Every finding on record at Apostolic Christian Home

Based on observation, interview, and record review, the facility failed to refer to residents who need assistance with feeding in a dignified manner during the lunch meal service. This has the potential to affect all 47 residents who reside in the facility.Findings include:Facility Resident Rights, reviewed 3/2011, documents You have the right to safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction.Facility Your Rights and Protections as a Nursing Home Resident, undated, documents You have the right to be treated with dignity and respect.Facility Diets, provided by V4 Dietary Manager/DM on 4/7/26, documents there are two residents who get pureed diets, 10 residents get mechanical soft diets, and 35 residents get regular diets.On 4/8/26 at 12:13pm during the lunch time meal pass at the steam table in the kitchen which is located directly across from the serving window to the dining room, V4 Dietary Manager/DM told V8 [NAME] All the feeders are ready! in a loud voice facing the dining room residents when referring to the residents that needed assistance with their meals in the dining room. At that time, V8 verified V4 was referring to the residents who needed assistance with feeding which included two residents who are on pureed diets, and 10 residents who get mechanical soft diets. At the time V8 made the above statement the dining room was full of residents eating their lunch meal and within earshot of V4. On 4/8/26 at 12:20PM, V8 [NAME] verified five residents were getting room trays, one resident was out of the building for dialysis, and the rest of the residents (41) were in the dining room to eat.Facility Room Roster, dated 4/7/26, documents 47 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to have an expiration or delivery date on bread and buns, failed to have current test strips to test the sanitation in the sanitizer container, failed to have test strips to test the temperature of the dishwasher, and failed to serve a lunch meal in a sanitary manner. This has the potential to affect all 47 residents who reside in the facility.Findings include: Facility Job Description for Dietary Cook, dated 12/11/18, documents The primary purpose of your job position is to prepare food in accordance with current applicable federal, state, and local standards, guidelines and regulations. To assure that quality food service is provided at all times. Food service personnel shall practice hygienic food handling techniques. Follow established Infection Control Policy.Facility Dietary- Receiving, Storage, and Issuing, dated January 2017, documents The Food Service Director is responsible for ordering, receiving, storing, and issuing all food items. In her absence, the Dietary Supervisor is responsible.Facility Infection Control, dated April 2026, documents The Dining Services Supervisor will supervise the cleaning and sanitizing of dishware and utensils, as well as the cleaning of the physical dining services department. The department will be maintained in a clean and sanitary manner to prevent foodborne illness. An approved dishwashing method and sanitizing agent/process will be used. Follow sanitizing agent manufacturer's instructions for use.Facility Steps to wash, rinse, and sanitize equipment and utensil, undated, documents for quaternary ammonium sanitizers, use according to directions with a minimum water temperature of 75 degrees. Sanitizer contact time is important.Facility Instructions to follow for cleaning and sanitizing the dining room tables using the Buckeye EC Sanitizer, undated, documents Get the clear, round, four-quart Cambro container, out of cabinet and fill with warm water and one pump of Pot N Pan detergent from the dispenser on the wall by the three-compartment sink.Facility Week at a Glance lunch meal on Wednesday 4/08/2026 at 12:00 PM was a fried chicken BLT/Bacon lettuce tomato sandwich, loaded tater tots, ranch dip, dill pickle spear, ice cream, fruit, salad, and milk.On 4/7/26 at 9:45AM, during the dietary tour with V4 Dietary Manager/DM, six packages of 12 count hamburger buns, and 16 loaves of white bread did not have an expiration or delivery date marked on them. At that time, V4 stated she did not know they did not have an expiration date marked on them and should have an expiration or delivery date on them. At that same time, the table sanitizer bucket was sitting on the three-compartment stainless steel sink in the kitchen, the dietary staff and V4 DM were unsure how to use the sanitizing strips, V4 DM tested the sanitizer bucket for sanitizer strength, and it did not meet the minimum for sanitizing strength. The dietary staff and V4 DM were unaware the sanitizing strips expired in June 2025. At that same time, the dietary staff and V4 DM were asked to check the dishwasher temperature by test strips to verify the dishwasher got up to temperature for sanitizing the dishes. The dietary staff and V4 DM were unsure where the dishwasher temperature test strips were, had never used the dishwasher temperature test strips before, and were unable to find any in the building. At that time, V4 DM stated she needed to order new sanitizer and dishwasher test strips.On 4/08/2026 from 12:00PM to 12:32 PM, kitchen staff were observed plating food during the lunch time meal. V8 [NAME] was observed multiple times touching her uniform with her gloves on to pull up her pants that were sliding down and did not perform hand hygiene or glove changes. At this same time, V8 was observed going to the warmer oven and opening the door on multiple occasions for pureed/soft foods or alternative meals residents ordered for lunch without changing her gloves or performing hand hygiene. The lunch meal was a fried chicken BLT/bacon lettuce tomato sandwich where V8 would use her gloved hand to pull out two pieces of bread from the bread bag, plate the resident's food, and then grab the chicken sandwich to cut into halves and put on resident's plates. At the same time, V4 Dietary Manager/DM was in the kitchen observing meal pass and reminded V8 not to touch her clothing and if she did, she needed to change her gloves and perform hand hygiene. Facility Room Roster, dated 4/7/26, documents 47 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to document medication administration of controlled medications on the Controlled Drug Receipt/Record Disposition forms for five out of five residents (R4, R20, R23, R40, and R45) reviewed for controlled substance medication administration documentation in the total sample of 26.Findings include:The facility's policy titled, Controlled Substance-Administration, Count and Destruction, dated 8/5/25, documents when an individual controlled substance is given, the controlled substance must be counted before the medication is given and signed off in the EMAR (Electron Medication Administration Record). On 4/7/26 at 12:10 PM, V5/Licensed Practical Nurse (LPN) V5 pulled out R4's medication card of Lyrica (Schedule V Controlled Substance and Pain Medication) 25 mg (milligrams) from the locked narcotic drawer on the medication cart. V5 popped one capsule out of the medication card into a medication cup and administered the medication to R4 without signing out the medication on the Controlled Drug Receipt/Record Disposition Form. There were no controlled substance records on or in V5's medication cart. V5 confirmed R4's Lyrica is a controlled substance, and she did not update the narcotic count or sign out the medication on the Controlled Drug Receipt/Record Disposition Form when V5 administered the Lyrica to R4. V5 also confirmed there were no controlled substance records on the medication cart.On 4/7/26 at 12:25 PM, V5 provided the narcotic reconciliation book for V5's medication cart located in the medication storage room. R4's Controlled Drug Receipt/Record Disposition Form was reviewed with V5/LPN. V5 confirmed there was a discrepancy between the amount of Lyrica (Schedule V Controlled Substance and Pain Medication) capsules documented on the Controlled Drug Receipt/Record Disposition Form and the amount of Lyrica capsules in the medication card. The Controlled Drug Receipt/Record Disposition Form documented there were 21 capsules of Lyrica left. There were 19 capsules in R4's Lyrica medication card. V5 confirmed there were 19 capsules of Lyrica left in R4's Lyrica medication card. V5 stated R4 was given one capsule of Lyrica this morning and one capsule at noon, so the count is off by two capsules because the count on the Controlled Drug Receipt/Record Disposition Form was not updated since counting with the off-going nurse at the beginning of the shift that started at 6:00 AM. V5 stated V5 does not update the count for controlled medications and does not sign out controlled medications on the Controlled Drug Receipt/Record Disposition Form at the time they are administered during the shift. The binder with the Controlled Drug Receipt/Record Disposition Forms for each controlled medication is kept in the medication room while administering medications. The counts for each medication administered during the shift are updated and signed at the end of the shift before counting with the oncoming nurse. On 4/8/26 at 11:50 AM, a reconciliation of all controlled substances for [NAME] Hall was completed with V5/LPN, including controlled substances contained in the medication cart and refrigerator. Six discrepancies were identified for controlled substance medications during the reconciliation between the amounts documented on the Controlled Drug Receipt/Record Disposition Forms and the actual amount in the medication cards. R20's Controlled Drug Receipt/Record Disposition Form for Pregabalin (Schedule V Controlled Substance and Pain Medication) 25 mg capsule documented 28 capsules were left. R20's Pregabalin medication card had 27 capsules remaining; R23's Controlled Drug Receipt/Record Disposition Form for Pregabalin 75 mg capsule documented19 capsules were left. R23's Pregabalin medication card had 18 capsules remaining; R23's Controlled Drug Receipt/Record Disposition Form for Hydroco(done)-APAP (Acetaminophen) (Schedule II Controlled Substance and Pain Medication) 10-325 mg tablet documented 7 tablets were left. R23's Hydrocodone-Acetaminophen 10-325 mg medication card had 6 tablets remaining. R40's Controlled Drug Receipt/Record Disposition Form for Hydroco(done)-APAP (Acetaminophen) 5-325 mg tablets documented 25 tablets were left. R40's Hydrocodone-Acetaminophen 5-325 mg medication card had 24 tablets remaining. R45's Controlled Drug Receipt/Record Disposition Form for Lorazepam (Schedule IV Controlled Substance and anti-anxiety medication) documented 52 tablets were left. R 45's Lorazepam card had 51 tablets remaining.On 4/8/26 at 11:56 AM, V5/LPN confirmed each of the discrepancies between the actual amount on hand and the amount documented on the Controlled Drug Receipt/Record Disposition Forms during the controlled substance reconciliation. V5 stated the controlled substance counts will be off until the end of V5's shift because the counts/records are not updated until the end of V5's shift before the controlled substances are reconciled with the oncoming nurse. V5 stated, I have always did it this way.

Based on observation, interview, and record review, the facility failed to revise a care plan to include the required information for a dialysis care plan and discontinue a diuretic off the care plan for one resident (R7) of 16 residents reviewed for care plan revision in a sample of 26.Findings include:On 4/07/2026 at 11:04 AM, R7 was alert and oriented, stated she gets dialysis three days a week on Monday, Wednesday, and Friday, and goes to East Peoria for hemodialysis. At that same time, R7 showed me her right upper arm fistula for dialysis.R7's Minimum Data Set/MDS, dated [DATE], documents R7 is cognitively intact, and dependent on renal dialysis.R7's Current Physician Orders, dated 3/9-4/9/26, documents Dialysis on Monday, Wednesday, and Friday. R7's current diagnoses include End Stage Renal Disease, and Dependence on Renal Dialysis dated 11/20/22. R7's current care plan has a problem start date of 12/31/21 Resident has a history of weight loss due to a daily diuretic.R7's dialysis care plan has no documentation of the following: Monitoring vital signs, weights, nutrition, and who to notify with concerns; Specific type and location of dialysis services, and the interventions and goals based upon the type of dialysis; If the resident receives Erythropoiesis-Stimulating Agent (ESA) therapy, what to monitor and when and to whom to report results; Which arm to use for blood pressure monitoring; Who to contact, such as the attending practitioner(s), nephrologist, and dialysis staff, for dialysis-related emergencies, concerns or complications; Monitoring for risk factors and managing complications such as hemorrhage, access site infection, hypotension, and to whom to report concerns; Assessment and care of the access site, including the use of PPE/Personal Protection Equipment as necessary, and other infection control measures; and the Approach to administering medications before, during, or after dialysis according to practitioner's orders.On 4/09/2026 at 2:33 PM, V16 CPC/care plan coordinator verified R7 was not on a diuretic (furosemide) anymore, needed taken off the care plan, and was discontinued 10/7/25. At that same time, R7 verified the dialysis care plan did not include what is required.

