Every finding on record at Alta Vista Healthcare & Wellness Centre

Based on interview and record review, the facility failed to ensure accurate documentation and monitoring parameters for the antipsychotic medication Quetiapine (an antipsychotic medication used to treat psychiatric conditions) for one of three residents reviewed (Resident 1).This failure had the potential to delay identification of adverse side effects associated with antipsychotic medication use, including changes in condition, excessive sedation, abnormal movements, and falls.Findings: On April 2, 2026, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included psychosis (a condition or symptom in which a person has difficulty distinguishing what is real from what is not real) and bipolar disorder (a mental health disorder characterized by significant changes in mood, energy, activity level, and ability to function). A review of Resident 1's physician record dated August 14, 2025, indicated the following: - QUEtiapine Fumarate Oral Tablet 25 MG (milligram) Quetiapine Fumarate Give 0.5 tablet by mouth at bedtime for BIPOLAR DISORDER. -Monitor for side effects of antidepressant medication due to use of QUETIAPINE every shift dry mouth, blurred vision, constipation, urinary retention, hypotension [low blood pressure], appetite changes, headache, insomnia [difficulty in sleeping] dyspepsia [indigestion], weight changes. Further review indicated the physician order did not include appropriate monitoring parameters specific to Quetiapine, an antipsychotic medication. A review of Resident 1's care plan dated August 21, 2025, indicated .The resident uses psychotropic medication (Quetiapine) for Behavior management .Interventions .Monitor/document/report PRN (as needed) any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia (movement disorder characterized by involuntary, repetitive, and uncontrollable body movements) .(shuffling gait, rigid muscles, shaking) . A review of Resident 1's electronic Medication Administration Record (eMAR) for the month of August 2025, indicated the monitoring parameters referenced side effects associated with an antidepressant medication rather than monitoring specific to Quetiapine or antipsychotic medications. On April 2, 2026, at 11:01 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the facility practice required licensed nurses to monitor residents receiving psychotropic medications for behaviors and adverse side effects every shift and document the monitoring in the eMAR. On April 2, 2026, at 1:45 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON stated receiving antipsychotic medications such as Quetiapine should be monitored for adverse side effects specific to the medication. The DON stated Resident 1's monitoring documentation referenced antidepressant medication monitoring rather than antipsychotic medication monitoring. The DON stated the licensed nurses should have verified the monitoring parameters and clarified the order with the physician. The DON stated antipsychotic medications such as Quetiapine require monitoring for adverse side effects specific to antipsychotic medications, which differ from monitoring parameters for antidepressant medications. The DON further stated that inaccurate monitoring parameters could delay the identification of adverse side effects associated with antipsychotic medication use. A review of the policy and procedure titled Physician Orders, dated August 21, 2020, indicated, .To have a process to verify that all physician orders are complete and accurate .The licensed nurse will confirm that physician orders are clear, complete and accurate as needed .

Based on observation, interview, and record review, the facility failed to ensure appropriate intervention was provided after a dialysis (the process of removing excess water and cleaning the blood in people whose kidneys no longer work) treatment for one of three residents reviewed for dialysis (Resident 42) when a post dialysis evaluation was not completed on August 7, 2025.This failure to assess and document Resident 42's health status after dialysis had the potential to result in unrecognized complications and delayed interventions. Findings:A review of Resident 42's Dialysis Communication Record, dated August 7, 2025, indicated the post (after) hemodialysis assessment section was left blank and did not contain documentation that Resident 42 was assessed and monitored after returning to the facility. On August 7, 2025, at 2:24 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse, LVN 1. LVN 1 stated the post hemodialysis assessment was not completed by the dialysis facility and/or assessed by the assigned nurse.On August 7, 2025, at 3:34 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated, post dialysis forms should include a completed assessment and monitoring of the dialysis treatment. The DON further stated any communication from the dialysis clinic must be followed up and documented to show all interventions provided to the resident.A review of the facility's policy and procedures (P&P) titled, Dialysis Management , dated January 25, 2024, indicated, .the Facility will arrange transportation to and from the dialysis provider, as well as for meals, medication administration, and a method of communication between the dialysis provider and the Facility.a pre and post dialysis evaluation will be completed by the licensed nurse.assessing, observing and documenting care of access sites daily, as applicable, such as.dressing will be changed in accordance with attending Physician's order .

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1a. Medication Room in Nursing Station 1 contained one (1) refrigerated medication vial opened without an open date label; and 1b. Medication Cart in Nursing Station 3 contained three (3) medications opened without an open date label.The deficient practices had a potential for residents to receive unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and not being removed from active stock.1a. During a concurrent observation and interview on [DATE] at 12:09 p.m. with the Assistant Director of Nursing (ADON), an inspection of the Medication Room in Nursing Station 1 identified one opened refrigerated multi-dose vial (MDV) of Tuberculin PPD (test agent used in the diagnosis of tuberculosis) 5 TU (test unit) per 0.1 ml (milliliter; unit of measurement) did not have an open date label. The ADON stated nursing staff were expected to have labeled the opened PPD vial with an opened date and the PPD vial was good for 30 days when opened according to the manufacturer. The ADON read the manufacturer's instructions printed on the outer box which indicated, Discard opened product after 30 days. When asked why it was important to know when the vial was opened, the ADON stated it was important to track if the vial was opened for more than 30 days to ensure the medication's sterility and potency was maintained. The ADON stated the opened, used and undated PPD vial should have been discarded.A review of the PPD vial manufacturer's instructions dated [DATE], indicated, A vial of [PPD] which has been entered and in use for 30 days should be discarded.1b. During a concurrent observation and interview on [DATE] at 3:21 p.m. with Licensed Vocational Nurse (LVN) 2, an inspection of the Medication Cart in Nursing Station 3 identified the following: - One budesonide inhalation suspension (used to treat asthma symptoms) foil pack with four unused ampules, was opened but did not have an open date;- One prefilled Humulin N KwikPen insulin (used to treat diabetes) pen, was opened but did not have an open date; and- One prefilled Lispro KwikPen insulin pen, was opened but did not have an open date.During the same observation and interview on [DATE] at 3:21 p.m., LVN 2 stated the above medications should have been labeled with open dates. LVN 2 reviewed the manufacturer's instructions on the budesonide inhalation suspension packaging which indicated, Once the foil envelope is opened, use the ampules within 2 weeks . LVN 2 stated the opened budesonide inhalation suspension foil package without an opened date should have been discarded. LVN 2 reviewed the pharmacy's red sticker label on the prefilled Humulin N KwikPen insulin pen which indicated, Discard 14 days after opening. LVN 2 reviewed the pharmacy's red sticker label on the prefilled Lispro KwikPen insulin pen which indicated, Discard 28 days after opening. LVN 2 stated she needed to ask the supervisor regarding what to do with the opened and undated prefilled insulin pens.During an interview on [DATE] at 4:22 p.m. with the ADON, regarding the opened and undated medications as listed above, the ADON stated the expectation was for nursing staff to follow the manufacturer expiration when opened. The ADON stated nursing staff should have written the opened date on the above listed medications. The ADON stated it was important to know the open date to know when the medication would have expired. During an interview on [DATE] at 4:26 p.m., the Director of Nursing (DON) stated the expectation was for nurses to have written the opened date on the medication when they opened it. The DON stated it was important to know the opened date to make sure the medication was still effective, and to ensure stability/sterility of the medication to prevent negative patient outcomes.During a follow-up concurrent interview and record review on [DATE] at 3:06 pm., the DON stated the facility did not have a policy regarding medication labeling. The DON stated nurses were expected to follow the manufacturer's instructions and the expirations on a list provided by the pharmacy. The DON provided the document from the pharmacy titled, Appendix 29: Medications with Shortened Expiration Dates, date revised February 2020, it indicated, The following medications have expiration dates shorter than the identified expiration date once placed into use .PPD - Discard 30 days after opened .Insulin - Discard 28 days after opening except for the following Insulins. The following insulins shall be discarded after opening as follows .Humulin N KwikPen (14 days) .Pulmicort (Budesonide) Discard 14 days after opening foil pack . A review of the budesonide inhalation suspension manufacturer's instructions dated [DATE], indicated, When an envelope has been opened, the shelf life of the unused ampules is 2 weeks when protected.A review of the prefilled Humulin N KwikPen insulin pen manufacturer's instructions dated [DATE], indicated, When stored at room temperature, Humulin N KwikPen can only be used for a total of 14 days. A review of the prefilled Lispro KwikPen insulin pen manufacturer's instructions dated [DATE], indicated, When stored at room temperature, Insulin Lispro can only be used for a total of 28 days.A review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, revised date February 2020, indicated, Outdated, contaminated, or deteriorated medications.are immediately removed from inventory, disposed of according to procedures for medication disposal.and reordered from the pharmacy.

