPR was initiated on Resident #7, his/her MOLST form was reviewed, and that CPR was stopped once his/her code status was found to be a DNR. The Surveyor interviewed Nurse #2 at 10:55 A.M. on [DATE]. Nurse #2 said he could not recall who initiated CPR on Resident #7. Nurse #2 said CPR was initiated prior to confirmation of Resident #7's code status, and was stopped once he/she was determined to be a DNR. Review of Resident #7's Nurse's Progress Notes, dated [DATE], indicated that Resident #7 became unresponsive, CPR was initiated, and 911 was called. The Notes indicated that Resident #7's MOLST was checked, and he/she was noted to be a DNR and CPR was stopped. The Notes indicated that Resident #7 was transferred to the hospital, and returned to the Facility the same day. The Investigation indicated that on [DATE], Resident #7 was treated in the hospital for an opiate overdose which required [MEDICATION NAME] (a medication used to temporarily reverse the effects of opioid medications in an emergency situation, which has no effect on non-opioid medications). There was no documentation at the time of survey to support that once CPR was started on Resident #7, that it was stopped in accordance with professional standards of practice. 2. Resident #65 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. During review of Resident #65's clinical record, the Surveyor observed four Informed Consent for [MEDICAL CONDITION] Administration Forms which were blank except for Resident #65's signature at the bottom of the page. The Surveyor interviewed the Director of Nurses (DON) at 2:30 P.M. on [DATE]. The DON said consent forms should not be signed by the resident and/or their legal representative until they were completed and reviewed with the resident or their responsible person. The Surveyor reviewed the four Informed Consent for [MEDICAL CONDITION] Administration Forms observed in Resident #65's clinical record with the DON. The DON said staff should not have had Resident #65 sign blank consent forms. 3. Resident #3 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the (YEAR) Drug Nursing Handbook indicated to rotate sites of insulin administration within same region (abdomen, thigh or deltoid) from one injection to the next to reduce risk of [DIAGNOSES REDACTED] (abnormal distribution of fat in the body). Review of the Facility's Subcutaneous (under the skin) Medication Administration Policy, revised ,[DATE], indicated to document and to rotate sites when administering subcutaneous injections. Review of Resident #3's Monthly Physician Orders, dated for (MONTH) (YEAR), indicated orders for: Humalog (fast-acting) Insulin, inject 12 units subcutaneously (sc) three times daily with meals; and, [MEDICATION NAME] N (intermediate-acting) Insulin 44 units sc twice daily. Review of Resident #3's MAR, dated for (MONTH) (YEAR), indicated that it did not include documentation of injection sites for the administration of the Humalog and [MEDICATION NAME] N Insulins. The DON said there was no documentation on Resident #3's MAR indicated [REDACTED]. There was no documentation at the time of survey to support that the Facility documented Resident #3's insulin injection sites. 4. Resident #35 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #35's Monthly Physician Orders, dated for (MONTH) (YEAR), indicated that they included an order for [REDACTED]. Review of the (YEAR) Nurse Drug Handbook indicated to instruct a resident to rinse mouth with water, without swallowing, after using [MEDICATION NAME] to help reduce a chance of getting thrush (fungal infection in the mouth). During an observation of a medication pass at 8:35 A.M. on [DATE], Nurse #9 instructed Resident #3 to take one puff of the [MEDICATION NAME] Inhaler, but did not instruct him/her to rinse his/her mouth with water after the inhalation as required. The Surveyor interviewed Nurse #9 at 8:40 A.M. on [DATE]. Nurse #9 said she did not instruct Resident #3 to rinse his/her mouth with water after being medicated with the [MEDICATION NAME] Diskus, as required. There was no documentation at the time of survey to support that the Facility ensured staff instructed Resident #3 to rinse after the administration of [MEDICATION NAME].

Based on interview and record review, for one of five sampled Residents (Residents #4), the Facility failed to develop and implement a care plan regarding the potential for Resident #4's aggression toward other residents and Resident #4 placed pillows over the heads of Resident #3 on 4/30/16 and Resident #5 on 5/14/16. Findings include: Resident #4's most recent Minimum Data Set Assessment Form, dated 5/1/16, indicated that his/her cognitive status was severely impaired and he/she exhibited verbally and physically abusive behavioral symptoms. Resident #4's health care proxy was activated shortly after his/her admission to the Facility. Resident #4's admission referral document contained a psychiatric evaluation note, dated 3/29/16, which indicated that Resident #4 was felt to be a risk of harm to others and had a history during his/her previous hospitalization s and in nursing facilities of wandering, being intrusive, and going onto other resident rooms and becoming assaultive toward residents or staff with redirection. The Surveyor interviewed Resident #4's Health Care Agent at 11:00 A.M. on 5/24/16. The Health Care Agenct said that Resident #4 was hospitalized after a physical altercation with a resident at the nursing home Resident #4 lived in previously and was admitted to the Facility following the hospitalization . Resident #4's care plan, dated 4/20/16, indicated that he/she exhibited behavioral disturbances including intrusive wandering. Resident #4's care plan did not indicate that Resident #4 exhibited aggressive behavior toward other residents. Nurses' notes in the clinical records of Resident #3 and Resident #4 indicated that around 10:40 P.M. on 4/30/16, Resident #4 was found standing next to Resident #3's bed and a pillow was placed over Resident #3's face. The Surveyor interviewed CNA #1 by telephone at 2:30 P.M. on 5/25/16. CNA #1 said she responded to an alarm and found Resident #4 standing next to Resident #3's bed. CNA #1 said Resident #3 was in bed and there was a pillow over his/her face. CNA #1 said Resident #4 was not holding the pillow but was leaning over Resident #3. CNA #1 said that she could not think of any other way the pillow could have ended up over Resident #3's face unless Resident #4 placed it there. CNA #1 said she removed the pillow from Resident #3's face and his/her eyes were wide and his/her facial expression looked relieved. CNA #1 said she assisted Resident #4 out of Resident #3's room and reported the alleged incident to the nurse. CNA #1 said that she worked on Resident #4's unit full time during the 3:00 P.M. to 11:00 P.M. shift and Resident #4 always wandered into other resident rooms. The Surveyor did not interview Resident #3 during the Survey about the alleged incident due to his/her severely impaired cognitive and communication abilities. The Surveyor interviewed the Director of Nurses at 11:45 A.M. on 5/24/16. The Director of Nurse said that she was not aware that Resident #4 was aggressive toward other residents in facility he/she resided in prior to his/her admission. The Director of Nurses said Resident #4 was hospitalized for [REDACTED].#4 hold the pillow on Resident #3's face, she considered that it was possible Resident #3 placed the pillow over his/her own face. The Director of Nurses said that she did not identify the potential that Resident #4 placed a pillow on Resident #3's face on Resident #4's behavioral care plan or update his/her behavior care plan interventions when he/she returned to the Facility. Nurses notes in the clinical records of Resident #4 and Resident #5 indicated that at 1:15 A.M. on 5/14/16, Resident #4 was found standing next to Resident #5's bed holding a pillow over Resident #5's face.

