**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to immediately inform and consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) ensure the severity of changes in condition were reported to physician for resident (Resident #1) who required colostomy, urostomy, or ileostomy for 1 of 4 residents reviewed for change in condition in that: 1. The facility failed to when notify the NP of the severity of the change in condition and the difficulties the nursing staff were having keeping Resident #1's ileostomy system secure and in place. 2. The facility failed to obtain a new physician order due to resident's change in condition causing skin breakdown. Resident #1 discharged to the hospital and was diagnosed with a sepsis bacterial infection and an AKI. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:48 p.m. While the IJ was removed on [DATE] at 10:50 a.m., the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The facility failure to when notifying and consulting with the physician the severity of the change and lack of improvement in a condition resulted in a delay of appropriate medical treatment and a worsening of a resident's condition resulting in Resident #1 requiring hospitalization. This failure had the potential to affect other residents not requiring ostomy care who may experience a significant change in condition. Findings included: Record review of Resident #1's Facesheet dated [DATE] reflected that resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on [DATE] with diagnosis but were not limited to unspecified severe protein-calorie malnutrition, Crohn's disease of both small and large intestine with intestinal obstruction; unsteadiness on feet; and anemia. Record review of Resident #1's Medical Doctor (MD) A's Encounter Notes Date of Service: [DATE] 8:06 p.m., reflected, HISTORY OF PRESENTING ILLNESS. The Resident #1 was a pleasant [AGE] year-old male patient, past medical history of schizophrenia, hyperlipidemia, heavy tobacco abuse for many years, comes to the hospital for evaluation of abdominal distention, discomfort and progressively increasing weight loss. Resident currently was with a NG tube in place gives limited information, information is obtained from Family #2. Per Family #2, Resident #1 had been noted to start losing weight at least since July of this year when he was noted to start losing weight on a psychiatry evaluation. Resident was noted to still have appetite close to normal but then. About mid-October he has been noted to have markedly decreased appetite and poor intake, followed by some on and off episodes of nausea and abdominal discomfort after eating small portions of solids or liquids. Resident had a quick and rapid decline in weight loss, calculated to be of a total of 50 pounds since July, but most of it noted since early to mid-October. Resident was admitted to hospital and found to have evidence of a high-grade SBO that was treated conservatively and resolved. Computer tomography (CT) scans reports did not show any significant or acute issue noted. Resident was told that he had a liver and gluteal masses that needed biopsy as there was a high suspicion of neoplasm apparently. Resident presented to radiology yesterday but was told after ultrasounds were done that there was no evidence of any mass in the liver nor in the gluteal region. During this time, resident had persisted with markedly decreased p.a. intake, and on the last few days has been noted to have no BMs and progressively increasing abdominal distention and discomfort and occasional episodes of vomiting reason for which she presented to the ER and subsequently admitted after being found to have a skin high-grade SBO with no transition point. Record review of Resident #1's hospital record dated [DATE] reflected, that resident had an ileostomy laparoscopic procedure occurred on [DATE]: resulting in an exploratory laparotomy, ileostomy creation and mucus fistula. Record review of Resident #1's Progress Notes dated [DATE] at 09:38 p.m., created by LVN F reflected, Resident #1 arrived via stretcher Family #2 at bedside. Resident alert and oriented times 3 out of 4, denies any c/o at present. Orders verified with MD on call. Vitals stable, afebrile. Total assist with Activities of daily living (ADLs). Able to use urinal, ileostomy to RUQ intact with staples in place. Oriented to call light system, bed in low position, water within reach. Record review of Resident #1's Progress Notes dated [DATE] at 09:35 p.m., created by LVN F reflected, Resident #1 alert, stable and oriented x3. Able to make needs known. Snacks given, and fluids encouraged. Total assist with ADLs. ileostomy bag draining liquid stools with frequent changes. Denies any c/o at present time. Safety and comfort measures in place. Record review of Resident #1's Baseline Care Plan dated [DATE], reflected under section D. Disease/Illness Management: wound and in the other section: Ileostomy. Record review of Resident #1's BIMS dated [DATE], reflected that the resident had a score of 13 out of 15 indicating that the resident was cognitively intake. Record review of Resident #1's Active Order Summary: Order Date/ Start Date of: [DATE]: Ileostomy right, lower, quadrant (RLQ) every shift. Colostomy/Urostomy/Ileostomy Care Qshift and PRN. Record review of Resident #1's Active Order Summary: Order Date/ Start Date of: Order Date/Start Date of: [DATE]: Ileostomy to RLQ every shift every 3 day(s). Change ileostomy bag and wafer every 3 days. Record review of Resident #1's Progress Notes dated [DATE] at 07:09 p.m. created by LVN C reflected, Note Text: Resident has ileostomy in place, site around ileostomy is excoriated and weeping clear serous drainage, this nurse attempted several methods to attach ostomy bag unsuccessfully, nurse tried ostomy paste, skin prep and ostomy powder, ostomy site left open to air with ABD pad in place to allow site to heal and minimize drainage, resident resting in bed currently laying on his left, side, ostomy bag in place attached onto ostomy ring, will continue to monitor site and provide appropriate treatment. Record review of Resident #1's Progress Notes dated [DATE] at 10:44 p.m., created by LVN H reflected, Ostomy site malfunction, and reinforced . No complaints of pain, no visible signs of distress visualized. Record review of Resident #1's Progress Notes dated [DATE] at 05:53 a.m. created by LVN E, Late Entry. Note Text: Resident AAO and able to make needs known. Ostomy site malfunction, and reinforced. Staples to ABD area covered with DCD . No complaints of pain, no visible signs of distress visualized. Continues with therapy to improve strength and endurance. Record review of Resident #1's Progress Notes dated [DATE] at 08:38 a.m. created by LVN B reflected, situation: I am calling about the following condition, signs, symptoms: N&V and ABD pain, and BM from rectum. This started on [DATE]. Since this started has it gotten worse. The following makes this condition WORSE: Nothing. The following make this condition Better: none. This condition, symptom, or sign has not occurred before. Treatment for the last episode (if applicable) is None. Background: The resident is in this NF for Post-Acute Care. The primary diagnosis - ileostomy and pertinent history: Last international normalized ratio (INR) (test to determine risk of clots in blood) result was on [DATE]. Record review of Resident #1's dated [DATE] at 08:38 a.m. completed by LVN B. Section S reflected: Situation: 1. The change in condition, symptoms, or signs I am calling about is/are: N&V ABD pain and BM from rectum. 2. This started on [DATE]. 3. Since this started it has gotten Worse. 4. Things that make the condition worse are: nothing. 5. Things that make the condition or symptom better are: none. 6. This condition, symptom, or sign has occurred before: No. 7. Treatment for the last episode: None. B. Background. Resident Description: The resident as at this NF for Post Acute Care. B. Primary Diagnosis: Ileostomy. Vital Signs: i. Most Recent Blood Pressure: 150/89. Dated: [DATE] 8:42 a.m. 4. GI/Abdomen 4b. Nausea 4c. Vomiting 4e. Decreased Appetite 4f. Abdominal Pain 4i. Decreased Bowel Sounds. 4j. Date of last BM [DATE]. A. Assessment Registered Nurse (RN) or Appearance Licensed Practical Nurse (LPN). LPN: Resident appears (e.g. short of breath, in pain, more confused): possible obstruction. Date and time: [DATE] 08:16 a.m. 4a. Reported to Medical Doctor (MD) B on call. Record review of EMT transport record dated [DATE] reflected, that EMT transport serviced received a call from the NF at 09:13:57 a.m. to transport Resident #1 to ER. Dispatch assigned an EMT to NF at 09:16:10 a.m., EMT enroute to NF at 09:35:51 a.m., EMT arrived at NF at 09:54:50 a.m., EMT departed from NF with resident at 10:38:16 a.m., and arrived at the ER with resident at 11:12:02 a.m. Record review of Resident #1's Active Order Summary: Order Date/ Start Date of: Order Date/Order Start Date of: [DATE]: Send Resident to ER. Record review of Resident #1's Progress Notes dated [DATE] at 02:04 p.m., created by LVN B reflected, Late Entry: Note Text: Resident left to go to hospital by way of (via) stretcher with ambulance to be transferred to ER. Alert and able to make needs known dry and clean gown on with Family #2 at his side with no concerns before leaving to go to the ER. Record review of Resident #1's Encounter Note signed by MD C [DATE] 02:32 p.m. Date of service: [DATE]. Transition of Care: Transition occurred. Electronic Summary of Care not incorporated. Manual reconciliation performed. Details: This is a copy of a signed encounter note documented in GEHRIMED. History and Physical History . Newly diagnosed Crohn's disease. Past Surgical History: Ex lap with ileostomy creation and mucous fistula repair . Chief Complaint / Nature of Presenting Problem: Evaluate after hospital stay for SBO, new diagnosis of cancer and Crohn's disease. History Of Present Illness: [AGE] year-old man with past medical history of schizophrenia presented to hospital with weight loss and abdominal pain, diagnosed with small bowel obstruction requiring NG tube due to malignant obstructing mass with widespread peritoneal disease. On [DATE] he had a cardiac arrest due to Co2 narcosis and septic shock status post CPR. Extubated 2 days later. Required TPN. He underwent ex lap, peritoneal biopsy, ileostomy creation and mucous fistula creation on [DATE]. So far biopsy is showing adenocarcinoma. Once stable discharged to NF for further rehabilitation. Resident was seen lying in bed, states his appetite was good, denies abdominal pain. Ostomy output is good. States he was able to ambulate with a walker and therapy today. Review Of Systems General: No complaint of malaise, fatigue, or change in appetite . Small bowel obstruction. Status post ileostomy, monitor ostomy output: Physical debility Consult physical therapy (PT)/occupational therapy (OT). Crohn disease. New diagnosis, established with GI for treatment . Ileostomy care. Severe protein-calorie malnutrition. Low weight with 50-pound weight loss in the last 6 months, registered dietitian, appetite was good. Adenocarcinoma. Presumed GI primary, follow-up oncology. Record review of Resident #1's Encounter Note signed dated by NP: [DATE] 7:41 p.m. Date of service: [DATE]. Visit Type: Day 2 admission Visit . Details: This is a copy of a signed encounter note documented evaluate recent admission from hospital, pain, debility. History Of Present Illness: [AGE] year-old man with past medical history of schizophrenia presented to hospital with weight loss and abdominal pain, diagnosed with small bowel obstruction requiring NG tube due to malignant obstructing mass with widespread peritoneal disease. On [DATE] he had a cardiac arrest due to carbon dioxide (Co2) narcosis and septic shock status post Cardiopulmonary Resuscitation (CPR). Extubated 2 days later. Required total parenteral nutrition (TPN). He underwent ex lap, peritoneal biopsy, ileostomy creation and mucous fistula creation on [DATE]. So far biopsy is showing adenocarcinoma (cancer that affects glands and glandular tissues). Once stable discharged to nursing facility (NF) for further rehabilitation. He is seen lying in bed, states his appetite is good, denies abdominal pain. Ostomy output is good. [DATE] patient seen in bed resting pain waxes and wane manage on tramadol. Record review of Resident's #1's provider report dated [DATE] reflected, on [DATE] at 10:45 a.m., NF learned that on [DATE] at 10:06 a.m., that Family #1 had concerns with Resident #1 discharge to ER with vomit and BM on him. Noted staff LVN B, CNA B, and CNA D as witnesses. Resident assessment on [DATE] at 08:15 a.m., completed by LVN B. Results: Resident #1 had ileostomy, experienced N&V, ABD pain, and rectum BMs. Resident sent to the ER. Level of cognition: BIMS score of 13. Diagnosis: pertinent medical diagnosis: acute respiratory failure with hypoxia; nutritional marasmus; unspecified severe protein-calorie malnutrition; Crohn's disease of both small and large intestine with intestinal obstruction; other schizophrenia; muscle weakness (generalized); dysphagia, unspecified; unsteadiness on feet; other symbolic dysfunctions; anemia, unspecified; other hyperlipidemia; nicotine dependence, unspecified, uncomplicated; and colostomy status. Interview on [DATE] at 11:27 a.m., Hospital Case Manager Nurse (HCMN) stated that Resident #1 admitted to the hospital ER from the NF on [DATE], after the NF had not taken care of the ileostomy bag and it had exploded BM waste had gotten into the midline incision and caused sepsis. She stated she had been provided with photographs of the resident's condition at the NF showing the resident covered in BM and vomit when he discharged from the NF to the ER. Interview on [DATE] at 01:10 p.m., Family #1 stated that Resident #1 received poor care at the NF on the onset of his care. He stated on [DATE], the NF staff had difficulties keeping up with the emptying of the Resident #1's ileotomy bag and he had begun leaking from being over full. He stated he learned that staff were not prepared to change ileostomy bags and seemed disturbed by having to empty the bag 8-times a day. He stated he learned that on [DATE] that Family #2 had to find a staff to empty the ileostomy bag that was full and leaking. He stated Family #2 learned that the staff had changed resident's ostomy bag multiple times that shift. He stated on the morning of [DATE], Family #2 arrived to find that the resident's ileotomy bag again full and leaking and unattached to the resident. He stated that the resident had been sitting up in the bed vomiting and having BMs all over himself after his ileotomy bag burst. He stated that the resident was left to set in his vomit and BM for 1.5 hours before EMT arrived. He stated once EMT arrived, the resident had to wait another 20 to 30 minutes while staff tried to clean him for the transport to the ER. Interview on [DATE] at 01:28 p.m. Family #2 stated on [DATE] at 08:05 p.m. she had pointed out right away that Resident #1's ileostomy bag needed to be emptied and LVN A and CNA C went back and forth debating who was going to empty the bag because CNA C acted scared to touch the full bag. She stated that LVN A informed CNA C to go get a new bag. She stated she assisted and guided CNA C on how to clean the resident ileostomy site. She stated on [DATE] at 04:15 p.m., and LVN A was in the resident's room preparing to change him because his ileotomy bag was full. She stated that LVN A told her that the staff had been changing his brief all day throughout the shift because he was having BMs from his rectum and leakage from the ileotomy bag. She stated that LVN A told her that the tape had not stayed stuck around the resident's stoma. She stated LVN A stated that the stoma would then leak bowel on to the bed from the ileotomy tubing. She stated at 06:16 p.m. she smelled bowel and pulled back the resident's sheet and the resident and his bed was covered in bowel and his ileotomy bag was full. She stated the top of the adhesive around the stoma had loosed and bowel had been seeping from the bottom area of the stoma. She stated she alerted the staff and LVN A came into the room, seen the bowel on the bed and stated she was not going to clean up the resident again. She stated that LVN A recommended to her that she should find another facility that could better meet the resident's needs. She stated she asked LVN A to speak to her supervisor and LVN A told her to go to the front desk and ask for them. She stated at the front desk, the staff told her to go to the nurse's station. She stated at the nurse's station the staff whose names she had not learned, looked without speaking when she voiced her concerns about LVN A's comments. She stated the staff passed her a form and told her to write down her concerns and told that the nightshift nurse should be coming in at 7:00 p.m. She stated that she took the form and waited back with the resident in his room, but no one came to clean or check on the resident. She stated from 06:15 p.m. to 07:15 p.m. the resident continued to sit in his own bowel uncleaned. She stated at 07:15 p.m. went back to the nurse's station to see who was coming to clean the resident. She stated again the nurses looked at her with no response. She stated that LVN A was called to the nurse's station. She stated that LVN A came and stated that she did not know who was going to clean the resident, and stated she was not going to do it. She stated she went back to the resident's room and around 8:00 p.m. LVN F came down and changed the resident. She stated she could see that the resident's stoma was bleeding, bowel was leaking from his rectum, and his skin broken down around the stoma. She stated LVN F told her that the skin breakdown was because the resident's bowel was leaking on him all day and all night. She stated LVN F taped the wafer around the resident's stoma and stated that should help and laid towels down near the stoma area to collect any bowel leakage and moisture. She stated on [DATE] she overheard the ADM saying, Why did we accept this man if we cannot meet his needs and now Family #2 is calling and complaining. She stated she went to the resident's room when the ADM called her phone. She stated that the ADM began apologizing, saying, Please allow us opportunity to serve him. She stated as she was speaking to the ADM, she smelled the foul smell of bowel, pulled back the resident's covers and saw that he was laying in bowel, and he did not have an ileotomy bag attached to him. She stated she began crying and told the ADM what she had seen and told the ADM she needed to come down to the resident's room immediately. She stated that the ADM entered the resident's room and seen the resident laying in his bowel with no ileotomy bag attached. She stated that the ADM called LVN C to the room and LVN C began immediately explaining that he had difficulties keeping the resident's ileotomy bag secured around the resident's stoma. She stated that she could see the breakdown around the resident's stoma had gotten worse. She stated that LVN C stated he had left off the ileotomy wafer so that the resident's stoma and skin could air out due to the skin break down. She stated that LVN C began cleaning up the resident and changed his bedding and reattached the ileotomy bag. She stated on [DATE] at 08:53 a.m., she received a call from LVN B that the resident had been vomiting after feeling nauseous and would be sent to the ER. She stated she arrived at the NF at 10:00 a.m., to find 2-EMT waiting in the hall of resident's room. She stated that she was horrified seeing that the resident was lying in a bed of his own vomit and feces and with his ileotomy bag full and the tubing leaking BM. She stated that the scene was so horrific no one would believe her if she told them, so she took photographs. She stated that the resident loved to eat and seen over to the side that he had a fresh breakfast tray that had not been touched or eaten from. She stated that breakfast was served at the NF at 7:00 a.m. She stated the resident told her he had vomited 3-times. She stated he sounded weak. She stated then CNA B and CNA C came into the room and began cleaning up to be sent to the ER. She stated one of the EMTs stated that they could not believe what they were seeing. She stated that the resident then stated that he needed to have a BM and CNA B told him to go head and the resident had BM on the bed. She stated then LVN B came in and began removing what tape that was attached to the resident's stomach, when one of the EMTs said, Stop, leave him that way so the ER physicians could see his condition, and then LVN B left the resident's room. She stated then the EMTs placed the resident on their stretcher and transported him out of the facility. Interview on [DATE] at 02:36 p.m., the ADM stated that she had first became aware that Resident #1 had issues with his Ileostomy bag on [DATE]. She stated that she called Family #2 who began expressing unpleasant nursing professionalism by LVN A. She stated she apologized to Family #2 and stated she would address the issue. She stated while they were speaking on the phone Family #2 began screaming and told her to come to the resident's room. She stated she was not aware that Family #2 was in the NH. She stated when she entered the resident's room, she could see that the resident was laying in his bed full of bowel that leaked from his ileotomy site and tubing. She stated she called LVN C to the room who had been on shift 12-hours who was about to come off shift and explained that they were having difficulties, keeping the wafer attached to the resident's skin and it had been making a mess during the whole shift and he had been doing what he could to keep the wafer attached. She stated that LVN C told her that he had been in and out of the resident's room [ROOM NUMBER]-different times trying to keep the wafer attached to the skin. She stated on [DATE], she received a text from LVN B that resident was going to the hospital for nausea and vomiting due to problems with his ileotomy bag. She stated on [DATE], Family #1 came to the NF and she learned that the resident was sent to the hospital from the NF covered in his own vomit and feces, explaining he had photographs he was going to send to her, that were not received. She stated that she informed DON A and the began an investigation and planned to call back Family #1 on [DATE] with their findings. She stated through their investigation, she learned that the resident had been vomiting, and had BMs from his rectum despite having an ileostomy. She stated that DON A spoke to LVN A who admitted that she had been frustrated while providing care to Resident #1 and had not been her most professional self. She stated that LVN A had been required to complete additional training courses on customer service and received an in-service counseling on customer service. She stated after the resident's discharge to the hospital she had made attempts to contact Family #1 and Family #2 with no avail and had not heard back on his status. She stated it had been her expectation that the nursing staff had contacted the NP. She stated that it had been the DON's responsible to ensure that the nursing staff were trained on ostomy care. Interview on [DATE] at 04:55 p.m., LVN B stated that she cared for Resident #1 on [DATE], when she that the resident was removing his ileotomy bag and that the resident may have caused blockage damage because the ileotomy had the inability to drain properly. She stated on or about 08:45 a.m. and used her stethoscope to listen for BMs in the resident's abdomen and had heard none and seen that his ileotomy bag had been empty. She stated thereafter, he began projectile vomiting. She stated she left the room and about 09:00 a.m., called Family #2 and informed her that resident would be sent to the ER. She stated CNA B and CNA C come in and cleaned up and prepare the resident for the ER. She stated the that the brown duo dermo tape used to tape down the wafer and protect the skin around the stoma would not stick to the resident's skin because there was a lot of drainage from his ileotomy bag leaving the resident's skin moist. She stated she had not returned to the resident's room because she had called the EMT, hospital, and prepared his discharged paperwork for the discharge to send him out to the hospital. She stated CNA B and CNA C were had still been cleaning the resident when EMT arrived. She stated she informed the EMT of the resident's history. She stated once the resident discharged , she learned from CNA B that he had BMs through his rectum, not through his ileotomy, so she called back the hospital and informed them. Interview on [DATE] at 06:35 p.m., Family #2 stated that that she had taken photographs on [DATE] of Resident #1 lying in the NF's bed covered in vomit and BM and had sent the photographs through text message to this surveyor. In an observation/interview while at the hospital on [DATE] at 07:06 p.m., Resident #1 was a thin male who appeared weak and frail and spoke slowly and appeared to be lethargic. He stated that he was admitted from the ER to the hospital and was doing much better than when he was at the NF of which he stated he had not wanted to return. He stated that they NF staff had not treated him well. He stated he had pushed the call button, and staff LVN A would say, I am not going to clean up that mess. He stated that he had sat in his bed with a leaking ileotomy bag for a long time every day he had been at the NF and it messed him and his bed. He stated in the late evening of [DATE], he had begun feeling nauseous. He stated on the early morning of [DATE], before breakfast, he vomited, 3-times. He stated that LVN A accused him of taking off his ileotomy bag, but he denied doing so. He stated he had not felt safe when he was at the facility. He stated that LVN C and LVN F were the only staff that helped clean him up, otherwise CNA B and LVN A kept acting like he was nasty and had not wanted to clean him up. Interview on [DATE] at 10:52 a.m. LVN C stated that he was on shift [DATE] from 6 a.m. to 6 p.m. and responsible for the nursing and ileostomy care for Resident #1 who he indicated had a cognitive rating of 3-4 out of 4, 4-being cognitively intact. He stated that he had complications adhering the wafer around the resident's stoma site his entire shift. He stated he had changed the ileotomy system 6-7 times because the wafer would not stay attached to the resident's skin. He stated the ileostomy leaked so quickly filling the ileotomy bag faster than normal