Based on observation, interview, and record review, the facility failed to ensure pain assessment and management were performed, for two of four residents reviewed (Resident's 12 and 7). This failure had the potential for Resident's 12 and 7 to experience pain and discomfort which could negatively impact mental and physical well-being. Findings: 1a. On August 5, 2025, at 10:30 a.m., an interview was conducted with Resident 12. Resident 12 was alert, resting in bed, and reported that her pain medication was not as effective as she hoped. Resident 12 stated, she recently had surgery and was receiving pain management interventions with medication and positional changes. On August 6, 2025, A review of Resident 12's record was conducted. Resident 12 was admitted [DATE], with diagnosis which included, displaced intertrochanteric fracture of right femur (broken portion of the right leg bone). The History and Physical (H&P), dated December 27, 2024, indicated Resident 12 had the capacity to understand and make decisions. A review of the Vitals and Pain only Evaluation dated December 10, 2024, indicated.Pain.should a pain assessment be conducted.Yes. Further review of Resident 12's record indicated there was no pain assessment/evaluation conducted for Resident 12 from January 2025 to July 2025. A review of Resident 12's Progress Notes, dated July 23, 2025, to August 6, 2025, indicated Resident 12 had surgery to the right hip on July 23, 2025. A review of the Physicians Orders indicated the following pain medications: .Dilaudid Oral Tablet 2 MG (milligrams - unit of measurement).Give 1.5 tablet by mouth every 4 hours as needed for Breakthrough Pain 10 NTE (not to exceed) 3 GM (grams – unit of measurement)/24 hours.order date July 22, 2025.active. .Dilaudid Oral Tablet 4 MG.Give 1 tablet by mouth every 6 hours as needed for MODERATE pain (5-7) notify MD if ineffective.order date July 28, 2025.active. .tramadol.Oral Tablet 50 MG.Give 1 tablet by mouth every 4 hours as needed for MILD pain (1-4) Notify MD if ineffective.order date July 28, 2025.active. A review of the Medication Administration Review (MAR) from July to August 2025, indicated the following: July 24, 2025, at 12:00 p.m. - Pain level 8, Dilaudid 2 mg given July 24, 2025, at 6:20 p.m. - Pain level 7, Dilaudid 2 mg given July 25, 2025, at 6:00 a.m. - Pain level 8, Dilaudid 2 mg given July 26, 2025, at 9:23 a.m. - Pain level 6, Dilaudid 2 mg given July 26, 2025, at 6:06 p.m. - Pain level 6, Dilaudid 2 mg given July 27, 2025, at 9:41 a.m. - Pain level 6, Dilaudid 2 mg given July 28, 2025, at 9:25 a.m. - Pain level 8, Dilaudid 2 mg given July 28, 2025, at 6:14 p.m. - Pain level 7, Dilaudid 2 mg given July 31, 2025, at 1:00 p.m. - Pain level 5, Dilaudid 2 mg given August 1, 2025, at 9:24 a.m. - Pain level 8, Dilaudid 2 mg given August 2, 2025, at 9:32 a.m. - Pain level 6, Dilaudid 2 mg given August 3, 2025, at 10:23 a.m. - Pain level 8, Dilaudid 2 mg given August 3, 2025, at 5:31 p.m. - Pain level 8, Dilaudid 2 mg given August 4, 2025, at 10:41 a.m. - Pain level 8, Dilaudid 2 mg given August 4, 2025, at 6:45 p.m. - Pain level 8, Dilaudid 2 mg given August 5, 2025, at 10:51 a.m., - Pain level 8, Dilaudid 2 mg given August 5, 2025, at 6:56 p.m. - Pain level 7, Dilaudid 2 mg given Further review of Resident 12's MAR from July 23, 2025, to August 6, 2025, indicated that the doses did not match the ordered pain scale ranges for Dilaudid 4 mg and 2 mg. A review of Resident 12's Care Plan Osteoporosis initiated November 2, 2022, revised August 1, 2025, indicated, .Give analgesics (medication) PRN (as needed) for pain.Resident may complain of pain.Give medications as ordered.Monitor/document for side effects and effectiveness. On August 6, 2025, at 1:04 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN 1). LVN 1 stated, Resident 12 preferred Dilaudid 2 mg and that she honored the resident's request. LVN 1 stated the physician's order was not followed and should have been clarified. LVN 1 further stated there was a potential for ineffective pain management if the medication was not provided according to the physician's order. On August 7, 2025, at 12:49 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for pain management was that the LVN should clarify orders that are potentially misleading or do not specify a complete range of coverage for a pain scale. She stated for breakthrough pain medication the nurses should know that pain medication should have a scalable range and if the pain reached a level outside of the range then the breakthrough medication should be provided. A concurrent record review of Resident 12's MAR was conducted with the DON. The DON stated both Dilaudid 2 mg and 4 mg were not given to Resident 12 according to the physicians order. The DON stated along with accuracy of administering pain medications the pain management should include a pain assessment and that I should be reviewed at least quarterly. The DON stated there should have been a pain assessment for Resident 12 during the months of March and June of 2025 and there was none. The DON further stated there was a potential for Resident 12 to not receive adequate pain management if the physicians orders were not followed and a pain assessment was not conducted to reflect the residents current pain status. 1b. A review of Resident 7's admission Record, dated August 6, 2025, indicated Resident 7 was initially admitted on [DATE], and re-admitted on [DATE], with diagnoses including osteoarthritis (condition where the protective cartilage in joints breaks down, causing pain) of the knee and acute (sudden) pain due to trauma (injury). A review of Resident 7's History and Physical (H&P), dated June 24, 2025, indicated Resident 7 had the capacity to understand and make decisions. A review of Resident 7's current Minimum Data Set (MDS, a care area assessment and screening tool), dated June 30, 2025, indicated the resident had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 14 - (intact cognition). A review of the Care Plan At risk/potential for acute pain/chronic pai related to OA (osteoarthritis) of the knee, initiated June 23, 2025, indicated Administer prescribed pain medication before and after activity and therapy.establish a pain management treatment plan.evaluate pain.monitor for factors/activities that precipitate or aggravate pain. A review of Resident 7's Physicians Orders, dated July 31, 2025, indicated a provider order for Oxycodone-acetaminophen (a potent controlled medication for pain) 10/325 milligram (mg, unit of measurement) every 6 hours as needed for severe pain (7-9). During a medication pass observation on August 6, 2025, at 12:38 p.m. with LVN 3, Resident 7 was observed requesting pain medication and stated having pain level 10 in his neck and back. LVN 3 was observed preparing and administering one oxycodone-acetaminophen 10/325 mg tablet to Resident 7. A review of Resident 7's clinical record on August 6, 2025, at 1:21 p.m., indicated there was no documented evidence of a provider order for pain medication prescribed for pain level 10. During a concurrent interview and record review on August 6, 2025, at 1:51 p.m. with the DON, Resident 7's clinical record, including the provider order for oxycodone-acetaminophen 10/325mg dated July 31, 2025, as listed above, was reviewed. The DON acknowledged the order for oxycodone-acetaminophen 10/325mg was prescribed for severe pain level 7-9 and did not include pain level of 10. The DON stated the expectation was for the nurse to have called and clarified with the provider if pain medication order needed to be changed when Resident 7 reported a pain level outside of the prescribed parameters. A review of the facility policy and procedure (P&P) titled, Pain Management, dated May 2023, indicated, .The Licensed Nurse will administer pain medications as ordered and document medication administered on the Medication Administration Record (MAR).Nursing Staff will provide education to residents.regarding residents pain management program as to appropriate expectations for pain management.A pain assessment will be completed for each resident upon admission, quarterly, when there is a new onset of pain, exacerbation of pain, or when there is a significant change in status. A review of the facility's P&P titled, Preparation and General Guidelines, revised February 2020, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.Medications are administered in accordance with written orders of the prescriber.If.a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate.

Based on observation, interview, and record review, the facility failed to ensure for one of one sampled resident reviewed for respiratory care (Resident 9) the licensed staff document before and after nebulizer assessments as ordered by the physician and evaluate the effectiveness of treatment. This failure had the potential to cause Resident 9 not to receive effective treatment and relief during episodes of respiratory distress. Findings:On August 4, 2025, at 11:11 a.m., a concurrent observation and interview was conducted with Resident 9. Resident 9 was observed coughing and stated she had shortness of breath. Resident 9 stated she had to asked for her breathing treatment and nobody checked her to see if it helped. A review of Resident 9's admission Record indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included COPD (a group of lung diseases that block airflow and make it difficult to breathe) and asthma (chronic respiratory condition characterized by inflamed and narrowed airways, making it difficult to breathe).A review of Resident 9's History and Physical, dated July 15, 2025, indicated Resident 9 had the capacity to understand and make decisions.A review of Resident 9's Order Summary Report, for the month of August 2025, indicated:- Dated July 14, 2025, Ipratropium-Albuterol. inhalation solution, 3 ml (milliliter-unit of measurement) inhale orally via nebulizer (breathing machine) every 4 hours as needed [PRN] for SOB (shortness of breath).-Dated July 14, 2025, After nebulizer treatment-document Pulse, RR [respiratory rate], O2 sat [saturation] (RA or L/min), LS (lung sound).-Dated July 14, 2025, Before nebulizer treatment- document .RR (respiratory rate), O2 sat (oxygen saturation) (RA (room air) or L/min (liter/minute- unit of measurement), LS each side.(NC- Normal Clear, W- wheezing (a high-pitched whistling sound produced when air flows through narrowed airways in the lungs), R- Rhonchi (continuous, low-pitched, rattling lung sounds that are often described as resembling snoring or gurgling), C- Crackles ( abnormal, discontinuous, nonmusical breath sounds heard during auscultation (listening) of the lungs) .A review of Resident 9's Medication Administration Record (MAR) for the month of July 2025 and August 2025, indicated Resident 9 was administered with 21 PRN nebulizer treatments on the following dates:-July 1, 2, 4, 6, 8, 9, 10, 15, 16, 19, 22, 25, 27, 28, 2025; and-August 4, 2025.Further review of Resident 9's MAR indicated there was no documentation of before and after treatment respiratory assessments or post treatment evaluations of effectiveness as ordered. On August 7, 2025, at 4:08 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the respiratory therapy documentation was not being completed for July and August 2025. The DON stated, the physician order requires before and after assessments, and the documentation should reflect both administration and effectiveness. The DON stated, the licensed nurses should have assessed Resident 9 before and after treatment and the assessments should have been documented. A review of the facility policy and procedure titled, Nebulizer, dated October 15, 2020, indicated .Monitor breath sounds, oxygen saturation, and pulse before and after treatment.Obtain the Resident's pulse during the treatment.Record all pertinent information in respiratory therapy notes and/or on the Medication Administration Record (MAR).

Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain intravenous (the administration of fluids, medications directly into a vein) access for two of eight residents (Resident 6 and 68) when: 1.Resident 6's PICC line (peripherally inserted central catheter) dressing was changed in a timely manner.2.Resident 68's peripheral dressing (a transparent covering placed over a peripheral intravenous insertion site) was labeled with the date, time and nurse's initials. These failures had the potential to delay the identification of intravenous catheter-related complications and result in infection, placing the residents at risk for worsened health conditions. Findings:1. On August 4, 2025, at 9:45 a.m., Resident 6 was observed sitting up in bed with a PICC line on the left forearm with a transparent dressing dated July 23, 2025. Resident 6 stated he had been receiving IV antibiotic medications for five weeks. A review of the admission record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses that included endocarditis (an infection of the heart's inner lining, usually involving the heart valves. A review of Resident 6's physician's order dated July 4, 2025, indicated, .change dressing and cap every day shift every 7 days.A review of Resident 6's care plan, dated July 4, 2025, indicated, .the resident is on IV medication r/t endocarditis .the resident will not have any complications related to IV therapy .On August 4, 2025, at 9:50 a.m., a concurrent observation and interview was conducted with Registered Nurse Supervisor (RNS). RNS stated, Resident 6's dressing should have been changed on July 30, 2025. On August 6, 2025, at 11:23 a.m., an interview was conducted with the Infection Preventionist (IP), the IP stated the PICC line dressing should be changed every seven days to prevent irritation and possible infection on the IV (intravenous) site.On August 7, 2025, at 12:20 p.m., an interview was conducted with the Director of Nursing (DON), the DON stated Resident 6 has an order for dressing to be changed every seven days, and it should have been changed on the 30th of July. The DON stated, if the licensed nurse identified that the date was out of range, the expectation would be to change the dressing immediately to ensure the site is clean and free from infection, which could affect the resident.A review of the facility's policy and procedure titled Central Venous Catheter Dressing Changes dated, July 2013, indicated, .change transparent semi-permeable membrane dressings every 5 to 7 days and PRN (when wet, soiled, or not intact) .2. On August 4, 2025, at 10:20 a.m., Resident 68 was observed in bed with a peripheral line dressing noted on the left hand, which was not labeled with the date, time, and initials. A review of the admission record indicated Resident 68 was admitted to the facility on [DATE], with diagnoses that included bacteremia (bacteria is present in the bloodstream). A review of Resident 68's physician's order dated July 21, 2025, indicated, .change peripheral IV line and dressing every 48 hours.A review of Resident 68's care plan report, dated July 20, 2025, indicated, .the resident is on antibiotic therapy .the resident will be free from any discomfort or adverse side effects of antibiotic therapy .On August 4, 2025, at 10:28 a.m., a concurrent observation and interview was conducted with the IP, the IP stated, Resident 68's dressing should have been labeled with the date, time, and initials in order to prevent infection.On August 7, 2025, at 12:20 p.m., an interview was conducted with the DON, the DON stated Resident 68 had an order to check the site every shift and change the dressing every 48 hours. The DON further stated, it was the facility's policy to label all IV dressings with date, time, and initials, to prevent infection.A review of the facility's policy and procedure titled Peripheral IV Dressing Changes dated, July 2013, indicated, .Peripheral IV dressing will be changed when needed to prevent catheter related infections associated with contaminated, loosened or soiled catheter-site dressing.apply and maintain transparent semi-permeable membrane dressing or sterile gauze for all peripheral intravenous catheter sites.label dressing with date, time and initials.

