Every finding on record at Amberwood Post Acute

Based on observations, interviews and record review the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases in four of four units.Specifically, the facility failed to:-Ensure staff performed hand hygiene before and after providing resident care; and,-Ensure staff followed enhanced barrier precautions (EBP) while providing direct resident care for residents who were identified as being on EBP. Findings include:I. Professional referenceAccording to the Center for Disease Control and Prevention (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, (2/27/24), retrieved on 5/4/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with, handwashing with water and soap, antiseptic hand rub, or surgical hand antisepsis.According to the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO), (4/2/24), retrieved on 5/4/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html,Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities.EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO.Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing).II. Facility policy and procedureThe Enhanced Barrier Precautions policy, revised December 2024, was provided by the nursing home administrator (NHA) on 4/23/26 1:21 p.m. It read in pertinent part, EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.The Hand Hygiene policy, undated, was provided by the NHA on 4/23/26 1:21 p.m. It read in pertinent part, hand hygiene will be done by all employees, volunteers and contract staff to reduce transfer of microbes to patients.Hand hygiene should be done before and after direct patient care, before and after each procedure, after using the bathroom, after blowing or wiping the nose, before and after eating, before and after collecting specimen, when hands are soiled, after any contact with contaminated materials, before re-entering nursing bag or patient's clean supplies.III. ObservationsOn 4/21/26 at 10:48 a.m. an unidentified certified nursing assistant (CNA) was leaving room [ROOM NUMBER], after caring for a resident who was identified as being on EBP, by a sign on the door. The CNA did not wear a gown while providing care.On 4/21/26 at 12:53 a.m. CNA #1 exiting a resident's room not wearing gloves. CNA #1 carried a soiled mechanical lift sling and placed it in the soiled laundry hamper. CNA #1 did not perform hand hygiene. CNA #1 walked down the hall to the nurse's cart. He ran his hands through his hair and over his face. Then CNA #1 used the facility's touch screen to document the care provided. Without performing hand hygiene, CNA #1 entered resident room [ROOM NUMBER] to answer a call light and assist a resident with a request without washing his hands before or after assisting that resident.On 4/22/26 at 9:41 a.m. CNA #2 entered resident room [ROOM NUMBER], who was on EBP per the sign on the door. CNA #2 entered the room and applied gloves, but did not apply a gown. CNA #2 provided the resident with incontinence care. CNA #2 left the resident's room with the soiled linens and trash disposed of in the proper hampers, removed the gloves but did not perform any hand hygiene prior to caring for another resident. On 4/23/26 at 9:59 a.m. licensed practical nurse (LPN) #1 entered room [ROOM NUMBER] to set up the feeding tube. The resident was identified as needing EBP due to the resident having a gastric tube feeding. LPN #1 did not perform hand hygiene before setting up the resident's tube and she did not wear a gown while handing the resident gastric tube and connecting the tubing. On 4/23/26 at 11:16 a.m. LPN #1 entered resident room [ROOM NUMBER]. This room was identified as needing EBP. While in the room LPN #1 provided care to Resident #1 and left with no hand hygiene.IV. Resident representative/family interviewOn 4/21/26 at 2:09 p.m. Resident #1's representative was interviewed. She said when she visited her sister she saw them working with Resident #1's feeding tube with no gloves or gown on .V. Staff interviewsCNA #1 was interviewed on 4/21/26 at 12:59 p.m. He said he washed hands for 20 seconds before and after going into a resident room to provide care.CNA #2 was interviewed on 4/22/26 at 9:53 a.m. was interviewed. She said she washed her hands for about 20 seconds before providing resident care. CNA #2 said when a resident was on EBP, she would put on gloves and booties when providing care.CNA #3 was interviewed on 4/22/26 at 10:04 a.m. CNA #3 said he performed hand hygiene before entering a resident's room and put on gloves to provide care assistance. CNA #3 said when he left the resident's room, he would remove the gloves and perform hand hygiene. CNA #3 said when providing care to a resident who was on EBP, he would also wear a gown. The director of nursing (DON) was interviewed on 4/23/26 at approximately 1:45 p.m. She said she wanted staff to perform hand hygiene as frequently as possible including when they enter and exit rooms. The DON said if a resident was on EBP she said she wanted her staff to follow EBP procedures. She said EBP required wearing a gown and gloves. LPN #2 was interviewed on 4/23/26 at 1:50 p.m. She said staff needed to wash their hands after performing any type of care, as well as when leaving the resident's room.

Based on interviews and record review, the facility failed to ensure the resident's representative was informed of changes in condition for one (#1) of three residents out of 17 sample residents.Specifically, the facility failed to:-Inform Resident #1's physician-appointed healthcare proxy when the resident had a change in condition, including when the resident started on an antibiotic medication; and,-Return phone calls to Resident #1's healthcare proxy's voice messages requesting information about the resident's condition in a timely manner.Findings include:I. Facility policy and procedureThe Notification of Changes policy, revised 2025, was provided by the nursing home administrator (NHA) on 4/23/26 at 1:21 p.m. It read in pertinent part, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. When residents are incapable of making their own decisions the representative will make any decisions that have to be made.II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit and encephalopathy.According to the 3/23/26 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. B. Resident #1's representatives interviewsResident #1's designated health care proxy was interviewed on 4/21/26 at 2:55 p.m. The health care proxy said the facility made it very difficult to contact Resident #1. She said facility staff did not return calls for days, making her worry about Resident #1 because she lived so far away and could not just drive over to check on the resident. The health care proxy said the resident was started on antibiotic treatment and she was not informed that Resident #1 had an infection and needed antibiotics until after the resident started on the medication. She said she had several questions about the medication and was not consulted on the medical decision prior to the start of the medication.Another one of Resident #1's representatives was interviewed on 4/21/26 at 2:55 p.m. The representative said she had called the facility several times; however, the facility never answered the phone. She said phone calls went to a general voice mailbox. The representative said her voicemail message requests for a return call were either not answered or took several days for someone from the facility to respond to the messages.C. Record review Grievances filed on behalf of Resident #1 were requested and provided by the NHA on 4/21/26 at 2:17 p.m. The grievances revealed there were several concerns regarding delays in the facility's response to the Resident #1's representatives requests for information about the resident and the delays in reporting changes in the resident's condition. The grievances revealed the following:A grievance, dated 12/30/25, revealed Resident #1's representative had concerns related to the representative's inability to get to speak to Resident #1 over the phone in a timely manner. The resident's representative called the facility to speak to Resident #1 on 12/28/25 but the call was not returned until three days later (on 12/31/25). The documented facility's response to the concerns was that a return call was placed to the resident's representative on 12/31/25 and the call went to the representative's voicemail. -There was no other documentation to indicate that the facility took further actions to resolve the communication delays. A grievance, dated 1/8/26 and filed by Resident #1's health care proxy revealed the resident's health care proxy wanted weekly calls since she said it was too hard to contact the nurses in the facility. The facility's response to the grievance documented that weekly follow-up calls would be completed in response to the concern, and that the resident's health care proxy was satisfied with the follow-up. A grievance, dated 2/1/26 and filed by Resident #1's health care proxy revealed the resident's health care proxy called to express concern over lack of notification for new medication the resident was started on but she was not informed of. The facility followed up by conducting in-services with their staff on 2/1/26, 2/3/26 and 2/5/26, regarding notifying residents' responsible parties about medication changes, as well as which staff members were responsible for the notifications. Additionally, the facility ensured Resident #1's health care proxy was listed correctly in their resident information. -The grievance failed to reveal information on whether or not the resident's health care proxy was satisfied with the facility's response to the concern.A grievance, dated 3/28/26 and filed by Resident #1's health care proxy revealed the resident's health care proxy expressed concern over a scheduled video call where she was unable to connect with staff. The health care proxy said she was upset about the lack of communication from the facility. The resident's health care proxy was called back on 3/31/26 by the activities director, who apologized for the miscommunication regarding the video call. The activities director said the health care proxy could call her if she needed anything from them. -The grievance failed to reveal information on whether or not the resident's health care proxy was satisfied with the facility's response to the concern.III. Other residents' representatives interviewsResident #10's representative was interviewed on 4/21/26 at 3:19 p.m. Resident 10's representative said Resident 10 was newly admitted to the facility. He said he called to check on the resident's status and the call was sent to the facility's voicemail. Resident #10's representative said it took the facility two days to return his call.Resident #6's representative and a secondary witness were interviewed together on 4/22/26 at 1:27 p.m. They said they attempted to contact the facility to report a suspected instance of verbal abuse that they over heard while on the phone with Resident #6 but the call was sent to the facility's voicemail. They said they tried to call the social services director (SSD) and were again sent to voicemail. They said they never received a return call. IV. Staff interviewsThe SSD was interviewed on 4/22/26 at 3:15 p.m. The SSD said she was not entirely sure where the concerns about the communication with Resident #1's representatives were coming from. She said all calls to the facility first went to the front desk receptionist and were then transferred to the nurses' stations for direct contact with nursing staff. The SSD said Resident #1's representatives had her cell phone number as well as the cell phone number for the director of nursing (DON), whom they could call if she was unable to get through to the nurses' station.Licensed practical nurse (LPN) #1 was interviewed on 4/23/26 at 11:09 a.m. LPN #1 said one of Resident #1's representatives often called his personal cell phone multiple times a day.The DON, the NHA, and the corporate nurse consultant were interviewed together on 4/28/26 at 12:34 p.m. The NHA said the Resident #1's healthcare proxy wanted a call from the facility staff every single day. The NHA said the facility was aware several of the resident's representatives' phone calls went to voicemail when the nurses were unable to pick up the phone calls.The corporate nurse consultant said that voicemail messages left in the facility's voicemail message system should be returned within 24 hours.The NHA said she did not think it was accurate that Resident #1's healthcare proxy was not getting called back and that the assistant director of nursing (ADON) was texting the health care proxy on a weekly basis to provide information. -However, there was no documentation for the weekly calls provided by the facility. The NHA said Resident #1's representative and health care proxy had her cell phone number as well as the cell phone number for the SSD and the DON. The representatives could have called any of them directly if they were unable to get through to the nurses' station. The NHA said Resident #1's representatives often called during shift change when it was harder to get through to the nurse on duty.The NHA said if the nurse was unable to answer the phone call, the call went directly to voicemail where it was later picked up and returned.

Based on record review and interviews, the facility failed to investigate an allegation of verbal abuse involving one (#6) of seven residents of 17 sample residents.Specifically, the facility failed to investigate an allegation of verbal threats overhead by a family member between Resident #6 and Resident #15. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised April 2021, was provided by the nursing home administrator (NHA) on 4/22/26 at approximately 9:20 a.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: other residents. The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements and protect residents from any further harm during investigations. Investigate and report any allegations within timeframes required by federal requirements.The Identifying Types of Abuse policy and procedure, revised September 2022, was provided by the NHA on 4/22/26 at 9:20 a.m. It read in pertinent part: As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Examples of mental and verbal abuse include but are not limited to: yelling or hovering over a resident, with the intent to intimidate.II. Resident #6 (alleged victim)A. Resident statusResident #6, aged less than 65, was admitted on [DATE]. According to the April 2026 computerized physician's orders (CPO), diagnoses included dysphagia, hemiplegia of the left side (paralysis of the left due to a stroke), attention and concentration deficit, delusional disorder, and major depressive disorder. According to the 3/20/26 minimum data set (MDS) assessment, Resident #6 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The MDS assessment indicated Resident #6 used a wheelchair for mobility and was dependent on staff for most of his activities of daily living (ADL). B. Resident #6 interviewResident #6 was interviewed on 4/21/26 at 2:23 p.m. Resident #6 said he did not think the arguing back and forth between Resident #15 and himself was a big deal. He said his roommate (Resident #15) said to shut the (explicative), and then they were both yelling back-and-forth at each other. He said he could not remember what they each yelled towards each other. He said there was no pushing, shoving or anything like that. C. Resident #6's representatives interviewsResident #6's guardian was interviewed over the phone on 4/22/26 at 11:55 a.m. She said that Resident #6 called her after the incident and she went to the facility to see what was going on. She said the staff had separated residents because they were yelling at each other. The guardian said apparently threats were made by Resident #15 towards Resident #6. She said Resident #6 told her that he was fearful of Resident #15.Resident #6's representative was interviewed on 4/22/26 at 1:27 p.m. The representative said while she was talking to Resident #6 on the phone on 3/15/26, she heard Resident #15 yelling loudly and making threats towards Resident #6. She then heard the nurse enter the room to calm down the situation. The representative said that she tried to call the facility to report the yelling and threatening behavior, but was sent to voicemail and no one called her back. She said she was worried about the situation, so she called the police and reported the threatening behavior. The representative provided a police report number during the call (see emergency services interview below).III. Resident #15 (alleged assailant) A. Resident statusResident #15, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included dementia, cognitive communication deficit, depression, and insomnia. According to the 3/2/26 MDS assessment, Resident #15 had moderate cognitive impairment with a BIMS score of eight out of 15. The MDS assessment revealed Resident #15 used a walker for mobility dependent on staff for most of his ADL. The MDS assessment indicated the resident did not have any behaviors. B. Resident interviewResident #15 was interviewed on 4/21/26 at 2:55 p.m. He said that he did not remember the incident between him and Resident #6.C. Resident #15's representative interviewResident #15's representative was interviewed on 4/23/26 at 10:45 a.m. The representative said Resident #15 did not remember the incident.Resident #15's representative said she was made aware of the incident the day after it happened. She said she was told Resident #6 was talking too loud on the phone and Resident #15 started yelling at Resident #6 to be quiet. She said she was told that because of the yelling the facility initiated a room move that night (3/16/26) to separate the two from being roommates. Resident #15's representative said she agreed to the room change. She said she had asked for the room change prior to 3/15/26 due the behaviors of Resident #6 when she visited Resident #15. She said that Resident #6 would masturbate on the other side of his privacy curtain and would yell racial slurs. She said that she told the director of nursing (DON). IV. Record reviewA request was made for an investigation regarding the allegations of verbal threats by Resident #6 towards Resident #15 (see staff interviews below). Review of both resident's electronic medical record revealed no documentation of the resident to resident verbal altercation or related concerns. A room change form in Resident # dated 3/16/26 revealed the reason for the resident's room change was Resident #15 and his roommate did not get along. Family requested he be moved.IV. Emergency services interviewA non-emergency dispatcher was interviewed on 4/22/26 at 5:26 p.m. The non-emergency dispatcher said there was an incident reported from Resident #6's representative. The non-emergency dispatcher said emergency medical services (EMS) responded to the call and not the police. V. Staff interviewsRegistered nurse (RN) #1 was interviewed on 4/23/26 at 10:00 a.m. RN #1 said she did not remember the verbal altercation between Resident #6 and Resident #15 all that well, since it occurred a while ago. She said that she did remember that there was loud yelling and arguing between Resident #6 and Resident #15. She said she did not hear the exact words exchanged and did not know if any threats were made by either resident.RN #1 said she could not remember exactly, but it was either the police or EMS who responded to the facility related to the resident's yelling. RN #1 said she reported the yelling to the DON that evening, but did not tell the DON about EMS responding to the facility for the residents yelling at each other. RN #1 said she talked to a family member or friend of Resident #6's regarding the verbal altercation. She said she could not remember who she talked to or the relationship to Resident #6.RN #1 said she had helped Resident #15 to change rooms, due to the resident-to-resident incident on 3/15/26.The social service director (SSD) and the corporate nurse consultant were interviewed together on 4/23/26 at 9:40 a.m. The SSD said she did not know much about the incident that took place between Resident #6 and Resident #15 on 3/16/26. The SSD said it was just an argument between two individuals and there were no threats, or anything else that would rise to the occasion of an allegation. She said it was a back and forth between two residents and nothing else.-However the incident was not investigated and the SSD was not present during the incident. Additionally, both residents had cognitive deficits and there was no documented interview with either resident at the time of the incident. The NHA, the DON and the corporate nurse consultant were interviewed on 4/23/26 at 12:30 p.m. The NHA and the DON said RN #1 had called the DON after the incident to initiate a room change for Resident #15 due to worsening dementia. The DON said that Resident #15's representative had asked for a room change prior to the incident that took place due to Resident #6 behaviors. The DON said that she was not made aware that the police or EMS were called about the incident and was not told that EMS had arrived in response to the resident-to-resident verbal alteration. The NHA said she did not report the resident's verbal exchange to the State Agency as abuse of a resident, because there were no threats made by either resident. She said the two residents were just having a disagreement and yelling at each other. The NHA said neither resident called the police or EMS. -However, no facility staff inquired how EMS showed up in response to the resident-to-resident verbal altercation where RN #1 believed it was necessary to initiate an immediate room move to separate the resident permanently. The DON and the NHA said that they followed up to prevent anything from happening in the future, by moving Resident #15 to another room and having compatible roommates.