Based on observation, interview, and record review the facility failed to perform hand hygiene with glove changes during urinary catheter care for one (R43) of two residents reviewed for catheter care in a sample of 26. Findings include: The facility's policy titled, Standard Precautions, review date 1/6/26, documents not in its entirety, Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain hazardous drugs and/or transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status. 1. You must wear gloves if you come into contact with blood, body fluids, or mucous membranes of any resident. Change gloves when they are torn. Change gloves after contact with each resident. There are glove holders in each room with a box of gloves for each resident. Wash your hands or use hand sanitizer each time you remove your gloves.R43's facility face sheet documents R43's date of admission to facility was 1/21/25 and R43's diagnoses include but not limited to Retention of urine, unspecified, Cutaneous-vesicostomy status Note: Suprapubic catheter 3/14/23, Personal history of Malignant Neoplasm of Prostate.Note:1995, Other Cerebral Infarction Note: Ischemic Stroke, Personal history of irradiation.R43's physician orders dated 3/1/26 documents R43 has an order for monthly suprapubic catheter change with an 18 French catheter and has orders to clean stoma daily with wound cleanser, apply collagen sheet cut to fit around stoma and cover with border dressing cut and taped T-pee style to stoma site.R43's current care plan documents R43 has a diagnosis of urinary retention and has a suprapubic catheter.On 4/08/2026 at 9:50 AM, V7 (Registered Nurse) observed doing suprapubic catheter care on R43. V7 performed hand hygiene, donned gown and gloves and laid out R43's treatment supplies on a clean surface. V7 used gloved hands to check R43's suprapubic site for old dressing but noted it was removed during shower. V7 removed her gloves and placed a new pair of gloves on without performing hand hygiene and then proceeded to cleanse around R43's suprapubic insertion site, then with a clean part of gauze, washed urinary catheter from insertion site and away from body. V7 removed gloves and placed new gloves on without performing hand hygiene and proceeded to place skin barrier and clean dressing. V7 then disposed of trash, gown, and gloves and performed hand hygiene.On 4/08/2026 at 10:05 AM, V7 (Registered Nurse) stated that she should have performed hand hygiene between glove changes.On 4/08/2026 at 10:15 AM, V2 (Director of Nursing) verified that hand hygiene should be performed between glove changes.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent weight loss for one (R2) of two residents reviewed for weight loss in a sample of 26.Findings include: Facility Liberalized Diet policy, dated April 14, 2022, documents Advantages for the resident are as follows: Positive outcomes reported by similar programs include weight maintenance and/or gain. The following safety and diet concerns will be included: We will continue to use supplements that will be included in the medication passes, depending on the resident need. Resident weights will be obtained and reviewed in a consistent manner as to indicate weight gain or loss.Facility Weight Assessment and Intervention/Gain or Loss, revised 3/4/26, documents Weight Assessment. Negative trends will be evaluated by the dietary supervisor and dietitian to determine whether or not significant weight change has occurred. Dietary coordinator will report the significant changes to Registered dietitian and chart in the resident's progress notes the significant weight change. Dietary coordinator will monitor and record the resident's weight and intakes as recommended by the Dietician/Medical Doctor. Registered Dietician makes recommendations in the resident's chart and on the notification form to the attending physician. Interventions for undesirable weight loss shall be based on careful consideration. The analysis and recommendations will be sent to the attending physician for orders when there is a negative significant trend in weight loss.Facility Licensed/Registered Dietician/RD/LD Nutritionist Professional license documents V15 is the facility RD/LD, and her license expires 10/31/2027.R2's medical record documents R2 is on a regular diet and liquids.R2's medical record documents R2 was offered a snack for the month of March 2026 and documents R2 is unavailable most of the time, and when she was available she did not reject any snack offered off the snack cart.R2's medical record documents on 11/05/2025 R2 weighed 137 pounds, and on 04/08/2026 R2 weighed 122.4 pounds which is a 10.66% weight loss. BMI/Body Mass Index 21.01.R2's current care plan, edited 2/24/26, documents Nutritional risk indicator score is high at this time. Follow diet as ordered. Encourage good food/fluid intakes with meals.R2's LD/RD note by V15, dated 4/2/26, which was marked INVALID, documents Resident continues on Regular Diet/General diet, BMI-21.3 (lower end for age/height). Recommend weekly wts (weights) x4 weeks and offer an appetite stimulant. Offer the resident alternatives if eating less than 50% percent at meals. Encourage good oral intakes. Continue to monitor status. Consult (V15) LD/RD as needed.On 4/09/2026 at 10:20 AM, V14 Licensed Practical Nurse/LPN stated I am (R2's) nurse today. We haven't tried any (nutritional) supplements for her, she gets chocolate milk with her meals, she has had a three-pound weight loss in the past month, she does go to the dining room for meals, and she does sleep more.On 4/09/2026 at 11:25 AM, V2 Director of Nursing/DON stated I noticed (V15's) note was grayed out so she did not finish note and I have reached out to (V15). (R2) has had some weight loss and I have contacted her family.

Based on observation, interview, and record review the facility failed to appropriately store oxygen nasal cannula when not in use and failed to ensure physician orders contained liter flow of oxygen to be administered for one (R43) of one resident reviewed for oxygen in a sample of 26. Findings include: The facility's policy Oxygen Administration last reviewed 3/10/26, documents not in its entirety, To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues .16. When resident is not using the O2 (oxygen) cannula, store in cloth bags provided. Make sure cannula is dry before putting in cloth bag. Procedure: 3. Check physician order for liter flow. R43's facility face sheet documents R43's date of admission to facility was 1/21/25 and R43's diagnoses include but not limited to Chronic Obstructive Pulmonary Disease, unspecified, Chronic Diastolic (Congestive) Heart Failure, Shortness of breath.R43's physician orders dated 1/21/25 documents R43 has the following order, Titrate oxygen for pulse ox (oximetry) > (greater than) 89% (percent) consistently per NC (nasal cannula) every shift. No further orders for oxygen liter flow in R43's medical record. R43's current care plan documents that R43 has a diagnosis of COPD (Chronic Obstructive Pulmonary Disease) and SOB (Shortness of Breath) and to monitor respiratory status, oxygen saturation, and provide oxygen as ordered. On 4/07/2026 and 4/8/2026 R43's oxygen nasal cannula was observed not in use and to be draped over oxygen concentrator in room and not in a bag. On 4/07/2026 9:30 AM R43 is reclining back in his recliner and in no distress. R43 stated he wears oxygen at night when he goes to bed but unsure at what liter flow. On 4/08/2026 at 1:50 PM, V7 (Registered Nurse) stated that R43 wears his oxygen at night on 2 liters. Verified that R43's orders do not have a specific order for liter flow and when asked how staff would know what liter to start at V7 stated, I would start at 2 liters, but I'd have to check our policy to see if there is a set liter flow that we are supposed to start with. V7 also verified that oxygen nasal cannula should be in the cloth bag hanging on the oxygen concentrator and R43's was not. 04/08/2026 2:08 PM V2 (Director of Nursing) stated that if the physician orders do not specify a liter flow for oxygen and just reads to titrate then it would be standard of care to administer at 2 liters. V2 also verified that if the oxygen tubing/nasal cannula was not in use it should be kept in the bag on the concentrator but, (R43) is known to take his out sometimes.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene, utilized appropriate Personal Protective Equipment (PPE), and properly cleaned and disinfected resident medical equipment during blood glucose monitoring and insulin administration for two of two residents (R4 and R28) reviewed for infection control practices and failed to ensure staff implemented appropriate infection prevention practices during incontinence care, including hand hygiene and glove changes, for one of two residents (R4) reviewed for incontinence care in the total sample of 26.Findings include:Merged Findings The facility's policy titled, Standard Precautions, dated 1/6/26, documents, Purpose: Standard Precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Standard precautions are based on the principle that all blood, body fluids, secretions, visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents. Furthermore, equipment or items in the resident's environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents. Standard precautions include hand hygiene, proper selection and use of PPE, safe injection practices, respiratory hygiene/cough etiquette, environmental cleaning and disinfection, and reprocessing of reusable resident medical equipment. Definition: You must wear gloves if you come into contact with blood, body fluids, or mucous membranes of any resident. Change gloves after contact with each resident. Wash your hands or use hand sanitizer each time you remove your gloves. The facility's Policy on Injections—Subcutaneous/Heparin, dated 7/8/25, documents, follow universal precautions when administering all injections. Wash your hands, apply disposable gloves, discard equipment properly in sharps container, dispose of gloves and alcohol wipe in infectious waste, and wash your hands. R4's medical record documents R4 admitted on [DATE] with diagnoses including Congestive Heart Failure; Pressure Ulcer of the Sacral Area and identifying R4 is frequently incontinent of bowel and bladder. On 4/7/26 at 12:05 PM, V5/Licensed Practical Nurse (LPN) was in dining room performing blood glucose monitoring and obtained R4's blood sample by fingerstick method without performing hand hygiene or donning gloves beforehand. V5 then placed blood-soiled test strip, alcohol pad, and blood glucose monitor inside the blood glucose monitor case used for multiple residents. V5 did not perform hand hygiene after obtaining R4's blood glucose level and moved R4's clean spoon sitting on dining room table by touching the spoon with V5's soiled hands. V5 then proceeded to administer insulin subcutaneous injection into R4's abdomen without performing hand hygiene or donning clean gloves. V5 did not perform hand hygiene after R4's insulin was administered. V5 then gathered case containing used supplies and soiled blood glucose monitor and placed case on top of medication cart. On 4/7/26 at 12:25 PM, V5/LPN stated V5 should have performed hand hygiene and put gloves on prior to performing fingerstick to obtain blood sample for blood glucose monitoring and before and after V5 administered insulin to R4. V5 confirmed V5 touched R4's clean spoon that was sitting on the dining room table with V5's soiled hands. I should have washed my hands before touching the clean spoon after I performed the (blood glucose check) for R4 without gloves on. V5 confirmed blood glucose monitor should have been cleaned and disinfected prior to putting monitor back in clean case. V5 stated the blood glucose monitor used for R4 is used for one other resident (R28). On 4/8/26 at 3:30 PM, V2/Director of Nursing confirmed V5 should have performed hand hygiene and applied gloves before V5 performed blood glucose check and administered insulin injection to R4. V2 stated hand hygiene should be performed by staff each time gloves are applied and removed. Hands should be washed with soap and water if they are soiled. The blood glucose monitor used for multiple residents should be cleaned and disinfected after each use and before the monitor is put back into its case. On 4/9/26 at 8:50am V10 and V11, CNAs/Certified Nursing Assistants provided incontinence care for R4. Throughout incontinence care, V10 did not perform hand hygiene or change gloves after removing R4's incontinence brief, or after cleaning R4's peri area and anal area and did not perform hand hygiene or change gloves before drying R4's peri areas and fitting R4 with a clean incontinence brief. During R4's incontinence care, V10 placed R4's soiled brief and the soiled washcloths on top of the under-pad on R4's bed. After providing the incontinence care, V10 picked up a large positioning wedge, wearing the same gloves and placed it behind R4's back and adjusted the coverlet over R4. After positioning R4, V10, then picked up the soiled towel, washcloths, and the soiled incontinence brief from R4's bed and put the brief in the trash receptacle in R4's room. V11 then removed his gloves, performed hand hygiene, and removed the trash bag containing soiled items, gloves and the soiled brief with his bare hands. V11 then tied the trash bag shut, without donning gloves, held the bag against his chest and left R4's room into the hallway with the bag held against his chest. On 04/10/26 at 9:25am, V1 DON/Director of Nursing verified hand hygiene and glove changes are to be done after incontinence care is done and before clean procedures are started, and a trash can should be placed so staff can dispose of soiled briefs are not placed on the resident's bed.