Based on interview and record review, the facility failed to ensure services provided meet professional standards of practice for one of five residents reviewed (Resident 4) when the facility did not clarify the physician's order for behavior monitoring during the use of an antipsychotic medication (drugs that affect brain chemicals to stabilize mood and thoughts), Vraylar (an antipsychotic medication used to treat bipolar disorder and schizophrenia). These failures had the potential for Resident 4 to receive Vraylar without adequate target behavior monitoring to assess the effectiveness of the medication. A review of Resident 4's admission Record, dated August 7, 2025, indicated Resident 4 was admitted on [DATE], with diagnosis of bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels). A review of the Physicians Orders indicated the following antipsychotic medication and behavior monitoring orders for Resident 4:- On May 13, 2025, Vraylor capsule 1.5 mg (milligrams, unit of measurement) one capsule by mouth one time a day for Bipolar Disorder as m/b (manifested by) episodes of manic behavior; and- On May 21, 2025, Monitor target behaviors for use of Vraylar due to Bipolar Disorder insert behaviors manifested/target behaviors. A review of Resident 4's medication administration record (MAR) dated May 28, 2025 through August 7, 2025, indicated nursing staff administered Resident 4 one Vraylar tablet daily and documented monitoring of target behavior for use of Vraylar as insert behaviors manifested/target behaviors without clarification of the specific target behavior on the following days: - On May 28, 2025, to May 31, 2025;- On June 1, 2025, to June 7, 2025;- On June 10, 2025, to June 30, 2025, and - On July 21, 2025, to August 7, 2025. During a concurrent interview and record review on August 7, 2025, at 8:12 a.m. with the Director of Nursing (DON), Resident 4's clinical record, including the provider orders as listed above and MARs dated May 28, 2025 through August 7, 2025, were reviewed. The DON acknowledged the order on May 21, 2025 for monitoring of target behaviors during use of Vraylar due to bipolar disorder insert behaviors manifested/target behaviors was unclear and stated nursing staff were expected to have clarified the missing target behavior on May 21, 2025 when the order was received by nursing staff for Resident 4.A review of the facility's policy and procedure (P&P) titled, Preparation and General Guidelines, revised February 2020, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.Medications are administered in accordance with written orders of the prescriber.If.a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was revised to reflect new physician recommendations and resident's worsening skin condition for one of one resident reviewed for skin condition (Resident 4).This failure had the potential to result in Resident 4's skin rash worsening and not being appropriately addressed. Findings:On August 4, 2025 at 10:05 a.m., a concurrent observation and interview with Resident 4, Resident 4 stated, he had multiple rashes that were being treated without relief. Resident 4 was observed scratching crusted areas all over the body including the abdomen, both upper and lower extremities, and the facial area.A review of Resident 4's admission Record, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included failure to thrive (a condition characterized by a significant decline in physical and functional status), dementia (forgetfulness), and eczematoid dermatitis (chronic or chronic inflammatory skin conditions).A review of Resident 4's History and Physical, dated April 28, 2025, indicated .Resident 4 does not have the capacity to understand and make decisions.A review of Resident 4's care plan, dated June 2, 2025, indicated Focus-Resident has potential for rashes and other s/sx (signs and symptoms) of allergic reaction .Interventions: Avoid scratching and keep hands and body parts from excessive moisture.monitor skin rashes for increased spread and signs of infection.seek medical attention if skin becomes bloody or infected.identify skin allergies and avoid them. A review of Resident 4's Physician Progress Note, dated July 1, 2025, .Assessment . Eczematous Dermatitis .Plan .Topical Therapy .Clobetasol 0.5% ointment (medicine used on the skin to reduce inflammation, redness, swelling, and itching) twice a day for flare .Oral Medication .hydroxyzine25 mg qhs (at bedtime) .Systemic Agent .dupixent (used for treatment of moderate to severe eczema [) .A review of Resident 4's SBAR (Situation, Background, Appearance, Review and Notify) Communication Form, dated July 5, 2025, indicated, .Resident noted with already existing rash with treatment to left foot, noted with rash to left foot exacerbated with scant bleeding .Further review of Resident 4's care plan indicated the care plan was not revised to reflect the physician recommendation and Resident 4's worsening skin condition.On August 6, 2025, at 12:33 p.m., a concurrent interview and record review was conducted with the Treatment Nurse (TN), TN stated if care plan interventions were not effective, the care plan needed to be revised. The TN further stated on July 5, 2025, Resident 4 developed an exacerbated rash with bleeding on the left lateral foot, which was a change in condition that should have been included in the care plan revision. On August 7, 2025, at 9:35 a.m., a concurrent interview and record review was conducted with the Registered Nurse Supervisor (RNS). The RNS stated when Resident 4's rashes worsened with bleeding, and after the dermatologist recommendations on July 1, 2025, the facility should have revised the care plan. The RNS stated, the Interdisciplinary team should have met to discuss the changes. The RNS stated there was no documented evidence that the IDT met or revised the care plan. A review of the facility's policy and procedure titled Person-Centered Care Plan, dated May 22, 2025, indicated .Comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment.A review of the facility policy and procedure titled Skin Integrity Management, dated July 31, 2024, indicated .Interdisciplinary Team (IDT) /Skin Committee will document discussion and recommendations for skin integrity issues .Review the resident's care plan and update as necessary .

Based on interview, and record review, the facility failed to follow the physician's order to hold the medication Furosemide (water pill) for blood pressure less than 110, for one out of three sampled residents reviewed (Resident 1). This failure had the potential to result in hypotension, placing Resident 1 at risk for medical emergency. Findings. A review of Resident 1's admission recorded indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses which included localized edema (swelling) and pulmonary hypertension (high blood pressure in the arteries of the lungs). A review of Resident 1's physician order dated January 26, 2025, indicated .Furosemide Oral Tablet 40 MG .Give 1 tablet by mouth one time a day for edema hold if SBP (systolic blood pressure - measures the pressure in the arteries when the heart beats and pumps blood) is < (less than) 110. A review of Resident 1's Medication Administration Record (MAR) for February 2025, indicated, Furosemide was administered on February 9, 2025, when Resident 1's blood pressure was 98/68, which was outside the prescribed parameters. On April 11, 2024, at 4:30 p.m., during a concurrent interview and record review with the Licensed Vocational Nurse (LVN). The LVN stated that she administered Furosemide on February 9, 2025, even though Resident 1's blood pressure was 98/68. The LVN further stated, the physician had given a verbal order to continue administering the medication despite the SBP being less than 110. A further review of Resident 1's progress notes and physician order did not indicate any documentation that Furosemide was to be administered with a systolic blood pressure less than 110 on February 9, 2025. No documentation of a verbal order from the physician was found. On April 14, 2025, at 9:22 a.m., during a concurrent interview and record review with the Director of Nursing (DON). The DON stated there was no documentation on February 9, 2025, to support the administration of Furosemide with a SBP below 110. The DON stated, there was no documentation from the licensed nurse and the physician authorizing the administration from the original medication parameters. A review of the facility policy and procedure titled, Medication Administration, dated January 1, 2012, indicated, .Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines . Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required and the results recorded . When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record i.e. BP, pulse, finger stick blood glucose monitoring, etc .The Licensed Nurse will chart the drug; time administered and initial his/her name with each medication administration and sign full name and title on each page of the Medication Administration Record (MAR).

Based on record review, interviews, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) user's manual, the facility failed to accurately code the Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) to reflect a Preadmission Screening and Resident Review (PASRR) Level II for 4 (Residents #14, #55, #62, and #80) of 6 sampled residents reviewed for MDS accuracy. Findings included: During an interview on 05/22/2024 at 9:00 AM, the Director of Nursing (DON) revealed that the facility did not have a policy on MDS accuracy and stated they followed the RAI manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, revealed All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions. The manual revealed Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. The manual revealed Coding Instructions for section A1500 included Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. 1. An Admission Record revealed the facility admitted Resident #14 on 04/02/2024. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified psychosis not due to a substance or known physiological condition and vascular dementia. An admission MDS, with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. MDS section A1500 indicated Resident #14 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had an active diagnosis of psychotic disorder and had taken an antipsychotic medication during the seven-day look-back period. Resident #14's care plan revealed a focus area, initiated 04/11/2024, that revealed the resident was prescribed psychotropic medication for behavior management related to a diagnosis of psychosis. Resident #14's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 04/06/2024, revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The document indicated the determination report was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 04/05/2024. During an interview on 05/21/2024 at 3:20 PM, the Social Services (SS) Supervisor revealed that Resident #14 had a PASRR Level II evaluation completed and was receiving psychiatrist services. The SS Supervisor indicated the MDS staff were responsible for coding section A of the MDS. 2. An Admission Record revealed the facility admitted Resident #62 on 10/18/2022. According to the Admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder (bipolar type), anxiety disorder, bipolar disorder, and major depressive disorder. A significant change MDS, with an Assessment Reference Date (ARD) of 03/11/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. MDS section A1500 indicated Resident #62 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had active diagnoses of anxiety disorder, depression, bipolar disorder, and schizophrenia and had taken an antipsychotic, antianxiety, and antidepressant medications during the seven-day look-back period. Resident #62's care plan included a focus area initiated 01/31/2023, that indicated the resident was prescribed psychotropic medications related to bipolar disorder, anxiety disorder, and schizoaffective disorder. Resident #62's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 11/18/2023, revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The document indicated the determination report was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 11/15/2023. During an interview on 05/21/2024 at 3:20 PM, the Social Services (SS) Supervisor revealed Resident #62 had a PASRR Level II and was receiving psychiatric and psychology services. The SS Supervisor further revealed that the MDS staff were responsible for coding section A of the MDS. 3. An Admission Record revealed the facility admitted Resident #80 on 01/22/2024. According to the Admission Record, the resident had a medical history that included diagnoses of anxiety disorder, other recurrent depressive disorders, and post-traumatic stress disorder (PTSD). An admission MDS, with an Assessment Reference Date (ARD) of 01/29/2024, revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. MDS section A1500 indicated Resident #80 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had active diagnoses of anxiety disorder, depression, and post-traumatic stress disorder and had taken an antidepressant medication during the seven-day look-back period. Resident #80's care plan included a focus area, initiated 02/07/2024, that indicated the resident was prescribed psychotropic medications related to behavior management. Resident #80's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 01/28/2024 revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The document indicated the determination report was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 01/25/2024. During an interview on 05/21/2024 at 3:20 PM, the Social Services (SS) Supervisor revealed Resident #80 had a PASRR Level II and was receiving psychiatrist services. The SS Supervisor revealed the resident refused the psychiatric services and preferred to talk it out with the resident's family and children. The SS Supervisor further revealed the MDS staff were responsible for coding section A of the MDS. During an interview on 05/23/2024 at 11:04 AM, the Director of Nursing (DON) revealed that a resident's PASRR was checked upon admission. The DON revealed it was hers and the MDS Coordinator's responsibility to check the PASRR portal daily. The DON indicated PASRR Level II evaluations were discussed in the daily morning meetings. The DON indicated she was aware the PASRR Level IIs should be coded in section A on the MDS assessments. She indicated it was the responsibility of the MDS coordinators to code section A of the MDS. The DON further indicated it was important that the MDS was coded accurately to ensure the resident received the appropriate care. The DON indicated it was her expectation that the MDS was coded accurately, and she was the registered nurse (RN) who signed off on them. The DON revealed going forward the facility planned to check the PASRR portal website a couple times a day for PASRR Level II evaluations. The DON revealed he MDS coordinators did not have access to the PASRR portal until April 2024 . During an interview on 05/23/2024 at 12:28 PM, the Administrator revealed that a Corporate MDS RN provided one-on-one training on coding section A of the MDS accurately on 05/22/2024. The Administrator revealed it was important that residents' MDS assessments were coded accurately so that the residents were in the proper setting and were receiving appropriate care. The Administrator indicated the DON and the Corporate MDS RN would be reviewing the assessments for accuracy going forward. The Administrator indicated it was his expectation that MDS assessments were accurate . 45555 4. An Admission Record indicated the facility originally admitted Resident #55 on 05/25/2022 and readmitted the resident on 04/22/2024. According to the Admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar disorder, and major depressive disorder. An admission MDS, with an Assessment Reference Date (ARD) of 04/29/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses that included anxiety disorder, depression, bipolar disorder, and schizophrenia, and the resident received antipsychotic and antidepressant medications during the seven-day look back period. Further review of the MDS indicated Resident #55 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Resident #55's care plan included a focus area, initiated 04/27/2024 and revised 05/22/2024, that indicated the resident had a positive Level I PASRR screening, indicating diagnoses of anxiety, depression, schizoaffective disorder, and bipolar disorder, and indicated that the resident was taking psychoactive medications. Interventions directed staff to coordinate provisions of special needs with the state Medical/Medicaid Agency (initiated 04/27/2024) and to provide psychiatric evaluation and treatment as needed (revised 05/22/2024). Resident #55's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 04/27/2024, indicated there were recommended specialized services to supplement the nursing facility's care to address the resident's mental health needs. The document indicated that the report was based on a review of the resident's medical and social history which revealed a significant medical condition with mental stressors that required nursing services. The report indicated a Level II evaluation was completed on 04/26/2024. During an interview on 05/22/2024 at 3:33 PM, MDS Coordinator #1 stated PASRR information was included on comprehensive MDS assessments, which included admission, annual, and significant change assessments. She stated she had access to the PASRR information from their system and she was able to see if a Level II was in place. She stated the Admission Coordinator provided the Level I and Level II PASRR information to the Director of Nursing (DON). She stated the MDS staff were responsible for completing section A of the MDS, which included the Level II PASRR information. She stated the DON was responsible for checking to see if the PASRR had been completed and reviewed the determination letter, then the DON notified the MDS staff if a Level II was in place. She stated the MDS staff were responsible to ensure the MDS information was accurate. After review of Resident #55's MDS, MDS Coordinator #1 confirmed that it was not accurate. During an interview on 05/23/2024 at 11:05 AM, the DON stated the MDS staff were responsible for the accuracy of the MDS assessments and since she signed the completed MDS assessment, she was also responsible. She stated the accuracy of the MDS assessments was important to provide quality care. The DON stated that going forward they would log into the online portal a couple of times a day to see if there was any PASRRs available to code on the MDS assessments. The DON stated that Resident #55's MDS was not accurate. During an interview on 05/23/2024 at 12:36 PM, the Administrator stated he expected the MDS assessments to be accurate. He stated they had a consultant at the facility to compete one-on-one training with the MDS staff the previous day. The Administrator stated the DON would be reviewing the PASRRs to ensure that the MDS was coded correctly. He stated he received PASRR portal access for more users in the facility and they were going to be doing ongoing education. The Administrator stated the accuracy of the MDS was important so they could provide the proper services for the resident that was specific to their needs.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a glucometer (device used to check blood glucose levels) was cleaned and disinfected between use to prevent the potential spread of infection for 2 (Resident #7 and Resident #26) of 4 residents observed receiving blood glucose checks. Findings included: A facility policy titled, Cleaning & [and] Disinfection of Resident Care Equipment, revised 01/01/2012, specified, Resident-care equipment, including reusable items and durable medical equipment is cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. The policy also indicated the following: - II. Reusable items are cleaned and disinfected or sterilized between residents. - VI. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturer's instructions. Observations on 05/22/2024 at 4:12 PM revealed Licensed Vocational Nurse (LVN) #3 performed a blood glucose test on Resident #7. The LVN performed a fingerstick using a lancet and applied a droplet of Resident #7's blood to the test strip which was inserted into the glucometer. After completing the test, LVN #3 took the glucometer out of Resident #7's room and placed it on top of the medication cart without cleaning or disinfecting it. LVN #3 continued to administer medications to other residents and then at 4:19 PM, entered Resident #26's room with the same uncleaned glucometer and performed a blood glucose test on Resident #26. LVN #3 then took the machine out to the medication cart and set the machine on top of the cart without cleaning or disinfecting it. During an interview on 05/22/2024 at 4:25 PM, LVN #3 stated the glucometer should be cleaned with the germicidal wipes between each use. He stated he was nervous trying to remember everything and forgot to disinfect the glucometer after using it. During an interview on 05/23/2024 at 11:46 AM, the Infection Preventionist stated glucometers should be cleaned before and after each use with a chemical approved by the Environmental Protection Agency (EPA) and they were currently using the purple-top wipes (Sani-wipe germicidal cloths). She stated it was important to do this to prevent the possible spread of bloodborne infections. During an interview on 05/23/2024 at 8:52 PM, Registered Nurse (RN) Supervisor #4 stated the glucometer should be cleaned before and after each use with the purple-top germicidal wipes to prevent the spread of infection. During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated the glucometer should be cleaned with germicidal Sani-wipes after each use. During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated the glucometer should be cleaned before and after use with an EPA-approved disinfectant. During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated glucometers should be cleaned before and after each use with an EPA-approved chemical that was based on the manufacturer's recommendations. She stated it was important to do this for infection control and to prevent the transmission of infections. During an interview of 05/23/2024 at 12:36 PM, the Administrator stated the glucometer should be cleaned before and after use with an EPA-approved solution or chemical.