causing a lot of liquid to excavate/come out from site and tubing, which further lead to more escalation from the stoma site. He stated he tried to reinforce the wafer with tape and strummer paste (adhesive paste). He stated the paste would be successful for a moment, but soon as the resident moved it would come off. He stated that he had interventions in place keep the wafer in place: strong adhesive, cleaned the area, and gave the skin around the stoma time to breathe and dry before applying a new wafer. He stated basically, every time the resident ate, liquid had swished out and pushed the wafer and bag off the resident. He stated the way the resident would favor laying on the right-side, same side as the stoma made it easier for the liquid bowel to [NAME] out. He stated that that he never had a patient like Resident #1 where the liquid would come gushing out from the stoma site and fill up the ileotomy bags so quickly. He stated he informed DON A and LVN F of the issues he had adhered the wafer to the resident. He stated he implemented a new intervention by laying towels and clean briefs on the bed near the stoma site to absorb some of the moisture. He stated on [DATE] he worked 6 a.m. to 6 p.m. and after experiencing a second day of issues with the resident's leaking stoma, contacted the resident's nurse practitioner (NP) making her aware of his new intervention to allow the site to dry and laying towels to absorb any leakage of which NP agreed with. He stated he had noted in progress notes the resident's condition but had not noted that he had contacted the NP. When asked why, he stated he had no answer. He stated he asked the resident to be as still as possible to assist with keeping the wafer in place, but soon as the resident would fall asleep, he would involuntarily move, and the wafer would come off. He stated on the evening of [DATE], Family #2 was at bedside and witnessed the stoma area drying and the towels absorbing the moisture with concerns. He stated some of the feces was on the towel that had leaked from the uncovered stoma. He stated he explained to Family #2 that the laid towels were an intervention placed to absorb any moister from the leaking stoma, and that the stoma was uncovered to allow it to dry from leaking. He stated Family #2 stated she understood and had no concerns. He stated after that shift he had not seen the resident again. Interview on [DATE] at 11:00 a.m., CNA D stated that on the morning of [DATE] CNA B approached to assist with cleaning Resident #1 for transport to the ER. She stated when she entered the resident's room, she saw a very thin man lying in bed vomiting, bowel drainage from his uncovered stoma, bowel draining from his ileotomy bag, and having a BM from his rectum. She stated that majority of the bowel drainage came from the ileotomy bag tubing. She stated that Family #2 and 2-EMTs were at bedside. She stated that the resident was covered in vomit and bowel. She stated that her and CNA B began removing the resident's soiled brief and soiled gown, and placed a new brief on the resident when he began to have another full BM. She stated the resident had not made any needs or concerns known nor appeared to be in pain or distress. She stated the resident was pretty quiet, was very cooperative, alert and somewhat oriented. She stated that there was no NF nurse in the room. She stated as CNA B picked up the resident's colostomy tubing, one of the EMTs stated to just leave the resident that way. She stated to the EMT that she should have gotten a nurse to reattach the ileotomy bag and the EMT stated no to leave it that way for the ER physicians to properly diagnosis the resident's condition. She stated then the EMTs transported the resident out of the NH. Interview on [DATE] at 11:17 a.m. CNA B stated on [DATE] she worked 6:00 a.m. to 2:00 p.m. and her first interaction with the Resident #1 had been sometime after 8:00 a.m. when she entered his room. She stated resident, lying in bed with his ileostomy site exposed, covered in vomit, and his ileotomy tubing leaking BM. She stated asked CNA D to come assist cleaning up the resident to send him to the ER. She stated once the resident was clean and in a new gown, she handed a sheet to 1 of 2 EMTs to cover the resident and they wheeled him out of the room on a stretcher. She stated that the resident's stoma site was exposed and not covered, and no nurse had come into the room while they cleaned up the resident. Interview on [DATE] at 11:37 a.m., LVN A stated that she no longer worked for the NF and had worked for them as a PRN nurse. She stated she recalled Resident #1 but could not recall speaking to or having interactions with or around Family #2 about the resident. She stated that she cared for the resident during two of her consecutive 12-hour shifts. Her and the CNA C worked the hall had to go to his room on[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents who required colostomy, urostomy, or ileostomy services received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 residents (Resident #1) reviewed for ostomy care in that: 1. The facility failed to ensure Resident #1's ileostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, to divert waste from the small intestine), wafer (the piece of the pouching system that sticks to your body and holds your pouch in place and should help protect the skin around your stoma from damage) and bag were in place. 2. The facility failed to empty Resident's #1's ileostomy bag timely and remain free from leakage. Resident #1 discharged to the hospital and was diagnosed with a sepsis bacterial infection and an AKI. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 05:48 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure resulted in Resident #1 requiring hospitalization. It also placed other residents with ileostomy and colostomy status at risk of skin breakdowns, pain, infections, hospitalization, and decreased quality of life. Findings included: Record review of Resident #1's Facesheet dated [DATE] reflected that resident was a [AGE] year old male who admitted to the facility on [DATE] and discharged on [DATE] with diagnosis that included acute respiratory failure with hypoxia (lungs fail to adequately oxygenate the blood and/or remove carbon dioxide); nutritional marasmus (a severe form of protein-energy malnutrition characterized by extreme weight loss, muscle wasting, and depletion of body fat); unspecified severe protein-calorie malnutrition, Crohn's disease of both small and large intestine with intestinal obstruction; other schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions, often including hallucinations, delusions, and disorganized thinking); muscle weakness (generalized); dysphagia (difficulty swallowing); unsteadiness on feet; anemia (a condition where your blood doesn't have enough healthy red blood cells to carry sufficient oxygen to your body's tissues, leading to symptoms like fatigue, weakness, and shortness of breath). Record review of Resident #1's Medical Doctor (MD) A's Encounter Notes Date of Service: [DATE] 8:06 p.m., reflected, HISTORY OF PRESENTING ILLNESS. The Resident #1 was a pleasant [AGE] year-old male patient, past medical history of schizophrenia, hyperlipidemia, heavy tobacco abuse for many years, comes to the hospital for evaluation of abdominal distention, discomfort and progressively increasing weight loss. Resident currently was with a NG tube in place gives limited information, information is obtained from Family #2. Per Family #2, Resident #1 had been noted to start losing weight at least since July of this year when he was noted to start losing weight on a psychiatry evaluation. Resident was noted to still have appetite close to normal but then. About mid-October he has been noted to have markedly decreased appetite and poor intake, followed by some on and off episodes of nausea and abdominal discomfort after eating small portions of solids or liquids. Resident had a quick and rapid decline in weight loss, calculated to be of a total of 50 pounds since July, but most of it noted since early to mid-October. Resident was admitted to hospital and found to have evidence of a high-grade SBO that was treated conservatively and resolved. Computer tomography (CT) scans reports did not show any significant or acute issue noted. Resident was told that he had a liver and gluteal masses that needed biopsy as there was a high suspicion of neoplasm apparently. Resident presented to radiology yesterday but was told after ultrasounds were done that there was no evidence of any mass in the liver nor in the gluteal region. During this time, resident had persisted with markedly decreased p.a. intake, and on the last few days has been noted to have no BMs and progressively increasing abdominal distention and discomfort and occasional episodes of vomiting reason for which she presented to the ER and subsequently admitted after being found to have a skin high-grade SBO with no transition point. Record review of Resident #1's hospital record dated [DATE] reflected, that resident had an ileostomy laparoscopic procedure on [DATE]: exploratory laparotomy, ileostomy creation and mucus fistula. Record review of Resident #1's Baseline Care Plan dated [DATE], reflected under section D. Disease/Illness Management: Psychiatric Illness, Psychiatric Medication, and Wound and in the other section Ileostomy. Record review of Resident #1's BIMS dated [DATE], reflected that the resident had a score of 13 out of 15 indicating that the resident was cognitively intake. Record review of NF's grievance dated [DATE] reflected, a delay in care of Resident #1's ileostomy bag, had poor customer service care provided by LVN A. An investigation stated by DON A. Resolution: Resident #1 pulled on his ileostomy bag and required excessive bag changes. LVN A became frustrated with Resident #1's behavior. An 1:1 customer service in-service and assigned a customer service course training was provided to LVN A. Record review of Resident #1's Progress Notes dated [DATE] at 09:38 p.m., created by LVN F reflected, Resident #1 arrived via stretcher Family #2 at bedside. Resident alert and oriented times ¾, Denies any c/o at present. Orders verified with MD on call. Vitals stable, afebrile. Total assist with Activities of daily living (ADLs). Able to use urinal, ileostomy to RUQ intact with staples in place. Oriented to call light system, bed in low position, water within reach. Record review of Resident #1's Progress Notes dated [DATE] at 09:35 p.m., created by LVN F reflected, Resident #1 alert, stable and oriented times 3. Able to make needs known. Snacks given, and fluids encouraged. Total assist with ADLs, ileostomy bag draining liquid stools with frequent changes. Denies any c/o at present time. Safety and comfort measures in place. Record review of facility's grievance dated [DATE] reflected, Family #1 reported delay in changing Resident #1's ileostomy bag and LVN A had poor customer service. Dated/Follow-up Investigation. Person assigned to investigation DON A. Resolution: Resident #1 pulled on his ileostomy bag and required excessive bag changes. LVN A became frustrated with Resident #1's behavior. LVN A given 1-on-1 customer service and assigned a course training on customer service. LVN A will change bag as needed. Record review of Resident #1's Progress Notes dated [DATE] at 07:09 p.m. created by LVN C reflected, Note Text: Resident has ileostomy in place, site around ileostomy is excoriated and weeping clear serous drainage, this nurse attempted several methods to attach ostomy bag unsuccessfully, nurse tried ostomy paste, skin prep and ostomy powder, ostomy site left open to air with ABD pad in place to allow site to heal and minimize drainage, resident resting in bed currently laying on his left, side, ostomy bag in place attached onto ostomy ring, will continue to monitor site and provide appropriate treatment. Record review of Resident #1's Progress Notes dated [DATE] at 10:44 p.m., created by LVN H reflected, Ostomy site malfunction, and reinforced . No complaints of pain, no visible signs of distress visualized. Record review of Resident #1's Active Orders Order Summary: Order Date/Order Start Date of: [DATE]: Ileostomy right, lower, quadrant (RLQ) every shift. Colostomy/Urostomy/Ileostomy Care each and Qshift and PRN. Record review of Resident #1's Active Orders Order Summary: Order Date/Order Start Date of: [DATE]: Ileostomy to RLQ every shift every 3 day(s). Change ileostomy bag and wafer every 3 days. Record review of Resident #1's Progress Notes dated [DATE] at 05:53 a.m. created by LVN E, Late Entry. Note Text: Resident AAO and able to make needs known. Ostomy site malfunction, and reinforced. Staples to ABD area covered with DCD . No complaints of pain, no visible signs of distress visualized. Continues with therapy to improve strength and endurance. Record review of Resident #1's Progress Notes dated [DATE] at 08:38 a.m. created by LVN B reflected, situation: I am calling about the following condition, signs, symptoms: N&V, ABD pain, and BM from rectum. This started on [DATE]. Since this started has it gotten worse. The following makes this condition WORSE: Nothing. The following make this condition Better: none. This condition, symptom, or sign has not occurred before. Treatment for the last episode (if applicable) is None. Background: The resident is in this NF for Post-Acute Care. The primary diagnosis - ileostomy and pertinent history: Last INR result was on [DATE]. Record review of 1 of 24 photographs taken of Resident #1 on [DATE] at or around 08:38 a.m. dressed in a brief and hospital gown, lying in bed covered in vomit and BM. The resident's face was not show and was shown from the midsection of his torso to his thighs. Towels and briefs covered in vomit and BM were observed lying near the resident. The resident's ileostomy bag/tubing not shown in photographs. Record review of Resident #1's Active Orders Order Summary: Order Date/Order Start Date of: [DATE]: Send Resident to ER. Record review of Resident #1's Situation, Sbar dated [DATE] at 08:38 a.m. completed by LVN B. Section S reflected: Situation: 1. The change in condition, symptoms, or signs I am calling about is/are: N&V ABD pain and BM from rectum. 2. This started on [DATE]. 3. Since this started it has gotten Worse. 4. Things that make the condition worse are: nothing. 5. Things that make the condition or symptom better are: none. 6. This condition, symptom, or sign has occurred before: No. 7. Treatment for the last episode: None. B. Background. Resident Description: The resident as at this NF for Post Acute Care. B. Primary Diagnosis: Ileostomy. Vital Signs: i. Most Recent Blood Pressure: 150/89. Dated: [DATE] 8:42 a.m. 4. GI/Abdomen 4b. Nausea 4c. Vomiting 4e. Decreased Appetite 4f. Abdominal Pain 4i. Decreased Bowel Sounds. 4j. Date of last BM [DATE]. A. Assessment Registered Nurse (RN) or Appearance Licensed Practical Nurse (LPN). LPN: Resident appears (e.g. short of breath, in pain, more confused): possible obstruction. Date and time: [DATE] 08:16 a.m. 4a. Reported to Medical Doctor (MD) B on call. Record review of EMT transport record dated [DATE], call received from NF at 9:13:57 a.m. Time call assigned for EMT dispatch to NF, 09:16:10 a.m. Time EMT enroute to NF, 09:35:51 a.m. Time EMT arrived at NF scene, 09:54:50 a.m. Time EMT departed from NF scene, 10:38:16 a.m. and arrived at the ER, 11:12:02 a.m. Record review of Resident #1's Progress Notes dated [DATE] at 02:04 p.m., created by LVN B reflected, Late Entry: Note Text: Resident left to go to hospital by way of (via) stretcher with ambulance to be transferred to ER. Alert and able to make needs known dry and clean gown on with Family #2 at his side. Family #1 or Resident had no concerns before leaving to go to the ER. Record review of ER hospital/physician progress note pg. 142. dated [DATE], reflected, principal problem: AKI. Record review of Resident #1's Encounter Note signed by MD C [DATE] 02:32 p.m. Date of service: [DATE]. Transition of Care: Transition occurred. Electronic Summary of Care not incorporated. Manual reconciliation performed. Details: This is a copy of a signed encounter note documented in GEHRIMED. History and Physical History . Newly diagnosed Crohn's disease. Past Surgical History: Ex lap with ileostomy creation and mucous fistula repair . Chief Complaint / Nature of Presenting Problem: Evaluate after hospital stay for SBO, new diagnosis of cancer and Crohn's disease. History Of Present Illness: [AGE] year-old man with past medical history of schizophrenia presented to hospital with weight loss and abdominal pain, diagnosed with small bowel obstruction requiring NG tube due to malignant obstructing mass with widespread peritoneal disease. On [DATE] he had a cardiac arrest due to Co2 narcosis and septic shock status post CPR. Extubated 2 days later. Required TPN. He underwent ex lap, peritoneal biopsy, ileostomy creation and mucous fistula creation on [DATE]. So far biopsy is showing adenocarcinoma. Once stable discharged to NF for further rehabilitation. Resident was seen lying in bed, states his appetite was good, denies abdominal pain. Ostomy output is good. States he was able to ambulate with a walker and therapy today. Review Of Systems General: No complaint of malaise, fatigue, or change in appetite . Small bowel obstruction. Status post ileostomy, monitor ostomy output : Physical debility Consult PT/OT). Crohn disease. New diagnosis, established with GI for treatment . Ileostomy care. Severe protein-calorie malnutrition. Low weight with 50-pound weight loss in the last 6 months, registered dietitian, appetite was good. Adenocarcinoma. Presumed GI primary, follow-up oncology. Record review of Resident #1's Encounter Note signed dated by NP: [DATE] 7:41 p.m. Date of service: [DATE]. Visit Type: Day 2 admission Visit . Details: This is a copy of a signed encounter note documented evaluate recent admission from hospital, pain, debility. History Of Present Illness: [AGE] year-old man with past medical history of schizophrenia presented to hospital with weight loss and abdominal pain, diagnosed with small bowel obstruction requiring NG tube due to malignant obstructing mass with widespread peritoneal disease. On [DATE] he had a cardiac arrest due to carbon dioxide (Co2) narcosis and septic shock status post Cardiopulmonary Resuscitation (CPR). Extubated 2 days later. Required total parenteral nutrition (TPN). He underwent ex lap, peritoneal biopsy, ileostomy creation and mucous fistula creation on [DATE]. So far biopsy is showing adenocarcinoma (cancer that affects glands and glandular tissues). Once stable discharged to nursing facility (NF) for further rehabilitation. He is seen lying in bed, states his appetite is good, denies abdominal pain. Ostomy output is good. [DATE] patient seen in bed resting pain waxes and wane manage on tramadol. Record review of ER hospital/physician progress note pg. 57. dated [DATE] created by MD A reflected, Assessment/Plan: severe sepsis, suspected due to abdominal wall cellulitis. Computer tomography (CT) abdomen showed no acute pathology. Continue broad spectrum intravenous therapy (IV) antibiotic. Continue IVF support, prn pressors. Monitor hemodynamics (blood flow and it's force) closely. AKI metabolic acidosis (excess acid in the body) and hyperkalemia (high potassium that can contribute to stroke and/or death). Suspect due to high ostomy (upper intestine BMs) output and poor P.O. (process of rehydrating someone by giving them fluids to drink) hydration that is administered per os (by mouth). Record review of hospital/Nephrology progress note pg. 64, dated [DATE], created by MD A reflected, Assessment, Plan and Recommendations: 1. AKI due to volume depletion, hypotension, and likely sepsis. Baseline low creatinine (indicate that the kidneys are not functioning properly or that there is a decrease in muscle mass) is likely underestimating degree of underlying kidney dysfunction. Cystatin C 1.05 milligram/litter renal function improved status post in vitro fertilization (IVF) resuscitation (the patient's kidneys are likely functioning better). Monitor close off IVF. 2. Acidosis, metabolic due to AKI and GI outputs. Persists despite alkali therapy in MVF (associated with an improvement in kidney function, which may afford a long-term benefit in slowing the progression chronic kidney disfunction). Give additional 2 amp sodium bicarbonate. 3. Hyponatremia. Due to high antidiuretic hormone (a chemical produced in the brain that causes the kidneys to release less water, decreasing the amount of urine produced) state in settling of volume depletion. Worsening with isotonic IVF. Give 2 amp sodium bicarbonate today repeat sodium this afternoon. Is sodium remains low will trial slightly hypertonic IVF. Avoid hypotonic IVF's. 4. Sepsis, likely. Concern for underling intra-abdominal process and wound infection due to likely fecal contamination. Agree with broad spectrum antimicrobials dose for renal function. Record review of Physical Therapy (PT) Wound Care (WOC) evaluation pg. 10-11, dated [DATE], created by PT. Principal problem: AKI active problems: SBO. Acidosis (high levels of acid in the body, disrupting the bloods normal acidity/power of hydrogen (pH) balance) . hyponatremia (abnormally low sodium levels in the blood: Symptoms causing sudden or gradual nausea, headaches, confusion, and fatigue). Procedure ileostomy, laparoscopic [DATE]. WOC therapy diagnosis: patient with decreased skin integrity associated with pressure wound. Course of events during hospitalization: presented from NF due to abdominal pain, nausea, and vomiting . Record review of hospital WOC evaluation initial assessment pg. 4, dated [DATE], created by Certified Wound, Ostomy, and Continence Nurse (CWON). Diagnosis presents with nausea vomiting abdominal pain. History of obstructive colon mass and peritoneal met with recent high-grade SBO and ostomy creatin chronic disease and schizophrenia was recently admitted here for SBO. He was discharged to NF on 0,[DATE]. In ER he was hypotensive with new AKI hyperkalemia acidosis and white blood cell (hemoglobin) of 24.000 grams per deciliter (g/dL), (elevated, normal range generally for men 13.8-17.2 g/dL, higher indicates infection) . General information: Patient lying in bed awake and oriented (AO) times 3, subject slash patient comments: I want to drink coffee. Does the patient have any pain: No. Mental Status: Follows commands. Mobility transfer: Maximize Assistant 25%. Preventative measures: Support surface. Atmosphere airfare, air mattress on tube feeds, oral diet, position to left/right with wedge pillow support. Patient visited at bedside for established ileostomy care patient was well known from previous admission. Nurse reports thought ileostomy site was leaking but at the first time I visit in the morning the pouch was intact the high output pouching system was connected to a drain bag boots, brown output noted . Record review of hospital/physician progress note pg. 164, dated [DATE], created by MD B. Percepts suspicious, suspect due to abnormal wall cellulitis (aggressive intra-abdominal inflammation) from inadequate maintenance of ostomy. CT abdomen showed no acute pathology. Blood cultures remained negative. Completed 7 days of antibiotics course. AKI metabolic acidosis and hyperkalemia, state and improved. Suspect due to high ostomy output and poor po hydration. Status post IVF. Record review of in-service dated [DATE] titled Customer Service signed acknowledgement of education by LVN A, CNA B, LVN C and DON A and presented by ADON. Record review of in-service dated [DATE] titled Ostomy Care signed acknowledgement of education by LVN A, LVN C, CNA B, and DON A and presented by ADON. Record review of Resident's #1's provider report dated [DATE] reflected, incident details. ` o Date/Time you first learned of incident: [DATE] at 10:45 a.m. o Date/Time the incident occurred: [DATE] at 10:06 a.m. NF o Brief narrative summary of the reportable incident: Family #2 concerns related to sending Resident #1 to the hospital with vomit and bowel movement (BM) on him. o Witnesses name and title: LVN B, CNA B, and CNA D o The date and time of the assessment: [DATE] at 08:15 a.m. o Name and title of person who completed assessment: LVN B o Results of the assessment: Resident #1 has ileostomy. Experiencing N&V, ABD pain, and BM from rectum. Resident sent to the hospital. o Level of cognition: BIMS score of 13. Diagnosis: pertinent medical diagnosis: acute respiratory failure with hypoxia; nutritional marasmus; unspecified severe protein-calorie malnutrition; Crohn's disease of both small and large intestine with intestinal obstruction; other schizophrenia; muscle weakness (generalized); dysphagia, unspecified; unsteadiness on feet; other symbolic dysfunctions; anemia, unspecified; other hyperlipidemia; nicotine dependence, unspecified, uncomplicated; and colostomy status. Interview on [DATE] at 11:27 a.m., HCMN stated on [DATE], the resident arrived at the ER after the NF failed to provide appropriate care resulting in the resident's ileostomy bag exploding and BM seeped into his midline incision causing sepsis. She stated that she felt like the resident was not able to advocate for himself, and being a nurse for a long time, found the resident's case complex, alarming, and after view photographs provided by Family #2 of the resident covered in BM and vomit when he discharged from the NF to the ER, required follow up. Interview on [DATE] at 01:10 p.m., Family #1 stated on the evening of [DATE], [DATE] and [DATE], that the NF staff had difficulties keeping up with the emptying of the resident's ileotomy bag resulting in excessive leakage. He stated on the morning of [DATE], he learned that Family #2 had arriving at the NF to find that the resident had been sitting up in the bed with vomit and BM all over him as his ileotomy bag had burst from being to full. He stated that the resident had sat in his bowel for 1.5 hours before the EMT arrived to transport the resident to the ER and EMT had to wait 20 to 30 minutes at bedside for the staff to clean the resident of the vomit and BM before transporting him to the ER. Interview on [DATE] at 01:28 p.m. Family #2 stated on [DATE], [DATE], and [DATE], Resident #1's ileostomy bag had overfilled and not remained secured in place causing BM to leak all over the resident, and his bed. She stated on [DATE], she asked to speak to LVN A's supervisor with no avail after LVN A refused to change the resident. LVN F came down and changed the resident. She stated she could