Based on interview and record review, for three of five sampled Residents (Residents #3, #4 and #5), the Facility failed to prevent adequate supervision in response to Resident #4's intrusive wandering into resident rooms and failed to prevent the impact of Resident #4's intusive wandering when he/she placed pillows over the heads of Resident #3 on 4/30/16 and Resident #5 on 5/14/16. Findings include: Resident #4's most recent Minimum Data Set Assessment Form, dated 5/1/16, indicated that his/her cognitive status was severely impaired and he/she exhibited verbally and physically abusive behavioral symptoms. Resident #4's admission referral document contained a psychiatric evaluation note, dated 3/29/16, which indicated that Resident #4 was felt to be a risk of harm to others and had a history during his/her previous hospitalization s and in nursing facilities of wandering, being intrusive, and going into other resident rooms and becoming assaultive toward residents or staff with redirection. Resident #4's health care proxy was activated shortly after his/her admission to the Facility. The Surveyor interviewed Resident #4's Health Care Agent at 11:00 A.M. on 5/24/16. The Health Care Agenct said that Resident #4 was hospitalized after a physical altercation with a resident at the nursing home Resident #4 lived in previously and was admitted to the Facility following the hospitalization . Nurses' notes in the clinical records of Resident #3 and Resident #4 indicated that around 10:40 P.M. on 4/30/16, Resident #4 was found standing next to Resident #3's bed and a pillow was placed over Resident #3's face. The Surveyor interviewed CNA #1 by telephone at 2:30 P.M. on 5/25/16. CNA #1 said she responded to an alarm and found Resident #4 standing next to Resident #3's bed. CNA #1 said Resident #3 was in bed and there was a pillow over his/her face. CNA #1 said Resident #4 was not holding the pillow but was leaning over Resident #3. CNA #1 said that she could not think of any other the pillow could have ended up over Resident #3's face unless Resident #4 placed it there. CNA #1 said she removed the pillow from Resident #3's face and his/her eyes were wide and his/her facial expression looked relieved. CNA #1 said she assisted Resident #4 out of Resident #3's room and reported the alleged incident to the nurse. CNA #1 said that she worked on Resident #4's unit full time during the 3:00 P.M. to 11:00 P.M. shift and Resident #4 always wandered into other resident rooms. The Surveyor did not interview Resident #3 during the Survey about the alleged incident due to his/her severely impaired cognitive and communication abilities. Resident #4's care plan, dated 4/20/16, indicated that he/she exhibited behavioral disturbances including intrusive wandering. Resident #4's care plan did not indicate that Resident #4 exhibited aggressive behavior toward other residents. The Surveyor interviewed the Director of Nurses at 11:45 A.M. on 5/24/16. The Director of Nurse said that she was not aware that Resident #4 was aggressive toward other residents in facility he/she resided in prior to his/her admission. The Director of Nurses said Resident #4 was hospitalized for [REDACTED].#4 hold the pillow on Resident #3's face, she considered that it was possible Resident #3 placed the pillow over his/her own face. The Director of Nurses said that she did not identify the potential that Resident #4 placed a pillow on Resident #3's face on Resident #4's behavioral care plan or update his/her behavior care plan interventions when he/she returned to the Facility. There was no indication that Resident #4's care plan ws updated. Nurses notes in the clinical records of Resident #4 and Resident #5 indicated that, about one week after Resident #4 returned to the Facility, Resident #4 was found standing next to Resident #5 and there was a pillow over Resident #5's face. Resident #5's nurses' note indicated that the pillow was removed and Resident #5 was not in any distress. Resident #4's nurses that staff members found Resident #3 at 1:15 A.M. on 5/14/16 holding a pillow over Resident #5's face. The nurses' note indicated that Resident #4 became aggressive and agitated when redirected out of Resident #5's room by staff members. The nurses' note indicated Resident #5 was sent to the hospital for evaluation. There was no documentation to indicate that Resident #5 was reevaluated for a change in his/her level of supervision after his/her return from the hospital.

Based on record review, observations and staff interviews, the facility failed to follow the resident's written plan of care and/or Physician's orders for 6 of 24 sampled residents (#3, #4, #5, #6, #8 and #11). Findings include: 1. For Resident #3, the facility did not provide close supervision/assistance for transfers and ambulation, proper clothing and footwear necessary to prevent falls which resulted in injury (laceration with sutures). Additionally, the resident's Physician orders were not followed for the administration of medication. Findings include: Resident #3 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. A. Falls: The resident's Admission Minimum Data Set (MDS) Assessment of 6/16/15 indicated the resident rarely understood others and rarely made self understood, had short and long term memory issues, was severely impaired cognitively, wandered daily, required limited assistance for transfers, required supervision for ambulation, extensive assistance for dressing, eating hygiene and bathing, was incontinent of bowel and bladder, had no falls and was administered an anti-psychotic medication daily. Review of the resident's Activity Care Plan, from 6/17/15 to present indicated to let the resident wander if restless. The resident's Quarterly MDS Assessment of 9/10/15 indicated the resident had inattention issues, was dependent for dressing and hygiene, had fallen once without injury and received anti-anxiety medication daily. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 9/20/15 at 11:20 P.M., indicated the resident had an unwitnessed fall at the end of the corridor from the resident's room. It was noted that the resident's pants were around the resident's knees. A care plan to not sustain a fall-related injury, dated 9/23/15, due to dementia, [MEDICAL CONDITION] and wandering, included the following approaches: -Provide a clutter free environment, -and Appropriate foot wear (not specifically identified), -and Invite, encourage and escort to activity program A Plan of Care for Falls with a review date of 9/23/15 included Supervised ambulation, assist as needed. The Interdisciplinary Care Plan dated 11/4/15 included goals of ambulation and transfers with supervision and the Resident to wear custom shoe orthotics to be worn when out of bed. The resident's Care Card, dated 11/7/15, indicated the resident required close supervision at all times. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 1/8/16 at 10:05 P.M., indicated the resident had a second fall in the corridor onto the floor. The fall was witnessed by staff who were not providing supervision. The resident wore non-skid socks. There was no indication if the resident wore the proper night wear. The resident sustained [REDACTED]. The intervention placed to prevent further occurrence was continuous, close supervision as he/she walks through the hallways. Review of of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 1/18/16 at 2:00 P.M., indicated the resident had an unwitnessed fall in the bedroom when the resident was found on the floor with a bed cord (used to raise and lower the resident's bed, and which was not secured to the bed) wrapped around the resident's left leg. No injury was sustained. The care plan was updated to shorten the bed cord which impeded the resident's self transfer from the bed causing the fall. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 2/18/16 at 4:40 P.M., indicated the resident had a witnessed fall when running in the hallway with pants around the ankle. This was the third fall in the hallway. The resident was wearing a Velcro shoe. Close supervision was not provided by staff. The resident sustained [REDACTED]. The resident was sent to the local hospital and received sutures to close the wound. The Falls care plan was updated 2/19/16 to encourage one-piece outfits and all pants to be assessed for proper fit. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 3/12/16 at 6:40 P.M., indicated the resident had an unwitnessed fall when staff heard a thump and found the resident lying on the right side on the corridor floor after running in the hallway. This was the fourth fall in the corridor. The resident was wearing non-skid socks, but did not receive close supervision during ambulation. The care plan was updated 3/12/16 with the repeated intervention that the resident needed supervision. Observation during the initial tour revealed the resident on 3/29/16 at 8:45 A.M. ambulating ad lib in the corridor without supervision, and wearing slipper socks, a shirt and trousers (not a one-piece outfit as planned.) Nurse #7 said that the resident ambulated independently throughout the unit to the end of corridors and at times, into other resident end bedrooms. On 3/30/16 at 2:00 P.M., the resident was observed in room [ROOM NUMBER](at the end of the hallway) on the bed of a female resident in a Tee shirt and shorts, wearing brown corduroy slippers. No close supervision was provided by staff. Proper footwear and clothing were not observed. Observation of the resident on 3/31/16 at 8:10 A.M. revealed the resident seated in the unit dining room in red sweat shirt and pants, not the one piece outfit as planned. During interview on 3/31/16 at 2:00 P.M., the Director of Nursing (DNS) said that the facility had not provided the wandering resident with close supervision and appropriate foot wear and clothing, as planned, to prevent falls with injury. B. Medication: Review of the resident's current Physician Orders, originated 6/10/15, indicated the resident was prescribed Polyethylene [MEDICATION NAME] 17 Grams/1 Dose Powder (a Stool Softener) Give 17 GM mixed in 8 Oz (Ounces) Fluid by Mouth Every Other Day. Review of the resident's January 2016 Medication Administration Record [REDACTED]. Review of the resident's February 2016 Medication Administration Record [REDACTED] instead of every other day as ordered, from 2/1/16 to 2/29/16. Review of the resident's March 2016 Medication Administration Record [REDACTED] instead of every other day as ordered, from 3/1/16 to 3/30/16. During interview of 3/30/16 at 2:30 P.M., Unit Manager (UM) #1 said that the facility administered the resident's prescribed medication in error. 