Based on record review and interviews, the facility failed to protect residents from physical abuse for two (#2 and #3) of five residents reviewed for abuse out of five sample residents.Specifically, the facility failed to protect Resident #2 and Resident #3 from physical abuse by Resident #1. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation policy, revised April 2021, was provided by the director of nursing (DON) on 10/15/25 at 10:45 a.m. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors and/or any other individual. The facility will develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents, neglect of residents and/or theft, exploitation or misappropriation of resident property. The facility will establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. The facility will provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements and protect residents from any further harm during investigations.II. Facility investigation of physical abuse towards Resident #2 and Resident #3 by Resident #1 on 7/30/25The facility investigation, dated 7/30/25, revealed that on 7/30/25, an incident occurred between Resident #1, Resident #2 and Resident #3. Resident #1 entered the room shared by Resident #2 and Resident #3. Resident #2 was upset Resident #1 entered their room and began throwing pieces of pineapple at Resident #1. Resident #1 became upset with Resident #2 and left the room, knocking a glass jar of pickles off Resident #2's dresser as he left the room to go outside and smoke. Upon returning to his room, Resident #1 discovered that his laptop had been shattered. Resident #1 returned to Resident #2 and Resident #3's room and asked Resident #2 if she broke his laptop. Resident #2 refused to respond to Resident #1's question, which angered Resident #1. Resident #1 then proceeded to remove the armrest from his wheelchair and threw it at Resident #2. The wheelchair armrest struck Resident #2 in the chest and then hit Resident #3 in the leg. The incident was not witnessed by staff, but staff responded when they heard the altercation. The residents were separated and assessed for injuries and no injuries were noted to any of the residents. The nursing home administrator (NHA), the DON and social services were notified and the police were called. The investigation documented that all three residents were interviewed by the facility following the incident. The interviews were as follows:Resident #3 said Resident #1 came into her and Resident #2's room and Resident #2 began throwing pineapple at Resident #1. Resident #3 said Resident #1 left the room and knocked over a jar of pickles on his way out. She said Resident #1 later came back to their room to ask Resident #2 if she broke his laptop and when Resident #2 did not answer him, he took the armrest off his wheelchair and threw it at Resident #2. Resident #3 said the armrest hit Resident #2 in the chest and then bounced off and hit her (Resident #3) in the leg. Resident #3 said she was not a part of the argument between Resident #1 and Resident #2, but she got caught in the middle of it. She said she did not want to be involved in the drama between Resident #1 and Resident #2.Resident #2 said she was upset because she found out Resident #1 took her vaporizer device. She said when Resident #1 came into her and Resident #3's room, she (Resident #2) threw pineapple at him which made Resident #1 mad so he left the room and knocked a jar of pickles off her dresser when he left. Resident #2 said Resident #1 later came back to the room and asked her if she broke his laptop. She said when she did not answer Resident #1, he got mad and threw his wheelchair armrest at her. Resident #2 said the armrest hit her and then hit Resident #3. She said the incident got out of hand and if she got mad at Resident #1 again, she would talk to staff about it instead of getting in another incident. Resident #1 said he took Resident #2's vaporizer device and she got mad at him and threw pineapple at him when he walked into Resident #2 and Resident #3's room. He said that made him mad and he knocked over a pickle jar as he left the room and then he walked off to cool down. Resident #1 said when he went back to his room, his laptop was broken. He said he went back to Resident #2's room to ask her if she broke his laptop, but she refused to answer him. Resident #1 said he got mad and threw the armrest from his wheelchair at Resident #2. He said the armrest hit Resident #2 and also hit Resident #3. He said he did not mean to hit anyone but he was frustrated. Resident #1 said if something like that happened again, he would go to a staff member before things escalated.The investigation documented other residents and staff members were interviewed about abuse and nobody had any concerns.Resident #1 and Resident #2's care plans were updated regarding the incident and both residents were counseled individually and agreed to utilize staff support and anger management strategies moving forward.III. Resident #1 (assailant)A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included paraplegia (paralysis of the lower half of the body caused by damage to the spinal cord), generalized anxiety disorder and depression.The 9/19/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. He was independent with most activities of daily living (ADL).The assessment indicated the resident had verbal behavioral symptoms directed toward others, such as threatening others, screaming at others or cursing at others on one to three days during the assessment look-back period. B. Resident interviewResident #1 was interviewed on 10/15/25 at 11:00 a.m. Resident #1 said Resident #2 accused him of taking her vaporizer device, which he said he did. He said he and Resident #2 liked to mess around and give each other a hard time. He said he got mad when Resident #2 started throwing fruit at him, so he knocked a jar of pickles off Resident #2's dresser when he left the room to go outside and smoke. Resident #1 said when he came back to his room, his laptop was broken so he went back to Resident #2 and Resident #3's room to ask Resident #2 if she broke his laptop. He said Resident #2 refused to answer him, so he got mad again and threw his wheelchair armrest at Resident #2. He said the armrest hit Resident #2 and Resident #3. He said he did not mean to hit anyone with the armrest and he should not have thrown it. He said now if he got mad, he tried to let the staff know instead of just reacting. Resident #1 said he liked hanging out with Resident #2 so he was working on controlling his temper better.C. Record reviewReview of Resident #1's physical aggression care plan, initiated 7/31/25, revealed the resident had the potential to be physically aggressive related to anger and poor impulse control. The resident smashed glass in another resident's room and then threw his wheelchair armrest at two other residents. Interventions included administering medications as ordered and monitoring/documenting for side effects and effectiveness, analyzing times of day, places, circumstances, triggers and what de-escalated the resident's behavior and documenting, assessing the resident and addressing for contributing sensory deficits, providing the resident with physical and verbal cues to alleviate anxiety, giving positive feedback, assisting the resident with verbalization of his source of agitation, assisting the resident to set goals for more pleasant behavior and encouraging the resident to seek out staff members when he was agitated.The 7/30/25 at 5:49 p.m. nurse progress note documented Resident #1 was found in another resident's (Resident #2) room where he had broken a pickle jar and was reportedly breaking other items belonging to the resident. The resident appeared agitated and was heard stating If somebody messes with me, I will mess with them. A registered nurse (RN) responded to the incident, assessed the situation, and redirected Resident #1 back to his own room. The RN educated the resident on the importance of respecting others' property and privacy. The resident responded with anger and stated he did not want anyone to talk to him and then entered his own room. A licensed practical nurse (LPN) followed up by checking on the resident in his room to ensure his safety and emotional status. The resident was observed to be upset and staff would continue to monitor him for safety and behavior.The 7/30/25 at 8:08 p.m. nurse progress noted documented Resident #3 reported another resident (Resident #1) entered her and her roommate's (Resident #2) room and smashed a glass jar along with other things belonging to Resident #2. As a result, there was broken glass on Resident #2's bed and on the floor. Resident #1 accused Resident #2 of smashing his laptop and the two residents began yelling profanities at each other. Resident #1 then detached the arm of his wheelchair and threw it in the direction of Resident #2, striking Resident #2 and Resident #3. Resident #1 then left the area. No injuries were reported by either Resident #2 or Resident #3 and neither resident reported any pain. The nurse spoke to Resident #1 and Resident #2 and instructed them to stay away from each other. Physician's orders were added to the residents' electronic medical records (EMR) for each resident to stay away from each other. The DON, the NHA, the physician and the residents' representatives were notified.The 7/31/25 physician's visit note documented Resident #1 and another resident (Resident #2) had an altercation last night (7/30/25) that became physical. Resident #1 threw part of a wheelchair at the other resident and she smashed his laptop. The police were called and the situation was controlled. Both residents were uninjured and remained in the facility. This was the first such event since Resident #1's admission. Resident #1 reported to the physician that the other resident was the instigator. The incident was an isolated episode and there were no changes made to Resident #1's plan of care. Resident #1 was aware of his behavior and that it would not be tolerated. If the incident recurred, the physician would reevaluate the resident's plan of care.The 8/1/25 at 12:41 p.m. social services note documented Resident #1 met with social services and openly discussed the events that occurred on 7/30/25. The resident admitted to taking Resident #2's vaporizer device and expressed genuine remorse for his actions. Resident #1 verbalized that he became overwhelmed and reacted impulsively when his property was broken, and he was especially regretful that anyone was hurt as a result. The resident said he felt safe and would like to repair the relationships that were impacted. Resident #1 agreed to practice anger management techniques and to seek staff support when he began to feel upset in the future. He was counseled on positive coping strategies and accepted responsibility for his role in the incident.IV. Resident #2 (victim)A. Resident statusResident #2, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2025 CPO, diagnoses included anxiety disorder, restlessness and agitation and depression.The 9/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with most ADLs.The MDS assessment indicated the resident did not have any behaviors. B. Resident interviewResident #2 was interviewed on 10/15/25 at 10:30 a.m. Resident #2 said Resident #1 took her vaporizer pen and when he came into her and Resident #3's room, she (Resident #2) was upset with him and told him to get out and she started throwing pineapple pieces at him. She said Resident #1 got mad and left the room, but pushed a pickle jar off her dresser as he left and it broke on the floor. Resident #2 said when Resident #1 was outside smoking, she went to his room and messed around with his stuff. She said when he came back from smoking, he came back to her room and asked her if she broke his laptop. Resident #2 said she did not answer him, which made him mad and he threw the armrest from his wheelchair at her. She said the armrest hit her in the chest and then bounced off and hit Resident #3's leg. She said it did not hurt and she did not have any injury from it. Resident #2 said the staff made Resident #1 get out of her room and she later told the DON that she did break his laptop because he stole her vaporizer device.Resident #2 said she liked hanging out with Resident #1. She said they were friends and they liked to pick on each other, but she said sometimes Resident #1 could get really mad and she could too. She said she was working on her anger and her reactions to things. She said she saw a counselor regularly. C. Record reviewReview of Resident #2's physical aggression care plan, initiated 7/31/25, revealed the resident had the potential to be physically aggressive related to anger and poor impulse control. The resident was involved in a fight with another resident and went into the other resident's room and broke stuff in retaliation to the other resident breaking stuff in her room. The police were called and the resident refused to talk with them. The residents were separated and monitored frequently for safety and to keep them apart. Interventions included administering medications as ordered and monitoring/documenting for side effects and effectiveness, analyzing times of day, places, circumstances, triggers and what de-escalated the resident's behavior and documenting, assessing the resident and addressing any contributing sensory deficits, assessing and anticipating the resident's needs, such as food, thirst, toileting needs, comfort level, body positioning and pain, providing the resident with physical and verbal cues to alleviate anxiety, giving positive feedback, assisting the resident with verbalization of her source of agitation, assisting the resident to set goals for more pleasant behavior, encouraging the resident to seek out a staff member when she was agitated, giving the resident as many choices as possible about her care and activities, monitoring/documenting/reporting as needed, any signs/symptoms of the resident posing danger to herself and others, when the resident became agitated, intervene before the agitation escalates, guiding the resident away from sources of distress, engaging the resident calmly in conversation and if the resident's response was aggressive, staff were to walk calmly away and approach the resident later.The 7/30/25 at 6:13 p.m. behavior progress note documented that Resident #1 went to Resident #2's room and smashed her stuff for no reason. Resident #2 did not tell the nurse or other staff members about the incident, but in return, Resident #2 went to Resident #1's room and broke his laptop, according to Resident #1. Resident #1 then returned to Resident #2's room and started throwing things at Resident #2 and the residents both started throwing things at each other. The night shift nurse supervisor came and took Resident #1 out of the room to de-escalate the situation. The DON was notified and the staff would continue to monitor the situation.The 8/1/25 at 12:39 p.m. social services progress note documented Resident #2 was interviewed privately and expressed regret regarding her involvement in the incident on 7/30/25. She acknowledged throwing pineapple pieces toward Resident #1 out of frustration and stated she now understood that was not an appropriate way to respond. Resident #2 verbalized that she felt safe in the facility and wished to move forward peacefully. She denied any further desire for retaliation and agreed to use staff support if she began to feel overwhelmed in the future. The resident also agreed to practice anger management strategies and to communicate with staff rather than escalating situations on her own. She declined any emotional support services but was aware that the support services were available to her if needed.V. Resident #3 (victim)A. Resident statusResident #3, age less than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included schizoaffective disorder, bipolar type (a mental health condition where one experiences episodes of psychosis along with bouts of mania and depression) and acute stress reaction. The 8/1/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with most ADLs.The MDS assessment indicated the resident did not have any behaviors. B. Resident interviewResident #3 was interviewed on 10/15/25 at 10:45 a.m. Resident #3 said Resident #1 came into the room she shared with Resident #2 and smashed several of Resident #2's belongings to the floor. She said Resident #2 told Resident #1 to leave their room, which he did, but then he came back. She said when he came back, Resident #1 and Resident #2 started arguing in the hall and then Resident #1 took off the armrest of his wheelchair and threw it at Resident #2. Resident #3 said the wheelchair armrest hit Resident #2 and then bounced off Resident #2 and hit her (Resident #3) in the leg. She said it did not hurt and she did not have a bruise or scratch. Resident #3 said the staff removed Resident #1 from the room and called the police. She said she, Resident #1 and Resident #2 all hung out together and Resident #1 and Resident #2 had not had any more issues since the incident on 7/30/25. Resident #3 said she was not afraid of Resident #1 and he was usually pretty nice.C. Record reviewThe 7/30/25 at 5:35 p.m. nurse progress note documented Resident #3 was hit in the right thigh with a wheelchair armrest as a result of an altercation between two other residents (Resident #1 and Resident #2). A full body skin check was performed. The resident's skin was intact with no abrasions, bruises or cuts noted. There were no injuries identified and the resident reported no pain. The DON and the physician were notified.The 8/1/25 at 12:40 p.m. social services progress note documented Resident #3 reported feeling startled by the situation on 7/30/25 but stated she felt safe and supported by staff. She expressed disappointment about being physically affected during the altercation, as she was unintentionally struck in the leg by the armrest thrown by Resident #1. Resident #3 stated that she believed the issue stemmed from a misunderstanding and she did not harbor resentment. She accepted Resident #1's apology and expressed that she too was open to using staff for mediation and support in future conflicts. Resident #3 was calm and cooperative during the follow-up and did not wish to change rooms at the time. She agreed to continue working toward a calm and respectful living environment.VI. Staff interviewsLPN #1 was interviewed on 10/15/25 at 11:40 a.m. LPN #1 said he had only worked at the facility for three months. He said Resident #1 was young and staff had to sometimes redirect his agitated behaviors, but he said he had never seen the resident be physically aggressive with staff or residents. LPN #1 said he received abuse training upon his hire to the facility and he had not seen any resident abuse. He said if he were to witness an abuse situation, he would report it to the DON or the NHA immediately.Certified nurse aide (CNA) #1 was interviewed on 10/15/25 at 11:50 a m. CNA #1 said she had not witnessed any abuse situations but she had heard of the incident with Resident #1 and Resident #2. She said Resident #1 could get aggressive with staff when he did not get his way immediately. She said he could be unpredictable with staff because he did not like feeling controlled. She said he was usually easy to calm down and redirect if staff talked to him calmly. She said Resident #1, Resident #2 and Resident #3 all hung out together and the three of them sometimes got into arguments, but she said all three residents were easily redirectable and staff would just separate them for a time and then they were fine with each other. She said she had not witnessed any further abuse situations with any of the residents when they were together. She said if she were to witness an abuse situation, she would report it immediately to the NHA.CNA #2 was interviewed on 10/15/25 at 12:00 p.m. CNA #2 said she was working on 7/30/25 when the abuse incident occurred between Resident #1, Resident #2 and Resident #3. She said Resident #1 was antagonizing Resident #2, going into her room and knocking stuff off of her dresser and talking smack to her. CNA #2 said Resident #1 removed one of the armrests from his wheelchair because he got frustrated with Resident #2 and threw it at her. CNA #2 said she did not know if the armrest hit Resident #2, but she said it did hit Resident #3 in the leg. She said Resident #3 did not have any injuries and the residents were separated and the police were called.CNA #2 said Resident #1 and Resident #2 had an up and down relationship, almost like a sibling rivalry. She said they would get frustrated and annoyed with each other and then would be fine together. She said the residents were kept separated for awhile but had since been allowed to hang out together because they were friends. She said staff kept a close eye on them and if Resident #1 or Resident #2 started to get upset with each other, staff told them to stay away from each other for awhile until they calmed down. She said the residents were compliant with following that intervention. CNA #2 said Resident #1 did not seem to be getting upset as much as he used to and there had been no further incidents with the residents.CNA #3 was interviewed on 10/15/25 at 12:07 p.m. CNA #3 said she had not witnessed any resident abuse situations personally, but she said if she did, she would immediately report it to the NHA. She said she heard about the incident on 7/30/25 with Resident #1, Resident #2 and Resident #3, but she was not working when the incident occurred. She said she heard Resident #1 and Resident #2 were arguing and Resident #1 threw his wheelchair armrest at Resident #2 and it hit Resident #2 and Resident #3 but they were not hurt. CNA #3 said after the incident, staff were instructed to keep Resident #1 and Resident #2 separated from each other and Resident #1 was moved to another room on a different hallway. She said Resident #1, Resident #2 and Resident #3 were friends. She said the residents were allowed to hang out together now and there had been no further incidents between them, but she said staff kept a close eye on the residents when they were together so no other situations occurred.The DON and the regional director of clinical services were interviewed together on 10/15/25 at 1:30 p.m. The DON said the incident on 7/30/25 involving Resident #1, Resident #2 and Resident #3 occurred after Resident #2 accused Resident #1 of taking her vaporizer device. She said Resident #1 went to Resident #2 and Resident #3's room and Resident #2 started throwing food at Resident #1 because she was upset about her vaporizer device. She said Resident #1 became upset and left the room, smashing Resident #2's jar of pickles as he left the room. The DON said Resident #1 went outside to smoke and when he returned to his room, he found his laptop smashed and went back to Resident #2's room to ask her if she broke his laptop. She said when Resident #2 did not answer Resident #1's question about the laptop, Resident #1 got angry, took the armrest off his wheelchair and threw it at Resident #2. The DON said the armrest hit Resident #2 in the chest and then bounced off and hit Resident #3 in the leg. She said neither resident sustained an injury. The DON said staff overheard the commotion and immediately intervened and separated the residents and Resident #1 was immediately moved to a room on another hallway. She said the police were called and by the time the police arrived, everything had calmed down and there were no further concerns. The DON said the residents were all placed on 15-minute checks and kept separated from each other for 72 hours to make sure there were no further issues. She said both Resident #1 and Resident #2 were spoken to about the incident and both agreed to mental health services visits. She said Resident #2 had been seeing a mental health services provider prior to the incident. She said Resident #1 had previously declined mental health services, but agreed to utilize the services following the incident with Resident #2. The DON said both Resident #1 and Resident #2 could be very short tempered with staff and they would occasionally yell and cuss, but they had never exhibited anything physically aggressive prior to the incident on 7/30/25. She said the residents, including Resident #3 were very good friends and it was hard to keep them apart after the incident, but she said they were now allowed to be together and both residents had agreed to come to staff if they were getting agitated or to walk away from each other. The DON said she checked in frequently with both residents to ensure they were doing okay and managing their frustrations successfully. She said the residents had her cell phone number and would call her sometimes if they were frustrated. She said staff knew to keep a close eye on them when they were together to ensure another incident did not occur between the residents.The regional director of clinical services said Resident #1 and Resident #2 had a sibling type relationship and the facility did not want to dissuade their interaction with each other. She said the staff was very aware of the history between the two residents and were all very diligent in monitoring the residents when they were together to ensure the situation did not escalate into another incident.

Based on observations, record review and interviews, the facility failed to ensure three (#43, #51 and #66) of three residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion out of 39 sample residents. Specifically, the facility failed to establish a consistent restorative nursing program within the facility to ensure Resident #43, Resident #51 and Resident #66 did not have a potential decline in activities of daily living (ADL). Findings include: I. Facility policy The Restorative Nursing Services policy, revised July 2017, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Restorative nursing care consists of nursing intervention that may or may not be accompanied by formalized rehabilitative services (physical, occupational or speech therapies). Restorative goals and objectives are individualized, resident-centered, and are outlined in the resident's plan of care. Restorative goals may include, but are not limited to supporting and assisting the resident in: -Adjusting or adapting to changing abilities; -Developing, maintaining or strengthening his/her physiological and psychological resources; -Maintaining his/her dignity, independence and self-esteem; and, -Participating in the development and implementation of his/her plan of care. II. Resident #43 A. Resident status Resident #43, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2024 computerized physicians orders (CPO), diagnoses included muscle weakness, chronic kidney disease, bipolar disorder, acute and chronic respiratory failure and muscle wasting. The 9/3/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on staff with transfers, toilet use, personal hygiene and bathing. The assessment indicated the resident had no behaviors and did not reject care. According to the MDS assessment, the resident did not receive restorative nursing services and the last time the resident received physical therapy services was on 8/28/24 for a total of 31 minutes. B. Record review A review of a list of residents on restorative programs documented Resident #43 was on a restorative program. A review of the restorative nurse aides (RNA) range of motion task charting from 9/11/24 to 10/11/24, a period of 30 days, revealed documentation that Resident #43 refused restorative services on 9/16/24. -There was no other documentation of the resident having received restorative services. -A review of Resident #43's October 2024 CPO did not reveal any physician's orders for restorative services. -A review of the resident's comprehensive care plan did not reveal a care plan focus for restorative services. III. Resident #51 A. Resident status Resident #51, age greater than 65, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included lymphedema, heart disease and obesity. The 9/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for dressing and personal hygiene. B. Resident interview Resident #51 was interviewed on 10/9/24 at 9:19 a.m. Resident #51 said her restorative program was not done as often as it was supposed to be. She said the facility had cut back on the restorative services program. Resident #51 said she was supposed to have restorative services two to three times per week but that had not happened. She said she needed restorative services because her knees were bone on bone and she needed to do what she could to maintain her abilities. C. Record review A review of a list of residents on restorative programs documented Resident #51 was on a restorative program. A review of the RNA restorative range of motion task charting revealed Resident #51 had two restorative sessions from 9/11/24 to 10/11/24, a period of 30 days. -A review of Resident #51's October 2024 CPO did not reveal any physician's orders for restorative services. A review of the residents comprehensive care plan did not reveal a care plan focus for restorative services. IV. Additional record review A performance improvement plan (PIP) was provided by the director of nursing (DON) on 10/14/24 at 1:00 p.m. The PIP was dated 8/20/24 and read in pertinent part, It was identified that the facility failed to ensure that the documentation by the MDS nurse, RNAs and the DON was not completed accurately and there are many residents that have incomplete assessments and chart notes. The DON did not complete the attestations and the MDS nurse or the DON did not consistently enter notes in the chart of residents receiving restorative services. The RNAs did chart but the charting lacks substance and is not concise. A restorative team of the DON, the MDS nurse, RNA and the DOR (director of rehabilitation) was formed to evaluate the charting process and implemented a training meeting to ensure that the documentation is concise and completed promptly. The RNAs will complete the comments section of the RNA weekly summary with a note about the resident's response to the restorative treatment they received. The MDS nurse and the DON will complete restorative notes going forward and will discuss outstanding documentation weekly. The DON will complete the attestations monthly. The RNAs will complete 6 (six) days of restorative with 2 (two) programs consisting of 15 minutes each to capture on the MDS assessment. Audit in 4 (four) weeks to evaluate the effectiveness of the new charting process - the expectation is that a 25% (percent) improvement in restorative charting will be achieved within the first month and charting will improve to reflect 100% compliance within the next 60 days. -However, record review for Resident #43 and Resident #51 revealed there was no documentation to indicate the residents were receiving their restorative programs (see record review above). V. Staff interviews The DON was interviewed on 10/14/24 at 1:00 p.m. The DON said the facility had a PIP in place for the restorative program. She said the facility went some time without a restorative program and realized they needed to train staff. She said the restorative program was back in full effect. -However, record review for Resident #43 and Resident #51 revealed there was no documentation to indicate the residents were receiving their restorative programs (see record review above). -The NHA provided a clarification email on 10/14/24 at 1:25 p.m. The NHA's email said the facility had had daily coverage for the restorative program for the past year and a half and the only time restorative staff were pulled from the program was when a scheduled certified nurse aide (CNA) called out sick or went on break. The restorative program supervisor (RNAS) was interviewed on 10/15/24 at 3:58 p.m. The RNAS said when a resident was placed on a restorative program, she was responsible for adding the task for charting so the RNA was reminded to chart the restorative service. She said the restorative programs needed work and that was why the PIP was started in September 2024. The RNAS said she began looking at the restorative program during other training and realized the facility needed to be more compliant with the restorative services. She said it was the responsibility of the therapy department to train restorative staff on how to perform the restorative programs. The RNAS reviewed the electronic medical records (EMR) for Resident #43 and Resident #51 and said she was not able to find documentation that restorative services were provided to either resident. She said if restorative services were not provided to the residents they would be at risk of decline in their functional abilities. The DON was interviewed a second time on 10/15/24 at 5:14 p.m. The DON said she began helping with the restorative program at the end of August 2024 when she found the restorative RNAs did not have access to the facility's electronic charting system in order to document the restorative services. She said a recent audit of resident restorative programs (during the survey) confirmed the RNAs were still not documenting appropriately. 48114 VI. Resident #66 A. Resident status Resident #66, under the age 65, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included anoxic brain damage (lack of oxygen to the brain) and persistent vegetative state. The 11/13/23 MDS assessment revealed the resident had severe cognitive impairment and a BIMS assessment was unable to be conducted. He required total staff assistance with oral hygiene, toileting hygiene, showering/bathing himself, upper and lower body dressing, personal hygiene and rolling left and right. B. Record review The activities of daily living (ADL) self-care deficit care plan, revised on 11/3/23, documented Resident #66 had actual ADL/mobility decline and required assistance related to vegetative state. Interventions included providing the assistance of one to two people for ADLs. The 9/19/24 rehabilitation screening form documented Resident #66 would benefit from occupational therapy (OT) to assess for a restorative nursing program (RNP) to follow through with upper extremity (UE) range of motion (ROM) and splinting. -Review of Resident #66's EMR revealed there was no documentation regarding restorative services being provided for Resident #66. C. Staff interviews The MDS coordinator (MDSC) was interviewed on 10/15/24 at 3:58 p.m. MDSC said Resident #66 had been on a restorative program and then had been back and forth to the hospital several times. She said Resident #66 should have been restarted on restorative services for passive range of motion for his wrist and joints. The MDSC said it was important for Resident #66 to receive restorative services so he did not get contractures. She said therapy would be evaluating the resident tomorrow (10/16/24) and recommending a new restorative program for him. The DON was interviewed on 10/15/24 at 5:00 p.m. The DON said she was not aware that she had to re-initiate the restorative program when Resident #66 returned from the hospital. She said she was not made aware that the resident was not receiving the passive range of motion services. She said Resident #66 would be evaluated again by therapy and put on a restorative program tomorrow (10/16/24). The NHA was interviewed on 10/15/24 at 6 p.m. The NHA said she thought the restorative issues had been corrected. She said she would be meeting with the RNAs weekly to look at restorative documentation going forward.

Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for four (#7, #17, #33 and #39) of four residents reviewed for personal funds accounts out of 39 sample residents. Specifically, the facility failed to notify Residents #7, #17, #33 and #39, who were Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person. Findings include: I. Record review A copy of residents' personal funds account balances, as of 10/15/24, was provided by the business office manager (BOM) on 10/15/24 at 5:06 p.m. It revealed in pertinent part, -Resident #7 had an account balance of $2,671.23 which was $671.23 over the allotted $2000.00 eligibility limit for Medicaid funded residents.; -Resident #17 had an account balance of $2,585.18 which was $585.18 over the allotted $2000.00 eligibility limit for Medicaid funded residents.; -Resident #33 had an account balance of $3,575.87 which was $1,575.87 over the allotted $2000.00 eligibility limit for Medicaid funded residents.; and -Resident #39 had an account balance of $2,681.23 which was $681.23 over the allotted $2000.00 eligibility limit for Medicaid funded residents II. Staff interviews The BOM was interviewed on 10/15/24 at 4:46 p.m. and again at 5:06 p.m. The BOM said she was responsible for managing the personal funds accounts for the residents at the facility. She said a personal funds account was offered to each resident upon admission and the facility provided account balance statements to residents every quarter. The BOM said each resident and/or their responsible party was responsible to spend down their account to ensure they did not exceed the allotted Medicaid allowed amount of $2000.00. She said if a resident exceeded the allotted $2000.00, the resident could be at risk of losing their Medicaid status. The BOM said she was aware there were four accounts that were significantly over the allotted $2000.00 Medicaid amount. She said she had just started working for the facility in August 2024. She said the facility had not yet notified the residents and/or their responsible parties about the spend down amounts for Resident #7, #17, #33 and #39. The BOM said she would provide the list to the nursing home administrator (NHA) and get started on the spend down for the residents. The NHA was interviewed on 10/15/24 at 6:00 p.m. The NHA said the BOM was responsible for monitoring the residents' personal accounts to ensure they did not exceed the allotted Medicaid amount of $2000.00. She said if a resident's account exceeded the allotted amount, then the resident could be at risk of losing their Medicaid status. The NHA said she was informed in August 2024 that one resident's account was over the allotted amount, however, she was not aware there were four other residents' accounts that had exceeded the $2000.00 limit. She said she would work with the BOM immediately to contact the residents and their family members to spend down the money.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with accepted professional standards for two of three treatment carts and one of three medication carts. Specifically, the facility failed to: -Ensure treatment carts were locked when unattended; and, -Ensure medication carts were locked when unattended. Findings include: I. Facility policy -The medication storage policy was requested from the facility but was not provided by the end of the survey on 10/15/24. II. Observations On 10/9/24 at 8:17 a.m. the treatment cart on the south hall was unlocked and unattended. Several residents and staff were walking in the hallway past the treatment cart. There were linens piled on top of the treatment cart. At 8:23 a.m. the treatment cart on the north hall was unlocked and unattended. There were several residents in the hall near the cart. At 2:14 p.m. the treatment cart on the south hall was unlocked and unattended. Residents were walking in the hallway, staff walked past the cart and maintenance walked past the cart. The cart remained unlocked until 2:33 p.m. when the nurse was notified and locked the cart. On 10/10/24 at 8:37 a.m. the treatment cart on the north hall was unlocked and unattended. A resident in a wheelchair went past the cart. At 8:39 a.m. the treatment cart on the south hall was unlocked and unattended. There were several residents walking by the cart in the hall. At 9:12 a.m. the treatment cart on the north hall was still unlocked and unattended. The nurse was notified and the cart was locked. At 1:41 p.m. the medication cart on the south hall was unlocked and unattended. A resident in a wheelchair went past the cart. Several staff members, including the director of nursing (DON), a therapy assistant and a certified nurse aide (CNA) passed the cart and the DON walked past the cart a second time. None of the staff members observed that the medication cart was unlocked. The nurse returned to the cart from a resident's room over 15 feet away from the cart at 1:46 p.m. and locked the cart at 1:51 p.m. III. Staff interviews An unidentified agency nurse was interviewed on 10/9/24 at 8:24 a.m. The agency nurse said the treatment cart should be locked when it was unattended so residents did not get into it. She said she had just arrived at the facility and the night shift staff must have left it unlocked. The DON was interviewed on 10/15/24 at 5:01 p.m. The DON said the treatment carts and medication carts should be locked when unattended. She said the carts had scissors and medications in them that would be dangerous to residents with mental health issues and wandering behaviors.

Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 14.63%, or six errors out of 41 opportunities for error. Findings include: I. Facility policy and procedure The Administering Medications policy and procedure, dated April 2019, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:00 p.m. It revealed in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI (quality assurance and performance improvement) committee to inform process changes and or the need for additional staff training. II. Medication administration observations On 10/10/24 at 9:02 a.m. licensed practical nurse (LPN) #2 was preparing and administering medications for Resident #3. The resident had a physician's order for Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml (milliliter). Inject 50 units subcutaneously in the morning for diabetes mellitus, ordered 8/23/24. -LPN #2 entered the room of Resident #3 with the resident's Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml. She turned the dial on the insulin pen to read 50 units, cleaned the resident's abdominal injection site with a personal hygiene wipe and administered the insulin injection to the resident without priming the insulin pen. Cross reference F760 for failure to ensure residents were free from significant medication errors. On 10/10/24 at 9:28 a.m. LPN #2 was preparing and administering medications for Resident #49. The resident had physician's orders for the following medications: Amlodipine Besylate oral tablet 10 mg (milligram), give one tablet by mouth one time a day for hypertension (HTN), hold for a systolic blood pressure (maximum blood pressure in your arteries when your heart beats) less than 110 mm/Hg (millimeters of mercury), ordered 7/27/2024. -LPN #2 did not check Resident #49's blood pressure prior to administration. Senna-Docusate Sodium oral tablet 8.6-50 mg, give 8.6 mg orally one time a day for bowel management, ordered 7/27/2024. -LPN #2 administered two tablets of senna-docusate, not one tablet as indicated in the physician order. On 10/15/24 at 9:04 a.m. LPN #5 was preparing and administering medications for Resident #43. The resident had physician's orders for the following medications: Psyllium oral packet (Metamucil) 25%, give one packet by mouth in the morning for constipation, ordered 8/28/2024. -The bulk bottle packaging directions read one rounded tablespoon, three times daily, however LPN #5 measured out three rounded plastic spoonfuls into one seven oz (ounce) glass. Aspirin oral capsule 81 mg, give one tablet by mouth one time a day, for cerebellar stroke syndrome, ordered 8/28/2024. -LPN #5 administered an 81 mg chewable aspirin tablet. Milk of Magnesia oral suspension, give 30 ml by mouth every 24 hours as needed for constipation, ordered 8/27/2024. -Resident #43 was administered the previous dose on 10/14/24 at 9:22 p.m., twelve hours prior. III. Staff interviews LPN #5 was interviewed on 10/15/24 at 9:37 a.m. LPN #5 said she used three spoonfuls of Metamucil because the package read one rounded tablespoon three times. The director of nursing (DON) and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:02 p.m. The DON said an insulin pen should be primed prior to administering the insulin. She said the pen should be dialed to two units and the insulin expelled from the pen prior to drawing up the prescribed dose of insulin. The DON said it was important to prime the insulin pen prior to administration to ensure the resident received the full dose of insulin. The DON said it was important to follow the physician's order when administering medications. The DON said if a resident received a higher amount of a medication, such as with the Metamucil, it could cause harm. The RCC said physician's orders for bulk medications, such as Metamucil, should match the directions on the bulk medication bottle. She said she would review and edit the physician's orders for Metamucil to make them more clear. She said the physician's order should match the format the facility was using, for example bulk versus a packet.