Based on record review and interview the facility failed to utilize a set standard to determine infections. This failure has the potential to affect all 48 residents who currently reside in the facility. Findings Include: The Facility's Antibiotic Stewardship policy dated 1/3/25 documents Antibiotic stewardship refers to a set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The medical director, pharmacist and the DON (Director of Nursing_ will demonstrate support and commitment to safe and appropriate antibiotic use at the (facility)_ The physicians, nursing staff and pharmacy will be responsible for promoting and overseeing antibiotic stewardship activities at the (facility) . This process will be in place for a review of antibiotics by the IP (Infection Preventionist) on a weekly basis. Was an antibiotic event filled out by the nurse taking the MD (Doctor) order? If any of the below questions can't be answered the IP will contact the MD ordering the antibiotic in question. 1. Does the resident have a bacterial infection that will respond to antibiotics? 2. If so, is the resident on the most appropriate antibiotic, dose and route of administration? 3. Can the spectrum of the antibiotic be narrowed, or the duration of therapy shortened? 4. Would the resident benefit from the additional infectious disease antibiotic expertise to ensure optimal treatment of the suspected or confirmed infection? The facility's Infection Control monitoring logs for January 2024 through December 2024 do not include any documentation of use of McGeers Data for the determination of infections. On 01/22/25 at 10:00 AM V2 (Director of Nursing) stated that she reviews medications at the end of the month off of a pharmacy report and makes sure that there was documentation for the reasoning of the antibiotic. After V2 (DON) ensures that there is a diagnosis then V8 (Licensed Practical Nurse/Infection Preventionist) reviews the antibiotic orders to ensure that all antibiotics were warranted per McGeers Criteria. On 1/22/25 at 10:10 AM V8 (LPN/Infection Preventionist) stated the nurses are supposed to be using McGeers Criteria when communicating with the doctors about infections. V8 stated Some of our infections have not met the criteria to be considered infections. On 01/22/25 at 10:20 AM V2 (DON/Infection Preventionist) confirmed that she had been notified that some of the antibiotic medication orders were obtained for residents who did not meet the criteria for an infection. V2 confirmed that there was no documentation of any McGeers Criteria being followed for any of the facility's infections. I need to educate the floor nurses on the McGeers Criteria because by the time we (V2/DON and Infection Preventionist and V8 LPN and Infection Preventionist) review the antibiotics the residents have already been started on them. The facility's Application for Medicare and Medicaid dated 01/21/25 documents that 48 residents currently reside in the facility.

Based on observation, interview and record review the Facility failed to follow the policy for documenting and monitoring a skin issue for one of 14 Residents (R7) reviewed for skin issues in a sample of 14. Findings include: The Facility Policy and Procedure for Assessment and Treatment of Skin Wounds, reviewed 2/1/24, documents: skin assessments will be done on admission, weekly by tub room and Certified Nursing Assistant (CNA) will call in the Director of Nursing (DON) or nurse on duty if changes and daily by CNA's providing care; all treatments will be monitored daily by the charge nurse and/or skin nurse and documented in the Electronic Treatment Record (ETAR); if a new skin breakdown is first noticed by the CNA, they will obtain a Skin Incident Report sheet found at the nurse's stations; they will fill out the appropriate portion of the form with the Resident name, description of skin issue, signature, date and shift, this form is then given to their nurse or directly reported to the nurse on duty; obtain a baseline measurement and assess the area then complete the remaining questions and initiate wound care; place the completed form in the DON/Skin Nurse folder; also notify the Physician and Resident's family; chart in Progress Notes (new skin observed, overall appearance of the wound, interventions taken and that the Family, Physician and Skin Nurse have been notified; a wound management will be initiated to track and provide weekly documentation; this documents ongoing assessments during healing until the wound or skin issues is healed or resolves; a photo of the wound will be taken at the discretion of the Charge Nurse/Skin Nurse; document overall condition of wound surrounding skin, warmth, edema, pain, drainage amount, color and any odor in the progress notes; and the Skin Treatment Nurse will measure and document on all skin wounds weekly in the Wound Management tab of the electronic medical record. The Facility Wound Summary Report, dated 1/21/25, does not document R7's Right Foot measurements or wound description. R7's Progress Notes, dated 12/10/24 through 1/21/25, does not document R7's Right Foot measurements or wound description. R7's Treatment Record, dated 12/10/24 through 1/21/25, does not document R7's Right Foot measurements or wound description. R7's Skin Incident Report, dated 12/22/24, documents a Right Heel skin incident that measures 3.0 centimeters/cm by 4.0 cm. The Skin Incident Report does not document that R7's Physician or Family were notified of the skin issue or care plan interventions. On 1/23/25 at 11:22 am, V15 (Licensed Practical Nurse/LPN) stated, I am a night shift nurse, and on the night of 12/22/24, we discovered a quarter size, dark brown with hard center area on (R7's) Right Heel/Calcaneous Heel Bone), I was not sure if it was a pressure ulcer or callous. I wanted to get a treatment on it, so I put some barrier ointment (Skin Prep) and gave (R7) some pressure ulcer boots to wear while in bed, to prevent any further skin breakdown. V15 confirmed that no documentation was entered in to R7's medical record at that time. I was the only nurse working and I got so busy, that I never went back and measured or documented the area on (R7's) Right Heel. We are supposed to fill out a Skin Incident Report, I put (R7's) name at the top of one and never went back and filled it out. I am so sorry, I know that I should have measured it and documented the skin area in the R7's chart, but I forgot. I cannot even remember how big it was or anything anymore. I did not notify (R7's) Responsible Party of the new area found. On 1/22/25 at 11:25 am, V8 (License Practical Nurse/LPN/Wound Nurse) performed wound care (skin barrier) to R7's Right Foot (Calcaneous Heel Bone). R7's Calcaneous Heel Bone had an approximate quarter size, intact black scabbed area, with no drainage. V8 stated, There is no Right Heel skin documentation in (R7's) progress notes. We classified this as a callous, and I do not do weekly skin measurements on any skin issue unless it is a pressure ulcer. On 1/23/25 at 11:35 am, V2 (Director of Nursing/DON) stated, We do not have any documentation in the Nursing Progress Notes on (R7's) Right Heel. Regardless that (R7) admitted on [DATE], to the Facility for a Right Hip fracture, required staff assistance for bed mobility and developed this skin breakdown on 12/22/24, I still classified this as a callous. We do not track measurements or wound description on any skin issues other than pressure ulcers, we can tell just by looking at it week to week, if it getting better or worse.

Based on observation, interview, and record review, the facility failed to ensure hand sanitation after glove changes were completed during pressure ulcer dressing changes for one resident (R4) of three residents reviewed for pressure ulcers in a sample of 14. Findings include: The facility's policy titled Standard Precautions, revised 11/3/2025, documents, Purpose: Standard Precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Standard precautions are based on the principle that all blood, body fluids, secretions, visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents. Furthermore, equipment or items in the resident's environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents. Standard precautions include hand hygiene, proper selection and use of personal protective equipment, safe injection practices, respiratory hygiene/cough etiquette, environmental cleaning and disinfection, and reprocessing of reusable resident medical equipment. 1. Wash your hands or use hand sanitizer each time you remove your gloves. R4's resident face sheet documents R4's date of admission to the facility was 8/7/23 and diagnosis on admission include: Metabolic Encephalopathy, non-pressure chronic ulcer of buttock limited to breakdown of skin-Moisture Associated Skin Damage (MASD inner gluteal clef, Type 2 Diabetes Mellitus with Foot Ulcer of Right Heel, Pressure Ulcer of Right Heel Stage Three-from Deep Tissue Injury (DTI)/Diabetic Ulcer, and Chronic Kidney Disease Stage Three B. R4's Minimum Data Set assessment (MDS), dated [DATE], documents R4 has one Stage Three Pressure Ulcer, Diabetic Foot Ulcer, and Moisture Associated Skin Damage (MASD). On 1/22/25, at 10:15 am, R4 was lying in bed in a prone position. V8 (Wound Nurse/Licensed Practical Nurse) and V9 (Certified Nursing Assistant/CNA) entered room, performed hand hygiene and donned gown and gloves. V8 (Licensed Practical Nurse/LPN) cleaned the over the bed table and prepared treatment supplies to perform suprapubic catheter site care, wound care to bilateral Buttocks and Right Heel. V8 removed R4's suprapubic catheter dressing, scant amount of brownish drainage present on dressing and insertion site reddened and disposed of soiled dressing. V8 (LPN) removed soiled gloves and donned a new pair of gloves but did not perform hand hygiene in between glove change. V8 (LPN) cleansed suprapubic site, kept gloves on and placed a new dry dressing. V9 (CNA) positioned R4 onto R4's left side and V8 (LPN) then proceeded to remove soiled dressings to bilateral buttocks/gluteal folds with the same gloves V8 (LPN) wore prior, when cleansing and placing the suprapubic dressing. V8 disposed of the soiled dressings from buttocks, removed gloves, and donned a new pair without performing hand hygiene. V8 (LPN) proceeded to cleanse moisture associated skin damage (MASD) to bilateral buttocks, place sure prep around wounds, removed gloves, disposed of them and donned new gloves without performing hand hygiene. V8 (LPN) then measured wounds (left buttock measured 1.5 cm (centimeters) x 1.5 cm and right buttock measured 4.0 cm x 2.5 cm), placed collagen sheet to wound beds on bilateral buttocks and applied foam dressings. V8 (LPN) removed gloves, disposed of them and placed new gloves on without performing hand hygiene. V4 (CNA) removed R4's right sock and held right leg/foot while V8 (LPN) removed soiled dressing, small amount of yellowish drainage noted on dressing, then measured right heel wound (1.5 cm x 3.0 cm), applied skin prep to peri-wound, removed soiled gloves, and donned a new pair of gloves without performing hand hygiene. V8 (LPN) placed collagen sheet to wound bed, applied barrier cream to peri-wound and then dressing. V8 removed gloves, gown and proceeded to wash hands. On 1/22/25, at 10:40 am, V8 (LPN) stated that she gets confused about when hand hygiene should be performed but agreed that it probably should be done with every glove change. V8 (LPN) also stated that gloves should be changed between performing treatments to different body sites to prevent cross contamination. On 1/22/25, at 10:49 am, V2 (Director of Nursing/DON) stated, our wound care policy does not indicate the need to wash hands between glove changes, however I'm hanging myself here by giving you this (hands over Facility Standard Precautions Policy) because it does state this (V2/DON points to section in Standard Precautions Policy that documents, Wash hands or use hand sanitizer each time you remove your gloves.).