Based on interviews, record review, and facility policy review, the facility failed to ensure an as-needed (PRN) psychotropic medication order was limited to 14 days unless there was documented rationale for the extended use and a specific duration of the order. This affected 1 (Resident #27) of 5 residents reviewed for unnecessary medications. Resident #27 had a PRN order for Ativan (a benzodiazepine) with no stop date or documented rationale for the continued use. Findings included: A facility policy titled, Behavior/Psychoactive Drug Management, revised 11/2018, specified, Any Psychoactive Medication ordered on a prn basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage and write the order for the medication; not to exceed the 14-day time frame. An Admission Record indicated the facility admitted Resident #27 on 05/01/2021. According to the Admission Record, the resident had a medical history that included diagnoses of schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder, and unspecified dementia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2024, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had taken antianxiety medications during the last seven days of the assessment period. Resident #27's care plan included a focus area, revised 02/07/2024, that indicated the resident used anti-anxiety medication that included Ativan related to anxiety disorder manifested by verbal agitation and verbal outbursts. Interventions directed staff to administer anti-anxiety medication as ordered by the physician and monitor for side effects and effectiveness every shift. The care plan indicated the resident used Ativan 0.5 milligrams (mg) with instructions to give one tablet by mouth every six hours as needed for anxiety manifested by verbal agitation and verbal outbursts. A review of Resident #27's physician orders revealed the resident received an order on 04/12/2024 for Ativan 0.5 mg with instructions to give one tablet by mouth every six hours as needed (PRN) for anxiety manifested by verbal agitation and verbal outbursts. There was no stop date to the order. A review of Resident #27's April 2024 Medication Administration Record (MAR) revealed the resident received the PRN Ativan on 04/21/2024 at 8:00 PM. A review of Resident #27's May 2024 MAR revealed the resident received the PRN Ativan twice on 05/10/2024 at 5:00 PM and 11:00 PM; and again on 05/13/2024 at 6:26 AM. A review of Resident #27's progress notes revealed no documentation of the resident being reassessed for the rationale of the ongoing use of the PRN Ativan. During an interview on 05/23/2024 at 8:52 AM, Registered Nurse (RN) #4 stated psychotropic medications included anxiety medications, and the resident could have a PRN order but should have a stop date of 14 days. She stated after 14 days, the resident should be reassessed to determine the ongoing need for the medication. She stated she was not sure why Resident #27 did not have a stop date on their Ativan. During an interview on 05/23/2024 at 9:08 AM, Licensed Vocational Nurse (LVN) #5 stated she was the desk nurse and did admissions. She stated a resident could have a PRN order for an anti-anxiety medication with a 14-day stop date until the resident was reassessed. She stated she was unsure why Resident #27's Ativan did not have a stop date. During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated a resident could have a PRN order for a psychotropic medication, but it should have a stop date. During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated a resident on a PRN psychotropic medication would need to have the order renewed after 14 days, and they would need to be assessed prior to the reordering of the medication to determine the ongoing need. She stated Resident #27 did have the behaviors to warrant the use of the medication. During an interview on 05/23/2024 at 12:36 PM, the Administrator stated there needed to be a 14-day stop date for psychotropic medications but deferred to the DON for the specifics. He stated Resident #27 may have just slipped through the cracks.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure splints were applied as ordered for 2 (Resident #18 and Resident #46) of 3 sampled residents reviewed for positioning and mobility. Findings included: A facility policy titled, Restorative Nursing Program Guidelines, revised 09/19/2019, indicated the restorative nursing program may include, G. Splinting and brace application. The policy also indicated, VII. The RNA [restorative nurse aide] carries out the restorative program according on [sic] the Care Plan. The RNA documents the frequency of the program, the amount of time the resident spent in the activity and their tolerance to the program. In addition, the RNA completes a written weekly summary for all residents on a Restorative Nursing Program. The Restorative Nursing Program Coordinator co-signs the weekly progress note. 1. An Admission Record indicated the facility most recently admitted Resident #18 on 02/18/2022. According to the Admission Record, the resident had a medical history that included diagnoses of muscle wasting and atrophy (shrinkage of muscles) to multiple sites and cachexia (a metabolic syndrome characterized by muscle mass loss). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/2024, revealed Resident #18 had short-term and long-term memory problems per a staff assessment of mental status (SAMS). The MDS indicated the resident had functional limitations in range of motion with impairment to the upper and lower extremities on both sides and was dependent for all activities of daily living (ADLs). According to the MDS, the resident received no or less than 15 minutes a day of restorative nursing program services, including splint or brace assistance, during the seven-day assessment look-back period. Resident #18's Order Summary Report, which listed active orders as of 05/22/2024, revealed the following RNA program orders: - An order started on 12/18/2023 directed an RNA to apply the resident's right elbow extension splint for two to five hours, as safely tolerated to prevent further development of contractures every day shift. - An order started on 12/18/2023 directed an RNA to apply the resident's right resting comfy hand splint for two to five hours as safely tolerated to prevent further development of contractures every day shift. Resident #18's care plan included a focus area, initiated on 03/17/2022, that indicated the resident had an ADL self-care performance deficit related to dementia and musculoskeletal impairment. Interventions initiated on 07/27/2023 indicated as part of the RNA program, the RNA was to apply an elbow extension splint to the resident's right upper extremity and a resting hand splint to the resident's right upper extremity for four hours five times per week or as tolerated. Another intervention, initiated on 05/23/2024 (during the survey), indicated a RA was to don and doff a left knee extension to prevent further development of contractures. The intervention did not specify the frequency or duration the knee extension was to be applied. During observations on 05/20/2024 at 12:58 PM, Resident #18 had contractures of all four extremities with no splints or hand rolls in place. Observations on 05/21/2024 at 10:43 AM and 2:12 PM revealed Resident #18 did not have any splints in place. Observations on 05/22/2024 at 9:35 AM and 12:32 PM revealed Resident #18 did not have any splints in place. A review of Resident #18's Restorative Program forms revealed the resident's splint/brace care was not documented as provided for one or more of the resident's ordered splints/braces on 11 of 22 days between 05/01/2024 and 05/22/2024. During an interview on 05/22/2024 at 12:15 PM, Restorative Nursing Assistant (RNA) #10 stated there were three RNAs, and two worked every day. She stated the RNAs did weights on Monday and Tuesday, and if they had time at the end of the shift, then they would do range-of-motion exercises with some of the residents, but they did not apply the splints. She stated Sunday 05/19/2024 would have been the last time the resident had the splints on. She stated she did not work, but her partner would have done it. She stated she had not had a chance to apply the splints that day. During an interview on 05/22/2024 at 2:30 PM, Licensed Vocational Nurse (LVN) #7 stated she did not apply the splints for the residents but did monitor to ensure that the splints were being put on as ordered. She stated she did not realize Resident #18's splints had not been applied the previous three days. During an interview on 05/23/2024 at 8:52 AM, Registered Nurse (RN) Supervisor #4 stated if a resident had orders for splints to be applied seven days a week, then the resident should have them on daily, and if they were not being applied, then the reason should be documented. She stated splints were important to prevent contractures. She stated she did not know why Resident #18's splints had not been applied. During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated RNA services should be provided seven days a week if that was what was ordered. She stated if it was not being done, then the reason should be documented. She stated the use of splints was important to prevent further contractures. During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated she was also the restorative nurse. She stated the proper use of splints was important for contracture management and needed to be followed because it was an order from the physician. During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated if RNA services were ordered seven days a week, then it should be provided seven days a week, and if not, then the reason should be documented. She stated splints were important to use for contracture management. She stated the RNA should have provided the treatment as ordered and should document why the splints were not on Resident #18. During an interview on 05/23/2024 at 12:36 PM, the Administrator stated he thought the RNA services were being provided. He stated they were assessing all the RNA residents to see if there had been any decline related to the services not being provided and they were doing one-on-one in-services with the RNAs. He stated they did not direct the staff to only do weights on Monday and Tuesday and were planning to revamp the Restorative system. 2. An Admission Record indicated the facility readmitted Resident #46 on 03/13/2023. According to the Admission Record, the resident had a medical history that included diagnoses of muscle wasting and atrophy (shrinkage of muscles) to multiple sites and poly-osteoarthritis (joint pain that involves five or more joints). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2024, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had functional limitation in range of motion with impairment to the upper and lower extremities on both sides. The MDS indicated Resident #46 was dependent for all activities of daily living (ADLs). According to the MDS, restorative services were provided for eating and/or swallowing during the assessment period and splint and brace assistance was not provided. Resident #46's care plan included a focus area initiated 08/17/2023 that indicated the resident had an ADL self-care performance deficit related to limited mobility and weakness. Interventions included an RNA program for the left resting hand splint, right elbow extension, and left elbow extension to be applied seven days a week up to five hours a day as safely tolerated. Observation on 05/20/2024 at 9:32 AM revealed Resident #46 had contractures of bilateral hands with no hand rolls or splints in place. Observations on 05/21/2024 at 10:32 AM and 2:10 PM revealed Resident #46 did not have any hand rolls or splints in place. Observations on 05/22/2024 at 7:40 AM, 9:15 AM, 11:32 AM, and 12:02 PM revealed Resident #46 did not have any hand rolls/splints in place. A review of Resident #46's Order Summary Report, revealed the following active orders: - An order dated 12/31/2023 indicated the RNA was to apply the resident's left upper extremity elbow extension splint every day shift as safely tolerated for contracture prevention. - An order dated 12/31/2023 indicated the RNA was to apply the resident's right upper extremity elbow extension splint every day shift as safely tolerated for contracture prevention. A review of Resident #46's Restorative Program form revealed no documentation to indicate sling/brace care was provided for one or more of the resident's ordered splints on 12 of 22 days between 05/01/2024 and 05/22/2024. During an interview on 05/22/2024 at 12:15 PM, Restorative Nursing Assistant (RNA) #10 stated there were three RNAs, and two worked every day. She stated the RNAs did weights on Monday and Tuesday, and if they had time at the end of the shift, then they would do range-of-motion exercises with some of the residents, but they did not apply the splints. She stated Sunday 05/19/2024 would have been the last time the resident had the splints on. She stated she did not work, but her partner would have done it. She stated she had not had a chance to apply the splints that day. During an interview on 05/22/2024 at 2:30 PM, Licensed Vocational Nurse (LVN) #7 stated she did not apply the splints for the residents but did monitor to ensure that the splints were being put on as ordered. She stated she did not realize Resident #46's splints had not been applied the previous three days. During an interview on 05/23/2024 at 8:52 AM, Registered Nurse (RN) Supervisor #4 stated if a resident had orders for splints to be applied seven days a week, then the resident should have them on daily, and it they were not being applied, then the reason should be documented. She stated splints were important to prevent contractures. She stated she did not know why Resident #46's splints had not been applied. During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated RNA services should be provided seven days a week if that was what was ordered. She stated if it was not being done, then the reason should be documented. She stated the use of splints was important to prevent further contractures. During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated she was also the restorative nurse. She stated the proper use of splints was important for contracture management and it was an order from the physician. During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated if RNA services were ordered seven days a week, then it should be provided seven days a week, and if not, then the reason should be documented. She stated splints were important to use for contracture management. She stated the RNA should have provided the treatment as ordered and should document why the splints were not on Resident #46. The DON stated they were doing a full sweep of all the RNA residents and revamping the program to make sure there was not anything that had been missed and involving the Director of Rehabilitation (DOR). She stated they started in-servicing with the RNAs and put it on their Quality Assurance Performance Improvement (QAPI) to monitor. During an interview on 05/23/2024 at 12:36 PM, the Administrator stated he thought that the RNA services were being provided. He stated they were assessing all the RNA residents to see if there had been any decline related to the services not being provided and they were doing one-on-one in-services with the RNAs. He stated they did not direct the staff to only do weights on Monday and Tuesday and were planning to revamp the Restorative system.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure care of a peripheral intravenous (IV) access site was provided and documented in accordance with accepted standards of nursing practice and facility policy for 1 (Resident #55) of 1 sampled resident reviewed for IV site care. Specifically, the facility failed to obtain physician's orders for IV flushes and dressing changes, failed to conduct and document assessments of the IV site, and failed to ensure the IV site was discontinued promptly when not needed for IV therapy. Findings included: A facility policy titled, Organizational Aspects of IV Therapy, effective 07/2013, specified, General Rules of IV Documentation 1. Document per facility policy - usually every shift if resident has an infusion catheter in place, or whenever and infusion treatment is given and 5. The shift note should include the following information: a. Date, time; signature and title of Nurse. b. Location and objective description of insertion site. The policy also indicated Nursing Responsibilities in Infusion Therapy included the following: - 8. Performing functions and procedures that are consistent with current standard of care, facility policy and procedure and that are within the scope of the State Nurse Practice Act. - 11. Clarifying an illegible, incomplete, or incorrect order. The policy also indicated, Scope of Practice for Specific Infusion Therapy Nursing Functions included, 5. Caring for and maintaining infusion equipment and catheters (peripheral and central venous access catheters). This includes flushing, dressing changes, site assessment, site rotation (for short peripheral catheters only), changing IV tubing and needleless connection devices. An Admission Record indicated the facility readmitted Resident #55 on 04/22/2024. According to the Admission Record, the resident had a medical history that included diagnoses of pneumonia and severe sepsis with septic shock. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS did not indicate the resident had IV access on admission or while a resident. An observation on 05/20/2024 at 9:43 AM revealed Resident #55 lying in bed with a peripheral IV access to the right foot. The dressing on the site was dated 04/29/2024, indicating the dressing had been in place for over 20 days. A Clinical Admission progress note, dated 04/22/2024, revealed Resident #55 had the peripheral IV access on the right foot on the date of the resident's readmission to the facility. A review of Resident #55's Order Summary Report revealed no orders for the care or maintenance of the IV access to the resident's right foot. Resident #55's care plan included a focus statement, dated as initiated 04/24/2024, which indicated the resident had impaired immunity and was on immunosuppressive therapy. The planned interventions directed staff to monitor/document/report any signs or symptoms of infection, including fever, redness, or drainage/swelling around wounds or catheter sites. As of 05/20/2024, Resident #55's care plan did not address that the resident had a peripheral IV access site in place. The care plan included no interventions that addressed the care and monitoring of the IV site. During an interview on 05/21/2024 at 12:38 PM, Registered Nurse (RN) Supervisor #4 stated Resident #55 returned from the hospital with the IV access to the right foot. RN Supervisor #4 stated she contacted the dialysis center to make sure they were not using it then discontinued it since it was no longer needed. She stated she discontinued it the morning of 05/21/2024. She stated she was not able to find any reason for the IV site or any care orders for the IV site, including flushes or dressing changes. During an interview on 05/22/2024 at 2:30 PM, Licensed Vocational Nurse (LVN) #7 stated if a resident had IV access, the nurse should assess the site for infection and infiltration. She stated there should be orders for care that included flushing the IV and assessing the site. She indicated the site should be monitored every shift and this should be documented in the nurses' notes. She stated a peripheral IV could stay in place for up to seven days and that the dressing over the insertion site should be changed every three days. She stated Resident #55's IV access should have been removed since they were not using the access. She stated she did not know why the IV access was not discontinued. During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated the admitting nurse should do a full body assessment and document any IV access. She stated the facility would need orders to monitor the site and flush the IV catheter. She stated the IV access should be assessed throughout any treatment being provided, and if the resident was not receiving treatment, the access should be removed. She stated a peripheral IV line could stay in until it infiltrated and then would need to be changed out. She was not sure how often the dressing over the access site should be changed. During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated if a resident had IV access, there should be physician's orders that included flushes, monitoring every shift, and dressing changes. She stated she thought the dressing should be changed once a week but was unsure how long a peripheral IV line could stay in place. During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated that upon admission, the nurse should do a skin assessment. If there was IV access and it was not needed, then the nurse should get an order and the IV should be removed. She stated that sometimes, they would keep the access for a few days in case it was needed. In that case, they should have orders for flushing of the IV catheter and for care of the site. She stated a peripheral IV access could stay in as long as it was intact and patent. She stated the dressing to the site should be changed every seven days. The DON stated she was not sure if Resident #55's IV access was used and stated the resident did not have orders for IV access and care. During an interview on 05/23/2024 at 12:36 PM, the Administrator stated if a resident was admitted with IV access, then the nurse should find out if it was needed and only keep it in place for the length of time it was needed. He stated they should have physician orders to care for the IV site.