see that the resident's stoma was bleeding, bowel was leaking from his rectum, and his skin broken down around the stoma. She stated on [DATE] and [DATE], resident laid in his bed without his ostomy system intake and towels and briefs laid beside him to collect the leakage. She stated on [DATE] at 08:53 a.m., she learned that resident had been vomiting and nauseas and was being sent to the ER. She stated she arrived at the NF at 10:00 a.m., 2-EMTs were waiting in the hall outside of the resident's room, and the resident in a bed of his own vomit, and feces. She stated that breakfast was served at the NF at 7:00 a.m. The resident stated that he had vomited 3-times, she stated he sounded weak. She stated then CNA B and CNA C came into the room and stated that they were going to clean him up before sending him out to the hospital. She stated that the resident then stated that he needed to have a BM. She stated that CNA B told him to go head and the resident had BM on the bed. She stated then LVN B came in and began removing what tape that was attached to the resident's stomach, when one of the EMTs said, Stop, leave him that way the ER physicians could see his condition, and then LVN B left the resident's room and had not returned. She stated then the EMTs placed the resident on their stretcher and transported him out of the facility. She stated once at the ER the resident was admitted with a BP of 73/51, dehydration, a high white blood count, skin breakdown around his stomach, and a new sepsis diagnosis. She stated that the resident could have died. Interview on [DATE] at 02:36 p.m., the ADM stated Resident #1 had issues with his Ileostomy bag on [DATE] and LVN C to assisted and explained to Family #2 the difficulties of keeping the ostomy system attached to the resident's skin. She stated that LVN C told her that he had been in and out of the resident's room [ROOM NUMBER]-different times trying to keep the wafer attached to the skin. She stated on [DATE], she received a text from LVN B that resident was going to the ER for nausea and vomiting for issues relating to his ileotomy bag. She stated that DON A spoke to LVN A who admitted that she had been frustrated while providing care to Resident #1 and had not been her most professional self. She stated that LVN A had been required to complete additional training courses on customer service and received an in-service counseling on customer service. Interview on [DATE] at 04:55 p.m., LVN B stated on [DATE], she learned that the Resident #1 may have had blockage damage because the site had the inability to drain properly. She stated that the resident had been removing the ostomy system. She stated she used a stethoscope to listen for bowel sounds in the resident's abdomen finding none. She stated the resident's ileotomy bag was empty. She stated that the resident had not complained of any pain but stated that he had felt nauseous. She gave the resident some prn emodin D. She stated thereafter, the resident began projectile vomiting and she tried to ask the resident questions about his condition, with responses. She stated she left the room and about 09:00 a.m., Family #2 about preparations to send the resident to the ER. She stated CNA B and CNA C had come into the room and began cleaned up the resident and she attempted to use brown duo dermo tape to tape down the wafer the resident's stoma site, but resident's skin was moist from site drainage. She called EMT, the hospital and prepared the resident's discharged paperwork. She stated CNA B and CNA C had still been cleaning the resident when EMT arrived. She stated she informed the EMT of the resident's medical history. Interview on [DATE] at 06:35 p.m., Family #2 stated that that she had taken photographs on [DATE] of Resident #1 lying in the NF's bed covered in vomit and BM and had sent the photographs through text message. She stated that the resident told her in the early morning hours of [DATE] he had BMs from his rectum and his ileotomy bag had filled up quickly. She stated that the resident told her that the staff had come into the room [ROOM NUMBER]-times to change him and each time they would complaint and go back and forth about who was going to change him. She stated that he told her he had begun vomiting at 07:30 a.m. and told her that CNA B had come to clean him up 2-hours later. She stated throughout his stay at the facility, he had been hungry, and the staff had begun cutting his portions down so he would fill up his ileotomy bag slower. She stated when the resident arrived at the ER on [DATE], she learned that the resident could have intermitted BMs. In an observation/interview while at the hospital on [DATE] at 07:06 p.m., Resident #1 stated while at the NF LVN A would say, I am not going to clean up that mess and accused him of taking off his ileotomy bag. He stated that CNA B and LVN A kept acting like he was nasty when they had cleaned him up. He stated he sat in his mess for a long time. He stated that he felt better being at the hospital and the staff at the hospital were able to keep his ileotomy bag attached. He stated that he could not provide any exact dates or times but stated everyday his bag leaked on to the bed and onto his stomach. He stated in the late evening of [DATE], he had begun feeling nauseous and on the morning of [DATE], he vomited, 3-times and the NF sent him to the ER. Interview on [DATE] at 10:52 a.m. LVN C stated that he was on shift [DATE] from 6 a.m. to 6 p.m. and responsible for the nursing and ileostomy care for Resident #1 who he indicated had a cognitive rating of 3-4 out of 4, 4-being cognitively intact. He stated that he had complications adhering the wafer around the resident's stoma site his entire shift. He stated he had changed the ileotomy system 6-7 times because the wafer would not stay attached to the resident's skin. He stated the ileostomy leaked so quickly filling the ileotomy bag faster than normal causing a lot of liquid to excavate/come out from site and tubing, which further lead to more escalation from the stoma site. He stated he tried to reinforce the wafer with tape and strummer paste (adhesive paste). He stated the paste would be successful for a moment, but soon as the resident moved it would come off. He stated that he had interventions in place keep the wafer in place: strong adhesive, cleaned the area, and gave the skin around the stoma time to breathe and dry before applying a new wafer. He stated basically, every time the resident ate, liquid had swished out and pushed the wafer and bag off the resident. He stated the way the resident would favor laying on the right-side, same side as the stoma made it easier for the liquid bowel to [NAME] out. He stated that that he never had a patient like Resident #1 where the liquid would come gushing out from the stoma site and fill up the ileotomy bags so quickly. He stated he informed DON A and LVN F of the issues he had adhered the wafer to the resident. He stated he implemented a new intervention by laying towels and clean briefs on the bed near the stoma site to absorb some of the moisture. He stated on [DATE] he worked 6 a.m. to 6 p.m. and after experiencing a second day of issues with the resident's leaking stoma, contacted the resident's nurse practitioner (NP) making her aware of his new intervention to allow the site to dry and laying towels to absorb any leakage of which NP agreed with. He stated he asked the resident to be as still as possible to assist with keeping the wafer in place, but soon as the resident would fall asleep, he would involuntarily move, and the wafer would come off. He stated on the evening of [DATE], Family #2 was at bedside and witnessed the stoma area drying and the towels absorbing the moisture with concerns. He stated some of the feces was on the towel that had leaked from the uncovered stoma. He stated he explained to Family #2 that the laid towels were an intervention placed to absorb any moister from the leaking stoma, and that the stoma was uncovered to allow it to dry from leaking. He stated Family #2 stated she understood and had no concerns. He stated after that shift he had not seen the resident again. Interview on [DATE] at 11:00 a.m., CNA D stated that on [DATE] she was on shift from 6:00 a.m. to 2:00 p.m. as a PRN CNA that morning. She stated sometime that morning, exact time unknown, CNA B approached her from another hall to assist with Resident #1 who had a lot of drainage from his ileotomy bag and BMs from his rectum. She stated that she was needed to assist CNA B clean up the resident up for transport to the ER. She stated she was not familiar with the resident as she worked a different hall than where he resided. She stated she knew that the resident had not been at the NF long and learned that day that his staff were having difficulties with the resident's ileotomy bag draining. She stated when she entered the resident's room, she saw a very thin man lying in bed vomiting, bowel drainage from his uncovered stoma, bowel draining from his ileotomy bag, and having a BM from his rectum. She stated that majority

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs, for 1 (CR #1) of 5 Residents reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for CR #1 to address the risk for falls. This failure placed residents who were fall risk at risk of serious harm and injury. An Immediate Jeopardy (IJ) was identified on 1/16/2025. The IJ template was provided to the Administrator and DON on 1/16/2025 at 3:45pm. While the IJ was removed on 1/18/2025 at 1:11 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at an increased risk of decline, and diminished quality of life. Findings included: Record review of CR#1's face sheet dated 12/14/24 reflected a [AGE] year-old female with an original admission date of 10/20/22 and re-admission 1/12/25. Her diagnoses included: Alzheimer's/Dementia (Mental Decline), Hypertension (blood pressure is high) and coronary artery disease (the heart is not receiving enough oxygen and could lead to heart attack). Record review of CR#1's Orders dated 1/1/25 - 1/31/25 revealed CR#1's Meclzine HCI oral tablet 12.5 mg given in the morning for dizziness and was discontinued 1/14/25; Lactulose Encephalopathy Oral Solution 20 GM-Give 30ml by mouth one time a day for maintain ammonia levels**Do not hold for loose stools** order date 9/5/2024 at 1:07pm and D/C Date 1/8/2025 at 2:36pm; Lactulose Encephalopathy Oral Solution 20 GM-Give 30ml by mouth two times a day for maintain ammonia levels**Do not hold for loose stools** order date 1/8/2025 at 2:36pm and D/C Date 1/11/2025 at 5:06am Lactulose Encephalopathy Oral Solution 20 GM/30ML (Lactulose) Give 30ml by mouth three times a day for elevated Ammonia Level- Order date -Date 1/11/2025 at 5:08am and D/C Date 1/14/2025 Record review of CR#1's completed Quarterly MDS assessment dated [DATE] and completed 11/11/24, reflected CR#1 had a BIMS of 6 which suggest severe cognitive impairment. She used a walker for mobility. CR#1 requires supervision or touching to sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walk 10 feet, walk 50 feet with two turns, walk 150 feet. B1000 [Vision] - revealed CR#1 has adequate vision - see fine detail, such as regular print in newspapers/books. J1900 - revealed CR#1 had two or more falls since admission with no injury. Record review of CR#1's care plan dated 11/13/24 revealed the following care areas: Problem: [CR#1] is cognitively impaired and has problems with short term, long term, impaired ability to understand others, and impaired ability to make daily decisions Alzheimer's, Dementia. Goal: [CR#1] staff will assist daily due to cognitive loss during the next 90 days. Target Date: 11/18/2024. CR#1 needs will be met and dignity will maintained through the next review. Target Date: 11/18/2024 Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs, Cue, reorient and supervise as needed. Identify yourself at each interaction. Face the resident the resident when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close door etc. The CR#1understands consistent, simple, directive sentences. Provide the resident with necessary cures-stop and return if agitated. Keep my routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Problem: [CR#1] has impaired visual function r/t Other: (Age related). Goal: [CR#1] will show no decline in visual function through the review date. Target Date: 11/18/2024. Interventions: Anticipate and assist with all visual needs. Identify/record factors affecting visual function including Physiological (glaucoma, crohn's, macular degeneration, cataracts, color discrimination, light sensitivity, dry eyes); Environmental (poor lighting, monochromatic, color scheme), Choice (refuses to wear glasses, use mag glass, turn on lights) etc. Keep both eyes clean and free from matter. Monitor both eyes for redness, drainage, swelling, s/s of infection, notify MD as needed. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Problem: [CR#1] is at risk for falls and is at risk for increased falls and injury r/t Dementia, Deconditioning, Gait/Balance problems. Goal: Dignity will be maintained. Incident of falls will be reduced, and no occurrence of injury will occur through next review. Target Date: 11/18/2024. Interventions: Anticipate needs, provide prompt assistance with ADLs and other special needs. Be sure The resident's call light is within reach and encourage the [CR#1] to use it for assistance as needed. The [CR#1] needs prompt response to all requests for assistance. Bed in the lowest position. Coordinate with appropriate staff to ensure a safe environment with floors free of clutter, adequate glare free light, call light accessible, bed in lowest position, handrails on walls, and personal items within reach. Problem: [CR#1] has had an actual fall on 7/10/24 with no injury; 9/20/24 with no injury, and 10/17/24 with no injury. Goal: [CR#1] will resume usual activities without further incident through the review date. Target Date: 11/18/2024. Interventions: [CR#1] 10/17/24-Send to ER. 7/10/24: Transfer to ER for eval and treatment. 9/20/24-Safety rounds. Administer pain medications prn per MD order for any pain or discomfort. Anticipate needs, provide prompt assistance with ADLs and other special needs. Call MD and RP for any changes in condition. Monitor/document/report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Participate in Falling Star/Fall Prevention Program per facility protocol: Call Light and other personal items within easy reach Position bed to the lowest level Provide 1:1 activities if bedbound. Record review of CR#1's Fall Risk Evaluations and Chart dated 1/25/2025 at 7:17am revealed the following: Effective Date: 10/21/22 at 6:14pm a score of 12 of 28 - Risk Category: At Risk Effective Date: 10/28/22 at 2:20am a score of 12 of 28 - Risk Category: At Risk Effective Date: 10/28/22 at 6:14pm a score of 5 out of 28 - Risk Category: No Category Effective Date: 11/5/22 at 9:27pm a score of 14 out of 28 - Risk Category: At Risk Effective Date: 2/5/23 at 6:30pm a score 14 out of 28 - Risk Category: At Risk Effective Date: 5/5/23 at 5:34pm a score of 12 out of 28 - Risk Category: At Risk Effective Date: 7/10/24 at 4:14pm a score of 10 out of 28 - Risk Category: At Risk Effective Date: 8/19/2024 at 4:14pm a score of 13 out of 28 - Risk Category: At Risk Effective Date: 9/20/24 at 11:59 a score of 26 out of 28 - Risk Category: At Risk Effective Date: 10/17/24 a score of 21 out of 28 - Risk Category: At Risk Effective Date: 1/11/25 at 3:00pm score of 18 out of 28 - Risk Category: At Risk Effective Date: 1/12/25 at 7:17am a score of 11 out of 28 - Risk Category: At Risk Record Review of Discharge summary dated [DATE] at 3:12pm revealed the following: Discharge Diagnosis: Intraparenchymal hemorrhage of brain (CMA/HCC) (HCC). Hospital Course: [CR#1] female with PMH of Alzheimer's, dementia, who presented for a bifrontal contusions, and a R SDH s/p fall (unwitnessed) found down on the floor. Patient endorses R shoulder & arm pain, right flank pain and headache. Patient noted to have laceration to R eyebrow. Initial CTH unremarkable. Repeat CTH demonstrated [NAME] acute R frontal lobe IPH, acute R SHD, trace R frontal SAH, acute hemorrhage in L frontoparietal IPH. CT Maxillocial demonstrated acute inferior R orbital & maxillary sinus fracturs and possible 0.2 cm thickness R intraorbital hematoma. CT C-spine & x-ray of R humerus, negative for acute abnormalities. No AC/AP use. NSGY consulted requiring no acute interventions. Opthal consulted for R orbital fracture, with no acute interventions. Patient should cont. Augmentin x7 more days for sinus fx ppx per face team. Patient should cont 3 more days of Keppra for total of 7d sz ppx. Patient is tolerating PO diet and ambulation, vital signs and labs are stable. Medically clear for discharge to SNF. Record review of facility nursing notes dated 8/15/24 at 2:00pm by LPN revealed, CR#1 found on knees in her room after lunch, small scrape noted on R finger, CR#1 C/O pain in her hands. Assessment completed. Record review of facility nursing notes dated 9/20/24 at 7:24pm by LPN revealed, nurse notified by CR#1's roommates' visitor that CR#1 had fallen. Upon Entering, LPN observed CR#1 sitting on the floor at bedside. CR#1 did not remember falling. CR#1 assessed, and neuro checks completed. Record review of facility nursing notes dated 10/17/24 at 3:04pm by LVN revealed, CR#1's found sitting on the floor. CR#1 informed LVN she just fell but cannot recall how she fell. CR#1 assessed and sent to hospital. Record review [CR#1] Lab Results Report dated 1/8/2025 revealed Ammonia is critically high (85.0). Record review [CR#1] Lab Results Report dated 1/10/2025 revealed Ammonia is critically high (128.0) Record review of facility nursing notes dated 1/11/2025 at 2:17pm by LVN A [Un-witnessed fall 1/11/2025 1:36pm] revealed, Head to toe assessment, ROM performed and injuries skin teat to rt lower arm and bruises to rt eyebrow lower lt forearm. Alert and confused x2-3 able to make needs known and VS 139/78 97.5 71 20 97% on RA Neuro VSS no c/o pain or discomfort. Will cont to monitor. FM, DON and on-call called. Record review of facility nursing notes dated 1/11/2025 at 2:17pm by LVN A [Un-witnessed fall 1/11/2025 1:36pm] revealed, CR#1 fell again in room and was found on her butt and has a bruise to her rt side of head by eyebrow. Record review of facility nursing notes dated 1/11/2025 at 3:21pm by RN A revealed, CR#1 will be transferring to local hospital for CT (x-ray) scan of the head s/p un-witnessed fall, family informed of findings. Record review of facility's Neurological (15 minute) Assessment Flow Sheet revealed the following: 1/11/25 at 1:45pm - Completed by LVN A 1/11/25 at 2:00pm - Completed by LVN A 1/11/25 at 2:15pm - Completed by LVN A 1/11/25 at 2:30pm - Completed by LVN A 1/12/25 at 3:40am- Completed by LVN A Record review of nursing notes on 1/12/25 at 3:33am by LVN B reveal CR#1 returned from hospital - S/P unwitnessed fall due to unsteady gait. CR#1 denied pain or discomfort. Report received from hospital RN indicated CR#1 has no broken bones and no bleeds. Record review of nursing notes on 1/12/25 effective at 7:25am by LVN A revealed effective at 7:37am CR#1 will be transferring to local hospital for CT scan of the head and X-ray to Lt arm s/p un-witnessed fall, family, MD, and DON notified. Record review of nursing notes on 1/12/25 effective at 7:25am by LVN A revealed Head to toe assessment, ROM performed c/o pain to her head Lt arm offered pain meds and refused. Alert and confused x3 not able to make needs known and VS 136/79 97.4 71 20 97% on RA, Neuro VS cont. Will cont monitor. CR#1CR#1 will be transferring to local hospital. Record review of nursing notes on 1/16/2025 effective at 7:30pm by BT revealed, CR#1 readmitted to facility around 7:30pm via stretcher under care of PCP with DX: Bifrontal contusion and R SDH. CR#1 has a history of Dementia and is a high fall risk. Sitter at bedside for safety. Medication reconsolidated with MD. Residents to continue ABT X 7 days and Keppra x 3 days more days. Head to toe assessment completed. Vitals: B/P 157/78 P:64 Temp:97.3 R:18 Resident has bruise on right eye with 4 sutures, forehead and on right arm w/contracture but denies pain. Night medication administered. Family and DON notified of arrival. Record review of the facility's Comprehensive Care Plans policy dated 04/2023 revealed the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Interview on 1/14/25 at 10:39am with CI - it was revealed that the concerns were the continuous unwitnessed falls and the appearance of a lack of staff supervision. Indicated CR#1 had unwitnessed falls 3 times over the weekend, twice in one day on 1/11/24 (2:17pm & 2:39pm), which was less than 30 minutes apart; the second fall resulted in injuries and a trip to the hospital. Confidential continued concern ignited with CR#1 returned from the hospital on 1/12/25 at 3:30am and at 7:30am had to be taken back to the hospital with multiple injuries and bruises, being a broken jaw, brain bleed, bruises and a fractured arm. There has not been meetings concerning interventions for CR#1's falls. Observation on 01/14/25 at 11:50am of CR#1's room, revealed bed not in a low position, no floor mates, no stars on the door and no star on the wall, which according to the facility, would notify all staff of a fall risk. Telephone Interview on 1/14/2025 at 1:48pm CNA B - Stated she is familiar with CR#1. She stated she is a floater in the facility and is not directly assigned to any one area. She stated CR#1 always walking a lot in the facility. States the CR#1 was walking perfectly fine about a week ago. CNA B stated she could not remember if resident was a fall risk and she had not seen a star on her door that would indicate CR#1 was a fall risk. She stated there was nothing in the care plan that required more frequent rounds. Interview on 1/14/2025 at 2:38pm with DON stated she was aware CR#1 had fallen twice on 1/11/2025. The DON was informed during the initial fall CR#1 was assessed and LVN A was directed to call the PCP. DON further stated CR#1 ambulates by herself. CR#1 likes to get in her closet and attempt to get clothes because CR#1 tells staff she is leaving so she packs her clothes. DON states that staff are informed to keep CR#1's clothes within reach because it prevents CR#1's attempts to get into the closet and risk falling. DON stated CR#1 is impulsive and CR#1's elevated Ammonia levels played a part in contributing to confusion and falling. DON stated fall precautions were in place in CR#1 care plan and MDS. DON stated staff were always checking on resident. DON stated CR#1 was on isolation at this time. DON states staff are informed to do frequent rounds, which is every two hours for CNA's and Nurses. States she will check with her staff to get the rounding requirements for CNA's and Nurses. DON stated Neuro checks were in place. CR#1 was sent out to local hospital after the second fall returned to the facility and again had an unwitnessed fall the third time, which she was sent back to the local hospital. Telephone Interview on 1/14/2025 at 2:49pm with LVN A stated on 1/11/2025, a CNA called out for help and she and she responded with the CNA. LVN A could not remember the CNA who called out. LVN A observed CR#1 on the floor. LVN A Completed head to toe assessment and ensured CR#1's ROM was Ok. LVN A observed CR#1 had a little skin tear on her arm and cleaned the area up, put a band-aid on the arm. LVN A stated the other arm sustained a small bruise. Stated she contacted PCP and CR#1's representative. She stated CR#1 told her she was putting on her shirt and she fell. LVN A stated the CNA helped CR#1 put her shirt on. LVN A still could not recall the name of the CNA who assisted her. LVN A stated on the second fall, CR#1 was found by a CNA and the CNA called and stated, she's on the floor again. This time CR#1 had other injuries in the facial area (eyebrow) and this time CR#1's representative was called and told CR#1 sent out to hospital. While waiting for EMS, LVN A stated CR#1 was placed in her wheelchair, stayed by nurses' station until EMS came. LVN A stated when the EMS came to pick CR#1 up, they were informed CR#1 had high levels of Ammonia. LVN A observed CR#1 has been up in about, but with an unsteady gait. LVN A stated CR#1 eats in dining area with other residents. CR#1 walks on a walker. LVN A stated she has observed CR#1 has really been unsteady and in the last few months has been required to use her walker continuously. LVN A further stated CR#1 was getting therapy. LVN A stated CR#1 refused to comply to verbal direction to walk with her walker. Telephone Interview on 1/14/2025 at 3:22pm CNA C stated she worked a double shift (6a-2p and 2p -10p). CNA C stated she worked with CR#1 on the 1/11/25. During the 2pm - 10pm she was informed CR#1 had fallen but did not witness the fall. She stated she was not in the area at that time. CNA C stated she could not remember who told her CR#1had fallen. CNA C stated she is required to make rounds every 2 hours and she makes more rounds more frequently if the resident is at risk. CNA C stated CR#1 is a fall risk, but she is not aware of the care plan requiring more frequent rounds. CNA C stated she is always redirecting CR#1 to use her wheelchair or walker because CR#1 doesn't like to all the time. Telephone Interview on 1/14/2025 @ 4:35pm with LPN B - Stated she was working when resident returned from the hospital 3:30am 1/12/2025. Stated when CR#1 returned from the hospital she was at her baseline as CR#1 was giving thank you's to the EMS personnel who transferred her from their stretcher to her bed. LPN B stated CR#1 stated she wanted to go to sleep. She stated CR#1 already had on her gown and CNA A went to the room to ensure CR#1 had fresh water and ensuring she was safe, then completed her rounds. LPN B stated CR#1 preferred her room the door closed, but she left it slightly cracked opened. LPN B stated CR#1 was under her care, and she completed neuros and documented in her chart (nursing notes) neuros back in place and updated care plan. LVN B stated she did not document on the neurological assessment flow sheet. She stated the care plan did not require additional or more frequent rounds than what was required by nursing staff (every two hours). LVN B stated she went into CR#1's room before her last round about 5:30am and CR#1 was still sleeping, she stated she completed other rounds then left the facility around 6:00am. Follow-Up Telephone interview on 1/14/2025 at 4 :49pm with LVN A - She