2. For Resident #4, the facility failed to follow the resident's care plan to provide supervision for transfers and ambulation, proper footwear, a toileting plan during the nighttime shift, and effective alarms/sensors to prevent 13 unwitnessed falls. Resident #4 was admitted to the facility in 2/2015 with [DIAGNOSES REDACTED]. A plan of care, initiated 2/23/15, to have no falls, included the following approaches: -Monitor gait, balance, and impulsive behaviors each day/during hall monitoring program, -Encourage use of proper fitting, non-skid footwear, -Assist with 1 transfers and 1 toileting provide increased assistance as appropriate, -Encourage involvement and attendance in activities, -and Bed alarm and tab alarm in wheelchair, The resident's Admission Minimum Data Set (MDS) Assessment, dated 2/27/15, indicated the resident usually made self understood, and sometimes understood others, wore eyeglasses, was moderately impaired cognitively with a BIMS score of 10/15, had disorganized thinking, was delusional, was verbally and physically behavioral to others, required extensive assistance of two for bed mobility, transfers, ambulation, toilet use, and bathing, required limited assistance of one for dressing and hygiene, was unsteady with balance during transitions from seated to standing position, moving, walking, turning around, and surface to surface transfers, had impairment of upper extremity on one side, used a walker and wheelchair, and was occasionally incontinent of bowel and bladder. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 3/8/15 at 1:30 A.M., indicated the resident had an unwitnessed fall in the bathroom when the resident slid off the toilet seat when self-toileting. The resident was wearing sneakers and the bed alarm was not functioning. No injury was noted. Staff recommended the bed alarm be placed out of view, and placed the Tab alarm on the top of the bathroom door on 3/9/15 to alert staff of resident self toileting and ambulation in the bathroom. Record review indicated the resident's weight bearing status on 3/25/15 was to be as tolerated with assistance of 1 person with a rolling walker for ambulation. Review of the Nurse's Notes of 3/31/15 on the daytime shift indicated the resident was non-compliant with the alarm. Review of 4/3/15 at 2:50 P.M. Nurse's Notes and Accident/Incident Report and Investigation Notes indicated the resident had an unwitnessed fall when staff found the resident on the floor in the bedroom. The resident was not wearing footwear, and was found next to the bedside table. The bed alarm did not sound. No injury was noted. The care plan was updated 4/3/15 to encourage non-skid footwear: new sneakers/shoes. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 5/29/15 at 11:00 P.M., indicated the resident had a second unwitnessed fall in the resident's room. The resident was ambulating in the room with regular socks on and fell , hitting his/her head against the wall. No alarms were noted, and the resident's bedroom door was closed at the time of the fall. The resident sustained [REDACTED]. The resident's Significant Change MDS Assessment, of 6/9/15 indicated the resident was severely impaired cognitively, wandered less than daily, required supervision of one person for transfers, ambulation and toilet use, utilized a walker, and had a fall without injury. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 5/29/15 at 11:00 P.M., indicated the resident had a third unwitnessed fall in the resident's room. The resident was seated alone in a chair, dosed off, hit head on the table and fell . No injury was noted. No staff supervision was noted. The facility updated the care plan 7/20/15 to offer bed when the resident was tired. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 8/2/15 at 10:00 A.M., indicated the resident had an unwitnessed fall on the facility's patio. The resident was unsupervised, dosed off when in a chair and fell . The resident had no injury. Staff did not offer the resident a nap when tired prior to the fall. The care plan was updated 8/3/15 to keep the resident in a supervised area. The resident's Quarterly MDS Assessment, of 9/3/15 indicated the resident wandered daily, required supervision of one person for transfers, ambulation and toilet use, was frequently incontinent of bowel and usually continent of bladder, and had a fall without injury. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes,dated 9/5/15 at 3:10 P.M., indicated the resident had a second unwitnessed fall in the bathroom when the resident tried to pull up his/her pants and lost balance. The resident wore non-skid socks, but no bathroom door Tab alarm was in place to alert staff the resident was in the bathroom. The facility recommended bladder patterning and the intervention was updated on the care plan for 9/18/15. Record review indicated no bladder assessment or patterning had been initiated by the facility, as planned. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 10/9/15 at 7:15 A.M., indicated the resident had a third unwitnessed fall in the bathroom when the resident was incontinent of urine. No injury was noted, however the resident did not have on non-skid foot wear. The care plan was updated 10/9/15 to again encourage resident compliance to wear non-skid footwear. The Falls Care Plan was updated 10/19/15 to place non- skid strips on the bathroom floor and initiate a 3 day bladder patterning. Bladder patterning was done on 10/25/15 but not summarized, although the 10/25/15 Bladder Assessment scored the resident as a candidate for prompted voiding. The toileting plan, dated 10/25/15, was to toilet the resident before and after meals, at hour of sleep and as needed. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 11/9/15 at 2:45 A.M., indicated the resident had a third unwitnessed fall in the bedroom when incontinent and trying to go to the bathroom. Staff found the resident on the floor. The resident complained of right ankle pain and an ordered X-Ray was negative for fracture. No bed alarm sounded and no footwear was on the resident. The resident had not used the walker. The care plan was updated 11/9/15 to encourage the resident to use the walker and wear non-skid socks when in bed. The resident's Quarterly MDS Assessment of 11/26/15 indicated the resident wandered daily, required limited assistance of one person for transfers, ambulation and toilet use, was frequently incontinent of bowel and bladder, and had a fall without injury and with minor injury. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 12/2/15 at 4:45 A.M., indicated the resident had a fourth unwitnessed fall in the bedroom when incontinent and trying to go to the bathroom. Staff found the resident on the floor, the Resident did not use the walker and had regular socks on. The alarms were not in place at the time of the fall. No injury was noted. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 12/11/15 at 4:00 P.M., indicated the resident had a resident witnessed fall in the hallway by the nurse's station, when the resident dropped some cookies to the floor, attempted to reach for them from a wheelchair, and fell to hands and knees. No injury occurred. The resident was noted to have Bootie-Type slippers on the feet, and was not being supervised by staff. Review of Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 12/16/15 at 4:30 P.M., indicated the resident had a fifth unwitnessed fall in the bedroom when the resident rolled out of bed. Alarmed floor mats were recommended to bilateral sides of the bed. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 12/17/15 at 4:30 P.M., indicated the resident had an unwitnessed fall in the dining room when the resident stood up from the wheelchair and fell . No injury was noted. Staff were not supervising this resident when the self transfer took place. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 12/24/15 at 10:15 A.M., indicated the resident had a sixth unwitnessed fall in the bedroom when the resident rolled out of bed onto the floor mat. No alarm sounded as planned. No injury occurred to the resident. The resident's Significant Change MDS Assessment of 1/18/16 indicated the resident required extensive assistance for toilet use, and had falls without injury and with minor injury. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes, dated 2/14/16 at 6:30 A.M., indicated the resident had an seventh unwitnessed fall ambulating to the bathroom in the bedroom. The bed alarm sounded and the resident wore non-skid socks. However, there were no floor mats beside the bed as noted in the investigation. Observation of the resident on 3/30/16 at 9:00 A.M. revealed the resident ambulating with a rolling walker and one person assist in the corridor with slipper socks on. At 10:15 A.M., the resident was observed in the Activity Room with episodes of verbal yelling and swearing. At 2:00 P.M., the resident was observed ambulating in the corridor to the Nursing station with the rolling walker but without staff assistance or supervision. At 3:45 P.M., the resident was observed ambulating to the far end of the corridor where the resident attempted to open the door to another resident's room, agitating that bedroom's resident to scream at the resident and provoke a verbal confrontation. Staff re-directed the resident after the resident to resident altercation. During interview on 3/31/16 at 2:30 P.M., the DNS said that the facility had not provided the supervision, required foot wear, toileting schedule and functioning alarms/mats necessary to prevent 13 falls. 3. For Resident #6, the facility failed to elevate the resident's heels when in bed. Resident # 6 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. A Physician's Order, originally dated from Admission to present, indicated that staff were to Float heels in Bed as Tolerated. The resident's Care Card, dated 11/7/15, indicated staff were to Off-Load heels using pillows. The resident's Annual MDS Assessment of 1/21/16 indicated the resident was unable to communicate, had vision devices, was severely impaired cognitively with a BIMS score of 5 out of 15, was dependent on staff for all Activities of Daily Living, was incontinent of bladder, required [MEDICAL CONDITION] care, and was on antipsychotic medication daily. The Care Area Assessment of 1/21/16 indicated the resident was at risk for developing pressure ulcers due to decreased mobility and incontinence. Review of the January, February and March 2016 Treatment Administrative Records indicated there was no documentation each day for floating heels in bed. Observation of 3/30/16 at 8:55 A.M. revealed the resident in bed asleep with geri-legs and slipper socks on, but no pillow under the heels to prevent pressure. During interview with the resident's primary daytime assigned Certified Nursing Assistant (CNA) on 3/30/16 at 8:58 A.M., after observing the resident with the Surveyor, CNA #1 said that maybe the nighttime staff took the resident's pillow away. During interview on 3/30/16 at 9:55 A.M., Unit Manager #1 said that there was no evidence the facility elevated the resident's heels when in bed as ordered. Observation of 3/31/16 at 8:00 A.M. revealed the resident asleep in bed and with bare heels on the mattress. Surveyor inquired with CNA #4 if the resident had a pillow to elevate the resident's heels off of the mattress. CNA #4 examined the resident and said there was no pillow or other off-loading device to float the resident's heels when in bed. 4. For Resident # 8, the facility failed to follow the Physician's treatment and medication orders. Resident #8 was admitted into the facility in 7/2014 and readmitted in 9/2015 with [DIAGNOSES REDACTED]. Review of a Quarterly MDS Assessment, dated 12/25/15, indicated the resident was cognitively intact as evidenced by a BIMS score of 15 of 15. A. Review of the Physician's order for 2/2016 indicated to conduct Pain assessment: Assess for Pain every shift (0-10) of the resident. Review of the 2/2016 MAR indicated [REDACTED] -on the daytime and evening shifts of 2/1/16, -on the evening shift for 2/2/16, -and on the daytime shift for 2/28/16. Review of the 3/2016 MAR indicated [REDACTED]. B. Review of the current Physician's order for 2/1/16 indicated to give the resident [MEDICATION NAME] (Nerve pain medication) 300 milligrams (mg) capsule by mouth twice a day at 8:30 A.M. and 12:30 P.M. Review of the MAR, dated 2/1/16 - 2/29/16, indicated that [MEDICATION NAME] 300 mg capsule not was given on 2/15/16, 2/16/16, 2/18/16, 2/24/16 and 2/25/16 at 12:30 P.M. Review of the Physician's order, dated 3/16, indicated an order for [REDACTED]. and 12:30 P.M.) Review of the 3/2016 MAR indicated [REDACTED].M. C. Review of the Physician's order for 2/2016 indicated an order to give the resident Atorvastatin Calcium F/C (Cholesterol medication) 40 mg tablet by mouth at the bedtime. Review of the 2/2016 MAR indicated [REDACTED]. Review of the 3/2016 MAR indicated [REDACTED].M. D. Review of the Physician's order, dated 2/2016, indicated an order to give the resident [MEDICATION NAME] 400 mg capsule by mouth everyday at the bedtime hour. Review of the 2/2016 MAR indicated [REDACTED]. Review of the 3/2016 MAR indicated [REDACTED]. E. Review of the Physician's order for 2/2016 indicated an order to give the resident [MEDICATION NAME] (insulin) 100 unit per milliliters (ml) vial- insulin and to inject 40 units subcutaneously at bedtime. Review of the 2/2016 MAR indicated [REDACTED]. Review of the 3/2016 MAR indicated [REDACTED]. F. Review of a Physician's Orders indicated a treatment order, dated 2/1/16, for the resident's Diabetic Foot Care every day. Review of the 2/2016 Treatment Sheet indicated diabetic foot care was not provided on 2/20/16, 2/21/16 and 2/26/16. 5. For Resident #11, the facility failed to follow the Physician's treatment and medication orders. Resident # 11 was admitted into the facility on ,[DATE] and readmitted on with [DIAGNOSES REDACTED]. A. Review of the current Physician's oxygen (O2) order, dated 2/1/16, indicated an order to check the resident's O2 saturation level every shift. Review of the 2/2016 O2 Treatment Flow Sheet indicated O2 saturation levels were not checked on 2/18/16, 2/19/16, 2/20/16 and 2/26/16. B. Review of the current Physician's (O2) treatment order of 2/1/16 indicated to document the number of hours every shift the resident used portable O2 while out of bed. Review of the 2/2016 O2 Treatment Flow Sheet indicated portable O2 hours for the resident when out of bed was not done on 2/18/16, 2/19/16, 2/20/16 and 2/26/16, during the 7:00 A.M. to 3:00 P.M. shift. C. Review of a Physician's (O2) Treatment order of 2/1/16 indicated to check the resident's lung sounds every shift and indicate: 1. Clear 2. Rhonchi 3. Crackles 4. Diminished 5. Congested 6. Rales 7. Rub 8. Wheeze. Review of the O2 treatment flow sheet, from 2/1/16 to 2/29/16, indicated no lung sounds documented from 2/1/16 to 2/29/16, between 11:00 P.M. to 7:00 A.M., and from 2/18/16 to 2/21/16, and 2/24/16 to 2/26/16, during 7:00 A.M. to 3:00 P.M. shift and on 2/13/16 on the 3:00 P.M. to 11:00 P.M. shift. D. Review of a Physician's (O2) order of 2/1/16 indicated to check the resident's respiratory rate every shift. Review of the O2 Treatment Flow Sheet, from 2/1/16 to 2/29/16, indicated no checking of the resident's respiratory rate from 2/18/16 to 2/20/16, and on 2/26/16 during 7:00 A.M. to 3:00 P.M. shift. E. Review of the Physician's (O2) order of 2/1/16 indicated to change and date O2 tubing and clean O2 concentrator filter weekly on Sunday, 11:00 P.M. to 7:00 A.M. shift. Review of the O2 Treatment Flow Sheet, dated 2/1/16 - 2/29/16, indicated no O2 tubing or O2 concentrator filter changed on 2/28/16 on Sunday during the 11:00 P.M. to 7:00 A.M. shift. F. Review of the Physician's treatment orders for 2/2016 indicated to check insertion site for bleeding or sign of dislodgement of [MEDICAL TREATMENT] catheter every shift each day. Review of the Treatment Flow Sheet, from 2/1/16 to 2/29/16, indicated no checking of the catheter to right chest wall every shift on 2/4/16, 2/18/16, 2/19/16, 2/22/16, 2/25/16, 2/28/16 during the 7:00 A.M. to 3:00 P.M. shift, and on 2/22/16 during the 3:00 P.M. to 11:00 P.M. shift. G. Review of the Physician's MEDICATION ORDERS FOR [REDACTED].M. Review of the 2016 MAR indicated [REDACTED]. H. Review of the Physician's Medication Orders of 2/2016 to give the resident [MEDICATION NAME] (for kidney failure) Softgel 1 mg capsule by mouth every day at 11:30 A.M. Review of the 2016 MAR indicated [REDACTED]. I. Review of the Physician's Medication Orders of 2/2016 to give the resident [MEDICATION NAME] (for heart burn) 20 mg Capsule by mouth every day at 11:30 A.M. Review of the 2016 MAR indicated [REDACTED].M. on 2/10/16, 2/14/16 and 2/22/16. J. Review of the Physician's Medication Orders of 2/2016 to give Vitamin B-6 [MEDICATION NAME] 100 mg tablet by mouth every day at 11:30 A.M. Review of the 2/2016 MAR indicated [REDACTED].M. on 2/10/16, 2/14/16, 2/19/16 and 2/22/16. K. Review of the Physician's Medication Orders of 2/2016 to give the resident Vitamin B-12 1,000 micrograms (mcg) tablet by mouth every day at 11:30 A.M. Review of the 2/2016 MAR indicated [REDACTED].M. on 2/14/16, 2/19/16 and 2/22/16. L. Review of the Physician's Medication Orders of 2/2016 to give the resident [MEDICATION NAME] 0.5 mg tablet by mouth twice a day at 11:30 A.M. and 8:30 P.M. Review of the 2/2016 MAR indicated [REDACTED].M. M. Review of the Physician's Medication Orders of 2/2016 to give the resident [MEDICATION NAME] 200 mg capsule by mouth three times a day. Review of the 2/3016 MAR for [MEDICATION NAME] 200 mg capsule by mouth three times a day at 5:30 A.M., 11:30 A.M. and 8:00 P.M. was not given on 2/4/16, 2/11/16, 2/13/16, 2/19/16, 2/22/16 2/24/16 2/26/16 and 2/28/16 at 11:30 A.M. During interview on 4/4/16 at 11:45 A.M., the Director of Nurses said that if there was no documentation for the medications and treatment orders, then there was no evidence that the facility followed the Physician's orders as written.