Based on observation, interview, and record review, the facility failed to ensure basic accommodations of needs were met when one of three residents, (Resident 1) ' s call light was not within reach. This failure had the potential for Resident 1 to have unmet needs and unable to call for assistance. Findings: On November 29, 2023, at 11:48 a.m., an unannounced visit to the facility on a complaint investigation was initiated. On November 29, 2023, at 12:54 p.m., observed Resident 1 sitting on the right side of his bed in a wheelchair. His over-bed table was in front of him, and his call light was on the left side of the bed on the floor, outside of Resident 1 ' s reach. On November 29, 2023, at 12:54 p.m., an interview was conducted with Resident 1. Resident 1 stated he used his call light to call for assistance. Resident 1 stated he would not be able to reach his call light and was concerned that he could not call for assistance. On November 29, 2023, at 1:19 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated she was taking care of Resident 1. The CNA stated the call light should always be within reach. The CNA stated Resident 1 ' s call light was not within his reach. A review of Resident 1 ' s medical records indicated he was admitted to the facility on [DATE], with diagnoses of stroke with hemiplegia, (paralysis of one side of the body), hemiparesis, (weakness of one side of the body), affecting right dominant side, aphasia, (affects a person's ability to express and understand written and spoken language), dysphagia, (difficulty swallowing), and anxiety disorder, (a chronic condition characterized by an excessive and persistent sense of apprehension). A review of Resident 1 ' s History and Physical dated September 29, 2023, indicated he had the capacity to understand and make decisions. A review of Resident 1 ' s Care Plan dated September 29, 2023, indicted Focus .The resident has an ADL, [activities of daily living], self-care performance deficit r/t, [related to], Limited Mobility, Weakness .Interventions .Encourage the resident to use bell to call for assistance . A review of the facility ' s policy and procedure titled Communication - Call System revised January 1, 2012, indicated .The Facility will provide a call system to enable residents to alert the nursing staff from their rooms . II. Call cords will be placed within the resident's reach in the resident's room. A. When the resident is out of bed, the call cord will be clipped to the bedspread in such a way as to be available to a wheelchair bound resident .