mentioned she started the Neuro checks on CR#1 after her first fall. She stated those checks are completed on the neurological assessment flow sheet and a note in the PCC. LVN A stated it is a responsibility of the nurses to update the care plans for the residents. She stated the care plan did not require additional or more frequent rounds that what was required by nursing staff. Telephone interview with CNA A on 1/14/2025 at 5:07pm-She stated she worked the 10p-6am shift on 1/11/25. States the ambulance brought CR#1 to facility early morning 1/12/2025. She stated the ambulance put CR#1 in the bed. CNA A stated she checked on CR#1 during her last rounds and CR#1was still sleeping. She stated CR#1's door was cracked open a little. States CR#1 did not get up during her shift. Stated she would have completed rounds more often had she known CR#1 was a fall risk. Stated when she left the facility CR#1 was in bed sleep. Stated she received training in the form of orientation. Interview with PT on 1/14/2025 at 5:27pm- stated she has been treating CR#1on and off for a few years. PT stated CR#1 has bad dementia. PT stated CR#1 should use her walker or wheelchair to get around the facility. PT stated CR#1 had a significant decline in motor skills after having Covid around February 2024. PT stated CR#1was in therapy from 7/13/24 - 9/20/24. PT stated CR#1 was evaluated for additional therapy on 1/6/24. PT stated she went to check on CR#1 in her room and was informed by nursing staff CR#1 had had a fall and went to the hospital. Interview with R#2 on 1/14/2025 at 5:58pm stated she witnessed the second fall on 1/11/25 because she was in CR#1's room. Stated CR#1 was trying to get up from a seated position and fell backwards. She stated staff does not check on CR#1 often; however, when CR#1 is in the common area, and she try to stand up staff will redirect. Observation on 1/15/25 at 10:50am revealed CR#1 lying in bed in the local hospital room. CR#1 appeared to have a black and blue eye on the right side and stitches above the brow area. CR#1's arm was bruised from the upper arm to the wrist area. The nurse assisted me by lifting the comforter and showing where CR#1 sustained bruising on her right thigh area upper thigh area a tear on her thigh her leg and a very swollen black and blue in color kneecap. Follow-Up Interview with DON on 1/15/2025 at 4:10pm - Who stated there wasn't enough time to put in additional interventions for the CR#1 as the falls were frequent and resulted in hospitalization. DON stated when CR#1 returned to the facility it was 3:30am and then CR#1 fell again and was taken to the hospital 7:30am. DON stated the interventions that will be in place when CR#1 returns to the facility will be a conference with CR#1's representative to see if CR#1 is a good fit for the facility. DON stated CR#1 has previously fallen, been placed on fall preventions, given physical and occupational therapy. Telephone Interview with CNA D on 1/16/2025 at 8:00am -Stated she worked the morning of 1/12/2025 on the 6am - 2pm shift. She stated she was the CNA assigned to CR#1. Stated she was assisting another resident who was in a contaminated room and did not witness the CR#1 fall nor hear a scream. CNA D stated she was informed afterwards and did see resident CR#1 before she went to the hospital. She stated CR#1 appeared to be disoriented and really confused. Stated CR#1 is usually independent and walks on her own and she sometimes has a wheelchair she uses but not often. CNA D stated she doesn't know why CR#1 was falling so much. CNA stated CR#1 did not have a yellow star on her door that she can remember. CNA D stated residents who are considered high fall risk also wear a wrist band. She stated she never observed CR#1 with a wrist band. She stated it was only 2 nurses and 2 CNA's working that shift. She stated there was no indication in CR#1's chart that indicated more frequent rounds should be completed. Interview with CNA E on 1/16/2025 at 10:00am-Stated she was working 6:00am - 2:00pm shift on 1/12/2025. She stated there were only two CNAs working the entire shift. Stated LVN A called her to CR#1's room to assist regarding CR#1's fall. CNA E she stated when she arrived in CR#1's room she witnessed LVN A was asking CR#1 questions. CNA E stated she yelled for the assigned CNA D and when CNA D arrived, she left the room and returned to her section to care for residents assigned to her. CNA E stated her last training was two weeks ago and residents who are fall risk has a star on their door. Interview with PCP on 1/16/25 at 11:50am stated she is notified on incidents regarding residents through NP or the on-call services. PCP Stated she has had concerns about CR#1's repeated falls. Stated the interventions tried were challenging to CR#1 because the interventions would have limited her functions. PCP stated most of CR#1's function related falls were attributed to her cognitive ability. PCP stated she has seen a significant decline in CR#1's cognitive area in the last year. Stated CR#1 was to use her wheelchair, but because CR#1 was so independent a lot of times she wouldn't. The skilled nursing is under the therapy department and occurs after hospitalization, which CR#1 has had in the past. CR#1's Cognitive area was limited and declining because the dementia has progressed this past year. PCP stated memory care could be more appropriate; however, there has not been a conversation in the past even though the progressive decline in CR#1 cognitive area and constant falls were occurring. PCP stated that there are many factors to resident placement in a memory care facility. One factor having to be Financial and if the insurance would pay for that type of care. PCP stated that once CR#1 returns to the facility and after a review of hospital documentation, PCP stated that that would be an intervention to address. Clarification Interview with DON on 1/16/2025 at 3:20pm-DON stated she is ultimately responsible for updating and developing the care plans. However, the nursing staff must update during the time of the incident (ex. Falls, etc). During the morning staff meetings, there are staff report on falls, etc. Based on the morning reports, care plans are reviewed during the meeting and given a finalization as long as the update doesn't restrict the resident's ability to function. An Immediate Jeopardy (IJ) was identified due to the above failures. The ADMIN and DON were notified and provided with the IJ template on 1/16/2025 at 3:45 p.m. Observed and Interviewed CR#1 in her room on 1/17/2025 at 11:10am -CR#1's personal appearance was clean, HOB raised and she was watching television and talking with her 1:1 aide, CNA F. CR#1 appeared to be alert, responding, and giving eye contact. When asked how things were going CR#1 stated she was feeling better then gave surveyor a compliment on hair and clothing items. CR#1 began rambling while attempting to speak, but there was no understanding. Interviewed CNA F on 1/17/2025 @ 11:20am who stated she is very familiar with CR#1 and her fall issues. She stated she is doing 1:1 with resident until further notice. Stated she and CR#1 had a good relationship, then CR#1 interrupted and stated she loved CNA F. The following Plan of Removal submitted by the facility was accepted on 01/17/2025 at 1:11 p.m. and included: Name of facility: Fall [NAME] Rehabilitation and Healthcare Center Date: 1/16/25 F 656 Care Plan Problem: The facility failed to develop and implement a comprehensive person-centered care plan for CR#1, which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The facility failed to implement preventive measures for CR#1's continuous falls, which resulted in severe injuries. On 1/11/2025 CR#1 fell at 2:17pm with minor injuries and again 22 minutes later at 2:39pm resulting in serious injuries requiring hospitalization. CR#1 was returned to the facility on 1/12/25 at 3:33am and at 7:37am CR#1 transferred to hospital for another unwitnessed fall. The facility failed to ensure CR#1, was provided the needed care and services to decrease the risk of falls through a person-centered care plan. CR#1 readmitted to facility this evening. Immediate action: 1. 1/13 /25 The facility administrator completed a self-report incident to HHSC due to unwitnessed fall with major injury. 2. 1/16/25The facility conducted an audit of residents with fall risk assessment with no risk scores 0-4 and at-risk scores 5-30 to ensure their comprehensive person-centered care plans are appropriate and meet their individual needs. No additional concerns were identified. Completed 1/17/25 3. On 1/16/25 The Don/Designee immediately initiated an audit of residents' currently residing in the facility comprehensive care plans who have had falls in the last 16 days, 6 residents with 8 falls where reviewed, to ensure fall prevention interventions are objective, measurable and timely. No additional concerns noted. Completed 1/16/25. 4. On 1/16/25 The Corporate nurse conducted a 1:1 in-service with the DON on the facility Fall Prevention Program Policy focusing on timely implementation of person center care plans to include adding measures that objectively meet the resident's needs. Interventions: 5. On 1/16/25 the DON/Designee initiated an in-service with the facility Licensed nursing staff on The Fall Prevention program. This included an explanation of Risk Assessments indicating fall risk and or no risk and the different interventions based on Fall risk assessment as well as the licensed nurse responsibility to immediately implement interventions to prevent or further prevent residents falls and injuries. Projected completion 1/17/25 6. On1/16/25 the DON/Designee initiated an in-service with the facility staff on the Fall Prevention Program Policy to include the Falling Star Program. A gold Star is added to the Resident name on the door, on their wheelchair/Walker and above their bed to alert Staff, the resident has had a fall and is at risk for additional falls. Projected completion on 1/17/25 7. On 1/16/25 the DON/Designee initiated an in-service with licensed nurses on immediately reporting all resident falls to the DON and or Administrator to seek guidance and ensure appropriate interventions are put in place following a residents fall. Projected completion 1/17/25 8. On 1/16/25 the Regional Corporate nurse/Designee initiated and in-service with the nurse managers and licensed nurses on the Facility Policy for Comprehensive Care Plans focusing on promptly updating resident plan of care following each fall with interventions to meet the residents' individualized needs, DON/MDS nurse and Designee will monitor care plans for appropriateness and completion. Completion date 1/17/25 Ongoing Projected completion 1/17/25 Any staff member not present or in service, will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 9. On 1/16/25 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 1/17/25. 10. Starting on 1/17/25 the facility Adm/Don and designee will review prior day falls and comprehensive care plans to ensure interventions chosen are individualized, appropriate and effective. Any interventions noted to be inadequate will be changed at that time. Completed 1/17/25. 11. An impromptu QAPI meeting was conducted with the facility's Medical Director, Dr. [NAME] on 1/16/25 to notify of the potential for non-compliance and the act[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (CR#1) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure precautionary interventions in place CR #1, who was a known fall risk that resulted in falls with serious injuries and multiple hospitalization. An Immediate Jeopardy (IJ) was identified on 1/16/2025. The IJ template was provided to the Administrator and DON on 1/16/2025 at 3:45pm. While the IJ was removed on 1/18/2025 at 4:29 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed facility residents who were fall risk at risk of serious harm and injury. Findings included: Record review of CR#1's face sheet dated 12/14/24 reflected a [AGE] year-old female with an original admission date of 10/20/22 and re-admission 1/12/25. Her diagnoses included: Alzheimer's/Dementia (Mental Decline), Hypertension (blood pressure is high) and coronary artery disease (the heart is not receiving enough oxygen and could lead to heart attack). Record review of CR#1's Orders dated 1/1/25 - 1/31/25 revealed CR#1's Meclzine HCI oral tablet 12.5 mg given in the morning for dizziness and was discontinued 1/14/25; Lactulose Encephalopathy Oral Solution 20 GM-Give 30ml by mouth one time a day for maintain ammonia levels**Do not hold for loose stools** order date 9/5/2024 at 1:07pm and D/C Date 1/8/2025 at 2:36pm; Lactulose Encephalopathy Oral Solution 20 GM-Give 30ml by mouth two times a day for maintain ammonia levels**Do not hold for loose stools** order date 1/8/2025 at 2:36pm and D/C Date 1/11/2025 at 5:06am Lactulose Encephalopathy Oral Solution 20 GM/30ML (Lactulose) Give 30ml by mouth three times a day for elevated Ammonia Level- Order date -Date 1/11/2025 at 5:08am and D/C Date 1/14/2025 Record review of CR#1's completed Quarterly MDS assessment dated [DATE] and completed 11/11/24, reflected CR#1 had a BIMS of 6 which suggest severe cognitive impairment. She used a walker for mobility. CR#1 requires supervision or touching to sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walk 10 feet, walk 50 feet with two turns, walk 150 feet. B1000 [Vision] - revealed CR#1 has adequate vision - see fine detail, such as regular print in newspapers/books. J1900 - revealed CR#1 had two or more falls since admission with no injury. Record review of CR#1's care plan dated 11/13/24 revealed the following care areas: Problem: [CR#1] is cognitively impaired and has problems with short term, long term, impaired ability to understand others, and impaired ability to make daily decisions Alzheimer's, Dementia. Goal: [CR#1] staff will assist daily due to cognitive loss during the next 90 days. Target Date: 11/18/2024. CR#1 needs will be met and dignity will maintained through the next review. Target Date: 11/18/2024 Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs, Cue, reorient and supervise as needed. Identify yourself at each interaction. Face the resident the resident when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close door etc. The CR#1understands consistent, simple, directive sentences. Provide the resident with necessary cures-stop and return if agitated. Keep my routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Problem: [CR#1] has impaired visual function r/t Other: (Age related). Goal: [CR#1] will show no decline in visual function through the review date. Target Date: 11/18/2024. Interventions: Anticipate and assist with all visual needs. Identify/record factors affecting visual function including Physiological (glaucoma, crohn's, macular degeneration, cataracts, color discrimination, light sensitivity, dry eyes); Environmental (poor lighting, monochromatic, color scheme), Choice (refuses to wear glasses, use mag glass, turn on lights) etc. Keep both eyes clean and free from matter. Monitor both eyes for redness, drainage, swelling, s/s of infection, notify MD as needed. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Problem: [CR#1] is at risk for falls and is at risk for increased falls and injury r/t Dementia, Deconditioning, Gait/Balance problems. Goal: Dignity will be maintained. Incident of falls will be reduced, and no occurrence of injury will occur through next review. Target Date: 11/18/2024. Interventions: Anticipate needs, provide prompt assistance with ADLs and other special needs. Be sure The resident's call light is within reach and encourage the [CR#1] to use it for assistance as needed. The [CR#1] needs prompt response to all requests for assistance. Bed in the lowest position. Coordinate with appropriate staff to ensure a safe environment with floors free of clutter, adequate glare free light, call light accessible, bed in lowest position, handrails on walls, and personal items within reach. Problem: [CR#1] has had an actual fall on 7/10/24 with no injury; 9/20/24 with no injury, and 10/17/24 with no injury. Goal: [CR#1] will resume usual activities without further incident through the review date. Target Date: 11/18/2024. Interventions: [CR#1] 10/17/24-Send to ER. 7/10/24: Transfer to ER for eval and treatment. 9/20/24-Safety rounds. Administer pain medications prn per MD order for any pain or discomfort. Anticipate needs, provide prompt assistance with ADLs and other special needs. Call MD and RP for any changes in condition. Monitor/document/report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Participate in Falling Star/Fall Prevention Program per facility protocol: Call Light and other personal items within easy reach Position bed to the lowest level Provide 1:1 activities if bedbound. Record review of CR#1's Fall Risk Evaluations and Chart dated 1/25/2025 at 7:17am revealed the following: Effective Date: 10/21/22 at 6:14pm a score of 12 of 28 - Risk Category: At Risk Effective Date: 10/28/22 at 2:20am a score of 12 of 28 - Risk Category: At Risk Effective Date: 10/28/22 at 6:14pm a score of 5 out of 28 - Risk Category: No Category Effective Date: 11/5/22 at 9:27pm a score of 14 out of 28 - Risk Category: At Risk Effective Date: 2/5/23 at 6:30pm a score 14 out of 28 - Risk Category: At Risk Effective Date: 5/5/23 at 5:34pm a score of 12 out of 28 - Risk Category: At Risk Effective Date: 7/10/24 at 4:14pm a score of 10 out of 28 - Risk Category: At Risk Effective Date: 8/19/2024 at 4:14pm a score of 13 out of 28 - Risk Category: At Risk Effective Date: 9/20/24 at 11:59 a score of 26 out of 28 - Risk Category: At Risk Effective Date: 10/17/24 a score of 21 out of 28 - Risk Category: At Risk Effective Date: 1/11/25 at 3:00pm score of 18 out of 28 - Risk Category: At Risk Effective Date: 1/12/25 at 7:17am a score of 11 out of 28 - Risk Category: At Risk Record Review of Discharge summary dated [DATE] at 3:12pm revealed the following: Discharge Diagnosis: Intraparenchymal hemorrhage of brain (CMA/HCC) (HCC). Hospital Course: [CR#1] female with PMH of Alzheimer's, dementia, who presented for a bifrontal contusions, and a R SDH s/p fall (unwitnessed) found down on the floor. Patient endorses R shoulder & arm pain, right flank pain and headache. Patient noted to have laceration to R eyebrow. Initial CTH unremarkable. Repeat CTH demonstrated [NAME] acute R frontal lobe IPH, acute R SHD, trace R frontal SAH, acute hemorrhage in L frontoparietal IPH. CT Maxillocial demonstrated acute inferior R orbital & maxillary sinus fracturs and possible 0.2 cm thickness R intraorbital hematoma. CT C-spine & x-ray of R humerus, negative for acute abnormalities. No AC/AP use. NSGY consulted requiring no acute interventions. Opthal consulted for R orbital fracture, with no acute interventions. Patient should cont. Augmentin x7 more days for sinus fx ppx per face team. Patient should cont 3 more days of Keppra for total of 7d sz ppx. Patient is tolerating PO diet and ambulation, vital signs and labs are stable. Medically clear for discharge to SNF. Record review of facility nursing notes dated 8/15/24 at 2:00pm by LPN revealed, CR#1 found on knees in her room after lunch, small scrape noted on R finger, CR#1 C/O pain in her hands. Assessment completed. Record review of facility nursing notes dated 9/20/24 at 7:24pm by LPN revealed, nurse notified by CR#1's roommates' visitor that CR#1 had fallen. Upon Entering, LPN observed CR#1 sitting on the floor at bedside. CR#1 did not remember falling. CR#1 assessed, and neuro checks completed. Record review of facility nursing notes dated 10/17/24 at 3:04pm by LVN revealed, CR#1's found sitting on the floor. CR#1 informed LVN she just fell but cannot recall how she fell. CR#1 assessed and sent to hospital. Record review [CR#1] Lab Results Report dated 1/8/2025 revealed Ammonia is critically high (85.0). Record review [CR#1] Lab Results Report dated 1/10/2025 revealed Ammonia is critically high (128.0) Record review of facility nursing notes dated 1/11/2025 at 2:17pm by LVN A [Un-witnessed fall 1/11/2025 1:36pm] revealed, Head to toe assessment, ROM performed and injuries skin teat to rt lower arm and bruises to rt eyebrow lower lt forearm. Alert and confused x2-3 able to make needs known and VS 139/78 97.5 71 20 97% on RA Neuro VSS no c/o pain or discomfort. Will cont to monitor. FM, DON and on-call called. Record review of facility nursing notes dated 1/11/2025 at 2:17pm by LVN A [Un-witnessed fall 1/11/2025 1:36pm] revealed, CR#1 fell again in room and was found on her butt and has a bruise to her rt side of head by eyebrow. Record review of facility's Neurological (15 minute) Assessment Flow Sheet by LVN A revealed the following: 1/11/25 at 1:45pm - Completed by LVN A 1/11/25 at 2:00pm - Completed by LVN A 1/11/25 at 2:15pm - Completed by LVN A 1/11/25 at 2:30pm - Completed by LVN A 1/12/25 at 3:40am- Completed by LVN A Record review of nursing notes on 1/12/25 at 3:33am by LVN B reveal CR#1 returned from hospital - S/P unwitnessed fall due to unsteady gait. CR#1 denied pain or discomfort. Report received from hospital RN indicated CR#1 has no broken bones and no bleeds. Record review of nursing notes on 1/12/25 effective at 7:25am by LVN A revealed effective at 7:37am CR#1 will be transferring to local hospital for CT scan of the head and X-ray to Lt arm s/p un-witnessed fall, family, MD, and DON notified. Record review of nursing notes on 1/12/25 effective at 7:25am by LVN A revealed Head to toe assessment, ROM performed c/o pain to her head Lt arm offered pain meds and refused. Alert and confused x3 not able to make needs known and VS 136/79 97.4 71 20 97% on RA, Neuro VS cont. Will cont monitor. CR#1CR#1 will be transferring to local hospital. Record review of nursing notes on 1/16/2025 effective at 7:30pm by BT revealed, CR#1 readmitted to facility around 7:30pm via stretcher under care of PCP with DX: Bifrontal contusion and R SDH. CR#1 has a history of Dementia and is a high fall risk. Sitter at bedside for safety. Medication reconsolidated with MD. Residents to continue ABT X 7 days and Keppra x 3 days more days. Head to toe assessment completed. Vitals: B/P 157/78 P:64 Temp:97.3 R:18 Resident has bruise on right eye with 4 sutures, forehead and on right arm w/contracture but denies pain. Night medication administered. Family and DON notified of arrival. Record review of the facility's Fall Prevention Program policy dated 01/2023 revealed the following: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines revealed the following: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. a. The risk assessment categorizes residents according to low, moderate, or high risk b. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. 2. Upon admission the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate on the fall risk assessment the resident's fall risk and initiate interventions on the resident's baseline care plan. 4. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. 6. High Risk Protocols: C. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, it's psychological, cognitive status, or recent change in functional status. D. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. System devices ii. Increase frequency of rounds iii. Sitter, if direct if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii. Schedule ambulation or toileting assistance viii. Family/caregiver or resident education ix. Therapy services referral x. Place Fall Prevention Indicator (Star) on the name plate to residence room xi. Place Fall Prevention Indicator (Star) on residents wheelchair. Interview on 1/14/25 at 10:39am with CI - it was revealed that the concerns were the continuous unwitnessed falls and the appearance of a lack of staff supervision. Indicated CR#1 had unwitnessed falls 3 times over the weekend, twice in one day on 1/11/24 (2:17pm & 2:39pm), which was less than 30 minutes apart; the second fall resulted in injuries and a trip to the hospital. Confidential continued concern ignited with CR#1 returned from the hospital on 1/12/25 at 3:30am and at 7:30am had to be taken back to the hospital with multiple injuries and bruises, being a broken jaw, brain bleed, bruises and a fractured arm. There had not been meetings concerning interventions for CR#1's falls. Observation on 01/14/25 at 11:50am of CR#1's room, revealed bed not in a low position, no floor mates, no stars on the door and no star on the wall, which according to the facility, would notify all staff of a fall risk. Telephone Interview on 1/14/2025 at 1:48pm CNA B - Stated she is familiar with CR#1. She stated she is a floater in the facility and is not directly assigned to any one area. She stated CR#1 always walking a lot in the facility. States the CR#1 was walking perfectly fine about a week ago. CNA B stated she could not remember if resident was a fall risk and she had not seen a star on her door that would indicate CR#1 was a fall risk. She stated there was nothing in the care plan that required more frequent rounds. Interview on 1/14/2025 at 2:38pm with DON stated she was aware CR#1 had fallen twice on 1/11/2025. The DON was informed during the initial fall CR#1 was assessed and LVN A was directed to call the PCP. DON further stated CR#1 ambulates by herself. CR#1 likes to get in her closet and attempt to get clothes because CR#1 tells staff she is leaving so she packs her clothes. DON states that staff are informed to keep CR#1's clothes within reach because it prevents CR#1's attempts to get into the closet and risk falling. DON stated CR#1 is impulsive and CR#1's elevated Ammonia levels played a part in contributing to confusion and falling. DON stated fall precautions were in place in CR#1 care plan and MDS. DON stated staff were always checking on resident. DON stated CR#1 was on isolation at this time. DON states staff are informed to do frequent rounds, which is every two hours for CNA's and Nurses. States she will check with her staff to get the rounding requirements for CNA's and Nurses. DON stated Neuro checks were in place. CR#1 was sent out to local hospital after the second fall returned to the facility and again had an unwitnessed fall the third time, which she was sent back to the local hospital. Telephone Interview on 1/14/2025 at 2:49pm with LVN A stated on 1/11/2025, a CNA called out for help and she and she responded with the CNA. LVN A could not remember the CNA who called out. LVN A observed CR#1 on the floor. LVN A Completed head to toe assessment and ensured CR#1's ROM was Ok. LVN A observed CR#1 had a little skin tear on her arm and cleaned the area up, put a band-aid on the arm. LVN A stated the other arm sustained a small bruise. Stated she contacted PCP and CR#1's representative. She stated CR#1 told her she was putting on her shirt and she fell. LVN A stated the CNA helped CR#1 put her shirt on. LVN A still could not recall the name of the CNA who assisted her. LVN A stated on the second fall, CR#1 was found by a CNA and the CNA called and stated, she's on the floor again. This time CR#1 had other injuries in the facial area (eyebrow) and this time CR#1's representative was called and told CR#1 sent out to hospital. While waiting for EMS, LVN A stated CR#1 was placed in her wheelchair, stayed by nurses' station until EMS came. LVN A stated when the EMS came to pick CR#1 up, they were informed CR#1 had high levels of Ammonia. LVN A observed CR#1 has been up in about, but with an unsteady gait. LVN A stated CR#1 eats in dining area with other residents. CR#1 walks on a walker. LVN A stated she has observed CR#1 has really been unsteady and in the last few months has been required to use her walker continuously. LVN A further stated CR#1 was getting therapy. LVN A stated CR#1 refused to comply to verbal direction to walk with her walker. Telephone Interview on 1/14/2025 at 3:22pm CNA C stated she worked a double shift (6a-2p and 2p -10p). CNA C stated she worked with CR#1 on the 1/11/25. During the 2pm - 10pm she was informed CR#1 had fallen but did not witness the fall. She stated she was not in the area at that time. CNA C stated she could not remember who told her CR#1had fallen. CNA C stated she is required to make rounds every 2 hours and she makes more rounds more frequently if the resident is at risk. CNA C stated CR#1 is a fall risk, but she is not aware of the care plan requiring more frequent rounds. CNA C stated she is always redirecting CR#1 to use her wheelchair or walker because CR#1 doesn't like to all the time. Telephone Interview on 1/14/2025 @ 4:35pm with LPN B - Stated she was working when resident returned from the hospital 3:30am 1/12/2025. Stated when CR#1 returned from the hospital she was at her baseline as CR#1 was giving thank you's to the EMS personnel who transferred her from their stretcher to her bed. LPN B stated CR#1 stated she wanted to go to sleep. She stated CR#1 already had on her gown and CNA A went to the room to ensure CR#1 had fresh water and ensuring she was safe, then completed her rounds. LPN B stated CR#1 preferred her room the door closed, but she left it slightly cracked opened. LPN B stated CR#1 was under her care, and she completed neuros and documented in her chart (nursing notes) neuros back in place and updated care plan. LVN B stated she did not document on the neurological assessment flow sheet. She stated the care plan did not require additional or more frequent rounds than what was required by nursing staff (every two hours). LVN B stated she went into CR#1's room before her last round about 5:30am and CR#1 was still sleeping, she stated she completed other rounds then left the facility around 6:00am. Follow-Up Telephone interview on 1/14/2025 at 4:49pm with LVN A - She mentioned she started the Neuro checks on CR#1 after her first fall. She stated those checks are completed on the neurological assessment flow sheet and a note in the PCC. LVN A stated it is a responsibility of the nurses to update the care plans for the residents. She stated the care plan did not require additional or more frequent rounds that what was required by nursing staff. Telephone interview with CNA A on 1/14/2025 at 5:07pm-She stated she worked the 10p-6am shift on 1/11/25. States the ambulance brought CR#1 to facility early morning 1/12/2025. She stated the ambulance put CR#1 in the bed. CNA A stated she checked on CR#1 during her last rounds and CR#1was still sleeping. She stated CR#1's door was cracked open a little. States CR#1 did not get up during her shift. Stated she would have completed rounds more often had she known CR#1 was a fall risk. Stated when she left the facility CR#1 was in bed sleep. Stated she received training in the form of orientation. Interview with PT on 1/14/2025 at 5:27pm- stated she has been treating CR#1on and off for a few years. PT stated CR#1 has bad dementia. PT stated CR#1 should use her walker or wheelchair to get around the facility. PT stated CR#1 had a significant decline in motor skills after having Covid around February 2024. PT stated CR#1was in therapy from 7/13/24 - 9/20/24. PT stated CR#1 was evaluated for additional therapy on 1/6/24. PT stated she went to check on CR#1 in her room and was informed by nursing staff CR#1 had had a fall and went to the hospital. Interview with R#2 on 1/14/2025 at 5:58pm stated she witnessed the second fall on 1/11/25 because she was in CR#1's room. Stated CR#1 was trying to get up from a seated position and fell backwards. She stated staff does not check on CR#1 often; however, when CR#1 is in the common area, and she try to stand up staff will redirect. Interview with HN on 1/15/2025 at 10:27am - who stated CR#1 was admitted to the hospital 1/12/2025 at 7:30am. She stated CR#1 was transported to hospital by EMS. HN stated resident had an admitting diagnosis of Intraparenchymal Hemorrhage of the Brain. Current Diagnosis is Right frontal Lobe IPA, Right Subdural, Broken jaw. She stated according to CR#1's labs drawn 1/13/2025 CR#1 has a UTI. She stated resident released a large amount of stool, which decreased her levels of Ammonia. She stated there were no signs of fractures on her right side, just bruising. She also stated based on lab reports the resident did not have sepsis. Observation on 1/15/25 at 10:50am revealed CR#1 lying in bed in the local hospital room. CR#1 appeared to have a black and blue eye on the right side and stitches above the brow area. CR#1's arm was bruised from the upper arm to the wrist area. The nurse assisted me by lifting the comforter and showing where CR#1 sustained bruising on her right thigh area upper thigh area a tear on her thigh her leg and a very swollen black and blue in color kneecap. Follow-Up Interview with DON on 1/15/2025 at 4:10pm - Who stated there wasn't enough time to put in additional interventions for the CR#1 as the falls were frequent and resulted in hospitalization. DON stated when CR#1 returned to the facility it was 3:30am and then CR#1 fell again and was taken to the hospital 7:30am. DON stated the interventions that will be in place when CR#1 returns to the facility will be a conference with CR#1's representative to see if CR#1 is a good fit for the facility. DON stated CR#1 has previously fallen, been placed on fall preventions, given physical and occupational therapy. Telephone Interview with CNA D on 1/16/2025 at 8:00am -Stated she worked the morning of 1/12/2025 on the 6am - 2pm shift. She stated she was the CNA assigned to CR#1. Stated she was assisting another resident who was in a contaminated room and did not witness the CR#1 fall nor hear a scream. CNA D stated she was informed afterwards and did see resident CR#1 before she went to the hospital. She stated CR#1 appeared to be disoriented and really confused. Stated CR#1 is usually independent and walks on her own and she sometimes has a wheelchair she uses but not often. CNA D stated she doesn't know why CR#1 was falling so much. CNA stated CR#1 did not have a yellow star on her door that she can remember. CNA D stated residents who are considered high fall risk also wear a wrist band. She stated she never observed CR#1 with a wrist band. She stated it was only 2 nurses and 2 CNA's working that shift. She stated there was no indication in CR#1's chart that indicated more frequent rounds should be completed. Interview with CNA E on 1/16/2025 at 10:00am-Stated she was working 6:00am - 2:00pm shift on 1/12/2025. She stated there were only two CNAs working the entire shift. Stated LVN A called her to CR#1's room to assist regarding CR#1's fall. CNA E she stated when she arrived in CR#1's room she witnessed LVN A was asking CR#1 questions. CNA E stated she yelled for the assigned CNA D and when CNA D arrived, she left the room and returned to her section to care for residents assigned to her. CNA E stated her last training was two weeks ago and residents who are fall risk has a star on their door. Interview with PCP on 1/16/25 at 11:50am stated she is notified on incidents regarding residents through NP or the on-call services. PCP Stated she has had concerns about CR#1's repeated falls. Stated the interventions tried were challenging to CR#1 because the interventions would have limited her functions. PCP stated most of CR#1's function related falls were attributed to her cognitive ability. PCP stated she has seen a significant decline in CR#1's cognitive area in the last year. Stated CR#1 was to use her wheelchair, but because CR#1 was so independent a lot of times she wouldn't. The skilled nursing is under the therapy department and occurs after hospitalization, which CR#1 has had in the past. CR#1's Cognitive area was limited and declining because the dementia has progressed this past year. PCP stated memory care could be more appropriate; however, there has not been a conversation in the past even though the progressive decline in CR#1 cognitive area and constant falls were occurring. PCP stated that there are many factors to resident placement in a memory care facility. One factor having to be Financial and if the insurance would pay for that type of care. PCP stated that once CR#1 returns to the facility and after a review of hospital documentation, PCP stated that that would be an intervention to address. Clarification Interview with DON on 1/16/2025 at 3:20pm-DON stated she is ultimately responsible for updating and developing the care plans. However, the nursing staff must update during the time of the incident (ex. Falls, etc). During the morning staff meetings, there are staff report on falls, etc. Based on the morning reports, care plans are reviewed during the meeting and given a finalization as long as the update doesn't restrict the resident's ability to function. An Immediate Jeopardy (IJ) was identified due to the above failures. The ADMIN and DON were notified and provided with the IJ template on 1/16/2025 at 3:45 p.m. Observed and Interviewed CR#1 in her room on 1/17/2025 at 11:10am -CR#1's personal appearance was clean, HOB raised and she was watching television and talking with her 1:1 aide, CNA F. CR#1 appeared to be alert, responding, and giving eye contact. When asked how things were going CR#1 stated she was feeling better then gave surveyor a compliment on hair and clothing items. CR#1 began rambling while attempting to speak, but there was no understanding. Interviewed CNA F on 1/17/2025 @ 11:20am who stated she is very familiar with CR#1 and her fall issues. She stated she is doing 1:1 with resident until further notice. Stated she and CR#1 had a good relationship, then CR#1 interrupted and stated she loved CNA F. The following Plan of Removal submitted by the facility was accepted on 01/17/2025 at 4:29p.m. and included: Name of facility: Fall [NAME] Rehabilitation and Healthcare Center Date: 1/16/25 F689- Accidents/supervision Problem: Facility failed to ensure CR#1 received adequate supervision and interventions to prevent falls with injuries. Facility failed to update CR#1's care plan even after her fall risk increased in short periods of time. Out of a score of 28.0 (most severe) for fall evaluations completed by the facility, CR#1's score peaked recently at 26. CR#1 sustained serious injury from falls and is currently hospitalized with a brain bleed and stitches above the right eye. The facility failed to implement preventive measures for CR#1's continuous falls, which resulted in severe injuries. On 1/11/2025 resident fell at 2:17pm with minor injuries and again 22 minutes later at 2:39pm resulting in serious injuries requiring hospitalization. The resident was returned to the facility at 1/12/25 at 3:33am and at 7:37am resident transferred to hospital for another unwitnessed fall. Immediate action: 1. 1/ 13/25 The facility administrator completed a self-report incident to HHSC due to unwitnessed fall with major injury. 2. 1/16/25The facility Don/Designee conducted an audit of residents with fall risk assessment. risk scores 0-9 mean no risk for fall and scores 10-30 means at risk for fall, to ensure their comprehensive person-centered care plans are appropriate and meet their individual needs. No new concerns were identified. Completed 1/17/25 3. On 1/16/25 The Don/Designee immediately initiated an audit of residents' currently residing in the facility comprehensive care plans who have had falls in the last 16 days, 6 residents with 8 falls where reviewed, to ensure fall prevention interventions are objective, measurable and timely. No new concerns were identified. Completed 1/16/25 4. On 1/16/25 The Corporate nurse conducted a 1:1 in-service with the DON on the facility Fall Prevention Program Policy focusing on timely implementation of person center care plans to include adding measures that objectively meet the resident's needs. Completed 1/17/15. Interventions: 5. On 1/16/25 the DON/Designee initiated an in-service with the facility Licensed nursing staff on The Fall Prevention program. This included an explanation of Risk Assessments indicating fall risk and or no risk and the different interventions based on Fall risk assessment as well as the licensed nurse responsibility to immediately implement interventions to prevent or further prevent residents falls and injuries. Projected completion 1/17/25 6. On1/16/25 the DON/Designee initiated an in-service with nursing staff, rehab, housekeeping and department heads on the Fall Prevention Program Policy to include the Falling Star Program. A gold Star is added to the Resident name on the door, on their wheelchair/Walker and above their bed to alert Staff, the resident has had a fall and is at risk for additional falls. Department heads ensure compliance during morning resident/room rounds. Any identified concerns are reported to the Administrator/DON immediately. Projected completion on 1/17/25. 7. On 1/16/25 the DON/Designee initiated an in-service with licensed nurses on immediately reporting all resident falls to the DON and or Administrator to seek guidance and ensure appropriate interventions are put in place following a residents fall. Projected completion 1/17/25 8.&nb[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of eight residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was not left unattended in her restroom for more than seven hours. The noncompliance was identified as PNC. The IJ began on 2/14/2024 and ended on 2/15/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm, malnutrition, missed medications, pressure injury, fatigue, and death. Findings included: Record review of Resident #1's face sheet, dated 1/31/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included legal blindness, hypertension (high blood pressure), weight loss, neuropathy (group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness, and pain in hands and feet), muscle weakness, difficulty in walking, GERD (Gastroesophageal Reflux Disease, chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), hearing loss, falls, arthritis (condition with swelling and tenderness of one or more joints), and edema (swelling caused due to excess fluid accumulation in the body tissues). Record review of Resident #1's Quarterly MDS assessment, dated 12/28/2023, with an ARD of 12/28/2023, reflected a BIMS score of 5, which indicated significant cognitive impairment. Resident #1 used a wheelchair for mobility, and she had no impairment of either upper or lower limbs. Resident #1 was to receive PT, but it had not begun. Resident #1 was not engaged in a toileting program, and she was frequently incontinent of bladder and bowel. Resident #1 had moderate difficulty hearing, and she was severely impaired in her vision. Record review of Resident #1's care plan, dated 1/4/2024, reflected a focus on her impaired cognitive function with interventions which included use of yes/no questions, cuing, monitoring for any changes in cognitive function. The care plan documented a focus on her ADL deficiency with interventions which included assistance with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene, and bathing. A focus on her incontinence with interventions which included assistance with dressing and hygiene, ensuring she was clean, monitoring incontinence status and skin breakdown, provision of incontinence care as needed, and weekly skin checks. A focus on Resident #1's unwanted behaviors, particularly crawling on the floor, with interventions which included a fall mat and lowered bed. A focus on her risk of skin breakdown with interventions which included provision of incontinence care as needed and weekly skin assessments. A focus on her blindness in both eyes with interventions which included monitoring for eye problems, observing for eye pain, and not arranging her personal items without her knowledge. The care plan did not document any focus or intervention referring to incontinence briefs. Record review of Resident #1's toilet use report, dated 1/31/2024, reflected documentation she was assisted with toileting every day for the previous thirty days. The report documented she required assistance daily for toileting. Record review of Resident #1's nurse's note, dated 2/14/2024, reflected the nurse was informed during report Resident #1 was out on pass. A CNA notified the nurse Resident #1 was found in her restroom in her wheelchair, and the CNA transferred Resident #1 to her bed. Per the note, Resident #1 complained of pain to the scalp and groin, but there was no injury noted in either location. Record review of Resident #1's February 2024 MAR reflected she was prescribed Latanoprost 0.05% solution one drop in the left eye at bedtime. The Latanoprost was administered at 7:00 PM on 2/14/2024. A prescription for Melatonin 3mg tablet, one tablet at bedtime for insomnia. Resident #1 was administered the Melatonin at 7:00 PM on 2/14/2024. A prescription for Zyrtec 10mg tablet, one tablet by mouth at bedtime for allergies. She received Zyrtec at 7:00 PM on 2/14/2024. Resident #1 was prescribed calcium carbonate 500mg chewable tablet one tablet by mouth before meals for a supplement. She was administered one tablet at 6:30 AM and 11:30 AM on 2/14/2024, but she was not administered the medication at 4:30 PM because she was absent from the facility. Resident #1 was prescribed a Med Plus 2.0 90ml supplement three times daily. She received one supplement at 7:00 AM and 7:00 PM but not at 2:30 PM on 2/14/2024 because she was absent from the facility without her medication. Resident #1 was prescribed Simethicone 180mg capsule four times daily form gas pain. She received it at 7:00 AM, 12:00 PM, and 10:00 PM, but she did not receive it at 5:00 PM on 2/14/2024. The reason documented for all missed medications on 2/14/2024 was that she had been absent from home without meds. Interview on 2/21/2024 at 3:04 PM with Resident #1, she said she was left alone in the restroom for a long time on 2/14/2024. Resident #1 said she was taken to the restroom after lunch and left alone. Resident #1 said she could not recall who took her to the restroom. Resident #1 said no one came back to check on her or get her. Resident #1 said a CNA found her in the restroom and said the CNA thought Resident #1 was out on pass with her sons. Resident #1 said she was found at 9:30 PM in her bedroom. Resident #1 said the staff treated her roughly. Resident #1 said she was left in the restroom in the past for an hour or two, but never for the amount of time she was on 2/14/2024. Resident #1 said the staff did not always answer call lights timely. Interview on 2/21/2024 at 1:24 PM with the family member of Resident #1, he said Resident #1 was left in her room for eight hours unattended. Resident #1's family member said the incident occurred on 2/14/2024. Resident #1's family member said previously on 2/1/2024 staff took Resident #1 to her restroom at 11:46 AM. The staff member exited Resident #1's restroom at 11:47 AM. No staff returned to the restroom until 12:48 PM. Resident #1's family member said a different staff member found Resident #1 in the restroom when the staff member was bringing Resident #1 her lunch. Resident #1 was left unattended in the restroom for one hour and one minute. Resident #1's family member described the videos. Resident #1's family member said on 1/10/2024 at 1:10 PM a staff member brought Resident #1 to the restroom. No other staff returned to the restroom and another family member found Resident #1 and got her out of the restroom at 2:37 PM. Resident #1's family member said another family member had video of that incident and the incident on 2/14/2024, but that video was not provided during the survey. Resident #1's family member said the facility would often let Resident #1's call light ring for extended periods of time, up to two hours. Record review of a written statement from LVN K, dated 2/14/2024, reflected she was informed by a CNA that Resident #1 was found in the restroom after LVN K was informed Resident #1 was on pass. Resident #1 complained of pain to the scalp and groin, but no injuries were observed. LVN K administered Resident #1 Tylenol, Hydroxyzine and Gas-X. Record review of a written statement from LVN J on 2/14/2024 reflected she was contacted by Resident #1's family member at 9:00 PM and was informed the resident was in the restroom from 1:45 PM until 9:00 PM. LVN J went to Resident #1's room and observed her being put to bed by a CNA. LVN J provided Resident #1 with a sandwich and juice. Resident #1 had no concerns or discomforts. Record review of an, undated, written statement from LVN I reflected she provided Resident #1 with her Tylenol and itchy pill then completed other tasks. A CNA took Resident #1 to the restroom and the resident asked to have her blood pressure checked. LVN I checked Resident #1's blood pressure, assisted her into a sweater, then went to the dining room for lunch duty. When she returned to the unit a CNA asked what time they would bring Resident #1 back to the facility. LVN I assumed Resident #1 had been taken from the facility. LVN I received a phone physician's order for Chlorhexidine mouth wash. At that time, she went to Resident #1's room and the room was quiet, the bathroom door was closed, and the room's lights were off. Record review of a written statement from CNA F, dated 2/15/2023, reflected she observed Resident #1 was not in her room at the beginning of CNA F's shift. CNA F asked the nurse where Resident #1 was and was informed she was out on pass. CNA F checked on Resident #1's room throughout the day. At approximately 9:15 PM she made Resident #1's bed, picked up a towel, attempted to place the towel in the restroom, and found Resident #1 in the restroom. She transferred Resident #1 to her room and provided her with snacks and drinks. Record review of a written statement from CNA D, dated 2/15/2024, reflected she worked on 2/14/2024. The statement documented CNA D entered Resident #1's room to pick up the lunch trays when Resident #1 requested to use the restroom. CNA D took Resident #1 to the restroom, handed her the call light cord, instructed her to pull when she was done, and left to complete other tasks. CNA D thought she returned to assist Resident #1. The statement read in part .I [CNA D] would never intentionally leave someone in the bathroom . Record review of an, undated, written statement from LVN L reflected she last saw Resident #1 at approximately 12:30 PM on 2/14/2024. LVN L asked LVN I where Resident #1 was and LVN I responded she must have been on a pass as LVN I saw Resident #1's family members. LVN L asked if Resident #1 had returned when LVN L was leaving at 5:00 PM on 2/14/2024. At approximately 8:30 PM on 2/14/2024 she called the facility and was informed Resident #1 had not yet returned to the facility. LVN L asked that staff to ensure Resident #1 was not in the facility. Shortly after the phone call, LVN K called her back and informed her Resident #1 was found in her restroom, in her wheelchair, and was facing the door. Resident #1 was in no acute distress. In an interview on 2/21/2024 at 3:17 PM with the DON, she said the facility made a self-report related to Resident #1's incident on 2/14/2024. Resident #1's family called the facility and said they did not see her on her in-room camera. Resident #1's assigned CNA, CNA D, reported after lunch she took Resident #1 to the restroom and then put her back to bed. Resident #1's unit charge nurse, LVN I, reported someone informed her Resident #1 was out of the facility on a pass. The facility reviewed the video of the halls and observed CNA's passing by Resident #1's room and checking on her. Resident #1 was in the facility the entirety of 2/14/2024. Resident #1 was provided with food and medicine during the time her family reported she was not in the room. The CNA took Resident #1 into the restroom. Resident #1's family would often take her out of the facility and would not tell any staff when they had taken the resident. Staff were observed on the video going by Resident #1's room to look for her. The DON said she informed Resident #1's family the facility would be reporting the incident. If it was determined any staff had intentionally placed Resident #1 in the restroom and not informed anyone, then the facility would begin safety measures for Resident #1 and disciplinary action for the staff who intentionally placed Resident #1 in the restroom and did not inform any other staff. The DON said CNA D, who had placed Resident #1 in the restroom was given a disciplinary action. The CNA reported she recalled placing Resident #1 in her bed after taking her to the restroom. The DON said LVN I, the charge nurse who reported Resident #1 was out of the facility on pass, received a disciplinary action for not reviewing the facility's out on pass binder to ensure Resident #1 was indeed on pass. The facility completed in-service trainings with the staff related to timeliness of care and responding to call lights, resident abuse, neglect, exploitation, and frequent rounding. Resident #1's family reported to the facility she was never seen on camera for the entirety of 2/14/2024. Resident #1's family was quick to call the facility anytime Resident #1 was not on the camera. The DON said it was baffling Resident #1's family waited eight hours to contact the facility. The CNA who