Based on observations, record review, and staff interviews, the facility failed to ensure that 2 of 9 applicable sampled residents with falls (#3 and #4) out of a total sample of 24 residents received adequate assistive devices and/or supervision to prevent accidents with injury. Findings include: 1. For Resident #3, the facility did not provide supervision and assistance for clothing and footwear necessary to prevent 6 falls which resulted in injury (laceration with sutures), from 8/13/15 to 3/12/16. Resident #3 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. An initial care plan with a goal for no injury due to safety risk, dated 6/10/15, had the following interventions: -Assess for contributors: Blood Pressure, standing/sitting pain, need to void, medications, gait, -Encourage use of call light, -Rehabilitation referral, -Instruct resident on safety measures, -and Adaptive devices. A Behavior care plan for wandering, dated 6/11/15 to present, indicated the resident was to be offered rest periods to sit. The resident's Admission Minimum Data Set (MDS) Assessment of 6/16/15 indicated the resident rarely understood others and rarely made self understood, had short and long term memory issues, was severely impaired cognitively, wandered daily, required limited assistance for transfers, required supervision for ambulation, extensive assistance for dressing, eating, hygiene and bathing, was incontinent of bowel and bladder, had no falls and was administered an anti-psychotic medication daily. The 6/16/15 Care Area Assessment for Falls indicated the resident constantly wandered about the unit without purpose, has decreased safety awareness, balance, strength, and coordination appeared to be within functional limits, was restless, intrusive, and difficult to redirect at times. Review of the resident's Activity Care Plan, from 6/17/15 to present, indicated: let the resident wander if restless. Review of the Progress Notes and Accident/Incident Report and Investigation Notes dated 8/13/15 at 7:50 P.M. indicated the resident had an unwitnessed fall when found laying on the floor in front of the resident's bed. No injury was noted. The resident was wearing slipper socks at the time. Staff noted the resident ran rather than walked on the unit and a referral was made for a Psychological evaluation for medication review. The resident's Quarterly MDS Assessment of 9/10/15 indicated the resident had inattention issues, was dependent for dressing and hygiene, had fallen once without injury and also received anti-anxiety medication daily. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 9/20/15 at 11:20 P.M. indicated the resident had an unwitnessed fall at the end of the corridor from the resident's room. It was noted that the resident's pants were around the resident's knees and staff were to provide supervision when the resident ambulated. The facility recommended interventions were for the resident to wear appropriate nightwear. No injury was noted. A Fall Risk Evaluation of 9/20/15 indicated the resident was a high risk for falls with a score of 12. A care plan to not sustain a fall-related injury, dated 9/23/15, due to dementia, brain injury and wandering, had the following approaches: -Use fall risk screen to identify risk factors, -Report falls to appropriate parties, -Provide a clutter free environment, -Remind resident and reinforce safety awareness, -Appropriate footwear (not specifically identified), -Encourage proper night wear at bedtime i.e., Johnny, -and Invite, encourage and escort to activity programs. The resident's Care Card, dated 11/7/15, indicated the resident required close supervision at all times. The resident's Quarterly MDS Assessment of 12/3/15 indicated the resident required extensive assistance for bed mobility and transfers, and had fallen once without injury. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 1/8/16 at 10:05 P.M. indicated the resident had a second fall in the corridor onto the floor. The fall was witnessed by staff who were not providing close supervision of the resident's ambulation. The resident wore non-skid socks. The resident sustained [REDACTED]. The facility recommended again that the resident needed supervision. A Fall Risk Evaluation of 1/8/16 indicated the resident was a high risk for falls with a score of 17. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 1/18/16 at 2:00 P.M. indicated the resident had a second unwitnessed fall in the bedroom when the resident was found on the floor with a bed cord (used to raise and lower the resident's bed, and which was not secured to the bed) wrapped around the resident's left leg. No injury was sustained. The care plan was updated to shorten the bed cord which impeded the resident's self transfer from the bed causing the fall. Fall Risk Evaluations indicated the resident had high risk scores of 19 on 1/18/16 and 2/18/16. Review of the 2/13/16 Nurse's Notes (time unknown) indicated the resident was observed by staff with right hand swollen (puffy) at Noon. The Nurse Practitioner ordered an X-Ray for a swollen right hand to R/O (Rule/Out) fracture. The X-Ray was negative for a fracture. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 2/18/16 at 4:40 P.M. indicated the resident had an witnessed, third fall when running in the corridor with pants around the ankle. The resident was wearing a Velcro shoe. Close supervision was not provided by staff. The resident sustained [REDACTED]. The resident was sent to the local hospital and received sutures to close the wound. The Falls care plan was updated 2/19/16 to encourage one-piece outfits and all pants were to be assessed for proper fit. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 3/12/16 at 6:40 P.M. indicated the resident had an unwitnessed fourth fall when staff heard a thump and found the resident lying on his/her right side on the corridor floor, after running in the hallway. The resident was wearing non-skid socks, but did not receive close supervision during ambulation. The care plan was updated 3/12/16 with the repeated intervention that the resident needed supervision. Observation during the initial tour revealed the resident on 3/29/16 at 8:45 A.M. ambulating ad lib in the corridor without supervision, and wearing slipper socks, a shirt, and trousers. Nurse #7 said that the resident ambulated independently throughout the unit toward each end of the corridors and at times, into other resident rooms at the end of the hallway. On 3/30/16 at 2:00 P.M., the resident was observed in Room 221 (an end corridor bedroom) on the bed of a female resident where the resident had ambulated to, in a Tee shirt and shorts, wearing brown corduroy slippers. Observation of the resident's bedroom revealed on 3/30/16 at 2:30 P.M. a pair of black Velcro-strapped orthopedic shoes next to the bedside table. Observation of the resident on 3/31/16 at 8:10 A.M. revealed the resident seated in the unit dining room in red sweat shirt and pants, not the one piece outfit as planned. The resident wore the black orthopedic shoes. During interview on 3/31/16 at 2:00 P.M., the Director of Nursing (DNS) said that the facility had not provided the wandering resident with close supervision, and appropriate footwear and clothing to prevent repeated falls with injury. 2. For Resident #4, the facility failed to provide supervision, footwear, a toileting plan during the nighttime shift, and effective alarms/sensors to prevent 13 unwitnessed falls. Resident #4 was admitted to the facility in 2/2015 with [DIAGNOSES REDACTED]. A plan of care, initiated 2/23/15, to have no falls, included the following approaches: -Monitor gait, balance, and impulsive behaviors each day/during hall monitoring program, -Encourage use of proper fitting, non-skid footwear, -Assist with 1 transfers and 1 toileting provide increased assistance as appropriate, -Monitor resident's non-compliance with weight bearing status, provide education and frequent reminders of risk of not following the plan-weight bearing as tolerated, -Encourage and remind resident of non-ambulatory status, -Encourage involvement and attendance in activities, -Call light within reach when in room, -Bed alarm and tab alarm in wheelchair, -Provide education regarding safety risks and benefits of compliance with plan, -and Explain interventions and rationale as clearly as possible to alleviate anxiety. The resident's Admission MDS Assessment, dated 2/27/15, indicated the resident usually made self understood, and sometimes understood others, wore eyeglasses, was moderately impaired cognitively with a BIMS score of 10/15, had disorganized thinking, was delusional, was verbally and physically behavioral to others, required extensive assistance of two for bed mobility, transfers, ambulation, toilet use, and bathing, required limited assistance of one for dressing and hygiene, was unsteady with balance during transitions from seated to standing position, moving, walking, turning around, and surface to surface transfers, had impairment of upper extremity on one side, used a walker and wheelchair, was occasionally incontinent of bladder and bladder, had fallen with fracture prior to admission, and was administered anti-psychotic medication daily. Record review of 3/4/15 at 5:00 P.M. Nurse's Notes and Accident/Incident Report and Investigation Notes indicated the resident had an unwitnessed fall in the bedroom when the resident attempted to stand and sit back in the wheelchair without the locks engaged. No injury was noted. The facility educated the resident regarding non-weight bearing status (since admission) and placed a Velcro alarm seat belt on the wheelchair. Clinical Record review indicated the the Tab alarm in the wheelchair and the Velcro alarmed seat belt due to resident non-compliance and agitation, toileting regularly. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 3/8/15 at 1:30 A.M. indicated the resident had an unwitnessed fall in the bathroom when the resident slid off the toilet seat when self-toileting. The resident was wearing sneakers, and had disabled the bed alarm. No injury was noted. Staff recommended the resident be re-educated to ask staff for assistance, placed the bed alarm out of view, and placed the Tab alarm on the top of the bathroom door on 3/9/15 to alert staff of resident self toileting and ambulation in the bedroom. Clinical review indicated the resident's weight bearing status on 3/25/15 was to be tolerated with assistance of 1 person with a rolling walker for ambulation. Review of Nurse's Notes of 3/31/15 on the daytime shift indicated the resident was non-compliant with alarm, per staff. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 4/3/15 at 2:50 P.M. indicated the resident had an unwitnessed fall when staff found the resident on the floor in the bedroom. The resident was not wearing footwear, and was found next to the bedside table. The bed alarm did not sound. No injury was noted. The care plan was updated 4/3/15 to encourage non-skid footwear: new sneakers/shoes. The Fall Risk Evaluation of 4/3/15 and 5/29/15 indicated the resident was a high risk for falls with scores of 24. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 5/29/15 at 11:00 P.M. indicated the resident had an unwitnessed, second fall in the resident's room. The resident was ambulating in the room with regular socks on felt dizzy, and fell , hitting the head against the wall. No alarms were noted, and the resident's bedroom door was closed at the time of the fall. The resident sustained [REDACTED]. The resident's Significant Change MDS Assessment, of 6/9/15 indicated the resident was severely impaired cognitively, wandered less than daily, required supervision of one person for transfers, ambulation and toilet use, was continent of bowel and bladder, utilized a walker, and had a fall without injury. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 7/20/15 at 4:00 A.M. indicated the resident had an unwitnessed fall in the TV room. The resident resident was seated alone in a chair, dosed off, hit head on the table and fell . No injury was noted. No staff supervision was noted. The facility updated the care plan 7/20/15 to offer bed when the resident was tired. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 8/2/15 at 10:00 A.M. indicated the resident had an unwitnessed fall on the facility's patio. The resident was unsupervised, dosed off when in a chair and fell . The resident had no injury. The care plan was updated 8/3/15 to keep the resident in a supervised area. The resident's Quarterly MDS Assessment, of 9/3/15 indicated the resident wandered daily, required supervision of one person for transfers, ambulation and toilet use, was frequently incontinent of bowel and usually continent of bladder, and had a fall without injury. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 9/5/15 at 3:10 P.M. indicated the resident had an unwitnessed, second fall in the bathroom when the resident tried to pull up pants and lost balance. The resident wore non-skid socks, but no bathroom door Tab alarm was in place to alert staff the resident was in the bathroom. The facility recommended bladder patterning, which was an intervention updated on the care plan for 9/18/15. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 10/9/15 at 7:15 A.M. indicated the resident had an unwitnessed, third fall in the bathroom when the resident was incontinent of urine. No injury was noted, however the resident did not have on non-skid foot wear. The care plan was updated 10/9/15 to encourage resident compliance to wear non-skid footwear. Record review indicated no bladder assessment or patterning had been initiated by the facility, as planned. Record review of Nurse's Notes of 10/19/15 indicated the resident was observed by staff with a bruise to the left elbow and left hip, and a hematoma to the left forearm. X Rays were ordered and were negative. The Falls Care Plan was updated 10/19/15 to place non- skid strips on the bathroom floor and initiate a 3 day bladder patterning. Bladder patterning was done on 10/25/15 but not summarized, although the 10/25/15 Bladder Assessment scored the resident as a candidate for prompted voiding. The toileting plan, dated 10/25/15, was to toilet the resident before and after meals, at hour of sleep and as needed. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 11/9/15 at 2:45 A.M. indicated the resident had an unwitnessed, third fall in the bedroom when incontinent and trying to go to the bathroom. Staff found the resident on the floor. The resident complained of right ankle pain and an ordered X-Ray proved negative. No bed alarm sounded and no footwear was on the resident. The resident had not used the walker. The care plan was updated 11/9/15 to encourage the resident to use the walker and wear non-skid socks when in bed. The Fall Risk Evaluation indicated the resident was a high risk for falls with a score of 15 on 11/9/15. The resident's Quarterly MDS Assessment of 11/26/15 indicated the resident wandered daily, required limited assistance of one person for transfers, ambulation and toilet use, was frequently incontinent of bowel and bladder, and had a fall without injury and with minor injury. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 12/2/15 at 4:45 A.M. indicated the resident had an unwitnessed, fourth fall in the bedroom when incontinent and trying to go to the bathroom. Staff found the resident on the floor, the Resident did not use the walker and had regular socks on. The alarms were not in place at the time of the fall. No injury was noted. The Fall Risk Evaluation indicated the resident was a high risk for falls with a score of 21 on 12/2/15. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 12/11/15 at 4:00 P.M. indicated the resident had a witnessed fall in the hallway by the nurse's station, when the resident dropped some cookies to the floor, attempted to reach for them from a wheelchair, and fell to hands and knees. No injury occurred. The resident was noted to have Bootie-Type slippers on the feet. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 12/16/15 at 4:30 P.M. indicated the resident had an resident unwitnessed, fifth fall in the bedroom when the resident rolled out of bed. The alarm sounded. The resident wore slipper socks. Alarmed floor mats were recommended to bilateral sides of the bed. The Fall Risk Evaluation indicated the resident was a high risk for falls with a score of 23 on 12/16/15. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 12/17/15 at 4:30 P.M. indicated the resident had an unwitnessed fall in the dining room when the resident stood up from the wheelchair and fell . No injury was noted. Staff were not supervising this resident when the self transfer took place. The resident had on slipper socks. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 12/24/15 at 10:15 A.M. indicated the resident had an unwitnessed, sixth fall in the bedroom when the resident rolled out of bed onto the floor mat. No alarm sounded as planned. The resident wore slipper socks. No injury occurred to the resident. The Fall Risk Evaluation indicated the resident was a high risk for falls with a score of 18 on 12/24/15. The resident's Significant Change MDS Assessment of 1/18/16 indicated the resident required extensive assistance for toilet use, was continent of bowel, had falls without injury and with minor injury, and was administered anti-anxiety medication daily. Review of the Nurse's Notes and Accident/Incident Report and Investigation Notes dated 2/14/16 at 6:30 A.M. indicated the resident had an unwitnessed, seventh fall in the bedroom ambulating to the bathroom. The bed alarm sounded and the resident wore non-skid socks. However, there were no floor mats noted in the investigation. Observation of the resident on 3/30/16 at 9:00 A.M. revealed the resident ambulating with a rolling walker and one person assist in the corridor with slipper socks on. At 10:15 A.M., the resident was observed in the Activity Room with episodes of verbal yelling and swearing. At 2:00 P.M., the resident was observed ambulating in the corridor to the Nursing station with the rolling walker but without staff assistance or supervision, and an odor of urine emanating from the resident's clothing. At 3:45 P.M., the resident was observed ambulating to the far end of the corridor where the resident attempted to open the door to another resident's room, agitating that bedroom's resident to scream at the resident and provoke a verbal confrontation. Staff re-directed the resident after the resident to resident altercation. During interview on 3/31/16 at 2:30 P.M., the DNS said that the facility had not provided the supervision, and assistive devices to prevent 13 falls, almost all of which were unwitnessed by staff. 3. Based on observation and staff interviews, the facility failed to maintain a hazard-free environment for 3 of 3 units (2nd, 3rd and 4th Floor Nursing Units) as it related to the storage of potentially harmful chemicals in an unsecured unit shower and resident bathrooms. Findings include:. During Environmental tours of 3/29/16, from 12:30 P.M. to 1:30 P.M., and 4:00 P.M. to 5:30 P.M., and on 3/30/16 from 4:00 P.M. to 4:30 P.M., with the Administrator and Director of Nursing, the following were observed: 2nd Floor Nursing Unit: 1. In the unsecured 2nd Floor Nursing Unit's Corridor Shower Suite, Surveyor observed a 4 ounce (oz.) opened plastic container of Aloe Vista moisturizing cream in the opened linen cart. The container had the warning: For External Use Only. 2. On the bathroom shelf for Room 208 was a 4 oz. opened plastic container of shampoo and body wash with the warning to Keep out of Eyes. 3. On the bathroom shelf for Room 211 were a 4 oz. opened plastic container of shampoo and body wash and a 16 oz. opened container of moisturizer. 4. On the bathroom shelf for Room 218 were a 4 fluid (fl.) oz. opened plastic container of alcohol free mouthwash, a 16 fl. oz. container of Cetaphil skin care lotion, and an 8 oz. container of Hydrogel wound dressing. 5. On the bathroom shelf for Room 219 were a 4 oz. opened plastic container of Aloe Vista moisturizing cream, a 7.5 oz. opened plastic container of Derma Daily moisturizing cream, a 12.5 fl. oz. opened container of shampoo, and a 13 oz. opened container of Vaseline cream. 6. On the bathroom shelf for Room 221 were a 4 oz. opened plastic container of Aloe Vista moisturizing cream, and a 7.5 oz. plastic container of Derma Vera lotion. 3rd Floor Nursing Unit: 1. On the bathroom shelf for Room 303 was an opened 7.5 plastic container of Derma Vantage, 2. On the bathroom shelf for Room 304 were an opened 33.8 fl. oz. container of Dry Mouth rinse, a 16 fl. oz. plastic container of Dry Mouth rinse and a 4 fl. oz. container of shampoo and body wash. 3. On the bathroom shelf for Room 307 was a 4 fl. oz. plastic container of shampoo and body wash 4. On the bureau and over the bed table in Room 308 were opened 7.5 oz. plastic containers of Derma Vantage, 5. On the bathroom shelf for Room 312 was a 4 fl. oz. plastic container of mouthwash 6. On the bathroom shelf for Room 316 were an opened 7.5 plastic container of Derma Vantage, and a 5 gram tube of Vitamin D ointment, 7. On the bathroom shelf for Room 317 was an opened 7.5 plastic container of Derma Vantage. 8. On the bathroom shelf for Room 318 were an opened 4 fl. oz. plastic container of sterile water, an opened 7.5 plastic container of Derma Vantage, and two (2) 4 fl. oz plastic containers of mouthwash. 9. In a plastic wash basin on the wooden tub lid in the bathroom for Room 319 was a 16 oz. plastic container of Aveeno skin lotion, 4th Floor Nursing Unit 1. On the bathroom shelf for Room 403 was an opened 7.5 plastic container of Derma Vantage, 2. On the bathroom shelf for Room 408 was an opened 4 oz. plastic container of Aloe Vista moisturizing lotion. During observation of the chemical hazards and interviews with the Administrator and the Director of Nursing on 3/30/16 at 4:35 P.M., both said the above items would be immediately secured.

