**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to identify a hazard, and the facility did not take action to reduce the risk for further injuries. On 10/28/24, Resident #2 was identified to have a rectangular shaped red mark to the right forearm measuring 10.3cm x 5.6cm, with scattered blisters. Resident #2 reported to the staff that the water in the shower room caused the injury. On 10/31/24 the resident went to the Urgent Care and was found to have a 2nd degree burn on the right arm. The facility continued to give showers in the identified shower room. On 11/5/24, After 3 residents received showers, a Department of Inspection, Appeals and Licensing (DIAL) staff measured the water temperature to be 145.2 degrees Fahrenheit. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 28, 2024 on November 5, 2024 at 4:55 p.m. The facility staff removed the Immediate Jeopardy on November 6, 2024 by implementing the following actions: 1. Resident #2 had treatment in place of the area on the right arm. 2. The 3 residents that were given showers on the morning of 11/5/24 had complete head to toe skin assessments completed and were questioned about the temperature of water. 3. Weekly skin assessments are recorded in each resident's chart in Point Click Care (PCC), no residents voiced concerns about shower temperature, or any injuries noted from skin assessments. 4. All showers were put out of use immediately after DIL staff reported water temperature finding of 145.2 degrees. The high temperature had the potential to harm other residents in the facility that receive showers. 5. All showers are regulated to prevent water temperatures above 120 degrees. 6. 1-[NAME] Plumner services contacted on 11/5/24 to assess the current plumbing system with additional monitoring thermometer installed on the water heater. 1-[NAME] Plumber's report isolated an incident of sediment build up that was resolved by maintenance staff with no further interventions required for safe water temperatures. 7. Maintenance will check water temperature in each shower room daily beginning 11/5 for the next 7 days and then on a weekly basis as a part of weekly system checks through TELS. Weekly system checks have no end date. 8. All nursing staff will be educated on how to monitor water temperature with a thermometer placed in the shower room by the end of day 11/6/24. If the water temperature is greater than 120 degrees, they are to cease the shower for the resident, and report to the administrator, maintenance or charge nurse and cease showers until the water temperature has been checked and deemed to be at a safe level. The scope lowered from J to D at the time of the Survey after ensuring the facility implemented staff education and procedures. The facility reported a census of 59 residents. The Minimum Data Set (MDS) for Resident #2 dated 8/9/24 revealed a diagnosis of quadriplegia (partial or complete paralysis of both arms and legs as a result of a spinal cord injury) and was dependent on staff for a shower. Resident had a Brief Interview for Mental Status (BIMS) score of 15 which suggested an intact cognition. The Care Plan for Resident #2 identified the need for total assistance with bathing and directed staff directed staff to offer a bath/shower 2 times a week and as needed. The Nursing progress notes for Resident #2 revealed: a. On 10/28/24 at 4:12 PM The nurse was notified by Physical Therapy (PT) of a skin alteration to resident's right arm. Upon assessment, the resident was noted with a rectangular shaped red mark to right forearm measured 10.3 centimeters (cm) x 5.6 cm with scattered blisters in the middle of the area. The resident stated this may have happened while in the shower earlier in the day. The area was cleansed, skin prep applied and family and provider notified. b. On 10/28/24 at 4:18 PM A change of condition: skin wound. The primary care provider was notified on 10/28/24 at 3 PM and the resident representative was notified at 3 PM. c. On 10/28/24 at 4:22 PM A condition follow-up: redness to right forearm with scattered blisters. An order for skin prep 2 times a day (BID) until healed. d. On 10/29/24 at 9:59 AM A condition follow-up: Staff J, Nurse Practitioner, was here to see the resident. Resident #2 complained of pain and burn on the site, skin looks red on surface. The treatment completed as ordered. No signs or symptoms of infection noted at this time. e. On 10/31/24 at 9:14 A condition follow-up: A new observation noted. The skin is still red, blisters are drained. A clear tape is covering the area. The resident complained of pain to the area. f. On 10/31/24 at 6:42 PM A condition follow-up: The arm was red with raised blisters, no signs or symptoms of infection. g. On 11/1/24 at 12:47 AM A condition follow-up: The area being monitored is from what resident stated was from water and then stating it was from the shower bar. The area is square in shape, has small intact blisters in the middle. The resident was out all day on Saturday and Sunday with friends and family and did not have a long sleeve shirt on when leaving facility. The resident stated it was sore. There was no bleeding or drainage noted. h. 11/1/24 at 7:45 AM Late entry: on 10/31/24 the resident and his friend came back with a note from Urgent care at Mercy. i. 11/1/24 at 6:26 PM Resident was seen by provider. A new order for a topical antibiotic (TAO) to be applied BID (2 times a day) and as needed (PRN), apply a non-adherent dressing and loosely wrap with Kerlix dressing. A voicemail was left for mother. During an interview on 11/5/24 at 1:09 PM, Resident #2 stated on 10/28/24, Staff B, Certified Nursing Assistant (CNA) assisted him to a shower chair and transported him to the upstairs shower room. Resident #2 stated when the water touched his forearm, he could feel the temperature and Staff B put the water on his right forearm. Resident #2 stated, She had to turn it down because it was scalding hot. Resident #2 stated he felt heat on his right (Rt) arm and felt discomfort when it was dried off with a towel. Resident #2 stated the CNA's that dressed him identified the reddened area and the therapist notified Staff D, Licensed Practical Nurse (LPN). Resident #2 stated Staff D assessed his arm and stated to leave it open. Resident #2 stated he notified his mother who came to the facility and was told it was a rash. Resident #2 stated his arm was painful, and was given Oxycodone for back pain but stated that did not relieve the burning pain. Resident #2 stated the facility provider assessed the reddened, blistered area on 12/29/24 who stated she was not sure what it was but the staff told her it was a rash and gave an order for skin prep to be applied. Resident #2 stated the blisters increased in size and he experienced prickly pain. Resident #2 stated he seen at the Urgent Care on 10/31/24 and treated for a 2nd degree burn to the right forearm. During an observation on 11/5/24 at 1:08 PM, Resident #2 had a reddened area to the right upper forearm/elbow area that revealed a dried, open, scared area inside the reddened skin. Resident #2's mother provided a picture of the affected area, verified by Resident #2, that was taken after a shower on 12/28/24 that revealed a reddened area with blisters in the center to the skin on his right forearm. A document titled Mercy One dated 10/31/24 revealed: a. History of present illness: Minor burn, patient notes a burn on right forearm and elbow. He notes that he lives in a home and was in the shower when he was burned. It is a second degree burn on his right arm at the elbow area. b. Assessment/Plan: 2nd degree burn. Keep clean and dry. Cover and use an antibiotic ointment on it, as needed, for the next 3-4 days until it is healing more and feeling better. During an interview on 10/4/24 at 2:58 PM The Director of Nursing (DON) stated Resident #2 was out of the facility over the weekend and received the shower that he said he received the burn on Monday 10/28/24. The DON stated the provider told her that the water in the shower may have exacerbated the area. The DON stated Resident #2 went to a clinic on his own. The DON stated she had followed up with the clinic staff who stated he was to put an antibiotic on the dressing, but they did not have an antibiotic order. The DON stated the facility provider was treating the area with skin prep to toughen up the blisters. The DON stated the maintenance supervisor keeps water logs and had tested water temperatures every day. During an interview on 11/5/24 at 9:52 AM, Staff K, CNA stated Resident #2 told her the shower water was too hot in the upstairs shower room. Staff K stated sometimes that shower room gets hot and they have to check it. Staff K reported giving 3 showers in that shower room this AM without incident. The metal grab bars could get hot if the water was turned all the way up and running straight down on to the bar. Staff K stated the water will get hot if turned all the way up. During an observation on 11/5/24 at 10:02 AM, in the shower room located in 100 Hall (identified as the upstairs shower room) the DIAL surveyor turned water on and tested the water temperature with her hand and the water was too hot to touch. A measurement was conducted with a thermometer that revealed 145.2 Fahrenheit. The Administrator was present for the test. During an observation on 11/5/24 at 10:37 AM, The administrator applied a sign onto the upstairs shower door that read out of order. During an interview on 11/5/24 at 11:25 AM, Staff I, CNA stated the shower room upstairs, if you turn it all the way up, potentially could burn your skin. Staff I stated, I don't turn it all the way up. I don't think anyone would turn it all the way up. During an interview on 11/5/24 at 3:02 PM Staff B, CNA stated she had assisted Resident #2 out of bed on 10/28/24 about 9 AM and into the shower room for the nurse to do bowel care before his shower. Staff B stated the entire time, the water was running, and she had tested the water. Staff B stated this was her first time to give Resident #2 a shower, he had a routine and would give instructions. Staff B stated Resident #2 let her know the water got cold and she had turned it up, then he could tell her if it was too hot. Staff B stated another aide took over after the shower. Staff B stated Staff E, LPN approached her when she was giving another shower, asked if she had seen anything red or raised on his arms and stated she did not see anything on Resident #2's right arm before or during the shower. Staff B stated she had given 4 showers before Resident #2 had his and the water was not overly hot. During an interview on 11/7/24 at 10:04 AM Staff E, LPN stated Resident #2 had lived in the facility about a year and was a typical [AGE] year old with an active social life. Staff E stated she had completed his bowel care and during that time, she did not visualize anything on his skin. Staff E stated after the shower, she was notified by therapy and assessed a red rectangular shape area with blisters to Resident #2's right arm. Staff E stated Resident #2 stated he was burned when the CNA ran water over his arm. Staff E stated she had notified the provider and received an order to apply skin prep and it was not normal to put skin prep on burns. Staff E stated she notified the mother, the DON and the Assistant Director of Nursing (ADON). Staff E stated she had questioned Staff B, CNA who denied having the water over his arm. Staff E stated that Resident #2 did not want to get the CNA into trouble. During an interview on 11/7/24 at 10:31 AM Staff M, CNA stated she had worked with Resident #2 on 10/28/24 and assisted his to undress for the shower. Staff M stated there was nothing, no redness to his arms and he did not have pain. Staff M stated she had assisted Resident #2 to the shower room then left the room. Staff M stated when Resident #2 returned from the shower, he had a red mark the size of her phone, with blisters to his right arm. Staff M stated she did not visualize the redness before the shower, but it was there after the shower. During an interview on 11/6/24 at 1:16 PM Staff L, Occupational Therapist (OT) stated on 10/28/24 he had entered Resident #2's room to assist in dressing after the shower. Resident #2 told Staff L that he had a burn to his right arm from hot water in the shower room upstairs. Staff L stated there was a red rectangular patch of redness to the upper forearm and lower humerus with small blisters in the center. Staff L stated he did not disagree with Resident #2 and notified the nurse. During an interview on 11/6/24 at 1:42 PM Staff C, CNA stated she was aware that the upstairs shower was pretty hot and stated she did not want to burn anyone. Staff C stated she was recently informed that there was a thermometer in the shower room and the staff were to measure the water to ensure it was not to rise above 120 degrees F. During an interview on 11/6/24 at 2:11 PM Staff F, CNA stated the water was too cold in the down stairs shower rooms, therefore Resident #2 would receive showers in the upstairs shower room. Staff F claimed the water was too hot to put her hand underneath it and would have to turn it down and test it before putting it on a resident. During an interview on 11/6/24 at 2:01 PM, Staff G, Certified Medication Aide (CMA) stated the water temperature in the upstairs shower room depended on how long it was on. Staff G stated she received a text message that read not to give showers until the problem was corrected. During an interview on 11/6/24 at 2:28 PM, Staff D, LPN stated Resident #2 told her on 10/29/24 that he received the injury in the shower room. Staff D stated she had not tested the water temperature, was not aware that the water was hot. Staff D stated, No one could figure out what it (the injury) was, I thought it was a spider bite because there was a blister on it. Document provided by the facility titled Test and Log the Hot Water Temperatures revealed: a. Test the water at various locations throughout your facility. b. For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temperature can still cause burns if exposure reaches five minutes. Many states have even stricter standards that can set maximum temperatures lower than 120 degrees Fahrenheit. Although 100 degrees Fahrenheit is considered a safe water temperature for bathing. c. Test temperature in shower areas. d. Check resident rooms at the end of each wing on a rotating basis or per facility policy. e. Note any discrepancies. f. Adjust water heater settings as required. g. Retest as necessary. A document titled Logbook Water Temps revealed: a. Date 10/31/24 8 Room's tested, room numbers not identified temp range 103 to 105F Laundry room and Kitchen 140F. Lacked testing of shower rooms. Signed by Staff H, Maintenance Supervisor. b. Date 10/25/24 room [ROOM NUMBER]- T 104F, room [ROOM NUMBER]- T 104F, room [ROOM NUMBER]- T103, room [ROOM NUMBER]-T104F room [ROOM NUMBER]-T104F, room [ROOM NUMBER]- 104F, room [ROOM NUMBER]- T 103F, room [ROOM NUMBER]-T 104F Laundry room & Kitchen 140F. Lacked testing of shower rooms. Signed by Staff H. A document titled Logbook Documentation revealed: a. Dated Oct. 24-30 (no year) Side 1 shower pass 108.4, Side 2 east shower pass 104, Side 2 west shower pass 103.8. Comments: Side 1 a little higher than normal. Completed by lacking a signature. b. Dated [DATE]-[DATE] (no year) Side 1 shower pass 108.2, Side 2 east shower pass 103.8, Side 2 west shower pass 104. Comments: Side 1 still a little high than normal, still at passing temperature, I will keep checking it. Completed by lacking a signature. A review of the Journal of American Medical Association Studies of Thermal Injury revealed the time for a 3rd degree burn to occur for a water temperature of 148 degrees F. for 2 seconds, water temperature of 140 degrees F for 5 seconds and a safe water temperature for bathing 100 degrees F. Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows: a. First-degree burns involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. b. Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. c. Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interviews, police report, and policy review the facility failed to properly secure exit doors and failed to ensure residents were adequately supervised for 1 of 7 residents reviewed for wandering and elopement risk (Resident #1). The facility staff failed to know the whereabouts of a resident who left the facility unattended. Resident #1 was last seen by staff on 8/21/24 at approximately 9:00 PM, and not found until 8/23/24 at approximately 6:45 AM. The resident reported he had walked several blocks from the facility to a retail store, and later admitted himself to the Emergency Department (ED) for an evaluation. On 8/27/24 at 12:00 PM, the Iowa Department of Inspections, Appeals, and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The IJ began on 8/21/24, the day Resident #1 left the facility without staff knowledge. Facility staff removed the Immediate Jeopardy on 8/28/24 through the following actions: a. Temporary alarms put in place until a permanent new call light and wander guard system could be installed. b. All staff educated on the presence and use of the alarms, and the need to check/investigate the doors and surrounding area outside whenever a door alarm sounded and prior to deactivating the alarm effective 8/27/24. Staff orientation included the elopement policy. Agency staff required to read and sign the education in the schedule binder prior to their worked shift effective 8/27/24. c. The facility conducted a door alarm drill for staff on the day shift on 8/22/24. d. Current residents were assessed for elopement/wandering risk on 8/22/24. Residents assessed at high risk had a further evaluation completed, their care plan updated with resident-centered information and interventions, and a wander alert device initiated as necessary. e. A facility-wide evaluation of the wander alert system conducted on 8/22/24. f. All residents shall be educated upon admission and during Resident Council quarterly about the facility's voluntary discharge process, leave of absence process, and signing out with the charge nurse whenever the resident left for an outing with family/friends. The scope was lowered from J to a G the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: The Census List revealed Resident #1 admitted to the facility on [DATE] to Side 1 (upper level) hallway and then moved to the Side 2 (lower level) hallway on 7/17/24. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 admitted to the facility from another long-term care (LTC) facility on 7/11/24 and had diagnoses of debility, diabetes, malnutrition, schizophrenia, and a hip fracture. The MDS recorded the resident had a Brief Interview for Mental Status score of 14 out of 15, which indicated cognition intact. The resident had no behaviors. The MDS indicated the resident used a walker and had independence for toileting, dressing, bed mobility, and transfers. The MDS documented the resident had no wander or elopement alarm. The Care Plan initiated 7/12/24 and revised on 8/7/24, revealed the resident had a self-care deficit in activities of daily living (ADL's) related to a recent left femur fracture. The resident transferred and ambulated independently using a front-wheeled walker, and he was his own responsible party. The Care Plan revealed the resident took medication for schizophrenia and had a risk for falls. The Care Plan lacked any information regarding prior wandering or elopement, or if the resident had a wander guard (a wander alert system). The Care Plan revised on 8/23/24 revealed the resident had impaired safety awareness and at risk for elopement related to a history of attempts to leave the facility unattended at a previous care facility. The staff directives included to monitor the placement of a wander guard on his left ankle. A Nursing admission Evaluation dated 7/11/24, completed by Staff I, Registered Nurse (RN), revealed Resident #1 admitted from another care facility. Resident alert but confused and deemed an elopement risk. An alarm protocol was initiated and a wander guard applied. The Progress Notes dated 7/11/24 to 7/31/24 revealed the following: a. On 7/11/24 at 2:48 PM, Staff I, RN, documented Resident #1 admitted to the facility from another LTC facility. Resident alert and oriented, and ambulated on his own without difficulty. The resident has a known history of wandering so a wander guard placed on his right ankle. Staff educated on the importance of listening for the wander guard alarms and to monitor the resident. b. On 7/11/24 at 3:54 PM, resident had a history of elopement while at home and attempted to leave a facility without informing staff. Elopement risk score 4, indicating the resident at risk for elopement. The resident met the elopement risk criteria for wandering and verbally expressed a desire to go home, packed up belongings to go home, or stayed near an exit door. He also had admitted to the facility within the past 30 days and had not accepted the situation. c. On 7/12/24 at 4:14 PM, the resident wandered the hallways a few times but had no exit seeking. d. The Progress Notes indicated the resident exhibited behaviors on: 8/1/24 at 12:39 PM 8/2/24 at 9:28 AM 8/2/24 at 4:48 PM 8/4/24 at 8:18 AM The progress notes lacked the behaviors the resident exhibited. e. On 8/8/24 at 12:59 PM, the nurse practitioner (NP) saw the resident. The NP ordered to monitor the resident for insomnia and wandering, Trazadone (an antipsychotic medication) 25 milligrams (mg) at bedtime (HS), and continue psychiatric services. Resident is his own power of attorney (POA) and aware of the new orders. f. On 8/22/24 at 1:10 AM, Certified Nursing Assistant (CMA) reported resident not in bed. Unable to locate the resident after a search of the facility and grounds done. Director of Nursing (DON) and provider on-call informed of the missing resident. Awaiting further instructions from the DON. g. On 8/22/24 at 1:30 AM, DON called back and informed Staff D, Licensed Practical Nurse (LPN) to call the police and report the resident missing. Police called. h. On 8/22/24 at 1:45 AM, police arrived. Resident last seen by staff at approximately 8:30 PM wearing jeans, dark shirt/hoodie, and a red hat. Resident had a wheeled walked and ambulated independently in the facility. The temperature outside was 61 degrees. The resident's roommate reported he saw the resident packed belongings into a black bag before he noted Resident #1 missing. Roommate unable to recall what time he last saw Resident #1. Resident #1 did not say anything to him about leaving the facility. Resident's walker not located at the facility or on the grounds. Police will inform the facility if and when they found the resident. i. On 8/23/24 at 7:03 AM, Social Services (SS) visited Resident #1 upon his return to the building. He stated he wanted to see the world and find his friend to get a painting job. He also stated he went to the hospital due to his knees swelled up and hurt. Hospital paperwork given to the nurse. A provider's Encounter Note dated 8/6/24 revealed Resident #1 had increased agitation and wandering at night (HS), and referred to psychiatric services. Resident alert and oriented to self. The resident reported chronic left hip pain. He had an unsteady walk, and had impaired memory and insight/judgement. Trazadone 25 mg ordered every HS. The Order Summary Report revealed the following: a. Monitor wandering every shift started on 8/8/24. b. Monitor placement and functioning of the wander guard every shift started on 8/25/24. Document a (+) if the wander guard in place on right ankle and functioned correctly, and a (-) if the device not working. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 7/1/24 to 7/31/24 lacked documentation of a wander guard. The MAR dated 8/1/24 to 8/31/24 revealed to monitor behaviors such as restlessness, agitation, and elopement started on 7/11/24 and discontinued on 8/5/24 at 5:21 PM. An order to monitor placement and functioning of the wander guard was added to the MAR on 8/25/24 at 3:20 PM. The TAR dated 8/1 - 8/31/24 revealed an order to monitor the resident for insomnia and wandering every shift started on 8/8//24 at 12:50 PM. A Police report created 8/22/24 at 2:41 AM revealed a police officer dispatched to the facility for a missing person on 8/22/24 at 1:10 AM. Staff D reported Resident #1 had gone missing from the facility in what they believed was a voluntary basis on 8/21/24 at 9:00 PM. Staff D reported Resident #1 had a history of walking away from the car/home/facilities he had been placed in. Resident #1 left with a silver walker and took his clothes with him. Staff reported the individual was homeless previously and that could be where he headed. Staff were advised to call if he resurfaced on his volition (own will). The ED Physician's Note recorded Resident #1 triaged in the ED on 8/22/24 at 9:11 PM. The resident presented to the ED for complaint of bilateral knee pain rated at 10 out of 10. The resident had a history of a fall and left hip fracture in 4/2024. X-rays of both knees revealed no acute findings. Labs revealed CK (an enzyme found in heart tissue and the muscle) was elevated and believed to be possibly related to him riding a bike for transportation. He was diagnosed with musculoskeletal pain and referred to follow up at a free clinic. He discharged from the ED on 8/23/24 at 5:13 AM. An Elopement/Wandering Evaluation dated 8/23/24 revealed the resident at high risk for elopement due to a history of wandering and an elopement in the past 6 months. A Condition Monitoring assessment dated [DATE] revealed the resident had an elopement on 8/22/24. Staff I documented a head-to-toe assessment completed and no abnormal findings noted. Resident alert and oriented x 4 (person, place, time, situation) and stated he was going out to see the world. Resident denied pain and rated pain 0 on a 0 to 10 pain scale. Resident seen at the ED on 8/22/24. Resident told SS he fell, and told Staff I his knees were bothering him so he went to the ED. Resident spent the night of 8/22/24 in the ED for observation. Resident had discharge paperwork with education about osteoarthritis. The Facility's Investigation File revealed the following written statements: a. A written statement dated 8/21/24 by Staff E, CNA, revealed she started her shift at about 10:14 PM. Staff realized the resident wasn't in his room. We looked everywhere but we did not find him. b. A written statement dated 8/22/24 by Staff F, CNA, revealed she saw Resident #1 a little bit after supper. He walked up the ramp without his walker and the dietary supervisor handed his walker to me. I gave the walker to Resident #1. He then walked toward the smoke door. It was around 6:45 PM when Staff G, RN, and I saw him. He wore a dark top and had a red ball cap on. It's 2:15 AM and it's 61 degrees in Des Moines. I searched all rooms and bathrooms on side one and side two and also checked the courtyard, as at one time you could walk around the building from the courtyard to circle drive. c. A written statement dated 8/22/24 by Staff G, RN, revealed she saw Resident #1 in the upper dining room around 6:30 - 6:45 PM trying to open the gate (by the ramp to access the upper/lower level). He did not use his walker so I went to him and asked Staff F to get his walker. Dietary got the walker for him and he returned to the lower dining room. I did not see him after that. Staff C, CNA, informed me at approximately 12:30 AM, Resident #1 could not be found. I checked the rooms and spoke to staff. I spoke with the resident's roommate (Resident #6). Resident #6 said he observed Resident #1 packing clothes in a black bag. Staff C and I checked for a black bag in the room and could not find it, and no walker found in the room. Around 9:50 PM, I heard the Circle Drive alarm going off and when I checked it, I saw Staff K, CNA, coming in (the door). Staff K said she just threw (out) the trash. d. A written statement dated 8/21/24 by Staff H, CNA, revealed at 7:45 PM I took the residents outside for a smoke and Resident #1 was with us. After smoking, Resident #1 went back inside. I didn't see him getting out of the building at all. e. A written statement dated 8/22/24 by Staff D, LPN, revealed I did not come into work until midnight so I did not see the resident at all. Staff C, CNA, reported about 12:30 AM the resident was not in his room and questioned if anyone had seen him. Resident #1 is independent throughout the facility so all staff informed Resident #1 missing and started searching the premises which include all rooms, bathrooms, and outdoor premises/grounds. A CNA left the facility to search around the facility up to the gas stations/convenience stores. Unable to locate the resident. DON and local law enforcement informed. f. A written statement dated 8/22/24 by Staff C, CNA, revealed on 8/22/24, we (the staff) noticed that no one had seen Resident #1 since around 8:30 PM. We scattered out to search for him around the property but he was not found. The nurse took over matters and took the proper elopement precautions steps after we didn't locate him. During observation on 8/26/24 at 9:47 AM, the lower lever Circle Drive exterior exit door had a rock propped between the door and the doorframe. At 10:15 AM, the rock remained on the floor in the vestibule by the exterior exit door, but the rock no longer propped the door open. On 8/27/24 at 1:05 PM, a rock remained on the floor by the Circle Drive exit door. At the time, the surveyor showed the Corporate DON and the Administrator the rock by the exit door and told them staff had reported they used the rock to prop the door open so staff could get back inside the building. During an interview 8/26/24 at 10:00 AM, Resident #6 reported his roommate went missing last week (the week of 8/21/24). He noticed his roommate wasn't around. His roommate had a black bag on his bed. The bag was about 2 ft tall (gesturing to show the size of the bag). He didn't think much about it. He usually went to bed before his roommate did. His roommate had packed everything and jumped the facility. He was gone for a couple of days. Resident #6 stated he thought that was the only problem the facility had with Resident #1 leaving. Resident #6 thought the facility needed to put an alarm system on Resident #1's ankle or moved him closer to the nurse's station so they could keep better track of him. During an interview 8/26/24 at 10:15 AM, Resident #1 reported he had lived at the facility about a month. He could come and go from his room as he liked. On the evening he left the facility, he was just going to go for a walk. He liked to walk to get exercise. He reported he walked down to the family dollar store. He doesn't know if they were open, he didn't go inside. Resident #1 stated at the crack of dawn though, he got out of there. He didn't want to get in trouble. Resident #1 stated he just wanted freedom. During an interview 8/26/24 at 10:40 AM, Staff A, Certified Medication Assistant (CMA) reported Resident #1 doesn't have any behaviors. He was independent and required some cues and reminders. Resident #1 got out of the facility about 3-4 days ago. She was uncertain what happened or why he left. The resident told staff when he returned to the facility he left because he was in pain and went to the hospital, but he never told staff he was in pain. Staff A reported wander guards are reliable. If a resident had a wander guard, it alarmed whenever the resident got near the doors. Whenever an alarm sounded, she checked the panel by the nurse's station to see which exit door was alarming, checked the door, then called out 'clear and disabled the alarm. The alarm tone sounded different if there was a wander guard in the area. Staff A reported Resident #1 had a wander guard since he came in 7/2024. His wander guard was still assembled. She thinks Resident #1 was small enough and somehow got the device off his wrist or ankle. Resident #1 could dress himself and reach his extremities. On the day of the incident (8/21/24), she administered his medication around 7:45 - 8:00 PM. There was a culture party that night and there were a lot of people and activities going on. Staff didn't have their undivided attention on all of the residents. She left around 9:00 PM, after she gave residents their medications. Staff A reported she thought maybe Resident #1 slipped out of the facility when the partygoers were leaving. Staff A reported she didn't see Resident #1 outside with the smokers at 7:30 PM. Between 8 and 8:30 PM, staff noticed he wasn't around. Resident #1 wasn't found prior to her leaving at 9:00 PM. Staff A reported the nurse who was supposed to work 6 PM - 6 AM didn't come to work until after 10:00 PM. The CNA let Staff G, RN, know they hadn't seen Resident #1. Staff looked for him. She looked in his room. She did not find a wander guard in his drawer, in his bed, or under his pillow. She thinks he had the wander guard on. Staff A reported Resident #1 often sat in a chair by the exit door. Staff A stated she didn't think there were enough eyes and ears to watch all of the residents. There were also a lot of new staff who were not as familiar or knew the residents. Staff A reported staffing on the evening shift consisted of 3 CNA's, 1 CMA, and 1 nurse for 50 residents on Side 2 (lower level). Wednesdays were a heavier shower days because several residents required a Hoyer for transfers, which left only 1 CNA to watch the other residents. Staff A stated the outside door to the Circle Drive didn't lock. Staff had to put a rock in the door in order to get back into the building. Staff A relayed there are no cameras in the building that she knew of to monitor the hallways or exit doors. During an interview 8/26/24 at 11:00 AM, Staff B, Licensed Practical Nurse (LPN), reported he worked the 6 AM to 6 PM shift on the lower level and took care of Resident #1 on the day he left the building. Staff B recalled Resident #1 didn't have any behaviors, complaints, or anything out of the ordinary when he saw him during his worked shift. He normally filled out a change in condition assessment if a resident had a change in condition such as new behaviors. He checked the wander guard on his ankle and it functioned. Resident #1 is very compliant, and he went out to the courtyard to smoke during the smoke time. He had no complaints of wanting to leave, and he attended all three meals. He was not exit seeking. Resident #1 liked to sit in the chair by the vending machine and the SS's office. The chair sat alongside the wall near the exit door to Circle Drive. Staff B thought the resident maybe walked by the exit door, he sat down, and it triggered the alarm. The facility had a Culture night that evening. It was an introduction for the staff and residents to get to know the new company and the people. He didn't know what happened (with Resident #1 missing) because he got his prize and left the facility. He didn't hear any alarms going off, and he didn't notice anybody walking in the area when he left the building. He stated he had not witnessed Resident #1 try to leave before. During an interview 8/26/24 11:20 AM, Social Services reported Resident #1 stayed to himself and liked to go for walks. She had not seen him try to leave the facility before. He sat in the chair by the exit door and watched the cars outside the window. The SS reported she was not in the facility when Resident #1 apparently left the facility. She got a text (message) from the DON the resident had left the building. The text came at 2:30 AM (on 8/22), but she didn't get the text message until she got up that AM. She drove around looking for Resident #1 before she came to the facility for work. She read his PASRR, and called the social worker at another facility to see if they knew a contact for the resident. She found out from staff at another care facility the resident had eloped from their facility, but the SS didn't know that before until this elopement happened. She also called the mission and shelters. The resident went to the ED sometime after he left the facility and was evaluated for knee pain. The Dr told him he had arthritis. He was discharged from the ED. Staff were out looking for him all day. She called the hospitals and shelters three times but still unable to locate him. Staff H, CNA, found Resident #1 sitting on a park bench near 6th (Avenue) and University. Staff H worked the evening/night shift. He went back to get him and he was gone. Someone had picked him up. She asked the resident after staff brought him back to the facility where he was going or why he left the facility. He told her he tried to find his friends and wanted to get a painting job. He wanted to see the world. During an interview 8/27/24 at 8:05 AM, Staff C, CNA, reported he had worked at the facility since 8/8/24 and worked the 10 PM to 6 AM shift. He had two days of orientation to go over exits, fire extinguishers, on-line education, and things like that. Resident #1 was independent but he checked on the resident and made sure he was ok, and helped do whatever he needed. A company had just bought the facility on 8/1/24. They were having a get to know you party, where staff introduced themselves to each other. The facility was pretty crowded inside. Staff C reported he worked the floor and took care of residents during the time. Resident #1 was ok. When the party got over, Resident #1 went out with the other residents to smoke. Staff C took care of residents while another staff person went out and supervised the smoking residents. The surveyor asked Staff C when he noticed Resident #1 missing. Staff C responded he noticed Resident #1 wasn't in his room but that was not unusual because he was independent and could go around the facility. Residents were allowed to go to different parts of the facility, go outdoors to the courtyard, or anywhere in the building at this facility. The residents had freedom to go where they wanted. Staff C reported he was assigned to 14-15 residents. He couldn't watch the residents when they could go all over the place. Staff C stated the facility needed to look at the resident ratio for safety reasons. Staff C stated around 12 or 12:30 AM, he noticed the resident had not been seen, so they checked the premises. They discovered he was not around. Staff C said come to think of it, he had not seen Resident #1 since he went out to smoke, but there was no cause for concern because he had never left the facility before. The resident was quiet and went about his business. He doesn't bother anyone. Staff C reported no interventions on Resident #1's care plan prior to the incident. He just kept an eye on him and kept him safe. Since the incident, he checked on the resident every hour. The facility also provided education about elopement and how to check the exits. During an interview on 8/26/24 at 12:30 PM, Staff D, LPN, reported she normally worked the 6 PM to 6 AM shift but she didn't come into work until 12:00 AM (on 8/22/23). When she arrived, another nurse was doing treatments and the CNA's made rounds. Staff D reported as she sat at the desk on the lower level, Staff C told her Resident #1 not in his room when he made rounds. Staff C had just started working at the facility and was not as familiar with the residents. She told him where to look. He came back and told her he couldn't find Resident #1. She told everyone they needed to look for him. Some staff got in their car and drove around to see if they could find him. They searched upstairs, downstairs, and the courtyard but still didn't see any signs of him. She talked to Resident #1's roommate. His roommate said he saw Resident #1 packing things in a black bag. Resident #1 didn't mention anything to his roommate about leaving. They continued to search for him. Staff D stated she attempted to call the Administrator but he didn't answer, so she called the DON and told her about the resident. She asked the DON if she should call the authority to report him missing. The DON said she needed to check on something first. Staff D reported she called the police around 1:30 AM. Resident #1 wandered at a facility he resided at previously. Staff D stated she was unsure what interventions were in place for Resident #1. She thought Resident #1 had a wander guard on him but he had a history of taking the wander guard off. She doesn't recall if he had a wander guard on prior to the incident. Staff D stated she was unsure if the wander guard was documented on the TAR but the wander guard should be listed on the resident's care plan. During an interview 8/26/24 at 12:10 PM, Staff E, CNA, stated she normally worked the 10 PM to 6 AM shift. Resident #1 didn't require a lot of care. Most of his cares were done when she got there on the night shift. She made sure he was in his room. Resident #1 would be up and wandered. He would go toward the doors. She let the nurse know to keep an eye on him. Sometimes he got a drink from the machine or got a cup of coffee and drank the coffee in the dining area. He also sat by the nurse's station. Resident #1 had a wander guard on when he lived upstairs (Side 1) and also had the wander guard when he moved downstairs (Side 2). He got moved downstairs for safety reasons. Staff E reported she came to work at 10 PM on the day of the incident, the search for Resident #1 was already going on. The nurse that was working had just started back, and didn't know what he looked like. Staff looked in rooms and around the building, under beds, closets, in the bathrooms, and checked other residents' rooms. They searched around the building and on the road. Some aides drove to the gas stations, across the street to the church, and behind the facility. They checked everywhere where he possibly could be. The last time someone saw him, he came in from a smoke break, it was between 8:45 -9 PM. The staff were busy putting residents back to bed, but there had been a gathering before this. Staff E reported it puzzled them that he had went outside of the building, because when an alarm went off, they checked the door and did a count of the residents. Staff E guessed maybe after the party, the wander guard didn't go off. Resident #1 was independent. He usually came out of his room and got something to drink, then returned to his room. He often sat in the area by the exit door. The chairs near the vending area were not in that location previously. The chairs had recently been placed there because the upstairs area was too packed. Someone was supposed to come and get the chairs. Staff E confirmed no cameras in the area by the exit doors but she heard the company planned to install cameras. Staff E stated she felt they had the required staff on duty the evening of the incident. During an interview 8/27/24 at 3:10 PM, Staff F, CNA, stated she only worked on Wednesdays and Saturdays 16-hour shifts. On the evening of Wednesday, 8/21, around 6:45 PM, she saw Resident #1 ambulate from the lower level dining room toward the upper level dining room without his walker. A dietary staff member from downstairs brought his walker to him. After that, she brought residents from the dining room to their room on the upper level and performed cares and helped the residents into bed. The night shift nurse walked down the hallway and asked her if she had seen Resident #1. She said no. She went and searched the resident rooms on the upper level, then the lower level, and the courtyard. She let the nurse know she couldn't find him. She also told another aide who came in at 10:00 PM to look for him. They went room to room and looked for him but still were unable to find him. Resident #1 resided on the upper level a couple days when he first got admitted . She doesn't know if he had a wander guard on when he got admitted or if he had a wander guard on when he resided downstairs. She didn't take care of him. Staff F stated on 8/21/24 evening, a culture night party was going on. The party started at 7:00 PM. There was a lot of activity going on, and people (staff) were coming and going. No alarms went off during this time. No alarms went off during her shift except the smoke door exit alarm. The alarm went off when the residents who smoked and the staff who supervised the residents came