placed Resident #1 in the restroom and was given a disciplinary notice was CNA D. The DON said CNA D was not working with Resident #1 any longer, and had additional training provided. The charge nurse who reported Resident #1 was on a pass was LVN I. The DON said 2/14/2024 was LVN I's last official day working at the facility, and she moved to an as needed basis. LVN I had not returned any calls from the facility. LVN I was instructed to complete trainings the additional trainings prior to any future shifts. The facility no longer had the video of the hall near Resident #1's room from 2/14/2024 but had photographs of the videos. The video did not go into the residents' rooms but could only see going down the hall. The photograph's documented staff entered Resident #1's room. The photographs were time stamped. The CNA who found Resident #1 was CNA F. Based on Resident #1's February MAR, her medications were administered late. The MA who signed the medication charts passed by Resident #1's room and she was not in the room. The MA did not go into Resident #1's restroom because she was informed Resident #1 was out on pass. The DON said the charge nurse never informed her who informed the charge nurse Resident #1 was out on pass, she only said she heard Resident #1 was out on pass. In an interview on 2/21/2024 at 3:39 PM with CNA F, she said she had been employed since April of 2023. CNA F said her primary duties included assisting residents with their ADL's which included bathing, feeding, showering, and incontinence care. She stated staff were to answer call lights as soon as possible. If she was working with another resident, she would go answer a call light, and inform the resident she would be back after completing tasks with the previous resident. CNA F said all staff were supposed to answer call lights. Staff were supposed to stay in a resident's restroom with the resident when assisting with toileting, even if the resident was semi-independent. Resident #1 was sweet, and she turned the call light on a lot. Resident #1 would typically ask for her medication and/or to go to the restroom when she pressed the call light. CNA F said she would usually take Resident #1 to the dining room for dinner. She would talk to Resident #1 when she was able. She checked on Resident #1 as often as she could. She worked on 2/14/2024. CNA F said when she began her shift, she would go into each resident's room to complete her checks, inform them she was their CNA for the day, and ensure the residents were in their rooms. CNA F said on 2/14/2024 she went into Resident #1's room and her wheelchair and she were not in the room. CNA F was informed by the nurse Resident #1 was out with her son. CNA F said she checked Resident #1's room throughout the day. Every time she walked down the hall, she would look into Resident #1's room and she was not in the room or in bed. She repeatedly asked the nurse if Resident #1 returned to the facility and was informed she was still with her family member. At dinner she passed Resident #1's tray and left it in the room. She checked Resident #1's room again after dinner and the tray was untouched. She left the tray in case she returned and was hungry. Sometime later she picked up Resident #1's tray and took it to the dining room. She then dumped her garbage and went in to make Resident #1's bed. She picked up a towel and was going to leave it in the restroom. She opened the restroom door and saw Resident #1 sitting in her wheelchair perpendicular to the toilet. CNA F said she asked Resident #1 when she got there, and Resident #1 said she had been there the entire time. Resident #1 thanked her for opening the restroom door. Resident #1 said she did not know when she went into the restroom, but it was after she finished eating lunch. Resident #1 tended to get up and walk in her room. Resident #1 felt around because she was blind. CNA F said Resident #1 was panicky when she was found in the restroom. CNA F said she transferred Resident #1 to sitting in her bed. Resident #1 said she did not know who left her in the restroom. CNA F informed the nurse of the incident. CNA F found Resident #1 in her restroom sometime between 8:45 and 9:15 PM. CNA F took her trash out, then made Resident #1's bed. CNA F sat with Resident #1 for a bit then let the nurse know about the incident. She also called the on-call executive and explained what happened. Resident #1 enjoyed staying in her room. CNA F had never found Resident #1 in her restroom before. Resident #1 wandered in her room trying to find the restroom. CNA F said residents who left the facility were supposed to be signed out by their family and signed in by their family when they returned. CNA F said she asked throughout day if Resident #1 had returned. She kept checking Resident #1's room throughout the day and did not see her wheelchair or her on the bed. She assumed Resident #1 was still out on pass. She did not see Resident #1 in her room for the entirety of the day on 2/14/2024. Resident #1 said she was in the restroom for the entire time she was unaccounted for on 2/14/2024. CNA F said Resident #1 did not leave her room without her wheelchair. In an interview on 2/21/2024 at 4:08 PM with MA H, she said she had been employed for one year. MA H said her primary duties included medication administration and customer service. Resident #1 was never quiet. Resident #1 would press her call light repeatedly throughout the day. Resident #1 would request Tylenol or an anti-itch medication. MA H said on 2/14/2024 she was working on Resident #1's hall. She thought Resident #1 was not in her room at all during the day. She looked into Resident #1's room and the resident was not in her bed, her wheelchair was not in the room, and the lights were turned off. She asked Resident #1's assigned CNA and was informed Resident #1 was taken out of the facility by her family. She did not administer Resident #1 any medication until the end of the day. MA H made her rounds and did not ever see Resident #1 on 2/14/2024. She was unsure when Resident #1 was found in the restroom. MA H said it was strange Resident #1 never yelled or pulled the emergency light for the time she was in the restroom. Resident #1 would never go to the restroom unassisted. She was informed by CNA F Resident #1 was out of the facility with Resident #1's family. In an interview on 2/22/2024 at 9:24 AM with LVN I, she said she worked on 2/14/2024. LVN I said she completed her morning medication pass and blood pressure checks. She then went to the dining room for lunch and helped pass trays and feed residents. When she returned to the nurse's station the CNA's asked what time they were going to bring Resident #1 back. Resident #1's family had a care plan meeting on 2/14/2024 and she thought they took Resident #1 out of the facility. While she was in the dining room assisting other residents with lunch, she asked her unit manager for help with a resident. LVN I said when she returned to the unit, the CNA's asked what time will they bring Resident #1 back. LVN I said she assumed Resident #1's family took her out of the facility. LVN I said when she asked her unit manager for help, the unit manager said she was with Resident #1's family. LVN I said she was in the dining room for at least two hours assisting with lunch. LVN I returned to the unit between 1:30 PM and 2:00 PM and that was when the CNA's asked her when Resident #1 was going to be brought back to the facility. LVN I said when the CNA's said they, she assumed Resident #1's family came and got her when a resident went on pass, typically the family would have to sign in and out of the pass book. Resident #1's family may have taken her out of the facility without signing the on passbook. The facility could not force families to sign the on passbook. LVN I said her shift on 2/14/2024 was from 6:00 Am to 6:00 PM. She did not see Resident #1 in her room before she left for the day. She continued looking towards Resident #1's room to determine if she had come back. At dinner time she checked to see if all the residents on the hall were eating. At that time Resident #1's room was still dark with no sound, she thought Resident #1 may be eating with her family. Resident #1 did not ever press the call light. LVN I said this was not typical. Resident #1 would often press the call light or yell out, and it was different because she did not use the call light or yell for assistance the entire time she was in the restroom on 2/14/2024. Attempted telephone interview with CNA D at on 2/22/2024 at 11:01 AM was unsuccessful. There was no answer, and no voice message system was available. Record review of the facility's Therapeutic Leave policy, dated 4/10/2023, reflected a policy statement which read It is the policy of this facility to allow residents to leave the facility for a non-medical visit, thereby known as therapeutic leave, in accordance with Federal and State guidelines and applicable Medicare, Medicaid, and private insurance guidelines. Each resident will be permitted to return to the facility after therapeutic leave, regardless of payment source. The policy documented it would coordinate with the resident or their RP the length of time the resident would be absent from the facility. Record review of the facility's Abuse, Neglect, and Exploitation policy, dated 1/8/2023, reflected a policy statement which read It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy defined Neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Per the policy, the facility would implement policies to ensure all residents were free from abuse, neglect, misappropriation of resident property, and exploitation. In an interview on 2/23/2024 at 1:38 PM with Resident #2, he said he had lived at the facility for six months to a year. Resident #2 said he did not receive much help from the facility staff as he was able to complete his ADL's independently. Resident #2 said he did not press the call button for assistance because he was able to complete any needed tasks independently. Resident #2 said he went to the restroom independently. Resident #2 said he had never been left unattended for long periods of time at the facility. Resident #2 denied he ever felt he was the victim of abuse, neglect, and/or exploitation while at the facility. In an interview on 2/23/2024 at 1:43 PM with Resident #3, he said he lived at the facility for four weeks. Resident #3 said the facility provided him with therapy routinely. Resident #3 said the facility staff answered call lights quickly. Resident #3 said the staff took him to the therapy department to exercise. Resident #3 said he did not need assistance to use the restroom. Resident #3 said he never was left unattended for a long period of time at the facility. Resident #3 said he had never been the victim of abuse, neglect, and/or exploitation while he lived at the facility. In an interview on 2/23/2024 at 1:49 PM with Resident #4, she said she lived at the facility since June 2023. Resident #4 said the staff at the facility were all sweethearts. Resident #4 said she loved all the staff who cared for her. Resident #4 said she was unable to get out of her bed without the use of a Hoyer lift. Resident #4 said she had a catheter in the past, but it was removed on 2/21/2024. Resident #4 said the staff changed her incontinence briefs routinely. Resident #4 said she was never left unattended for a long period of time. Resident #4 said the staff answered call lights as soon as possible. Resident #4 said she had no concerns with the care provided by the facility staff. In an interview on 2/22/2024 at 1:39 PM, can M said she was employed by the facility for approximately four months. CNA M said her primary duties were to ensure all the residents assigned to her were well taken care of and to assist the residents with their ADL's. CNA M said she recently received a training related to resident's out on pass. CNA M said if a resident left the faciity on a pass, the resident's RP had to sign the resident in and out of the facility. CNA M said if she became aware a resident was going to be leaving on pass with his/her family, CNA M would inform the nurse and instruct the family to sign the resident out with the nurse and let the nurse know when the resident would be returning. In an interview on 2/22/2024 at 1:49 PM with DA O, she said she was employed by the facility for five years in the kitchen. DA O said she received in-service training as needed. DA O said if a resident went out on pass with his/her family, the family was to report that to the resident's nurse. DA O said the resident's family was to sign the resident out with the nurse and in the out on pass log kept at the nurse's station. In an interview on 2/22/2024 at 1:51 PM, LVN N said he was employed for five years. LVN N said his primary duties were to act as the charge nurse for his unit. LVN N said he recently received an in-service training related to residents who were out on pass with their family. LVN N said when a resident left the faciity on a pass, the resident's RP was required to sign the passbook kept at the nurse's station. LVN N said prior to the resident leaving, and upon his/her return, LVN N was required to complete a head-to-toe assessment of the resident documenting any injury or skin concerns. LVN N said he was also required to administer the resident's medications due when he/she left and provide the resident's RP with any medications the resident may need while away from the facility. LVN N said the facility's ability to determine if a resident was out on pass with his/her family began with the receptionist who documented all visitors. LVN N said the RP of a resident who went out on pass was required to notify the facility he/she had left. LVN N said if the resident was not marked as out on pass, he/she would be assumed to be at the facility. In an interview on 2/23/2204 at 10:39 AM with LVN P, she said she was employed since January of 2024. LVN P said her primary duties were to provide care required of an LVN. LVN P said she received recent in-service training related to resident abuse, neglect, and exploitation. LVN P said if she was ever concerned a resident was the victim of abuse, neglect, and/or exploitation she would immediately notify the Admin, who was the facility's abuse coordinator. LVN P said she would report any signs or symptoms a resident may have been the victim of abuse, neglect, and/or exploitation. LVN P said after notifying the Admin, she would complete a skin assessment of the resident, and notify the resident's PCP and family. The Admin would begin investigating the incident and would interview staff about the allegations. Resident abuse included verbal, sexual, physical abuse, and neglect. LVN P said neglect could be not answering a resident's call light for a long time or an injury that could have been prevented with appropriate care. Neglect was not attending to a resident's needs. Misappropriation of resident's property referred to stolen or missing items. LVN P said she recently received an in-service training related to residents out on pass with their family. LVN P said the resident's family was required to sign the resident out and back in when he/she returned. LVN P said the out on pass binder was a blue binder kept at the nurse's station. Anytime a resident was out on pass the nurse was responsible to ensure the out on pass binder was signed by the resident's family member. The nurses had to complete a head-to-toe assessment of the resident before he/she left the facility and when he/she returned. The nurses were required to chart the time the resident left the facility, and the estimated time he/she was going to be out on pass. The nurse was also required to administer any medications the resident was due when he/she left and provide the medication he/she may need while out on pass to the resident's family with administration instructions. LVN P said she had also received an in-service training related to rounding. LVN P said she was instructed to complete rounds every two hours. LVN P said she was in the hall more often than was required, but she ensured she completed rounds every two hours. In an interview on 2/23/2024 at 11:12 AM with LVN Q, she said she was employed for one year and four months. LVN Q said she recently received an in-service training related to resident abuse, neglect and/or exploitation. LVN Q said she was instructed to report any concerns a resident may be the victim of abuse, neglect, and/or exploitation immediately to the Admin. Abuse included physical, financial, emotional abuse, taking away a resident's rights, or causing him/her harm. Resident neglect included not answering a resident's call light or addressing his/her needs. LVN Q said she received an in-service training related to residents who were out of the facility on a pass. LVN Q said she was instructed to request the resident's family sign the out on pass log prior to leaving with the resident. LVN Q said the log was kept at the nurse's station. LVN Q said the nurses were to complete a head-to-toe assessment of the resident prior to his/her leaving and upon his/her return. The training addressed the nurses were to assess the resident's vital signs and administer his/her medications prior to his/her leaving on pass. LVN Q said she was required to document when the resident left on pass and the estimated time, he/she would be returning to the facility. She was instructed during the in-service training she had to complete another head-to-toe assessment and complete vital sign assessment when the resident returned from being out on pass. She had received an in-service training on completing resident rounds recently. She was trained that when she came in for her shift, she was to complete resident rounds, check all residents assigned to her, and ensure the residents were aware she was their assigned nurse. She was expected to give a report to the nurse replacing her when he/she first arrived, and she expected to receive a report from the nurse she was replacing. The nurses were expected to complete the first resident round with the nurse coming in to replace them. During that initial resident round, the outgoing nurse would inform the incoming nurse of any new, changed, or altered orders for each resident. The information shared during this initial resident round included any resident's change of condition, new medication, if any residents had any falls, any new resident behaviors, upcoming resident labs, and any resident who required x-rays. In an interview on 2/23/2024 at 2:12 PM with CNA S, she said she was employed by the facility for two years. CNA S said her primary duties included assisting residents with their ADL's, checking on each resident to ensure their health and safety, providing baths, completing resident rounds often, checking resident restrooms to ensure no residents were in the restroom unknown, and changing residents' incontinence briefs. CNA S said she recently received an in-service training. CNA S said the facility pr[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the resident was free from misappropriation of property for two of six residents (Resident #4 and Resident #5) and six of six (CR #2, CR #3, CR #6, CR #7, CR #8, and CR #9) closed records reviewed for misappropriation of property. 1. The facility failed to ensure that unknown staff did not misappropriate Resident #4, Resident #5, CR #2, CR #3, CR #6, CR #7, CR #8, and CR #9's controlled medications in November of 2023. 2. The facility failed to have a system in place to identify drug diversion of controlled substances. These failures could place residents at risk for misappropriation of medications and uncontrolled pain. The noncompliance was identified as PNC. The IJ began on 11/20/23 and ended on 11/21/2023. The facility had corrected the noncompliance before the survey began. Findings included: 1. Record review of Resident #4's face sheet, dated 2/23/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included end-stage renal disease (condition where the kidney reaches advanced state of loss of function), chronic viral hepatitis C (viral infection that causes inflammation of liver that leads to liver inflammation), osteoarthritis (progressive disorder of the joints caused by gradual loss of cartilage and resulting in the development of bony spurs and cysts at the margins of the joints), dependence on renal dialysis (blood purifying treatment given when kidney function is not optimum), schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), anxiety disorder (group of mental illnesses that cause constant fear and worry), anuria (lack of urine production) and oliguria (output of less than 400ml of urine per day), chronic fatigue (disorder characterized by extreme fatigue with no underlying medical condition), muscle weakness, hypertension (high blood pressure), and thrombocytopenia (condition where abnormally low level of platelets are observed). Record review of Resident #4's quarterly MDS assessment, dated 1/17/2024, with an ARD of 1/17/2024, reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #4 had no impairment to her upper extremities, impairments of both lower extremities, and used a wheelchair for mobility. Resident #4 received OT and PT services. Record review of Resident #4's medication report, dated 2/26/2024, reflected prescriptions which included Norco 5-325mg tablet one tablet by mouth every six hours as needed for pain. The prescription was written on 6/13/2023 and was active on 2/26/2024. Record review of Resident #4's November 2023 MAR reflected a prescription written on 6/13/2023 for Norco 5-325mg tablet one tablet by mouth every six hours as needed for pain. She was administered the medication on 11/29/2023 at 7:30 PM and on 11/30/2023 at 11:50 AM and 9:15 PM. Resident #4 was not administered the medication at any other time during the month of November 2023. In an interview on 2/23/2024 at 1:49 PM with Resident #4, she said she had lived at the facility since June 2023. Resident #4 said she had no concerns with the care provided by the facility staff. In an interview on 2/26/2024 at 3:32 PM with Resident #4, she said she had no concerns with the medications administered by the facility. Resident #4 said she never had any concerns she was not provided the correct medications. Resident #4 said she never had medication withheld. Resident #4 said if she was in pain, all she had to do was ask for medication and it was administered. 2. Record review of Resident #5's face sheet, dated 2/26/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included cerebral infarction (the blood flow to the brain is disrupted due to issues with the arteries that supply it, stroke), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness), generalized anxiety disorder (group of mental illnesses that cause constant fear and worry), chronic pain syndrome (persistent or intermittent pain that last for more than 3 months), and hypertension (high blood pressure). Record review of Resident #5's significant change MDS, dated [DATE], with an ARD of 2/8/2024, reflected a BIMS score of 6, which indicated significant cognitive impairment. Resident #5 had an impairment to one side of her upper and lower extremities, and she did not use a mobility device. She received diuretic, opioid, and antiplatelet medications. She received hospice care services, but she did not receive any OT, PT, or ST services. Record review of Resident #5's census report, dated 2/26/2024, reflected she was not discharged from the facility except from 1/23/2024 to 1/29/2024. Record review of Resident #5's medication report, dated 2/26/2024, reflected a discontinued prescription, dated 1/5/2023, for Norco 10-325mg tablet, one tablet every six hours as needed for pain. Record review of Resident #5's November 2023 MAR reflected a prescription for Norco 10-325mg tablet one tablet every six hours for pain as needed. Resident #5 received the medication at 3:02 PM on 11/2/2023, at 3:54 PM on 11/5/2023, at 8:41 AM on 11/6/2023, at 3:19 PM on 11/14/2023, at 8:28 AM and 3:43 PM on 11/15/2023, at 7:38 AM on 11/16/2023, at 5:14 PM on 11/19/2023, at 9:30 AM and 5:10 PM on 11/20/2023, at 8:08 AM on 11/21/2023, at 12:57 PM on 11/22/2023, at 1:07 PM and 7:13 PM on 11/23/2023, at 11:00 PM on 11/24/2023, at 8:33 AM on 11/25/2023, at 11:04 AM on 11/26/2023, at 7:50 AM and 5:14 PM on 11/29/2023 and at 7:10 AM on 11/30/2023. In an interview on 2/26/2024 at 3:44 PM with Resident #5, she said she had no concerns with her medications. Resident #5 said all she had to do was ask and the facility would provide the medications when requested. In an interview on 2/26/2024 at 3:45 PM with Resident #5's RP, she said she had no concerns with the care provided by the facility. Resident #5's RP said she never was concerned that her family member received the wrong medications. Anytime her family member was in pain the facility would provide medication for the pain. If her Resident #5 asked for pain medication the facility would provide it. 3. Record review of CR #2's face sheet, dated 2/26/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 11/14/2023. CR #2 had diagnoses which included acute pyelonephritis (sudden and severe inflammation of kidney due to a bacterial infection), COPD (Chronic Obstructive Pulmonary Disease, a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), paroxysmal atrial fibrillation (sudden onset disease of the heart characterized by irregular and often faster heartbeat), muscle weakness, ataxic gait (an unsteady, uncoordinated walk, with a wide base and the feet thrown out, coming down first on the heel and then on the toes with a double tap), lack of coordination, cognitive communication deficit (difficulty with any aspect of communication that is affect by a disruption of cognition), and myopathy (term for diseases that affect the muscles). Record review of CR #2's admission MDS, dated [DATE], with an ARD of 11/7/2023, reflected a BIMS score of 10, which indicated a moderate cognitive impairment. CR #2 had no impairment of either upper or lower extremities and did not use a mobility aid. CR #2 required assistance or total dependence on all ADL's except eating. He was administered anticoagulant, insulin, antibiotic, diuretic (water pills), and hypoglycemic (medication used for low blood sugar) medications during the review period. CR #2 received OT, PT, and ST services. Record review of CR #2's medication report, dated 2/26/2024, reflected a prescription for Hydrocodone-Acetaminophen 5-325mg tablet one tablet every six hours as needed for pain. Record review of