Based on observation, interview, and record review, the facility failed to ensure one of three residents, (Resident 3), was assisted with his meal in a dignified manner when the Certified Nursing Assistant (CNA 2), stood over the resident. This failure caused Resident 3 to feel rushed and had the potential for compromised dignity. Findings: On November 29, 2023, at 11:48 a.m., an unannounced visit to the facility on a complaint investigation was initiated. On November 29, 2023, at 1:15 p.m., observed Resident 3 sitting in a wheelchair in the hallway. Resident 3's lunch tray was on the over-bed table in front of Resident 3. CNA 2 was standing beside Resident 3 as he was feeding Resident 3. On November 29, 2023, at 1:34 p.m., an interview was conducted with Resident 3. Resident 3 stated he needed assistance with eating his lunch. Resident 3 stated he felt rushed while CNA 2 was assisting him with lunch. On November 29, 2023, at 1:58 p.m., an interview was conducted with CNA 2. CNA 2 stated that he should have been seated while assisting Resident 3 with his lunch. A review of Resident 3's medical record indicated he was admitted on [DATE], with diagnoses of amyotrophic lateral sclerosis, (ALS - is also called Lou Gehrigsdisease. It's a neuromuscular disorder that causes muscle weakness), anxiety disorder, (a chronic condition characterized by an excessive and persistent sense of apprehension), and major depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 3's History and Physical dated January 31, 2023, indicated he had the capacity to understand and make decisions. A review of Resident 3's Care Plan initiated May 23, 2023, indicated Focus . The resident has an ADL self-care performance deficit r/t Limited Mobility, Weakness secondary to left humerus fracture (history), Amyotrophic Lateral Sclerosis .Interventions . EATING: Extensive with one person assist . A review of a Nursing Times article titled Assisting Patients with Eating and Drinking to Prevent Malnutrition dated October 9, 2017, indicated .Assisting patients .Helping patients who cannot eat and drink independently takes time, understanding and patience. It must not be rushed and any nurse who is involved in this task should not be interrupted . 7. Sit down at the patient's eye level. This aids effective communication but also provides reassurance the patient that you have the time to help the patient to eat .

Based on interview and record review, the facility failed to assess the need for duplicated medication (Depakote-medication for seizure and mood stabilizer for behavior management) to manage behavior for one of five sampled residents (Resident 1). This failure had resulted for Resident 1 to receive two different forms of Depakote for 11 days which could potentially cause drug adverse reaction, complication, and hospitalization . Findings: On August 7, 2023, at 10:25 a.m., an unannounced visit was conducted to investigate quality care issues. On August 7, 2023, Resident 1 ' s record was reviewed. The Physician ' s Order by Licensed Vocational Nurse (LVN) 1, dated 06/27/2023, at 4:54 p.m., indicated an order for, Depakote ER Oral Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for SCHIZOAFFECTIVE DISORDER (D/O) BIPOLAR TYPE (mental illness that can affect thoughts, mood, and behavior) MANIFESTED BY (M/B) MOOD SWINGS INFORMED CONSENT (I/C) OBTAINED BY MEDICAL DOCTOR (M/D). The resident ' s record further indicated another order from Registered Nurse (RN) 1, on June 28, 2023, at 13:27 p.m., for, Depakote Oral Tablet Delayed Release (DR) 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for M/B MOOD SWINGS IC OBTAINED. On October 2, 2023, at 2:35 p.m., RN 1 was interviewed on Depakote ER and Depakote DR orders made on June 27, 2023, and June 28, 2023, respectively. RN 1 stated ER stands for extended release and DR was for delayed release. RN 1 stated that if there had been a previous order already for Depakote ER, she should have clarified with the MD first before ordering Depakote DR. RN 1 stated she did not see the order for Depakote ER. RN 1 stated it should have been discontinued before ordering the Depakote DR to avoid duplication of orders. RN 1 indicated both medications belong to the same drug classification. A review of June 2023 and July 2023, MAR (Medication Administration Record) was conducted with RN 1. The MAR indicated both Depakote ER and DR were administered at 9 p.m., on June 28, 2023, through July 7, 2023. The resident's Depakote DR was discontinued on July 11, 2023, when the resident ' s (family member) visited and found the resident swollen and having difficulty breathing. A review of Resident 1's record documented on July 11, 2023, at 7:52 p.m., titled, Change in Condition (CIC), indicated, Situation: The Change In Condition/s report and mood stabilizer on this CIC Evaluation are/were: Altered mental status Other change in condition Tired, Weak, Confused, or Drowsy .Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily roused, difficult to arouse) Increased confusion (e.g. disorientation); Functional Status Evaluation: General Weakness .Nursing observations, evaluation, and recommendations are: Resident appears to have decreased level of consciousness with weakness accompanied with decreased O2 saturation .Family is at bedside and have been notified regarding change of condition. Doctor (Dr-name of doctor ' s PA-Physician ' s Assistant) is aware Resident has been transferred to (name of hospital) at 7:56 pm. On October 2, 2023, at 2:53 p.m., the Director of Staff Development (DSD) was interviewed regarding Resident 1 ' s Depakote ER and Depakote DR medication. The DSD stated ER was extended release and DR was delayed release. The DSD stated they belong to same family of medication but different and separate medication. The DSD stated the medication should have been reviewed with MD. The DSD stated that there could be a potential adverse reaction for new medication like changes in cognitive status or changes in condition like lethargy and changes in VS (vital signs). The DSD stated to prevent it from happening again, the licensed nurses had to verify and double check for any previous orders to avoid duplication of medication orders. On October 2, 2023, at 3:10 p.m., a concurrent record review and interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 verified her initials made on July 1, 2023, Medication Administration Record (MAR), signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 2 stated it was an unnecessary medication. LVN 2 stated, to prevent duplication, one had to pay attention to previous orders to prevent error. On October 2, 2023, at 3:24 p.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 verified her initials made on June 28, 2023, July 3, 4, 9, and 10, 2023 MAR, signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 3 stated both Depakote ER and DR belong to same classification of medication. LVN 3 stated to prevent it from happening in the future, make sure to check the previous order before entering new ones to avoid duplication. LVN 3 stated duplication can cause over-medication and patient may get lethargic. LVN 3 stated she heard the family was saying the resident was more sleepy and not as active, and it caused him to be lethargic. LVN 3 stated it could cause changes with mentation and residents may not be able to protect themselves from a potential fall. On October 2, 2023, at 4:12 p.m., the Director of Nursing (DON) and Administrator (ADM) were interviewed regarding Resident 1 ' s Depakote ER 500 mg at bedtime and Depakote DR 500 mg at bedtime medication duplication of orders, and interviews conducted with nurses verifying they have administered both medications on June 28, 2023, through July 11, 2023. The order produced unnecessary medication to address behavior management. A review of the policy and procedure titled, Medication- Administration, dated January 1, 2012, indicated, .To ensure the accurate administration of medications for residents in the facility .If the Attending Physician increases or changes a medication order, this is an automatic stop or discontinue order for original order .Nursing staff will keep in mind the seven 'rights' of medication when administering medication . A review of the facility policy titled, Behavior/Psychoactive Drug Management, dated November 2018, indicated, Policy: It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial well-being .G. Appropriate dosage must be prescribed .The treatment should be at the lowest possible dose to improve the target symptoms being monitored .

Based on interview and record review, the facility failed to prevent administration of unnecessary medication to one of five sampled residents (Resident 1), when Resident 1 was administered with Depakote (medication used to treat seizures and bipolar disorder)DR (delayed released -delayed release of drugs in the body) and Depakote ER (extended released-drug is released slowly to provide a prolonged therapeutic effect), at bedtime without adequate indication for duplicated use. The facility failure had resulted in Resident 1 receiving unnecessary medication for 11 days which could potentially cause drug adverse reaction, complications, and unnecessary hospitalization . Findings: On August 7, 2023, at 10:25 a.m., an unannounced visit was conducted to investigate quality care issues. On August 7, 2023, Resident 1 ' s record was reviewed. The Physician ' s Order by Licensed Vocational Nurse (LVN) 1, dated 06/27/2023, at 4:54 p.m., indicated an order for, Depakote ER Oral Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for SCHIZOAFFECTIVE DISORDER (D/O) BIPOLAR TYPE (mental illness that can affect thoughts, mood, and behavior) MANIFESTED BY (M/B) MOOD SWINGS INFORMED CONSENT (I/C) OBTAINED BY MEDICAL DOCTOR (M/D). The resident ' s record further indicated another order from Registered Nurse (RN) 1, on June 28, 2023, at 13:27 p.m., for, Depakote Oral Tablet Delayed Release (DR) 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for M/B MOOD SWINGS IC OBTAINED. On October 2, 2023, at 2:35 p.m., RN 1 was interviewed on Depakote ER and Depakote DR orders made on June 27, 2023, and June 28, 2023, respectively. RN 1 stated ER stands for extended release and DR was for delayed release. RN 1 stated that if there had been a previous order already for Depakote ER, she should have clarified with the MD first before ordering Depakote DR. RN 1 stated she did not see the order for Depakote ER. RN 1 stated it should have been discontinued before ordering the Depakote DR to avoid duplication of orders. RN 1 indicated both medications belong to the same drug classification. A review of June 2023 and July 2023, MAR (Medication Administration Record) was conducted with RN 1. The MAR indicated both Depakote ER and DR were administered at 9 p.m., on June 28, 2023, through July 7, 2023. The resident's Depakote DR was discontinued on July 11, 2023, when the resident ' s (family member) visited and found the resident swollen and having difficulty breathing. A review of Resident 1's record documented on July 11, 2023, at 7:52 p.m., titled, Change in Condition (CIC), indicated, Situation: The Change In Condition/s report and mood stabilizer on this CIC Evaluation are/were: Altered mental status Other change in condition Tired, Weak, Confused, or Drowsy .Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily roused, difficult to arouse) Increased confusion (e.g. disorientation); Functional Status Evaluation: General Weakness .Nursing observations, evaluation, and recommendations are: Resident appears to have decreased level of consciousness with weakness accompanied with decreased O2 saturation .Family is at bedside and have been notified regarding change of condition. Doctor (Dr-name of doctor ' s PA-Physician ' s Assistant) is aware Resident has been transferred to (name of hospital) at 7:56 pm. On October 2, 2023, at 2:53 p.m., the Director of Staff Development (DSD) was interviewed regarding Resident 1 ' s Depakote ER and Depakote DR medication. The DSD stated ER was extended release and DR was delayed release. The DSD stated they belong to same family of medication but different and separate medication. The DSD stated the medication should have been reviewed with MD. The DSD stated that there could be a potential adverse reaction for new medication like changes in cognitive status or changes in condition like lethargy and changes in VS (vital signs). The DSD stated to prevent it from happening again, the licensed nurses had to verify and double check for any previous orders to avoid duplication of medication orders. On October 2, 2023, at 3:10 p.m., a concurrent record review and interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 verified her initials made on July 1, 2023, Medication Administration Record (MAR), signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 2 stated it was an unnecessary medication. LVN 2 stated, to prevent duplication, one had to pay attention to previous orders to prevent error. On October 2, 2023, at 3:24 p.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 verified her initials made on June 28, 2023, July 3, 4, 9, and 10, 2023 MAR, signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 3 stated both Depakote ER and DR belong to same classification of medication. LVN 3 stated to prevent it from happening in the future, make sure to check the previous order before entering new ones to avoid duplication. LVN 3 stated duplication can cause over-medication and patient may get lethargic. LVN 3 stated she heard the family was saying the resident was more sleepy and not as active, and it caused him to be lethargic. LVN 3 stated it could cause changes with mentation and residents may not be able to protect themselves from a potential fall. On October 2, 2023, at 4:12 p.m., the Director of Nursing (DON) and the Administrator (ADM) were interviewed regarding Resident 1 ' s Depakote ER 500 mg at bedtime and Depakote DR 500 mg at bedtime medication duplication of orders, and interviews conducted with nurses verifying they have administered both medications on June 28, 2023, through July 11, 2023. The order produced unnecessary medication to address behavior management. A review of the facility policy titled, Medication - Verification, dated January 1, 2012, indicated, Purpose: Medications are administered safely and appropriately as ordered. Policy: I. It is the responsibility of Nursing Staff to be aware of the classification, action, correct dosage, and side effects of medication before administration.