Based on record review and interview the facility failed to conduct quarterly Quality Assurance/QA Performance Improvement meetings and assure the required Committee Members were present for the last calendar year. This failure has the potential to affect all 47 Residents who currently reside in the facility. Findings Include: Facility Census and Condition Report, dated 3/19/24, documents 47 Residents residing in the Facility. The Facility's Quality Assurance Performance Improvement/QAPI Guidance Plan, revised 1/5/24, documents: the purpose of the QAPI is to take proactive approach to continually improve the way we care for and engage with our Residents, Caregivers and other partners; to do this, all employees will participate in ongoing QAPI efforts which support our mission by meeting the physical, mental and spiritual needs of the residents of this home.; QAPI includes all employees, all departments and all services provided; the Governance and Leadership will be integrated into the responsibilities and accountabilities of top-level management by including them in quarterly QAPI meetings; QAPI leadership team will be comprised of the Administrator, and Director of Nursing who together will provide ongoing leadership to the QAPI team; and the QAPI team will meet quarterly and will be facilitated by the Director of Nursing. Facility Employee Roster, dated 2/27/24, documents V6 (Infection Control Coordinator) as the Facility designated Infection Control Preventionist. The Facility Quality Assurance Meeting Attendance Sheet, dated 4/20/23, documents V1 (Administrator), V2 (Director of Nursing), V4 (Medical Director), V7 (Abuse Coordinator/Social Services) and V8 (Environmental Services) in attendance. The Facility Quality Assurance Meeting Attendance Sheet, dated 7/20/23, documents V1 (Administrator), V2 (Director of Nursing), V4 (Medical Director), V5 (Human Resources) and V6 (Infection Control Nurse) in attendance. The Facility Quality Assurance Meeting Attendance Sheet, dated 10/19/23, documents V1 (Administrator), V2 (Director of Nursing), V4 (Medical Director), V6 (Infection Control Nurse) and V7 (Abuse Coordinator/Social Services) in attendance. The Facility Quality Assurance Meeting Attendance Sheet, dated 1/18/24, documents V1 (Administrator), V2 (Director of Nursing), V4 (Medical Director), V6 (Infection Control Nurse) and V7 (Abuse Coordinator/Social Services) in attendance. On 3/21/24 at 11:35 am, V2 (Director of Nursing) stated, We usually meet quarterly, on the third Thursday of the month, at 7:00 am in the morning. (V1/Administrator), myself (V2) and V4/Medical Director) are all in attendance and I invite all other Department Heads to attend, only if they can make it. It is not mandatory for them. Before COVID, we used to hold the 'QA' meetings and they would take all morning and everyone would attend, but that all changed since COVID. I did not realize that a Medical Director, Administrator, Director of Nursing, Infection Preventionist and two other staff were required to attend the QA meetings.

Based on observation, interview, and record review the facility failed to follow a physician ordered wound treatment and ensure cross contamination did not occur during a surgical wound dressing change for one (R18) of three residents reviewed for wound care in the sample of 21. Findings include: The facility's Clean Dressing Change Policy, reviewed 2/1/24, documents: To protect open wound from contamination; prevent infection and spread of infection; provide for optimal healing; wash hands; place plastic bag/waste basket near foot of bed to receive soiled dressing; position the bag to avoid reaching across the sterile field or the wound when disposing of soiled articles; form a cuff by turning down the top of the trash bag to provide a wide opening and to prevent contamination of instruments or gloves by touching the bags edge; slowly remove soiled dressing; discard soiled dressing in the plastic bag; wash hands, put on new gloves; use (Brand) Wound Cleanser if no solution is specifically ordered; always wipe from clean area toward the less clean area; use each gauze pad for only one stroke; apply prescribed medication if ordered; follow Physicians order for type of dressing; secure dressing edge with tape or method as ordered by Physician; remove gloves and place in plastic bag; wash hands; assist Resident to comfortable position; return equipment to designated area; discard bag containing dressings in infectious waste container; and wash hands. The facility's Physicians Order policy and procedure, revised 7/7/23, documents Responsibility: Licensed Nurse, Place new orders into (electronic charting system) as appropriate making sure to discontinue any previous orders no longer being used and All new telephone orders, e-mailed orders, and verbal orders are to be directly entered into (electronic charting system) and the Dr (doctor) will e-sign them. The facility's undated Personal Protective Equipment for Nurses and CNA's (Certified Nursing Assistant's) policy and procedure documents Procedures when disposable gloves are used: Anytime there is a possibility of being splashed or that you or your clothes may come into contact with possible infectious bodily fluids: urine, stool, emesis, blood, airborne infectious pathogens, and sputum. Examples listed when to use gloves include: All treatments/dressing changes, When cleaning up any bodily fluids and/or blood, and At any time you deem it necessary to prevent the spread of possible infectious disease. The facility's Handwashing policy and procedure, reviewed 1/26/2024, documents Purpose: To prevent conditions that allow pathogens to live, multiply, and spread. General Considerations when hand washing must be done include: Before and after direct or indirect resident contact, Before preparing or administering medications, and After direct or indirect contact with a resident's excretions, secretions, or blood. Hand washing it the single most important way to prevent the spread of infection and disease. The Face Sheet for R18 documents the following diagnoses: Complete traumatic amputation at level between knee and ankle, right lower leg subsequent encounter 9/25/23; History of right leg amputations with Gangrene, Sepsis and Osteomylitis to right leg. Delayed surgical wound healing; PVD (Peripheral Vascular Disease); Idiopathic Peripheral Autonomic Neuropathy; Long-Term use of antibiotics; Paroxysmal A-fib; Heart-Valve Replacement; CHF (Congestive Heart Failure), A-flutter (Superventricular Arrhythmia - fast rate); Ischemic Cardiomyopathy (damaged heart muscle from lack of blood flow); Atherosclerotic Heart Disease (damage to heart's major blood vessels limiting blood flow to the heart); Acquired absence of right leg below knee amputation; Gangrene right leg status post BKA (below the knee amputation); Presence of Aortocoronary Bypass Graft (heart surgery to restore blood flow to the heart) in 12/2001. The current Physician Orders documents the following dated orders: 3/20/24 Doxycycline 100 milligrams twice daily due to suspected soft tissue infection to right leg wound. Culture pending; 3/12/24 Cleanse stump wound. Apply collagen silver to stump. On open areas on lower leg apply collagen powder, cover with oil emulsion gauze. Cover entire lower leg with non-bordered foam dressing and secure with tape to form a sleeve to cover entire lower leg from knee down. Do not tape to skin. Secure in place with (compression dressing), first layer over the knee, apply ring and fold over pulling (compression stocking) up to knee. Change daily. Once a day; 10/31/23 Elevate leg at all times! On 3/19/24 at 4:14 pm, R18 was sitting up in a wheelchair with visible below the knee amputation. R18 raised his right pant leg revealing a bandaged stump. Legs were not elevated at this time. R18 stated he has had multiple surgeries, has had infections, and the doctors just keep cutting more of his leg off which started with his toes. On 3/20/24 at 8:35 am, V2 DON (Director of Nursing) stated We will be culturing (R18's) stump today per doctor order and then he will start the antibiotic for suspected infection to wound. On 3/20/24 at 10:18 am, R18 was sitting on the side of his bed with his pant leg pulled up. Legs were not elevated at this time, On the seat of R18's wheelchair held a white basket that contained treatment supplies, including a package of gauze, wound cleanser, wound treatments, dressings, and tape. V3 LPN (Licensed Practical Nurse) and V2 DON entered R18's room to perform wound measurement and treatment to R18's right stump. V3 LPN pulled a bottle of hand sanitizer from her uniform pocket, applied it to her hands, put the bottle of hand sanitizer back into her uniform pocket, pulled gloves out of the same uniform pocket and applied the gloves to her hands. V3 LPN squatted down in front of R18 with R18's wheelchair to the left and behind her. V3 LPN removed the compression stocking and the soiled dressing which held yellow/tan wet drainage. R18's right stump surgical wound bed was covered with gray sloughing and yellow/tan drainage. With soiled gloves V3 LPN pulled the white basket closer to her, retrieved the wound cleanser, reached into the package of gauze and retrieved gauze pads. V3 LPN sprayed the gauze pads with the wound cleanser, put the wound cleanser back into the white basket and wiped R18's surgical wound bed. V3 LPN repeated this same process three times and a fourth time. V3 LPN retrieved a gauze pad and wiped R18's wound bed dry. With same soiled gloves, V3 LPN reached into the white basket and retrieved a wound culture kit which contained a red cap with two swabs and the vial to hold the swabs. V3 LPN opened the kit by holding the red cap with swabs in her right soiled gloved hand and the vial container with her left soiled gloved hand and pulled them apart. V3 LPN then rubbed the two swabs onto R18's wound bed to obtain wound culture, placed the red cap with the swabs back into the vial, and pushed them together to close the kit. V3 LPN reached back into the white basket, retrieved gauze from the package of gauze, and the wound cleanser, sprayed the cleanser onto the gauze, put the wound cleanser back into the white basket and wiped R18's peri wound area. V3 LPN repeated this same step one more time. V3 LPN then removed her soiled gloves, reached into her right uniform pocket, retrieved the hand sanitizer, squeezed the liquid onto her left hand, and put the hand sanitizer back into her uniform pocket and retrieved another pair of gloves from the same uniform pocket. V3 LPN reached into the white basket, retrieved a bottle of (water-free moisturizer), sprayed R18's peri wound with the (water-free moisturizer) and with gloved hands rubbed the moisturizer over R18's peri wound area. Without performing hand hygiene V3 LPN reached into the white basket and retrieved a package containing collagen silver, opened the package and pulled the collagen silver out, applied the collagen silver to R18's wound bed, and pulled off the excess edges. V3 LPN reached back into the white basket, retrieved a non bordered dressing, placed it around R18's stump wound, reached back into the basket retrieving tape and began securing dressing with the tape and placed the tape back into the basket. After applying the compression dressing to R18's dressing, V3 LPN removed her gloves by retrieving the hand sanitizer from her uniform pocket and after use put the hand sanitizer back into the same uniform pocket. V3 LPN picked up the white basket and the wound culture kit and exited R18's room, walked to the nurse's station, set the basket on the desk, grabbed the culture kit by the red cap, filled out the label, logged into the nurse's station computer using the computer mouse and keyboard. V3 LPN opened the medication room door, picked up the biohazard laboratory bag, handed the bag to V2 DON who held the bag open for V3 LPN to place the culture kit into the bag. V3 LPN walked up to the medication cart, logged into medication cart computer to look up R18's medication orders, opened a medication cart drawer, retrieved R18's card of antibiotic, pushed the medication into a medication cup, closed medication cart drawer, walked out of med room, closed medication room door, walked to R18's room, and administered the antibiotic to R18. V3 LPN exited R18's room, went back to medication room, opened the medication room door, logged back into the computer and signed off R18's antibiotic, exited the medication room, closed the door and walked to the nurse's station desk and picked up the white basket. On 3/20/24 at 10:45 am, V3 LPN stated the white basket contains treatment supplies for R18 only, not for anyone else and after the wound treatment is done the basket goes into the medication room so the next nurse just grabs the basket and will have all R18's supplies together. V3 LPN stated V10 LPN is the wound nurse and recommended trying the (water-free moisturizer) instead of the collagen powder to prevent the dressing from sticking to R18's leg. V3 LPN stated V10 LPN did not get a physician order for the moisturizer but stuck a note in R18's basket and she said she would get the order if it worked. On 3/21/24 at 10:01 am, V3 LPN stated, We are supposed to use hand sanitizer every time our hands get contaminated and before putting on gloves and after taking them off. On 3/21/24 at 11:30 am, V2 DON stated, All employees should be performing hand hygiene before and after glove removal, or when they touch contaminated objects. On 3/21/24 at 2:00 pm, V2 DON confirmed V3 LPN contaminated treatment supplies during R18's surgical wound treatment and should have performed hand hygiene between dirty and clean. V2 DON also confirmed there is no physician order for the use of the (water-free moisturizer) to be used for R18 because the facility wanted to try it first to see if it would work.