CR #2's November MAR reflected he was not administered the medication between 11/1/2023 and 11/16/2023. An attempted telephone interview with CR #2 on 2/26/2024 at 3:27 PM was unsuccessful. A voice message was left requesting a return call. 4. Record review of CR #3's face sheet, dated 2/23/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 11/7/2023. CR #3 had diagnoses which included metabolic encephalopathy (alteration of brain function or consciousness due to failure of other internal organs), dementia (group of symptoms that affects memory, thinking, and interferes with daily life), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), cerebral infarction (the blood flow to the brain is disrupted due to issues with the arteries that supply it, stroke), cognitive communication deficit (difficulty with any aspect of communication that is affect by a disruption of cognition), schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), malignant neoplasm (cancerous tumor) of the breast, and hypertension (high blood pressure). Record review of CR #3's admission MDS, dated [DATE], with an ARD of 10/25/2023, reflected a BIMS score of 13, which indicated minimal cognitive impairment. CR #3 was independent in her ADL's, used a wheelchair or walker for mobility, and had no impairment of either upper or lower extremities. She received OT, PT, and ST services. Record review of CR #3's care plan, dated 11/13/2023, reflected a focus on her ADL self-care deficit with interventions which included supervision with eating, oral hygiene, and personal hygiene, dependence on staff for toileting, showering, dressing, and transfers. A focus on her risk of skin breakdown with interventions which included repositioning, use of a pressure reducing mattress, provision of incontinence care, and weekly skin assessments. A focus on CR #3's dementia with interventions which included explanation of care services provided and involved her RP in care planning. Record review of Resident #3's medication report, dated 2/26/2024, reflected prescriptions which included Norco 5-325mg tablet one tablet by mouth one time for pain written on 11/3/2023 and discontinued on 11/4/2023, and Hydrocodone-Acetaminophen 10-325mg one tablet every six hours as needed for pain written on 10/23/2023. Record review of CR #3's November 2023 MAR reflected a prescription for Norco 5-325mg tablet one tablet by mouth one time for pain written on 11/3/2023 and discontinued on 11/4/2023. The MAR did not document this prescription was administered. The MAR documented a prescription for Hydrocodone-Acetaminophen 10-325mg one tablet every six hours as needed for pain written on 10/23/2023 and discontinued on 11/8/2023. Resident #3 had the prescription administered on 11/5/2023 at 10:45 AM. There was no other documentation the medication was administered to CR #3. Attempted telephone interview with CR #3 on 2/26/2024 at 3:29 PM was unsuccessful. A voice message was left requesting a return call. 5. Record review of CR #6's face sheet dated 2/1/2024 revealed an [AGE] year-old resident admitted on [DATE] and discharged on 11/19/2023. Per the face sheet, CR #6's diagnoses included heart failure (progressive heart disease that affects pumping action of the heart muscles), COPD (chronic obstructive pulmonary disease, a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), obesity (condition characterized by abnormal or excessive fat accumulation), respiratory failure (any condition that affects breathing function or the lungs themselves and can result in failure of the lungs to function properly), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), metabolic encephalopathy, muscle weakness, chronic pain, lymphedema, peripheral vascular disease, and arthritis. Record review of CR #6's five-day MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. The MDS documented she was independent in all ADL's and used a motorized wheelchair or walker for mobility. Per the MDS, CR #6 was prescribed scheduled pain medication, and she was frequently in pain. The MDS revealed the pain interfered with her therapy activities and sleep. The MDS documented she was prescribed opioid medication. Per the MDS, CR #6 received OT and PT services. Record review of CR #6's baseline MDS dated [DATE] revealed her expected stay at the facility was ten to fourteen days. The care plan documented she was expected to discharge home or to the community with a family member and/or caregiver. Per the care plan, CR #6 was admitted for skilled nursing services. The care plan revealed she would receive treatment, medication administration and monitoring, change of condition monitoring and reporting, labs and medication as ordered. The care plan documented she received orders for PT. Record review of CR #6's hospital discharge instructions dated 11/8/2023 revealed she was to continue taking oxycodone-acetaminophen at the prescribed 10-325mg tablet one tablet every six hours as needed for pain. Record review of CR #6's controlled substance disposition record dated 11/10/2023 revealed she was provided with eight tabs of oxycodone-acetaminophen 10-325mg tablet. The record documented the instructions for the medication were to take one tablet every six hours as needed for pain. Per the record, CR #6 was administered one tablet at 5:45 AM, 12:30 PM, and 6:50 PM on 11/11/2023, at 12:43 AM, 7:42 AM, 1:42 PM, and 8:45 PM on 11/12/2023, and at 2:52 AM on 11/13/2023. Record review of CR #6's November 2023 MAR printed on 2/1/2024 revealed a prescription for oxycodone-acetaminophen 10-325mg tablet one tablet every six hours as needed for pain. Per the MAR, CR #6 was administered one tablet at 1:00 AM, 7:00 AM, 1:00 PM, and 7:00 PM on 11/17/2023, 11/18/2023, and 11/19/2023, and at 1:00 PM and 7:00 PM on 11/16/2023. The prescription was written on 11/16/2023 at 12:45 PM. Record review of CR #6's medication report dated 2/1/2024 revealed she was prescribed oxycodone with acetaminophen 10-325mg tablet one tablet every six hours for pain on 11/16/2024. Telephone interview on 2/26/2024 at 3:31 PM with CR #6, she said on one occasion she was provided with the wrong medication when she lived at the facility. CR #6 said she informed the nurse the medication was wrong. CR #6 said the nurse took the medication away and brought her the correct medication. CR #6 said the facility should have known the correct medications. She felt someone at the facility stole her medications, or the facility sent her the wrong medications. CR #6 was only provided the wrong medication on one occasion. She was unsure if she took the wrong medication or not. She was upset the facility brought her the wrong medication, and if she took the wrong medications that could have caused her harm. Record review of the facility's internal investigation reflected CR #6 informed the facility her oxycodone tablet looked different than usual on 11/13/2023. The nurse checked the pill through the pill identifier, and it was determined to be baclofen. CR #6 reported feeling loopy after taking the medication. The pharmacy that provided the oxycodone reviewed their processes and video and determined the correct medication was sent to the facility. The pharmacy sent medications with red labels for controlled medications and blue for non-controlled. The pharmacy reported the person that switched the labels did not know the color coding. The pharmacy informed the facility the labels on the oxycodone was switched with a non-controlled substance. A total of nine medication cards' labels were switched. The facility reviewed footage and found no information which would determine who changed the medication labels. Any resident whose medication was tampered with had their medication replaced. Record review of a written statement from LVN N, dated 11/13/2023, reflected he was notified by a resident that she did not feel like herself after taking the medication. The resident informed LVN that she thought either her insulin or pain medication was making her feel unwell. LVN N was informed by the resident she did not think the pain medication looked like the pills she had taken in the past. LVN Ndiscovered the medication was not oxycodone as labeled and he immediately informed the DON. LVN N had not had any concerns for misappropriated medications prior to this incident. Record review of a medication error assessment, completed on 11/15/2023, reflected the pharmacy had filled CR #6's oxycodone prescription with baclofen. The assessment documented CR #6 did not feel well as a result of receiving the wrong medication. 6. Record review of CR #7s' face sheet, dated 2/26/2024, reflected a [AGE] year-old male who was admitted on [DATE] and discharged on 11/14/2023. CR #7 had diagnoses which included cerebral infarction (the blood flow to the brain is disrupted due to issues with the arteries that supply it, stroke), hemiplegia and hemiparesis, COPD (chronic obstructive pulmonary disease, a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), a displaced fracture of the lateral end of the left clavicle, type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), muscle weakness, heart failure (progressive heart disease that affects pumping action of the heart muscles), cognitive communication deficit (difficulty with any aspect of communication that is affect by a disruption of cognition), adjustment disorder (short term condition arising due to difficulty in managing the stressful life changes such as coping with work-related problems, loss of loved ones, or relationship issues that leads to significant impairment in functioning), visual disturbances (any condition which affects the eyes or vision), and bariatric surgery (surgery to assist in weight loss) status. Record review of CR #7's 5-day MDS assessment, dated 11/14/2023, with an ARD of 11/14/2023, reflected a BIMS score of 15, which indicated no cognitive impairment. CR #7 had an impairment of one upper extremity, no impairment to his lower extremities, and did not use a mobility device. CR #7 required maximal assistance or was totally dependent on staff for all ADL's except oral hygiene and eating. He was administered antidepressant and diuretic medications during the review period. CR #7 received OT and PT services. Record review of CR #7's November MAR reflected he had a prescription, dated 11/9/2023, and discontinued on 11/16/2023, for hydrocodone-acetaminophen 5-325mg tablet one tablet twice daily for pain. CR #7 refused the medication on the mornings of 11/10/2023, 11/11/2023, and 11/12/2023. CR #7 was not administered the medication on the mornings of 11/13/2023 and 11/4/2023, but the reason was documented in his progress notes (no note was observed documenting the reason the medication was not provided). He received the medication on the evenings of 11/10/2023, 11/11/2023, and 11/13/2023. He was not administered the medication on the evening of 11/12/2023 because he was nauseous or on 11/14/2023 because he was not at the facility. Record review of CR #7's medication report, dated 2/26/2024, reflected a prescription for Hydrocodone-Acetaminophen 5-325mg tablet one tablet twice daily for pain. Record review of CR #7's progress notes reflected no note related to pain medications on 11/13/2023 or 11/14/2024. 7. Record review of CR #8's face sheet, dated 2/23/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 11/08/2023. CR #8 had diagnoses which included a displaced tri-malleolar fracture (ankle fracture) of the right lower leg, neutropenia (condition characterized by abnormally low levels of white blood cells), paraplegia (paralysis of the lower half of the body), sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), anemia (deficiency of healthy red blood cells in blood), thyrotoxicosis (excessive quantities of thyroid hormones), hypertension (high blood pressure), paroxysmal atrial fibrillation (sudden onset disease of the heart characterized by irregular and often faster heartbeat), cerebral infarction (the blood flow to the brain is disrupted due to issues with the arteries that supply it, stroke), end-stage renal disease (condition where the kidney reaches advanced state of loss of function), bacteremia (the presence of bacteria in the blood), and dependence on renal dialysis (blood purifying treatment given when kidney function is not optimum). Record review of CR #8's significant change MDS assessment, dated 11/8/2024, with an ARD of 11/8/2024, reflected a BIMS score of 8, which indicated a moderate cognitive impairment. CR #8 had no impairment to either her upper or lower extremities, and she used a wheelchair for mobility. CR #8 received no therapeutic or restorative services. Record review of CR #8's care plan, dated 10/3/2023, reflected a focus on her impaired cognitive function with interventions which included cuing and reorienting, provision of a consistent routine, and monitoring for any changes of condition. A focus on her decline in functional abilities with interventions included therapeutic services as ordered, and assistance with sitting-to-standing mobility and toileting. A focus on CR #8's ADL self-care deficit with interventions included assistance with bathing, bed mobility, dressing, eating, locomotion, personal hygiene, toileting, and transfers, and monitoring for changes in condition. A focus on her fall risk with interventions which included anticipation of needs, ensuring her bed was in the lowest position, and ensuring a safe space. A focus on her fractured ankle with interventions which included encouragement to lie down, monitoring for pain and/or discomfort, and notification if the current pain or non-pharmacological pain management was ineffective. Record review of CR #8's medication report, dated 2/26/2024, reflected prescriptions which included Norco 5-325mg tablet one tablet every eight hours for pain written on 11/2/2023, and Norco 5-325 mg tablet one tablet every eight hours as needed for pain written on 11/8/2024. Record review of CR #8's November 2023 MAR reflected a prescription for Norco 5-325mg tablet one tablet every eight hours for pain written on 11/2/2023 and discontinued on 11/8/2024. The medication was administered daily at 3:00 PM and 11:00 PM on 11/2/2023 and 7:00 AM, 3:00 PM and 11:00 PM from 11/3/2023 through 11/7/2023. CR #8 had a prescription for Norco 5-325 mg tablet one tablet every eight hours as needed for pain written on 11/8/2024 and discontinued on 11/8/2024. The MAR did not document the medication was ever administered. 8. Record review of CR #9's face sheet, dated 2/26/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 11/19/2023. CR #9 had diagnoses which included sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), malignant neoplasm (cancerous tumor), immunodeficiency (the immune systems inability to fight infection or disease effectively) due to drug use, a displaced fracture of the lateral malleolus of the fibula (ankle fracture), neoplasm (tumor) related pain, and acute kidney failure (condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days). Record review of CR #9's discharge MDS, dated [DATE], with an ARD of 11/3/2023, reflected her short-term memory was not impaired, and she was independent in her cognitive skills for making decisions regarding tasks for daily life. She was dependent on staff for all ADL's except eating and oral hygiene. CR #9 was administered antibiotic and opioid medications during the review period. CR #9 received no OT, PT, or ST services. Record review of CR #9's medication report, dated 2/26/2024, reflected prescriptions which included Oxycodone 5mg tablet one tablet every six hours as needed for pain written on 10/31/2023. Record review of CR #9's November 2023 MAR reflected a prescription for Oxycodone 5mg tablet one tablet every six hours as needed for pain written on 10/31/2023 and discontinued on 11/5/2023. The medication was administered on 11/3/2023 at 5:02 AM. CR #9 was not administered the medication at any other time. In an interview on 2/23/2204 at 10:39 AM with LVN P, she said she was employed since January of 2024. LVN P said her primary duties were to provide care required of an LVN. LVN P said misappropriation of resident's property referred to stolen or missing items. She was required to administer medications as ordered by the resident's prescriber. She administered a resident's first dose of a controlled substance, ensured it was placed on the medication cart appropriately, and after a MA could administer the medication. She administered as needed pain medications. LVN P said prior to administering the medication she would ask the resident his/her pain level, ensure the medication was the correct medication, and the medication was administered at the correct time. She ensured the correct resident received the correct medication by reviewing the resident's name on the MAR, checked the resident's picture on the MAR, asked the resident his/her name, and read the label on the medication's blister pack. She completed multiple medication checks prior to administering a resident any medication, and even more for a controlled medication. LVN P said she never saw an altered medication container. If she ever observed medication packaging which had been altered, she would inform another nurse, ask that nurse to verify the incorrect packaging, and discard the medication if needed. LVN P said she never had missing medication on a medication cart assigned to her. The nurses reconciled all medications on the medication carts and in the medication storage room at shift change. In an interview on 2/23/2024 at 11:12 AM with LVN Q, she said she was employed for one year and four months. LVN Q said she typically only administered medication through a gastronomy tube and as needed medications. She ensured the residents received the correct medications by following the established protocols which included checking the resident's name, the resident's face, the medication dosage, the quantity of medication to be administered, and the resident's pain levels. LVN Q said prior to administering any pain medications she had to document it in the computerized MAR. The MAR had a photo of the resident. The nurses reconciled the medication carts at each shift change. The nurses would ensure the amount of medication on the medication cart matched the number of medications in the medication log. The nurses physically inspected each medication's packaging to ensure it was intact. She never saw any medication packaging altered. The pharmacy placed tape across the packaging to ensure the labels could not be altered. She never had any missing medication on a medication cart assigned to her. If she ever observed altered medication packaging or if her cart was missing medications, she would inform the DON immediately. In an interview on 2/26/2024 at 6:41 AM with LVN J, she said the medication cart count and review was completed at the beginning and end of each shift. LVN J said that was done to ensure the residents received the correct amount of medication during the previous shift, the medications were accounted for, and the medication packaging appeared to be intact. LVN J said this was important because the residents needed to receive their medications per the physician's orders. In an interview on 2/26/2024 at 6:47 AM with LVN V, she said the medication cart count and reviews were completed to ensure the medication on the cart were accurate to what was documented in the controlled substance binder. LVN V said this would help to ensure each resident received his/her medication appropriately and no medication was missing. In an interview on 2/26/2024 at 7:29 AM with the DON, she said the electronic medication dispensing system was controlled by the pharmacy. The DON said the pharmacy restricted access to the system to nurses, provided the nurses with an access code, and restocked the system with controlled substances monthly or as needed. The IV medications and the non-narcotic temperature sensitive medications stored in the refrigerator were audited weekly as neither were narcotic. When the medications were administered to the residents they were prescribed to, the medication administration was documented in the resident's MAR. No one other than nurses had access to the electronic medication dispensing system. The MA's did not have access to the electronic medication dispensing system. The DON said when housekeeping cleaned the medication storage room, a nurse was required to stand in the room while it was cleaned. The housekeepers were not allowed to remain in the room unattended. If the pharmacy became aware of a discrepancy with the medications stored in the electronic medication dispensing system, the pharmacy would contact the facility, and an immediate audit would be completed. A nurse could not access the electronic medication dispensing system without a second nurse. When a resident was prescribed a controlled substance located within the electronic medication dispensing system, the pharmacy provided a specific code to be entered by the nurse to obtain that specific prescription. After the nurse entered the code, a second nurse had to enter his/her access code to verify a witness had observed the initial nurse obtained the medications. The system could not be closed until the nurse counted the amount of medication remaining in the system and entered the number. If the number was incorrect, that would alert the pharmacy to a discrepancy which would trigger an audit. The pharmacy completed an audit each time the system was restocked. In an interview on 2/26/2024 at 9:46 AM with the DON, she said the recent medication administration and possible diversions were not pharmacy initiated. The DON said a nurse brought the medication concerns to her attention. The DON said medication labels had been switched between controlled medications and non-controlled medications. The nurse verified the medication he was about to administer was not the correct medication for the resident. The DON contacted the pharmacy as she thought the pharmacy possibly stocked the wrong medication in the blister pack. The pharmacy responded the medication's blister pack's sticker was altered. The pharmacy provided controlled medications in a red blister pack. The person responsible for the medication diversion took the controlled substance sticker and switched with non-controlled blister pack. The DON said the person responsible was never definitively identified. The DON said after reviewing all the medication carts, it was determined that nine controlled medication packages had been switched with non-controlled medication packages, but all but one had either discharged or been discontinued. The resident who was not discharged and whose medication was not discontinued was CR #6. The facility placed cameras in the medication rooms, conducted in-service trainings with all staff responsible for administering controlled medications, communicated with the pharmacy to ensure it had completed a review of[TRUN

