Every finding on record at Agape Rehabilitation & Nursing Center, A Waters CM

Based on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record review, observation, and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 2 residents (Resident #13 and #62) of 18 residents reviewed for MDS assessments.The findings include: Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed .A1500 .Preadmission Screening and Resident Review (PASRR) .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition .Section GG .Functional Abilities .Limitation in Range of Motion .Code 1 .if resident has impairment on one side . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Atrial Fibrillation, and Muscle Weakness. Further review revealed a new diagnosis was added on 11/11/2025 for Left Wrist Contracture (the permanent tightening or shortening of muscles, tendons, skin, or other soft tissues that restricts joint movement and reduces flexibility). Review of a Notice of Pre-admission Screening Resident Review (PASRR) Level II Outcome for Resident #13 dated 8/12/2018, revealed .Notice of PASRR Level II Outcome .Nursing Facility Approval .You are approved for nursing facility services .your PASRR Level II evaluation remains good during your stay .The individual meets criteria for having diagnosis of .Serious mental illness .Major Depressive Disorder .Anxiety Disorder . Review of an annual MDS assessment dated [DATE], revealed Resident #13 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed .Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition .no . Review of a quarterly MDS assessment dated [DATE], revealed Resident #13 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #13 had no functional limitation in range of motion of the upper extremities. During an observation on 5/18/2026 at 3:50 PM, revealed Resident #13 was lying in bed and the resident's left hand was contracted. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder, Major Depressive Disorder, and Anxiety. Review of a PASRR Level II Outcome for Resident #62 dated 4/4/2024, revealed .Notice of PASRR Level II Outcome .Nursing Facility Approval .You are approved for nursing facility services .your PASRR Level II evaluation remains good during your stay .The individual meets criteria for having diagnosis of .Serious mental illness .Post Traumatic Stress Disorder, Major Depressive Disorder, Mood Disorder . Review of an annual MDS assessment dated [DATE], revealed Resident #62 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed .Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition .no . During a medical record review and interview on 5/19/2026 at 2:00 PM, the Director of Nursing (DON) reviewed the MDS assessments for Resident #13 and Resident #62 and confirmed the facility failed to accurately code the MDS assessments to reflect Resident #13's limited range of motion of the upper extremity and serious mental illness. Further interview revealed the facility failed to accurately code Resident #62's serious mental illness. During a medical record review and interview on 5/19/2026 at 2:05 PM, the Licensed Practical Nurse MDS Coordinator reviewed the MDS assessments for Resident #13 and #62 and confirmed the facility failed to accurately code the MDS assessments to reflect Resident #13's limited range of motion of the upper extremity and serious mental illness. Further interview revealed the facility failed to accurately code Resident #62's serious mental illness.

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a person-centered care plan related to a left-hand contracture for 1 resident (Resident #13) of 4 residents reviewed for care plans for range of motion (ROM) and resident mobility.The findings include: Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, revised 3/23/2021, revealed .The Comprehensive Care Plans will be reviewed and updated .based on changes in the resident's condition and/or newly developed health/psycho [psychological]-social issues .The .Care Plan Coordinator .will attend the Morning .meetings .review 24 Hour Report(s) .new or changed orders .They [Care Plan Coordinator] will then see that the care plans for these residents are revised and updated as necessary . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Atrial Fibrillation, and Muscle Weakness. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Continue review revealed no impairment in ROM to the upper extremity including the left shoulder, left elbow, left wrist, and left hand. Review of an orthopedic outpatient office visit note for Resident #13 dated 8/22/2025, revealed the resident .does not have good motor function in her left upper extremity . Review of an Occupational Therapy (OT) Evaluation and Plan of Treatment for Resident #13 dated 8/25/2025, revealed .will exhibit a decrease in edema in the left hand to .wrist .in order to improve functional use of UEs [Upper Extremities] during ADLs [Activities of Daily Living] .decrease in range of motion .at risk for contracture(s) . Review of an Occupational Therapy Treatment Encounter Note for Resident #13 dated 8/28/2025, revealed .L (left) hand and gentle ROM in prep [preparation] for application of soft palm guard .agitation expressed . Review of an Occupational Therapy Treatment Encounter Note for Resident #13 dated 9/8/2025, revealed .instruction in brace .applications and hygiene .Pt [Patient] issued a palm guard for daily use after hygiene/bathing to hand . Review of an Occupational Therapy Discharge Summary for Resident #13 dated 9/8/2025, revealed .full extension achieved passively while wearing palm guard .Pt and Caregivers educated in LUE [Left Upper Extremity] positioning . Review of a History and Physical for Resident #13 dated 11/11/2025, revealed .acute visit for c/o [complaints of] left hand/wrist pain .states she [Resident #13] cannot lift her left wrist and mover [move] her fingers on her left hand .left wrist contracture .has left palm guard . Review of the comprehensive care plan for Resident #13 dated 12/11/2025, revealed a care plan had not been developed or implemented for the resident's left-hand contracture. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation on 5/18/2026 at 3:50 PM, revealed Resident #13 lying in bed and the resident's left hand was contracted. Continued observation revealed the Director of Nursing (DON) attempting to apply the palm guard to Resident #13's left hand. Further observation revealed Resident #13 refused to allow placement of the palm guard. During an interview on 5/18/2026 at 4:50 PM, Certified Nursing Assistant (CNA) A stated she cared for Resident #13 routinely and the resident was non-compliant with ROM exercises and placement of left palm guard. During an interview on 5/18/2026 at 4:55 PM, Licensed Practical Nurse (LPN) A stated she cared for Resident #13 routinely and the resident was non-compliant with palm guard placement to the left hand. During an interview on 5/18/2026 at 4:48 PM, CNA B stated she cared for Resident #13 routinely and the resident was non-compliant with range of motion exercises and placement of left palm guard. During an interview on 5/19/2026 at 1:25 PM, the DON confirmed the facility failed to develop a care plan for the contracture to Resident #13's left hand. During an interview on 5/19/2026 at 1:55 PM, the MDS/Care Plan Coordinator confirmed the facility failed to develop a care plan for the contracture to Resident #13's left hand. During an interview on 5/19/2026 at 1:45 PM, the Medical Director, the provider for Resident #13, stated the resident had arthritic changes to the left upper extremity arise around 8/2025. The resident refused treatment such as range of motion exercises and palm guard placement to the left hand. The physician stated the contracture was unavoidable due to the normal progression of the arthritic disease and the resident's refusal of ROM exercises and palm guard placement.

Based on facility policy review, observations and interview, the facility failed to ensure kitchen cooking/serving equipment was maintained in a sanitary condition, failed to ensure food items were sealed properly, and failed to ensure dented cans were discarded, which had the potential to affect 65 of 65 residents. The findings include: Review of the facility's policy titled, Food Storage dated 11/25/2019, showed .Food storage areas are clean .containers for bulk items .have tight-fitting lids .dented cans are returned to the vendor upon delivery or stored in a separate area . Review of the facility's policy titled, Cleaning & Sanitization dated 9/2/2020, showed .ensure the food service department is maintained according to state and federal regulations as well as a clean, sanitary, and safe environment . Observation of the cooking and food preparation area with the Certified Dietary Manager (CDM) on 2/20/2024 at 10:40 AM, showed the following: - Gas stovetop ranges had dried, black, greasy food debris present on surface and inner area. - Griddle cooktop had black, grease-like food debris present on inner corners of the cooktop. - Boiler-less Steamer had greasy, brown-yellow residue present on the metal pan insert, standing water in the bottom of steamer was observed to be turbid, brown, and contained free floating brown food debris, and crusty yellow food debris was impacted on the insulated strip of the streamer door. - Stagnant brownish-yellow water was present on the floor behind steamer. - Convection oven temperature dials on the top and bottom ovens had dried, brownish-yellow food debris. - Toaster Oven temperature dials x [times] 3 had dried food debris present. - One 15-ounce (oz) (3/4 full) container of Ground Cumin was not sealed. - One 36-oz box of Iodized Salt (1/4 full) was not sealed. Observation of the dry storage area with the CDM on 2/20/2024 at 10:45 AM, showed the following: - Two 49.5-oz cans of mushroom soup were dented. - One 50-oz can of tomato soup was dented. Observation of the clean dish storage area with the CDM on 2/20/2024 at 10:50 AM, showed the following: - Two 1/2-inch-deep roasting pans had dried, crusty, yellow food debris. - Two 6-inch small plates had crusty yellow food debris present to the bottom of each plate. - Two small bowls had dried, yellow food debris present on the inside of the bowls. During an interview on 2/20/2024 at 11:36 AM, the CDM confirmed the dented cans had not been discarded, spices were not sealed appropriately, and the kitchen equipment (gas stove, griddle cooktop, steamer, roasting pans, serving dishware, etc) was not maintained in a sanitary condition.