Based on observation, interview and record review the Facility failed to perform hand hygiene and maintain adequate infection control during a Pressure Ulcer dressing change for one Resident (R7) of two Residents reviewed for Pressure Ulcers in a sample of 21. Findings include: Facility Procedure for Clean Dressing Change Policy, reviewed 2/1/24, documents: to protect open wound from contamination; prevent infection and spread of infection; provide for optimal healing; wash hands; place plastic bag/waste basket near foot of bed to receive soiled dressing; position the bag to avoid reaching across the sterile field or the wound when disposing of soiled articles; form a cuff by turning down the top of the trash bag to provide a wide opening and to prevent contamination of instruments or gloves by touching the bags edge; slowly remove soiled dressing; discard soiled dressing in the plastic bag; wash hands, put on new gloves; use (brand name) wound cleanser if no solution is specifically ordered; always wipe from clean area toward the less clean area; use each gauze pad for only one stroke; apply prescribed medication if ordered; follow Physicians order for type of dressing; secure dressing edge with tape or method as ordered by Physician; remove gloves and place in plastic bag; wash hands; assist Resident to comfortable position; return equipment to designated area; discard bag containing dressings in infectious waste container; and wash hands. R7's Physician Order Sheet/POS, dated 1/21/24 through 3/21/24, documents R7's Right Heel treatment of cleanse, sure prep (skin protectant) surrounding wound, apply medication (collagen silver) cut to fit open area only, cover with non-bordered dry dressing and wrap with dry dressing (Kerlix) and change daily. R7's POS also documents an order to ensure heels are off loaded with heel boots and pillow, please remove heel boots and put on (don) gripper socks for stand aid transfers. R7's Multi Wound Chart Details, dated 2/28/24, documents: Wound One (Right Heel Pressure Ulcer) acquired on 9/13/23, and measuring 3.2 centimeters/cm by 1.4 cm by 0.2 cm with moderate, serosanguineous drainage. The wound charting documents a right heel treatment order of collagen sheet silver, cover with super absorbent non-bordered four by four, wrap with stretch gauze bandage and reinforce with silk tape. R7's current Care Plan, documents on 2/9/24, a Physician Order for Antibiotic (Cephalexin) for a resolved right heel infection. On 3/19/24 (at 9:35 am, 10:10 am and 12:45 pm) and on 3/20/24 (at 10:04 am and 12:10 pm) and 3/21/24 (at 9:25 am and 10:30 am) R7 was in R7's recliner with legs elevated on the footrest, with no heel boots on. R7's heel boots were on the floor and at the foot of R7's bed. On 3/20/24 at 10:04 am, V3 (Licensed Practical Nurse/LPN) entered R7's room, with R7's wound supply bin/basket, to perform right heel pressure ulcer care. R7 was in recliner with legs elevated on footrest, with no heel boots on. R7's heel boots were on the floor, at the foot of R7's bed. V3 removed R7's soiled dressing and continued to clean R7's right heel pressure ulcer with wound cleanser by spraying the wound cleanser onto R7's heel, then placed the bottle of wound cleanser onto the floor at R7's recliner footrest, then with gauze, cleansed/wiped R7's right heel with approximately five strokes, with the same gauze in a circular motion, red drainage and contaminated wound cleaner dripped onto the floor, at R7's footrest. V3 then picked up the bottle of wound cleanser off of the floor again, sprayed R7's Right Heel and continued to cleanse/wipe R7's right heel and placed the wound cleanser back onto the floor. V3 then picked up the bottle of wound cleanser off the floor and placed it onto the window ledge, next to R7's wound supply bin/basket. V3 then removed and disposed the contaminated gloves into R7's waste basket across the room (over five feet). V3 hand sanitized and put on clean gloves. When V3 was retrieving new wound supplies from R7's wound care bin/basket, V3 could not locate a non-border dry dressing, so V3 removed V3's gloves and exited R7's room to retrieve a new non-border dry dressing. When V3 re-entered R7's room, V3 placed the new non-border dry dressing package onto R7's recliner footrest and the clean package fell on to the floor. V3 picked up the package off the floor and placed it back onto R7's recliner footrest. V3 then put a new pair of gloves on, without performing hand hygiene, and completed R7's treatment. V3 did not apply sure prep (skin protectant) to R7's peri wound area. V3 was kneeling on the floor at R7's recliner footrest, and as V3 opened the wound supply packages, V3 placed them onto V3's right leg, instead of into the waste basket. V3 then removed the contaminated gloves and tossed them towards the waste basket and the gloves fell on to the floor. V3 then walked over to pick up the soiled gloves off the floor and placed them in the waste basket. V3 then placed R7's right sock back on and re-positioned R7's Right Foot, then covered R7's foot with R7's blanket and placed the bottle of wound cleanser back into the wound supply bin/basket. On 3/21/24 at 10:01 am, V3 (LPN) stated, We are supposed to hand sanitize every time our hands get contaminated and before putting on gloves and after taking them off. I did toss the gloves over to the garbage can, and I probably should have cleaned my hands after picking them up off the floor and not a good idea that I put that wound cleanser bottle onto the floor and should have wiped up the drainage on the floor. I did not even think about it when I was picking up the clean dressing package off of the floor. On 3/21/24 at 11:30 am, V2 (Director of Nursing) verified that V2 entered R7's room after wound care was almost completed and stated, I did see (V3) toss the gloves onto the floor and pick them up and (V3) should have not done that. All employees should be performing hand hygiene before and after glove removal, or when they touch contaminated objects. V2 also verified that V3 (LPN) should not have placed the wound cleanser onto the floor and stated, (V3) should have put down a towel or wound dressing pad before starting the treatment to avoid the drainage and wound cleanser from dripping onto the floor.

Based on observation, interview, and record review the facility failed to obtain a physician order for the use of oxygen, follow the manufacturers guidelines for tubing changes, and store oxygen tubing per facility policy and procedure for one (R20) of two residents reviewed for oxygen in the sample of 21. Findings include: The facility's Oxygen Administration policy and procedure, revised 2/22/2024, documents A physician's order is required to use O2 (oxygen). The standing orders may be used in an emergency situation, but the physician must be notified after oxygen is initiated. Be sure to enter O2 use in the Treatment MAR (Medication Administration Record). The oxygen tubing will be discarded and replaced every 90 days. Please label oxygen tubing with date changed if possible. If a humidifier bottle is being used, this is required to be emptied, cleaned and refilled with distilled water every twice weekly. Replace humidifier bottle per annual recommendations. When resident is not using the O2 cannula, store in cloth bags provided. The (Brand/Company) Oxygen Manufacture Guidelines for nasal cannula, dated 2024, documents Check with your healthcare provider for your prescribed airflow setting when choosing the proper nasal cannula. You'll find (Brand/Company) offers a variety of nasal cannulas to fit most airflow needs. And to ensure the best oxygen delivery possible, remember to replace your nasal cannula at least once every 14 days. The facility's Physicians Order policy and procedure, revised 7/7/23, documents Responsibility: Licensed Nurse, Place new orders into (electronic charting system) as appropriate making sure to discontinue any previous orders no longer being used and All new telephone orders, e-mailed orders, and verbal orders are to be directly entered into matrix and the Dr (doctor) will e-sign them. The current Physicians Orders documents the following dated Physician Orders: 1/9/24 If on oxygen change tubing every 90 days, Special Instructions: Change cannula and tubing every 90 days while on oxygen; and 1/9/24 Check behind ears to monitor skin daily if on continuous oxygen therapy, once a day. As of 3/21/22 at 3:00 pm, there was no physician order for the administration of oxygen for R20. The TAR's (Treatment Administration Record) and the MAR's, dated 1/1/24 through 3/22/24, do not include oxygen orders. The January TAR, documents physician order, dated 1/9/24 Check behind ears to monitor skin daily if on continuous oxygen therapy every shift and Check oxygen saturations q (each) shift on continuous oxygen ever shift prn (as needed). The Admission MDS (minimum data set) assessment for R20, dated 1/15/24 documents oxygen therapy was used during the look back period. On 3/19/24 at 4:00 pm, R20 stated she only uses the oxygen when she needs it, and it has been a while. An oxygen sign was noted on the outside of R20's door. R20 was lying in bed on her back with eyes open and without oxygen infusing. An oxygen concentrator was next to R20's nightstand, plugged into a wall electrical outlet with a humidifier bottle and oxygen cannula tubing attached. The undated humidifier bottle was half full of clear liquid and the undated nasal cannula tubing was resting stretched out over the top of the oxygen concentrator. There were no dates on the humidifier bottle or the oxygen nasal cannula tubing to indicate when they were initiated. On 3/20/24 and 3/21/24 between 8:00 am and 4:00 pm, R20's oxygen concentrator was unchanged, without dates on oxygen tubing and humidifier bottle, and oxygen tubing stretched out over the top of the concentrator and not in a cloth bag. On 3/22/24 at 9:23 am, V9 (Brand/Company) Customer Service Representative stated all oxygen tubing should be changed every two weeks. On 3/22/24 at 3:00 pm, V2 DON confirmed R20 did not have a physician order for oxygen and should have and she called and clarified the order for oxygen administration for R20 the afternoon of 3/22/24.