back into the building. Staff F reported normally when an alarm went off, she checked the door, went outside and checked the parking lot and looked down the sidewalks to see if she saw anyone. She then came back into the facility and checked the rooms to ensure each resident was accounted for. Staff F reported she entered a code to exit the facility, and she pressed the green button on the wall to enter the building so it doesn't set the alarm off. The alarm may also trip if it took too long for someone to enter or leave the facility. Staff had to go to the Side 1 nurse's station desk and press the button to clear or deactivate the alarm to the exit door. Staff F reported staff not supposed to shut the alarm off until everything was clear. In a follow up interview 8/27/24 at 4:35 PM, Staff F reported the residents' smoke time scheduled at 7:30 PM but it depended on how fast the resident smoked their cigarette and how long they stayed outside. The smoking time varied from 15 minutes to ½ hour. During an interview 8/26/24 at 1:35 PM, Staff G, RN, stated she worked the 6 PM to 6 AM shift. She worked on Side 1 and also had responsibility for a few residents on the [NAME] end of Side 2. Whenever an alarm sounded, she checked to see which area alarmed. Staff G reported many times visitors came or left the facility and didn't enter the code, which triggered the alarm to go off. If she didn't see anyone when the alarm sounded, she looked outside to see if she saw someone, and then checked and accounted for the residents. The alarm sounded if a resident with a wander guard, got near the exit door. Staff G reported she checked the wander guards every shift. A list of residents due for wander guard checks showed up on the computer. Wander guard checked for placement and functioning and documented in the EHR. Staff G reported she was uncertain if Resident #1 had a wander guard prior to the incident. She was not normally assigned to Resident #1. On the evening of the incident, Staff C came and told her he had tried to find Resident #1. She told him to check the courtyard. The other nurses were aware and they had done a headcount. She went and checked the public bathrooms. Staff also checked other areas of the building. She went to Resident #1's room. The roommate mentioned Resident #1 had packed things in a black bag but the roommate didn't know what time that occurred. Staff C and Staff G looked for the black bag. Staff G stated she looked in the closet and his half of the closet was empty. A staff person drove around to areas by the facility to see if they could find him outside. Staff G reported she didn't hear any wander guard alarms while she passed meds and when she went in and out of the resident rooms. There was culture party downstairs in the dining room and there were a lot of people coming in and out. The door alarm kept going off so she checked the door and turned the alarm off. The maintenance man from a sister facility also helped her turn off the alarm by the nurse's station. She stood by the medication cart in the hall by the upper dining room, but she saw who came or left from the party. At the time, residents waited to go outside to smoke. She asked the residents to wait until the people from the party left. She did not see Resident #1 leave the facility when she worked that night. She seldom saw Resident #1 upstairs. She saw him by the exit door to the courtyard once, but he liked to sit by by the Circle Drive exit doors. Staff G again reported she was certain she did not hear any wander guard alarm or exit door alarm th[TRUNCATED]

Based on observations, interviews and clinical record review, the facility failed to safely serve the recommended therapeutic meals according to physician orders and speech therapy recommendations for 2 of 2 residents reviewed (Res #4, and Res #26). The facility contains 16 residents on a mechanically altered diet. The facility reported a census of 60. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 07/09/24 at 03:26 PM. The IJ began on 07/08/24. Facility staff removed the Immediate Jeopardy on 07/11/24. The facility staff removed the Immediate Jeopardy by implementing the following actions: 1. 100% Audit of Resident diet orders on 07/09/24 2. 100% Audit of resident diet cards on 07/09/24 3. 100% Care plan audit for all residents to verify diet and texture are accurate on 07/09/24 4. 100% Audit completed of diet type and texture, with any additional diet texture restrictions to follow a triple check process on 07/09/24 5. All staff educated on the signs and symptoms of choking or swallowing issues on 07/09/24 6. All staff were educated on 07/09/24 for competency of providing correct textures in regard to modified diets 7. An in-service was completed in person by the dietician and verbally communicated by nurse management to staff members regarding diet textures on 07/11/24 8. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 07/09/24 to address the IJ. The scope was lowered from a K to an E at the time of the survey after ensuring the facility implemented education. Findings Include: 1. The Quarterly Minimum Data Set (MDS) for Resident #26, dated 06/13/24, documented a Brief interview for mental status (BIMS) score of 04, which indicated severely impaired cognition. It failed to document her relevant diagnoses of dysphagia, oropharyngeal phase, and documented that she did not have trouble swallowing. Resident #26's Care Plan documented her diagnosis of dysphagia, oropharyngeal phase. The Care Plan directed staff to observe the resident for the signs and symptoms of dysphagia, including choking, pocketing, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appearing concerned during meals with initiated date of 9/14/18. It documented her diet as mechanical soft texture. Review of Resident #26's doctor's order summary revealed her diet was noted as mechanical soft texture, thin consistency, no bread, no watermelon. In an interview on 07/08/24 at 12:46 PM with Staff A, Speech Language Pathologist, reported that she made the recommendation on 07/01/24 to remove breads from Resident #26's diet, citing coughing while consuming bread products. She made the recommendation to move the resident to one-on-one eating assistance on 05/02/24 due to the resident's risk of aspiration and choking. A direct observation of the lunch service on 07/08/24 at 12:30 PM revealed Resident #26 was served a mechanically soft diet with an unmodified garlic breadstick and slice of unmoistened pound cake. Resident #26 was unobserved by staff members when she was originally served. Resident #26 began to immediately consume the pound cake, coughing heavily while she did so. Shortly after consuming the pound cake, Resident #26 picked up and took a bite of the garlic breadstick. She began to cough again. The Speech Language pathologist intervened after her initial bite of the garlic breadstick, removing it from her and reminding the resident that she couldn't have bread anymore. The Speech Language Pathologist sat with Resident #26 to ensure she was observed during her meal, and provided education to three different staff members about Resident #26's diet. The Speech Language Pathologist summoned Staff B, Licensed Practical Nurse (LPN) to assess Resident #26 by listening to her lungs and checking her pulse oxygen levels due to her strong coughing. In an interview on 07/08/24 at 12:37 PM with Staff C, Registered Nurse (RN), she stated that Resident #26 was supposed to stop getting bread with meals a week ago, but the kitchen has sent her bread on more than one occasion since then. She noted Resident #26 was also supposed to be encouraged to take drinks between bites of food. In an interview on 07/08/24 at 12:46 PM with Staff A, she noted that if she had not intervened she believed the resident would have consumed the entire garlic breadstick. She further noted that bread products, such as pound cake in the format it was served to Resident #26, was also not to be served to the resident due to the risk of choking and aspiration it poses to her. She noted this is not the first issue she has had with the kitchen serving improper diets to the residents. She recalls having to send food back to the kitchen on several occasions. The most recent was when the resident was served large whole chunks of chicken, instead of her prescribed mechanically softened diet. She noted she is often the one to catch these issues and correct them. She noted the facility has often not been assisting the resident one-on-one as recommended. She revealed that she had brought this to the attention of previous facility leadership and nothing had been done about it. She was hopeful that the new facility leadership would take these issues more seriously. A direct observation on 07/09/24 at 12:13 PM of the lunch meal revealed Resident #26 was served her appropriate diet. She was observed coughing only briefly on three occasions during her meal. A direct observation on 07/10/24 at 08:18 AM showed that Resident #26 was again served the appropriate diet. She was observed lighting coughing just twice during this meal. In an interview on 07/10/24 at 11:01 AM with The Regional Director of Nutritional services she noted the facility uses the International Dysphagia Diet Standardization Initiative (IDDSI) to inform dietary choices for residents, but further noted they use a more generic diet order system with only three diet levels. Regular, Mechanically Soft, and Puree. In an interview on 07/11/24 at 11:46 AM with Staff D, Dietary Cook, she revealed that on Monday the kitchen did not have enough blushing pears for everyone and substituted Pound Cake for the residents. She indicated she did not document this in the substitutions log and this change was not approved by the dietician. She indicated she did not know how to conduct the fork test, and indicated there was no pound cake remaining to perform a fork test. Review of IDDSI documentation showed the organization currently recommends items like pound cake undergo the Fork Test if being served unmodified to a resident on a level 5 (Mechanically soft) diet, or a level 4 (Puree) diet. The fork test involves using a fork to gently crush a food item, if the item deforms easily and does not return to its previous shape it can be considered on a case-by-case basis for individuals at risk of aspiration and choking. IDDSI framework further noted crumbly textures, like cake, are a choking risk because they need good tongue control to bring crumbly pieces together and mix with enough saliva to hold together to be moist and safe to swallow. A direct observation on 07/10/24 at 12:02 PM revealed a chaotic kitchen service. Staff D, Dietary Cook, was preparing resident plates before locating their diet slip. After plating the resident's food, Staff D then located their diet slip in her stack of slips and immediately passed it on to the next staff member. During this service she plated an incorrect diet for Resident #24, plating a regular diet instead of a mechanically soft diet. This required the intervention of the Region Director of Nutritional Services to correct. Review of Speech Therapy Encounter Notes dated 07/08/24 documented the resident was served and ate a bite of the garlic breadstick, as well as the need for one-on-one assistance at all times during meal service. It further details the education was provided to three separate Certified Nursing Assistants (CNAs). Review of a facility led interview with the Speech Language pathologist dated 07/08/24 at an unknown time documented the observation above and continued to describe Resident #26's coughing as large/strong coughs. It further details that nursing staff was required to assess the resident for possible aspiration. It continued to detail the Speech Language Pathologist spoke with kitchen staff after the incident and asked if they required a second recommendation to be made regarding bread. The kitchen staff are reported to have indicated to her they did not require an additional recommendation and they would fix the issue for the next meal. Review of a facility document titled Principles and Guidelines Used in Meal Planning from the Long-Term Care Diet Manual with an edition date of 2017 documents under the Pureed Diet section, subsection's D and E, bread and plain-cake product are considered to be of similar texture and require a similar treatment to be included in pureed diets, or diets where bread has been excluded due to risk of aspiration or choking. 2. The Minimum Data Set (MDS) for Resident #4, dated 10/01/23, documented a Brief interview for mental status (BIMS) score of 04, indicating severely impaired cognition. It documented relevant diagnoses of Non-Alzheimer's dementia, dysphagia - unspecified, dysphagia - oropharyngeal phase, cognitive communication deficit. It further documented her ability to eat as requiring supervision or touching assistance. Resident #4's care plan documented the resident's dysphagia, as well as a need to observe the resident during meal service for the signs and symptoms of dysphagia, including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appearing concerned during meals. It revealed her diet to be regular diet with pureed texture with a start date if 07/08/24. Review of Resident #4's Doctor's order summary documented the resident's diet as pureed texture with thin liquids as of 07/08/24. A direct observation on 07/09/24 at 12:16 PM revealed Resident #4 had been served a pureed diet with the addition of Cheeto Puffs and a lettuce salad for lunch. The lettuce salad was turned away at the table, but resident #4 was observed consuming approximately 5 full-sized Cheese Puffs before Staff A observed the resident and intervened. The Cheeto Puffs were removed from Resident #4 by Staff A. In an interview on 07/09/24 at 12:51 PM with Staff A, she noted Resident #4 had been moved to a pureed diet on 07/08/24 and was transitioned during the evening meal. She noted that the resident should not have Cheeto Puffs on a pureed diet, and intervened as soon as she saw to prevent possible choking or aspiration. In an interview on 07/09/24 at 02:54 PM with Staff E, Dietary Cook, she revealed the diet slips had been printed on Sunday for the entire week. She indicated she knew of recent changes to Resident #4's diet, but when she showed me the diet slip for Resident #4 it showed she was still on mechanically soft diet. She indicated the dietary manager is in charge of updating new diet orders, and stated she knows they should not be printing diet slips in advance. She noted it is the dietary cook's job to follow the diet slips, not to change them in the system. In an interview on 07/09/24 at 03:00 PM with Staff F, Dietary Aide, she noted there had been a significant turnover in the kitchen, and indicated staff should be screening to ensure residents are not given items they cannot have. In an interview on 07/09/24 at 03:09 PM with Staff G, Certified Medication Aide (CMA), she revealed it is everyone's job to watch during meal times for signs and symptoms of choking and aspiration, as well as to verify residents are being served the appropriate diets. She noted there is no formal system to notify CMAs and CNAs about what the diets are and if there are only diet changes. They only notice a diet has changed when they see a resident served a new diet, at which time they often verify the change to ensure the resident had been given the correct diet. She acknowledged that based on her understanding of safe diets, she does not believe Cheeto Puffs are acceptable on a pureed diet. She indicated the kitchen has had issues service the appropriate diet, and revealed that on several occasions in the last few months the kitchen has served another resident, Resident #1, graham crackers despite her being on a pureed diet. In an interview on 07/09/24 at 04:36 PM with the Regional Director of Operations, she noted she believed IDDSI classifies Cheeto Puffs as transitional foods. She stated her understanding is that because biting and chewing are not required because they can break down with saliva they could be used on a pureed diet. Review of IDDSI catalogue reveals that Cheeto puffs are classified as transitional foods and can be safe for residents up to dysphagia level 5 diets, which are also known as mechanically soft diets. Resident #4 was on a pureed diet at the time of the incident. It further indicated transitional foods should be broken into smaller pieces of approximately 1.5 x 1.5 cm across if used on any diet lower than level 7, which under IDDSI guideline is a regular, unmodified diet. In an interview on 07/10/24 at 11:01 AM with The Regional Director of Nutritional services she noted residents can have Cheeto Puffs at higher diet levels, and in some cases puree, under IDDSI guidelines. She also noted the expectation is for diet slips to be printed the evening before dining service, not in advance for the entire week. In an interview on 07/10/24 at 02:39 PM with Staff A, she indicated she does not follow IDDSI guidelines. She recommends a more generic three phase diet that includes regular, mechanically soft, and pureed diets. Under the guidelines she believes the facility uses and based on her education as a Speech Language Pathologist she does not believe Cheeto Puffs are an acceptable food on a pureed diet. She further indicated she is not aware of any pureed diet in which whole Cheeto Puffs would be acceptable. Review of facility document titled Therapeutic Diets with a last reviewed date of 08/16/23 documented diet tray cards will be updated to reflect diet and nutritional interventions to unclude but not limited to Low Concentrated Sweets, No Added Salt, Fortified Foods, Double Portions, Double Protein, and Supplements. Review of a facility document titled Menus and Recipes with a last reviewed date of 11/27/23 documented meals should be prepared according to the facility approved menu. The menu shall be approved by the Registered Dietician in the state of practice. It further documented Therapeutic and mechanically altered diets shall be available on a spreadsheet as ordered by a physician, and all changes to a menu or recipe shall be approved by the registered dietician. Review of a facility document titled Nutritional Services Menus with a last reviewed date of 11/27/23 documented changes which must be made following the start-up of the menus shall be provided to the Registered Dietician in a timely manner for approval. Changes which must occur due to shortage of stock, ect. Shall be reviewed for approval with the Registered Dietician. These changes shall be recorded on the menu substitution log and signed off by the Registered Dietician. Review of the Menu Substitution log lacked documentation of the changes to the menu on 07/08/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, Nurse Practitioner (NP ) interview, and Registered Nurse (RN)/Certified Wound Ostomy Continence Nurse (CWOCN) interview, Job Description forms and facility policy review, the facility failed to provide an assessment and interventions for a 2 of 3 residents who presented with a condition change. (Resident #2 and #3) The facility identified a census of 58 residents. On [DATE] at 2:30 p.m. the Iowa Department of Inspections, Appeals and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff dtermined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on [DATE] after the facility staff completed the following: 1. NP/Designee Completed 100% Audit on All Residents; Change of Condition Evaluation in EMR/PCC on [DATE]. 2. 100% Care Plan Audit Completed; Interventions in Place for Residents with a Change in Condition on [DATE]. 3. DON/Designee Completed 100% Education w/Nursing Staff on the Following on [DATE]: Identifying Early Change in Condition; Completing Change in Condition Evaluation Utilizing SBAR/eInteract in EMR/PCC. Implementing Interventions with Change in Condition. Monitoring Change in Condition X72 Hours or Until Condition Improves; Utilizing Shift to Shift Reporting. DON/Designee will Incorporate Education on Change in Condition with New Hires as part of Orientation. 4. Facility will Monitor through Facility Audit Tool (5) Residents, X5/Week for X4 Weeks and then Monthly to ensure ongoing Compliance. Monitored Findings will be Reviewed during Monthly QAPI Meeting. The scope was lowered from and J to a G at the time of the survey. Findings include: 1. A Minimum Data Set (MDS) assessment form dated 3.1.24 indicated Resident #3 had diagnosis that included a cognitive communication deficit, Anemia, Atrial Fibrillation (AF), Hypertension (HTN), Renal Insufficiency, Diabetes Mellitus (DM), Respiratory Failure, morbid obesity, required assistance with personal care and muscle weakness. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8 (moderately impaired cognitive skills), an impairment of both sides of her lower extremities, dependent on staff with toileting hygiene, required substantial to maximum assistance of staff with rolling/repositioning and as always incontinent of her bowels and bladder. The assessment identified the resident as at risk for pressure ulcers however with no pressure ulcers and not on a turning/repositioning program. A Care Plan revealed the following Focus area and Interventions as dated: a. I/my responsible party requested a full code status. (initiated 2.25.22) 1. Staff to have called for an ambulance. (initiated 2.25.22) 2. Provision of emergency measures as appropriate. (initiated 2.25.22) b. A diagnosis of HTN. (initiated 3.8.22) 1. Staff to have monitored for and document any edema. (initiated 3.8.22) c. Anticoagulant medication use with a risk of abnormal bleeding, hemorrhage and/or increased/easy bruising related to (r/t) anticoagulant use of Coumadin/Warfarin. (initiated 2.16.23) d. The resident had a pressure ulcer to the left heel or potential for pressure ulcer development. (initiated 3.8.22) 1. Monitor/document/report any as needed (PRN) changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage. (initiated 3.8.22) An email from Staff A, Assistant Director of Nursing (ADON) dated 4.5.24 at 9:59 a.m. to a NP revealed the following: Hey, the husband of Resident #3 made us send the resident to the hospital and we had no documentation related to (r/t) you having identified the resident as terminal or about the conversation you had with the resident's husband and etc. She requested a full code/CPR (cardiopulmonary) status so we really needed to be documenting everything on her. An email from the NP dated 4.5.24 at 3:50 p.m. revealed the following response to the above documented email: Sorry I have/had no right to say/write that someone is/was terminal until proven. I referred to Hospice because of the decline in health. I sent her to the hospital and they sent her back and the husband made the decision to refuse Hospice care. If her Husband is/was her Power of Attorney (POA), he had the right of decision to make her a Do Not Resuscitate (DNR) or FULL Code. During an interview 4.10.24 at 3 p.m. the Director of Nursing (DON) confirmed the facility staff failed to properly assess the resident and they should have due to (d/t) her CPR status. Review of the resident's Progress Notes revealed the following as dated: a. 3.25.24 at 1:43 p.m. - A NP addressed the resident's code status as CPR. b. 3.25.24 at 1:49 p.m. - The resident experienced a change of condition r/t skin wounds and pressure ulcers. The blood pressure, pulse, respirations, temperature and pulse oximetry documented on this date revealed documentation from a 1.22.24 assessment. This assessment failed to identify the resident's current vital signs. c. 3.25.24 at 2:01 p.m. - Two (2) small scabbed areas to the resident's right 2nd toe and a small 0.5 centimeter (cm) x 0.5 cm scab to the top of the right end toe. Also noted to have a small scabbed area to her left third toe with no assessment provided. d. 3.26.24 and 3.27.24 - No assessment completed. e. 3.28.24 - The interdisciplinary team met to review the resident's changes in weight and overall decline in her physical health. No assessment completed. f. 3.28.24 at 11:05 a.m. - New order received on 3.27.24 which discontinued the treatment to the resident's right buttock. No assessment completed r/t skin issues and her overall decline in physical health. g. 3.29.24 thru 3.31.24 - No assessments completed r/t skin issues and her overall decline in physical health. h. 3.30.24 at 2:39 a.m. - PT/INR (prothrombin time and international normalized ratio) drawn with a reading of 7.3 (critically high). Order received for administration of 5 milligrams (mg) of Vitamin K and recheck PT/INR in the afternoon of 3.30.24. No further assessment completed. According to an email 4.23.24 at 10:25 a.m. the resident's therapeutic PT/INR range should have been 2.0 - 3.0 i. 3.30.24 at 2:45 a.m. - Order received to discontinue (DC) current Coumadin order with a plan for an establishment of new Coumadin dosing with the providers when the critical PT/INR of 7.3 had been resolved. No further assessment completed. j. 3.30.24 at 6:45 p.m. - Received an order to hold Coumadin for one (1) more day an recheck the PT/INR on 3.31.24 with nofurther assessment completed. k. 3.31.24 at 3:35 p.m. - Attempted to draw PT/INR times (x) 2 attempts and without success. A new Physician's order received to try again in morning. No further assessment completed. l 4.1.24 at 10:45 a.m. - Order received to send the resident the emergency room (ER) d/t edema to her right hand and an elevated PT/ INR. No further assessment completed. m. 4.1.24 at 1:04 p.m. - The NP completed the following assessment: Staff requested the NP to see the Resident for swelling to her right arm. Objective: Edema first observed to right arm on 02/25 from blood draw and resolved with elevation of extremity. The Resident also had an open areas to her buttocks with treatment orders in place. Staff also reported an elevated INR of 7.3 as they held her Coumadin/Warfarin until the next PT/INR draw. Staff report attempted to redraw blood but failed with multiple trials. Today staff reported an acute change in the resident's health from baseline, with changes in skin color and temperature. The resident demonstrated consciousness to herself, tail bone pain and appetite changes. The resident denied nausea and vomiting, chest pain and shortness of breath. n. 4.1.24 at 1:24 p.m. - The NP received a call from the hospital ER where a PA notified her the resident's INR had improved and down to 4.3 from 7.3. The PA also confirmed the resident's right swollen hand which resulted from the attempted blood draws and no diagnosis identified. The PA reported the resident came to the hospital with a report of right-hand swelling and they planned a transfer back to the facility. The NP discussed with PA that resident required a more diagnostic workup because her health had gradually changed from baseline. The resident had been disoriented during an assessment, staff reported a sore buttock which might have gotten worse and the resident complained of tailbone pain. The NP also mentioned of her lower left extremity swelling. The PA at the hospital promised to take a closer look. Without any significant diagnosis, PA planned to send resident back to facility for routine care. o. 4.1.24 at 8:30 p.m. - Resident returned from the ER with no new orders but rather a follow up with the primary care provider (PCP) for her PT/INR and continued pressure ulcer care to her buttocks. The current PT was 41.1 and INR was . The Resident took medications without difficulty. Blood sugar (BS) 89 at HS (hour of sleep) staff gave the resident a banana and snack. No further assessment completed. A Weekly Wound Observation form dated 4.2.24 at 1:53 p.m. included the following assessment to the resident's worsening right buttock: 4.5 cm x 5.0 cm and 0.1 cm deep. 60% dermis and 40% necrotic (dead) tissue. A small amount of sero-sanguineous drainage and no odor. A Skin Observation tool dated 4.2.24 at 4:46 p.m. provided no assessment. p. A Progress Note entry dated 4.2.24 at 5:41 p.m. included the following: Resident seen by a NP that morning who diagnosed the ulcers on the resident's buttocks as a Kennedy ulcer (an ulcer that occurred as part of the dyeing process) and unavoidable. The wound to the resident's right buttock appeared much larger and now included her left buttock. No further assessment completed. q. 4.3.24 at 1:26 p.m. - No assessments completed by the facility nursing staff throughout the entire day. r. 4.4.24 at 10:54 a.m. - The resident alert without verbal responses to the nurse. The resident had been alert to self only. No further assessment completed. Review of the Hospital's ER report dated 4.5.24 indicated the resident arrived in the ER at 10:31 a.m. and was admitted at 10:35 a.m. A Certificate of Death form filed 4.10.24 indicated the resident passed away 4.5.24 at 3:30 p.m. from Sepsis. During an interview 4.11.24 at 3:54 p.m. Staff C, Certified Nursing Assistant (CNA) confirmed he found the area on the resident's gluteal region which he indicated it looked like a bruised, blistered area the size of a quarter. He reported the area to Staff A who assessed the area and applied a cream. The next time the staff member observed the ulcered area had been about another week and at that time he described the area as the size of an orange, the blister opened up as the skin flapped and drainage present in/on her brief. At that point the resident presented as coherent however the staff member kept saying staff needed to send her to the hospital. When the resident became really weak and made moaning noises the staff member called the resident's husband with a status report and the husband directed him to get her to the hospital Staff C state on 4.1.24 a Physician and Staff A came down to the resident's room and the staff member showed them new ulcered areas on her upper back and her thighs. The staff member offered that he felt like the facility management failed to take the direct care workers word/assessments seriously and they are the ones that saw everything. During an interview 4.11.24 at approximately. 12 p.m. a NP confirmed she observed the area on the resident's gluteal region on 3.25.24 and described it more like an unopened blister but not pressure of which the facility told her they thought the area presented as a [NAME] Ulcer. The NP confirmed once the blistered area presented itself staff should have assessed the area as a means to monitor the status. The NP indicated she had not observed the resident again until 4.1.24 when she was told in a meeting the resident had a swollen right arm. When she reviewed the Progress Notes there had been no assessment present so she had to assess the area herself but she expected staff to have assessed the area prior. Following the assessment she called the resident ' s husband who directed her to send the resident to the ER. The facility transferred the resident to the ER via the ambulance and after the hospital assessed and intervened they called her and told her they planned to send her back to the facility. The NP directed the hospital staff to wait as the resident ' s current condition had not been her baseline. The NP confirmed she expected staff to thoroughly assess a resident with a condition change on a regular basis and/or until resolved. During an interview 4.12.24 at 8:08 a.m. an RN/CWOCN at the hospital confirmed she cared for the resident while hospitalized . The RN, CWOCN voiced several concerns with the 1st having been the resident's full code status and 2nd it had been obvious by the condition of the resident's skin on arrival to the hospital the nursing facility neglected her care and treatment. Based on the location of all of her wounds she laid on her left side most of the time. Staff failed to reposition her and/or treat the resident ' s wounds appropriately. Although the wound on her buttocks turned into a Kennedy ulcer the etiology had been pressure and should have been treated accordingly. When this hospital staff member 1st treated the resident ' s wound on her buttocks she described the smell as horrendous and it was obvious to her no treatment had occurred. The resident should have been treated appropriately again, due to her desire for CPR and all life sustaining measures and she was not. During an interview 4.11.24 at 11:04 a.m. the DON indicated the facility had no policy on what to assess with a condition change but she had been told by a Corporate Nurse the facility charted by exception (a deviation from normal). During an interview 4.11.24 at 2:21 p.m. Staff B, RN indicated he never witnessed the blistered area on the resident's gluteal area, rather he described the area the 1st time her observed it as a darker coloration of the right buttock, oval shaped and open. The staff member had not recalled any depth, drainage, odor or signs of infection to the area. Upon assessment he described the area as a pressure area because she refused to get out of bed. The pressure area got worse and worse and it changed to a Kennedy ulcer as she declined in health. Staff B indicated the facilities standard of practice r/t assessments as a result of a change of condition from baseline had been 72 hours from when the change started. The staff member confirmed he had never been directed to document by exception. During an interview 4.12.24 at 10:42 a.m. Staff D, RN confirmed three (3) staff members attempted to draw blood on 3.29.24 without success because her arm had been swollen but on 3.30.24 they were successful at the blood draw. The staff member confirmed the resident's arm as swollen on 3.29.24 and told Staff E about the status but failed to perform an assessment herself. The staff member confirmed if a resident exhibited a change of condition staff assessed for seven (7) days. Pertaining to this resident the staff member indicated all nurses should have been assessed the resident through her entire decline in her medical condition. During an interview 4.12.24 at 9:44 a.m. the resident's husband verbalized the following concerns: a. The facility staff failed to reposition her every 2 hours as expected. The husband confirmed he visited his wife every day for 5-6 hours per day and each time no staff member came into her room to reposition her. b. The swelling in/on her arm began Sunday 3.31.24 but the facility staff failed to assess the area. It has not been until 4.1.24 when he insisted staff send her to the ER. The Resident's husband felt the edema in/on her arm resulted when Staff D poked the resident so many times to draw her PT/INR which had been the hospital's conclusion as well. 2. A MDS assessment form dated 3.27.24 indicated Resident #2 had diagnosis that included Cardiorespiratory Conditions/Debility, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Interstitial Pulmonary Disease and a mild cognitive impairment. The assessment indicated the resident had a BIMS score of 9 out of 15 (moderately impaired cognitive skills) and required supervision to moderate assistance with his activities of daily living. A Care Plan revealed the following Focus area and Interventions as dated: a. I elected for a full code status. (revised 6.8.21) 1. Provision of all life sustaining measures. (initiated 2.27.21) 2. Hospitalization for acute status changes and send for tests/treatments as ordered. (revised 5.27.21) b. The resident with COPD r/t smoking. (revised 7.13.23) 1. Monitor for difficulty breathing on exertion. (initiated 7.13.23) 2. Monitor, report and document signs and symptoms of acute respiratory insufficiency i.e. anxiety, confusion, restlessness, shortness of breath (SOB) at rest cyanosis (blue color) and somnolence (tired). (initiated 6.8.21) 3. Application of oxygen when SOB or SPO2 (saturation of peripheral oxygen) registered below 90%. (initiated 9.7.23) Review of the facilities Progress Notes revealed the following as dated: a. 3.31.24 at 3:34 p.m. - A condition change evaluation form had been completed. b. 4.1.24 and 4.4.24 - No assessment completed. c. 4.5.24 at 5:40 a.m. - The resident had not felt well and suffered from a congested cough. No further assessment completed. d. 4.6.24 - No assessment completed. e. 4.7.24 at 6:05 a.m. - Resident still had not felt well. No further assessment completed f. 4.7.24 at 6:36 p.m. - Resident admitted to the hospital with Acute Respiratory Failure. An ER Hospital admission form indicated the resident arrived in the ER 4.7.24 at 8:56 a.m. and admitted at 8:57 a.m. with a chief complaint of SOB. The Resident's SPO2 registered at 70 (95% or higher signified a normal range) with room air only when the medics arrived at the nursing facility. The medics placed a CPAP (continuous positive airway pressure) machine which increased his CPO2 to 90%. Active diagnosis in the ED had been Acute Hypoxic Respiratory Failure as his primary diagnosis, Pneumonia due to an infectious organism, Lactic Acidosis and a fever. The Resident had been placed on a ventilator when hospitalized . 3. Review of the facilities Job Description for a Licensed Practical Nurse (LPN) revised 5.2022 the essential functions included the following: a. Assess and document the resident's condition and nursing needs. 4. Review of the facilities Job Description: Director Nursing (DON) form revised 5.2022 the essential functions included the following: a. Provided personal care to residents in a manner conductive to their safety and comfort conistent with the Company Clinical Policies and Procedures as well as the state/federal guidelines and regulations. 5. A Notification of a Change of Condition policy revised 4.26.23 included the following: The attending Physician/Physician Extender (NP, Physician Assistant (PA) or Clinical Nurse Specialist) should have been notified of a change in the resident's condition, per standards of practice and federal and/or state regulations. The change in condition included, but not limited to the following: a. Significant change or unstable vital signs. b. Onset of pressure injuries. c. Signs/symptoms of infection. d. Change in the level of consciousness. Once a change of condition had been identified the policy directed the facility staff to have documented the resident's change of condition in the Interdisciplinary Team Notes (Progress Notes).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to administer pain medication as ordered by a physician leaving 4 out of 4 residents reviewed without adequate pain control (Resident #4, #19, #20, and #21). Four residents reviewed were not administered their Controlled II pain medication as ordered for prolonged periods of time. The nurses and CMAs stated the medication was not available to give, therefore they did not give it. Resident #21 went 8 days without receiving his three times a day routine order of Percocet (an oral opioid pain medication). The other 3 residents did not receive their Fentanyl patches (potent opioid pain patch) as ordered every 3 days. In a 22 day period, the 3 residents reviewed did not have their patch applied every 3 days as ordered resulting in Resident #4 going 11 days, Resident #19 going 12 days, and Resident #20 going 7 days without Fentanyl during the 22 day review period. This situation resulted in Immediate Jeopardy to residents health and safety for the facility. The facility was notified of the Immediate Jeopardy on 6/29/23. The facility abated the Immediate Jeopardy situation on 6/29/23 lowering the scope from a K to an E after staff education was complete and the facility ensured all scheduled/ordered pain medications were available for residents. The facility reported a census of 62 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented that Resident #4 diagnoses included Multiple Sclerosis (MS), osteomyelitis of the vertebra (infection of the bone), and non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented a score of 8 out of 15, which indicated moderate cognitive impairment. Resident #4 required total dependence of 2 for transfers, and personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #4 received pain medication both routine and PRN (as needed) in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a moderate level and documented that she had pain occasionally. A Medication Administration Record (MAR) for the month of June 2023, directed staff to administer a Fentanyl Patch 12 mcg (microgram)/hr(hour) transdermal (absorbed through the skin) application at bedtime every 3 days for chronic pain to Resident #4. The start date was 2/20/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/2/23, it was applied the following day on 6/3/23. The resident had a patch applied on 5/5/23 and 5/8/23, then this resident did not have a patch applied again until 5/21/23. On 6/21/23 at 4:00 p.m., When asked if she had pain, this resident stated she did. When asked to rate the pain, she stated it was at a 5 on a scale of 0-10 and the pain was on her bottom. Resident lying in bed at the time. On 6/22/23 at 11:20 a.m., it was noted that Resident #4 had a patch on her right chest dated 6/21/23. Resident was asleep. This resident woke up but required some patting on the arm by staff. On all observations of Resident #4 during this survey Resident #4 had been awake, eyes opened, and responsive with exception of this observation. 