Based on facility policy review, medical record review and interviews, the facility failed to report an allegation of abuse timely for 1 resident (Resident #20) of 24 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse Prevention Program dated 1/19/2017, showed .When an alleged or suspected case of abuse .is reported .the administrator, or person in charge of the facility, will notify the following .agencies of such incident immediately .State Licensing and Certification Agency . Resident #20 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Mild Intellectual Disabilities, Anxiety Disorder, Osteoporosis and Hypertension. Review of Resident #20's comprehensive care plan dated 8/27/2021, showed .a DX [diagnosis]/HX [history] of mild intellectual disability .Behavior .has an alteration in behaviors as evidenced by .fixation on male staff and residents .refers to them as her boyfriends .exhibits attention seeking behaviors and confabulates stories .has made the statement that her brother in law sexually abused her in the past and her family denies this has occurred .Hx of hallucinations and delusions . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] (assessment prior to allegation of abuse), showed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of a Nurse Practitioner (NP) Progress note dated 12/22/2023, showed .acute visit as pt [patient] reported she was inappropriately touched by a male .reports the male entered her room and grabbed her lotion and started rubbing lotion on her legs and then up her torso onto her breast then stuck his hand down her brief .discussed with Psych .the resident reports feeling safe in her current environment . Review of a Psychiatric NP note dated 12/22/2023, showed .patient required telehealth visit today after she made accusations that a custodian [Housekeeping Floor Technician] had made inappropriate contact with her of a sexual nature. Patient has a history of erotomanic delusions (when you think someone is in love with you, but they are not) there have been a few instances since the patient has been a resident here where she felt she had a romantic relationship with people whom she did not. Her sister reports this has happened frequently in the past. Her sister also reports long history of delusional thought processes and hallucinations .She [Resident # 20] reports she feels safe at the facility and has no concerns in regard to the custodian. She reports she has no concerns with him continuing to work at the facility including her room. With the patient's history of confabulations and delusional thought processes it is likely she is just currently having exacerbation of symptoms . During an interview on 2/20/2024 at 11:00 AM, Resident #20 stated the Housekeeping Floor Technician hurt her (the resident did not specify a date). The resident also stated the Housekeeping Floor Technician sat her up in the bed, laid her across the bed, and applied lotion to her private area (the resident demonstrated by rubbing between her thighs) without gloves on. The resident stated she did not have clothes on, it hurt her, she asked the Housekeeping Floor Technician to stop and he did. Resident #20 stated she reported the incident to the Administrator and Director of Nursing (DON). During an interview on 2/21/2024 at 8:00 AM, Licensed Practical Nurse (LPN) #1 stated Resident #20 made an allegation of abuse approximately 6 months ago (unsure of the exact date). The resident reported to another nurse (unsure of which nurse) the Housekeeping Floor Technician touched her inappropriately. During an interview on 2/21/2024 at 8:40 AM, Registered Nurse (RN) #1 stated she was familiar with Resident #20. The resident made an allegation (unsure of the exact date and who the resident reported it to) the Housekeeping Floor Technician had touched her inappropriately. During an interview on 2/22/2024 at 9:25 AM, Resident #20 stated 2-3 months ago (unable to give the exact date) she was sitting up on the side of the bed and the Housekeeping Floor Technician was mopping the floor in her room. The resident stated the Housekeeping Floor Technician grabbed her, walked to the bedside table to get the hand lotion, and began rubbing the lotion on her thighs and inside her brief. The resident stated the Housekeeping Floor Technician rubbed the lotion on her for approximately half an hour and when she told him to stop, he stopped. During a telephone interview on 2/22/2024 at 10:30 AM, Certified Nursing Assistant (CNA) #4 stated she cared for Resident #20 routinely on night shift (7:00 PM-7:00 AM). Resident #20 informed CNA #4 around 11:00 PM (unsure of exact date but it was in December) to watch out for the Housekeeping Floor Technician because he rubbed her [Resident #20] inappropriately on her legs and down there. The resident did not state a specific time or date the incident occurred. The CNA reported the allegation to LPN #2 and the LPN informed the DON. During a telephone interview on 2/22/2024 at 10:52 AM, LPN #2 stated she cared for Resident #20 when the resident reported an allegation of abuse. The LPN stated CNA #4 reported (unable to recall the exact date) Resident #20 had stated the Housekeeping Floor Technician had grabbed her and touched her inappropriately. LPN #2 reported the allegation of abuse to the DON immediately. During an interview on 2/22/2024 at 3:15 PM, with the Administrator and the DON, the DON stated LPN #2 had notified her on 12/21/2023 at approximately 11:15 PM, a report by Resident #20 of Housekeeping Floor Technician rubbing lotion on her thighs and down there. When the DON asked LPN #2 what down there meant, the LPN stated the resident pointed to her groin area. The DON stated she contacted the Administrator immediately of the alleged allegation. The Administrator stated he arrived at the facility approximately 20 minutes after he was notified of the allegation and the DON arrived at the facility a short time later. Interview continued and the Administrator stated he and the DON interviewed Resident #20 the night of 12/21/2024. The resident reported the Housekeeping Floor Technician came into her room around 8:00 AM on 12/21/2023 and rubbed lotion on Resident #20 down there (groin area) for 2 hours. The Administrator confirmed he did not report Resident #20's allegation of abuse to the state agency and Adult Protective Services in the 2 hour timeframe required.

Based on facility policy review, medical record review and interview, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) screen was accurate after a mental health diagnosis was identified for 2 of 5 residents (Resident #2 and #38) reviewed for PASARR. The findings include: Review of the facility's policy titled, PASRR [PASARR] PROCESS undated, showed .federally mandated process that requires all states to pre-screen all residents .identify people, including adults, (residents), with mental illness .to ensure people [residents], receive the required services for mental illness . Resident #2 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Anxiety, Alcohol Dependence, Major Depressive Disorder, and Post Traumatic Stress Disorder (PTSD). Review of a PASARR dated 1/4/2022, showed Resident #2 had mental health conditions of Major Depression and Anxiety Disorder with a substance abuse related disorder for Alcohol use. PTSD was not included as a mental health condition. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #2 had an active diagnosis of PTSD. Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes Mellitus, PTSD, and Anxiety. Review of a PASARR dated 9/23/2019, showed Resident #38 had mental health conditions of Depression and Anxiety Disorder. PTSD was not included as a mental health condition. Review of a quarterly MDS assessment dated [DATE], showed Resident #38 had an active diagnosis of PTSD. During an interview on 2/22/2024 at 11:11 AM, the Director of Nursing (DON) confirmed Resident #2 and #38's mental health condition of PTSD had not been captured on the readmission/admission PASARR.

Based on facility policy review, observations and interview, the facility failed to ensure garbage and refuse were properly contained in 2 of 2 dumpsters (dumpster A and B). The findings include: Review of the facility's policy titled, Waste Disposal dated 2/29/2016, showed .dispose of waste in a manner that does not create a nuisance or breeding place for insects and rodents .keep dumpster lids closed at all times .keep dumpster and dumpster site areas clean and free of debris . Observation of the outside dumpster area on 2/20/2024 at 11:15 AM, with the Certified Dietary Manager (CDM), showed 2 dumpsters present for waste disposal. The entry door (right door) to the dumpster area had come off the hinge and was propped up on the wall beside dumpster B. The area around dumpster A had 2 torn plastic bags, 3 used disposable gloves, and pieces of paper debris present on the ground. Dumpster A had a wet, decayed wooden pallet exposed to the elements, propped up beside the dumpster. The hard plastic roof covering dumpster A was missing and left dumpster A's contents open to air, elements, and potential exposure to pests. Dumpster B had no drain plug intact and the outer doors were open, which left dumpster B's contents open to air, elements, and potential exposure to pests. Dumpster B had a wooden door propped up on the wall and had a discarded toilet stored behind the dumpster with trash debris (paper, disposable gloves, leaves) observed inside the toilet bowl. During an interview on 2/20/2024 at 11:36 AM, the CDM confirmed the dumpster area had not been maintained in a good working order or sanitary conditions.

Based on observation and interview, the facility failed to repair the handwashing soap dispensers in 2 of 4 handwashing stations (station A and C), failed to ensure hot water was available in 1 of 4 handwashing stations (station D), and failed to repair 2 of 4 paper towel dispensers (station A and C) observed during the initial kitchen tour. The findings include: Observation of the food preparation area on 2/20/2024 at 11:00 AM, with the Certified Dietary Manager (CDM), showed the paper towel holder and soap dispenser above handwashing stations A and C were not in a good working order and hot water was not assessable on handwashing station D. During an interview on 2/20/2024 at 11:36 AM, the CDM stated handwashing station B was the only fully functioning handwashing station present in kitchen. The CDM confirmed the essential kitchen equipment had not been maintained in a good working order.

Based on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 Resident (Resident #2) of 5 residents reviewed for abuse. The findings include: Review of facility abuse policy titled ABUSE PREVENTION PROGRAM revised 1/2019 showed .It is the policy of this facility to prohibit and prevent resident abuse .by anyone, including .other residents .the following definitions shall pertain .the individual must have acted deliberately .Physical Abuse: Hitting . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Major Depressive Disorder, and Emphysema. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 14 indicating the resident was cognitively intact. The resident required assistance of one or more persons with activities of daily living (ADLs). Review of the medical record showed Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, and Encephalopathy. Review of the quarterly MDS assessment dated [DATE] showed Resident #2's BIMS score was 3 indicating the resident had severe cognitive impairment. The resident required assistance of one or more persons with ADLs. Review of facility investigation showed on 2/26/2023 at 4:30 PM, Resident #1 was propelling down the hallway in her wheelchair and bumped into Resident #2's wheelchair who was near the 100-hall nurse's station. Their wheelchairs became interlocked, Resident #1 started yelling and hit Resident #2 with her water pitcher on his chest and poured water on him. During observation and interview with Resident #1 on 3/29/2023 at 10:45 AM, in the resident's room the resident stated, .yeah I did .I hit him with my water pitcher and poured water on him . During a telephone interview on 3/29/2023 at 10:10 AM, Certified Nurse Assistant (CNA) #1 stated, .[Resident #2] was up there sitting by the nurse's station [100-hall nurse's station] the one by the day room, and [Resident #1] came up behind him [Resident #2]. They were both in a wheelchair and she yelled out 'don't touch me!' and threw water on him [Resident #2] .I turned around when she started yelling and I seen her throw a water cup at him and it hit him in the chest . During a telephone interview on 3/29/2023 at 12:50 PM, Licensed Practical Nurse (LPN) #2 stated.he [Resident #2] didn't do anything to provoke her [Resident #1] he was just sitting there sucking on a sucker and she just must have thought he was in her way so she rolled up to the left of him. When she was going to go past him she bumped into his wheelchair and then she immediately started yelling and she took her water pitcher and she hit him with it in the chest and chin. She never let go of it she just hit him with it and when the lid come off she poured the water on him .[Resident #2] did not touch her I watched every bit of it from the time she came out of her room .