Based on interviews and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by staff for three residents (R1, R2 and R3) out of three residents reviewed for abuse in a sample of three. Findings include: The facility's Abuse Prevention policy reviewed 1/1/23, documents It is the policy of the Apostolic Christian Home of Roanoke NOT to tolerate abuse, neglect, or misappropriation of funds or exploitation involving our residents by any individual. Characteristics of residents at risk for abusive and/or neglectful situations: Diagnosis of dementia, Below age 55, Lack of family/visitors, Total dependence on staff for care, Impaired communication, Exhibit physically aggressive behavior, Exhibit wandering behavior, Incontinence .Abuse: Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Also, depriving an individual of goods and services necessary to obtain physical, mental, & psychosocial well-being. Physical abuse: Including but not limited to hitting, kicking, pinching, choking, shoving, pushing, biting, slapping, punching, striking with object, burning, cutting. Verbal/psychological abuse: Including but not limited to words, signs or gestures to intimidate and demean; cursing, harassing, ridiculing, and threatening. POSSIBLE INDICATORS: helplessness, hesitation to talk openly, implausible stories, confusion, disorientation, anger, fear, withdrawal, depression, denial, agitation. The facility's abuse investigation for R1 dated 5/5/23 documents An activity aide reported that she overheard the sound of a slap from across the dining room. When she look towards the sound, she witnessed a CNA (Certified Nursing Assistant) (V3, CNA) pushing the hand of resident (R1). When interviewed, (V3, CNA) reported that she was kneeling down adjusting the foot pedals on the wheelchair of resident (R1). (R1) slapped (V3, CNA) across the face and in response, (V3, CNA) moved (R1)'s hand out of the way. R1's medical record documents R1 has a diagnosis of Alzheimer's disease with late onset, dementia with psychotic disturbance and major depressive disorder with psychotic symptoms. R1's current care plan documents Resident may display verbal or physical behaviors. Attempt distraction and redirection. R1's minimum data set (MDS) documents a brief interview for mental status (BIMS) as a four. A BIMS score of 0-7 indicates the resident is severely cognitively impaired. R2's medical record documents R2 has a diagnosis of moderate dementia with agitation. R2's MDS documents a BIMS score as a 99. A score of 99 indicates a residents can not complete the assessment due to cognitive impairment. R3's medical record documents R3 has a diagnosis of dementia. R3's MDS documents a BIMS score of two. On 5/15/23 at 8:52 AM, V4, Activities Aide (AA), stated This happened a week ago Friday (5/5/23). I have a small group of ladies I do exercises with in the dining room. I was on the other side of the dining room when I heard a really loud smack. I didn't know what was going on, but when I looked up, I saw V3, Certified Nursing Assistant, (CNA), standing up in front of (R1) bringing her hand down and smacking (R1) on the back of the hand like you would when you discipline a child. A resident should never be treated like that. (R1) has dementia and she doesn't know any better, you don't discipline the residents. I reported it to the administration. (V1, Administrator) told me what I saw was (V3, CNA) pushing (R1)'s hand away. I told him that her hand definitely came down and smacked (R1)'s hand. It wasn't her pushing the hand away. (V3, CNA) was standing, not kneeling. On 5/15/23 at 9:08 AM, V5, Activities Director, On Monday after the incident took place, (V4, AA) came to me because she heard the abuse was unfounded by the facility. I told her that it was, and she told me she can't work here because she can't be in a place that doesn't investigate abuse. After the morning meeting, she handed me a letter and quit. On 5/15/23 at 9:42 AM, V6, CNA stated I've worked here the last six years and (V3, CNA) does make comments to residents that come off rude. There was one comment that she made last week that I reported to (V1, Administrator). (V3, CNA) said If a resident hits me, I'll hit them back. On 5/15/23 at 10:08 AM, V7, CNA, stated (V3, CNA) is rude to the residents. About two months ago, I was working with (V3, CNA) and heard her tell (R2) Why don't you go die. On 5/15/23 at 10:13 AM, V8, CNA, stated A week or two ago I was in (R1)'s room with (V3, CNA) assisting her with transferring (R1). Because of (R1)'s dementia, she repeats phrases. She can also get combative during cares. Well, during the transfer (R1) kept repeating something like Oh, my back hurts over and over. (V3) told (R1) Oh shut up! I couldn't believe she said that. There was another incident I witnessed about a month ago between (V3, CNA) and (R3). I heard (R3) tell (V3, CNA) Don't say damn to me and V3 responded saying I didn't say damn, I said bitch! There is one other thing I heard (V3, CNA) say. It's been within the last month, but I heard (V3, CNA) make a comment and she said, If a resident hits me, I'll hit them back. On 5/16/23 at 7:56 AM, V3, CNA stated I went to get (R1) from lunch to take her to her room and her foot pedal was swung over to the side. So, I bent over and moved the pedal in place and when I picked up (R1)'s leg to put it on the pedal, she smacked me on the forehead. She smacked me hard enough that it rattled me. When she smacked me, I immediately pushed her hand away, stood up and walked away from the situation. I was not kneeling. If I kneel, I'm not getting back up. I was bent over when she smacked me. (R1) hits all time. She sucker punched me about a month ago.

Based on interview and record review, the facility failed to report an allegation of verbal abuse to the abuse coordinator for three residents (R1, R2, R3) and failed to submit an accurate report of physical abuse to the state agency for one resident (R1) out of three residents reviewed for abuse in a sample of three. Findings include: The facility's Abuse Prevention policy reviewed 1/1/23 documents Illinois law requires that when any administrator, agent, or employee of a long term care facility has knowledge that a resident has been subjected to abuse or neglect, they should immediately report the allegation to the Administrator, at any time of day or night, or another member of the Abuse Prevention Team in their absence. It is also the responsibility of covered individuals (any owner, operator, employee, manager, agent, or contractor of this facility), to report if they have reasonable suspicion of a crime committed against a resident of the facility. The report must be made to the police and State Survey Agency. In this case, reports should be made to the [NAME] County Sheriff and to the Illinois Department of Public Health. Covered individuals must make the report within 2 hours after first suspecting a crime has occurred if the suspected crime involves serious bodily injury to the individual, or within 24 hours if there is no serious bodily injury involved. Failure to report reasonable suspicion of crime can result in a civil monetary penalty of up to $300,000 and/or exclusion from participation in any federal health care program. R1's minimum data set (MDS) documents a brief interview for mental status (BIMS) as a four. A BIMS score of 0-7 indicates the resident is severely cognitively impaired. R2's MDS documents a BIMS score as a 99. A score of 99 indicates a residents can not complete the assessment due to cognitive impairment. R3's MDS documents a BIMS score of two. The facility's abuse investigation reported to the state agency for R1 dated 5/5/23 documents An activity aide reported that she overheard the sound of a slap from across the dining room. When she look towards the sound, she witnessed a CNA (Certified Nursing Assistant) (V3, CNA) pushing the hand of resident (R1). When interviewed, (V3, CNA) reported that she was kneeling down adjusting the foot pedals on the wheelchair of resident (R1). (R1) slapped (V3, CNA) across the face and in response, (V3, CNA) moved (R1)'s hand out of the way. On 5/15/23 at 8:52 AM, V4, Activities Aide (AA), stated This happened a week ago Friday (5/5/23). I have a small group of ladies I do exercises with in the dining room. I was on the other side of the dining room when I heard a really loud smack. I didn't know what was going on, but when I looked up, I saw (V3, Certified Nursing Assistant, (CNA), standing up in front of (R1) bringing her hand down and smacking (R1) on the back of the hand like you would when you discipline a child. A resident should never be treated like that. (R1) has dementia and she doesn't know any better, you don't discipline the residents. I reported it to the administration. (V1, Administrator) told me what I saw was (V3, CNA) pushing (R1)'s hand away. I told him that her hand definitely came down and smacked (R1)'s hand. It wasn't her pushing the hand away. (V3, CNA) was standing, not kneeling. I gave (V1, Administrator) my statement that says I saw (V3, CNA) slap (R1)'s hand and not push it away. V4's, AA, statement dated 5/5/23 documents I was in the dining room sitting with a small group of ladies doing sensory visits near the door leading to the courtyard. I heard (R1) yell out a bit as a CNA came over to talk to her. I heard some commotion coming from the North side of the dining room. As I looked up to see what was happening, I witnessed and heard (V3, CNA) slap (R1)'s hand. (V3, CNA) then took (R1) from the dining room. On 5/15/23 at 9:42 AM, V6, Certified Nursing Assistant (CNA) stated I've worked here the last six years and (V3, CNA) does make comments to residents that come off rude. There was one comment that she made last week that I reported to (V1, Administrator). (V3, CNA) said If a resident hits me, I'll hit them back. On 5/15/23 at 9:51 AM, V4, AA, stated The commotion 'I'm referring to in my statement was when (R1) slapped (V3, CNA). The slap is what made me look up. On 5/15/23 at 9:55 AM, V1, Administrator, stated No one ever reported to me that (V3, CNA) made a comment about hitting a resident. That's considered potential abuse and we would suspend the CNA and do an investigation. On 5/15/23 at 10:08 AM, V7, CNA, stated (V3, CNA) is rude to the residents. About two months ago, I was working with (V3, CNA) and heard her tell (R2) 'Why don't you go die.' I didn't report it to the administration because nothing gets done. They don't do anything about abuse. On 5/15/23 at 10:13 AM, V8, CNA, stated A week or two ago I was in (R1)'s room with (V3, CNA) assisting her with transferring (R1). Because of (R1)'s dementia, she repeats phrases. Well, during the transfer (R1) kept repeating something like 'Oh, my back hurts' over and over. (V3) told (R1) 'Oh shut up!' I couldn't believe she said that. There was another incident I witnessed about a month ago between (V3, CNA) and (R3). I heard (R3) tell (V3, CNA) 'Don't say damn to me' and V3 responded saying 'I didn't say damn, I said bitch!' There is one other thing I heard (V3, CNA) say. It's been within the last month, but I heard (V3, CNA) make a comment. She said, 'If a resident hits me, I'll hit them back.' I didn't report any of them to the administration because things like that are being swept under the rug and they don't look into it. On 5/16/23 at 9:50 AM, V1, Administrator, was asked by the surveyor why the allegation of physical abuse that was reported to the state agency on 5/5/23 documents that V3, CNA, pushed R1's hand away, but the written and verbal statement given to him by V4, AA, on 5/5/23 documents that V3, CNA slapped R1's hand. V1, Administrator, stated I have no answer for you on that.

Based on observation and record review, the facility failed to have admission documents that did not require residents to waive potential facility liability for losses of personal property for one (R35) of two residents reviewed for vision/hearing in the sample of 23. Findings include: The facility's Resident and Facility Contract, undated, documents X. The facility is not responsible for loss or damage of any personal property belonging to the resident. The resident acknowledges that failure to abide by the rules and regulations of the contract will result in the breach of this contract. This contract has a line at the bottom that requires a signature of the resident/responsible party and nursing home representative. On 6-22-22, at 10:50am, R35 sat in her room with bilateral hearing aids in. R35 stated that they are new because one had gotten broken. R35 is unsure of how it got broke and stated that V7 (R35's family member) was taking care of it. On 6-22-22, between 11:40am and 11:55am, V3 Social Service Director/SSD stated the following: Nursing had informed V3 that R35's hearing aids went through the wash and were broken. (R35's) family took (R35) to a hearing aid place and got new ones made at the family's expense. V3 confirmed this loss was a facility error. V3 stated that no replacement agreement was made between (R35's) family and the facility. V3 stated this was, due to it being in the contract that residents sign that the facility will not be liable for mishaps like that. On 6-22-22, at 1:30pm, V7 (R35's family member) stated the following: (R35) had taken out one of (R35's) hearing aids and who knows where (R35) put it. It was found by the CNA (Certified Nurse Assistant). It went through the wash and wasn't working at all. V7 denied any offer by facility to pay for part or all of the new one. The facility's Lost Items Report Form for R35, signed by V1 Administrator and dated 5-6-22, includes the following: R35's hearing aid is listed as a lost item. Immediate action taken by facility: searched room, notified Social Service (V3). V3 documented, Informed by nursing that hearing aid had gone through laundry. Attempted to let it dry out. On 5-10-22 family took resident to audiologist. Picked up new hearing aids on 6-15-22.

Based on observation, interview, and record review, the facility failed to perform incontinence care for one (R289) of two residents reviewed for incontinence care in a sample of 23. Findings include: Facility Toileting Assistance policy, revised 8/1/18, documents, (It is the) responsibility of a licensed nurse and CNA/Certified Nurse Aide to provide the resident who is unable to toilet self with adequate means for elimination, and once eliminations has been completed assist the resident to cleanse the perineal area well with tissue if resident is unable to do for themselves. Instruct female resident to clean from front to back. Wash and dry perineal area well with attend wipes. Notice: This is to be done with every toileting. R289's MDS/Minimum Data Set Assessment, dated 6/14/22, documents R289 is alert and oriented, occasionally incontinent of urine, and is not on a toileting program. On 6/21/22 at 10:00am, R289 was in her recliner and mechanically lifted from her recliner chair into bed to use the bed pan by V5 and V6 (CNAs/Certified Nurse Aides). R289 stated, I leaked a little into my brief. R289s urine soiled brief was removed and put into the garbage, R289 urinated into the bed pan, V6 left the room with the mechanical lift, and V5 removed R289s bed pan. At that same time V5 stated, I cannot find any wipes as she was looking through the bedside dresser, went into the bathroom, and looked in R289s closet. V5 then repeated the above process of looking through R289s bedside dresser, bathroom, and closet, and restated, I cannot find any wipes. V5 did not use any wipes, washcloths, or toilet paper/tissue to provide incontinence care for R289. V5 then went back to R289 and rolled R289 onto her side, put a blue incontinence brief on R289, covered up R289 with a blanket, and went out of the room with the garbage bag. On 6/21/22 at 10:15am, R289 stated, They usually use wipes to clean me after I go to the bathroom, I don't know why they did not this time, and I use the bedpan to go to the bathroom. I wear briefs all the time because I can't hold my pee, I take a water pill, and I have stage four kidney disease. On 6/22/22 at 3:42pm, V2 Registered Nurse/RN Director of Nursing/DON stated, I would expect peri-care to be given when a person is incontinent. On 6/23/22 at 9:30am, V2 DON stated, I talked to (V5), and she said she did not use any wipes to perform incontinence care on (R289) because there were not any in the room, so she didn't use anything, and just put on her brief.