Based on observation, interview, and record review, the facility failed to ensure the licensed nurse completed an assessment for self-administration of medications for one of three residents (Resident 2). This failure had the potential for unsafe self-administration of medications, duplication of medications, and interactions with other medications for Resident 2. Findings: On February 10, 2023, at 11:45 a.m., an announced visit to the facility was conducted to investigate an allegation of abuse. On February 10, 2023, at 1:25 p.m., a concurrent observation and interview were conducted with Resident 2. Resident 2 stated he was purchasing his own supplies during his stay in the facility. Resident 2 opened the top drawer of the dresser and took out various medications. Resident 2 stated he has Benadryl cream for bites on his legs, Tums tablets for his heartburn, Benadryl tablets (anti-allergy medication), and Pepto Bismol liquid (for heartburn). On February 14, 2023, at 12:20 p.m., an interview with Resident 2 was conducted. Resident 2 stated he ordered his medications online and have them delivered. Resident 2 further stated, he used the Pepto Bismol, Benadryl, Tums, and cream on himself when needed. Resident 2 stated the facility did not have stock of these medications when he requested them. Resident 2 stated, the facility knew he had these medications. Review of Resident 2's record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease (a disorder of the central nervous system), Seizures (temporary abnormalities in muscles and movement), Gastro-Esophageal Reflux Disease (acid or bile in the stomach irritates the food pipe). Further review of Resident 2's record indicated no documentation that the licensed nurse completed an assessment for Resident 2 for self-administration of medications. On February 14, 2023, at 1 p.m., the Director of Nursing (DON) was interviewed. She stated the resident could not keep medications at bedside without a self-administration of medication assessment. On February 14, 2023, at 1:30 p.m., a concurrent interview and record review with the DON was conducted. The DON stated, Resident 2 did not have a self-administration assessment completed. The DON further stated the resident could not keep medications at bedside. On February 14, 2023, at 2:30 p.m., an interview with the Licensed Vocational Nurse (LVN) was conducted. The LVN stated, Resident 2 had no orders for Tums or cream for Resident 2's bites on his legs. The LVN further stated, he was not aware Resident 2 kept medications in his dresser to use when necessary. On February 14, 2023, at 3:15 p.m., an observation of the LVN was conducted. The LVN went to Resident 2's room, removed the medications from the resident's drawer, and brought them to the nurse's station. The LVN removed one bottle of Pink Bismuth Subsalicylate (Pepto Bismol), one bottle of Tum's chewable tablets, and one bottle of Diphenhydramine (Benadryl) tablets. A review of the facility's policy and procedure titled Medication-Self Administration, dated January 1, 2012, indicated .To provide residents with the opportunity to self-administer medications determined by the attending physician and the Interdisciplinary Team (IDT) .the IDT will assess the resident's cognitive, physical and visual ability to carry out this responsibility based on a review of an assessment by a licensed nurse .the Assessment for Self-Administration of Medications .The resident may not begin self-administration of medications prior to the approval of the IDT and the Attending Physician .The Attending Physician must provide a written order permitting the resident to self-administer medications .

Based on interview and record review, the facility failed to ensure the safeguarding of the resident's information against loss for one of three sampled residents (Resident A), when Resident A's medical chart could not be located. This failure had the potential for Resident A's care being compromised which could have a negative impact on resident's physical and psychosocial wellbeing. Findings: On February 2, 2023, at 11:30 a.m., an unannounced visit to the facility was conducted to investigate an Administrative issue. A review of Resident A's record, indicated, Resident A was admitted to the facility November 28, 2022, with diagnoses which included anxiety disorder (a feeling of worry, nervousness). A review of Resident A's facility document titled, Follow-up Report, dated January 20, 2023, indicated, .On 1/17/2023, the Nurse Practitioner (NP) for patient (name of resident) carne to the facility to do patient visit. When NP asked for patients' chart, the facility realized it was missing. Facility has performed extensive search for missing chart and cannot locate it at this time . On February 2, 2023, at 11:40 a.m., during an interview with the Medical Records Director (MRD), the MRD stated there is a process for the facility to safeguard the medical records. The MRD stated only an authorized employee can access a resident's medical record. The MRD stated the residents' medical charts were placed at the nurses station. The MRD stated the facility utilized a laminated plastic to indicate which department borrowed a resident's medical chart. The MRD stated on January 17, 2023, she was unable to locate resident's medical chart and did not know who had borrowed it. The MRD stated she created a new medical chart for the resident. On February 3, 2023, at 12:05 p.m., Resident A was interviewed. He stated the staff informed him that his medical chart was lost. On March 6, 2023, at 4:02 p.m., during an interview with the Director of Nursing (DON), the DON stated the staff seacrhed the entire facility to locate the lost medical chart of the resident. On May 4, 2023, at 9:50 a.m., during an interview with the DON , the DON stated Resident A's medical chart was not found.

Based on observation, interview, and record review, the facility failed to provide a safe environment to prevent injuries and accidents for one sampled resident (Resident 1) while the resident was being transported to her dialysis (process of removing waste from the blood by a machine) clinic using the facility's transport bus. The facility failed to properly secure Resident 1's wheelchair in the bus during the transport which resulted in the resident and wheelchair tilting backwards and causing Resident 1 to hit her head on the back wall of the bus. Resident 1 complained of pain to the back of the head and upper back area. Resident 1 was later transported to the hospital emergency room (ER) for further evaluation and treatment. Findings: On May 17, 2016, at 9:40 a.m., an unannounced visit was made to the facility. Review of Resident 1's medical record indicated she was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Resident 1 received dialysis treatment three times a week at a dialysis clinic away from the facility. A written investigative summary and time line of the events, dated May 2, 2016, was provided by the facility Assistant Administrator (AA) and indicated the following: .8:56 am while driving to the Dialysis (clinic), (Resident 1's name) strap became loose and slipped through the tightening clasp causing the chair to move forward and to subsequently tilt back when accelerating. 8:57 am (name of van driver) pulled the bus over to the side of the road and repositioned, re-strapped, and double checked all fittings and buckles. 8:57 am (name of van driver) asked if she (Resident 1) was ok, she stated my back hurts a little but I'm ok. The facility's written investigative summary of events further indicated Resident 1 complained of back pain, wanted to go to the emergency room (ER), and was afraid of being transported by the facility bus. On May 17, 2016, at 9:55 a.m., the facility bus driver, who was also the Maintenance Supervisor (MS), was interviewed. He was asked about the incident involving Resident 1 while inside the facility bus being transported to the dialysis clinic on May 2, 2016. The MS stated, Straps came off loose, referring to the front anchor straps from the floor that went around the bottom frame of the resident's wheelchair when the bus came to a stop at a red light. The MS stated the bus then accelerated forward at the green light. The MS stated Resident 1 was still seated in the wheelchair when the wheelchair was tilted backward toward the back wall of the bus. The MS stated the straps that came off were old, defective, and thrown away after the accident, and new anchor straps had been ordered. The MS could not confirm if the defective straps were the reason they came off, or if the MS did not properly secure them. When the MS was asked about his job responsibilities at the facility, the MS stated he was hired two months ago and his main job responsibility was as Maintenance and Housekeeping Supervisor. The MS stated he was to make sure life and safety equipment used by residents in the facility were in good working condition. The MS further stated he was given additional work responsibility to take over as a bus driver, transporting residents to their scheduled appointments (such as at dialysis clinics) when the main bus driver was not available. The MS was further asked if he was given orientation or training regarding resident safety when transporting residents, prior to assuming the responsibility as facility bus driver. The MS stated, No training, no orientation. On May 17, 2016, at 11:35 a.m., an interview with the Administrator and the Assistant Administrator (AA) was conducted. The Administrator and AA were asked if, prior to the accident involving Resident 1, the facility bus drivers including the MS had been provided with safety training and orientation for transporting residents on the facility bus. The Administrator acknowledged the designated facility bus drivers including the MS did not receive safety training and/or orientation on safe transport of residents until after the accident occurred with Resident 1. The Administrator could not confirm if the wheelchair straps came off because they were defective, or because the MS did not properly secure them. The Administrator was asked if the facility had a safety policy and procedure for transporting residents in the facility bus. The Administrator was not able to provide the requested policy. The Administrator, instead, provided a written, undated document titled, Van Driver/Transporter Job Description. The job description indicated the driver's principal responsibilities which included: .Provides transportation of residents to and from physician appointments in a timely manner . Maintains a high level of safety following safety policies and procedures while in Center and transporting residents. Maintains van (bus) in good working condition . On June 20, 2016, at 9:25 a.m., Resident 1 was observed at the dialysis clinic prior to the start of her dialysis treatment. Resident 1 was seated in a wheelchair and had an AKA of the left leg. Resident 1 was awake, alert, and able to communicate verbally. In a concurrent interview with Resident 1, on June 20, 2016, at 9:25 a.m., she was asked about her health condition, and the incident she had inside the facility's transport bus on May 2, 2016. Resident 1 stated she was sitting in her wheelchair which was anchored at the back end of the bus. The resident stated she was so scared when the straps at the bottom of her wheelchair came off, and as the bus accelerated forward she was abruptly pushed backward toward the wall of the bus. The resident explained that the backward force tipped her wheelchair backwards in a tilted position, with her legs thrown upward and her head in a downward direction as the wheelchair traveled backward toward the back wall of the bus. Resident 1 stated, The driver (the facility's Maintenance Supervisor) didn't even notice I fell backward. I have to keep yelling at him to stop the van (facility bus). Resident 1 stated she hit the back of her head and upper back on the back wall of the bus and sustained a small bump on the back of her head. The resident further stated she had pain on her head and upper back area after the incident. On June 20, 2016, at 9:35 a.m., the dialysis Registered Nurse (RN 1) was interviewed regarding Resident 1's health condition before, during, and after her dialysis treatment on May 2, 2016. RN 1 stated Resident 1 was alert, oriented, and complained of upper back pain. The resident's physician at the dialysis clinic was notified of the incident with orders to send Resident 1 to the ER for further evaluation and treatment. RN 1 stated Resident 1 requested and wanted to complete her dialysis treatment at the clinic prior to being transferred to the ER. Resident 1's dialysis treatment record dated May 2, 2016, indicated, .complained of back pain . 5/10 (moderate pain on pain scale on 1/10), .symptomatic hypotension (abnormally low blood pressure): lightheadedness, cramping.Sent to ER (acute hospital's name) for evaluation and possible CT (CAT Scan/x-ray) of the head. Seen by (physician's name). A review of the ER physician and nurse's notes dated May 2, 2016, indicated Resident 1 complained of headache, dizziness, and moderate pain on the head and neck. The diagnostic considerations (potential injury result) Resident 1 was being assessed for included closed head injury, fractures (broken bone) and hematoma (bruise). Resident 1 further received laboratory tests including CT Scan of the head and spine, and was admitted to the hospital as in-patient for further observation and treatment. The CT Scan results indicated, No apparent fracture (of the head and spine) or dislocation .