Based on facility policy review, medical record review, review of facility investigation, and interviews the facility failed to prevent abuse for 1 resident (#2) of 4 residents reviewed for abuse. The findings include: Review of the facility policy Abuse Prevention Program, undated, revealed .This facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents .Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, mental anguish or deprivation by an individual .Physical Abuse: Hitting, slapping, pinching, kicking, etc . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status of 3 indicating severe cognitive impairment and required supervision with 1 person physical assistance with locomotion on and off unit. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status of 15, indicating the resident was cognitively intact, had delusions, had no physical behavioral symptoms directed toward others, and required 2 person physical assistance for bed mobility and transfer, and required 1 person limited assistance for locomotion on unit. Review of a comprehensive care plan revised on 1/3/2022 revealed Resident #1 had alteration in behaviors and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility investigation dated 1/8/2022 revealed .Resident [#1] was observed sitting in the hallway in her w/c [wheelchair] making physical contact with another residents [Resident #2] face and chest when CNA [Certified Nurse Aide] came out of a room .When asked resident [Resident #1] why she did that, the resident states 'I don't know she wouldn't leave me alone' .Residents were immediately separated, and resident was taken to nurses station for one on one supervision .New order was given .send to [local hospital] for inpatient psych eval [evaluation] .Resident to be 1 on 1 with staff while up x 72 hours, alarming stop door sign placed on door while in bed . Review of an emergency department provider note dated 1/8/2022 revealed Resident #1 did not meet criteria for inpatient psychiatric services and was sent back to the nursing home. Review of a psychiatric provider note dated 1/10/2022 revealed .Staff requested evaluation after the resident was involved in an altercation over the weekend where she struck another resident. She [Resident #1] was sent out for psych evaluation but did not meet admission criteria and was transferred back to this NF .She does recall the incident over the weekend and reports feeling anxious at the time; however, she struggles to identify specific triggers . During a telephone interview on 1/27/2022 at 2:50 PM Licensed Practical Nurse (LPN) #1 stated on 1/8/2022 an agency CNA reported seeing Resident #1's hand come down and may have struck Resident #2's face and chest. LPN #1 stated Resident #2 had bleeding from her lower lip and a noticeable red mark to her chest. LPN #1 said Resident #2 was unable to communicate what had happened. When asked, the resident stated she didn't know why she did that and that Resident #2 would not leave her alone. The LPN stated Resident #1 was brought to the nurse's station and was sent out for psychiatric evaluation. During a telephone interview on 1/27/2022 at 3:23 PM the Director of Nursing confirmed on 1/8/2022 the abuse occurred between Resident #1 and Resident #2.

Based on facility policy review, observation, and interview, the facility failed to discard expired and damaged food items and failed to ensure food items were not open to air in 2 of 3 coolers, 1 of 1 bread racks, and 1 of 1 freezers. The findings include: Review of the facility policy Food Storage dated [DATE], revealed .Food is stored and prepared in clean safe sanitary manner that will comply with state and federal guidelines . Observation of the kitchen with Dietary Aide #1 on [DATE] at 9:43 AM, revealed the following: In the upright cooler: (5) cartons of 2% (percent) milk with a use by date of [DATE] In the milk cooler: (13) cartons of 2% (percent) milk with a use by date of [DATE] On the bread rack: (3) packages of 12 count hotdog buns with a use by date [DATE] (6) 1lb (pound) loaves of whole wheat bread with a use by date of [DATE] (2) 1lb loaves of sandwich bread with a use by date of [DATE] (1) 1lb sandwich bread with the bread damaged and open to air with a hole in the bottom of the bag (5) slices left in a 1lb bag of wheat bread with a use by date of [DATE] In the walk-in freezer: (2) frozen burger patties in a box open to air (1) 20 lb box of frozen peas open to air (20) frozen biscuits in a box open to air Interview with the Dietary Director on [DATE] at 10:30 AM, in the kitchen, confirmed the facility failed to ensure expired food items were not available for resident use, failed to ensure damaged foods were not available for resident use, and failed to ensure foods were not stored open to air.

Based on facility policy review, medical record review, observation, and interview the facility failed to promote resident rights to respect and dignity, and ensure privacy for 1 resident (#8) of 1 resident reviewed of 19 sampled residents. The findings include: Review of the facility policy Dignity and Respect, dated 7/91, revealed .Residents' individual preferences .clothing .are elicited and respected by the facility .Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by . Review of the facility policy Activities of Daily Living, dated 3/17, revealed .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident was severely cognitively impaired. Further review revealed dressing required extensive assistance of 2 staff members. Medical record review of Resident #8's care plan, dated 12/26/18, revealed .Assist me with bed mobility, transfers, toileting, grooming, dressing, and locomotion . Observation and family interview with Resident #8's family on 3/24/19 at 12:45 PM, in the resident's room, revealed the resident was .left in hospital clothes, and never has pants on . The resident was dressed in a hospital gown, without pants, at the time of the interview. Observation and family interview with Resident #8's family on 3/25/19 at 4:57 PM, in the resident's room, revealed the resident remains in bed dressed in a hospital gown, and no pants. .I wish they would put clothes on him every day .it would make him feel better, and stay warmer . Observation of Resident #8 on 3/26/19 at 8:31 AM, from the 100 hallway, revealed resident lying disheveled, and uncovered with his legs and brief exposed. Interview with the Director of Nursing (DON) on 3/26/19 at 8:54 AM, in the 100 hallway, revealed it would depend on the resident's preferences and needs as to what clothing she would expect them to have on. Continued interview confirmed, .honestly, it is easier to provide care to some of them in a gown .if people are up and going to therapy, they need shirt and pants on . Interview with the DON on 3/26/19 at 9:10 AM, in the conference room, confirmed the facility failed to promote resident rights to respect and dignity, and to ensure privacy for Resident #8.

Based on medical record review, and interview, the facility failed to revise the care plan for 1 resident (#71) of 18 sampled residents. The findings included: Medical record review revealed Resident # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy Fall Prevention Program, revised 3/17 revealed, .When a fall occurs .These interventions will be documented in the medical record as well as the Kardex (medical information system used to communicate information about patients) /CNA (certified nursing assistant) Communication Sheet Review of facility's Incident Case Report dated 4/10/18 with completion date of 5/1/18 revealed, . new action is to use the bedpan opposed to bedside commode . Medical record review of the care plan dated 4/10/18 revealed no intervention for use of a bed pan. Medical record review of Post Incident Documentation, dated 4/14/18, revealed, . new interventions put in place? Yes .New intervention added to Care Plan / Kardex? Yes . Review of Resident #71's current KARDEX revealed, no intervention for use of bedpan , further review revealed, .Fall interventions: Non-skid socks. Interview with CNA # 1 on 5/02/18 at 7:44 AM, in the station 3 hallway, confirmed Resident #71 used bedside commode (BSC) for toileting. Interview with the Director of Nursing (DON) on 5/02/18 at 10:52 AM, in the DON's office, confirmed the facility failed to revise the care plan for Resident #71 following a fall.

Based on facility policy review, review of facility investigation, medical record review, observation, and interview, the facility failed to implement a new intervention and monitor effectiveness of interventions after a fall for 1 resident (#71) of 4 residents reviewed for falls of 18 sampled residents. The findings included: Review of the facility policy Fall Prevention Program, revised 3/17 revealed, .When a fall occurs .These interventions will be documented in the medical record as well as the Kardex (medical information system used to communicate information about patients) /CNA (certified nursing assistant) Communication Sheet For 72 hours following the fall, staff will document .The resident's reaction/response to the new fall intervention placed . Medical record review revealed Resident # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record Review of Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident required staff assistance for transfers and toileting. Medical Record Review of progress notes dated 4/14/18 revealed, This nurse was approached by CNA and told that resident had fallen in the floor . Review of facility's Incident Case Report dated 4/10/18 (correct date 4/14/18) revealed, . new action is to use the bedpan opposed to bedside commode . Medical record review of Post Incident Documentation, dated 4/14/18, revealed, . new interventions put in place? Yes .New intervention added to Care Plan / Kardex? Yes . Medical record review of the care plan dated 4/10/18 revealed no intervention for use of a bedpan. Review of Resident #71's current KARDEX (not dated) revealed no intervention for the use of a bedpan. Further review revealed, .Fall interventions: Non-skid socks . Observation of Resident # 71 on 5/01/18 at 7:56 AM, in the resident's room, revealed the resident lying in bed with a bedside commode (BSC) and safety mat at the bedside. Observation of Resident #71 on 5/02/18 at 7:33 AM, in the resident's room, revealed a BSC and safety mat in place at the bedside. Interview with CNA #1 on 5/02/18 at 7:44 AM, in the station 3 hallway, confirmed Resident #71 uses a BSC for toileting. Interview with the Director of Nursing (DON) on 5/02/18 at 8:27 AM, in the DON's office, confirmed Resident #71's fall occurred on 4/14/18 and the Incident Case Report date of 4/10/18 was incorrect. Further interview confirmed after falls occur, the resident would be assessed, the DON would be called to assist with new interventions and staff would complete a report. Continued interview confirmed the Interdisciplinary Team would review the interventions the following day to ensure the new intervention was appropriate. Further interview confirmed the facility would monitor the effectiveness and resident's response of the new intervention for 3 days after a fall, and review/revise as needed. Continued interview confirmed the new interventions would be added to the Kardex and the care plan would be updated. Interview with Resident #71 on 5/02/18 at 9:38 AM, in the resident's room, confirmed Resident #71 used BSC or bathroom for toileting and stated, .I hate a bedpan . Interview with the DON on 5/02/18 at 10:52 AM, in the DON's office, confirmed the facility failed to implement the new intervention and monitor effectiveness following Resident #71's fall.

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure dental services were provided for 1 resident (#17) of 18 sampled residents. The findings included: Review of the facility policy Dental Services - Professional, revised 3/17 revealed, .routine and emergency dental services are available to meet the resident's oral health .nursing services is responsible for notifying Social Services of a resident's need for dental services .Social Services personnel will be responsible for assisting the resident/family in making dental appointments . Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed .Obvious or likely cavity or broken natural teeth . Observation of Resident #17 on 4/30/18 at 10:34 AM, in the resident's room revealed the resident with tooth decay. Interview with the Director of Social Services on 5/2/18 at 8:20 AM, in the Social Services Office, confirmed Resident #17 had tooth decay and was scheduled to be seen by dental services on 4/20/18. Further interview confirmed Resident #17 was not seen by dental services on 4/20/18 despite being scheduled. Continued interview confirmed the facility failed to provide dental services for Resident #17 since admission to the facility on [DATE].