Based on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside for two residents (R33 and R139) of 16 residents reviewed for medications in a sample of 23. Findings include: The facility's policy Medication Administration, revised 10-2-18, documents, Procedure: 11. Administer medication to resident. Observe them taking the medication. Stay with the resident until he/she has swallowed the drug. 1. On 6-21-22, at 12:04pm, R33 sat on the bed. On R33's bedside table were two capsules in a plastic medication cup and two medication cups filled with 30ml (millimeters) of a clear liquid medication. At this time, R33 confirmed those were (R33's) medications and stated that some of them (nurses) wait for R33 to take the medications some don't wait for R33 to take the medications. R33's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 6-22-22, at 12:05pm, three pills in a medication cup were on R139's (R33's roommate) bedside table. On 6-22-22, at 12:11pm, R139 arrived back to R33 and R139's room with therapy and said, There are my pills. R139's current POS includes orders for Curamin 2706 mg one tablet four times per day, Omega-3 fish oil capsule 300 - 1,000mg three times a day, and [MEDICATION(S)] picolinate 200 mcg (micrograms), one tablet three times a day. On 6-21-22, at 2:57pm, V4 Registered Nurse/RN confirmed that R33's [MEDICATION(S)] and [MEDICATION(S)] pills and liquid [MEDICATION(S)] were left on R33's beside table. V4 also confirmed that R139's Curamin, fish oil, and [MEDICATION(S)] pills were left on R139's bedside table while R139 was out of the room. V4 stated, I don't usually leave them and shouldn't have.

Based on observation, interview, and record review, the facility failed to protect two residents (R1, R2) from physical, verbal, and psychological abuse for two of three abuse allegations reviewed. This failure resulted in a R1 expressing recurring fear whenever staff approach the resident, exhibiting crying and agitation, exhibiting physically aggressive behaviors, declining to eat, declining medications, declining cares, and declining to get out of bed. R1 also has extensive pain and bruising to R1's bilateral hands and wrists. Findings include: The facility's Abuse Prevention policy, dated 2/21/18, documents, Abuse: Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Physical abuse: Including but not limited to hitting, kicking, pinching, choking, shoving, pushing, biting, slapping, punching, striking with an object, burning, cutting. Possible indicators: cuts, laceration, puncture wounds, bruises, welts, discoloration. Verbal/psychological abuse: Including but not limited to words, signs, gestures to intimidate and demean, cursing, harassing, ridiculing, and threatening. Possible indicators: helplessness, hesitation to talk openly, implausible stories, confusion, disorientation, anger, fear, withdrawal, depression, denial, and agitation. The policy also documents, Behavior Management & Catastrophic Reactions: If a resident becomes agitated and will not be distracted, make sure they are safe and leave the area. 1. R1's BIMS (Brief Interview of Mental Status), dated 8/19/19, documents a score of 11 (moderately impaired cognition). R1's Care plan, dated 8/27/19, documents, R1 is usually in a good mood, but may make negative comments. The care plan also documents, R1 may display behaviors such as anger/verbal abuse toward staff. R1 may display that during time of ADLs (Activities of Daily Living). An approach/intervention that was documented regarding these behaviors was: Explain to R1 what you will be doing prior to working with her. If R1 refuses, explain consequences of not participating in cares needed. If R1 become angry and begins raising her voice or starts to verbally abuse staff, remind R1 that you respect her and that she needs to respect you also. Ensure that R1 is safe. Leave R1 and allow her to calm down and approach later. On 10/22/19 at 2:55 p.m., V3 (Certified Nursing Assistant-CNA) stated, I got to the facility (10/17/19) at 4:00 p.m. V5 and V6 (Both CNAs) told me that R1 was combative during cares and they showed me the scratches on their arms. I told them to just let me care for her the rest of the night so it would be a different person. I went in to check on R1. She had dried blood on her lips. Then, I found that she had blood in her mouth. I asked her what happened. She was upset, crying, and paranoid. R1 stated, 'Two girls held me down and one pulled my dentures out.' I cleaned her mouth out and tried to comfort her as much as possible. She had so much blood in her mouth I couldn't tell if R1 had any sores or not in her mouth. After, I got her mouth cleaned out, R1 stated, 'I wish I could make them drink their blood like they did to me.' V3 also stated, R1 used to be crabby then about a month ago R1 got sick, and R1 was more mellow and passive more friendly. Thursday (10/17/19) when I came in R1 was paranoid and terrified. R1 knows who I (V3) am so she was trying to protect me (V3). R1 kept saying you (V3) can't be in here they are going to find you (V3) and they are listening. R1 was scared to death crying fearing they were going to hurt her again. When I (V3) did rounds (10/17/19) R1 was acting nervous each time I (V3) was in there acting scared. R1's behavior were worse on Saturday (10/19/19). R1 wasn't eating or taking her medications. R1 was scared to let anyone to care for her. R1 didn't want anyone to do anything with her like changing or washing her up. Saturday (10/19/19) and Sunday (10/20/19) night R1 would just start to tear up for no reason. We even were trying to distract her from thinking about the incident. Even up until tonight (10/22/19) R1 was so scared that they (perpetrators) were still around and worried when I came into her room. That they were listening to us and were going to hurt us. She has not ate anything since Friday (10/18/19) morning. She's not eatten anything. She was eating really good prior to this. She is just a completely different person. Her and I would joke around back and forth. There is no joking, now she just seems to be upset all the time. As of Sunday (10/20/19) she was still telling myself and other staff the same story of what happened. All night last night, R1 was saying her hands hurt. When I go in I'll rub the top of her hand to let her know I'm in the room with her. She grimaced when I lightly touched it and said her hand was really sore. Over the weekend (10/19-10/20/19) I didn't see her sleeping at all R1 was just constantly watching out the door. On 10/22/19 at 1:15 p.m., V5 (CNA) confirmed that she removed R1's dentures on the evening of 10/17/19, and stated, R1 was refusing to allow us to take her dentures out. The corners of her mouth were bleeding. We needed to get the dentures out. Then afterwards R1 got really upset with me and started becoming combative, hitting, and scratching us (V5 and V6 CNA). Even though R1 was combative we (V5 and V6) continued with her cares. On 10/22/19 at 1:30 p.m., V6 stated, In report we were told that R1's dentures needed to come out. Obviously, we aren't going to leave the dentures in if there were sores even if R1 was refusing. R1 was trying to hit, punch, bite, and kick V5 while she was trying to get R1's dentures out. Then, the behaviors continued throughout the rest of her cares too. R1 kicked the crap out of both of us. We looked like we had been in a cat fight. Normally, we do approach at a different time. R1 told us no and said, 'I'm leaving my dentures in.' We told her they needed to come out because of sores. We didn't know that R1's gums were bleeding. I didn't see any blood before or after we took the dentures out. On 10/22/19 at 3:00 p.m., V4 (Licensed Practical Nurse) stated, I instructed V5 and V6 to take R1's dentures out. R1 was refusing to allow them (V5 and V6) to take her teeth out. R1 always doesn't want her dentures out. We can't even hardly be quick enough getting them out to clean them before she wants them back because she hates going without her dentures. V5 and V6 were covered in the scratches and marks because of getting R1's dentures out. On 10/22/19 at 12:30 p.m., V2 (Director of Nursing) stated that R1 was refusing to have her dentures removed, but she needed her teeth out regardless. R1's Nurse's notes, dated 10/18/19 at 12:32 p.m., documents, R1 refused breakfast, lunch and 12:00 p.m. medications stating she was upset and did not want to eat. R1's Nurse's notes, dated 10/18/19 at 8:04 p.m., documents, (R1) upset with bedtime cares, swinging arms, hitting at CNAs, kicking and yelling at CNAs,scratching CNAs causing deep marks to CNAs' skin. R1's Nurse's notes, dated 10/19/19 5:37 a.m., document, Right hand has irregularly shaped red/purple bruise across top of hand, 10 cm (centimeters) x 12 cm. Left middle finger has purple bruise 4.5 cm in length extending from first knuckle to second knuckle. Left forearm has 4.5 cm x 3 cm red/purple bruise, the side of left index finger space between index finger and thumb has 3.5 cm x 5 cm dark purple bruise. On 10/23/19 at 9:40 a.m., V7 (CNA) stated, I was there on Friday (10/18/19) 3rd shift. R1 was physically scared of us as caregivers to take care of her. R1 was physically shaking and crying when we tried to take care for her. R1 had the look of being lost. She can be troublesome, but the other CNAs and I normally don't have any issues with her. R1 clawed at my arm when we turned her, and she has never done this to me before. I reported this to the nurse, and said she's never done this to me. I also told them R1 is not acting right. She is traumatized by something. She's not even eating. R1 hasn't eaten since Thursday (10/17/19).If someone is in the room that she doesn't trust she say she doesn't want to talk to them. R1 had had bruises on her bilateral wrists, her right upper arm/shoulder area, and left forearm. To touch her left hand/wrist she would tell you it hurt. The way she is acting now is not a behavior she seems traumatized. She's continuing to act like she is fearful. R1 is crying when we provide cares. I just want R1 and the other residents to be safe. It breaks my heart that this smiling happy woman who could be a little troublesome at times is now this scared fearful woman who is scared of all of us. R1's Nurse's notes, dated 10/19/19 at 3:11 p.m., document, R1 did pinch one CNA and called them names. R1 also stated she wanted to kick them in the face and make them drink blood like she is. RN asked if she would like to get up for supper, even if she would like to stay in her room, resident declined stating she does not want to eat. R1's Nurse's notes, dated 10/19/19 at 6:27 p.m., document, Several bruises to left and right arm. Right wrist has significant bruising and swelling, she also has bruising to back of right upper arm. Resident is very quiet during bath. R1 cried off and on during her bed bath. R1 refuses any medications or food. R1's Nurse's notes, dated 10/20/19 at 1:00 a.m., document, Offered food and nourishment which R1 refuses. R1's eyes darken with moisture when nurse expresses desire to help her. R1's Nurse's notes, dated 10/20/19 at 8:30 a.m., document, R1 refused room tray, giving very short angry responses to questions. At one point CNAs offered her a drink and she responded with hell no. R1's Behavior Monitoring events, dated 10/20/19 at 1:08 p.m., document, Pinching, cussing, grabbing, threatening to punch staff, hitting, and pushing. R1's Nurse's notes, dated 10/20/19 at 5:47 p.m., document, R1 refused to get up out of bed. Refused supper tray when offered and refused any of her suppertime medication. On 10/23/19 at 2:00 p.m., V9 (Registered Nurse) stated, Saturday (10/19/19) I worked 2:00 p.m. to 10:00 p.m. I went to check on R1 and I found the bruising. R1's right wrist was swollen and covered in bruising along with bruising on the left wrist. While doing cares R1 told the CNA I'm going to kick you in the mouth and make you drink your blood like I had to.' R1 cried frequently and was very terrified. R1 wasn't the normal R1 we know. She normally jokes and talks with staff. R1 was listening for every sound. Anytime she heard something in the hall she would say, 'Who is that? Don't let them in here.' When she wasn't acting scared she would just stare at the wall. R1 did complain of her wrist hurting. These behaviors are different now, in the past some CNAs had issues with her complaining of getting up, but she would never refuse medications or food. She was never scared and paranoid. R1's never expressed these behaviors before. On 10/28/19 at 2:15 p.m., V22 (CNA) stated, Sunday (10/20/19) I worked 4:00 p.m. to 10:30 p.m. When we (V25 CNA and V22) went in R1 kept saying, 'Shut the door. Shut the door. They are going to get you too.' R1 knew who we were. We tried to get R1 to eat or drink. She refused to eat or drink anything. She had not been out of bed at that point since Thursday night. V25 and I provided care and she was horrible. Her eyes were bugging out, but she wouldn't look at us at all. R1 acted traumatized. She didn't want us to even touch her. This is not behaviors she is scared to death. She was unhappy at times but never like this before. Monday (10/21/19) and Tuesday (10/22/19) night I checked in on her and she still acted scared. Please believe me these are not behaviors this is not R1. V22 began crying and stated, Nothing like this should have ever happened, tears in V22's eyes and lips trembling. If a resident refuses you walk out and let the nurse know. R1 is in her right mind to know that she can refuse to take her teeth out. There's no reason why she can't leave them in. They use lots of glue on her upper dentures, and you have to pry them out. I can't imagine them trying to get her dentures out while she is fighting them. On 10/22/19 at 10:55 p.m., V8 (Registered Nurse) stated, I came into the facility (10/20/19) to sit with R1. When I sat with her she was in a different state of mind. R1 always knows who I am and has talked to me about my son. She normally smiled when I went into her room. She can be an unhappy person but she always smiled at me. So different wise she wouldn't smile she just stared at me and was reluctant to talk at all. I didn't actually ask her what happened. R1 seemed to be very afraid of noises in the hallway always looking at the door. R1 seemed scared and had very few words. R1 was telling me be careful they would follow me. I saw the bruises on her hands. Something had happened to R1 for her to act this way, and it wasn't good. R1's Nurse's notes, dated 10/22/19 at 12:34 a.m., document, R1 awake at this time. lying supine, eyes wide open, when nurse entered dark room, 'Who are you?' she said. As nurse said her name, R1 said, 'Oh come over here.' R1 asked nurse to, 'Stay, don't leave right away.' R1 spoke in a clear voice and her eyes were very alert and looking to the door at every sound, raising her head up and asking who it was. When light touch applied to her left lower arm and hand, she winced and pulled her hand away from nurse saying, 'Ouch, don't squeeze that. R1's Behavior Monitoring events, dated 10/23/19 at 1:47 p.m., documents, (R1) refusing cares, meals, drinks. When asked questions gives very short, terse answers. R1's Medication Administration History, dated 10/1-10/23/19, document that up until 10/19/19 R1 was receiving her medications on a regular basis. The history also documents that R1 was refusing to take her medications on 10/19-10/23/19. On 10/23/19 at 2:30 p.m., V30 (Dietary Manager) provided R1's Food Intake Record, dated 10/19. R1's Food Intake Record documented that R1 has had no intake of meals since supper of 10/17/19. V30 stated, R1 has not eaten anything since supper on 10/17/19 according to this intake record. On 10/22/19 at 9:45 a.m., R1 had a large dark purple bruise to her right wrist extending into thumb area. The entire top of R1's left hand had light purple bruising that extended above her wrist, and scattered dark purple to light purple bruising to her bilateral. arms small skin tear to left arm. R1 stated that she's not having a good day, but it's none of this surveyors business why it's a bad day. She also turned to the wall, and stated she didn't want to talk to this surveyor. On 10/22/19 at 11:35 a.m., V11 (Registered Nurse) assessed R1's bilateral hands. R1 had light purple bruising noted throughout the entire top of left hand. R1 states, It hurts. R1 grimaced when V11 asked R1 to perform range of motion in R1's left hand. R1 was unable to make a fist or grasp states pain in her left hand is a 9 on a scale of 0-10. R1's right hand and wrist had dark purple bruising on approximately half of the top of the hand including R1's thumb. V11 asked R1 how the bruising happened and R1 stated, It was those women who held me down. One was up top and two were down low. I'm not giving names because I don't want this happening to me again. It all started with them taking out my teeth. R1 acted angry and only stared at the wall stating, I told them No and they took my dentures out anyways. On 10/23/19 at 9:25 a.m., V27 (Licensed Practical Nurse) stated, R1 will normally get up and eat. Now, R1 is refusing to get out of bed and eat. R1 didn't get out of bed or eat anything the entire weekend (10/19-10/20/19). It wasn't until yesterday (10/22/19) morning that they could get R1 to get out of bed, but R1 still isn't eating. On 10/23/19 at 10:35 a.m., R1 was asked by this surveyor if R1 was experiencing pain. R1 stated she did not want to talk to this surveyor. This surveyor reassured R1 that it was safe to talk to me. With tears in her eyes, R1 stated to me, You weren't here when I needed you, and R1 asked the surveyor to leave the room. On 10/23/19 at 1:00 p.m., V26 (R1's Family) sitting at R1's bedside. stated, Something has happened this isn't normal for R1. I've been here the last three days while they have been giving cares, and she acts absolutely petrified. During cares, R1 is literally shaking and crying scared of what could happen. R1 is able to hold my hand with her left hand but she is unable to completely close her hand around my hand or make a fist. R1 has obviously has sustained some kind of injury. During this investigation, interviews with V3, V7, V10, V11, V12, and V20 confirmed that R1 made the same allegation to each of these staff members that R1 was held down and her dentures were ripped out of her mouth. V1 also confirmed that V2 was aware of R1 making this statement also. On 10/23/19 at 11:10 p.m., V14 (Social Services Director) stated, At times, during cares R1 would occasionally get agitated and refuse cares. She would yell and call people names. I've just been made aware this week of the increase in R1's behaviors lately. R1 hasn't been coming out for meals, and R1 was typically a person who would come out for all meals. This week she has been refusing to eat, refusing medications, refusing cares, and refusing to allow housekeepers to clean her room. The behaviors of being fearful of the staff and paranoid that someone is going to hurt her are new behaviors for her. Also, the refusing to get out of bed and to eat is also new. R1 didn't have these behaviors before. On 10/29/19 at 11:35 a.m., V21 (Medical Director) stated, If R1 continues to refuse to eat, refuse cares, and refuse medications this could lead to her death. The staff should have left R1 alone when she verbally refused to have her dentures out and then became combative. There is not a whole lot of harm related to leaving a resident's dentures in. By continuing cares while R1's being combative puts R1 at risk for injuring herself. 2. R2's Minimum Data Set assessment dated [DATE] documents [DIAGNOSES REDACTED]. On 10/23/19 at 2:10pm, V9, Registered Nurse (RN), stated she was working on 10/6/19 when she heard V13, CNA, yelling I'm tired of you (R2) treating me like s**t, this has to stop now! as V13 left R2's room. V9 stated she thought this was verbal abuse. V9 stated she called V2, Director of Nursing (DON) to report the verbal abuse, who said she had already reprimanded V13 a week earlier on another similar issue. V13's personnel file documents V13 was interviewed on 10/11/19 and disciplined for the witnessed incident (10/6/19) and admitted She did cuss, and that she shouldn't have. On 10/23/19 at 3:10pm, V13 stated (R2) was being very rude to me. I (loudly) told her to quit treating me like s**t. This happened in the hall and her room. On 10/23/19 at 3:40pm, V2 stated she did not feel this was verbal abuse as V13 did not say quit treating me like s**t to R2's face.