2. An MDS dated [DATE], documented that Resident #19's diagnoses included MS and chronic pain. The MDS revealed a BIMS score of 15 out of 15, which indicated intact cognition. This resident required total dependence of 2 staff for transfers. She required total dependence of 1 staff for personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #19 received pain medication both routine and PRN in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a 5 out of 10 (0 is no pain and 10 is the worse pain you can imagine) and documented that she had pain frequently. A Medication Administration Record for the month of June 2023, directed staff to administer a Fentanyl Patch 25 mcg/hr transdermal application at bedtime every 72 hours (3 days) for chronic pain to Resident #19. The start date was 3/4/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/2/23, it was applied on 6/5/23. It revealed that she was to get a patch placed on 6/8/23 and did not have a patch applied until 6/14/23. She was scheduled to have a patch applied on 6/17/23 and did not have it applied until 6/20/23. It was documented that it was not available on 6/23/23. The MAR also directed staff that Oxycodone (opioid) 5 mg tablet was to be administered orally 4 times a day to Resident #19. The order date was 6/8/23. From 6/8/23 at 5 p.m. when the first dose was to be given to 6/12/23 at 6:00 a.m. the doses were not given. The 6:00 a.m. dose on 6/13/23 and all 4 doses on 6/14/23 and 6/15/23 were not available. The 8:00 p.m. dose on 6/23/23 was also not available. On 6/21/23 at 4:54 p.m., Resident #19 stated she was in pain and rated it at a 9 out of 10. She stated that she needed to lie down. She stated she hurt everywhere. Resident appeared to be in pain. She was pale and did not move during the conversation. On 6/22/23 at 10:30, Resident #19 was observed to have a patch last placed on 6/20/23 on her left chest. Resident #19 rated her pain at a 9 and stated she hurt all over. She added that the medication person is going to give her pain meds now and they will help. She said she went without the patch a few days ago and she became very sick. She stated she was throwing up and everything. She stated once they were able to get a patch the sickness went away. 3. An MDS dated [DATE], documented that Resident #20's diagnoses included anxiety and chronic pain syndrome. The MDS revealed a BIMS score of 15 out of 15, which indicated intact cognition. This resident required extensive assist of 1 for transfers and personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #20 received pain medication both routine and PRN in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a 4 out of 10 and documented that she had pain frequently. A Medication Administration Record for the month of June 2023, directed staff to administer a Fentanyl Patch 25 mcg/hr transdermal application at bedtime every 72 hours for chronic pain syndrome to Resident #20. The start date was 5/1/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/3/23. The last patch prior to this was applied on 5/30/23 and 3 days from that was 6/2/23. This resident went 4 days without the absorption of the patch from 6/2/23 when it should have been applied to 6/6/23. She had the patch applied again on 6/9/23, it wasn't applied on 6/12/23 then it was applied again on 6/15/23. On 6/21/23 at 4:55 p.m., Resident #20 stated she was in pain and rated her pain at an 8 out of 10. She stated it hurt in her tailbone and back. The resident appeared to be in pain. The DON (Director of Nursing) was notified of where Resident #19 and Resident #20 were rating their pain. Both residents had been outside to smoke and were sitting beside their respective beds in their wheelchairs in their room. These two residents are roommates. Both residents had facial grimacing. Resident #19 had guarded movements and sat very still. Observation on 6/22/23 at 10:35 a.m., noted Resident #20 had a patch on her right chest. It was not labeled. Resident #20 stated her tailbone pain is at an 8 which is constant, and her stomach pain was at a 5. She stated they were supposed to give her a suppository 2 nights ago and they never did. She stated she was constipated. When asked if they have missed giving her some pain medications, she said yes. She stated the reason she didn't receive her medication was they didn't have the medication to give. When asked if she was given anything to help with her pain she said no, they told me they didn't have anything else to give. 4. A MDS dated [DATE], documented that Resident #21's diagnoses included malignant neoplasm of the larynx (cancer of the voice box) and chronic pain. The BIMS score for Resident #21 was 12 out of 15 which indicated moderate cognitive impairment. This resident required extensive assist of 2 for transfers and extensive assist of 1 for personal hygiene. The Pain Management section revealed that Resident #21 received routine pain medication in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated his pain at a 6 out of 10 and documented that he had pain frequently. A MAR for the month of June, directed staff to administer Percocet 5-325mg three times a day at 8:00 a.m., 2:00 p.m., and at 8:00 p.m. to Resident #21. The MAR revealed that Resident did not receive his scheduled Percocet from 6/13/23 at 2:00 p.m. through 6/20/23. The MAR documented that he received a dose at 8:00 a.m. on 6/21/23. On 6/27/23 at 10:31 p.m. observed Resident #21 lying in bed. He nodded his head in affirmation that he did know they didn't have the pain meds to give him. When asked if he was in pain during that time, his eyes widened and he nodded a definite yes. When asked if he remembers what level his pain was at during that time and if he could rate it he shook his head no. He affirmed by nodding that he had went about a week without the pain medication and this happened a couple of weeks back. On 6/21/23 at 10:26 a.m., Staff C, Certified Nurse Aide/Certified Medication Aide (CNA/CMA), when asked what the circled initials meant on the MAR/TAR (/Treatment Administration Record) she stated it meant that they didn't have the medication. She stated it happened more than she would like to admit. She said the DON said to just pass the medications that you can. When asked why some residents had Fentanyl patches and another did not, she stated she did not know. She said maybe it had something to do with pharmacy. She said the facility does not want to report these things. Staff C stated she is told not to get so upset about things. On 6/21/23 at 2:45 p.m., the DON stated she was looking into the Fentanyl patches not being given. When asked what she knew about it, she just shook her head no. On 6/21/23 at 3:00 p.m., Staff C, when asked again about the numerous Fentanyl patches that weren't applied, she stated that the night shift which is mainly agency nurses put the patches on. She acknowledged all of the holes with the Fentanyl patches. She stated it meant they did not get the patches put on. She did not think there was drug diversion. She thought it was more laziness, destroyed. On 6/21/23 at 4:07 p.m., Staff D, Register Nurse (RN) traveler with the facility corporation and the Nurse Consultant stated they were aware of this too and looking into it, when they were told there was a concern with the Fentanyl patches and narcotics not being given. On 6/22/23 at 10:30 a.m., Staff A, CMA stated that medications are getting missed and sometimes it's because staff don't understand the different names of Vitamins i.e. ascorbic acid vs Vitamin C and sometimes they just don't look for the medications. Staff A stated that Resident #4 was without Percocet. Staff A stated she had sent the information that he was out of his Percocet and needed more several times but she was not sure if they had gotten it. She stated that Staff E, RN had told her they were getting a script (prescription for a physician) for the Percocet. Staff A said she had sent the tag in about 5 days before he was out of them. Staff A said it was ample time, more than 3 days to get it ordered. Staff A stated they (nurses) had tried to get it out of the e-kit (emergency medication kit) but he needed a new script. She said that he went 8 days without the Percocet. Staff A did not think there was any drug diversion just laziness. She stated that Resident #4 was going through withdrawal symptoms. Stated he was really tired. Staff B, RN, was part of the above conversation. He stated that there normally are medications up front. Staff B stated they can go up and get them. Staff B stated he did not think there was any drug diversion, just sloppy nursing. On 6/22/23 at 4:06 p.m., Staff F, Nurse Practitioner (NP), stated the facility let her know that the 3 ladies did not receive their patches. She stated she took a look at them and discontinued 2 of the 3 ladies patches as she did not feel they needed it. She said the 3rd lady was a different story. She stated she did know about another resident not getting his Percocet. She found out through faxes. She will look for the faxes of the facility notifying her of the pain medication not being given. Staff F stated it was okay to call her back with any further questions. Stated it was recently brought up to her about the Fentanyl patches not being administered, but she had been notified of this before and was notified by fax. No faxes were provided. On 6/22/23 at 2:30 p.m., Staff G, NP stated that no one had notified her of medications not being given. She had not heard about Fentanyl patches not being available. She had not heard about Resident #4 not getting his Percocet. She said there would be no reason for this. If not contacting her they could contact other providers to get a script or to get these medications ordered. She said in Resident #4's case she saw him after a fall and had abdominal x-ray/test done related to pain. She said at that time she reviewed his medications and did not feel he needed anything more for pain as he was on several medications that helped with pain. Staff G looked at Resident #4's MAR. She stated now that she knows he went without Percocet for that many days she will need to go back to Resident #4 and ask him about pain control. She said she came in to see 5 residents on this day and she was still at the facility because she finds things out when she talks with residents and feels she needs to take care of it. She stated a lot of the stuff she ends up doing are things the nurse should be doing but for some reason it is not getting done. She repeated that there is no reason the residents should not be receiving their medication. She stated a provider and pharmacy can be called. On 6/22/23 at 3:05 p.m., Staff E, RN stated that it was reported to her that Resident #4 did not have Percocet. She stated the CMA did not tell her until the last day that she worked. Staff E stated that sometimes she worked 2-3 days in a row. She stated that afternoon she called the pharmacy for it and the pharmacy said they were waiting on a script for it. Staff E stated that the pharmacy calls the care provider to get the script. She stated that the pharmacy was located out of state, so the pharmacy didn't always call the provider for the nurses. Staff E stated that on weekends it depends on who is on call, the provider might not write a script. Staff E didn't think she had called the on call provider the day she found out about needing a Percocet refill. Staff E stated she reported it on to the next shift but did not remember who. Staff E stated she did think it was important for the residents to have their meds. Staff E stated the facility was running bubble packs as well as cards with medications (meds) in them. Staff E stated that she was running meds all the time. Staff E said she did not want to put the facility under the bus or anything, but the nurses are continually getting meds out of this system because the meds are not filled. Staff E stated it was like all day long they were pulling meds from the ekit (emergency kit storage). Staff E stated it was very time consuming. Staff E stated the fax machine was down for a long time. She said she had been there for 6 months and the facility finally got a fax machine this week. She stated they were unable to fax the pharmacy because of it. Staff E stated they had to call the pharmacy or Staff F, LPN and another nurse had been emailing the pharmacy. Staff E stated that she always called the pharmacy and they would get upset when you have a huge list, the pharmacy wanted the list sent instead. She stated the pharmacy also sometimes did not send the meds. Staff E said that every day she pulled medications out of the ekit, even though the meds had been requested from the pharmacy. Staff E stated that the CMAs don't let the nurse know if there is a med missing, they will just circle it. Staff E said that she and another nurse have reported to the DON that the med aides (CMA's) aren't reporting that there are not meds in the carts. Staff E then went into the medication room. The system was hooked up to a computer. Staff E stated the nurses are able to type in the name of a resident and the medication needed and then you can get it out of the ekit. She stated that the nurses run meds for the residents and then deliver them. She said that it happened often that all of the meds are not there. Staff E said that often times with narcotics, the pharmacy will say a script was needed. Staff E stated that it could be difficult to get a script. Staff E said she honestly did not know if there was drug diversion at the facility, it's pretty scary. Staff E said that she had seen that people have signed things off and she had wondered how the CMAs have signed stuff off that the facility did not have. Staff E was unable to give any specific examples of this nor could she give a time frame. Staff E stated that Staff A and Staff C had told Staff E that night shift agency aides are not passing the meds. Staff C was really good about reporting to Staff E but Staff A didn't always report. Staff E said that Staff A would report to Staff B, but he was Staff A's son in law. Staff E stated she reported this to the DON and nothing really happened. Staff E stated that she did not want to be fired or anything but many things needed fixed. Staff E became tearful and said it's hard to work here because it's very busy and many things get missed. On 6/26/23 at 3:13 p.m., Staff I, RN Hospice stated she had brought up concerns regarding Resident #19 going through withdrawals. Staff I said the facility set her up on routine Oxycodone with the Fentanyl patch before related to Resident #19 requesting so much PRN (as needed) Oxycodone. Staff I said that with Resident #19 taking both of the meds she would still rate her pain at an 8 or 9. Staff I said that Resident #19 had a history of MS so it could be hard to tell with her because you don't know if she is masking pain. When asked who she goes through for medications, she stated they go through the facility doctor first. Staff I said that a lot of times they do things without communicating with her. Staff I stated she has to ask for an updated medication list for Resident #19. Staff I said she sees Resident #19 two times a week. When asked if she knew about Resident #19 not receiving her Fentanyl patch, Staff I stated that she would notice it would be dated for 5 days prior or not on her at all. Staff I said she had her hospice aide check the date on the patch and the hospice aide was to let Staff I know if the date was more than 3 days old or if there was no patch. Staff I stated that Resident #19 would ask Staff I if Staff I would go and see when she was due for her next dose of pain medication. Staff I stated that Resident #19 would ask more about the oxycodone and not the patch. Staff I said she had been Resident #19's case manager for almost 2 months now and that Resident #19 had went on hospice on 1/27/23 and there was a different hospice nurse case manager before Staff I. Staff I said that Resident #19 can make her own decisions and Resident #19 did have a son and a daughter that she wants us to update on her care. Staff I had a conversation with Resident #19 about missing Fentanyl patches. Staff I said that back in May she had went in and noticed that Resident #19 hadn't had one (Fentanyl patch) changed and Staff I brought it up to her and they were able to get a new one started. Staff I stated that since then Resident #19 had been able to let Staff I know if it was taken care of or not taken care of. Staff I stated that in June Resident #19 told Staff I that the Fentanyl patch wasn't being taken care. Staff I said that she spoke with the floor nurse and spoke with the ADON (Assistant Director of Nursing) and it seemed like every time Staff I would talk to somebody, they would tell Staff I they'd get the Fentanyl Patch shortly. Staff I stated she did not feel the issue got addressed. Staff I stated that the other hospice nurse spoke with the floor nurse on June 14th when the other hospice nurse noticed that the patch had not been changed and her roommate noticed the patch had not been changed. Staff I stated that she knew she was biased because them discontinuing the patch after the fact is doing her a disservice. On 6/26/23 at 4:20 p.m., Resident #19 stated that she was in pain and rated her pain at a 9 and ½. This resident was lying in bed. Stated she was feeling really bad and was going downhill fast. When asked what she meant by that she stated she just wasn't doing good. When asked about the Fentanyl patch, she said they took that off last week and told her that she didn't need it. When asked what she thought about that, she stated it really didn't help her much anyway. This resident had opened her eyes when the door was knocked on but did not open them very far. This resident did not move any extremities nor her head when she talked. When asked if staff check on her and ask her about her pain, she stated sometimes. When asked if they were checking twice a day, she stated no. When asked if she ever has no pain, she said no. When asked what the lowest her pain had been in the past few months, she stated a 6 or 7. The MAR for Resident #19 for the month of June 2023, directed staff to do a twice a day pain assessment with 0 as no pain, 1-3 as mild pain, 4-6 as moderate pain, and 7-10 as severe pain. The documentation of the pain revealed that from June 1st through June 26th this resident had pain rated four times at 7, two times at 8 and one time at a 6, the rest of the documentation revealed 0's or there were times when it wasn't filled out. On 6/26/23 at 4:30 p.m., Resident #4 was lying in bed smiling. Stated she really didn't have any pain. She was feeling pretty good. Resident #4 was wide awake and appeared happy. She asked about what time it was. The MAR for Resident #4 for the month of June 2023, directed staff to record pain on a 0-10 scale twice a day. The documentation of the pain revealed that from June 1st through the first part of June 26th this resident had 40 times the pain was not rated. On 6/27/23 at 9:15 a.m., Staff J, agency RN, stated he thought there was a Fentanyl patch on the 2nd floor downstairs for a day or so that was not put on. Staff J stated he did not put on but he did leave a note and passed it on. Staff J stated there was no way for him to get the patch. He stated he talked to day shift. He said that it was pretty complicated to talk to pharmacy on the weekend. He said he did assessments. When told about the patches that weren't placed and the time frame the residents went without a Fentanyl patch, he stated he did not know that they did not have patches for that long. Staff J stated he worked a lot on the 2nd floor (where all 4 residents resided). Staff J stated he would work a few days and then off but when he would come back he did not recall seeing any resident going a long time without a patch. Staff J stated that the CMAs do not apply Fentanyl. Staff J said that medications being not available happened quite often. Staff J stated that every time something happened when there wasn't a medication, he always left a note. Staff J stated that he would give a verbal report but he also would write the meds on the sheet and then hand it to the next shift. Staff J stated that the pharmacy says that he needs to fax when he did get a hold of the pharmacy. Staff J stated that the facility's fax was not working and on weekends the pharmacy was not available. Staff J stated that if you want to order more than one or two meds the pharmacy would say to fax the list of meds as the pharmacy preferred faxes. Staff J stated that he always made sure he put it on the sheet that they have so the day nurse would know what the situation was and then they could handle it during the day. When asked about the sheet, he stated he was not very sure where the sheet was kept. Staff J stated that they hand over a copy of it to the next nurse. Staff J stated that sometimes he would pass 8:00 p.m. meds but most of the time it's a CMA. Staff J stated he didn't know about Resident #21's Percocet. Staff J stated that he felt the residents received good care and he thought the communication with the pharmacy was the biggest concern. On 6/27/23 at 9:45 a.m., Staff E stated she did not know where the pharmacy book was in the back (2nd floor). She stated she wasn't sure what they did when the nurses and CMAs filled out the sheets with the meds that are needed. Staff E said she didn't see the book and she thought the sheets might just get thrown away. She pulled a couple of sheets out of the box with things that needed to be shredded. On 6/27/23 at 10:25 a.m., Staff E pulled 2 more pharmacy sheets out of the box when asked if there were any more sheets in the box. On 6/27/23 at 9:50 a.m., Staff H, Licensed Practical Nurse (LPN), stated the facility got a new machine and it copies and prints but it doesn't fax. Staff H stated she had developed a process with the pharmacy where you have an encryption code so the emails between Staff H and the pharmacy can go between us without HIPPA violations. Staff H stated that she had been doing this for 2 months. Staff H stated she receives sheets from the CMAs and on Mondays, Tuesdays, and Wednesdays Staff H forwards the sheets on to the pharmacy and then writes emailed to pharmacy and the date and time. Staff H stated she then puts the sheets into the pharmacy book. Staff H stated that she only worked on the 1st floor. Staff H state the process to get medication was the doctor writes out the order for her on a script, then she would take a picture and email to the pharmacy, after that she documented in the electronic health record to make it an active order. Staff H stated she would usually then call the pharmacy and let them know that she had put in an active order and she would pull a couple of doses of the medication so that they could cover the first couple of doses that needed to be given. Staff H stated that not all nurses have access to their medication system. She stated that sometimes they have agency nurses and the agency nurses cannot get into the facility's medication system. Discussed Resident #19's medication and Staff H stated that Resident #19 had been in pain since she has been here. Staff H stated that Resident #19 should not go without her pain medication. Staff H said that Resident #19 was so frail and pale and always looked like she was in pain. When told the pain level had been signed often as no pain for this resident, Staff H stated that was not right. Staff H stated what she thought staff were doing was seeing if Resident #19 was sleeping and marking it 0, they should be asking her. Staff H said that Resident #19 needed her pain medication. Staff H stated that hospice staff could call the pharmacy too and Staff H stated she did not know why agency nurses wouldn't just call the pharmacy. Staff H stated if they are writing down on the sheet that there was not a med available then it should be in the pharmacy book down there. They should be putting those sheets in to the pharmacy book and those papers should not be shredded. Staff H stated that usually on Mondays there are a lot of meds to order. Staff H stated that she just called the pharmacy and asked them how could she get the meds without a fax and they said she could use her own email but she would need to use their encryption. Staff H stated that's what she did. Staff H stated she did not want to put down the company but they had people running to another facility to fax orders because their facility couldn't get the meds. On 6/27/23 at 11:32 a.m., Staff K, CMA/CNA, stated that it did happen when meds were not available. Staff K stated she circled her initials on the MAR's when meds were not available. Staff K stated that she actually asks her nurse if the med is printable, meaning they can get it from the medication system, but if not to circle it and write a note on 24 hour report. When asked how often she thinks this happens, she stated daily. She stated it had gotten better because they had a new ADON who listens. Staff K stated that they tell the resident when we don't have a med for them and most of the time they are not surprised, unless it's a pain med, anti coagulant (blood thinner), anti anxiety, etc. Staff K stated they have one resident who gets upset if he did not get his oxycodone (pain medication), Lyrica (blocks pain signals in nervous system), or Clonazepam (anti-anxiety). Staff K sated that it took time but they were able to get it for him because they would call the pharmacy and the on call physician and get it pulled. Staff K stated that sometimes the on call doctor doesn't answer and sometimes the pharmacy doesn't answer. On 6/27/23 at 12:03 p.m., Staff L, RN stated she passes medications when they need someone. Staff L stated she would just get meds out of their medication system if she needed a med. She stated she has had trouble with the system jamming. Staff L stated she leaves at 10:30 p.m. and asks prior to leaving if anybody needs anything. Staff L stated she worked noon to 10:30 p.m. Staff L stated that they were checking every night now, they check the MARS and TARS they have to sign. Staff L, RN stated she knew that medications not being available was a problem and they had been working on it real hard. Staff L stated that the facility lost a couple of nurses about a month ago and then it wasn't brought to our attention. Staff L stated after that she went to check not too long ago for gaps and that's when she noticed it was a couple weeks ago. Staff L stated she had no clue that Resident #21 went without Percocet. Staff L stated that they could have called the on call providers. Staff L stated that they can get a hold of pharmacy 24 hours a day and they could get a hold of a physician 24 hours a day. Staff L stated that there was always 2 nurses in the facility so any of them can call and get medication. Staff L stated that they had trouble with faxing a while back. Staff L stated that it was routine orders that the facility had trouble with getting. Staff L stated she did not know who would tell Resident #21 they couldn't get the Percocet. Staff L stated they could always get Percocet. When told that Resident #21 said he was in pain during the time he did not receive the Percocet, Staff L nodded understanding and stated that she was somewhat related to Resident #4, and he will always tell you he has pain. Staff L stated that Staff E, Staff H, and Staff B, all know what to do (how to retrieve medications). Staff L stated that no one ever told her that the facility was out of narcotics for residents, until the facility caught it. Staff L stated that Resident #19 had been on narcotics about 7 months. Staff L stated that Resident #19 is in pain now and stated that Resident #19 was addicted. Staff L said that the meds are available. She stated that staff could also call the ADON, the DON, or Staff L and they would come in and get the meds for the staff. Staff L stated that pretty much every day that she works she takes meds out of the facility's medication system. On 6/28/23 at 9:02 a.m., Staff I called and wanted to give an update on Resident #19. She stated she wanted to give an update on Resident #19's pain. Staff I stated that Resident #19 was rating her pain at a 9 out of 10 and described it as sharp and throbbing. Staff I stated that Resident #19's roommate had piped up and said that Resident #19's moaning and groaning through out the night. Staff I stated she felt Resident #19's pain