Based on record review and interviews, the facility failed to assist residents in obtaining routine or emergency dental services as needed for three (#18, #32 and #51) of four residents reviewed for dental services out of 39 sample residents. Specifically, the facility failed to ensure dental services were offered to Resident #18, Resident #32 and Resident #51. Findings include: I. Facility policy The Emergency Dental Care policy, revised April 2007, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:30 p.m. It read in pertinent part, Emergency dental care is available to all residents of this facility. Emergency dental care is available on a twenty-four (24) hour basis. Should a resident need emergency dental care, the dental consultant shall be notified so that arrangements for the emergency care can be made. Social services shall contact the consultant dentist to set up the appointment. Should social services be unavailable, the charge nurse shall contact the consultant dentist. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate, broken, or otherwise damaged teeth or any problem of the oral cavity appropriately treated by a dentist that requires immediate attention. II. Resident #18 A. Resident status Resident #18, age 67, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body). The 9/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of nine out of 15. He required partial/moderate assistance for upper body dressing and personal hygiene. He required supervision or touching assistance with oral hygiene. The MDS assessment indicated the resident had no dental issues and was edentulous (did not have teeth). B. Resident interview and observation Resident #18 was interviewed on 10/9/24 at 3:42 p.m. Resident #18 said he had asked to be seen by the dentist and had not seen the dentist since he was admitted to the facility. He said he would like to see the dentist and get dentures. He said he would like to eat hard food, such as steak. An observation of Resident #18's mouth during the interview revealed the resident had no teeth. C. Record review The care plan for nutrition, revised 9/16/24, documented Resident #18 had potential risk for altered nutritional intake related to being edentulous, left hemiplegia (paralysis of one side of the body), denied chewing difficulty and fed himself after some set-up assistance. Interventions included evaluating the need for assistance with eating and drinking as needed providing meal set-up assistance if needed, providing food preferences per resident choice and observing for signs and symptoms of dysphagia (swallowing difficulties) as evidenced by pocketing food in the mouth, coughing, choking, drooling or holding foods in mouth. The 9/19/24 admission summary note documented Resident #18,would like a dental and vision referral. The ancillary care plan, initiated 10/14/24, documented Resident #18 would have access to audiology, dental, podiatry and ophthalmology services quarterly, per request, and/or as needed. Interventions included ensuring oral health and preventing dental issues, scheduling regular dental check-ups and cleanings, providing treatment for dental conditions (fillings, extractions) as needed, educating Resident #18 and staff on oral hygiene practices and monitoring denture care and adjustments, if needed. -Review of Resident #18's electronic medical record (EMR) revealed there was no documentation indicating that a referral had been made for the resident to be seen by the dentist. -A consent for dental services was signed on 10/4/24, however, there was no documentation that the resident was referred to be seen by the facility's dental provider since his admission III. Resident #32 A. Resident status Resident #32, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2024 CPO, diagnoses included anxiety disorder and depression. The 8/12/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required setup or clean-up assistance with eating and oral hygiene. The MDS assessment indicated the resident had no dental issues and was edentulous. -However, the resident had upper and lower teeth which were chipped (see resident observation and interview below). B. Resident interview and observation Resident #32 was interviewed on 10/9/24 at 2:20 p.m. Resident #32 said he had been asking to see the dentist since he was admitted to the facility. He said he had never been seen by the dentist. He said his teeth were bothering him and had some pain in his mouth. He said he had let staff know that he needed to be seen by the dentist and had not heard when he would be seen. An observation of Resident #32's mouth during the interview revealed the resident had upper and lower teeth that were chipped and needed to be repaired. C. Record review A 3/27/24 nurse practitioner note documented Resident #32 presented with a chief complaint of tooth pain, which had been managed with ibuprofen. The resident was seeking further relief from his symptoms and required a dental appointment. On 4/26/24 the social services note documented Resident #32 informed the social services director (SSD) of cracked teeth and tooth pain. The note indicated the SSD would submit an emergency evaluation to the dentist for the resident to be evaluated and treated by a dentist. On 6/6/24 the dental note documented Resident #32 was on the facility dentist's schedule for dental treatment, however, Resident #32 was in the hospital. The ancillary care plan, revised 8/7/24, documented Resident #32 would have access to audiology, dental, and ophthalmology services quarterly, per the resident's request, and/or as needed. Interventions included ensuring oral health and preventing dental issues, scheduling regular dental check-ups and cleanings, providing treatment for dental conditions (fillings, extractions) as needed, educating Resident #32 and staff on oral hygiene practices and monitoring denture care and adjustments. On 9/5/24 a progress note documented Resident #32 was not seen by the dentist and he was placed on the reserve list for the next dental visit. On 9/5/24 the dental note documented Resident #32 was on the schedule to be seen for treatment, but the dentist ran out of time, so he was not seen. IV. Staff interviews The SSD was interviewed on 10/15/24 at 12:46 p.m. The SSD saidResident #18 requested to be seen by a dentist on 9/19/24 and was not referred to a dentist until 10/4/24. SSD said timely referral was considered to be within a week unless it was an emergency. She said when the dentist was at the facility on 10/10/24, he did not see half of the residents. The SSD said Resident #32 was discharged from the facility to the hospital for surgery and was gone for a few months. She said when he came back from the hospital he was put back on the list to be seen by the dentist. She said she thought he was seen in August 2024. She said she would need to look to see if she was notified of the dental appointment mentioned by the medical doctor in March 2024. The SSD said appointments for ancillary services were posted on the facility's communication board. She said the CNAs should be informing residents when the dentist was coming to the facility. The director of nursing (DON) was interviewed on 10/15/24 at 5:00 p.m. The DON said ancillary services should be offered to all residents. She said she did not know often residents were referred for ancillary services. She said residents needing to be seen by the dentist should be seen at least every six months. The DON said social services was responsible for scheduling ancillary appointments, along with the interdisciplinary team (IDT) involvement. She said ancillary services should be arranged and scheduled timely. The nursing home administrator (NHA) was interviewed on 10/15/24 at 6:00 p.m. The NHA said social services was responsible for scheduling ancillary services. She said she recognized the SSD needed help to be able to submit referrals and complete her job duties timely. She said ancillary services should be submitted timely. 47960 V. Resident #51 A. Resident status Resident #51, age greater than 65, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included lymphedema, heart disease and obesity. The 9/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for dressing and personal hygiene. B. Resident interview Resident #51 was interviewed on 10/9/24 at 9:37 a.m. Resident #51 said she requested to see the dentist in September 2024, on a Friday. She said the dentist came on a Thursday instead and she was not notified or taken to see the dentist. Resident #51 said she still wanted to see the dentist and did not know when or if she was scheduled to see the dentist. C. Record review A 9/5/24 appointment progress note documented Resident #51 was not seen by the dentist on that date and was placed on the reserve list for the next dental visit. -A review of the dental reserve list failed to show documentation of the resident's name on the list to see the dentist at the next visit to the facility. Review of Resident #51's comprehensive care plan, revised on 8/12/24, revealed a care plan focus for ancillary services, to include dental needs. The goal was to provide ancillary services to maintain and improve the residents quality of life as needed or requested. The intervention for oral health was to ensure oral health and prevent dental issues by scheduling regular dental check ups and cleanings. A review of the October 2024 CPO revealed the resident had physician's orders to see a dentist as needed. D. Staff interviews The DON was interviewed on 10/14/24 at 1:00 p.m. The DON said she was not aware that Resident #51 had requested to see the dentist and would look into why she was not seen. The SSD was interviewed on 10/15/24 at 12:49 p.m. The SSD said the facility was having trouble with dental services from the existing provider and they had been looking for a backup dental provider. The SSD said Resident #51 did not have a dental emergency so she was referred to another dentist. -However, there was no documentation in Resident #51's EMR to indicate a referral to another dentist had been made.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff followed proper infection control procedures for cleaning resident rooms; -Ensure residents were assisted with hand hygiene prior to meals; -Ensure glucometers were cleaned appropriately following use; and, -Ensure personal protective equipment (PPE) was worn appropriately and appropriate infection control procedures were followed during wound care for a resident on enhanced barrier precautions (EBP). Findings include: I. Failure to follow proper infection control procedures for cleaning resident rooms A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 10/23/24 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. B. Facility policy and procedure The Cleaning and Disinfecting of Resident Rooms policy, revised August 2013, was received from the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis (daily, three times per week) and when surfaces are visibly soiled. Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Perform hand hygiene after removing gloves. C. Manufacturers guidelines The manufacturer guidelines for the Micro-Kill Q3 disinfectant used by the facility were retrieved on 10/28/24 from https://www.medline.com/media/catalog/Docs/MKT/LITe21856_OTH_MicroKill%20Q3%20Technical.pdf. It read in pertinent part, Micro-Kill Q3 is a concentrated one-step disinfectant formulated for general hospital cleaning and the disinfection of hard, nonporous, non-food surfaces. Micro-Kill R3 is EPA (environmental protection agency) approved for use against SARS-CoV-2 (cause of COVID-19). Requires a three-minute contact time for many bacteria and viruses. Eliminates odors and is fragrance-free. Soft surface spot sanitizer treatment. D. Housekeeping observations On 10/15/24 at 8:40 a.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER], a double occupancy room with EBP in place. HK #1 put on gloves and entered the room. HK #1 sprayed Micro-Kill Q3 disinfectant on the door handle of the residents' room and immediately wiped it off. She proceeded to wipe the overbed table on one side of the room and then the other overbed table on the other side of the room. HK #1 sprayed, and immediately wiped off, the first resident's walker, fan and dresser then proceeded to wipe the other resident's dresser with the same rag before walking into the bathroom. HK #1 sprayed and immediately wiped the grab bar, the light switch and the towel bar in the residents' bathroom. She walked back to the resident's trash can and removed the trash bag. She put the trash bag in the receptacle on her cart and removed her gloves. Without performing hand hygiene, HK #1 put on new gloves and returned to the room. HK #1 checked the temperature of the residents' refrigerator and went back to her cart to write down the temperature on the log sheet. She went back to the refrigerator and placed the temperature log back in its holder. HK #1 went back to her cart and removed a dirty mop head, put a new dry mop head on the mop and proceeded to dry mop both sides of the room. She put the mop back on her cart, without removing the dirty mop head, her gloves or performing hand hygiene, and retrieved the toilet bowl cleaning wand from her cart. HK #1 went back into the bathroom and cleaned the toilet bowl with the wand. After cleaning the toilet bowl, HK #1 wiped the top of the toilet with a paper towel. She did not spray the top of the toilet with disinfectant. She removed a urine output measuring cup from the top back of the toilet and used the urine-soiled paper towel it was sitting on to wipe the toilet seat and the area where the urine output measuring cup had been sitting. HK #1 sprayed the bathroom mirror with glass cleaner and immediately wiped it off with a paper towel. Then she wiped the sink with a paper towel that was wet with water. She did not spray the area with disinfectant. HK #1 removed the trash from the bathroom and replaced the trash can liner. She removed her gloves and put new gloves on without performing hand hygiene. HK #1 poured disinfectant on the floor and wet mopped the entire room and bathroom. She swept the trash from the pile she made while mopping the floor. HK #1 finished cleaning the room at 8:52 a.m. -HK #1 did not perform hand hygiene before she started cleaning room [ROOM NUMBER]. -HK #1 did not perform hand hygiene between glove changes. -HK #1 did not use separate rags or mop heads for each side of the residents' room or the bathroom. -HK #1 did not clean all of the high touch surfaces in the residents' room. -HK #1 did not allow the disinfectant to remain on surfaces for any amount of time before wiping it off. -HK #1 did not clean the toilet from an area of cleaner to dirtier. -HK #1 did not change her gloves or perform hand hygiene after cleaning the toilet and before cleaning the residents' mirror and sink. On 10/15/24 at 9:10 a.m. HK #2 was observed cleaning room [ROOM NUMBER], a double occupancy room. HK #2 put on gloves and sprayed the bathroom with disinfectant. She returned to the residents' room and sprayed the disinfectant on the first resident's call light and overbed table and immediately wiped them down. She wiped the resident's dresser, the phone, items on the dresser and the top of the refrigerator. HK #2 documented the temperature of the refrigerator then moved to the other side of the room. Without changing rags or changing gloves and performing hand hygiene, HK #2 sprayed the second resident's overbed table and nightstand and wiped them down immediately. HK #2 dropped the rag on the floor, picked it up and used it to wipe down the bottom of the overbed table and the table the resident's refrigerator was on. She got a new rag at 9:12 a.m. and sprayed the other overbed table and wiped it down immediately, then wiped the resident's shelf and the top of the dresser. HK #2 picked up the second resident's remote for the television but did not wipe it down. She sprayed and immediately wiped down the front of the dresser. HK #2 got a new rag and wiped the second resident's call light, then sprayed, and immediately wiped off, the wall and cable protector near the resident's bed. HK #2 sprayed and immediately wiped down the resident's nightstand, then wiped the light switch. At 9:16 a.m. HK #2 put on new gloves without performing hand hygiene. HK #2 cleaned the residents' toilet with the toilet wand. Without changing gloves or performing hand hygiene, she got a new rag and cleaned the sink with the rag which was wet with water. She dried the sink with paper towels. HK #2 wiped the towel rack and the soap dispenser. She wiped the top of the toilet with paper towels, raised the toilet seat and wiped the toilet with the same paper towels. HK #2 removed her gloves but did not perform hand hygiene and proceeded to spread floor cleaner in the bedroom and bathroom. She mopped the floor of one side of the bedroom without gloves on. After mopping the first side of the room, she put new gloves on, put a new mop head on and mopped the other side of the bedroom and the bathroom floor. HK #2 put another new mop head on and mopped the entire bedroom floor a second time. HK #2 finished cleaning the room at 9:23 a.m. -HK #2 did not perform hand hygiene before she started cleaning room [ROOM NUMBER]. -HK #2 did not perform hand hygiene between glove changes. -HK #2 did not use separate rags for each side of the residents' room or the bathroom. -HK #2 did not clean all of the high touch surfaces in the residents' room. -HK #2 did not allow the disinfectant to remain on surfaces for any amount of time before wiping it off. -HK #2 did not clean the toilet from an area of cleaner to dirtier. -HK #2 did not change her gloves or perform hand hygiene after cleaning the toilet and before cleaning the residents' mirror and sink. E. Staff interviews HK #1 was interviewed on 10/15/24 at 8:52 a.m. HK #1 said she used odor control, Microkill concentration disinfectant for high touch areas, glass cleaner and soap. She said she always sprayed the disinfectant and immediately wiped the surface down. She said she was not aware of any contact time requirements for the cleaning solutions used. HK #2 was interviewed on 10/15/24 at 9:23 a.m. HK #2 said she had been with the facility for ten years. She said she was trained by the housekeeping manager when she first started. She said she was not aware of any contact time requirements for the cleaning solutions used. The housekeeping supervisor (HKS) was interviewed on 10/15/24 at 9:35 a.m. The HKS said she had been employed at the facility since June 2024. She said she was responsible for training new staff and she also had new staff train with two other housekeepers before they were able to clean on their own. The HKS said the proper way to clean residents' rooms was to perform hand hygiene, put gloves on, take disinfectant and odor control solution and spray the sink, toilet and call light, get the trash and remove it from the room, clean each side of the room separately and with a different rag for each side, sweep each side of the room and clean the bathroom last, mop the entire room using a different mop head for each side of the room, and mop the bathroom last. She said it was important to clean high touch surfaces, such as the call lights, overbed tables, bathroom doorknob, main doorknob, window sills, remote controls for the beds and televisions and light switches. The HKS said the regular housekeeper had called in today (10/15/24) and HK #1 was filling in but she normally worked in the laundry room. The NHA was interviewed on 10/15/24 at 9:42 a.m. The NHA said it was important to clean residents' rooms in a specific manner to prevent the spread of infection. She said each side of the residents' rooms should be cleaned separately and the rooms should be cleaned from the cleanest area to the dirtiest area. II. Failure to ensure residents were assisted with hand hygiene prior to meals A. Observations During a continuous observation of the lunch meal service in the dining room on 10/15/24, beginning at 11:37 a.m. and ending at 12:02 p.m., the following observations were made: At 11:40 a.m. a resident touched the wall and the cart by the door of the kitchen to request coffee. He was directed back to his table. He was not offered hand hygiene. At 11:40 a.m., a resident was sitting at her table with gloves on. The resident was folding utensils into napkins for other residents to use at mealtime. She reached into the bag on her wheelchair and continued folding utensils into napkins without changing her gloves. She touched the straw in her cup and took a drink then continued folding utensils into napkins. -She did not remove her gloves or perform hand hygiene after reaching into her personal bag or touching the straw in her cup. At 11:44 a.m. another resident wheeled himself into the dining room with one of his hands on the wheel of his wheelchair. He gave staff a high five at 11:48 a.m. He was not offered hand hygiene after touching the wheel of his wheelchair. At 11:56 a.m. the resident wrapping utensils into napkins coughed into her glove. She touched her table and then the armrest on her wheelchair before continuing to wrap utensils. -She did not remove her gloves or perform hand hygiene after coughing into her glove. At 11:58 a.m. a female resident was wheeled to her table and shook hands with another female resident. She was not offered hand hygiene. Staff began serving drinks to residents at 12:00 p.m. A male resident reached into the beverage cart and got his own sweetener at 12:01 p.m. Staff began serving food trays at 12:02 p.m. There was a moist towelette provided to each resident but residents were not reminded or encouraged to use the wipes and assistance was not offered or provided to open the towelette package. -None of the residents above were observed performing hand hygiene. B. Staff interviews The director of nursing (DON) and the regional clinical consultant (RCC) were interviewed on 10/15/24 at 5:01 p.m. The DON said residents were provided with wipes or a warm washcloth before meals. She said staff should offer hand hygiene to residents, or at least open the towelette package, for them. The RCC said providing hand hygiene for residents was important to help prevent the spread of infection. 51160 III. Failure to ensure glucometers were cleaned appropriately following use; and, A. Professional reference According to the Basic Nursing third edition, Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022), page 2257-2258, Select and clean a fingerstick site with an alcohol-based (or other antiseptic) pad. Allow the site to dry thoroughly. This helps protect the patient from infection by removing some surface microorganisms. B. Facility policy and procedure The Blood Sampling Capillary Finger Stick policy and procedure dated, September 2014, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:00 p.m. It revealed in pertinent part, Wipe the area to be lanced with an alcohol pledget. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. The Administering Medications policy and procedure dated, April 2019, was provided by the NHA on 10/15/24 at 6:00 p.m. It revealed in pertinent part Staff follows established facility infection control procedures (handwashing, antiseptic technique, gloves, isolation precautions) for the administration of medications. C. Observations During a continuous observation on 10/10/24, beginning at 8:43 a.m. and ending at 10:00 a.m., the following was observed: At 9:02 a.m. licensed practical nurse (LPN) #2 entered Resident #3's room to obtain the resident's blood sugar level with a glucose monitor LPN #2 used a personal hygiene wipe (not an alcohol wipe) to clean the hand of Resident #3 prior to completing a fingerstick for glucose monitoring. LPN #2 proceeded to use the same personal hygiene wipe to clean the glucometer before immediately placing the glucometer back in its plastic storage bag and exiting the room. At 9:07 a.m. LPN #2 returned Resident #3's room with a Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml (milliliters). LPN #2 cleaned the resident's abdominal injection site with a personal hygiene wipe and proceeded to administer the insulin injection to the resident. D. Staff interviews LPN #2 was interviewed on 10/10/24 at 9:25 a.m. LPN #2 said she cleaned Resident #3's fingers with a personal hygiene wipe because an alcohol prep pad could falsely increase the blood glucose reading. LPN #2 said she was instructed to use the personal hygiene wipe by the director of nursing (DON). LPN #2 said the glucometers should be cleaned with an alcohol prep pad after each use. -However, LPN #2 had been observed using a personal hygiene wipe to clean the glucometer after using it to obtain Resident #3's blood glucose level (see observation above). LPN #2 said she used an alcohol prep pad to clean a resident's skin prior to the administration of insulin. -However, LPN #2 had been observed using a personal hygiene wipe, instead of an alcohol wipe, to clean Resident #3's abdomen prior to the injection of the insulin (see observation above). The DON and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:02 p.m. The DON said all the residents at the facility had their own glucometers and did not share. The DON said the glucometers should be cleaned according to manufacturer recommendations. She said the glucometers used at the facility should be cleaned with a bleach wipe, adhering to the manufacturer's recommended dwell time (the amount of time a disinfectant needs to remain wet on a surface to kill germs and achieve the desired level of disinfection). The DON said, prior to performing a finger stick for glucose monitoring, Resident #3's finger should have been cleaned with soap and water or an alcohol prep pad and allowed to dry. The DON said it was important to clean the site prior to the injection in order to prevent infection, bloodborne illness or cross contamination. The DON said LPN should have cleaned the resident's injection site with an alcohol prep pad prior to administering the injection. E. Facility follow up On 10/10/24 at 10:45 a.m. a document was provided by the marketing director (MKD) along with the DON. The document was dated 10/10/24 at 10:13 a.m., during the survey. It documented that LPN #2 had been confused regarding cleaning Resident #3's finger for the fingerstick blood sugar and the injection site. The document indicated LPN #2 was educated by the DON regarding the proper procedure after the observation. IV. Failure to ensure PPE was worn appropriately and appropriate infection control procedures were followed during wound care for a resident on EBP A. Professional references The Centers for Disease Control and Prevention (CDC) (2022), Donning and doffing personal protective equipment (PPE), was retrieved on 10/17/24 from: https://www.cdc.gov/niosh/learning/safetyculturehc/module-3/8.html read in pertinent part, Donning means to put on and use PPE properly to achieve the intended protection and minimize the risk of exposure. The gown should fully cover the torso from neck to knees, arms to end of wrists, and wrap around the back. The gloves should extend to cover the wrist of the isolation gown. According to the Basic Nursing third edition, Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022), page 1669-1673 read in pertinent part, [NAME] the gown. [NAME] gloves. If you are wearing a gown, make sure that the glove cuff extends over the cuff of the gown. If skin is visible between the gown and the glove, tape the glove cuff to the gown cuff, covering all visible skin. To provide complete protection of hands and wrists, no skin should be visible between the glove and gown. B. Observations During a continuous observation on 10/10/24, beginning at 1:33 p.m. and ending at 2:06 p.m., the following was observed: The assistant director of nursing (ADON) directed the wound care nurse (WCN) and certified nurse assistant (CNA) #1 to don PPE of a gown and gloves prior to entering Resident #45's room, who was on EBP. -They did not perform hand hygiene prior to putting on the PPE. After CNA #1 entered the room, the ADON directed CNA #1 to wash her hands. CNA #1 entered the resident's bathroom, performed hand hygiene and donned new gloves. -CNA #1 had exposed wrists, as her gown sleeve was not tucked inside her gloves. The ADON opened a clean trash liner and stood at the foot of the bed while the WCN performed the resident's wound care. -The ADON's wrists and watch were exposed, as her PPE gown sleeves were not tucked inside her gloves. The ADON directed the WCN to wash his hand multiple times throughout the wound care process. The ADON directed the WCN to sign and date the dressing. Wearing the same gloves he had used to perform the wound care, the WCN reached his gloved hand under his PPE gown to retrieve a marker from his scrub pocket to time and date the dressing. C. Staff interviews The DON said, prior to entering a room with EBP, facility staff should have performed hand hygiene and then donned a gown and gloves. The DON said that wrists, watches and bracelets should not have been exposed while wearing a gown and gloves. The DON said, in order to prevent the potential spread of infection, staff should not reach under a protective gown to retrieve items from their pockets while wearing PPE.

Based on record review and interviews, the facility failed to incorporate the recommendations from the PASRR (preadmission screening and resident review) Level II determination and evaluation report into the assessment, care planning and transition of care for two (#65 and #43) of three residents reviewed out of 39 sample residents. Specifically, the facility failed to initiate therapy as recommended by the PASRR Level II in a timely manner for Resident #65 and Resident #43. Findings include: I. Facility policy and procedure The Behavioral Health Services policy and procedure, revised February 2019, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care. Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or post-traumatic stress disorder(s) will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable. Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress. II. Resident #65 A. Resident status Resident #65, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included schizophrenia (a chronic illness that effects a persons thoughts, feelings and behaviors), history of suicidal behavior and third degree burns over more than 60% of his body. The 9/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident needed set up assistance with eating, oral hygiene, toileting and personal hygiene. B. Record review Resident #65's care plan, revised 10/10/24, revealed the resident had a Level II PASRR focus of at risk for complications due to meeting the criteria for referral for evaluation and treatment. The goal was to avoid complications of the mental health diagnosis to the extent possible. Interventions included to allowing the resident to make choices within decision making abilities, allowing the resident time to adjust to changes in routine and schedule, providing a psychiatric/psychology evaluation as indicated/ordered, and referring the resident the resident was referred for psychiatric psychiatric case consultation, therapy and crisis intervention/safety plan. Resident #65's PASRR Level II, dated 9/13/24, documented the recommended treatment was to provide psychiatry case consultation, case management, individual therapy and a crisis intervention/individual safety plan. The 10/10/24 progress note documented a referral was sent per Resident #65's request for counseling. A review of the October 2024 CPO revealed a physician's order for a counseling referral was placed on 10/10/24. -However, the facility failed to process the referral until 10/10/24, three weeks after the Level II PASRR notice of determination was received. III. Resident #43 A. Resident status Resident #43, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2024 CPO, diagnoses included bipolar disorder (mental disorder that causes abnormal shifts in a person's mood and behavior), acute and chronic respiratory failure and muscle wasting. The 9/3/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She had no behaviors and did not reject care. The resident was dependent on staff with transfers, toilet use, personal hygiene and bathing. B. Record review Resident #43's care plan, revised 8/12/24, documented the resident had a level II PASRR for self isolation and a medical diagnosis that required adjunctive behavioral care. The interventions included a focus of staff to work with the resident to enhance her quality of life by implementing the PASRR Level II recommendations to prevent and mitigate effects of the major mental illness. The interventions included providing a psychiatry consultation and providing individual therapy. A behavioral health services referral was documented on 3/22/24 for Resident #43. A therapy progress note was entered on 6/17/24. A review of the residents October 2024 CPO did not reveal a physician's order for behavioral health services. -A review of Resident #43's electronic medical record (EMR) did not reveal additional documentation that the resident was receiving behavioral services. IV. Staff interviews The social service director (SSD) was interviewed on 10/15/24 at 1:00 p.m. The SSD said it was her responsibility to facilitate referrals for behavioral health services. She said she had referred Resident #43 to behavioral health services, then referred the resident to another behavioral health services provider and when that provider vacated the position. The SSD said she did not have documentation indicating she initiated a new referral for Resident #43 upon the behavioral health services provider leaving their position at the facility. The SSD said she needed help and was not able to keep up with all of her responsibilities and did not have an assistant to help her. The SSD said a referral for behavioral health services for Resident #65 was sent on 10/10/24 and the notice of determination was obtained on 9/19/24. She said a week was a reasonable amount of time to expect a referral to be sent. -However, Resident #65's notice of determination was received on 9/19/24 and a referral to behavioral health services was not completed until 10/10/24 (during the survey). The director of nursing (DON) was interviewed on 10/15/24 at 5:01 p.m. The DON said she was not aware that behavioral health services were not being provided for Resident #43 or Resident #65. She said the SSD needed help to ensure the residents receive the care they need.