Based on observations, record review and interview, for 1 of 3 sampled residents (Resident #2) the Facility failed to implement fall prevention care plan interventions and provide adequate assistance devices to prevent accidents. On 11/11/15, Resident #2 was found on the bathroom floor, and the alarm on the bathroom door had not sounded. Resident #2 was subsequently determined to have sustained a right femoral neck fracture which required surgery to repair. Findings include: Resident #2's Significant Change Minimum Data Set (MDS), reference ASPEN MDS viewer online, dated 09/07/15 indicated that he/she required the extensive assistance of two or more persons when transferring between surface and when using the toilet. Resident #2's fall risk care plan indicated that Resident #2 required the physical assistance of one person when transferring between surfaces and using the toilet, required an alarm on the bathroom door, a motion alarm while in bed and chair, and a pressure alarm while in bed. The Alarm Checklist dated for 11/08/15 through 11/14/15 indicated that Resident #2 had a pressure alarm on his/her bed. The checklist was initialed to indicate Resident #2's pressure alarm was properly placed, activated, and had a working battery in place on all shifts for the dates between 11/08/15 through 11/14/15. The word Door had been written above the word Pressure under the Alarm Type column, but there was no date to indicate when the word Door was added. The Surveyor interviewed the Director of Nursing at 7:15 A.M. on 12/04/15. The DON said that the Certified Nursing Assistant's (CNA) responsibilities included a check of resident alarms at the start of each shift and signing the Alarm Checklist to document completion of the alarm checks. A Facility incident report dated 11/13/15 indicated that at approximately 2:00 pm on 11/11/15, Resident #2 was found sitting on the bathroom floor. The Facility Incident Report indicated that Resident #2 told staff that he/she tried to go to the bathroom and fell out of his/her wheelchair. The Facility Incident Report indicated Resident #2 was evaluated at the hospital, where it was determined that Resident #2 had sustained a right femoral neck fracture which required surgery to repair. The DON said that investigation of Resident #2's fall indicated that the alarm on Resident #2's bathroom door had not sounded when Resident #2 entered the bathroom. The DON said the investigation indicated that the two pieces of the door alarm were not fitted together as required to activate the alarm. The DON said that, after Resident #2's fall, she added Resident #2's door alarm to the Alarm Checklist so that the CNAs would check the door alarm for placement and function at the start of each shift.

Based on record review and interview for 1 of 3 sampled Residents (Resident #1), the Facility failed to notify the physician of the Resident's large right arm bruise with swelling, which had an underlying humeral fracture. Findings include: Resident #1 was admitted to the Facility in 8/2012 with the following pertinent diagnoses; [MEDICAL CONDITIONS] and dementia. Review of the Quarterly Minimum Data Set of 6/4/15, indicated Resident #1 had moderate cognitive impairment, was an extensive assist of 2 for bed mobility and toilet use, was totally dependent for transfers and bathing with a physical assist of 2, and was non ambulatory. Review of the nursing documentation indicated there were no documented notes from 8/3/15 until 8/10/15 at 8:00 P.M. (9 days). Review of the Nurse's Note of 8/10/15 at 8:00 P.M., indicated Resident #1 was found to have a large bruise (10 centimeters (cm.) in length by 10 cm. in width) with swelling on the right upper arm. The Nurse Practitioner (NP) was notified of the arm bruise, and the staff nurses were instructed to monitor Resident #1 and report the status of Resident #1's right arm to the NP in the morning. Review of the Nurse's Note of 8/11/15 at 10:40 A.M., documentation indicated the NP was notified of Resident #1's discomfort in the right arm. The NP ordered a portable X-Ray of the right arm and shoulder indicated a [MEDICAL CONDITION]. The NP ordered Resident #1 to be transferred to the Community Hospital Emergency Department, and the Healthcare Proxy (HCP) was updated. Review of the Physician's Emergency Department Report documentation indicated a Computerized Tomography (CT) scan, dated 8/11/15 showed that Resident #1 had a right humeral neck fracture, a mildly depressed oblique [MEDICAL CONDITION] tibial plateau of the right lower extremity, and moderate hemarthrosis (an accumulation of blood in the joint cavity) with soft tissue swelling around the knee. Review of the Facility's Investigation documentation of 8/11/15 at 8:00 P.M., for the right humerus and tibia fractures indicated it was unknown how Resident #1's injuries occurred. Certified Nursing Assistant (CNA) #1 found the injuries on 8/10/15 at 8:00 P.M. during bedtime care. The Surveyor interviewed Family Member (FM) #1 at 12:30 P.M. on 9/10/15. FM #1 stated that on 8/8/15, (after lunch but before 1:15 P.M.), when FM #1 left, Resident #1 was leaning to the side of the wheelchair; Resident #1 screamed when FM #1 and a Certified Nursing Assistant (FM #1 called over) attempted to reposition Resident #1 in the wheelchair. FM #1 stated that Resident #1 was wearing long sleeves on 8/8/15 and FM #1 could not visualize the right arm; however, FM #1 said, Looking back now, that's when (referring to the day) the arm was injured. FM #1 was again visiting on 8/10/15 at approximately 1:00 P.M.; FM #1 asked Nurse #1 to look at Resident #1's arm. FM #1 said, What happened to Resident #1's arm? It's all black and blue from the right shoulder to just above the bend in the arm (elbow joint). Nurse #1 said to FM #1 and FM #2 that there is no report written up about the right upper arm. When the Facility called FM #1 at 8:00 P.M. on 8/10/15 about the arm bruise (and FM #1 later learned that it was fractured), FM #1 said, I already told the day Nurse. (Nurse #1 about the bruise. This is an approximate 7 hour delay in Physician notification. During an interview at 10:55 A.M. on 9/11/15, Nurse #1 stated that one of the Family Members (#1 or #2) pointed out that this Resident had a problem with his/her arm. Nurse #1 said the the Surveyor, I was on the left side of Resident #1 and never saw this Resident's right arm. Nurse #1 stated that she should have been more attentive, and that she did not assess the arm further after the Family Members mentioned it to Nurse #1. When asked if Nurse #1 looked at the right arm, she said that she had not looked at the arm. In addition, Nurse #1 said that she did not report that FM #1 and FM #2 said that Resident #1 had a bruised arm to the Physician on 8/10/15. During an interview with FM #2 on 9/11/15 at 2:00 P.M., FM #2 said that on 8/10/15, she and FM #1 found the bruise on Resident #1's right upper arm. The Surveyor asked, Did Nurse #1 see the bruise on the right arm? FM #2 said, We told Nurse #1 about it, and she stood on the right side of the wheelchair and lifted up Resident #1's short sleeve and saw the bruise. Please refer to F225.