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for two of six residents (Resident #4 and Resident #5) and six of six (CR #2, CR #3, CR #6, CR #7, CR #8, and CR #9) closed records reviewed for pharmacy services. 1. The facility failed to ensure one former resident (CR #6) received the correct medication. CR #6's medication labels were switched. 2. The facility failed to ensure discontinued medication was discarded and controlled medication was destroyed according to standard protocols as nine medication packages were altered. These failures could place residents at risk for drug diversion, delay in medication administration, and receiving the wrong medications. The noncompliance was identified as PNC. The IJ began on 11/20/23 and ended on 11/21/2023. The facility had corrected the noncompliance before the survey began. Findings included: 1. Record review of Resident #4's face sheet, dated 2/23/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included end-stage renal disease (condition where the kidney reaches advanced state of loss of function), chronic viral hepatitis C (viral infection that causes inflammation of liver that leads to liver inflammation), osteoarthritis (progressive disorder of the joints caused by gradual loss of cartilage and resulting in the development of bony spurs and cysts at the margins of the joints), dependence on renal dialysis (blood purifying treatment given when kidney function is not optimum), schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), anxiety disorder (group of mental illnesses that cause constant fear and worry), anuria (lack of urine production) and oliguria (output of less than 400ml of urine per day), chronic fatigue (disorder characterized by extreme fatigue with no underlying medical condition), muscle weakness, hypertension (high blood pressure), and thrombocytopenia (condition where abnormally low level of platelets are observed). Record review of Resident #4's quarterly MDS, dated [DATE], with an ARD of 1/17/2024, reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #4 had no impairment to her upper extremities, impairments of both lower extremities, and used a wheelchair for mobility. Resident #4 received OT and PT services. Record review of Resident #4's medication report, dated 2/26/2024, reflected prescriptions which included Norco 5-325mg tablet one tablet by mouth every six hours as needed for pain. The prescription was written on 6/13/2023 and was active on 2/26/2024. Record review of Resident #4's November 2023 MAR reflected a prescription written on 6/13/2023 for Norco 5-325mg tablet one tablet by mouth every six hours as needed for pain. She was administered the medication on 11/29/2023 at 7:30 PM and on 11/30/2023 at 11:50 AM and 9:15 PM. Resident #4 was not administered the medication at any other time during the month of November 2023. Interview on 2/23/2024 at 1:49 PM with Resident #4, she said she had lived at the facility since June 2023. Resident #4 said she had no concerns with the care provided by the facility staff. Interview on 2/26/2024 at 3:32 PM with Resident #4, she said she had no concerns with the medications administered by the facility. Resident #4 said she never had any concerns she was not provided the correct medications. Resident #4 said she never had medication withheld. Resident #4 said if she was in pain, all she had to do was ask for medication and it was administered. 2. Record review of Resident #5's face sheet, dated 2/26/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included cerebral infarction (the blood flow to the brain is disrupted due to issues with the arteries that supply it, stroke), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness), generalized anxiety disorder (group of mental illnesses that cause constant fear and worry), chronic pain syndrome (persistent or intermittent pain that last for more than 3 months), and hypertension (high blood pressure). Record review of Resident #5's significant change MDS, dated [DATE], with an ARD of 2/8/2024, reflected a BIMS score of 6, which indicated significant cognitive impairment. Resident #5 had an impairment to one side of her upper and lower extremities, and she did not use a mobility device. She received diuretic, opioid, and antiplatelet medications. She received hospice care services, but she did not receive any OT, PT or ST services. Record review of Resident #5's census report, dated 2/26/2024, reflected she was not discharged from the facility except from 1/23/2024 to 1/29/2024. Record review of Resident #5's medication report, dated 2/26/2024, reflected a discontinued prescription, dated 1/5/2023, for Norco 10-325mg tablet, one tablet every six hours as needed for pain. Record review of Resident #5's November 2023 MAR reflected a prescription for Norco 10-325mg tablet one tablet every six hours for pain as needed. Resident #5 received the medication at 3:02 PM on 11/2/2023, at 3:54 PM on 11/5/2023, at 8:41 AM on 11/6/2023, at 3:19 PM on 11/14/2023, at 8:28 AM and 3:43 PM on 11/15/2023, at 7:38 AM on 11/16/2023, at 5:14 PM on 11/19/2023, at 9:30 AM and 5:10 PM on 11/20/2023, at 8:08 AM on 11/21/2023, at 12:57 PM on 11/22/2023, at 1:07 PM and 7:13 PM on 11/23/2023, at 11:00 PM on 11/24/2023, at 8:33 AM on 11/25/2023, at 11:04 AM on 11/26/2023, at 7:50 AM and 5:14 PM on 11/29/2023 and at 7:10 AM on 11/30/2023. Interview on 2/26/2024 at 3:44 PM with Resident #5, she said she had no concerns with her medications. Resident #5 said all she had to do was ask and the facility would provide the medications when requested. Interview on 2/26/2024 at 3:45 PM with Resident #5's RP, she said she had no concerns with the care provided by the facility. Resident #5's RP said she never was concerned that her family member received the wrong medications. Anytime her family member was in pain the facility would provide medication for the pain. If her Resident #5 asked for pain medication the facility would provide it. 3. Record review of CR #2's face sheet, dated 2/26/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 11/14/2023. CR #2 had diagnoses which included acute pyelonephritis (sudden and severe inflammation of kidney due to a bacterial infection), COPD (Chronic Obstructive Pulmonary Disease, a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), paroxysmal atrial fibrillation (sudden onset disease of the heart characterized by irregular and often faster heartbeat), muscle weakness, ataxic gait (an unsteady, uncoordinated walk, with a wide base and the feet thrown out, coming down first on the heel and then on the toes with a double tap), lack of coordination, cognitive communication deficit (difficulty with any aspect of communication that is affect by a disruption of cognition), and myopathy (term for diseases that affect the muscles). Record review of CR #2's admission MDS, dated [DATE], with an ARD of 11/7/2023, reflected a BIMS score of 10, which indicated a moderate to significant cognitive impairment. CR #2 had no impairment of either upper or lower extremities and did not use a mobility aid. CR #2 required assistance or total dependence on all ADL's except eating. He was administered anticoagulant, insulin, antibiotic, diuretic (water pills), and hypoglycemic (medication used for low blood sugar) medications during the review period. CR #2 received OT, PT, and ST services. Record review of CR #2's medication report, dated 2/26/2024, reflected a prescription for Hydrocodone-Acetaminophen 5-325mg tablet one tablet every six hours as needed for pain. Record review of CR #2's November MAR reflected he was not administered the medication between 11/1/2023 and 11/16/2023. An attempted telephone interview with CR #2 on 2/26/2024 at 3:27 PM was unsuccessful. A voice message was left requesting a return call. 4. Record review of CR #3's face sheet, dated 2/23/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 11/7/2023. CR #3 had diagnoses which included metabolic encephalopathy (alteration of brain function or consciousness due to failure of other internal organs), dementia (group of symptoms that affects memory, thinking and interferes with daily life), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), cerebral infarction (the blood flow to the brain is disrupted due to issues with the arteries that supply it, stroke), cognitive communication deficit (difficulty with any aspect of communication that is affect by a disruption of cognition), schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), malignant neoplasm (cancerous tumor) of the breast, and hypertension (high blood pressure). Record review of CR #3's admission MDS, dated [DATE], with an ARD of 10/25/2023, reflected a BIMS score of 13, which indicated minimal cognitive impairment. CR #3 was independent in her ADL's, used a wheelchair or walker for mobility, and had no impairment of either upper or lower extremities. She received OT, PT and ST services. Record review of CR #3's care plan, dated 11/13/2023, reflected a focus on her ADL self-care deficit with interventions which included supervision with eating, oral hygiene, and personal hygiene, dependence on staff for toileting, showering, dressing, and transfers. A focus on her risk of skin breakdown with interventions which included repositioning, use of a pressure reducing mattress, provision of incontinence care, and weekly skin assessments. A focus on CR #3's dementia with interventions which included explanation of care services provided and involved her RP in care planning. Record review of Resident #3's medication report, dated 2/26/2024, reflected prescriptions which included Norco 5-325mg tablet one tablet by mouth one time for pain written on 11/3/2023 and discontinued on 11/4/2023, and Hydrocodone-Acetaminophen 10-325mg one tablet every six hours as needed for pain written on 10/23/2023. Record review of CR #3's November 2023 MAR reflected a prescription for Norco 5-325mg tablet one tablet by mouth one time for pain written on 11/3/2023 and discontinued on 11/4/2023. The MAR did not document this prescription was administered. The MAR documented a prescription for Hydrocodone-Acetaminophen 10-325mg one tablet every six hours as needed for pain written on 10/23/2023 and discontinued on 11/8/2023. Resident #3 had the prescription administered on 11/5/2023 at 10:45 AM. There was no other documentation the medication was administered to CR #3. Attempted telephone interview with CR #3 on 2/26/2024 at 3:29 PM was unsuccessful. A voice message was left requesting a return call. 5. Record review of CR #6's face sheet dated 2/1/2024 revealed an [AGE] year-old resident admitted on [DATE] and discharged on 11/19/2023. Per the face sheet, CR #6's diagnoses included heart failure (progressive heart disease that affects pumping action of the heart muscles), COPD (Chronic Obstructive Pulmonary Disease, a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), obesity (condition characterized by abnormal or excessive fat accumulation), respiratory failure (any condition that affects breathing function or the lungs themselves and can result in failure of the lungs to function properly), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), metabolic encephalopathy, muscle weakness, chronic pain, lymphedema, peripheral vascular disease, and arthritis. Record review of CR #6's five-day MDS dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. The MDS documented she was independent in all ADL's and used a motorized wheelchair or walker for mobility. Per the MDS, CR #6 was prescribed scheduled pain medication, and she was frequently in pain. The MDS revealed the pain interfered with her therapy activities and sleep. The MDS documented she was prescribed opioid medication. Per the MDS, CR #6 received OT and PT services. Record review of CR #6's baseline MDS dated [DATE] revealed her expected stay at the facility was ten to fourteen days. The care plan documented she was expected to discharge home or to the community with a family member and/or caregiver. Per the care plan, CR #6 was admitted for skilled nursing services. The care plan revealed she would receive treatment, medication administration and monitoring, change of condition monitoring and reporting, labs and medication as ordered. The care plan documented she received orders for PT. Record review of CR #6's hospital discharge instructions dated 11/8/2023 revealed she was to continue taking oxycodone-acetaminophen at the prescribed 10-325mg tablet one tablet every six hours as needed for pain. Record review of CR #6's controlled substance disposition record from the local pharmacy dated 11/10/2023 revealed she was provided with eight tabs of oxycodone-acetaminophen 10-325mg tablet. The record documented the instructions for the medication were to take one tablet every six hours as needed for pain. Per the record, CR #6 was administered one tablet at 5:45 AM, 12:30 PM, and 6:50 PM on 11/11/2023, at 12:43 AM, 7:42 AM, 1:42 PM, and 8:45 PM on 11/12/2023, and at 2:52 AM on 11/13/2023. Record review of CR #6's November 2023 MAR printed on 2/1/2024 revealed a prescription for oxycodone-acetaminophen 10-325mg tablet one tablet every six hours as needed for pain. Per the MAR, CR #6 was administered one tablet at 1:00 AM, 7:00 AM, 1:00 PM, and 7:00 PM on 11/17/2023, 11/18/2023, and 11/19/2023, and at 1:00 PM and 7:00 PM on 11/16/2023. The prescription was written on 11/16/2023 at 12:45 PM. Record review of CR #6's medication report dated 2/1/2024 revealed she was prescribed oxycodone with acetaminophen 10-325mg tablet one tablet every six hours for pain on 11/16/2024. Telephone interview on 2/26/2024 at 3:31 PM with CR #6, she said on one occasion she was provided with the wrong medication when she lived at the facility. CR #6 said she informed the nurse the medication was wrong. CR #6 said the nurse took the medication away and brought her the correct medication. CR #6 said the facility should have known the correct medications. She felt someone at the facility stole her medications, or the facility sent her the wrong medications. CR #6 was only provided the wrong medication on one occasion. She was unsure if she took the wrong medication or not. She was upset the facility brought her the wrong medication, and if she took the wrong medications that could have caused her harm. Record review of the facility's internal investigation reflected CR #6 informed the facility her oxycodone tablet looked different than usual on 11/13/2023. The nurse checked the pill through the pill identifier and it was determined to be baclofen. CR #6 reported feeling loopy after taking the medication. The pharmacy that provided the oxycodone reviewed their processes and video and determined the correct medication was sent to the facility. The pharmacy sent medications with red labels for controlled medications and blue for non-controlled. The pharmacy reported the person that switched the labels did not know the color coding. The pharmacy informed the facility the labels on the oxycodone was switched with a non-controlled substance. a total of nine medication cards' labels were switched. The facility reviewed footage and found no information which would determine who changed the medication labels. Any resident whose medication was tampered with had their medication replaced. Record review of a written statement from LVN N, dated 11/13/2023, reflected he was notified by a resident that she did not feel like herself after taking medication. The resident informed LVN that she thought either her insulin or pain medication was making her feel unwell. LVN was informed by the resident she did not think the pain medication looked like the pills she had taken in the past. LVN discovered the medication was not oxycodone as labeled and he immediately informed the DON. LVN had not had any concerns for misappropriated medications prior to this incident. Record review of a medication error assessment, completed on 11/15/2023, reflected the pharmacy had filled CR #6's oxycodone prescription with baclofen. The assessment documented CR #6 did not feel well as a result of receiving the wrong medication. 6. Record review of CR #7s' face sheet, dated 2/26/2024, reflected a [AGE] year-old male who was admitted on [DATE] and discharged on 11/14/2023. CR #7 had diagnoses which included cerebral infarction (the blood flow to the brain is disrupted due to issues with the arteries that supply it, stroke), hemiplegia and hemiparesis, COPD (Chronic Obstructive Pulmonary Disease, a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), a displaced fracture of the lateral end of the left clavicle, type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), muscle weakness, heart failure (progressive heart disease that affects pumping action of the heart muscles), cognitive communication deficit (difficulty with any aspect of communication that is affect by a disruption of cognition), adjustment disorder (short term condition arising due to difficulty in managing the stressful life changes such as coping with work-related problems, loss of loved ones, or relationship issues that leads to significant impairment in functioning), visual disturbances (any condition which affects the eyes or vision), and bariatric surgery (surgery to assist in weight loss) status. Record review of CR #7's 5-day MDS, dated [DATE], with an ARD of 11/14/2023, reflected a BIMS score of 15, which indicated no cognitive impairment. CR #7 had an impairment of one upper extremity, no impairment to his lower extremities, and did not use a mobility device. CR #7 required maximal assistance or was totally dependent on staff for all ADL's except oral hygiene and eating. He was administered antidepressant and diuretic medications during the review period. CR #7 received OT and PT services. Record review of CR #7's November MAR reflected he had a prescription, dated 11/9/2023, and discontinued on 11/16/2023, for hydrocodone-acetaminophen 5-325mg tablet one tablet twice daily for pain. CR #7 refused the medication on the mornings of 11/10/2023, 11/11/2023, and 11/12/2023. CR #7 was not administered the medication on the mornings of 11/13/2023 and 11/4/2023, but the reason was documented in his progress notes (no note was observed documenting the reason the medication was not provided). He received the medication on the evenings of 11/10/2023, 11/11/2023, and 11/13/2023. He was not administered the medication on the evening of 11/12/2023 because he was nauseous or on 11/14/2023 because he was not at the facility. Record review of CR #7's medication report, dated 2/26/2024, reflected a prescription for Hydrocodone-Acetaminophen 5-325mg tablet one tablet twice daily for pain. Record review of CR #7's progress notes reflected no note related to pain medications on 11/13/2023 or 11/14/2024. 7. Record review of CR #8's face sheet, dated 2/23/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 11/08/2023. CR #8 had diagnoses which included a displaced tri-malleolar fracture (ankle fracture) of the right lower leg, neutropenia (condition characterized by abnormally low levels of white blood cells), paraplegia (paralysis of the lower half of the body), sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), anemia (deficiency of healthy red blood cells in blood), thyrotoxicosis (excessive quantities of thyroid hormones), hypertension (high blood pressure), paroxysmal atrial fibrillation (sudden onset disease of the heart characterized by irregular and often faster heartbeat), cerebral infarction (the blood flow to the brain is disrupted due to issues with the arteries that supply it, stroke), end-stage renal disease (condition where the kidney reaches advanced state of loss of function), bacteremia the presence of bacteria in the blood), and dependence on renal dialysis (blood purifying treatment given when kidney function is not optimum). Record review of CR #8's significant change MDS, dated [DATE], with an ARD of 11/8/2024, reflected a BIMS score of 8, which indicated a significant cognitive impairment. CR #8 had no impairment to either her upper or lower extremities, and she used a wheelchair for mobility. CR #8 received no therapeutic or restorative services. Record review of CR #8's care plan, dated 10/3/2023, reflected a focus on her impaired cognitive function with interventions which included cuing and reorienting, provision of a consistent routine, and monitoring for any changes of condition. A focus on her decline in functional abilities with interventions included therapeutic services as ordered, and assistance with sitting-to-standing mobility and toileting. A focus on CR #8's ADL self-care deficit with interventions included assistance with bathing, bed mobility, dressing, eating, locomotion, personal hygiene, toileting, and transfers, and monitoring for changes in condition. A focus on her fall risk with interventions which included anticipation of needs, ensuring her bed was in the lowest position, and ensuring a safe space. A focus on her fractured ankle with interventions which included encouragement to lie down, monitoring for pain and/or discomfort, and notification if the current pain or non-pharmacological pain management was ineffective. Record review of CR #8's medication report, dated 2/26/2024, reflected prescriptions which included Norco 5-325mg tablet one tablet every eight hours for pain written on 11/2/2023, and Norco 5-325 mg tablet one tablet every eight hours as needed for pain written on 11/8/2024. Record review of CR #8's November 2023 MAR reflected a prescription for Norco 5-325mg tablet one tablet every eight hours for pain written on 11/2/2023 and discontinued on 11/8/2024. The medication was administered daily at 3:00 PM and 11:00 PM on 11/2/2023 and 7:00 AM, 3:00 PM and 11:00 PM from 11/3/2023 through 11/7/2023. CR #8 had a prescription for Norco 5-325 mg tablet one tablet every eight hours as needed for pain written on 11/8/2024 and discontinued on 11/8/2024. The MAR did not document the medication was ever administered. 8. Record review of CR #9's face sheet, dated 2/26/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 11/19/2023. CR #9 had diagnoses which included sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), malignant neoplasm (cancerous tumor), immunodeficiency (the immune systems inability to fight infection or disease effectively) due to drug use, a displaced fracture of the lateral malleolus of the fibula (ankle fracture), neoplasm (tumor) related pain, and acute kidney failure (condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days). Record review of CR #9's discharge MDS, dated [DATE], with an ARD of 11/3/2023, reflected her short-term memory was not impaired, and she was independent in her cognitive skills for making decisions regarding tasks for daily life. She was dependent on staff for all ADL's except eating and oral hygiene. CR #9 was administered antibiotic and opioid medications during the review period. CR #9 received no OT, PT or ST services. Record review of CR #9's medication report, dated 2/26/2024, reflected prescriptions which included Oxycodone 5mg tablet one tablet every six hours as needed for pain written on 10/31/2023. Record review of CR #9's November 2023 MAR reflected a prescription for Oxycodone 5mg tablet one tablet every six hours as needed for pain written on 10/31/2023 and discontinued on 11/5/2023. The medication was administered on 11/3/2023 at 5:02 AM. CR #9 was not administered the medication at any other time. In an interview on 2/23/2204 at 10:39 AM with LVN P, she said she was employed since January of 2024. LVN P said her primary duties were to provide care required of an LVN. LVN P said misappropriation of resident's property referred to stolen or missing items. She was required to administer medications as ordered by the resident's prescriber. She administered a resident's first dose of a controlled substance, ensured it was placed on the medication cart appropriately, and after a MA could administer the medication. She administered as needed pain medications. LVN P said prior to administering the medication she would ask the resident his/her pain level, ensure the medication was the correct medication, and the medication was administered at the correct time. She ensured the correct resident received the correct medication by reviewing the resident's name on the MAR, checked the resident's picture on the MAR, asked the resident his/her name, and read the label on the medication's blister pack. She completed multiple medication checks prior to administering a resident any medication, and even more for a controlled medication. LVN P said she never saw an altered medication container. If she ever observed medication packaging which had been altered, she would inform another nurse, ask that nurse to verify the incorrect packaging, and discard the medication if needed. LVN P said she never had missing medication on a medication cart assigned to her. The nurses reconciled all medications on the medication carts and in the medication storage room at shift change. In an interview on 2/23/2024 at 11:12 AM with LVN Q, she said she was employed for one year and four months. LVN Q said she typically only administered medication through a gastronomy tube and as needed medications. She ensured the residents received the correct medications by following the established protocols which included checking the resident's name, the resident's face, the medication dosage, the quantity of medication to be administered, and the resident's pain levels. LVN Q said prior to administering any pain medications she had to document it in the computerized MAR. The MAR had a photo of the resident. The nurses reconciled the medication carts at each shift change. The nurses would ensure the amount of medication on the medication cart matched the number of medications in the medication log. The nurses physically inspected each medication's packaging to ensure it was intact. She never saw any medication packaging altered. The pharmacy placed tape across the packaging to ensure the labels could not be altered. She never had any missing medication on a medication cart assigned to her. If she ever observed altered medication packaging or if her cart was missing medications, she would inform the DON immediately. In an interview on 2/26/2024 at 6:41 AM with LVN J, she said the medication cart count and review was completed at the beginning and end of each shift. LVN J said that was done to ensure the residents received the correct amount of medication during the previous shift, the medications were accounted for, and the medication packaging appeared to be intact. LVN J said this was important because the residents needed to receive their medications per the physician's orders. In an interview on 2/26/2024 at 6:47 AM with LVN V, she said the medication cart count and reviews were completed to ensure the medication on the cart were accurate to what was documented in the controlled substance binder. LVN V said this would help to ensure each resident received his/her medication appropriately and no medication was missing. In an interview on 2/26/2024 at 7:29 AM with the DON, she said the electronic medication dispensing system was controlled by the pharmacy. The DON said the pharmacy restricted access to the system to nurses, provided the nurses with an access code, and restocked the system with controlled substances monthly or as needed. The IV medications and the non-narcotic temperature sensitive medications stored in the refrigerator were audited weekly as neither were narcotic. When the medications were administered to the residents they were prescribed to, the medication administration was documented in the resident's MAR. No one other than nurses had access to the electronic medication dispensing system. The MA's did not have access to the electronic medication dispensing system. The DON said when housekeeping cleaned the medication storage room, a nurse was required to stand in the room while it was cleaned. The housekeepers were not allowed to remain in the room unattended. If the pharmacy became aware of a discrepancy with the medications stored in the electronic medication dispensing system, the pharmacy would contact the facility, and an immediate audit would be completed. A nurse could not access the electronic medication dispensing system without a second nurse. When a resident was prescribed a controlled substance located within the electronic medication dispensing system, the pharmacy provided a specific code to be entered by the nurse to obtain that specific prescription. After the nurse entered the code, a second nurse had to enter his/her access code to verify a witness had observed the initial nurse obtained the medications. The system could not be closed until the nurse counted the amount of medication remaining in the system and entered the number. If the number was incorrect, that would alert the pharmacy to a discrepancy which would trigger an audit. The pharmacy completed an audit each time the system was restocked. In an interview on 2/26/2024 at 9:46 AM with the DON, she said the recent medication administration and possible diversions were not pharmacy initiated. The DON said a nurse brought the medication concerns to her attention. The DON said medication labels had been switched between controlled medications and non-controlled medications. The nurse verified the medication he was about to administer was not the correct medication for the resident. The DON contacted the pharmacy as she thought the pharmacy possibly stocked the wrong medication in the blister pack. The pharmacy responded the medication's blister pack's sticker was altered. The pharmacy provided controlled medications in a red blister pack. The person responsible for the medication diversion took the controlled substance sticker and switched with the non-controlled blister pack. The DON said the person responsible was never definitively identified. After reviewing all medication carts, it was determined that nine controlled medications had been switched with non-controlled medications, but all but one had either discharged or been discontinued. The resident who was not discharged and whose medication was not discontinued was CR #6. The facility placed cameras in the medicati