Based on facility policy review, medical record review, observation, and interview, the facility failed to post an isolation precaution sign on the door of 1 Resident (#328) of 3 residents on isolation precautions of 18 residents sampled of 73 total residents. The findings included: Review of the facility policy Reverse Isolation revised 11/17 revealed, .Place 'Please see nurse before entering room' sign on the outer door . Medical record review revealed Resident #328 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order dated 4/25/18 revealed, .reverse isolation (isolation procedures designed to protect a patient from infectious organisms that might be carried by the staff, other patients, or visitors) for [DIAGNOSES REDACTED] (an abnormally low count of a type of white blood cell) . Medical record review of the care plan dated 4/25/18 revealed, .I am in reverse isolation because my immune system is low and I am susceptible to bacteria/viruses .Post signs at my door informing visitors to check in with licensed staff prior to entering room . Observation during initial tour of Resident #328's room, on 4/30/18 at 9:45 AM, in the station 3 hallway, revealed no isolation precaution sign on the door. Interview with Certified Nurses Aid (CNA) #2, on 4/30/18 at 9:45 AM, in the station 3 hallway, revealed Resident #328 was on reverse isolation precautions and a mask needed to be worn when entering the resident's room for his protection. Interview with the Registered Nurse Consultant, on 4/30/18 at 10:06 AM, in the Station 3 hallway, confirmed Resident #328 was on reverse isolation precautions and the facilty failed to post a sign on the resident's door to notify staff and visitors of the reverse isolation.

Based on medical record review, observation, and interview, the facility failed to provide adequate nursing staff to meet the needs of 2 residents ( #5, #13) of 6 residents ( #1, 3, 5, 9, 12, and 13) sampled for quality of care and residents who attended the resident council meetings. The findings included: Medical record review of Resident #13 revealed she had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 3/3/18 revealed she did not show signs of cognitive loss or communication limitations; she required assistance with all her activities of daily living (ADLs). Her plan of care with an effective date of 3/5/18 stated she had an ADL self-care problem because she required assistance with ADLs. Observation on 3/13/18 at 5:45 AM revealed the facility had a census of 76 residents, and there were a total of two certified nurse aides, (CNA) #1 and CNA #2, and two licensed practical nurses, (LPN) #1 and LPN #6 in the facility. On 3/13/18 at 6:10 AM CNA #2 was interviewed in the hallway. She stated they were supposed to have three CNAs working; however, one called in and that left just her and another CNA to care for 76 residents. She stated the LPNs helped when they could; however, they were still unable to meet the needs of the residents timely when they only had two aides working. CNA #2 was asked if any of the residents experienced falls or were not able to make it to the bathroom on time due to not having the third CNA to help. CNA #2 stated Resident #13 was not assisted to the bathroom timely and had a bowel movement in her incontinence brief when she normally made it to the bathroom and voided on the toilet. Interview with Resident #13 in her room on 3/13/18 at 8:15 AM, revealed she had been in the facility for a little over a week, and she felt she could, get better care at home. She stated when she put her call light on it, takes forever to get help. She stated she put her call light on last night because she needed to have a bowel movement (BM) and waited 10 minutes in her bed and when no one came and she could not hold it any longer she got up by herself with her walker to go to the bathroom. She stated her doctor told her not to get up without help because of her blood pressure, but she had no choice. She stated, just as she stood up she had an accident and got (BM) on the floor and in her brief. She stated once she got into the bathroom, she put the call light on because she had BM up her back and she needed help to get cleaned up. She stated she had to wait 20 more minutes while sitting on the toilet in the bathroom before staff arrived. The resident stated she found it frustrating to have to wait. Medical record review of Resident #5's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status score of 14/15 (indicating he was cognitively intact). Continued review revealed Resident #5 required extensive assistance of 2 staff for bed mobility and transfers. Interview with Resident on 3/12/18 at 3:44 PM, in his room, revealed the facility needed more staff on the third shift. He stated, It just seems like there were no staff in the building on night shift. When asked if his call light was answered timely, he stated it took a while for it to get answered, but did not state how long. Review of the Resident Council Meeting Minutes for (MONTH) (YEAR) through (MONTH) (YEAR) revealed residents voiced concerns every month related to the facility not having adequate staff to meet their needs and/or not having care needs met timely. Cross reference F565. Interviews were conducted on 3/14/18 at 9:48 AM with the Director of Nursing (DON) and the Administrator in the activity room. The DON stated the goal was to have 3 to 4 CNAs and 2 nurses on the 11:00 PM to 7:00 AM shift. She stated a CNA called in prior to the beginning of the 3/12/18, 11:00 PM to 7:00 AM shift and she attempted to get a replacement without any luck. She stated the 11:00 PM to 7:00 AM staff called her at home after the shift started and informed her that the CNA had not come to work. Continued interview confirmed she informed them of the call off and again attempted to call in a replacement without any success. The Administrator was informed of what Resident #13 had stated about taking 30 minutes to get her light answered, and CNA #2 confirmed the resident had bowel incontinence because she (CNA #2) was unable to answer her call light in a timely manner, the Administrator stated if the resident stated it took 30 minutes then it took 30 minutes. The Administrator stated, Then we can do better. She stated they experienced high turnover and were having a hard time recruiting staff, despite advertising on the radio and on social media sources. She stated they also had a difficult time getting employees to fill in for staff who called off, despite offering pay incentives to work overtime and pick up additional shifts.

Based on review of the Resident Council Meeting Minutes, medical record review, observations, and interviews the facility failed to ensure the residents' concerns/grievances related to staffing and call light response time were promptly acted upon for residents who attended resident council meetings, and for two (Resident #5 and #13) of six residents (Residents #1, #3, #5, #9, #12, and #13) sampled for quality of care. The findings included: Review of the resident Council Meeting Minutes for the past six months (October (YEAR) - (MONTH) (YEAR)) revealed the following: On 10/4/17 one resident stated he was not being changed at night on the second to third shift. He stated the facility needed more nurses and aides. On 11/1/17 one resident stated he was not being changed at night on the third shift. The minutes indicated, Multiple residents at the meeting complained of late night/early morning staff not answering call lights. On 12/6/17 one resident stated he was still not being changed on the second and third shift. The minutes indicated, Residents stated some staff just walks in the room and turns call light off and walks out without asking what they need. On 1/3/18 the minutes indicated, Residents stated call lights were still being turned off at times without finding out what the problem is. They also stated that if the call lights were answered it took a while to be answered. One resident stated if the call light was answered, some staff said they would be back, but did not come back or came back 1 to 2 hours later. On 2/7/18 the residents stated they felt the call lights could be answered timelier on the first and third shifts. On 3/7/18 one resident stated her call light was not being answered timely and one resident stated he was not being changed. Continued review revealed none of the Resident Council Meeting minutes included documentation of previous concerns raised by the group and what action had been taken to resolve them. Observation on 3/13/18 at 5:45 AM of the available staffing revealed the facility had a census of 76 residents; had a total of two certified nurse aides (CNA) #1 and CNA #2; and two licensed practical nurses (LPN) #1 and LPN #6 in the facility. Continued observation and interview with CNA #2 on 3/13/18 at 6:10 AM in the hallway revealed, they were supposed to have three CNAs working; however, one called in and that left just she and another CNA to care for 76 residents. She stated the LPNs helped when they could; however, they were still unable to meet the needs of the residents timely when they only had two aides on duty. CNA #2 was asked if any of the residents experienced falls or were not able to make it to the bathroom on time due to not having the third CNA to help. CNA #2 stated Resident #13 was not assisted to the bathroom timely and had a bowel movement in her incontinence brief when she normally made it to the bathroom on time and voided on the toilet. Medical record review for Resident #13 revealed she had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 3/3/18 revealed she did not show signs of cognitive loss or communication limitations; she required assistance with all her activities of daily living (ADLs). Her plan of care with an effective date of 3/5/18 stated she had an ADL self-care problem because she required assistance with some ADLs. Interview with Resident #13 her room on 3/13/18 at 8:15 AM, confirmed she had been in the facility for a little over a week and she felt she could, get better care at home. She stated when she put her call light on it, takes forever to get help. She stated she put her call light on last night because she needed to have a bowel movement (BM) and waited 10 minutes in her bed and when no one came and she could not hold it any longer she got up by herself with her walker to go to the bathroom. She stated her doctor told her not to get up without help because of her blood pressure, but she had no choice. She stated, just as she stood up she had an accident and got (BM) on the floor and in her brief. She stated once she got into the bathroom, she put the call light on because she had BM up her back and she needed help to get cleaned up. She stated she had to wait 20 more minutes while sitting on the toilet in the bathroom before staff arrived. The resident stated she found it frustrating to have to wait. Observation and interview on 3/12/18 at 3:44 PM with Resident #5 in his room revealed the facility needed more staff on the third shift. He stated, It just seems like there were no staff in the building on night shift. When asked if his call light was answered timely, he stated it took a while for it to get answered, but did not state how long. Review of Resident #5's Admission MDS assessment revealed he had a BIMs score of 14 (indicating he was cognitively intact). Interview on 3/14/18 at 9:48 AM the Director of Nursing and the Administrator in the activity room revealed the Administrator was asked about how complaints from the resident council were handled. The Administrator stated after the resident council meeting, the department heads were given the complaints about their areas and they were supposed to address them. The Administrator was asked for documentation related to the ongoing complaints about staffing and call light response from the resident council. The Administrator did not provide any documentation to demonstrate any efforts had been made by the facility to resolve the residents' grievances. The Administrator stated the staff were inserviced (educated) about answering call lights timely; however, she did not provide documentation of the inservice.