Based on record review and interviews for 1 or 3 sampled Residents, (Resident #1), the Facility failed to identify, investigate and report a suspected abuse in a timely manner. In addition the Facility failed to interview pertinent witnesses (Family Member #1 and Family Member #2). Findings include: Resident #1 was admitted to the Facility in 8/2012 with the following pertinent diagnoses; [MEDICAL CONDITIONS], dementia, [MEDICAL CONDITION] and sustained a right humerus fracture and right tibial fracture of unknown etiology at the Facility. The Policy for Resident Abuse, Neglect, Mistreatment and Misappropriation Prevention, dated 4/2015, stated, Each resident has the right to be free from abuse, neglect, (and) mistreatment. It is the (Facility's policy) to implement policies to identify, investigate and protect residents from abuse, neglect, (and) mistreatment, Injury of unknown source is defined as any resident injury where: 1) the source of the injury was not observed, or 2) the source of the injury cannot be explained by the resident, and the injury is suspicious because of its extent, location, the number of injuries observed at one time or the number of incidents of injuries over time. Review of the Nurse's Note of 8/10/15 at 8:00 P.M., documentation indicated Resident #1 was found to have a large bruise (10 centimeters (cm.) in length by 10 cm. in width) with swelling on the right upper arm (an injury of unknown origin). The Nurse Practitioner (NP) was notified of the arm bruise, and staff nurses were instructed to monitor Resident #1 and to report to the NP in the morning the status of Resident #1's right arm. The Surveyor interviewed Family Member (FM) #1 and FM #2 at 12:30 P.M. on 9/10/15 and at 2:00 P.M. on 9/11/15. Both FM #1 and FM #2 stated that they reported to Nurse #1 (on 8/10/15, after lunch but before 1:15 P.M.), a large black and blue mark which was from Resident #1's right shoulder to just above anticubical space (elbow joint), measured 10 centimeters (cm) in length by 10 cm in width. The Surveyor interviewed Nurse #1 at 10:55 A.M. on 9/11/15. Nurse #1 stated that she said one of the Family Members pointed out that this Resident had bruising on the right upper arm. Nurse #1 said that Nurse #1 should have been more attentive, and that Nurse #1 did not assess, report or investigate the cause of the bruising and swelling on the right upper arm (which resulted in a fractured humerus) on 8/10/15. (This is an approximate 7 hour delay in identifying, reporting and investigating a bruise of suspicious origin). Interview with the Director of Nursing Services (DNS) at 8:30 A.M. on 9/10/15, the DNS said, Resident #1's bruised arm should have been reported and investigated and disciplinary action was taken. The DNS said that FM #1 and FM #2 were not interviewed as part of the Facility's investigation.

Based on observation, record review and interviews, the facility failed to follow the written plan of care for 2 residents (#10 and #16) of a total sample of 22. Findings include: 1. For Resident #16 the Facility failed to provide staff assistance with ambulation. Resident #16 was admitted to the facility in 2/2011 with [DIAGNOSES REDACTED]. Review of the Falls Care Plan, dated 2/10/13, indicated the following interventions: - Monitor for unsafe behaviors. - Encourage resident to use call light for assistance with transfers and ambulation. - Tab alarm in chair. - Wears gait belt. Review of the CNA (Certified Nurse Aide) Kardex, dated 3/5/13, indicated that Resident #16 walked with the assistance of 1 staff member, utilizing a gait belt and a rolling walker. Review of the nurse's notes, dated 3/31/13, indicated Resident #16 fell while being ambulated to the dining room by another resident. Resident #16 fell in the dining room and sustained a 2.5 centimeter (cm) laceration to the back of the head and was sent to the hospital returning with 4 staples. The facility investigation, dated 3/31/13, further indicated the resident's tab alarm was disconnected. During an interview with Unit Manager #1 on 11/14/13 at 10:05 A.M., she said that Resident #16 should have been ambulated by staff. It was not the facility practice to allow residents to assist other residents with ambulation. Unit Manager #1 said the facility's investigation showed that the tab alarm was disconnected. The surveyor observed Resident #16 on 11/14/13 at 8:40 A.M. Resident #16 was seated in a chair. An alarm was present on the chair and Resident #16 wore sneakers. Refer to F323. 2. For Resident #10, the facility failed to provide an elevated toilet seat as recommended by the Occupational Therapist (OT). Resident #10 was admitted to the facility in 9/2013 with [DIAGNOSES REDACTED]. Review of the OT discharge summary, dated 10/29/13, indicated the resident needed an elevated toilet seat to safely go to the bathroom independently. On 11/13/13 at 11:40 A.M. the surveyor observed Resident #10's bathroom. There was no elevated toilet seat as recommended by OT. During an interview on 11/13/13 at 11:50 A.M. with OT#1, she said when a resident is discharged from occupational therapy, the therapist is suppose to educated the staff to ensure that all recommendations are followed. She said the education was not done for Resident #10 and the resident did not have the elevated toilet seat as recommended for safe toileting. Refer to F323.

Based on observation, record review, and staff interview, the Facility failed to provide adequate supervision and effective interventions to prevent accidents from occurring for 2 (#10 and #16) of 12 applicable residents with accidents in a total sample of 22. Findings include: 1. For Resident #16 the Facility failed to provide adequate supervision and assistance to prevent Resident #16 from falling and sustaining a laceration to the head which required 4 staples. Resident #16 was admitted to the facility in 2/2011 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 11/29/12, indicated that the Resident had severe cognitive impairment, required extensive assistance of 1 for ambulation and transfers and had no falls since the last assessment. Review of the nurse's notes, dated 12/8/12, indicated that at 3:50 P.M., Resident #16 was found on the floor in front of the nurses' station and sustained a 1.5 centimeter (cm) by 0.5 cm skin tear to the base of the left thumb. The Facility investigation, dated 12/8/12, further indicated that a tab alarm would be placed on the Resident #16's chair. Review of the Falls Care Plan, dated 12/11/12, indicated the following interventions: - Monitor for unsafe behaviors. - Encourage resident to use call light for assistance with transfers and ambulation. - Tab alarm in chair. Review of the nurse's note, dated 2/10/13, indicated that at 8:05 A.M., while ambulating to the dining room with staff and without a gait belt, Resident #16 fell and sustained a 5 cm by 4 cm bruise to the right cheek. The Facility investigation, dated 2/10/13, further indicated that staff were educated regarding the use of a gait belt. Review of the Falls Care Plan indicated that on 2/10/13 the care plan was updated to include: wears gait belt. Review of the Quarterly MDS Assessment, dated 2/21/13, indicated the resident had severe cognitive impairment and required extensive assistance of 1 for ambulation and transfers. Review of the CNA (Certified Nurse Aide) Kardex, dated 3/5/13, indicated that Resident #16 walked with the assistance of 1, utilizing a gait belt and a rolling walker. Review of the nurse's notes, dated 3/31/13, indicated that Resident #16 fell while being ambulated to the dining room by another resident. Resident #16 sustained a 2.5 cm laceration to the back of the head. Resident #16 was sent to the hospital and returned with 4 staples. The Facility investigation, dated 3/31/13, further indicated that the staff were educated on the importance of monitoring residents in the hallway. During an interview with Unit Manager #1 on 11/14/13 at 10:05 A.M., she said that Resident #16 should have been ambulated by staff. It was not the facility practice to allow residents to assist other residents with ambulation. Unit Manager #1 said the investigation showed that the resident's tab alarm was disconnected. The surveyor observed Resident #16 on 11/14/13 at 8:40 A.M. Resident #16 was seated in a chair. An alarm was present on the chair and Resident #16 wore sneakers. 2. For Resident #10, the facility failed to provide adequate devices to prevent 2 falls. Resident #10 was admitted to the facility in 9/2013 with [DIAGNOSES REDACTED]. Review of the Occupational Therapist (OT) discharge summary, dated 10/29/13, indicated the resident needed an elevated toilet seat to safely go to the bathroom independently. Review of the Accident/Incident Report, dated 11/11/13, indicated the resident had an unwitnessed fall at 9:45 A.M. The resident was getting off the toilet, lost his/her balance and fell . Review of an Accident/Incident Report, dated 11/11/13, indicated the resident had an unwitnessed fall at 10:30 A.M. (45 minutes after the last fall). The resident said he/she slipped when getting up from the toilet. On 11/13/13 at 11:40 A.M. the surveyor observed Resident #10's bathroom. There was no elevated toilet seat as recommended by OT. During an interview on 11/13/13 at 12:00 P.M. with Unit Manager (UM) #3, she said the resident is supposed to have an elevated toilet so he/she can safely go to the bathroom. UM #3 said the interventions recommended by the OT to prevent the resident from falling were not implemented.