Based on record review and interviews the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for one (#76) of two residents reviewed for discharge out of 39 sample residents. Specifically, the facility failed to reassess Resident #76's status at the time the resident sought to return to the facility after a facility-initiated transfer to the hospital, and directed the hospital to discharge the resident to a sister facility instead of allowing the resident to return to the facility. Findings include: I. Facility policy and procedure The Facility-Initiated Transfer or Discharge policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility; the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered; the resident has failed, after reasonable and appropriate notice to pay for a stay at this facility; or the facility ceases to operate. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. If the facility does not permit a resident's return to the facility based on an inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights. The facility will send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman. Notice will occur at the same time the notice of discharge is provided to the resident and resident representative. If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the facility during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility. II. Resident #76 A. Resident status Resident #76, age 65, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the July 2024 computerized physician orders (CPO), the diagnoses included schizoaffective disorder, bipolar disorder. The 7/8/24 minimum data set (MDS) assessment revealed the resident had short term memory impairment with severe impairment in making decisions regarding daily life. She required supervision or was independent with all activities of daily living (ADL). The assessment documented the resident had hallucinations, delusions, physical behaviors directed toward others, verbal behaviors directed toward others and wandering during the assessment period. The assessment indicated that the resident's return to the facility was not anticipated and active discharge planning had occurred. B. Record review The behavioral care plan, initiated on 7/5/24, documented Resident #76 was verbally aggressive with staff and peers. The resident had a history of calling emergency services if her expectations were not met, declining medication if they appeared different or a different brand from a previous facility, physically hitting another resident and making false accusations. Resident #76 was difficult to redirect when cycling. She yelled and expressed her delusions and hallucinations at herself in the mirror. The interventions included administering medications as ordered, anticipating and meeting needs promptly, documenting and recording behavioral episodes, encouraging the resident to verbalize feelings, establishing a rapport, maintaining a calm, slow and understandable approach, notifying the physician and responsible party of episodes of aggression and abusive behaviors, observing and documenting changes in behavior and potential triggers, observing for clinical factors influencing behavioral indicators, reducing stimuli, and staying calm and composed, avoiding direct eye contact and staring, using short and clear sentences and avoiding any chance for a power struggle. -A review of the comprehensive care plan did not reveal a discharge care plan had been developed. Cross reference F622: the facility failed to ensure a proper discharge process was provided to Resident #76. The 6/27/24 behavior progress note documented Resident #76 began speaking over other speakers during a resident meeting with a resident advocate. The facility staff attempted to address the resident's behavior by asking her to hold her comments until the appropriate time, however Resident #76 continued to speak over others, refused to listen and continued to disrupt the meeting. The 7/2/24 behavior progress note documented Resident #76 had provided a personal shopping list to the activity director (AD). Upon asking the resident some questions about the items, Resident #76 became verbally aggressive, repeatedly using profane language, despite the AD attempting de-escalation techniques. The 7/3/24 behavior progress note documented Resident #76 called the police stating that someone had stolen her money. The 7/5/24 interdisciplinary team (IDT) progress note documented Resident #76 continued to express delusions, disorganized thoughts and speech, chaotic behavior, anxiety, apathy and blank facial expressions. The 7/5/24 IDT note further indicated Resident #76 had been accepted to the locked behavioral unit at a sister facility. The 7/5/24 nursing progress note documented Resident #76 had pushed another resident without cause. The charge nurse got in between the residents and separated them. Resident #76 continued to have behavioral outbursts. Resident #76 said she did not hit anyone, continued to use profanity and shouted at other residents. The resident was able to be redirected to the lobby but kept on showing aggression toward staff and other residents. The 7/6/24 nursing progress note, documented at 6:37 a.m., revealed Resident #76 had an episode of yelling and screaming at staff and refused to take her evening medication on 7/5/24. She did not sleep and was wandering the hallways. The 7/6/24 nursing progress note further indicated that the resident was being sent to the hospital due to her behavior and that they had spoken with the hospital and informed them to transfer her to another facility at discharge. Another 7/6/24 nursing progress note documented the resident returned to the facility at 6:33 p.m. and had refused all care at the hospital. The 7/8/24 physician progress notes documented the resident had exhibited 27 reported behaviors since her admission to the facility, including dissatisfaction with meals, calling emergency services for non-emergencies, loud outbursts in the dining room, intrusive behaviors, delusions, hallucinations, disorganized thinking, persistent feelings of being watched or persecuted and strong beliefs that were not based in reality. The resident was scheduled to transfer to another facility from the hospital. The 7/8/24 behavior progress note documented Resident #76 displayed almost harmful behavior by standing close to a male resident and looking like she was going to push him out of her way. The NHA intervened and redirected Resident #76 into alternate activities. The 7/11/24 change of condition note documented Resident #76 was sent to the hospital due to very hostile and aggressive behavior toward staff and she was not able to be redirected. The physician ordered for the resident to be sent to the hospital for behavior management and then discharged to a sister facility. -However, review of Resident #76's electronic medical record (EMR) revealed there was no documentation to indicate the facility had reassessed the resident after her transfer to the hospital to determine if the resident was able to return to the facility. -There was no documentation in Resident #76's EMR to indicate what needs the facility could not meet after the resident's hospitalization . III. Staff interviews The social services director (SSD) was interviewed on 10/15/24 at 12:46 p.m. The SSD said Resident #76 had been a resident at the facility, but had since been discharged to a sister facility. She said Resident #76 had a diagnosis of schizoaffective disorder and would refuse to take her psychotropic medications. She said the resident would constantly yell throughout the day, call emergency services daily and was verbally and physically aggressive. The SSD said the facility IDT had met with Resident #76's primary care physician (PCP) and determined, based on the resident's behaviors, the facility was not able to care for the resident and meet her needs (see 7/8/24 physician progress note above). -However the facility did not have any documentation indicating a discharge plan was in progress and had been discussed with the resident. The SSD said they planned to discharge the resident to a sister facility, however the paperwork was taking a long time. She said, in the meantime, the resident was sent to the hospital due to her behaviors and the facility instructed the hospital to discharge her to the accepting sister facility. The SSD said Resident #76 was her own responsible party. She said she never discussed the discharge planning with Resident #76. The SSD said she was responsible for discharge planning. She said a care plan focus for discharge planning should have been developed within Resident #76's comprehensive plan of care. The director of nursing (DON) and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:00 p.m. The DON said Resident #76 had severe mental health issues and would not take her medications, despite multiple attempts by multiple staff members. She said Resident #76 was disruptive to the community and verbally and physically aggressive. The DON said the facility determined Resident #76's needs would be better met at a sister facility. The RCC said the discharge process should be included as part of the comprehensive care plan. The NHA was interviewed on 10/15/24 at 6:00 p.m. The NHA said the SSD was responsible for documenting the active discharge plan and developing the discharge plan of care. The NHA confirmed the active discharge process and the discharge care plan was not documented for Resident #76.

Based on interviews and record review, the facility failed to ensure residents were permitted to remain in the facility and not transfer or discharge for one (#76) of two residents out of 39 sample residents. Specifically, the facility failed to provide Resident #76 with an appropriate discharge process. Findings include: I. Facility policy and procedure The Facility-Initiated Transfer or Discharge policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility; the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered; the resident has failed, after reasonable and appropriate notice to pay for a stay at this facility; or the facility ceases to operate. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. If the facility does not permit a resident's return to the facility based on an inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights. The facility will send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman. Notice will occur at the same time the notice of discharge is provided to the resident and resident representative. If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the facility during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility. II. Resident #76 A. Resident status Resident #76, age 65, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the July 2024 computerized physician orders (CPO), the diagnoses included schizoaffective disorder, bipolar disorder. The 7/8/24 minimum data set (MDS) assessment revealed the resident had short term memory impairment with severe impairment in making decisions regarding daily life. She required supervision or was independent with all activities of daily living (ADL). The assessment documented the resident had hallucinations, delusions, physical behaviors directed toward others, verbal behaviors directed toward others and wandering during the assessment period. The assessment indicated that the resident's return to the facility was not anticipated and active discharge planning had occurred. B. Record review The behavioral care plan, initiated on 7/5/24, documented Resident #76 was verbally aggressive with staff and peers. The resident had a history of calling emergency services if her expectations were not met, declining medication if they appeared different or a different brand from a previous facility, physically hitting another resident and making false accusations. Resident #76 was difficult to redirect when cycling. She yelled and expressed her delusions and hallucinations at herself in the mirror. The interventions included administering medications as ordered, anticipating and meeting needs promptly, documenting and recording behavioral episodes, encouraging the resident to verbalize feelings, establishing a rapport, maintaining a calm, slow and understandable approach, notifying the physician and responsible party of episodes of aggression and abusive behaviors, observing and documenting changes in behavior and potential triggers, observing for clinical factors influencing behavioral indicators, reducing stimuli, and staying calm and composed, avoiding direct eye contact and staring, using short and clear sentences and avoiding any chance for a power struggle. The 6/27/24 behavior progress note documented Resident #76 began speaking over other speakers during a resident meeting with a resident advocate. The facility staff attempted to address the resident's behavior by asking her to hold her comments until the appropriate time, however Resident #76 continued to speak over others, refused to listen and continued to disrupt the meeting. The 7/2/24 behavior progress note documented Resident #76 had provided a personal shopping list to the activity director (AD). Upon asking the resident some questions about the items, Resident #76 became verbally aggressive, repeatedly using profane language, despite the AD attempting de-escalation techniques. The 7/3/24 behavior progress note documented Resident #76 called the police stating that someone had stolen her money. The 7/5/24 interdisciplinary team (IDT) progress note documented Resident #76 continued to express delusions, disorganized thoughts and speech, chaotic behavior, anxiety, apathy and blank facial expressions. The 7/5/24 IDT note further indicated Resident #76 had been accepted to the locked behavioral unit at a sister facility. -However, there was no documentation to indicate the reason for the expected discharge to the sister facility or the anticipated date of the pending discharge. The 7/5/24 nursing progress note documented Resident #76 had pushed another resident without cause. The charge nurse got in between the residents and separated them. Resident #76 continued to have behavioral outbursts. Resident #76 said she did not hit anyone, continued to use profanity and shouted at other residents. The resident was able to be redirected to the lobby but kept on showing aggression toward staff and other residents. The 7/11/24 change of condition note documented Resident #76 was sent to the hospital due to very hostile and aggressive behavior toward staff and was not able to be redirected. The physician ordered for the resident to be sent to the hospital for behavior management and then discharged to a sister facility. -A review of Resident #76's EMR did not reveal documentation to indicate that the resident or the resident's representative had been notified of the resident's immediate discharge to the hospital. C. Staff interviews The social services director (SSD) was interviewed on 10/15/24 at 12:46 p.m. The SSD said Resident #76 had been a resident at the facility, but had since been discharged to a sister facility. She said Resident #76 had a diagnosis of schizoaffective disorder and would refuse to take her psychotropic medications. She said the resident would constantly yell throughout the day, call emergency services daily and was verbally and physically aggressive. The SSD said the facility IDT had met with Resident #76's primary care physician (PCP) and determined, based on the resident's behaviors, the facility was not able to care for the resident and meet her needs. She said they planned to discharge the resident to a sister facility, however the paperwork was taking a long time. She said, in the meantime, the resident was sent to the hospital due to her behaviors and the hospital was instructed to discharge her to the accepting sister facility. The SSD said she was not aware if Resident #76 was given a 30-day or immediate discharge notice. She said Resident #76 was her own responsible party. She said she never discussed Resident #76's right to appeal the discharge with her or her family. The director of nursing (DON) and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:00 p.m. The DON said Resident #76 had severe mental health issues and would not take her medications, despite multiple attempts by multiple staff members. She said Resident #76 was disruptive to the community and verbally and physically aggressive. The DON said the facility determined Resident #76's needs would be better met at a sister facility. The RCC said the facility did not issue Resident #76 a 30-day or immediate discharge notice when the resident was discharged to the hospital. The RCC said the facility did not provide Resident #76 with the education of the right to appeal the discharge. The RCC said a 30-day discharge notice should be given when the facility determined they could not meet a resident's needs. She said the discharge notice should include the resident's right to appeal the discharge. She said the discharge process should be documented in the resident's medical record and be included as part of the comprehensive care plan. The NHA was interviewed on 10/15/24 at 6:00 p.m. The NHA said the facility did not provide Resident #76 with a discharge notice. She said a 30-day discharge notice should have been provided and education given to the resident regarding the appeal process. The NHA said the facility felt they could not care for Resident #76 due to her unpredictable behavior.

Based on observations, record review and interviews, the facility failed to ensure services provided to residents met professional standards of quality for one (#15) of one resident out of 39 sample residents. Specifically, the facility failed to ensure Resident #15's as needed (PRN) pain medications had physician ordered parameters related to the strength of the medications and the severity of the resident's pain level (on a pain scale of 1-10). Findings include: I. Professional Reference According to the Society for Post Acute and Long-term Care (AMDA), Pain Management clinical practice guideline (2021) , retrieved on 10/17/24 from: https://paltmed.org/sites/default/files/2024-02/PainManagement2021CPGFinal.pdf, Levels of pain management identify pain levels by severity. Non-opioid analgesics for mild pain, low potency opioids for moderate pain, high potency opioids for severe pain, and adjunctions combined with any step.Giving PRN analgesics based on guesswork may limit the benefits and increase the risk of harm. Orders for PRN analgesics need to be clear and specific about the location and type of pain that they are intended to treat. II. Facility policy and procedure The Administering Medications policy and procedure, dated April 2019, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:00 p.m. It revealed in pertinent part, If a resident uses PRN medications frequently, the attending physician and interdisciplinary care team,with support from the consultant pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. III. Resident Status Resident #15, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder, bipolar disorder and diabetes mellitus. The 7/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. IV. Record Review Review of Resident #15's October 2024 CPO revealed the following physician's orders: Oxycodone oral tablet 5 milligrams (mg). Give 5 mg by mouth every six hours as needed for pain,ordered 9/29/24. -There were no administration parameters for the level of pain the medication should be given for. Tramadol oral tablet 50 mg. Give 50 mg by mouth every six hours as needed for pain, ordered 9/28/24. -There were no administration parameters for the level of pain the medication should be given for. Tylenol (acetaminophen) oral tablet 325 mg. Give two tablets by mouth every six hours as needed for fever/chills or mild pain. -The order indicated the Tylenol should be given for mild pain, however, there was no indication as to what mild pain was on a scale of 1-10. Resident #15's pain management care plan, initiated 1/5/24, revealed the resident was at risk for pain or discomfort due to general decline. The goal was for the resident's pain to be relieved to a tolerable level as indicated by the resident, using verbal or nonverbal communication to the extent possible. Interventions included assessing the resident for non-verbal indicators of pain and assessing the resident's pain every shift as indicated. V. Staff Interviews Licensed practical nurse (LPN) # 1 was interviewed on 10/15/24 at 11:36 a.m. LPN #1 said PRN pain medications should have pain perimeters. LPN #1 said a resident was asked to verify their pain level on a pain scale of 1-10 and to describe where the pain was. LPN #1 said the physician's orders were reviewed for the pain perimeters for which strength of medication to give. LPN #1 said if a resident was non-verbal she would use a non-verbal pain scale. LPN #1 said she assessed facial expressions and body tension to determine a pain scale level and then medicated the resident for pain based on the severity of pain and medication order. LPN #3 was interviewed on 10/15/24 at 11:38 a.m. LPN #3 said some pain medications were scheduled and some were PRN. LPN #3 said the physician's orders should have pain scale parameters. LPN #3 said each medication should specify what level of pain, on a 1-10 pain scale, the medication should be given for. LPN # 3 said if a resident requested a specific medication she would verify if their reported pain level met the ordered pain level parameter. LPN #3 reviewed the PRN pain medication orders for Resident #15. LPN #3 said she thought there should be pain scale parameters for each medication, but she said she would verify it with the director of nursing (DON). LPN #3 said the PRN pain medication orders for Resident #15 were ordered by an emergency department physician. The DON and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:02 p.m. The DON said pain medications should have administration parameters to indicate what level of pain each medication should be given for. The RCC said the facility had reviewed, updated and audited the PRN pain medication orders for Resident #15 (during the survey).

Based on record review and interviews, the facility failed to provide the resident representative with the proper discharge notifications for one (#182) of two residents out of 39 sample residents. Specifically, the facility failed to develop and implement a collaborate discharge plan with Resident #182 Findings include: I. Facility policy and procedure The Facility-Initiated Transfer or Discharge policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. II. Resident #182 A. Resident status Resident #182, age 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia, type 2 diabetes mellitus, depression and history of traumatic brain injury. The 9/26/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required setup assistance with dressing and eating and supervision with personal hygiene and toileting. The resident had hallucinations and physical and verbal behavioral symptoms directed towards others. -The assessment indicated active discharge planning was not occurring for the resident. -The assessment indicated no referral had been made to the local contact agency and the reason was referral not wanted. B. Record review A behavior note, documented on 10/3/24 at 7:52 p.m., revealed referrals were sent to many memory care facilities for placement and the facility would keep Resident #182 safe until he could be transferred to a more appropriate facility. A behavior note, documented on 10/8/24 at 3:48 p.m., revealed the resident entered a female resident's room without permission the prior evening and kissed her. The facility was actively seeking placement at other facilities for appropriate placement of Resident #182 and the referral process was prioritized to maintain the safety and security of the community. A behavior note, documented on 10/11/24 at 4:12 a.m., revealed the resident was exhibiting behaviors of fear, agitation, anger, anxious, restless, and combativeness. The resident was hallucinating and hit and kicked multiple staff members. The facility called 911 to assist staff and the resident was transported to the hospital for evaluation. -There was no documentation in Resident #182's EMR to indicate the resident or resident representative had been involved in the development of a discharge plan for the resident. C. Staff interviews The social services director (SSD) was interviewed on 10/15/24 at 12:49 p.m. The SSD said Resident #182's discharge planning process was not documented in the resident's EMR or the resident's comprehensive care plan. The regional clinical consultant (RCC) was interviewed on 10/15/24 at 5:00 p.m. The RCC said the discharge process should be documented in the resident's medical record and be included as part of the comprehensive care plan. The NHA was interviewed on 10/15/24 at 6:00 p.m. The NHA said the SSD was responsible for documenting the active discharge plan and developing the discharge plan of care.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#24) of four residents reviewed for assistance with ADLs out of 39 sample residents. Specifically, the facility failed to ensure Resident #24's fingernails were trimmed and clean. Findings include: I. Facility policy The Activities of Daily Living (ADL), Supporting policy, revised March 2018, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:30 p.m. It read in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care). A resident's ability to perform ADLs will be measured using clinical tools, including the MDS (minimum data set) assessment, functional decline or improvement will be evaluated in reference to the assessment reference date (ARD). Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate. II. Resident #24 A. Resident status Resident #24, age 85, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease and chronic obstructive pulmonary disease (COPD). The 8/30/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required setup or clean up assistance with eating and oral hygiene. He required substantial/maximal assistance with toileting hygiene, showering/bathing himself and upper and lower body dressing. B. Observations and resident interview On 10/10/24 at 4:03 p.m. Resident #24's finger nails were long and dirty. His fingernails extended past the tip of his fingers and had brown matter underneath them. Resident #24 said he wanted his fingernails cut. He said he did not know the last time his fingernails were trimmed. C. Record review The ADL care plan, revised on 3/10/23, documented Resident #24 had an ADL self-care performance deficit related to cellulitis, deep vein thrombosis (DVT), anaphylaxis episode and history of venous ulcers. The resident preferred a sponge bath as an alternative when he did not want a shower. Interventions included bathing/showering, checking nail length and trimming and cleaning on bath days and as necessary, reporting any changes to the nurse, offering a sponge bath two to three times a week and providing a sponge bath when a full bath or shower could not be tolerated. D. Staff interviews Licensed practical nurse (LPN) #6 was interviewed on 10/10/24 at 4:05 p.m. LPN #6 said Resident #24's fingernails were long and dirty. She said staff should be washing residents' hands all the time. She said residents' fingernails should be trimmed every couple of weeks. She said if the resident's nails were not trimmed, the residents could hurt themselves. She said staff should be keeping the residents' nails clean and trimmed. The director of nursing (DON) was interviewed on 10/15/24 at 5:00 p.m. The DON said nail care should be done as needed and should be checked during bathing. She said CNAs should be cleaning residents' hands and checking their nails. She said the nurses would do the trimming of fingernails when necessary. The DON said staff should be cleaning residents' hands multiple times per day to keep their hands and nails clean.

Based on observations, record review and interviews, the facility failed to ensure residents were provided services that meet professional standards for one (#51) of one resident out of 39 sample residents. Specifically, the facility failed to ensure Resident #51's leg wraps for lymphedema (a chronic condition that causes swelling due to a buildup of lymph fluid in the body) were ordered in a timely manner. Findings include: I. Resident status Resident #51, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included lymphedema, heart disease, and obesity. The 9/24/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She was dependent on staff for dressing and personal hygiene. II. Record review A progress note documented by the nurse practitioner (NP), dated 9/17/24 at 11:15 a.m., revealed Resident #51 was referred to the lymphedema clinic and the NP requested the facility obtain lymphedema wraps for the resident. -However, a physician's order for the lymphedema wraps was not entered into Resident #51's electronic medical record (EMR), which resulted in the resident not receiving the recommended treatment. The care plan for risk of skin breakdown was revised on 8/28/23. An intervention was to administer treatments as ordered. There was not a care plan for edema (swelling) or use of the wraps. III. Staff interviews The director of nursing (DON) was interviewed on 10/14/24 at 1:00 p.m. The DON said they had problems finding someone to come to the facility to measure Resident #51's legs for the lymphedema wraps. She said measuring the legs was a specialized service and there were specific companies designated to do so. The regional clinical consultant (RCC) sent an email on 10/14/24 at 1:48 p.m. which indicated the DON had entered a physician's order into Resident #51's EMR for the leg wraps and documented a progress note. The RCC said the facility was working with the director of rehabilitation to get the needed measurements.

Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#18) of one resident out of 39 sample residents. Specifically, the facility failed to arrange optometry services timely for Resident #18. Findings include: I. Resident #18 A. Resident status Resident #18, age 67, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body). The 9/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of nine out of 15. He required partial/moderate assistance for upper body dressing and personal hygiene. He required supervision or touching assistance with oral hygiene. The assessment indicated the resident had adequate vision and had corrective lenses. B. Resident observation and interview On 10/9/24 at 3:41 p.m. Resident #18 said he had asked to be seen by the eye doctor and had not been seen. He said he needed glasses to see. During the interview, Resident #18 was not wearing eyeglasses. C. Record review A 9/19/24 admission summary note documented Resident #18 indicated that he would like a dental and vision referral. The activities care plan, initiated on 9/23/24, documented Resident #18's activities of interest included driving, cooking barbeque, camping, hiking, watching preferred television choices, going outdoors, socializing with peers and listening to music such as R&B and oldies. Interventions included staff making sure the resident had his glasses on during group activities of interest due to a visual deficit. The ancillary care plan, initiated 10/14/24, documented Resident #18 would have access to audiology, dental, podiatry and ophthalmology services quarterly per request and/or as needed. Interventions included ensuring eye health and visual acuity, performing regular eye exams to detect vision changes and eye conditions, as tolerated prescribing and managing eyeglasses or contact lenses, if needed treating common eye conditions (cataracts, glaucoma) and educating Resident #18 on eye care and safety measures. -There was no documentation in Resident #18's electronic medical record (EMR) to indicate the resident had been referred to see the eye doctor. -A consent for vision services was not obtained until 10/4/24. D. Staff interviews The social services director (SSD) was interviewed on 10/15/24 at 12:46 p.m. The SSD said when she started working at the facility in October of 2023, none of the residents had been reviewed or referred for ancillary services. She said most of the new admissions were caught up, however, she said recently she had struggled with referring residents for ancillary services, such as vision services timely. She said she was doing the best she could but it had been hard for her to keep up. The SSD said ancillary services were offered every quarter and upon admission. She said she went over ancillary services during care conferences or in conversation. She said she would ask the residents if they needed vision, hearing or dental services. The SSD said the eye doctor came to the facility quarterly. She said the eye doctor would be at the facility on 10/22/24 and she would make sure Resident #18 was seen. The director of nursing (DON) was interviewed on 10/15/24 at 5:00 p.m. The DON said ancillary services, including vision services should be offered to all residents. She said she did not know how often residents were referred for ancillary services. She said residents needing to be seen by the eye doctor should be seen every six months. The DON said social services was responsible for scheduling ancillary appointments, along with the interdisciplinary team (IDT) involvement. She said ancillary services should be arranged and scheduled timely. The DON said Resident #18 should have been seen by the eye doctor more timely. The nursing home administrator (NHA) was interviewed on 10/15/24 at 6:00 p.m. The NHA said social services was responsible for scheduling ancillary services. She said she recognized the SSD needed help to be able to submit referrals and complete her job duties timely. She said ancillary services should be submitted timely.

Based on interviews and record review, the facility failed to ensure one (#65) of two residents reviewed for accidents out of 39 sample residents received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically, the facility failed to implement a plan of care that adequately addressed the risks posed to Resident #65 and other residents in the facility due to Resident #65's smoking habit and history of self-inflicted injury from fire. Findings include: I. Facility policy and procedure The Smoking policy, dated 6/17/24, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Smoking is a privilege. To be an independent smoker, residents must demonstrate that they are safe to smoke by staff assessment and must comply with all smoking rules. II. Resident #65 A. Resident status Resident #65, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included schizophrenia (a chronic illness that effects a persons thoughts, feelings and behaviors), history of suicidal behavior and third degree burns over more than 60% of his body. The 9/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident needed set up assistance with eating, oral hygiene, toileting and personal hygiene. B. Record review The admission assessment was completed on 9/19/24 by licensed practical nurse (LPN) #7. It documented the resident did not smoke and did not use tobacco products. A smoking assessment was completed on 9/25/24 at 5:08 p.m. by registered nurse (RN) #1. The assessment revealed Resident #65 smoked, smoked over ten times per day, was able to light his own cigarettes and was able to smoke without supervision. The trauma care plan, initiated on 10/10/24, revealed Resident #65 was at risk for decreased psychosocial well being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing related to being in a self inflicted fire or explosion and triggered by conversations about this event when not prompted or initiated by self. The resident's goal was to demonstrate effective coping strategies. The interventions included monitoring Resident #65 for signs and symptoms of decreased psychosocial wellbeing, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and reporting abnormal findings to the physician, and avoid triggering the resident by not engaging or initiating questions regarding the self inflicted fire that resulted in his burns. The psychosocial care plan, initiated 10/10/24, identified the resident had a history of hallucinations, suicidal ideations and delusions which were controlled by medications. The goals were to have the residents' psychosocial needs met and minimize the risk for decline in mood and behavior. The interventions included allowing the resident to voice his feelings and frustrations as indicated and to observe for tearfulness, increased agitation and decreased participation in care. -A review of Resident #65's comprehensive care plan did not reveal a care plan that addressed the resident's smoking. -A review of Resident #65's electronic medical record (EMR) did not include documentation to indicate the facility's plan to monitor Resident #65 who had a history of self-inflicted burns, smoked independently and had possession of a lighter III. Staff interviews The social service director (SSD) was interviewed on 10/15/24 at 12:29 p.m. The SSD said Resident #65 obtained the burns on his body by dousing himself in gasoline at a gas station and then lighting himself on fire two years ago prior to his admission to the facility. She said he was hallucinating and hearing voices when that incident occurred and was subsequently diagnosed with schizophrenia and put on medication. She said the facility only had one supervised smoker (this was not Resident #65). She said she was not aware that Resident #65 was not supervised during smoking. The SSD said there should have been a safety plan in place and a care plan to address Resident #65's safety when smoking. She said Resident #65 should be supervised when smoking due to his history of self inflicted burns. RN #2 was interviewed on 10/15/24 at 1:21 p.m. RN #2 said she was aware of how Resident #65 obtained the burns on his body and she was not aware he was smoked. She said RN #1 usually was responsible for completing the smoking assessments for residents. RN #2 said upon reflection she did remember seeing cigarettes and a lighter on the resident's dresser in his room recently. The assistant director of nursing (ADON) was interviewed on 10/15/24 at 1:24 p.m. The ADON said she was aware of how Resident #65 obtained the burns on his body. She said he was not safe to smoke unsupervised. The NHA and the director of nursing (DON) were interviewed together on 10/15/24 at 1:49 p.m. The DON said Resident #65 denied smoking upon admission. She said the resident did not exhibit concerns of fire safety upon admission. She said she was not aware the resident currently smoked. The NHA said Resident #65 was able to smoke independently. She said he deserved the autonomy to be able to smoke until he showed otherwise. IV. Facility follow-up The NHA provided documentation on 10/15/24 at 6:00 p.m. that showed Resident #65 would be evaluated daily to continue to smoke independently for the next 90 days to ensure the safety of Resident #65 and the residents in the community.

Based on observations and interviews, the facility failed to ensure one (#3) of one resident out of 39 sample residents were free of significant medication errors. Specifically, the facility failed to ensure the insulin pen was primed prior to administration for Resident #3. Findings include: I. Professional reference According to the Tresiba product information, dated July 2022, retrieved on 10/16/24 from https://www.mynovoinsulin.com/insulin-products/tresiba/support-and-resources/videos-and-resources.html, Priming the pen, turn the dose selector to 2 (two) units, hold the pen with the needle pointing up, tap the pen gently to allow any air bubbles to ride to the top, depress and hold the dose button with the needle pointing up. II. Facility policy and procedure The Administering Medications policy and procedure dated, April 2019, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:00 p.m. It revealed in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI (quality assurance and performance improvement) committee to inform process changes and or the need for additional staff training. Insulin pens containing multiple doses of insulin are for single-resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident. III. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus. The 8/30/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Observation On 10/10/24 at 9:02 a.m. licensed practical nurse (LPN) #2 was preparing and administering medications for Resident #3. LPN #2 entered the room of Resident #3 with the resident's Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml. LPN #2 turned the dial on the insulin pen to read 50 units, cleaned the injection site on the resident's abdomen and administered the insulin to the resident. -LPN #2 did not prime the insulin pen prior to administering the insulin to the resident. C. Record review The October 2024 CPO documented the following physician's order: -Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml (milliliter). Inject 50 units subcutaneously in the morning for diabetes mellitus, ordered 8/23/24. IV. Staff interviews LPN #2 was interviewed on 10/10/24 at 9:28 a.m. LPN #2 said when she administered insulin, she would turn the dial on the insulin pen to the ordered unit dose. LPN #2 said she would clean the skin with an alcohol prep pad then injects insulin being sure to rotate injection sites. The director of nursing (DON) and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:02 p.m. The DON said an insulin pen should be primed prior to administration. She said the insulin pen should be dialed to two units and the insulin expelled from the pen prior to drawing up the prescribed dose of insulin The DON said it was important to prime the insulin pen to ensure the resident had received the full dose of insulin.