Based on facility policy review, medical record review, facility investigation, and interview the facility failed to ensure two residents (#2, #3) were free from abuse of 10 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse Protocol, dated 11/2016, revealed .Each resident has the right to be free from abuse .2. Abuse means the willful infliction of injury . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 10 indicating resident with moderately impaired cognition. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 6 of 15 indicating resident with severe cognitive impairment. Review of a facility investigation dated 12/19/17 revealed .nurse notified of an altercation .upon entering room this nurse was told by CNA on staff that she had witnessed resident in bed #2 being hit by her mother. CNA on staff had separated the altercation .resident in bed #2 stated that resident in bed #1 had hit her in the face with a closed fist more than once .Resident in bed #1 stated resident in bed #2 mother stated to daughter be good, you need to stay here and proceeded to slap daughter. Resident in bed #2 proceeded to hit her mother. Resident in bed #2 stated she couldn't stand to see resident in bed #2 slap her mother, so she went over there and slapped resident in bed #2. Resident in bed #1 stated she got me, pulled my hair and bit my hand and when she did that I slapped the hell out of her . Review of facility investigation statements and interview with the Assistant Director of Nursing (ADON) on 3/13/18 at 9:51 AM, in the activity room, confirmed resident #2 had been smacked by her mother. Continued interview revealed resident #3's hair was pulled and her hand had been bitten by resident #2.

Based on medical record review and interview, it was determined the facility failed to provide sufficient discharge preparation for home health services for one Resident (#1) of five Residents reviewed. The findings included: Medical record review of a Record of Admission and a Client [DIAGNOSES REDACTED].#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's Brief Interview for Mental Status (BIMS) score was 15 on a scale of zero-to-15, with 15 being the highest score achievable to indicate an intact cognition. Continued review revealed the Resident required limited assistance with all Activities of Daily Living (ADLs) except eating and bathing; and Resident #1 was independent with eating and required extensive assistance with bathing. Further review of the MDS Assessment revealed the discharge from the facility was planned. Medical record review of an Interdisciplinary Progress Note dated 10/31/2016, at 10:54 AM, and completed by the Director of Social Services (DSS), revealed, .Resident is requesting to be discharged home today . Medical record review of a Physician's Telephone Order dated 10/31/2016, at 4:49 PM, revealed, Discharge home with home health .skilled nsg (nursing) . Continued review of the Interdisciplinary Progress Notes on 10/31/2016, at 4:50 PM, revealed, .Resident discharged home . Medical record review revealed no documentation a home health provider was notified to arrange skilled nursing services, prior to, or on the day of, the Resident's discharge on 10/31/2016. Medical record review of a prescription pad sheet with an order dated 11/1/2016 and signed by the facility's Nurse Practitioner revealed, .(Home Health Provider) to begin services 11/2/16 d/t (due to) change in provider services for HH (Home Health) . Interview with the DSS on 12/14/2016 at 4:26 PM, in the Conference Room, revealed the DSS coordinated planned discharges and included arranging home health services for post-discharge care, as ordered. Further interview revealed the DSS stated, .Most people d/c'd (discharged ) to home from here need home health .it's rare that they don't . Telephone interview with the Care Transition Coordinator with Home Health Provider (HHP) #1 on 12/14/2016 at 6:50 PM, revealed the HHP (#1) had provided services for Resident #1 in the past. Continued interview confirmed the facility's DSS did not notify HHP #1 until 11/1/2016 (the day after Resident #1 was discharged from the facility). Continued interview confirmed HHP #1 declined to provide home health services for Resident #1 and recommended the facility notify another HHP. A second interview with the DSS on 12/14/2016 at 7:00 PM, in the Conference Room revealed the DSS stated, (HHP #1) had seen (Resident #1) in the past, I assumed they would again .so I called them (HHP #1) on 11/1/2016 .they refused to provide home health to (Resident #1) .recommended I call another home health (provider) . Continued interview revealed the DSS notified HHP #2 on 11/1/2016 and HHP #2 services were initiated on 11/2/2016, as ordered. Further interview confirmed the DSS was made aware of the intended discharge on the morning of 10/31/2016 at 10:54 AM, but failed to ensure home health services were arranged prior to Resident #1's discharge on 10/31/2016 at 4:50 PM (approximately six hours later). Telephone interview with Registered Nurse #1 with HHP #2 on 12/14/2016 at 8:00 PM confirmed Resident #1's start of care date for home health services was 11/2/2016 (two days after discharge from the facility). Continued interview confirmed the Resident was discharged from home health services on 11/18/2016. Interview with the Administrator on 12/14/2016 at 9:27 PM, in the Conference Room, confirmed the facility failed to ensure sufficient preparation and arrange home health services prior to the Resident's discharge on 10/31/2016.

Based on medical record review and interview, it was determined the facility failed to provide sufficient discharge preparation for home health services and an antibiotic was not administered as ordered for one Resident (#1) of five Residents reviewed. The findings included: Medical record review of a Record of Admission and a Client [DIAGNOSES REDACTED].#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Summary and Skilled-Long Term Care Orders dated 10/26/2016 revealed Resident #1 was admitted to the hospital on [DATE] with [MEDICAL CONDITION] secondary to her right lower extremity wounds. Intravenous (IV) antibiotics were started on 10/22/2016 and administered through a Midline IV Catheter. Infectious Disease (ID) was involved in Resident #1's care due to the resistant bacteria in her leg wound and recommended treatment with [MEDICATION NAME] for a period of two weeks. Continued review revealed, Resident #1 received the 10/26/2016 dose of [MEDICATION NAME] prior to discharge. Further review revealed, upon discharge from the hospital to the facility, Resident #1 needed an additional 10 days of [MEDICATION NAME]. Medical record review of a Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the discharge from the facility was planned. Medical record review of a Physician's Telephone Order dated 10/26/2016 revealed an order for [REDACTED]. Medical record review of an Interdisciplinary Progress Note dated 10/31/2016, at 10:54 AM, and completed by the Director of Social Services (DSS), revealed, .Resident is requesting to be discharged home today . Medical record review of a Physician's Telephone Order dated 10/31/2016, at 4:49 PM, revealed, Discharge home with home health .skilled nsg (nursing) . Continued review of the Interdisciplinary Progress Notes on 10/31/2016, at 4:50 PM, revealed, .Resident discharged home . Medical record review of an Interdisciplinary Progress Note dated 10/31/2016 at 4:50 PM, revealed, : .Resident discharged home with son . Medical record review of a prescription pad sheet with an order dated 11/1/2016 and signed by the facility's Nurse Practitioner revealed, .(Home Health Provider) (#2) to begin services 11/2/16 d/t (due to) change in provider services for HH (Home Health). Will need IV [MEDICATION NAME] 1 GM (gram) until 11/6/16 D/T (due to) missed dose today . Telephone interview with the Care Transition Coordinator with Home Health Provider (HHP) #1 on 12/14/2016 at 6:50 PM, revealed the HHP (#1) had provided services for Resident #1 in the past. Continued interview revealed HHP #1's business hours of operation are Monday through Friday from 8:00 AM, to 5:00 PM. Further interview confirmed the facility's DSS did not notify HHP #1 until 11/1/2016, which was the day after Resident #1 was discharged from the facility. Continued interview confirmed HHP #1 declined to provide home health services for Resident #1 and recommended the facility notify another HHP. Interview with the DSS on 12/14/2016 at 7:00 PM, in the Conference Room revealed the DSS stated, (HHP #1) had seen (Resident #1) in the past, I assumed they would again .so I called them (HHP #1) on 11/1/2016 .they refused to provide home health to (Resident #1) .recommended I call another home health (provider) . Continued interview revealed the DSS notified HHP #2 on 11/1/2016 and HHP #2's services were not initiated until the next day on 11/2/2016. Further interview confirmed the DSS was notified by Resident #1 on the morning of 10/31/2016 (at 10:54 AM), but the DSS failed to ensure home health services were arranged prior to Resident #1's discharge on 10/31/2016. Telephone interview with Registered Nurse #1 with HHP #2 on 12/14/2016 at 8:00 PM confirmed Resident #1's start of care date for home health services, including the IV [MEDICATION NAME], was 11/2/2016. Continued interview confirmed the Resident was discharged from home health services on 11/18/2016. Telephone interview with the facility's Nurse Practitioner on 12/14/2016 at 8:55 PM, confirmed the administration of the IV [MEDICATION NAME] was necessary to treat the Resident's infection and should not have been missed on 11/ . Continued interview confirmed the order for the [MEDICATION NAME] was extended from 11/5/2016 to 11/6/2016 due to the missed dose. Interview with the Administrator on 12/14/2016 at 9:27 PM, in the Conference Room, confirmed the facility failed to ensure timely arrangements for home health services prior to the Resident #1's discharge on 10/31/2016. Continued interview confirmed the facilities failure resulted in the [MEDICATION NAME] not being administered on 11/1/2016, as ordered.