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident, staff and family interviews, record review, and policy review, the facility failed to provide safe mechanical lift transfers for 5 of 7 residents reviewed (Residents #4, #7, #14, #16, and #18). The facility failed to transfer residents safely by not following the Hoyer lift recommendations and locking the lift while raising the resident, not having a clear process in place to ensure staff were using the appropriate sling for transfers, and allowing a non-certified staff to assist in the Hoyer transfer. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of January 9, 2023 on April 25, 2023 at 1:44 P.M. The Facility Staff removed the Immediate Jeopardy on April 26, 2023 through the following actions: a. Education of nursing staff on proper use of Hoyer lift and ensuring the brakes are not locked when raising the resident. b. Removing the Invacare Hoyer lift from service until compatible slings can be obtained. c. A new process was implemented to put the size of sling the resident was to use on the Kardex and placed copies at each nurse's station. d. Nursing staff return demonstrations of a Hoyer lift transfer completed by the Director of Nursing (DON) and Nurse Manager. e. Education of nursing staff that all mechanical lift transfers are to be completed with two certified nursing staff. The scope lowered from a K to an E at the time of the survey after ensuring the facility implemented education and made appropriate changes to their processes and procedures. The facility identified a census of 69 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS indicated Resident #4 required extensive assistance of one person for bed mobility, total assistance of two persons for transferring, and total assistance of one person for toilet use. Resident #4 was always incontinent of bowel and bladder and used oxygen therapy. The MDS included diagnoses of diabetes mellitus, anemia, heart failure, multiple sclerosis, non-Alzheimer's dementia, depression, schizophrenia, respiratory failure, and osteomyelitis of the vertebrae. The Care Plan initiated 5/13/16 and a revision date of 2/16/23, had a fall risk focus area, with a goal for the resident to not sustain any preventable serious injury if a fall should occur. Interventions directed staff to be sure the call light was within reach, half side rail in place for ease in bed mobility and safety, encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility, ensure that resident was wearing appropriate footwear when ambulating or in the wheelchair, follow facility fall protocols, and provide the resident a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light. Provide resident with activities that minimize the potential for falls while providing diversion and distraction and have physical therapy (PT) evaluate and treat as ordered and as needed. The Care Plan initiated 3/13/16 also had an activities of daily living (ADL) self-care performance deficit focus area related to activity intolerance, muscle weakness, obesity, and fatigue with a goal that the resident would maintain their current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. Interventions directed staff to encourage the resident to utilize half side rails for increased bed mobility, encourage resident to be up in the wheelchair for meals, assistance of one staff person for bed mobility and dressing and the resident required mechanical aid (Hoyer) and assistance of two staff for transfers. A fall Incident Report dated 2/12/23 at 8:34 PM documented the resident was found lying on the floor with her feet facing the bed and a pillow under her head. Blood noted to be coming from the back of the residents head. Per staff the resident was being transferred from the wheelchair to bed by full mechanical lift (Hoyer) and assistance of two staff when she fell sideways out of the lift after the Hoyer sling caught on the wheelchair arm. The Hoyer sling was still on the lift and the bottom straps observed to not be crossed. The resident was assessed and a laceration viewed to the back of the scalp after flushing the area. The ambulance was called to transport to the emergency room for further assessment. Vital signs were stable at (T),Temperature 97.4, (HR) Heart Rate 96, (R) Respirations per minute 20, (BP) Blood Pressure 127/54, and (PO2) pulse oximeter of 94% on room air. Neurological assessment intact and pupils were equal and reactive to light. Resident was oriented to person, place, and situation. Predisposing environmental factors included clutter, poor lighting, food on the floor, and crowding. Predisposing physiological factors included impaired memory. The Physician was notified of the fall at 8:57 PM. A progress note dated 2/12/23 at 8:56 PM, documented the resident was found lying on her back with her feet facing the bed on the floor with a pillow under her head. Blood noted to be coming from the back of the residents head. Per the Certified Nursing Assistant (CNA) the resident was being transferred from the wheelchair to bed by full mechanical lift (Hoyer) and assistance of two staff and fell sideways out of the lift after the Hoyer sling caught on wheelchair arm. The Hoyer sling was still on the lift and the bottom straps observed to not be crossed. Vital signs were stable and neurological assessment intact. Laceration observed to back of the head. The Emergency Medical Technician's (EMT's) were notified of need for transfer of the resident due to a head injury. A progress note dated 2/13/23 at 1:28 AM, documented the resident returned to the facility at 1:10 AM via ambulance from the emergency room. Documents received stated the resident was treated for injuries sustained from a fall earlier. Diagnosis of laceration of the scalp. The resident received 5 staples to the laceration on the back of her head. The computerized tomography (CT) scans of the cervical spine and head without contrast were both negative. Hospice was notified of residents return to the facility and will come to the facility to assess and readmit to hospice. Resident resting in bed with no complaints of pain, call light in reach and vital signs stable. A physician progress note dated 2/13/23 at 11:58 PM, documented the resident was seen to follow up with an injury to resident's posterior head and post hospital visit. Resident returned to the facility with staples in her posterior head laceration. Surrounding skin was red with no drainage. The resident complained of pain rating at 5 out of 10 and her pain was managed by Tylenol. Resident was awake and alert. Lungs were clear to auscultation, respirations were even and unlabored. Pulse oximeter 97%. Posterior head laceration noted to have some swelling, erythema, and staples. Resident was alert, awake, and oriented to self. Plan was to monitor laceration to posterior head for bleeding, use Tylenol for pain, monitor for signs and symptoms of infection, and notify the provider of metal status changes. In an observation on 4/13/23 at 1:50 PM, Staff G, Certified Nursing Assistant (CNA) and Staff H, CNA transferred Resident #4 from her wheelchair into her bed. Staff G, CNA removed resident's oxygen and the liberator (portable oxygen tank) was turned off. They hooked the sling up to the locked Hoyer using the green loops on the top and the purple loops on the bottom. The resident was instructed to cross her arms and hug herself and she complied. Staff H, CNA used the remote to raise the resident out of the chair. Staff H, CNA unlocked the Hoyer and steered the Hoyer so the resident was positioned in the center of the bed and lowered her down. The sling was removed from the Hoyer. Oxygen was applied once laid down in bed. In an observation on 4/18/23 at 9:40 AM, Staff I, CNA and Staff J, CNA completed a Hoyer transfer for Resident #4 from her wheelchair to bed. Oxygen was removed prior to the transfer. Staff J, CNA placed the Hoyer from the side of the chair with legs apart and it was locked. The sling was a bariatric sling and did not have straps that crisscross under the legs. The staff reported this was the same sling that is always used for this resident. The staff hooked the sling up to the Hoyer using the purple loops on the bottom and the green loops on the top. She was raised up out of the chair, the Hoyer was unlocked and the staff guided to the center of the bed and gently lowered onto the center of the bed. She was rolled side to side and the sling was removed from under her. Staff reapplied resident oxygen and covered her up. The call light was given to resident. In an interview on 4/12/23 at 12:21 PM with Resident #4's Power of Attorney (POA), he stated that the facility was not always the best at updating him on changes in Resident'#4's condition. He stated he recalled an incident in February when the resident fell from a Hoyer and was sent to the hospital and the facility never notified him. He stated he was notified by the hospital when she was admitted for the night but not by the facility. He stated he had a long conversation with the Administrator about this and it has been better since. In an interview on 4/18/23 at 12:22 PM, the Assistant Director of Nursing (ADON) stated it is the expectation that all Hoyer and EZ Stand transfers be completed with two staff without exception. In an interview on 4/18/23 at 1:05 PM, the Administrator acknowledged Staff L, CNA was involved in the fall from the Hoyer with Resident #4. Staff L, CNA terminated her position on the night of the fall (2/12/23). The administrator reported per punch detail, Staff L, CNA punched out at 10:19 PM and wrote a note stating that was her last day. He stated she was very upset over the fall and she was not transferring Resident #4 with the Hoyer by herself, she had another staff person with her (Staff M, CNA). The Administrator did report that she had been involved in a fall from a Hoyer a few weeks prior in which she was transferring using the Hoyer by herself. He stated they had done a lot of education with Staff L, CNA on this and she was not doing Hoyer transfers by herself any longer. On 4/18/23, the Administrator provided a written statement from Staff M, CNA stating that he worked in the facility on 2/12/23 and he was walking past a room with a resident slid down in her chair on the opposite hall he was working. He reported it to Staff L, CNA and they both entered the resident's room and helped guide Resident #4 to the floor in a lying position. Staff L, CNA then left to get a Hoyer and brought it into the room and they adjusted the sling behind the residents back as the resident was on the floor. They hooked the resident up to the Hoyer lift. As Staff L, CNA was raising the Hoyer, the resident shifted herself to the right. Staff M, CNA told Staff L, CNA to stop but the resident shifted herself so fast Staff L, CNA did not have time to react causing the resident to fall out of the sling onto the floor hitting her head on the back right of the Hoyer lift. Staff L, CNA immediately went and got the nurse and the nurse called 911 because the fall caused injury to the resident's head. The ambulance arrived and took the resident to the hospital. In a phone interview on 4/19/23 at 9:23 AM, Staff O, Registered Nurse (RN) stated Staff L, CNA came and got her to report resident #4 fell and was on the floor and had a head laceration. Staff O, RN was agency and she did not know the resident so was unsure of her baseline. Staff reported to her they were Hoyer transferring the resident from the chair and she fell out the right side of the sling. The resident was on the floor when she entered the room and a pillow was under her head. Resident #4 was covered with a blanket as she reported feeling cold. Staff O, RN reported she completed an assessment, vital signs were taken and a neurological assessment was completed and were intact. Staff O, RN left the room to get the resident's chart and items for the laceration to the back of her head. Upon return she completed another assessment and vital signs, pulse oximeter, and neurological assessment were done. Resident remained on the floor in the same position until the ambulance arrived as she didn't want to move her. Staff O, RN stated neither staff involved mention to her at all that resident had been lowered to the floor and that they were completing a Hoyer transfer off the floor. They stated it was from the wheelchair and the Hoyer sling had caught on the arm of the wheelchair. She questioned if the sling was to be crisscrossed under the resident's leg and she was informed the resident didn't use that type of sling and that the sling was correctly put under the resident and she was correctly hooked up to the lift. In a phone interview on 4/19/23 at 9:55 AM, Staff L, CNA reported she did work on 2/12/23 and was involved with the fall from the Hoyer for Resident #4. She reported she was working with another CNA who was agency and a male (Staff M, CNA). At around 7:40 PM, he notified her that the resident was attempting to get out of her wheelchair or was sliding out of the wheelchair. She entered the room to assist him. She noted the resident was sliding out of the chair and the staff were not able to lift her back up into the chair. They made the decision to lower her to the floor. She was laid on the floor on her back. She then went to find a Hoyer to lift the resident back into her chair but it took her about 5 minutes to locate and get the Hoyer back to the room. She was unsure if a nurse was notified of the resident being on the floor. She stated she did not notify the nurse. They used the sling that had been under her in the wheelchair and tucked it under her so they could hook her up to the Hoyer. Hooked her up to the machine using the black loops on the top and the green loops on the bottom. She was positive the sling was correctly hooked to the lift and they left the sling attached to the machine after the incident. She reported she was running the controls and the other male CNA was located behind the wheelchair with the residents feet pointed towards him. She stated the resident's head was pointed toward her and no one was touching her as they couldn't reach her. The wheelchair was in the way for him and she couldn't reach around Hoyer to touch her while running the control. She stated she got the resident about half way up and the male CNA stated Her arm! She stated she immediately stopped the machine but the resident then slid out the right side of the sling. She reported the residents head, arm, shoulder, and chest area came out the side of the sling and she hit her head on the base of the lift. Staff L, CNA then lowered the lift back down and went and found the nurse on the 100 hall. The nurse came to the resident's room and assessed her. Staff L, CNA reported she did raise the residents head enough to put a pillow under it for comfort. She reported she left the room to go answer a light and assist another resident. She stated they used the sling that had been under her in the wheelchair and she was not aware of a chart for sizing of Hoyer slings. She stated she was not aware of any other residents falling out of a Hoyer and never anyone under her care. In an interview on 4/19/23 at 11:51 AM, the DON stated that Staff M, CNA (agency) was involved in the fall from the Hoyer for Resident #4, and returned to the facility the next morning and talked to them about the incident. He took the DON and Staff N, OTA/Therapy Coordinator to the room and showed them with the Hoyer what had happened. Per an email sent on 4/25/23 at 4:40 PM, Staff P, Regional Director of Operations reported he had interviewed Staff M, CNA and he had reported he had worked one shift at the facility on 2/13/23 and remembered the incident with Resident #4. He reported the resident was sliding from her chair and so she was lowered by staff to the floor. Staff got the mechanical lift to get her up off of the floor. While the resident was in the lift on the floor she began moving around and hit her head on the tan cover at the base of the lift that covers the leg separation bar. There was no malicious intent by the other staff he was with, the resident just hit her own head. In a phone interview 4/26/23 at 9:22 AM, Staff M, CNA reported that he did speak with Staff P, Regional Director of Operations yesterday while he was at work. The email statement that was sent by Staff P, Regional Director of Operations from their interview yesterday and was reviewed with him. Staff M, CNA's original write up regarding the incident was then reviewed with him. He stated he remembers the night as it was Super Bowl Sunday. He stated he felt the place was very short staffed. He reported he was not actually working in the hall that the resident was in but noted her to be sliding out of her chair when he walked by. He immediately got a hold of Staff L, CNA and they went into the room to assist her. The resident was slid all the way down in the chair. So they lowered her to the floor and placed her sling under her. At that point Staff L, CNA went to get a Hoyer to lift her up. He stated once she was back with the lift they hooked the resident up to the Hoyer and Staff L, CNA was running the controls and he was located at the residents feet. He stated he felt that Staff L, CNA may not have been paying the closest attention to what she was doing as she was arguing with the roommate at the same time she was running the lift. He stated he did not feel that she had any malicious intentions but maybe wasn't paying the closest attention to what she was doing. He said Staff L, CNA began to lift the resident using the controller. He said that the resident was maybe a foot or so off the ground and he thought maybe she got scared and jolted herself to the right a bit and her right arm came out and then she jolted to the right one more time before Staff L, CNA could stop the lift and her right arm, then her head and upper body came out of the right side of the sling and fell to the floor and resident struck her head on the base of the Hoyer. He stated her bottom half remained in the sling but her top half came out the side. He stated Staff L, CNA immediately lowered the Hoyer back to the floor. Staff L, CNA then went and got the nurse and he stayed with the resident until the nurse arrived. He could see the back of her head was bleeding. He also reported he asked both Staff L, CNA and the nurse what kind of action needed to be taken with an incident like this and they both said nothing different than any other fall. 2. Resident #7's MDS assessment dated [DATE] identified a BIMS score of 14, indicating intact cognition. The MDS indicated Resident #7 required extensive assistance of one person for bed mobility, total dependence of two people for transfers, and total dependence of one person for toilet use. Resident #7 was wheelchair dependent and always incontinent of bowel and bladder. The