Based on observation, record review and interviews, the facility failed to ensure two (#43 and #116) of four residents reviewed out of 30 sample residents were as free from accident hazards as possible. The facility failed to assess and implement interventions to prevent Residents #43 and #116 from falling. As a result, Resident #43's hospital records indicated a head cat scan was completed in comparison from 12/7/22 and 12/11/22 and revealed a head injury; and Resident #116 was not fully assessed after an unwitnessed fall for potential injuries. Resident #43 had a history of falls prior to initial admission to the facility on [DATE]. The facility was aware of the resident's fall risk upon admission. The resident's medical record revealed the resident had diagnoses of dementia and [CONDITION(S)] with increasing confusion, poor safety awareness, impulsivity and an unsteady gait. The resident often refused to request assistance or failed to request assistance. The resident needed extensive assistance with all activities of daily living, particularly with transfers, toileting needs and bed mobility. There was no documentation that the resident refused care and assistance when it was provided. There were no documented notes that revealed the resident's ability to use the call light was assessed or that other methods of requesting staff assistance were pursued. The resident had two unwitnessed falls from 12/6/2021 to 12/11/22. On 12/6/2022, the resident's fall occurred while going to the bathroom unassisted and resulted in her hitting her head and she developed a fist size bump on her head. She was sent to the emergency room for a cat scan. The fall on 12/11/2021 occurred as the resident was going to the bathroom unassisted. The facility failed to effectively implement care-planned interventions to prevent a fall where the resident sustained an injury, new acute subdural hemorrhage along the cerebral falx and left tentorial leaflet of her head, and occipital pain. Additonally, the facility failed to: -Prevent Resident #116, who was assessed to be at a high risk for falls, from experiencing a fall; -Fully assess Resident #116 for injuries and physical decline after having an unwitnessed fall; and, -Assess care-planned interventions after the resident's fall and implement interventions to address contributing factors of the residents fall, for Resident #116. Findings include: I. Facility policy The fall management policy revised on 9/10/19 provided by the corporate nurse consultant (CNC) on 2/14/22 at 9:46 a.m. read in pertinent part: The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Procedure: -A fall risk evaluation will be completed within the first twenty-four hours following admission, using the facility fall risk evaluation. A baseline plan of care will be initiated for residents evaluated to be at risk. -Please note interventions are to be re-evaluated when a resident falls. The following interventions are to be initiated and or considered: -Assess the environment and make appropriate changes, bed in lowest position, placement of furniture, lighting, personal items within reach, non-slip footwear, night light, walker, wheelchair within reach if applicable. The call light and fluids should be within reach of the resident. -Positioning devices (low bed, fall mat, defined perimeter mattress, bolsters). -Complete a thorough analysis of fall - time of day, location of fall, causative factors. Identify whether the interventions were in place at the time of the fall. Interview staff and residents if able to identify potential causative. -Educate and communicate implemented interventions to direct care staff via verbal report. -Document in the computer the resident's response to interventions and alter interventions if they are not successful. -If a resident experiences a fall with head injury, the fall is unwitnessed, or a resident self-reports a fall, neurological checks will be initiated. -Review the IDT risk management to ensure complete and appropriate interventions have been implemented. -Review that a care plan has been initiated. -Provide revisions to the plan of care as necessary after falls II. Resident #43 A. Resident status Resident #43, age 80, was readmitted on [DATE]. According to the February 2022 computerized physician orders (CPO), pertinent diagnoses included [CONDITION(S)], [CONDITION(S)], dementia, arthritis and anxiety. The 12/29/21 minimum data set (MDS) assessment revealed the resident had a moderate cognitive deficit with a brief interview for mental status (BIMS) score of eight out of 15. She required extensive assistance with two people for bed mobility and toileting. Extensive assistance of one person for transfers, dressing and hygiene. She had supervision of one person for meals. She had no rejection of cares. She was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning and moving on and off the toilet. She had no pain. She had a history of falls with injury. B. Observations Resident #43 was observed on 2/9/22 at 10:30 a.m. seated in the dining room. She was slouched in her wheelchair and looked around at the other residents in the room. She had one foot pedal on the wheelchair but her feet were on the ground. She had regular socks on without shoes. She wore oxygen and she was just sitting three feet from a table. Resident #43 was observed on 2/10/22 at 12:05 p.m. in the dining room having lunch. She slouched in her wheelchair and her feet were on the floor. She had socks on with no shoes. Resident #43 was observed on 2/14/22 at 9:45 a.m. sitting in front of her television. She had a fall mat up against the wall in her room and her feet were on the ground. There was a call light on the bed next to her. The bedside table was set up in front of her. C. Record review The nurse note dated 12/7/21 at 12:10 a.m. for Resident #43, provided by the CNC on 2/14/22, read in pertinent part: At 10:25 p.m. nurse heard a patient scream out. Upon entering the residents room she was witnessed on the restroom floor parallel to the toilet seat. She was on her back holding the back of her head. Resident was alert and oriented to person and place.The resident stated she hit her head on the way down. Her vital signs were normal. Upon assessment the pupils were equal, round, and reactive to light and accommodation (PERRLA) and intact. Her hand grasps were equal, she was able to move all extremities and a fist sized bump was felt to the back of her head. No other injuries were reported by the resident or observed by this nurse. Resident remained on the ground with a pillow to support her head until paramedics arrived. Family was called with no answer and the physician was notified. Resident stated she was aware she needed to press the call light for assistance but was unsure why she did not use it. A non emergent transport company was notified for transport to the emergency room . The nurse note dated 12/11/22 at 9:01 a.m. for Resident #43 read in pertinent part: Resident #43 family members were visiting with her and told the nurse the resident had to use the restroom urgently. The nurse assisted the resident to the bedside commode and instructed the resident to use her call light when she was finished. Before transferring the resident to the commode she put on non skid socks. The nurse told a certified nurse aide (CNA) to check on the resident while she attended to another resident. The CNA told the nurse the resident was on the floor and she hit her head. The nurse told another CNA to go and get the registered nurse (RN). The director of nurses (DON) completed the head to toe assessment. She instructed the other nurse to call 911 because the resident was screaming in pain when moved. The paramedics arrived and transported the resident to the hospital. -The resident received one assist for toileting and was left alone in the bathroom. She was not steady on her feet and she should have not been left alone. -The baseline care plan for Resident #43 dated 11/28/21 was blank and incomplete for fall assessments. The activities of daily living (ADL) care plan for Resident #43 dated on 12/5/21 read in pertinent part; Resident #43 had a decline in cognition and recent hospitalization due to a fall. The resident risk for complications related to immobility, including contractures, skin-breakdown, and fall-related injury will be minimized through the review date.The resident will improve and maintain current level of mobility through the review date. Interventions were to provide call light within reach, encourage the use of it, and answer promptly. Use a wheelchair and walker for mobility. Invite the resident to activity programs that encourage physical activity, physical mobility, such as exercise group, walking activities to promote mobility. Monitor, document and report any signs and symptoms of immobility: contractures forming or worsening, skin-breakdown and fall related injury. Provide a gentle range of motion as tolerated with daily care. Provide supportive care, assistance with mobility as needed. Document assistance as needed. Physical and occupational therapy referrals as ordered. The fall care plan for Resident #43 revised on 12/5/21 read in pertinent part; Resident #43 was at risk for falls related to decreased mobility, history of falls, and medication use.The resident's risk for falls will be minimized through the review date. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident and family and caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in the wheelchair. Physical and occupational therapy evaluation and treatment as ordered.Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter and remove any potential causes. Educate family caregivers and the interdisciplinary team as to the causes. One intervention was updated on 1/13/22 to stay with the resident while using the bedside commode. No other interventions were added or updated after the 12/7/21 fall or the 12/11/21 fall. Hospital assessment note on 12/11/22 read in pertinent part: Resident #43 complains of headache from a fall on 12/10/22 where she struck her head on the cabinet. She reports ongoing occipital head pain, denies vision or hearing change, focal numbness or tingling or weakness. There was no nausea, vomiting or loss of consciousness, confusion or other related symptoms. Head cat scan on 12/11/22 revealed : new acute subdural hemorrhage along the cerebral falx and left tentorial leaflet of her head compared to the one on 12/7/22. The plan was to check orthostatic blood pressure, evaluation from physical and occupational therapy and admit her to the hospital for observation. She was readmitted to the facility on [DATE]. Fall assessment on 12/6/21 for Resident #43 read in pertinent part; According to the nurse, Resident was aware she needed to press the call light for assistance out of bed but was unsure why she did not. She said she hit her head when she fell and had a fist size bump developed. She was sent to the emergency room for an assessment. Fall assessment on 12/22/21 for Resident #43 read in pertinent part; The nurse assisted the resident to the bedside commode, the nurse instructed the resident to call when finished, the nurse also instructed resident not to stand up without help, the nurse gave the resident her call light and taught the resident how to use her call light as usual. Before transferring resident to the commode, the nurse put non skid socks on resident.The nurse told the residents CNA to go check on the resident while the nurse was attending to another resident that also needed help.The CNA later came to the nurse and said resident was on the floor, apparently bump her head. The nurse who happened to be the director of nurses (DON) came and did the head to toe assessment and told another nurse to call 911 because the resident was screaming in pain when moved. The fall risk evaluation for Resident #43 dated 12/5/21 and 12/6/21 revealed: The resident was alert and oriented and had balance problems while standing, gate problems: jerking, unstable when [NAME], unsteady gait, shuffling gait. Required the use of assistive devices such as a walker, cane, wheelchair and furniture. The fall risk evaluation for Resident #43 dated 12/11/21 revealed: The resident had periods of confusion. And gait and balance were normal. She had balance problems while walking and standing. Decreased muscular coordination and change in gait when walking through a doorway. The December 2022 computerized physician orders (CPO)s for Resident #43 revealed; -[MEDICATION(S)] sodium gel one percent ( % ). Apply to both knees topically four times a day. Order date was 11/26/21. -Monitor pain every shift using zero to 10 pain scale every shift. Order date was 12/09/2021. The December 2022 medication administration record (MAR), revealed Resident #34s pain level was zero to two. D. Interviews Resident #43 and her family were interviewed on 2/14/22 at 12:23 p.m. Resident said she did have a few falls but she was ok. She was eating lunch in her room and family sat at bedside. Family said he was there when she fell and hit her head. He said she was left alone in the bathroom and she tried to get up and fell . He said she did not know how to use the call light and had multiple falls in the past. Certified nurse aide (CNA) #2 was interviewed on 2/14/22 at 1:00 p.m. She said Resident #43 needed assistance for all cares. She said she was confused and did not use her call light. She said the resident was in the dining room a lot with activities and not left alone. She tried to get up on her own a few times and fell . She said the resident had a fall mat beside her bed. Director of therapy (DOT) was interviewed on 2/14/22 at 1:35 p.m. He said Resident #43 came to the facility from home with worsening dementia and multiple falls. He said she was doing well when she first arrived at the facility but over time she made little progress during therapy and had decreased safety awareness. He said she failed to understand how or when to use the call light. The resident was very impulsive and would get up on her own and then fall. She was now a max assist for bed mobility, transfers and toileting. Recommendations to staff to have constant supervision for the resident, a fall mat and a low bed position for safety. He said he verbally told the facility staff as he was not responsible for updating care plans. He did recommend restorative rehabilitation for continued support. CNA #4 was interviewed on 2/14/22 at 2:30 p.m. He said Resident #43 was not on restorative rehabilitation services. The director of nurses (DON) was interviewed on 2/14/22 at 4:15 p.m. She said when a resident fell , an RN assessment was completed. When the fall was unwitnessed, neurological (neuro) assessments were completed every 15 minutes for the first hour, then every 30 minutes for four hours and then every 24 hours. Resident #43 did not have any neuros completed because she was sent out of the hospital for assessments. The interdisciplinary team which was the risk management team met to discuss all falls and update interventions in the care plan. The staff followed the interventions to keep the resident as safe as possible. She did the immediate assessment for Resident #43 and sent her to the hospital because she complained of severe pain. When a resident was a high fall risk, the staff had to stay with the resident for added safety. She said Resident #43 was a high risk resident and she had her call light next to her. -Even though the resident was sent out to the hospital she returned within 48 hours. The record should have indicated neurological checks were continued upon her return. II. Resident #116 A. Resident status Resident #116, age 80, was admitted on [DATE] and was discharged from the facility to the hospital on 10/16/21, the resident did not return to the facility. According to the October 2021 computerized physician orders (CPO) diagnosis included history of repeated falls, generalized muscle weakness, chronic fatigue, need for assistance with personal care and cognitive communication deficits. The 10/6/21 discharge minimum data set (MDS) assessment, revealed the resident had intact cognition with a brief interview for mental status (BIMS) and was able to obtain a score of 14 out of 15 with cuing on one of the recall questions. The resident had no negative behavioral expressions and did not reject care assistance. The resident had no limitations in either the upper or lower extremities; but was not steady when standing and walking and needed the assistance from staff to stabilize; and used a walker assistive device while walking or a manual wheelchair to get around the facility. The resident needed extensive assistance from two staff for transfers, walking and showering/bathing; and extensive assistance from one staff with bed mobility, using the toilet, dressing and grooming. The resident was not on a toileting program to maintain and manage continence and was occasionally incontinent of bladder and frequently incontinent of bowel. The resident was receiving occupational and physical therapy. B. Preadmission history Hospital report dated 10/29/21 read in pertinent part: Patient admitted to the hospital on 10/24/21. History of present illness: chief complaint: weakness, ambulatory dysfunction, falling, and shortness of breath. Patient with no reported medical history besides admission to the hospital from 8/6/21 to 8/25/21 for COVID-19 related pneumonia and acute hypoxemic [CONDITION(S)]. The patient was then discharged to an inpatient rehabilitation facility from 8/25/21 to 9/7/21. Then discharge to home. Patient was admitted into the emergency room for severe generalized weakness, ambulatory dysfunction and repeated falling at home and continued shortness of breath. Emergency medical services (EMS) reports that on arrival the patient was unable to get up out of a chair and was unable to stand. He has been on one liter of oxygen at baseline since he left the hospital. He denies fever, dysuria, hematuria. He states he feels worse than when he had COVID-19 originally. Physical Exam: General appearance: alert, awake; .Neck: no jugular vein distention (JVD) at the sides of the neck, no masses or swelling; .Extremities: moves all, no calf tenderness; Musculoskeletal: normal inspection; .Neurologic/ central nervous system (CNS): alert, oriented X3 (person, place and time) C. Resident interview and observation Resident #116 was no longer residing in the facility; observations and interviews were not possible. D. Fall investigation Fall investigation report quality assurance documentation dated 10/2/21; investigation completed by the previous director of nursing (DON), documented the resident had a fall on 10/2/21 at approximately 2:30 a.m. The investigation findings report revealed: Nursing description: the nurse was called to the resident's room by a certified nurse aide (CNA). Upon entering room the nurse observed the resident to be lying on his back on the floor with head towards room door near the bathroom. The resident had on non-skid socks; there were no wet spots of liquids on floor; and the call light was on the resident's bed. The resident had a bowel movement accident. The report documented the Resident #116 told staff I didn't hurt myself, I was trying to get to the bathroom and lost my balance. When asked why the resident did not use a call light for assistance, the resident said I just really had to go. Per the investigative report Resident #116 was assessed by the nurse on duty and was found to be free from bumps, bruises or abrasions; and the resident's range of motion and hand grip was within normal limits and at his baseline. The resident level of alertness and orientation was assessed to be at baseline. The nurse initiated neurological checks to assess potential nervous system damage related to the resident fall. The resident denied pain at the time for the post fall assessment. Nursing staff assisted the resident off the floor and took him to the bathroom to get washed up. The resident went back to bed with the call light left within reach. The nurse reminded and encouraged the resident to use the call light for assistance. The resident was not sent to the hospital for further assessment. The neurological assessment flow sheet was examined and the facility nurse started the first neurological checks at 2:45 a.m. The purpose of the neurologic assessment was to detect changes in level of consciousness; pupil response; motor function: hand grasp and motor functioning of the upper and lower extremities; pain response; vital signs (blood pressure, temperature, pulse and respiration in the appropriate columns); and additional observations of potential seizures, headaches, vomiting and paralysis. Review of the neurological flow sheet initiated after the resident's fall revealed the nurse stated neurological checks on 10/2/21 at 2:25 a.m. Per the documented schedule the nurse was supposed to conduct scheduled neurological checks every 15 minute for the first hour; every 30 minutes for the next two hours; every hour for the next three hours; every four hours for the next 16 hours; and every eight hours for the next 72 hours. -The nurse failed to complete all neurological checks and missed the last 15-minute check at 3:45 a.m. and the next four 30 minute checks. The documenting revealed the nurse did not conduct the scheduled neurological checks because the resident was asleep. -One of the purposes of the neurological checks was to ensure the resident was not experiencing serious side effects of potential head injury. The investigation report identified the following predisposing and contributing factors that could have been contributing factors of the resident's 10/2/21 fall: -Low/poor lighting in the resident room; -Gait imbalance previous identified as a contributing factor to the resident's risk of falling; -Prior assessment identifying the resident as being at a high risk for falls; -Incontinence status; -Impaired memory; -Having a fall in past 30 days; -Recent admissions less than 72 hours prior; -Ambulating without assistance and being on the way to the bathroom. The investigation report failed to document a review of the resident's care plan and current interventions to minimize the risk for the resident falling including assessment of current interventions, predisposing and contributing factors, and development and implementing additional interventions to mitigate the identified contributing factors to the resident 10/2/21 fall. The investigation also failed to identify or assess the missing 15-minute neurological checks. E. Record review Hospital physical therapy session progress note dated 9/27/21, read in pertinent part: Diagnosis: generalized weakness, falls, shortness of breath, and long [NAME] effects of COVID-19. Precautions: falls, oxygen therapy, and confusion. -Patient alert and oriented however does present with acute confusion throughout treatment (i.e. forgetting patient's role, requiring multiple cues for safety awareness .). -Assessment/plan: Patient has demonstrated a decline in functional mobility since admission. Now requiring maximal assistance for transfers and moderate directed assistance (MODA) for short distance ambulation. Patient presenting with deficits in safety awareness, activity tolerance, gait, strength, balance, and gross functional mobility. Patient will benefit from aggressive, daily therapeutic intervention to optimize functional independence and lower fall risk. Hospital occupational therapy session progress note dated 9/27/21, read in pertinent part: Confusion present. Able to follow simple commands with cueing for attention to task. Maximal assistance to move from lying to sit transfer, multiple rest breaks mid-transfer. Limited by weakness and fatigue. Fall risk assessment dated [DATE] revealed Resident #116 was at a high risk for falls related to a number of factors including three or more diagnoses increasing risk of the resident falling. The resident had experienced three or more falls in the past 90 days; was having periods of confusion; and was having problems with walking and balance while standing and turning; and required the use of an assistive device while waking, due to unsteady gait. The resident's health and physical report dated 9/30/21 released the resident was presenting with frequent falls and significant fatigue. Physical therapy evaluation and plan of treatment dated 9/30/21, revealed: -Functional Assessment: Bed mobility needed maximum assistance; transfers needed maximum assistance. Gait level surfaces needed contact guard assistance and assistive device: front wheeled walker. Walked 15 feet, observed to have forward trunk lean, decreased step length bilaterally, wide base of support, and decreased heel strike/toe off, flat weight acceptance bilaterally. -Fall Predictors: Excessive postural sway on initial stance, impulsive ambulation and reduced insight for unsafe situations. -Assessment summary impressions: Patient now presents with decreased strength, balance, and gait abnormalities leading to potential falls risk. Skilled physical therapy required to address aforementioned deficits in order to maximize safety and allow for discharge back into the community. -Basic Mobility .Sit to stand substantial needed maximal assistance; chair or bed to chair transfer needed substantial/maximal assistance; toilet transfer attempted but not completed; walking needed partial/moderate assistance. The comprehensive care plan, initiated 9/30/21 read in pertinent part: The resident is at high risk for falls related to generalized weakness secondary to past COVID-19 and pneumonia diagnosis The goal for the resident was to minimize the risk for falls. Interventions included: -Anticipate and meet the resident's needs. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. -The resident needs prompt response to all requests for assistance. -Educate the resident and caregivers about safety reminders and what to do if a fall occurs. -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Resident on isolation until 10/14/21 due to new admission quarantine requirements for not being fully vaccinated. -Resident needs encouragement to ask for assistance with transfers. -Ensure that the resident is wearing appropriate footwear or non skid socks when ambulating or mobilizing in the manual wheelchair. -Physical therapy to evaluate and treat as ordered and as needed. -The resident needs a safe environment with: the bed in low position at night and personal items within reach. There was no care plan focus for toileting assistance or management of any activities of daily living (ADL) needs; and no interventions related to activity fatigue, muscle weakness, unsteady gait/balance and intermittent confusion. Resident #116 had a fall in the early hours of 10/2/21 there were not notes in the resident medical record to document the details of the fall; the assessment of the resident following the fall; status of potential injuries after the fall; consultation with the resident's physician after the fall; or notification to the resident's representative. (cross referenced to F580). Skilled nursing note dated 10/3/21 at 8:42 a.m., read in pertinent part: Late entry: Resident is alert. ADL/function: Resident has an unsteady gait requiring supervision. Resident has impaired balance. Resident has weakness. Mood/behavior: resident is impatient or anxious, calls a lot, failure to thrive.Nursing to manage medication administration, observe for behaviors or any changes in condition and document and report -There was no mention of the resident falling in the skill note documented above. Interdisciplinary team (IDT) note dated 10/4/21 at 10:30 a.m. read: IDT team meets weekly to discuss anticipated needs include: recent fall; need for moderate/maximum transfers assistance; help dressing; physical therapy; occupational therapy; speech therapy; attempt; poor cognition. -The note did not explain any of the noted areas, assessment or outcome of the IDT meeting. Encounter note dated 10/5/21 at 12:00 a.m., read in pertinent part: Date of service: 10/5/21. Reason for visit: admission history and physical. History of present illness: Patient is seen in his room lying flat in bed awake and alert and in a good mood. He remains generally weak but denies being short of breath, he appears to have some short-term memory deficit but does not carry a diagnosis of dementia. He is aware of his memory difficulty. He is not complaining of headache, change in vision, change in speech or hallucinations or depression. possible cognitive deficit as above he has evidence of short-term memory deficit on today's evaluation which one cognitive assessment in the facility. -There was no specific mention of the residents 10/2/21 fall in the facility and no assessment or further recommendations following the fall. IDT- risk management review note dated 10/5/21 at 8:03 a.m., read: Date of incident: 10/2/21. Type of incident: unwitnessed fall. Root cause: cognitive and mobility deficit. Treatment required: N/A (not applicable). Interventions put into place: resident encouraged to use call light and ask for assistance. Referrals made: N/A; continue with therapies . Skilled nursing note 10/7/21 at 3:35 p.m., read in pertinent part: Resident is alert. ADL/function: Resident has weakness. Resident has paralysis. Resident has no complaints of pain. Encounter note dated 10/8/21 at 12:00 a.m., read in pertinent part: Date of service: 10/8/21. Reason for visit: recent fall. Patient seen and examined today in his room, lying in bed, no acute distress. He is seen today to follow-up on reported fall from 10/2/21. Patient does not recall the fall however, he does deny any pain at this time. He is currently seen stable on supplemental oxygen and continues to deny any dyspnea, cough or chest pain/pressure. Patient followed by speech therapy in addition to physical and occupational therapy. He continues with significant fatigue during sessions but does feel that he is making progress.Patient denies further complaints at this time and nursing staff notes no further acute issues with the patient. Diagnosis and assessment plan: fall - Patient sustained a fall on 10/2/21 with no injuries. He continues to work with therapy though has continued fatigue. Possible cognitive deficit; as above he has evidence of short-term memory deficit on today's evaluation of one cognitive assessment in the facility. Skilled nursing dated 10/12/21 at 11:54 a.m., read in pertinent part: ADL/function: Resident does not weigh bear. Resident has an unsteady gait requiring supervision. Resident has impaired balance. Resident has weakness. -This note shows a decline in ability to be [TRUNCATED]