Based on medical record review, review of facility investigation, review of the facility policy, and interview, the facility failed to investigate an injury of unkown origin for one resident (#11) and failed to follow the abuse policy for one resident (#87) of five residents reviewed for abuse, of thirty-three residents reviewed, resulting in physical harm to resident #11 and psychological harm to resident #87. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident had [MEDICAL CONDITION] Disease and contractures to all four extremities. Medical record review of a nurse's note dated October 7, 2014, at 5:00 p.m., revealed "...R (right) ext (extremity) swollen upper knee swollen...upon palpation to right extremity resident with moaning and facial grimacing-NP (nurse practitioner) notified-NO (new order)...to obtain X-Ray (R) knee and (R) femur..." Medical record review of a Radiology Interpretation dated October 7, 2014, revealed "...Right Hip...findings: a comminuted fracture (a fracture in which the bone is broken in several places or is shattered, creating numerous fragments) is present in the femoral neck and intratrochanteric region...There is a displacement of the greater trochanter..." Review of an Orthopedic consult dated October 7, 2014, revealed, "...nursing home resident with (R) intertrochanteric [MEDICAL CONDITION]. non-ambulatory previously. She does have bilateral lower and upper extremity contractures...unsure of mechanism of injury..." Interview on January 13, 2015, at 2:48 p.m., with Licensed practical nurse (LPN) #3, in the conference room, revealed the LPN was notified of the change in resident condition by the resident's son at 5:00 p.m., on October 7, 2014. Continued interview revealed the LPN did not notice any changes on the prior assessments completed at 10:00 a.m., and 2:00 p.m. Interview and medical record review with the facility Medical Director on January 14, 2015, at 2:02 p.m., in the bookkeeping office, revealed the resident was at increased risk for a fracture due to age and medication use (no specific medication given), and a fracture could have occurred when the resident was repositioned or moved. Review of the facility policy Abuse Protocol, last reviewed April 2014, revealed "...The facility will attempt to identify and proactively correct situations in which abuse is possible..." Interview and review with the Administrator and Regional Nurse Consultant on January 14, 2015, at 2:25 p.m., in the bookkeeping office, confirmed the injury was not investigated as an injury of unknown origin. Resident #87 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of a facility investigation dated December 2, 2014, revealed "...Date of Occurrence: 12/2/14...Resident reported to RN (Registered Nurse)(Assessment) Nurse that (resident) was afraid of the 'short, fat, blonde nurse.' (Resident) stated the 'nurse' fussed (at) (resident). The RN (Assessment) Nurse then asked a CNA (Certified Nursing Assistant) to assist (resident) (with) care. The RN (Assessment) Nurse overheard the CNA making rude comments to the resident (and) talking 'short' to the resident...Summary of interview with resident: The resident reported the CNA (named) has threatened (resident), poked (resident) in the back with...finger, told (resident)...wishes (resident) would die (and) told (resident)...doesn't like (resident)...Summary of investigator's findings: Investigation reveals RN Assessment Nurse heard CNA being verbally abusive to resident by stating 'You have made a mess,' and 'you are going to be up in your w/c (wheelchair) all night.'..." Review of the resident's statement obtained by the facility from the Director of Nursing (DON) dated December 5, 2014, revealed "...Spoke with resident...on 12/3/2014 regarding concern from 12/2/14. Resident states that CNA (named CNA #1) is mean...pokes (resident) in the back...tells (resident)...doesn't like her and fusses at (resident) when (CNA #1) has to clean (resident) up..." Medical record review of a Psychiatric Progress Note dated December 8, 2014, revealed "...(Patient) readily recalled events with CNA whom (resident) feared, and events were consistent with what (resident) told staff..." Review of the facility policy, Abuse Protocol, last reviewed April 2014, revealed "...The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion...Verbal abuse is any use of oral, written or gestured language that is made to Residents directly or within their hearing range, including disparaging or derogatory remarks regardless of their age, ability to comprehend, or disability...Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a Resident...Protection...Intervene immediately when you see abuse or neglect, even when you just suspect it, by telling the perpetrator to stop...they should immediately be separated from the Resident..." Interview on January 13, 2015, at 9:00 a.m., with the DON, in the conference room, confirmed the resident was able to tell the DON the CNA's name when interviewed, and confirmed the abuse policy was not followed when the resident made an accusation of abuse, the CNA was sent into the resident's room, and the RN did not intervene when overhearing the conversation. Refer to F224 c/o # and #

Based on medical record review, facility policy review, and interview, the facility failed to prevent an accident during care for one resident (#11) of four residents reviewed for accidents, of thirty-three residents reviewed, resulting in harm to resident #11. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired and required total assistance of two or more staff persons for bed mobility and transfers. Medical record review of the resident's Care Plan dated August 29, 2014, revealed, "...Problem...(resident) continues to be at risk for falls d/t (due to) poor safety awareness...Goal...decrease risk for falls related injuries...transfer and mobility with 2 staff..." Medical record review of a Status Change dated October 4, 2014, revealed "...called to room by CNA (certified nursing aide) pt (patient) fell OOB (out of bed). Observed patient lying on right side, agitated, with blood on floor underneath...head called 911..." Medical record review of a Physician telephone order dated October 4, 2014, revealed "...Send to...(hospital) for eval (evaluation) and treatment 2 (secondary) fall with laceration..." Medical record review of a hospital emergency report dated October 4, 2014, revealed, "...mechanism of injury...rolled out of bed at NH (nursing home)...laceration location...behind right ear, 0.5 cm (centimeters)...MD (medical doctor) at bedside...laceration secured with surgiseal..." Medical record review of a nurse's note dated October 4, 2014, at 5:00 p.m., revealed "resident returned to facility...from ER (emergency room ) resident sent to ER secondary to fall from bed with laceration at 2:30 p.m..." Review of the facility policy Fall Prevention Program, revised July 2014, revealed "...The Fall Prevention Program is designed to ensure a safe environment for all Residents...Anticipate needs by assessing normal routines and times of increased risk..." Telephone interview with CNA #5 on January 14, 2015, at 11:06 a.m., revealed the CNA was providing incontinence care to the resident in the resident's room, rolled the resident on the resident's side, turned away from the resident to pull the privacy curtain, and the resident fell from the bed while the CNA was turned around. Interview and review of the facility investigation with Regional Nurse Consultant #1 on January 14, 2015, at 2:04 p.m., in the bookkeeping office, revealed "...CNA providing peri-care turned head away to pull privacy curtain, felt resident against legs, attempted to catch resident but slid to floor..." Continued interview confirmed the facility failed to prevent the fall on October 4, 2014, resulting in harm (a head laceration requiring medical intervention) to resident #11. c/o: #

Based on medical record review, review of facility investigation, review of the facility policy, and interview, the facility failed to provide effective adminstration to protect from abuse one resident (#87) of five residents reviewed for abuse, of thirty-three residents reviewed, resulting in psychological harm to resident #87. The findings included: Review of a facility investigation dated December 2, 2014, revealed "...Date of Occurrence: 12/2/14...Resident reported to RN (Registered Nurse)(Assessment) Nurse that (resident) was afraid of the 'short, fat, blonde nurse.' (Resident) stated the 'nurse' fussed (at) (resident). The RN (Assessment) Nurse then asked a CNA (Certified Nursing Assistant) to assist (resident) (with) care. The RN (Assessment) Nurse overheard the CNA making rude comments to the resident (and) talking 'short' to the resident...Summary of interview with resident: The resident reported the CNA (named) has threatened (resident), poked (resident) in the back with...finger, told (resident)...wishes (resident) would die (and) told (resident)...doesn't like (resident)...Summary of investigator's findings: Investigation reveals RN Assessment Nurse heard CNA being verbally abusive to resident by stating 'You have made a mess,' and 'you are going to be up in your w/c (wheelchair) all night.'..." Review of the statement obtained by the facility from RN Assessment Nurse #1 dated December 2, 2014, revealed "...Overheard (resident #87) calling out. Went into room and there was odor of BM (Bowel Movement)...When I informed (resident #87) that I would get some help (resident #87) stated 'Don't get the short/fat one.' (Resident #87) could not tell me the name of the person (the resident) was afraid of. The CNA on the hall was informed of (resident #87) need...When informed (CNA #1) stated 'It shouldn't have to be this way.' (CNA #1) entered the room. I waited outside the door. The CNA was short with the resident...asked (resident) why...was playing 'in it'. I was unable to hear (resident #87) reply...(CNA #1) made other statements such as 'get your foot out of it' and 'You've made a mess of the floor mat.'...At one time it sounded like (CNA #1) told (resident)...was going to be up in...wc all night..." Review of a statement written by CNA #1 on December 5, 2014, revealed the CNA denied any physical or verbal abuse toward the resident. Further review revealed, after completing all care for resident #87, "...When I came out of the room (staff member) was standing there and we spoke...I went on to the next person that's when (Assistant Director of Nursing/ADON) told me that they needed to speak to me when I finished. After finishing I went up the hall and (ADON) called me into the office where (Administrator, DON (Director of Nursing), ADON) were. (Administrator) informed that (resident #87) had stated that (resident) was afraid of me. That I was suspended upon completing an investigation..." Medical record review of a Psychiatric Progress Note dated December 8, 2014, revealed "...(Patient) readily recalled events with CNA whom (resident) feared, and events were consistent with what (resident) told staff..." Review of the facility policy, Abuse Protocol, last reviewed April 2014, revealed "...The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion...Verbal abuse is any use of oral, written or gestured language that is made to Residents directly or within their hearing range, including disparaging or derogatory remarks regardless of their age, ability to comprehend, or disability...Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a Resident...Protection...Intervene immediately when you see abuse or neglect, even when you just suspect it, by telling the perpetrator to stop...they should immediately be separated from the Resident..." Interview on January 13, 2015, at 8:35 a.m., with RN Assessment Nurse #1, in the conference room, confirmed RN Assessment Nurse #1 stayed outside of the resident's room when CNA #1 entered the room because of the comments resident #87 had made. Further interview confirmed the RN did not intervene at the time of the verbal abuse. Review of the facility investigation, statements of staff, and interviews confirmed the RN overheard CNA #1 verbally abusing resident #87, reported the abuse to the Administrator, and CNA #1 was not stopped immediately from providing care to resident #87, or other residents, by the RN Assessment Nurse, the DON, the ADON, or the Administrator. c/o #