MDS included diagnoses of diabetes mellitus, thyroid disorder, Alzheimer's dementia, cerebral palsy, non-Alzheimer's dementia, seizure disorder, depression, schizophrenia and suicidal ideation. The Care Plan initiated on 7/27/18 with a revision date of 4/7/23, revealed a fall risk focus area related to cognition and being unaware of safety needs and cerebral palsy and a goal that the resident will have no unaddressed falls. Interventions directed staff to anticipate and meet resident needs, encourage resident to wear gripper socks, follow therapy recommendations for transfers and mobility - assist of two people for Hoyer lift transfers, place call light in reach, and skid strips next to bed. The Care Plan initiated on 7/27/18 with a revision date of 4/7/23, also had an ADL self-care performance deficit focus area related to cerebral palsy with a goal the resident maintain their current level of function. Interventions directed staff to encourage the resident to utilize half side rails for increased bed mobility, one person assistance with bed mobility and assistance of two staff with transfers - Hoyer lift only. In an observation on 4/12/23 at 2:00 PM, Staff Q, CNA and Staff R, CNA completed a Hoyer transfer for Resident #7. The resident was sitting in her wheelchair and had the Hoyer sling in place under her. They brought the Hoyer in and hooked her up to it using the blue loops on the top and the purple loops on the bottom. The Hoyer legs were spread and the Hoyer machine was locked. Staff Q, CNA then used the remote to raise the resident into the air and then the machine was unlocked and steered around with Staff R, CNA assisting to guide the resident until she was centered over the bed. She was encouraged to give herself a hug during the transfer. Once she was centered over the bed she was lowered onto the bed and unhooked from the machine. The resident tolerated the process well. The sling was removed from under her by rolling her side to side. 3. Resident #14's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS indicated Resident #14 required total dependence of one person for bed mobility and toilet use and total dependence of two people for transfers. Resident was always incontinent of bowel and bladder and was wheelchair dependent. The MDS included diagnoses of atrial fibrillation, diabetes mellitus, thyroid disorder, arthritis, anxiety disorder, depression, respiratory failure, and morbid obesity. The Care Plan initiated on 2/28/22 with a revision date of 4/7/23, revealed an ADL self-care performance deficit activity intolerance focus area related to impaired balance and limited mobility and a goal to maintain current level of function with ADL. Interventions directed staff to assist with bed mobility using two people, encourage to discuss feelings about self-care deficit, praise all efforts at self-care, and Hoyer transfers with assistance of two people. In an interview on 4/19/23 at 2:35 PM, Resident #14 stated she had been a Hoyer lift transfer since admitting to the facility. Staff used the same style and size sling for all transfers. They normally use two staff for her transfers but Staff L, CNA had transferred her alone a couple of times but nothing recent. Felt secure most of the time with her transfers except when the transfer was being completed with one staff person. 4. Resident #16's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS indicated Resident #16 required extensive assistance of one person for bed mobility, total dependence of two people for transfers, and total dependence of one person for toilet use. She was wheelchair dependent, used oxygen, and always incontinent of bowel and bladder. The MDS included diagnoses of heart failure, renal insufficiency, cerebrovascular accident, hemiplegia, anxiety disorder, depression, bipolar disorder, schizophrenia, and chronic obstructive pulmonary disease. The Care Plan initiated on 2/10/22 with a revision date of 4/20/22, revealed an ADL self-performance deficit with a goal to maintain current level of function with ADL's. Interventions directed staff to assist resident to turn and reposition in bed, encourage use of enabling bars/side rails to maximize independence with turning and repositioning in bed, allow sufficient time for dressing and undressing, and requires the assistance of two people for Hoyer transfers. A fall Incident Report dated 1/9/23 at 3:04 PM, documented the nurse was alerted to Resident #16's room by a loud noise and yelling coming from the resident's room. The nurse arrived and observed the resident resting with her head and torso supported in the lift sling and her legs in the wheelchair under the armrest. The Hoyer sling was attached to the lift and the Hoyer lift was tipped sideways with the lift portion between the resident's legs and on her groin. The resident was assisted to the floor with the sling and the assistance of six staff. Resident was assess for injury and it was noted the resident had bruising and raised and abraded areas on her inner thigh. Resident had functional range of motion per her baseline but complained of left hip pain. While being assessed, the resident's eyes rolled back and her body began to shake. Her eyes were fixed open and she was not responsive to verbal or physical stimuli. The nurse directed staff to call 911 and the resident was having suspected seizure activity. Paramedics arrived and transported the resident to the hospital for evaluation. Immediate action: Resident was assisted to the floor, assessed for injury and sent to hospital via ambulance. Resident noted to have an abrasion to front of left thigh. Resident oriented to person. Predisposing environmental factors included clutter, furniture, crowding, and equipment malfunction. Physician was notified of incident. A progress note date 1/9/23 at 3:41 PM, documented the nurse was alerted to Resident #16's room by a loud noise and yelling coming from the room. The nurse arrived and observed the resident resting with her head and torso supported in the lift sling and her legs in the wheelchair under the armrest. The Hoyer sling was attached to the lift and the Hoyer lift was tipped sideways with the lift portion between the resident's legs and on her groin. Resident was assisted to the floor with the lift sling and the assistance of six staff. Resident was assessed for injury and it was noted that she had bruising and pinched areas on her inner thigh. Resident had functional range of motion per her baseline but complained of pain. While being assessed, the resident's eyes rolled back and her body began to shake. Her eyes were fixed open and she was not responsive to verbal or physical stimuli. The nurse directed staff to call 911 as the resident was having suspected seizure activity. Paramedics arrived and transported the resident to the emergency room for evaluation. A progress note dated 1/9/23 at 11:24 PM, documented Resident #16 returned to the facility at approximately 10:00 PM via ambulance. Resident was found to have a clear CT scan and x-rays showed no broken bones or fractures. The resident reported her tailbone and bottom were sore. Resident was given her bedtime medications which included pain medication. Vital signs were stable upon arrival back to the facility (T - 97.8, HR - 74, R - 20, BP - 122/86, and oxygen level was 96% on room air). Resident voiced no other concerns at that time. A physician progress note dated 1/11/23 at 6:29 PM, documented resident had a fall on 1/9/23 from a malfunction of the Hoyer and landed on her back. She was transported to the emergency room. A head CT, back and hip x-ray was done. Hip x-ray was negative for fracture but it did show a contusion of the hip. The head CT was unremarkable. Today she complained of occipital headache, onset was after the fall on 1/9/23, describes it as intermittent throbbing and rates the pain at a 5. She was seen for post emergency room visit. No acute distress and oriented x 4. Plan: Celebrex 100 milligrams (mg) by mouth twice daily as needed for headache as previously ordered, utilize Tylenol as previously ordered and notify the provider with any changes. In an interview on 4/19/23 at 11:51 AM, the DON acknowledged the fall from a Hoyer involving Resident #16 had occurred when Staff L, CNA was operating the Hoyer without a second person at the time. She stated she was not aware of other staff operating mechanical lifts independently. In an interview on 4/25/23 at 8:10 AM, Staff N, OTA/Therapy Coordinator reported he held several in-services throughout the week following the incident with the Hoyer tipping and a staff person using the mechanical lift independently. He stated the in-service consisted of them watching a YouTube video and then they worked in groups of two and practiced Hoyer transfers of a person from the bed to the wheelchair and then back to bed. He stated he observed and let them do the transfers unless he saw a concern, then he would educate and correct at the time. He stated Staff L, CNA did attend the in-service and completed the transfer perfectly. He stated that he feels she knew exactly how to complete the transfers but it was a behavior thing that she chose to take short cuts. 5. Resident #18's MDS assessment dated [DATE] identified a BIMS score of 3, indicating severely impaired cognition. The MDS indicated Resident #18 required total dependence of one person for bed mobility and toilet use and total dependence of two people for transfers. Resident was wheelchair dependent and had a feeding tube. Resident was always incontinent of bowel and bladder. The MDS included diagnoses of anemia, cerebrovascular accident, altered mental status, and dysphagia. The Care Plan initiated on 9/9/13 with a revision date of 12/9/21, revealed a fall risk focus area related to dementia, inability to recognize safety issues, poor gait/balance, and need for assistance with transfers with a goal to not sustain any preventable serious injury. Interventions directed staff to ensure proper footwear with transfers or in wheelchair, anticipate and meet resident needs, ensure call light is available and encourage to use for assistance, encourage participation in activities that promote exercise, physical activity for strengthening and improve mobility, non-skid strips in place next to bed, and half side rail on bed to help roll herself from side to side. The Care Plan initiated on 9/9/13 with a revision date of 12/9/21, revealed an ADL self-care performance deficit focus area related to a history of transient ischemic attack, muscle weakness, contractures/hemiparesis, and cognitive deficits related to dementia with a goal to not have any preventable decline in the resident's current level of function in ADL's. Interventions directed staff to utilize one person to check and change resident, anti-slip one way slide in wheelchair at all times due to repeated falls, use her wheelchair for locomotion, use two people for all Hoyer transfers, and encourage the resident to participate to the fullest extent possible with each interaction. In an observation on 4/20/23 3:50 PM, Staff S, CNA and Staff T, Hospitality Aide performed a Hoyer transfer for Resident #18. The resident was sitting in her wheelchair with the Hoyer sling in place. The resident's daughter present for transfer. Staff T, Hospitality Aide was running the Hoyer. Staff S, CNA was placing the sling on the boom of the Hoyer. Top loops were on the green and the bottom loops were on purple. The Hoyer was not locked. Staff T, Hospitality Aide raised the boom of the lift and the resident's daughter assisted as the resident's left foot had foot drop and started to get stuck under the lift. The daughter assist in guiding the resident's legs. The wheelchair was pushed back towards the other side of the room and the resident was lowered to the bed. Staff T, Hospitality Aide has been employed at the facility since 11/23/22 and worked as a dietary aide and moved into the hospitality aide position on 2/26/23. In an interview on 4/20/23 at 4:23 PM, The Administrator stated Staff T, Hospitality Aide would be sent to CNA class. She hadn't started things yet so they hadn't enrolled her yet. The facility provide Hospitality Aide policy identified that no hands on care is allowed in this position. In an interview on 4/19/23 at 11:51 AM, the DON stated she wasn't sure but thought staff measured the resident to decide what kind and size of sling a resident should use with the Hoyer lift. She stated there is normally one sling in the room unless it gets dirty and then it is replaced with the same type and size sling that was in there previously. In an interview on 4/19/23 at 1:00 PM, the Administrator reported the Maintenance Supervisor performed monthly preventative maintenance on the Hoyer lifts in the facility to ensure they are functioning properly and that the wheels are

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to administer pain medication as ordered by a physician leaving 4 out of 4 residents reviewed without adequate pain control (Resident #4, #19, #20, and #21). Four residents reviewed were not administered their Controlled II pain medication as ordered for prolonged periods of time. The nurses and CMAs stated the medication was not available to give, therefore they did not give it. Resident #21 went 8 days without receiving his three times a day routine order of Percocet (an oral opioid pain medication). The other 3 residents did not receive their Fentanyl patches (potent opioid pain patch) as ordered every 3 days. In a 22 day period, the 3 residents reviewed did not have their patch applied every 3 days as ordered resulting in Resident #4 going 11 days, Resident #19 going 12 days, and Resident #20 going 7 days without Fentanyl during the 22 day review period. This situation resulted in Immediate Jeopardy to residents health and safety for the facility. The facility was notified of the Immediate Jeopardy on 6/29/23. The facility abated the Immediate Jeopardy situation on 6/29/23 lowering the scope from a K to an E after staff education was complete and the facility ensured all scheduled/ordered pain medications were available for residents. The facility reported a census of 62 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented that Resident #4 diagnoses included Multiple Sclerosis (MS), osteomyelitis of the vertebra (infection of the bone), and non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented a score of 8 out of 15, which indicated moderate cognitive impairment. Resident #4 required total dependence of 2 for transfers, and personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #4 received pain medication both routine and PRN (as needed) in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a moderate level and documented that she had pain occasionally. A Medication Administration Record (MAR) for the month of June 2023, directed staff to administer a Fentanyl Patch 12 mcg (microgram)/hr(hour) transdermal (absorbed through the skin) application at bedtime every 3 days for chronic pain to Resident #4. The start date was 2/20/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/2/23, it was applied the following day on 6/3/23. The resident had a patch applied on 5/5/23 and 5/8/23, then this resident did not have a patch applied again until 5/21/23. On 6/21/23 at 4:00 p.m., When asked if she had pain, this resident stated she did. When asked to rate the pain, she stated it was at a 5 on a scale of 0-10 and the pain was on her bottom. Resident lying in bed at the time. On 6/22/23 at 11:20 a.m., it was noted that Resident #4 had a patch on her right chest dated 6/21/23. Resident was asleep. This resident woke up but required some patting on the arm by staff. On all observations of Resident #4 during this survey Resident #4 had been awake, eyes opened, and responsive with exception of this observation. 2. An MDS dated [DATE], documented that Resident #19's diagnoses included MS and chronic pain. The MDS revealed a BIMS score of 15 out of 15, which indicated intact cognition. This resident required total dependence of 2 staff for transfers. She required total dependence of 1 staff for personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #19 received pain medication both routine and PRN in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a 5 out of 10 (0 is no pain and 10 is the worse pain you can imagine) and documented that she had pain frequently. A Medication Administration Record for the month of June 2023, directed staff to administer a Fentanyl Patch 25 mcg/hr transdermal application at bedtime every 72 hours (3 days) for chronic pain to Resident #19. The start date was 3/4/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/2/23, it was applied on 6/5/23. It revealed that she was to get a patch placed on 6/8/23 and did not have a patch applied until 6/14/23. She was scheduled to have a patch applied on 6/17/23 and did not have it applied until 6/20/23. It was documented that it was not available on 6/23/23. The MAR also directed staff that Oxycodone (opioid) 5 mg tablet was to be administered orally 4 times a day to Resident #19. The order date was 6/8/23. From 6/8/23 at 5 p.m. when the first dose was to be given to 6/12/23 at 6:00 a.m. the doses were not given. The 6:00 a.m. dose on 6/13/23 and all 4 doses on 6/14/23 and 6/15/23 were not available. The 8:00 p.m. dose on 6/23/23 was also not available. On 6/21/23 at 4:54 p.m., Resident #19 stated she was in pain and rated it at a 9 out of 10. She stated that she needed to lie down. She stated she hurt everywhere. Resident appeared to be in pain. She was pale and did not move during the conversation. On 6/22/23 at 10:30, Resident #19 was observed to have a patch last placed on 6/20/23 on her left chest. Resident #19 rated her pain at a 9 and stated she hurt all over. She added that the medication person is going to give her pain meds now and they will help. She said she went without the patch a few days ago and she became very sick. She stated she was throwing up and everything. She stated once they were able to get a patch the sickness went away. 3. An MDS dated [DATE], documented that Resident #20's diagnoses included anxiety and chronic pain syndrome. The MDS revealed a BIMS score of 15 out of 15, which indicated intact cognition. This resident required extensive assist of 1 for transfers and personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #20 received pain medication both routine and PRN in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a 4 out of 10 and documented that she had pain frequently. A Medication Administration Record for the month of June 2023, directed staff to administer a Fentanyl Patch 25 mcg/hr transdermal application at bedtime every 72 hours for chronic pain syndrome to Resident #20. The start date was 5/1/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/3/23. The last patch prior to this was applied on 5/30/23 and 3 days from that was 6/2/23. This resident went 4 days without the absorption of the patch from 6/2/23 when it should have been applied to 6/6/23. She had the patch applied again on 6/9/23, it wasn't applied on 6/12/23 then it was applied again on 6/15/23. On 6/21/23 at 4:55 p.m., Resident #20 stated she was in pain and rated her pain at an 8 out of 10. She stated it hurt in her tailbone and back. The resident appeared to be in pain. The DON (Director of Nursing) was notified of where Resident #19 and Resident #20 were rating their pain. Both residents had been outside to smoke and were sitting beside their respective beds in their wheelchairs in their room. These two residents are roommates. Both residents had facial grimacing. Resident #19 had guarded movements and sat very still. Observation on 6/22/23 at 10:35 a.m., noted Resident #20 had a patch on her right chest. It was not labeled. Resident #20 stated her tailbone pain is at an 8 which is constant, and her stomach pain was at a 5. She stated they were supposed to give her a suppository 2 nights ago and they never did. She stated she was constipated. When asked if they have missed giving her some pain medications, she said yes. She stated the reason she didn't receive her medication was they didn't have the medication to give. When asked if she was given anything to help with her pain she said no, they told me they didn't have anything else to give. 4. A MDS dated [DATE], documented that Resident #21's diagnoses included malignant neoplasm of the larynx (cancer of the voice box) and chronic pain. The BIMS score for Resident #21 was 12 out of 15 which indicated moderate cognitive impairment. This resident required extensive assist of 2 for transfers and extensive assist of 1 for personal hygiene. The Pain Management section revealed that Resident #21 received routine pain medication in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated his pain at a 6 out of 10 and documented that he had pain frequently. A MAR for the month of June, directed staff to administer Percocet 5-325mg three times a day at 8:00 a.m., 2:00 p.m., and at 8:00 p.m. to Resident #21. The MAR revealed that Resident did not receive his scheduled Percocet from 6/13/23 at 2:00 p.m. through 6/20/23. The MAR documented that he received a dose at 8:00 a.m. on 6/21/23. On 6/27/23 at 10:31 p.m. observed Resident #21 lying in bed. He nodded his head in affirmation that he did know they didn't have the pain meds to give him. When asked if he was in pain during that time, his eyes widened and he nodded a definite yes. When asked if he remembers what level his pain was at during that time and if he could rate it he shook his head no. He affirmed by nodding that he had went about a week without the pain medication and this happened a couple of weeks back. On 6/21/23 at 10:26 a.m., Staff C, Certified Nurse Aide/Certified Medication Aide (CNA/CMA), when asked what the circled initials meant on the MAR/TAR (/Treatment Administration Record) she stated it meant that they didn't have the medication. She stated it happened more than she would like to admit. She said the DON said to just pass the medications that you can. When asked why some residents had Fentanyl patches and another did not, she