Based on observations, record review and interviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (#1 and #3) of six sample residents reviewed for accidents. Specifically: Resident #1: The resident was assessed by an occupational therapist and was recommended wheelchair modifications which included elevating leg rests with foot pedals. The use of leg rests was not care planned or implemented on a consistent basis. Without the leg rests, the resident was required to hold his legs up for the duration of transport in his wheelchair. On 5/19/16, the resident was being pushed down the hallway in his wheelchair by a nurse aide. There were no leg rests on the wheelchair. Before reaching his room, the resident dropped his legs, and his feet hit the floor. He fell forward out of his chair and onto the ground. The resident sustained [REDACTED]. Resident #3: The occupational therapist said the resident should use leg rests. The use of leg rests were not care planned or implemented on a consistent basis. Without the leg rests, the resident was required to hold her legs up for the duration of transport in her wheelchair. The findings included: I. Resident #1 A. Professional Reference According to Physical Medicine & Rehabilitation Principles and Practice, 5th Edition, 2010, pages 2098 and 2102: To properly specify a wheelchair, it is important to understand both the intentions and the abilities of the user .a physical examination should focus on aspects of the patient that will help justify the wheelchair and seating system, determine the most appropriate wheelchair and seating system, and assure that medical issues are appropriately addressed. Most wheelchair users require support for their feet and legs. This support is provided by footrests. Footrests are fixed, folding, swing-away, or elevating .It is essential to assess limitations in knee and foot range of motion .The feet must remain on the footrests at all times during propulsion, and therefore, some type of cradle in recommended .Footrests are commonly placed between 1 to 2 inches from the ground to ensure that sufficient ground clearance is maintained. B. Regulatory Reference A Colorado Board of Nursing representative documented the following on 7/20/16 at 12:58 p.m.: According to the Nurse Aides Act 12-38.1-102(5) Practice of a nurse aide or nursing aide practice means the performance of services requiring the education, training, and skills specified in this article for certification as a nurse aide. Such services are performed under the supervision of a dentist, physician, podiatrist, professional nurse, licensed practical nurse, or other licensed or certified health care professional acting within the scope of his license or certificate. Therefore the tasks within the CNA (certified nurse aide) scope of practice is limited to those tasks set forth in the Chapter 10 Rules, Section 7. You will note that assessment and determining nursing interventions and equipment needed (essentially planning care for the patient/client ) is not within the CNA scope of practice as set forth in CRS12-38.1-102 (5) and the State Board of Nursing Chapter 10 Rules, Section 7. C. Resident Status Resident #1, age 76, was admitted to the facility on [DATE]. According to the 5/2016 computerized physician orders, [DIAGNOSES REDACTED]. The resident was hard of hearing. The resident was admitted to Hospice services on 3/29/16. According to the 4/5/16 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. No mood or behavior symptoms were noted. He required extensive assistance for all activities of daily living (ADLs) except for eating, for which he required limited assistance. D. physician progress notes [REDACTED].>A physician progress notes [REDACTED].reports some pain while propelling in WC (wheelchair) in knees .WC dependent, wheeled by staff today .moderately HOH (hard of hearing) .mild sob (shortness of breath) with any exertion .BLE (bilateral extremity) edema trace shin down, ace wrap in place .appears very tired, sleepy in WC most day, quiet .Insure safe, structured environment. Expect ongoing decline in cognition, function, and nutritional status as disease progresses. A physician order, dated 3/23/16, read, OT (occupational therapy) to eval and tx (treat) 3 - 4 x(times)/week for 30 days (3/23/16 - 4/21/16). Tx to include ther(apeutic) ex(ercises), ther(apeutic) act(ivities), self care tasks, neuro re-ed(ucation), w/c management/mobility and pt(patient)/caregiver education. E. Therapy Services Assessment The resident's record included the following occupational therapy progress notes: -3/23/16 (Initial Evaluation): Patient referred to skilled OT due to exacerbation of impaired ADL performance, impaired balance, impaired coordination, impaired functional activity tolerance, impaired functional activity tolerance, impaired strength and impaired transfers indicating the need for OT to increase w/ADLs, provision of modalities and strengthening .very HOH .Pt (patient) presents this day with gross weakness, fatigue, limited B(oth) knee extension, L(eft) knee pain, lack of coordination, and edema which is limiting pt's participation in ADL tasks, functional mobility, and standing/sitting tolerance. -3/30/16: Pt measured and then trialed manual standard w/c 20 in width and 20 depth and demo(nstrated) increased upright posture with comfortcare cushion and also elevating leg rests added. Pt demo increase upright posture and neck/trunk alignment. -3/31/16 (Discharge Summary): Pt has been seen for skilled OT services for past week with pt now being d/c (discharged ) from therapy services due to transitioning per pt/family request to hospice care .Skilled interventions include modification of wheelchair components to enhance the patient's function/posture . F. Care Plan The safety awareness care plan, initiated 7/9/14 and revised 8/27/15, identified the resident was at high risk for injuries related to impaired decision-making abilities and impaired sensory deficits. The care plan did not address the resident's self-propelling abilities while in the wheelchair. There was no documentation in the care plan pertaining to the therapist's recommendation to use elevating leg rests on the resident's wheelchair. G. physician progress notes [REDACTED].>A physician progress notes [REDACTED].memory loss .mood/behaviors stable .knee pain .when propel in WC .asleep in WC .appears tired .BLE (bilateral extremities edematous at 3+, ace wrap in BLE .moves BLE weakly, raises RLE (right lower extremity. Diminished AROM (active range of motion) in LLE .cooperative on exam .spoke with (family member), updated on BLE edema . H. Accident - 5/19/16 The resident's record included the following nurses' notes: 5/19/16 9:11 p.m. - .Resident noted to be lying on Lt (left) side in hallway .Noted large hematoma to Lt side of head. Resident states head hurts and arm hurts .Per staff report CNA (certified nurse aide) was pushing resident to room and feet got stuck under chair and resident fell out of chair. Neuros started. 5/19/16 11:19 p.m. - CNA approaches nurse and states that (he/she) needs help. This nurse rounds the corner and sees the resident laying on the ground on his left arm, grabbing the side rail with his right arm, wheelchair behind him Res(ident) has large hematoma to L side of forehead with 2 small skin tears bleeding. Res states that his left arm hurts .CNA states that he was pushing the res down the hall in his wheelchair when his legs dropped and the resident fell forward out of the chair and onto the ground. Following fall resident c/o (complained of) head and L arm pain 9/10. PRN (as needed) pain medication given .MD and Hospice RN notified . 5/20/16 7:30 a.m. - Resident continues monitoring due to fall. Hospice nurse . was in around midnight to assess resident who c/o pain, prn morphine was given, neuro WNL (within normal limits). Wound due to fall was found on the left leg after being put in bed. Dressing order for tx (treatment) in the TAR (treatment administration record), will continue to monitor. 5/20/16 2:38 p.m. - X-ray result acute vertical oriented distal femur fracture, MD notified, order to send res(ident) to hospital . I. Emergency Department - 5/20/16 The Emergency Department report, dated 5/20/16, included the following documentation: Patient had a reported fall from wheelchair last night. It is reported patient fell forward striking his left periorbital area and injuring his left hip area. Had outpatient x-ray this morning that demonstrated a femur fracture .swelling to left periorbital/forehead region .alert and oriented to person .cooperative, appropriate mood and affect .As compared to the prior hip x-rays from 2009, there is a new fracture across the right femoral neck .acute left femoral neck fracture across site of previous internal fixation .There is a large scalp hematoma overlying the left greater the right frontal bones. This extends into the periorbital region. There is no evidence of fracture of the globe or abnormality in the retroseptal left orbit .The resident will be discharged in serious condition .Return to the emergency department for any worrisome or worsening symptoms. J. Return to Facility (5/20/16) and Subsequent Death (5/23/16) Nurses' notes from 5/20/16 to 5/23/16 included the following documentation: 5/20/16 9:35 p.m. - Res(ident) arrives back at facility via stretcher .Res is noted to be a/o (alert and oriented upon arrival, alert to place, self, date .This nurse receives report from __ ED (emergency department) from ___RN (registered nurse) .states that she is not sure he will even survive transport. Following report from ED, this nurse calls on-call hospice to speak with nurse that is with resident at (Hospital). Receives call back from (hospice nurse), this nurse voices concern that report does not sound good on the resident and asks why we are sending him back in his current condition. (Hospice nurse) states that They don't want him to die in the hospital and that they are sending him back to (Facility). (Hospice nurse) arrives at facility shortly after resident's arrival and goes to assess resident. (Hospice nurse) also give orders to increase Roxanol .for pain/dyspnea . 5/21/16 2:16 p.m. - Res(ident) cont(inues) on f/u (follow up) with head injury and left hip fx (fracture). Res remains on bed rest, medicated for pain prn x 2 .both doses effective for some relief and better at this time .Hospice Chaplain visited . 5/21/16 10:32 p.m. - .Res has periods of apnea as long a 30 seconds at times. O2 (oxygen) sats (saturation) mid 80's on 5 liters per nasal cannula. 5/22/16 6:31 a.m. - Pt (patient) slept throughout the night with occasional gurgling but seemed calm. Pain meds (medications) given as ordered. Pt sats @ mid 60's and continue to monitor. 5/22/16 11:36 a.m. - Resident continues unresponsive, shallow breathing .Re is on 8 L(iters) O2 per nasal cannula in his mouth because he is mouth breathing . 5/23/16 6:19 a.m. - Res was unresponsive with shallow breathing, found without vital signs at 0205 a.m Death pronounced .at 0250 . The Certificate of Death, filed on 6/6/16, indicated the cause of death was atherosclerotic cardiovascular disease with congestive heart failure. The Certificate listed the following two significant conditions contributing to death- left femur fracture and chronic obstructive pulmonary disease. K. Interview with Occupational Therapist The occupational therapist (OT) was interviewed on 7/19/16 at 10:25 a.m. She said the following: We picked him up (for skilled therapy services on 3/23/16) because he was having a big decline and eating less and less. He used to wheel himself around using his legs and then had the decline. Now he needed max assist, now he could push a couple strokes. He was having increased swelling. He was sliding out of his wheelchair, so we put him in a new wheelchair deeper but not as wide, placing him back further so as to not slide as much, and new cushion to help keep him back to prevent further sliding We put elevated leg rests. Before he was using his feet, but now he was no longer using his feet. He couldn't keep them up. He had to use the leg rests. If he was going from point A to point B, we put leg rests on him because he could no longer keep his legs up . The OT said the purpose of the leg rests was to move safely from place to place. They (residents) could fall, their leg could get stuck underneath .He (the resident) could only (self) propel a couple inches. The OT said new therapy recommendations were relayed by the director of rehabilitation services to the nursing staff at the morning meeting. They're supposed to continue that on a daily basis. L. Interview with Director of Rehabilitation Services The director of rehabilitation services (DRS) was interviewed on 7/19/16 at 11:00 a.m. She said the following: -Skilled therapy services were discontinued for the resident on 3/31/16 because he was transitioning to Hospice services. -In one of the morning meetings during the last week of March, she verbally told the nursing staff that the resident was provided with a new wheelchair, a new cushion, and new leg rests. -We try to let our residents be as independent as they can. As long as a wheelchair is fit for them and their feet are flat it (self propelling) is an option. It's at the discretion of the caregiver at the time to make that decision if that person can lift up their feet for a little distance. If going down the hall, then go get leg rests if (a resident) is not doing cueing or not having strength. -If (OT) says it's not okay to self-propel, they should automatically have the footrests on all the time. -Written therapy recommendations for the leg rests with foot pedals were not given to Nursing. -During the months of April and May, she often saw the resident in his wheelchair at different areas in the facility. The leg rests were frequently not attached to the wheelchair during these observations. The DRS said in a subsequent interview on 7/19/16 at 1:30 p.m. that residents' physical abilities, including the ability to lift their legs while being pushed in a wheelchair, could vary from day to day. She said, Earlier in the day they're stronger, at night they're tired. It depends on what's going on around them. M. Interview with the Consulting Clinical Officer The consulting clinical officer (CCO) was interviewed on 7/19/16 at 1:03 p.m. She said the following: -Leg rests were used for residents who did not have the ability to lift their legs. Therapy did not communicate to Nursing that the resident could not lift his legs or self propel in his wheelchair. -The use of leg rests with foot pedals while being pushed by a staff member in a wheelchair was not care planned for the resident. -When asked by the nurse aide if he wanted to use leg rests, the resident would sometimes say no. These refusals were not documented. -Prior to the accident, nurse aides had not received training on proper wheelchair ambulatory technique. -On the day of the accident (5/19/16), the resident demonstrated to the nurse aide that he could lift his legs. That was the determining factor for not putting leg rests on the wheelchair prior to transporting the resident from the nurses' station to his room. -Staff could not anticipate if or when a resident would drop their feet during wheelchair ambulation. N. Interview with Family Member A family member was interviewed on 5/24/16 at 7:36 a.m. and on 7/19/16 at 5:20 p.m. The family member said the following: -The resident was hard of hearing and would say No if he could not hear a question being asked by a staff member. During visits to the facility, the resident's hearing aides were not always observed to be in his ears, and the leg rests were almost never on his wheelchair. When staff told him about footrests, he didn't hear them .He would be okay to put them on if asked . Once you explained why he understood. -The resident had some dementia and COPD (chronic obstructive pulmonary disease). At a care conference on 5/2/16, family members brought up concerns about staff not using leg rests when moving the resident about in his wheelchair. -On several occasions, staff was observed to tilt the wheelchair backwards while transporting the resident in the facility so he was almost looking at the ceiling. I think they were finding a way to go from point A to point B quickly. O. Facility Failures The facility failed to provide adequate supervision and assistive devices to prevent accidents for resident #1 as outlined below: -Nurse aides were not trained in proper wheelchair ambulatory technique. -When the resident was discharged from skilled therapy on 3/31/16, the OT's recommendation to use the new leg rests while pushing the resident in his wheelchair was not communicated to the nursing staff in a written form. The care plan was not revised to reflect the new recommendation. -The facility did not have a policy or system in place to ensure residents' feet would remain on footrests at all times during propulsion, in accordance with professional standards. -Nurse aides were given the option to not use leg rests with foot pedals on a wheelchair if they determined a resident had the ability to lift his or her legs during ambulation. Nurse aides were acting outside their scope of practice when they made an assessment of a resident's physical abilities and condition, and when they determined the equipment needed for a resident. Because the resident's feet were not safely resting on foot pedals while he was being pushed in his wheelchair by a nurse aide down the hallway to his room, his feet got stuck under chair and fell out of chair. He sustained a left femur fracture and hematoma to his head. The left femur fracture was determined to be a significant condition contributing to his death four days later. II.Resident #3 A. Resident Status Resident #3, age 75, admitted to the facility on [DATE] and readmitted [DATE]. According to the 7/19/16 Admission Record, [DIAGNOSES REDACTED]. According to the 6/27/16 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required extensive assistance from one person for locomotion on and off unit. B. Record Review A fall risk care plan initiated 9/9/15 and revised 5/23/16 identified the resident's risk for falls due to inconsistent gait, psychotropic medication use, and multiple falls. Interventions included anticipating needs, ensuring call light was within reach, and encouraging the resident to ask for assistance and responding to requests promptly. A fall care plan initiated 9/15/15 documented the resident had multiple falls while at the facility and interventions included therapy evaluations and treatment, medication evaluations, walking programs, fall mat, frequent checks during meals, non-skid socks, and ensuring pathway was clear to bathroom. An activities of daily living (ADL) care plan initiated 10/8/15 and revised 5/25/16 identified the resident had a self-care deficit due to limited range of motion (ROM). Interventions included Resident prefers to self propel in wheelchair. A fall risk evaluation dated 7/18/16 documented the resident was at high risk for falls. Certified nurse aide (CNA) documentation was reviewed. Over the 14 days prior to review, the resident required assistance from staff for wheelchair locomotion on the unit 22 times and off the unit 20 times. According to the CNA documentation, the resident had performed these tasks independently five times. Nurse's notes were reviewed. The nurse's note dated 7/6/16 documented the resident refused placement of the footrests. There was no other documentation of refusal of footrests. C. Observations On 7/18/16 at 11:56 a.m. resident #3 was observed in her wheelchair being assisted to the table by CNA #4. The resident was not using her hands or feet to assist with the movement of the wheelchair. The staff member was pushing the wheelchair and there were no footrests in place. On 7/18/16 at 1:00 p.m. CNA #1 was observed pushing the resident in her wheelchair down the hall to the resident's room. The resident was not using her hands or feet to assist in the movement of the wheelchair and no footrests were in place. On 7/18/16 at 1:06 p.m. the resident was observed being pushed in her wheelchair into the hallway from her room by a visitor. The resident then asked CNA #2 to push her to the gym. CNA #2 pushed the resident from her room to the therapy gym without footrests in place. The resident did not use her hands or feet to assist in the movement of the wheelchair. The CNA did not ask the resident if she needed footrests or if she would be able to hold her legs up for the duration of the transportation. The CNA was observed walking at a standard walking pace during the transportation. D. Staff Interviews CNA #4 was interviewed on 7/19/16 at 10:00 a.m. She said that when they are pushing residents in wheelchairs without footrests, they need to go slowly. She said that some residents do not use footrests because they use their feet for mobility while in the wheelchair. She said that resident #3 varies with the level of assistance she needs and that sometimes she refuses the use of the footrests. She said that they ask her every time they push her if she needs the footrests. CNA #1 was interviewed on 7/19/16 at 10:07 a.m. She said that the use of footrests depends on the resident. She said that some residents are able to hold their legs up and others are not. She said that some refuse or even hide the footrests, and that when refusals happen, it is reported to the nurse so it can be documented. CNA #3 was interviewed on 7/19/16 at 10:17 a.m. She said that when they are transporting residents in wheelchairs, they are supposed to go slowly, watch their feet, and make sure they have a safe environment. She said the use of footrests was resident specific. She said that if residents pedal themselves independently, they don't use the footrests during transportation. She said that she had not had any residents refuse the use of footrests, but if they did, it would be documented in the chart. Occupational Therapist (OT) was interviewed on 7/19/16 at 10:47 a.m. She said that resident #3 will sometimes be almost catatonic and slow to respond, and is sometimes unable to lift her legs when asked. She said there should be footrests available for use for resident #3. The director of rehab services (DRS) was interviewed on 7/19/16 at 1:31 p.m. She said that resident #3 does not have footrests because she is able to safely propel herself in her wheelchair. She said that the resident does not like the foot rests to be in place and will refuse them. E. Resident Interview Resident #3 was interviewed on 7/19/16 at 10:22 a.m. She said that staff frequently assists her when she is using her wheelchair. She said that they do not offer to put footrests on; that she just lifts her legs when they are pushing her.

Based on record review and interviews, the facility failed to ensure one of 24 sample residents (#63) was notified of all of her rights related to discharge from the facility on 1/7/14. This failure contributed to the resident's unexplained discharge from the facility to an uncertain location without the resident aware of her right to appeal the discharge. The discharge made the resident feel "terrible," as if she did not have "any rights," and now, fearful of another discharge "if she did something the facility didn't like." Cross-reference F319; psychosocial adjustment difficulties The findings include: Resident #63, age 54, originally was admitted to the facility on [DATE]. According to the 1/14 computerized physicians orders (CPO), the resident had [DIAGNOSES REDACTED]. The most recent minimum data set (MDS), dated [DATE], revealed: -The resident had no cognitive deficits, scoring a 15/15 on the BIMS (brief interview of mental status). The resident was coded with moods of feeling down, depressed, or hopelessness and little or no energy and trouble staying asleep. Behaviors included verbal behavior symptoms directed toward others such as threatening, screaming or yelling at others during the review period. -The resident had limited physical abilities, was dependant on staff for toileting, transfers and was wheelchair bound due to [MEDICAL CONDITION] her paralyzed on her left side; she was coded to require extensive assistance of one staff person for transfers, bed mobility and toileting. Per the face sheet, the resident was her own responsible party. 1. Record Review Review of a telephone order dated 1/7/14 (untimed) documented: "Ok to D/C (discharge) resident to shelter, if shelter is full, resident needs to be taken to nearest ER (emergency room ). D/C resident with all meds as prescribed." Review of a nurses' note dated 1/7/14 at 4:50 p.m., documented the following: "Resident was discharged to a shelter by two staff members. Resident took all medications with instructions upon discharge. Resident refused vitals to be taken. Resident was given discharge paperwork and left with some of belongings. Resident agreed to leave some belongings at facility to hold until resident was able to come arrange for pick up of belongings. (name of medical director of facility) gave discharge order to discharge to shelter for behaviors. The resident was verbally abusive towards staff when given notice of discharge. Resident left around 4:45 p.m. to shelter." Review of a Social Service (SS) note dated 1/8/14 documented, in part: -"On 1/7/14 writer was approached by nursing home administrator (NHA) informing that we would be pursuing d/c (discharge) per the decision by IDT (interdisciplinary team), including the med(ical) director based on on-going refusals by (resident #63) to comply with safe smoking practices as well as posing concern re: aggressive behavior towards other residents. -It was determined that she is no longer safe to remain here ...writer and unit Mgr (manager) met with (resident #63) to discuss this plan, she was calm in hearing this plan and asked no questions ...she angrily began explaining that the other female resident involved in verbal altercation was (derogatory name and engaged in derogatory behavior)...I asked if she wanted to say or ask anything, she said it wouldn't matter because "everyone thinks (she) is a ... liar anyway." -Nurse then placed a call to physician to request d/c orders. D/C packet initiated..." --Writer placed call to (consultant) to inform her of situation, she reviewed all details and reiterated that a shelter had to be chosen/secured prior to d/c ...it was later reported to me that (resident's) physician was not in favor of d/c... Review of the discharge paperwork found in front of the resident's clinical record titled "Discharge to Home," revealed handwritten information on the front of the form as follows: "(Name of shelter); address and phone number of the shelter" and another written comment that read: "D/C (discharge) 1/7/14." -The form included instructions of steps to follow upon discharge. It read in part, "...receive an order from attending physician ...layman's terms only (go over form with the family and assure they understand, then have them sign) ...once completed have responsible party sign ..." -There was no documentation the form had been reviewed with the resident and the form was unsigned. -The form included no information about the reason for the resident's discharge, the resident's right to appeal the discharge, and the name address and phone number of the LTC ombudsman. Review of a nurses' note on 1/7/14 revealed the resident was returned to the facility on [DATE] at 9:30 p.m. 2. Interviews a. Resident Interviews On 1/9/14 at approximately 11:15 a.m., on 1/13/14 at 2:53 p.m., and 1/16/14 at 10:40 a.m., resident #63 was interviewed. -The resident stated the facility did not want her here anymore. She stated she was taken to a homeless shelter by two facility staff a few days ago. -The resident stated the day they sent her out of the facility to the shelter, she was told she was no longer going to be a resident here anymore and was being sent out to a shelter. The resident stated she was not notified ahead of time that she was being discharged . The resident stated they (facility staff) told her they wanted her somewhere safe; the resident stated "(the shelter) was not a safe place to take me." The resident then stated it made her feel (terrible) to go to a shelter. -The resident stated she did not remember being asked to sign any paperwork the day they sent her out to the shelter and she did not remember being notified that she had a right to appeal the discharge. She stated the social worker just came into her room on 1/7/14 and told her the doctor said she was being discharged and that they all agreed with it. -The resident said she did not feel like she had any rights here and she was fearful she might be discharged again if she did something the facility did not like. On 1/10/14 at 3:15 p.m., Driver #1 (the activity coordinator) was interviewed. -Driver #1 confirmed he was involved in the transfer of the resident to a shelter on 1/7/14, stating he was instructed to transfer the resident by the social service director (SSD). Driver #1 stated he was not given any explanation as to why the resident was being discharged , only that he had heard there was another incident involving resident #63 and another resident on 1/6/14. Driver #1 stated he and another staff person were asked to drive the resident to a shelter in the facility van. -Driver #1 stated he helped pack up all of the resident's belongings and was instructed if the resident could not go into the homeless shelter, he was to take the resident to closest emergency room and contact the corporate psychiatrist (name of corporate person) and she would take care of the paperwork. -Driver #1 stated he was given the discharge papers and they left the facility with the resident between 5:20 p.m. and 5:30 p.m. Driver #1 stated they were given notice the shelter doors opened at 5:00 p.m. and he was concerned there was not a pre-determined time set up for the resident to get to the shelter. -Driver #1 stated there was a very long line at the shelter doors when they arrived. He said the second staff person got in line for the resident and when he reached the front of the line was told the shelter was full. Driver #1 said he then proceeded to the nearest hospital emergency room , contacted the corporate contact person for further instructions and was told to wait for further instructions prior to taking the resident into the hospital. -Driver #1 stated they waited for over an hour in the van before they received a phone call to return the resident to the facility and place her on 1:1 (supervision). Driver #1 stated the resident was quiet and talking to the other staff person the entire time. Driver #1 stated he could tell the resident was upset and saw her eyes welling up with tears. On 1/14/14 at approximately 10:25 a.m., the social service director (SSD) was interviewed regarding the resident's discharge to the shelter on 1/7/14. -The SSD stated the interdisciplinary team (IDT), including the nursing home administrator (NHA) and the medical director, met on 1/6/14 and reviewed the resident and the challenges she was presenting. -The SSD stated the resident had not been in compliance with the smoking policy (smoking in undesignated areas), so the medical director felt that based on the resident's history and unwillingness to follow smoking rules, she was proving to be unsafe to the community. -The SSD stated that on 1/7/14 in the morning, she was told the resident was going to be informed of the plan to discharge her. The SSD also stated that because the resident had a recent verbal exchange with her former roommate on 1/6/14, this was the final 'event' and triggered an immediate discharge. The SSD stated she was responsible for locating a shelter and was in communication with the consultant about each step. The SSD stated she was pursuing the direction she was given. -The SSD stated it was an unfortunate situation (the discharge to the shelter) and it was not how she wanted to help the resident. She stated the challenge was keeping the resident safe and everyone else safe at the same time. -The SSD said the resident was not given written information on the reason for the discharge, the location she was being discharged to, or information on her right to appeal the discharge. On 1/15/14 at 9:50 a.m., the second staff member (the facility concierge and also a certified nurse aide) who was involved with the resident's transfer out of the facility on 1/7/14 to a shelter was interviewed. -He stated they were instructed to take the resident down to a women's homeless shelter and it was around 5:45 p.m. as they were waiting for the paperwork. He stated the social worker brought the discharge papers to the resident for her to sign and told her that by signing the paper she understood she was leaving under her own recognizance. However, see above; the resident did not sign the discharge papers. -He stated all of the resident's belongings were packed up and her room was emptied out; some of her belongings had to be placed in storage. He stated that it was cold that day and traffic was bad and they arrived at the shelter about 6:15 p.m. He stated the lady at the shelter told him the shelter was full and when he saw the accommodations of the shelter (mats on the floor and bins of blankets) he knew no one would be able to help her up off the floor or take her to the toilet. -He stated they then took the resident to the hospital as directed and they waited in the van for over an hour but he did have to take her inside to the bathroom to be changed. On 1/16/14 at approximately 11:40 a.m., the director of nursing (DON) was interviewed. -The DON stated she was not included in the decision to discharge the resident to the shelter. She stated she was made aware of the plans in an "update" where she learned the resident was having some behaviors, staff was looking at discharging her to a homeless shelter and the Ombudsman was going to be contacted. -The DON stated she and the social worker tried talking to the resident to calm her down and said if one took the time to talk to the resident, she did well. She also said the facility had different doctors try to address the resident's behaviors as well as starting an anti-depressant. -The DON stated she believed the resident's behaviors were related to losing so much control of her life and wanting to gain that back. On 1/16/14 at 12:00 p.m., a frequent visitor to the facility was interviewed per phone. The frequent visitor stated she had met with the resident approximately two weeks prior to the resident's discharge to the shelter. She stated she had talked to the resident about wanting to move to another part of the state. The frequent visitor stated she was contacted by the facility the day the resident was being discharged to the shelter because she had threatened a resident and was in agreement with the facility. She stated she reminded the facility at that time to inform the resident of her right to appeal.