Based on medical record review, review of facility investigation, review of the facility policy, and interview, the facility failed to protect from abuse one resident (#87) of five residents reviewed for abuse, of thirty-three residents reviewed, resulting in psychological harm to resident #87. The findings included: Resident #87 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Discharge Minimum Data Set (MDS) dated [DATE], and the Annual MDS dated [DATE], revealed the resident had moderately impaired cognitive skills for daily decision making. Review of a facility investigation dated December 2, 2014, revealed "...Date of Occurrence: 12/2/14...Resident reported to RN (Registered Nurse)(Assessment) Nurse that (resident) was afraid of the 'short, fat, blonde nurse.' (Resident) stated the 'nurse' fussed (at) (resident). The RN (Assessment) Nurse then asked a CNA (Certified Nursing Assistant) to assist (resident) (with) care. The RN (Assessment) Nurse overheard the CNA making rude comments to the resident (and) talking 'short' to the resident...Summary of interview with resident: The resident reported the CNA (named) has threatened (resident), poked (resident) in the back with...finger, told (resident)...wishes (resident) would die (and) told (resident)...doesn't like (resident)...Summary of investigator's findings: Investigation reveals RN Assessment Nurse heard CNA being verbally abusive to resident by stating 'You have made a mess,' and 'you are going to be up in your w/c (wheelchair) all night.'..." Review of the statement obtained by the facility from RN Assessment Nurse #1 dated December 2, 2014, revealed "...Overheard (resident #87) calling out. Went into room and there was odor of BM (Bowel Movement)...When I informed (resident #87) that I would get some help (resident #87) stated 'Don't get the short/fat one.' (Resident #87) could not tell me the name of the person (the resident) was afraid of. The CNA on the hall was informed of (resident #87) need...When informed (CNA #1) stated 'It shouldn't have to be this way.' (CNA #1) entered the room. I waited outside the door. The CNA was short with the resident...asked (resident) why...was playing 'in it'. I was unable to hear (resident #87) reply...(CNA #1) made other statements such as 'get your foot out of it' and 'You've made a mess of the floor mat.'...At one time it sounded like (CNA #1) told (resident)...was going to be up in...wc all night..." Medical record review of the Social Service Progress Notes dated December 2, 2014, revealed "...This writer spoke to resident to review concern that resident had with staff member. Resident...stated...preferred that staff person to not work with (resident #87) again..." Review of a statement written by CNA #1 on December 5, 2014, revealed the CNA denied any physical or verbal abuse toward the resident. Further review revealed, after completing all care for resident #87, "...When I came out of the room (staff member) was standing there and we spoke...I went on to the next person that's when (Assistant Director of Nursing/ADON) told me that they needed to speak to me when I finished. After finishing I went up the hall and (ADON) called me into the office where (Administrator, DON (Director of Nursing), ADON) were. (Administrator) informed that (resident #87) had stated that (resident) was afraid of me. That I was suspended upon completing an investigation..." Review of the resident's statement obtained by the facility from the DON dated December 5, 2014, revealed "...Spoke with resident...on 12/3/2014 regarding concern from 12/2/14. Resident states that CNA (named CNA #1) is mean...pokes (resident) in the back...tells (resident)...doesn't like her and fusses at (resident) when (CNA #1) has to clean (resident) up..." Medical record review of a Psychiatric Progress Note dated December 8, 2014, revealed "...(Patient) readily recalled events with CNA whom (resident) feared, and events were consistent with what (resident) told staff..." Review of the facility policy, Abuse Protocol, last reviewed April 2014, revealed "...The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion...Verbal abuse is any use of oral, written or gestured language that is made to Residents directly or within their hearing range, including disparaging or derogatory remarks regardless of their age, ability to comprehend, or disability...Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a Resident...Protection...Intervene immediately when you see abuse or neglect, even when you just suspect it, by telling the perpetrator to stop...they should immediately be separated from the Resident..." Interview on January 12, 2015, at 4:00 p.m., with RN Assessment Nurse #1, in the conference room, confirmed the resident's call light was on and, when RN Assessment Nurse #1 went into the room, the resident stated had a bowel movement. The RN Assessment Nurse #1 sent CNA #1 in to clean the resident. RN Assessment Nurse #1 overheard CNA #1 being "short" with the resident. Continued interview with RN Assessment Nurse #1 confirmed CNA #1 was the CNA as described by the resident, but did not consider it abusive, "more...tone", and the RN Assessment Nurse #1 reported CNA #1 immediately to the Administrator. Interview on January 13, 2015, at 8:35 a.m., with RN Assessment Nurse #1, in the conference room, confirmed RN Assessment Nurse #1 stayed outside of the resident's room when CNA #1 entered the room because of the comments resident #87 had made. Interview on January 13, 2015, at 9:00 a.m., with the DON, in the conference room, confirmed the resident was able to tell the DON the CNA's name when interviewed, and confirmed the facility failed to protect the resident from verbal abuse when the resident made an accusation of abuse, the accused CNA was sent into the resident's room, and the RN did not intervene. c/o #

Based on medical record review and interview, the facility failed to follow the care plan for one resident (#11) of four residents reviewed for accidents, of thirty-three residents reviewed, resulting in physical harm to resident #11. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired and required total assistance of two or more staff persons for bed mobility and transfers. Medical record review of the resident's Care Plan dated August 29, 2014, revealed, "...Problem...(resident) continues to be at risk for falls d/t (due to) poor safety awareness...Goal...decrease risk for falls related injuries...transfer and mobility with 2 staff..." Medical record review of a Status Change dated October 4, 2014, revealed "...called to room by CNA (certified nursing aide) pt (patient) fell OOB (out of bed). Observed patient lying on right side, agitated, with blood on floor underneath...head called 911..." Medical record review of a Physician telephone order dated October 4, 2014, revealed "...Send to...(hospital) for eval (evaluation) and treatment 2 (secondary) fall with laceration..." Medical record review of a hospital emergency report dated October 4, 2014, revealed, "...mechanism of injury...rolled out of bed at NH (nursing home)...laceration location...behind right ear, 0.5 cm (centimeters)...MD (medical doctor) at bedside...laceration secured with surgiseal..." Medical record review of a nurse's note dated October 4, 2014, at 5:00 p.m., revealed "resident returned to facility...from ER (emergency room ) resident sent to ER secondary to fall from bed with laceration at 2:30 p.m..." Review of the POS [REDACTED]. Telephone interview with CNA #5 on January 14, 2015, at 11:06 a.m., revealed the CNA was providing incontinence care to the resident in the resident's room, rolled the resident on the resident's side, turned away from the resident to pull the privacy curtain, and the resident fell from the bed while the CNA was turned around. Further interview confirmed the CNA did not have another staff member present during care. Interview and review of the facility investigation with Regional Nurse Consultant #1 on January 14, 2015, at 2:04 p.m., in the bookkeeping office, revealed "...CNA providing peri-care turned head away to pull privacy curtain, felt resident against legs, attempted to catch resident but slid to floor..." Continued review and interview confirmed there was not two staff members providing care as required by the MDS and care plan, and the fall on October 4, 2014, resulted in harm (a [MEDICAL CONDITION] requiring medical intervention) to resident #11. c/o: #

Based on medical record review, review of the facility policy, observation, and interview, the facility failed to prevent a significant weight loss for one (#106) resident of forty residents reviewed. The facilities failure resulted in harm to resident #106. The findings included: Resident #106 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nutritional assessment dated [DATE], revealed, "...wt. (weight) 115 (pounds) IBW (Ideal Body Weight) 105 (pounds)...Diet Order: Regular..." Medical record review of the dietary note dated June 4, 2012, revealed "...Resident returned from the hospital, (6-2-12)...had a colonoscopy...appetite is fair...10 (pounds) (above)...IBW...mechanical soft diet...low residue, wt 115 (pounds)..." Review of the weight record revealed the resident weighed 111 pounds on June 6, 2012. Review of the weight record revealed the resident weighed 105 pounds on July 3, 2012, (5% weight loss in one month). Medical record review of a physician's order dated July 5, 2012, revealed, "...Mighty shakes with meals..." Review of the July, 2012, Medication Record revealed the mighty shakes were initialed as administered on July 6, 2012, through July 11, 2012, three times a day. Medical record review of a physician's order dated July 9, 2012, revealed "...diet texture (change) to mechanical soft solids/thin liquids..." Medical record review of a dietary note dated July 12, 2012, revealed "...weight on 6/7/12...111.0 (pounds)...Res. (resident) has had wt (weight) loss of 10 (pounds) since...returned from the hospital...Res. will receive super cereal for breakfast (and) shake tid (three times a day) for extra cals (calories) (and) pro. (protein) as a precaution for further wt. loss..." Medical record review of a physician's order dated July 13, 2012, revealed " [MEDICATION NAME] (appetite stimulant) 40mg (milligrams) po (by mouth) q (every) day ...Restorative feeding/dining (at) breakfast (and) lunch ..." Review of the facility policy, Weight Change, revealed, " ...all residents with a significant weight change will be assessed ...Where indicated residents will be provided with fortified foods with increased calorie and/or protein, house supplements or placed on the Medical Nutrition Therapy Program..." Observation on July 12, 2012, at 8:30 a.m. revealed the breakfast tray was delivered to the resident with 2% milk, juice, oatmeal, bacon, toast, and egg. Further observation revealed no mighty shake on the tray. Observation and interview on July 12, 2012, at 8:45 a.m., with Licensed Practical Nurse (LPN) #2 confirmed no mighty shake on the breakfast tray or on the meal ticket. Further observation revealed the Certified Nursing Assistant feeding the resident, and the resident drank approximately ? of the milk, juice and ate a few bites of oatmeal. Interview on July 12, 2012, at 8:50 a.m., at the Nursing Station, with the Clinical Nutrition Director confirmed the dietary department did not receive the order for the mighty shakes, and if the order had been received the mighty shake would be noted on the meal ticket. Interview on July 12, 2012, at 9:00 a.m. in the conference room, with the Food Service Director confirmed the dietary department had not received the order for the mighty shakes. Interview on July 12, 2012, at 1:40 p.m., in the conference room, with LPN #3, confirmed the mighty shake was initialed as administered on July 6, 7, 9, 10, and 11, 2012, at 8:00 a.m., and 12:00 noon, however LPN #3 confirmed did not visualize the mighty shake on the resident's tray. Review of the weight record revealed the resident weighed 96 pounds on July 13, 2012. (9 pound loss in 10 days) Interview on July 16, 2012, at 2:00 p.m., in the conference room, with the Food Service Director, confirmed the Registered Dietician had not assessed the resident. Interview on July 16, 2012, at 2:25 p.m. with the Food Service Director, in the conference room, confirmed the Registered Dietician had not been notified when the resident had the 5% weight loss. Interview on July 16, 2012, at 2:45 p.m. in the conference room ,with the Director of Nursing (DON), confirmed would expect the Registered Dietician to see the resident at the time of the 5% weight loss.