stated she did not know. She said maybe it had something to do with pharmacy. She said the facility does not want to report these things. Staff C stated she is told not to get so upset about things. On 6/21/23 at 2:45 p.m., the DON stated she was looking into the Fentanyl patches not being given. When asked what she knew about it, she just shook her head no. On 6/21/23 at 3:00 p.m., Staff C, when asked again about the numerous Fentanyl patches that weren't applied, she stated that the night shift which is mainly agency nurses put the patches on. She acknowledged all of the holes with the Fentanyl patches. She stated it meant they did not get the patches put on. She did not think there was drug diversion. She thought it was more laziness, destroyed. On 6/21/23 at 4:07 p.m., Staff D, Register Nurse (RN) traveler with the facility corporation and the Nurse Consultant stated they were aware of this too and looking into it, when they were told there was a concern with the Fentanyl patches and narcotics not being given. On 6/22/23 at 10:30 a.m., Staff A, CMA stated that medications are getting missed and sometimes it's because staff don't understand the different names of Vitamins i.e. ascorbic acid vs Vitamin C and sometimes they just don't look for the medications. Staff A stated that Resident #4 was without Percocet. Staff A stated she had sent the information that he was out of his Percocet and needed more several times but she was not sure if they had gotten it. She stated that Staff E, RN had told her they were getting a script (prescription for a physician) for the Percocet. Staff A said she had sent the tag in about 5 days before he was out of them. Staff A said it was ample time, more than 3 days to get it ordered. Staff A stated they (nurses) had tried to get it out of the e-kit (emergency medication kit) but he needed a new script. She said that he went 8 days without the Percocet. Staff A did not think there was any drug diversion just laziness. She stated that Resident #4 was going through withdrawal symptoms. Stated he was really tired. Staff B, RN, was part of the above conversation. He stated that there normally are medications up front. Staff B stated they can go up and get them. Staff B stated he did not think there was any drug diversion, just sloppy nursing. On 6/22/23 at 4:06 p.m., Staff F, Nurse Practitioner (NP), stated the facility let her know that the 3 ladies did not receive their patches. She stated she took a look at them and discontinued 2 of the 3 ladies patches as she did not feel they needed it. She said the 3rd lady was a different story. She stated she did know about another resident not getting his Percocet. She found out through faxes. She will look for the faxes of the facility notifying her of the pain medication not being given. Staff F stated it was okay to call her back with any further questions. Stated it was recently brought up to her about the Fentanyl patches not being administered, but she had been notified of this before and was notified by fax. No faxes were provided. On 6/22/23 at 2:30 p.m., Staff G, NP stated that no one had notified her of medications not being given. She had not heard about Fentanyl patches not being available. She had not heard about Resident #4 not getting his Percocet. She said there would be no reason for this. If not contacting her they could contact other providers to get a script or to get these medications ordered. She said in Resident #4's case she saw him after a fall and had abdominal x-ray/test done related to pain. She said at that time she reviewed his medications and did not feel he needed anything more for pain as he was on several medications that helped with pain. Staff G looked at Resident #4's MAR. She stated now that she knows he went without Percocet for that many days she will need to go back to Resident #4 and ask him about pain control. She said she came in to see 5 residents on this day and she was still at the facility because she finds things out when she talks with residents and feels she needs to take care of it. She stated a lot of the stuff she ends up doing are things the nurse should be doing but for some reason it is not getting done. She repeated that there is no reason the residents should not be receiving their medication. She stated a provider and pharmacy can be called. On 6/22/23 at 3:05 p.m., Staff E, RN stated that it was reported to her that Resident #4 did not have Percocet. She stated the CMA did not tell her until the last day that she worked. Staff E stated that sometimes she worked 2-3 days in a row. She stated that afternoon she called the pharmacy for it and the pharmacy said they were waiting on a script for it. Staff E stated that the pharmacy calls the care provider to get the script. She stated that the pharmacy was located out of state, so the pharmacy didn't always call the provider for the nurses. Staff E stated that on weekends it depends on who is on call, the provider might not write a script. Staff E didn't think she had called the on call provider the day she found out about needing a Percocet refill. Staff E stated she reported it on to the next shift but did not remember who. Staff E stated she did think it was important for the residents to have their meds. Staff E stated the facility was running bubble packs as well as cards with medications (meds) in them. Staff E stated that she was running meds all the time. Staff E said she did not want to put the facility under the bus or anything, but the nurses are continually getting meds out of this system because the meds are not filled. Staff E stated it was like all day long they were pulling meds from the ekit (emergency kit storage). Staff E stated it was very time consuming. Staff E stated the fax machine was down for a long time. She said she had been there for 6 months and the facility finally got a fax machine this week. She stated they were unable to fax the pharmacy because of it. Staff E stated they had to call the pharmacy or Staff F, LPN and another nurse had been emailing the pharmacy. Staff E stated that she always called the pharmacy and they would get upset when you have a huge list, the pharmacy wanted the list sent instead. She stated the pharmacy also sometimes did not send the meds. Staff E said that every day she pulled medications out of the ekit, even though the meds had been requested from the pharmacy. Staff E stated that the CMAs don't let the nurse know if there is a med missing, they will just circle it. Staff E said that she and another nurse have reported to the DON that the med aides (CMA's) aren't reporting that there are not meds in the carts. Staff E then went into the medication room. The system was hooked up to a computer. Staff E stated the nurses are able to type in the name of a resident and the medication needed and then you can get it out of the ekit. She stated that the nurses run meds for the residents and then deliver them. She said that it happened often that all of the meds are not there. Staff E said that often times with narcotics, the pharmacy will say a script was needed. Staff E stated that it could be difficult to get a script. Staff E said she honestly did not know if there was drug diversion at the facility, it's pretty scary. Staff E said that she had seen that people have signed things off and she had wondered how the CMAs have signed stuff off that the facility did not have. Staff E was unable to give any specific examples of this nor could she give a time frame. Staff E stated that Staff A and Staff C had told Staff E that night shift agency aides are not passing the meds. Staff C was really good about reporting to Staff E but Staff A didn't always report. Staff E said that Staff A would report to Staff B, but he was Staff A's son in law. Staff E stated she reported this to the DON and nothing really happened. Staff E stated that she did not want to be fired or anything but many things needed fixed. Staff E became tearful and said it's hard to work here because it's very busy and many things get missed. On 6/26/23 at 3:13 p.m., Staff I, RN Hospice stated she had brought up concerns regarding Resident #19 going through withdrawals. Staff I said the facility set her up on routine Oxycodone with the Fentanyl patch before related to Resident #19 requesting so much PRN (as needed) Oxycodone. Staff I said that with Resident #19 taking both of the meds she would still rate her pain at an 8 or 9. Staff I said that Resident #19 had a history of MS so it could be hard to tell with her because you don't know if she is masking pain. When asked who she goes through for medications, she stated they go through the facility doctor first. Staff I said that a lot of times they do things without communicating with her. Staff I stated she has to ask for an updated medication list for Resident #19. Staff I said she sees Resident #19 two times a week. When asked if she knew about Resident #19 not receiving her Fentanyl patch, Staff I stated that she would notice it would be dated for 5 days prior or not on her at all. Staff I said she had her hospice aide check the date on the patch and the hospice aide was to let Staff I know if the date was more than 3 days old or if there was no patch. Staff I stated that Resident #19 would ask Staff I if Staff I would go and see when she was due for her next dose of pain medication. Staff I stated that Resident #19 would ask more about the oxycodone and not the patch. Staff I said she had been Resident #19's case manager for almost 2 months now and that Resident #19 had went on hospice on 1/27/23 and there was a different hospice nurse case manager before Staff I. Staff I said that Resident #19 can make her own decisions and Resident #19 did have a son and a daughter that she wants us to update on her care. Staff I had a conversation with Resident #19 about missing Fentanyl patches. Staff I said that back in May she had went in and noticed that Resident #19 hadn't had one (Fentanyl patch) changed and Staff I brought it up to her and they were able to get a new one started. Staff I stated that since then Resident #19 had been able to let Staff I know if it was taken care of or not taken care of. Staff I stated that in June Resident #19 told Staff I that the Fentanyl patch wasn't being taken care. Staff I said that she spoke with the floor nurse and spoke with the ADON (Assistant Director of Nursing) and it seemed like every time Staff I would talk to somebody, they would tell Staff I they'd get the Fentanyl Patch shortly. Staff I stated she did not feel the issue got addressed. Staff I stated that the other hospice nurse spoke with the floor nurse on June 14th when the other hospice nurse noticed that the patch had not been changed and her roommate noticed the patch had not been changed. Staff I stated that she knew she was biased because them discontinuing the patch after the fact is doing her a disservice. On 6/26/23 at 4:20 p.m., Resident #19 stated that she was in pain and rated her pain at a 9 and ½. This resident was lying in bed. Stated she was feeling really bad and was going downhill fast. When asked what she meant by that she stated she just wasn't doing good. When asked about the Fentanyl patch, she said they took that off last week and told her that she didn't need it. When asked what she thought about that, she stated it really didn't help her much anyway. This resident had opened her eyes when the door was knocked on but did not open them very far. This resident did not move any extremities nor her head when she talked. When asked if staff check on her and ask her about her pain, she stated sometimes. When asked if they were checking twice a day, she stated no. When asked if she ever has no pain, she said no. When asked what the lowest her pain had been in the past few months, she stated a 6 or 7. The MAR for Resident #19 for the month of June 2023, directed staff to do a twice a day pain assessment with 0 as no pain, 1-3 as mild pain, 4-6 as moderate pain, and 7-10 as severe pain. The documentation of the pain revealed that from June 1st through June 26th this resident had pain rated four times at 7, two times at 8 and one time at a 6, the rest of the documentation revealed 0's or there were times when it wasn't filled out. On 6/26/23 at 4:30 p.m., Resident #4 was lying in bed smiling. Stated she really didn't have any pain. She was feeling pretty good. Resident #4 was wide awake and appeared happy. She asked about what time it was. The MAR for Resident #4 for the month of June 2023, directed staff to record pain on a 0-10 scale twice a day. The documentation of the pain revealed that from June 1st through the first part of June 26th this resident had 40 times the pain was not rated. On 6/27/23 at 9:15 a.m., Staff J, agency RN, stated he thought there was a Fentanyl patch on the 2nd floor downstairs for a day or so that was not put on. Staff J stated he did not put on but he did leave a note and passed it on. Staff J stated there was no way for him to get the patch. He stated he talked to day shift. He said that it was pretty complicated to talk to pharmacy on the weekend. He said he did assessments. When told about the patches that weren't placed and the time frame the residents went without a Fentanyl patch, he stated he did not know that they did not have patches for that long. Staff J stated he worked a lot on the 2nd floor (where all 4 residents resided). Staff J stated he would work a few days and then off but when he would come back he did not recall seeing any resident going a long time without a patch. Staff J stated that the CMAs do not apply Fentanyl. Staff J said that medications being not available happened quite often. Staff J stated that every time something happened when there wasn't a medication, he always left a note. Staff J stated that he would give a verbal report but he also would write the meds on the sheet and then hand it to the next shift. Staff J stated that the pharmacy says that he needs to fax when he did get a hold of the pharmacy. Staff J stated that the facility's fax was not working and on weekends the pharmacy was not available. Staff J stated that if you want to order more than one or two meds the pharmacy would say to fax the list of meds as the pharmacy preferred faxes. Staff J stated that he always made sure he put it on the sheet that they have so the day nurse would know what the situation was and then they could handle it during the day. When asked about the sheet, he stated he was not very sure where the sheet was kept. Staff J stated that they hand over a copy of it to the next nurse. Staff J stated that sometimes he would pass 8:00 p.m. meds but most of the time it's a CMA. Staff J stated he didn't know about Resident #21's Percocet. Staff J stated that he felt the residents received good care and he thought the communication with the pharmacy was the biggest concern. On 6/27/23 at 9:45 a.m., Staff E stated she did not know where the pharmacy book was in the back (2nd floor). She stated she wasn't sure what they did when the nurses and CMAs filled out the sheets with the meds that are needed. Staff E said she didn't see the book and she thought the sheets might just get thrown away. She pulled a couple of sheets out of the box with things that needed to be shredded. On 6/27/23 at 10:25 a.m., Staff E pulled 2 more pharmacy sheets out of the box when asked if there were any more sheets in the box. On 6/27/23 at 9:50 a.m., Staff H, Licensed Practical Nurse (LPN), stated the facility got a new machine and it copies and prints but it doesn't fax. Staff H stated she had developed a process with the pharmacy where you have an encryption code so the emails between Staff H and the pharmacy can go between us without HIPPA violations. Staff H stated that she had been doing this for 2 months. Staff H stated she receives sheets from the CMAs and on Mondays, Tuesdays, and Wednesdays Staff H forwards the sheets on to the pharmacy and then writes emailed to pharmacy and the date and time. Staff H stated she then puts the sheets into the pharmacy book. Staff H stated that she only worked on the 1st floor. Staff H state the process to get medication was the doctor writes out the order for her on a script, then she would take a picture and email to the pharmacy, after that she documented in the electronic health record to make it an active order. Staff H stated she would usually then call the pharmacy and let them know that she had put in an active order and she would pull a couple of doses of the medication so that they could cover the first couple of doses that needed to be given. Staff H stated that not all nurses have access to their medication system. She stated that sometimes they have agency nurses and the agency nurses cannot get into the facility's medication system. Discussed Resident #19's medication and Staff H stated that Resident #19 had been in pain since she has been here. Staff H stated that Resident #19 should not go without her pain medication. Staff H said that Resident #19 was so frail and pale and always looked like she was in pain. When told the pain level had been signed often as no pain for this resident, Staff H stated that was not right. Staff H stated what she thought staff were doing was seeing if Resident #19 was sleeping and marking it 0, they should be asking her. Staff H said that Resident #19 needed her pain medication. Staff H stated that hospice staff could call the pharmacy too and Staff H stated she did not know why agency nurses wouldn't just call the pharmacy. Staff H stated if they are writing down on the sheet that there was not a med available then it should be in the pharmacy book down there. They should be putting those sheets in to the pharmacy book and those papers should not be shredded. Staff H stated that usually on Mondays there are a lot of meds to order. Staff H stated that she just called the pharmacy and asked them how could she get the meds without a fax and they said she could use her own email but she would need to use their encryption. Staff H stated that's what she did. Staff H stated she did not want to put down the company but they had people running to another facility to fax orders because their facility couldn't get the meds. On 6/27/23 at 11:32 a.m., Staff K, CMA/CNA, stated that it did happen when meds were not available. Staff K stated she circled her initials on the MAR's when meds were not available. Staff K stated that she actually asks her nurse if the med is printable, meaning they can get it from the medication system, but if not to circle it and write a note on 24 hour report. When asked how often she thinks this happens, she stated daily. She stated it had gotten better because they had a new ADON who listens. Staff K stated that they tell the resident when we don't have a med for them and most of the time they are not surprised, unless it's a pain med, anti coagulant (blood thinner), anti anxiety, etc. Staff K stated they have one resident who gets upset if he did not get his oxycodone (pain medication), Lyrica (blocks pain signals in nervous system), or Clonazepam (anti-anxiety). Staff K sated that it took time but they were able to get it for him because they would call the pharmacy and the on call physician and get it pulled. Staff K stated that sometimes the on call doctor doesn't answer and sometimes the pharmacy doesn't answer. On 6/27/23 at 12:03 p.m., Staff L, RN stated she passes medications when they need someone. Staff L stated she would just get meds out of their medication system if she needed a med. She stated she has had trouble with the system jamming. Staff L stated she leaves at 10:30 p.m. and asks prior to leaving if anybody needs anything. Staff L stated she worked noon to 10:30 p.m. Staff L stated that they were checking every night now, they check the MARS and TARS they have to sign. Staff L, RN stated she knew that medications not being available was a problem and they had been working on it real hard. Staff L stated that the facility lost a couple of nurses about a month ago and then it wasn't brought to our attention. Staff L stated after that she went to check not too long ago for gaps and that's when she noticed it was a couple weeks ago. Staff L stated she had no clue that Resident #21 went without Percocet. Staff L stated that they could have called the on call providers. Staff L stated that they can get a hold of pharmacy 24 hours a day and they could get a hold of a physician 24 hours a day. Staff L stated that there was always 2 nurses in the facility so any of them can call and get medication. Staff L stated that they had trouble with faxing a while back. Staff L stated that it was routine orders that the facility had trouble with getting. Staff L stated she did not know who would tell Resident #21 they couldn't get the Percocet. Staff L stated they could always get Percocet. When told that Resident #21 said he was in pain during the time he did not receive the Percocet, Staff L nodded understanding and stated that she was somewhat related to Resident #4, and he will always tell you he has pain. Staff L stated that Staff E, Staff H, and Staff B, all know what to do (how to retrieve medications). Staff L stated that no one ever told her that the facility was out of narcotics for residents, until the facility caught it. Staff L stated that Resident #19 had been on narcotics about 7 months. Staff L stated that Resident #19 is in pain now and stated that Resident #19 was addicted. Staff L said that the meds are available. She stated that staff could also call the ADON, the DON, or Staff L and they would come in and get the meds for the staff. Staff L stated that pretty much every day that she works she takes meds out of the facility's medication system. On 6/28/23 at 9:02 a.m., Staff I called and wanted to give an update on Resident #19. She stated she wanted to give an update on Resident #19's pain. Staff I stated that Resident #19 was rating her pain at a 9 out of 10 and described it as sharp and throbbing. Staff I stated that Resident #19's roommate had piped up and said that Resident #19's moaning and groaning through out the night. Staff I stated she felt Resident #19's pain