Based on observation, interview and record review, the facility failed to provide, for five (Residents B, C, D, E and F) of 88 residents, an environment free from verbal abuse, harassment, and intimidation by Resident A. This failure resulted in emotional distress and fear for Residents B, C, D, E and F, placing them in jeopardy of severe, negative psychosocial response from ongoing persistent expressions of anger and harassment from Resident A. Due to the facility's failure to implement an environment free from verbal abuse and intimidation from Resident A, the Administrator and the Director of Nursing (DON) were verbally notified of an Immediate Jeopardy situation on October 8, 2015 at 10:30 a.m. The Administrator and DON were informed of the observed and documented negative psychosocial responses of Residents B, C, D, E and F to Resident A's ongoing, escalating behavior towards residents and staff. The DON and Administrator were both informed of the lack of plan and implemented measures to prevent an environment of abuse from Resident A. The Immediate Jeopardy was removed, in the presence of the Administrator on October 8, 2015, at 4:45 p.m., after the facility's plan of action was verified that Resident A had been discharged to a psychiatric hospital and the facility's initiation and coordination of psychological evaluation and treatment of [REDACTED]. Findings: On September 15, 2015, at 10 a.m., an unannounced complaint investigation was conducted at the facility. On September 15, 2015, at 10:15 a.m., Resident A was interviewed. Resident A stated on September 2, 2015, I was in the dining room and was being harassed by (name of Resident F) when (name of Social Services Director) harasses me. Resident A stated he called the local Police Department's non emergency number. Resident A stated the verbal harassment from the Social Services Director (SSD) was recorded by the Police Department dispatch. On September 15, 2015, at 10:20 a.m., Resident A was observed. Resident A was sitting in a high back wheelchair and was able to independently wheel himself around the facility hallways. Resident A was observed stopping at residents' rooms and talking to residents from outside their doorway. Resident A's record was reviewed. Resident A's [DIAGNOSES REDACTED]. Resident A's record indicated Resident A was able to move about the facility in a wheelchair and transfer from wheelchair to bed and toilet. The physician's progress note, dated July 2, 2015, indicated .S (subjective): you leave before I kill you and call the police to pick your body up .O (observation): very verbally abusive, yelling and get very belligerent, anxious, irritable angry with very expansive mood (easily annoyed, provoked to anger) .S/H (suicidal/homicidal): pt (patient) is homicidal .Plan: Transfer pt to acute inpt (inpatient) psychiatric hospital for evaluation . The document titled IDT (Interdisciplinary Team) dated July 31, 2015, indicated, The IDT has convened this meeting due to resident's (Resident A) escalating behavior that has started to negatively impact other residents .(name of Resident A) is noted to be verbally aggressive and harassing other residents causing altercations and emotional distress to the other residents. (One female resident - Resident D) had complained of having stomach distress after she was harassed by (name of Resident A)) . The physician's progress note dated August 19, 2015, indicated O: .continue to be hostile, aggressive and verbally abusive to others. Pt (patient) is suspicious and paranoid, and belligerent .P (plan): Pt will require hospitalization for evaluation and treatment of [REDACTED]. There was no documented evidence that indicated Resident A was transferred to an acute inpatient hospital for evaluation between July 2, 2015 to August 19, 2015. Review of Resident A's Behavioral care plan initiated on March 11, 2015 indicated: Problem/Need: Behavioral symptom directed toward: Others, Self Manifested by: suspiciousness, paranoia, refusal of care, non compliance, false accusations, misinterprets actions of others, manipulation Approaches: maintain consistency in routine across all shifts, determine triggers and de-escalation techniques and educate staff, involve resident in decisions regarding care and routine, encourage expression of feeling of anger, frustration and guilt, encourage resident to attend social activities, utilize diversion, distraction, or redirection to limit reoccurrence, assess for pain or discomfort, speak and move calmly when assisting or treating resident, explain paranoia are not real and provide reality orientation, psychiatric consult, provide praise for acceptable behavior, assess resident's understanding of the situation, provide education to resident, responsible party, and staff regarding special care needs. The behavioral care plan problems were updated and indicated: 1. March 11, 2015, Refused to be seen by psychiatrist. 2. May 11, 2015, Accused a staff member of poisoning him. 3. June 13, 2015, Accused staff of giving him a wrong medication. 4. July 14, 2015, Accused supervisor of violating resident quality of life. 5. July 16, 2015, Verbally abusive tried to hit staff. 6. July 21, 2015, Threatens staff (suing, calling DHS (Department of Health), DOJ (Department of Justice), etc.) 7. July 27, 2015, Verbally inappropriate towards other residents. 8. [DATE], Inappropriate comments towards other residents. The behavioral care plan approaches were updated and indicated: 1. March 11, 2015, Explain risks and benefits, monitor behavior every shift .social services to reassure and follow up as needed. 2. May 11, 2015, Report to ombudsman, IDT (Interdisciplinary Team) meeting with ombudsman. 3. May 20, 2015, Report to DHS, 2 staff to care all the time, inservice staff. 4. July 14, 2015, Explanation given out but never listen .SSD notified. 5. July 21, 2015, Listen to resident concerns, reality orientation as needed. 5. July 27, 2015, Encourage resident to verbalize needs and concerns, explain to resident that inappropriate behavior towards other resident is not acceptable. 6. September 2, 2015, Frequent visual checking of resident .close supervision with resident during meal time in the dining room. Further review of Resident A's record indicated: 1. September 2, 2015, Resident A initiated a verbal argument with a male resident (Resident F) in the dining room during breakfast time. 2. September 9, 2015, Resident A kept following around and harassing Physical Therapist (PT) while in the middle of walking (therapy) another resident (Resident E). PT said Resident E ended up not wanting to continue .due to (name of Resident A's) unpleasant behavior and comments . 3. September 10, 2015, Resident A was .ranting in the hallway around residents and staff . using expletive language. On September 15, 2015, at 11:30 a.m., Resident F was interviewed. Resident F stated during breakfast time on September 2, 2015, he and Resident A had an argument. Resident F stated Resident A was going on an on about the difference in their background. Resident F stated SSD intervened and handled the situation professionally. Resident F's record was reviewed. Resident F's history and physical dated, August 30, 2015, indicated Resident F had the capacity to understand and make decisions. Resident F's Minimum Data Set (MDS - assessment tool) dated September 26, 2015, indicated a BIMS (screener for mental and cognitive status) score of 15 (a score of 13-15 means cognitively intact). The Police Department dispatch recording of Resident A's call on September 2, 2015 was reviewed by both the HFEN and HFES. The recording did not indicate any verbal abuse towards Resident A. On September 15, 2015, at 10:30 a.m., Facility Staff 1 (FS 1) was interviewed. FS 1 stated on September 10, 2015, Resident A was in the hallway banging and yelling on the door of the Administrator's office. FS 1 stated Resident A kept on yelling and, Started calling us (staff) every name on the book. Like no brain, you have fungus on your toes, etc. FS 1 stated other residents and visitors were around. FS 1 further stated, We were afraid he (Resident A) was going to throw his cell phone and other residents may be hurt. FS 1 stated the facility had to call the (name of the local) Police Department. On September 15, 2015, at 10:45 a.m., Resident B was interviewed. Resident B stated he witnessed Resident A's behavior on September 10, 2015. Resident B stated Resident A would tell him (Resident B) every day he needed to be gone the next day, and he (Resident B) would be thrown out of the facility. Resident B further stated Resident A was constantly (verbally) abusing him and others. Resident B stated he did not feel safe in the facility because of Resident A. Resident B's record was reviewed. Resident B's history and physical dated July 21, 2015, indicated Resident B had the capacity to understand and make decisions. Resident B's MDS dated [DATE], indicated a BIMS score of 15. On September 29, 2015, at 3:08 p.m., PT was interviewed. PT stated on September 9, 2015, while in the middle of walking Resident E, Resident A started following her around and talking loudly. PT stated Resident E got upset and bothered with Resident A's tone of voice and did not want to walk anymore. PT stated this was the only time Resident E did not finish her walk. On [DATE], at 2:10 p.m., Resident E was interviewed. Resident E was unable to remember the incident and appeared confused. On September 30, 2015, at 2:25 p.m., Resident C was interviewed. Resident C stated she witnessed Resident A arguing with another resident. Resident C stated she got scared. Resident C stated the verbal altercations made her anxious and feel unsafe. Resident C's record was reviewed. Resident C's history and physical dated February 11, 2015, indicated Resident C had the capacity to understand and make decisions. Resident C's MDS, dated [DATE] indicated a BIMS score of 14. On September 30, 2015, at 3:30 p.m., Resident D was interviewed. Resident D stated, on July 29, 2015, Resident A started yelling loudly at her through her doorway, I'm sorry about your problem! Resident D stated Resident A would not stop yelling about her problem. Resident D stated she felt scared and embarrassed. Resident D stated the incident was emotionally distressing and facility staff was aware. Resident D stated she could not get out of her room that day. Resident D further stated, after the incident Resident A had been coming to her door every single morning and would sing Home on the Range in a creepy voice. Resident D stated Resident A also followed her around if she was out in the hallway speaking in a low tone to intimidate her. Resident D stated when she was in the dining room Resident A would stare at her. Resident D stated Resident A Makes me want to stay in my room. Resident D stated I do not turn my back on him. I don't trust him, and I do not feel safe when he's around. Resident D stated, Please, please help us get him out of here. Resident D's record was reviewed. Resident D's history and physical dated February 5, 2015, indicated Resident D had the capacity to understand and make decisions. Resident D's MDS, dated [DATE], indicated a BIMS score of 15. On October 6, 2015, at 10:40 a.m. FS 2 was interviewed. FS 2 stated she witnessed Resident A saying things to Resident D. FS 2 stated that Resident D doesn't want to leave her room anymore because of Resident A. FS 2 stated she has been encouraging Resident D to get up everyday. FS 2 further stated when Resident D was out of her room, FS 2 would keep her by her side to keep Resident A away from Resident D. FS 2 stated, It is not right for other residents, such as (Resident D's name), to feel uncomfortable leaving their rooms. FS 2 stated This is also the other residents' home and they should feel comfortable to go out and do normal things. FS 2 stated Resident A scares her and tells her every day You're going down, you're going to jail. On October 6, 2015, at 1 p.m., Registered Nurse 1 (RN 1) was interviewed. RN 1 stated she was the supervisor on July 29, 2015. RN 1 stated she was aware of the incident between Resident A and Resident D. RN 1 stated Resident D had complained of stomach upset due to the emotional distress Resident D experienced from Resident A's actions. RN 1 stated they monitored Resident D for 72 hours after the incident. On October 6, 2015, at 1:16 p.m., FS 3 was interviewed. FS 3 stated Resident A has been telling her everyday, I'm going to report you to the Health Department. You will get fired. FS 3 further stated Resident A tried to hit her, He told me he was going to punch me so I had to lock myself in a room. FS 3 stated Resident A makes me feel scared. He's always yelling. On October 8, 2015, at 10 a.m., Resident C was interviewed. Resident C stated Resident A was still terrorizing them. Resident C stated, We just try to stay away from him. On October 8, 2015 at 10:15 a.m., the Administrator and DON stated Resident A was reported to have kicked Licensed Vocational Nurse 1 (LVN 1) on October 7, 2015. The Administrator stated Resident A cornered LVN 1 into Nurses' Station 3 and blocked the exit with his wheelchair. Resident A was accusing LVN 1 of poisoning him. The Administrator stated that on the same day Resident A was asked about the incident. Resident A stated he could not recall what happened. The facility's undated policy and procedure titled, Abuse - Prevention Program indicated .The facility does not condone any form of resident abuse, neglect and/or mistreatment .The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents . On October 8, 2015, at 1:00 p.m., the facility presented and had begun implementation a corrective plan of action, including but not limited to : *An order from Resident A's attending physician and attending psychiatrist for immediate discharge and placement to a psychiatric hospital for evaluation and treatment. *A one on one Certified Nursing Assistant (CNA) monitoring Resident A's behavior and whereabouts 24/7 until transfer and discharge had been executed to ensure the safety and well being of other residents and staff. *Coordination of an appropriate medical transportation and accepting psychiatric hospital. *Requested assistance from local law enforcement to assist with transfer of Resident A. *Coordination of psychological evaluation and treatment for [REDACTED]. The Administrator notified CDPH at 4:45 p.m. on October 8, 2015, that Resident A was transferred by ambulance to a psychiatric hospital, and the Immediate Jeopardy was removed at that time.