Based on medical record review, review of facility policy, review of the Dietician Contract, observation, and interview, the facility failed to complete skin assessments, implement dietary recommendations, obtain physician orders for wound treatments, ensure the Registered Dietician assessed the resident, and ensure measures were in place to reduce pressure for resident #27. The facility also failed to ensure skin assessments were completed for resident #107. The facility's failure resulted in delayed treatments and harm to resident #27. The findings included: Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set, dated dated dated [DATE], revealed the resident was at risk for developing pressure ulcers, had a stage 3 pressure ulcer (right heel), had a pressure reducing device for the bed, and required extensive assistance with bed mobility. Medical record review of the Wound/Skin Healing Record dated March 7, 2012, revealed, "...pre-admit...stage III (pressure ulcer)...Right heel...0.5 x 0.9 x (less than) 0.2 (centimeters) ...wound bed brown (eschar)..." Medical record review of the Wound/Skin Healing Record dated April 3, 2012, revealed, "...(right heel) 0.4 x 0.7 x (less than) 0.2 (centimeters)...granulation tissue...slough...brown eschar..." Review of the next Weekly Wound Report dated April 17, 2012 (two week time period from the last assessment) revealed "...(right) lateral heel stage 3 0.4 x 0.7 (less than) 0.2 (centimeters)...loose eschar..." Medical record review of a skin assessment dated [DATE], revealed, "...small area of eschar to (right) heel...0.5 cm x 1 cm...no other skin breakdown noted... " Medical record review of a skin assessment dated [DATE], revealed, "...healing stage (2) (pressure ulcer) Rt (right) heel Stage (2) (pressure ulcer) coccyx-noted 7/4/12 Reddened area around coccyx...Pressure sores are to be measured weekly by skin assessment nurse..." Medical record review revealed the wound assessment completed on July 6, 2012 for the right heel pressure ulcer did not describe the size or color of the wound. Medical record review revealed the next wound assessment dated [DATE], revealed, "... eschar on (right heel) (1cm x 0.5 cm) 2 stage (2) wounds on coccyx (...3 cm x 1.5 cm) (...1.5 cm x 1 cm) Excoriated around wound bilat (bilateral) buttocks...Pressure sores are to be measured weekly by the skin assessment nurse..." Medical record review of the care plan dated March 15, 2012, revealed "...Perform complete skin assessment and record...1 time weekly starting 03/15/2012..." Interview on July 11, 2012, at 2:15 p.m., with the Director of Nursing, in the conference room, confirmed the pressure ulcer on the coccyx identified on July 4, 2012 was found as a stage II sore. This resident was assessed on admission as hi-risk for pressure sores and required extensive assistance with bed mobility. Interview on July 16, 2012, at 1:30 p.m., with the Director of Nursing, in the hall, confirmed no wound assessment with a full description of the size and color had been completed for the pressure ulcer on the right heel the week of April 10, 2012, or from June 12, 2012 until July 11, 2012. Medical record review of a Dietary Note dated April 19, 2012, revealed, "...admitted [DATE]...stage (3) (right) lateral heel, labs alb ([MEDICATION NAME]) 2.5 (reference range 3.2-4.6) on 3/3/12...Recommend Prosource liquid 1 oz (ounce) bid (twice a day)..." Medical record review of a High Risk Follow-Up form dated May 17, 2012, signed by the Registered Dietician, revealed "...unstageable decub (decubitus) (right) lateral heel...Recommend 1 oz liquid protein in 6-8 oz juice or other liquid bid (twice a day), [MEDICATION NAME] (appetite stimulant) 400mg (milligrams) bid..." Medical record review of a physician's order dated May 18, 2012, revealed "...1 oz liquid protein bid and [MEDICATION NAME] 400 mg bid..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview on July 11, 2012, at 2:15 p.m, with the DON, in the conference room, confirmed a delay (from April 19, 2012 until May 21, 2012, thirty-one day lapse) in starting the dietary recommendation of prosource. Review of the facility policy Stage III Pressure Ulcer, revealed, "...Cleanse area with normal saline or wound cleanser ...obtain physician order for [REDACTED]. Medical record review of the Treatment Records dated March 7, 2012, through March 31, 2012, and April 1, 2012, through July 31, 2012, revealed a treatment of [REDACTED]. Medical record review revealed no physician's order for the [MEDICATION NAME] treatment or any physician ordered treatment since the resident's admission on March 7, 2012 for the stage III pressure ulcer to the right heel. Interview on July 11, 2012, at 10:40 a.m. with the DON, in the conference room, confirmed no physician's order had been obtained since the resident's admission on March 7, 2012, for treatment for [REDACTED]. Observation and interview on July 11, 2012, at 5:30 p.m. with the resident's physician revealed two stage 2 pressure ulcers on the coccyx and a pressure ulcer on the right heel with eschar, as described by the physician. Interview with the physician, at this time confirmed the physician was unable to recall being notified of the stage III pressure ulcer to the resident's right heel. Medical record review of the care plan reviewed on May 31, 2012, revealed "...Use pillows, pads, or wedges to reduce pressure on heels and pressure points..." Observation and interview on July 12, 2012, at 8:30 a.m. with Certified Nursing Assistant (CNA) #1 revealed the resident lying on the bed with the heels touching the mattress. Review of the Dietitian Contract revealed, "...All patients with pressure ulcers (stage 2 or more) will be assessed monthly by the registered dietician..." Interview on July 16, 2012, at 10:45 a.m. in the conference room, with the Clinical Nutrition Director, confirmed the resident was not assessed by the Registered Dietician until April 19, 2012, a delay in assessment of forty-three days from the resident's admittance on March 7, 2012, with a stage 3 pressure ulcer. Resident #107 was admitted to the faciility on May 25, 2012, with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged to the hospital on June 29, 2012. Medical record review of the admission Minimum Data Set, dated dated dated [DATE], revealed the resident scored fourteen on the Brief Interview for Mental Status (BIMS) indicating the resident was independent with daily decision making, required extensive assistance with bed mobility, transfers and walking, had a Stage I pressure ulcer, was at risk for development of pressure ulcers, and a pressure reducing device was used on the bed and chair. Medical record review of the (named skin) Risk Assessment Scale dated May 25, 2012, revealed a score of seventeen (17) and "...A score of 17 or below requires a weekly skin assessment/documentation in the medical record..." Medical record review of the Interim Care Plan dated May 25, 2012, revealed "...Resident is at risk for skin breakdown due to [MEDICATION NAME] therapy, auto immume disease...Stg (stage) 1 coccyx...turn q (every) 2 hrs (hours) and PRN (as needed)..." Medical record review of the admission nursing assessment dated [DATE], revealed the resident had an excoriated sacrum. Medical record review of the skin assessment dated [DATE], revealed the sacral area was red and a protective ointment was being applied daily. Medical record review revealed the next skin assessment was completed on June 8, 2012, and revealed "...coccyx area reddened with a pencil eraser sized area opened..." Interview on July 11, 2012, at 3:25 p.m., with the Assistant Director of Nursing (ADON), in the conference room revealed the resident was placed on a pressure reducing mattress upon admission to the facility. Continued interview revealed the resident was to receive a weekly skin assessment and confirmed the resident did not receive a skin assessment from May 29, 2012, until June 8, 2012, a three day delay. Interview on July 12, 2012, at 12:25 p.m., with the physician, in the Administrator's office, revealed the physician had visited the resident on June 8, 2012, when the pressure ulcer increased to Stage II at the request of the nursing staff, the resident frequently rejected care, (turning and repositioning, and medications to assist with wound healing). Continued interview revealed the resident's pressure ulcer declined quickly and was unavoidable due to the resident's non-compliance.

Based on medical record review, review of facility policy, observation, and interview, the facility failed to notify the physician of a pressure ulcer for one (#27) of forty residents reviewed. The facility's failure resulted in a delay of physician treatment and harm to resident #27. The findings included: Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set, dated dated dated [DATE], revealed the resident was at risk for developing pressure ulcers, had a stage 3 pressure ulcer (right heel), had a pressure reducing device for the bed, and required extensive assistance with bed mobility. Medical record review of the Wound/Skin Healing Record dated March 7, 2012, revealed, "...pre-admit...stage III...Right heel...0.5 x 0.9 x (less than) 0.2 (centimeters) ...wound bed brown (eschar)..." Medical record review of the Wound/Skin Healing Record dated April 3, 2012, revealed, "...(right heel) 0.4 x 0.7 x (less than) 0.2 (centimeters)...granulation tissue...slough...brown eschar..." Review of the next Weekly Wound Report dated April 17, 2012, revealed "...(right) lateral heel stage 3 0.4 x 0.7 (less than) 0.2 (centimeters)...loose eschar..." Medical record review of a skin assessment dated [DATE], revealed, "...small area of eschar to (right) heel...0.5 cm x 1 cm...no other skin breakdown noted... " Medical record review of a skin assessment dated [DATE], revealed, "...healing stage (2) Rt (right) heel Stage (2) coccyx-noted 7/4/12 Reddened area around coccyx...Pressure sores are to be measured weekly by skin assessment nurse..." Medical record review revealed the next wound assessment dated [DATE], revealed, "... eschar on (right heel) (1cm x 0.5 cm) 2 stage (2) wounds on coccyx (...3 cm x 1.5 cm) (...1.5 cm x 1 cm) Excoriated around wound bilat (bilateral) buttocks...Pressure sores are to be measured weekly by the skin assessment nurse..." Medical record review of the care plan dated March 15, 2012, revealed "...Perform complete skin assessment and record...1 time weekly starting 03/15/2012..." Review of the policy Stage III Pressure Ulcer, revealed, "...Cleanse area with normal saline or wound cleanser ...obtain physician order for [REDACTED]. Medical record review of the Treatment Records (dated March 7, 2012, through March 31, 2012,) and April 1, 2012, through July 31, 2012, revealed a treatment for [REDACTED]. Medical record review revealed no physician's order on admission or after for any treatment for [REDACTED]. Interview on July 11, 2012, at 10:40 a.m. with the DON, in the conference room, confirmed no physician's order had been obtained since the resident's admission on March 7, 2012, for treatment for [REDACTED]. Observation and interview on July 11, 2012, at 5:30 p.m. with the resident's physician revealed two stage 2 pressure ulcers on the coccyx and a pressure ulcer on the right heel with eschar, as described by the physician. Interview with the physician on July 11, 2012, at 5:30 p.m., in the resident's room, confirmed the physician was unable to recall being notified of the stage III pressure ulcer to the right heel.