Based on observation, interview, and record review, the facility failed to identify potential abuse, investigate an allegation of abuse, and failed to remove the alleged perpetrators from the facility immediately for three residents (R1, R2, R3) of three abuse allegations reviewed. The facility failed to identify potential abuse in order to investigate and protect a resident from physical abuse resulting in serious psychosocial harm and extensive bruising and pain of R1's bilateral wrists and hands. R1 with moderate confusion and who was dependent on staff for care, reported to staff that she was held down by two staff members and a third staff member ripped her teeth out against her will. However, staff did not report R1's allegation to the administrator immediately, therefore the facility failed to provide protection for the resident allowing ongoing access to the resident by the alleged perpetrators. When facility administration became aware of the allegation, the facility failed to identify the allegation as potential abuse, and did not conduct an abuse investigation. The resident expressed recurring fear whenever staff approached the resident, exhibited crying and agitation, exhibited physically aggressive behaviors, declining to eat, declining medications, declining cares, and declining to get out of bed. Findings include: 1. R1's BIMS (Brief Interview of Mental Status), dated 8/19/19, documents a score of 11 (moderately impaired cognition). R1's Care plan, dated 8/27/19, documents, R1 is usually in a good mood, but may make negative comments. The care plan also documents, R1 may display behaviors such as anger/verbal abuse toward staff. R1 may display that during time of ADLs (Activities of Daily Living). On 10/22/19 at 11:35 a.m., V11 (Registered Nurse) assessed R1's bilateral hands. R1 had light purple bruising noted throughout the entire top of left hand. R1 states, It hurts. R1 grimaced when V11 asked R1 to perform range of motion in R1's left hand. R1 was unable to make a fist or grasp, states pain in her left hand is a 9 on a scale of 0-10. R1's right hand and wrist had dark purple bruising on approximately half of the top of the hand including R1's thumb. V11 asked R1 how the bruising happened and R1 stated, It was those women who held me down. One was up top and two were down low. I'm not giving names because I don't want this happening to me again. It all started with them taking out my teeth. R1 acted angry and only stared at the wall stating, I told them No and they took my dentures out anyway. On 10/22/19 at 2:55 p.m., V3 (Certified Nursing Assistant-CNA) stated, I got to the facility at 4:00 p.m. on 10/17/19. V5 and V6 (Both CNAs) told me that R1 was combative during cares. V5 and V6 showed me the scratches they had on their arms from R1. I told them to just let me care for R1 the rest of the night so it would be a different person. R1 had dried blood on her lips. Then, I found that she had blood in her mouth. I asked R1 what happened. She was upset, crying, and paranoid. R1 stated, 'Two girls held me down and one pulled my dentures out.' I cleaned R1's mouth out and tried to comfort her as much as possible. R1 had so much blood in her mouth. After I got her mouth cleaned out, R1 stated, 'I wish I could make them drink their blood like they did to me.'' V3 also stated, When I did rounds (10/17/19) R1 was acting nervous each time I was in there acting scared. R1's behaviors were worse on Saturday (10/19/19). R1 wasn't eating or taking her medications. She was scared to let anyone care for her. R1 didn't want anyone to do anything with her like changing or washing her up. Saturday (10/19/19) and Sunday (10/20/19) night R1 would just start to tear up for no reason. Even up until tonight (10/22/19) R1 was so scared that they (perpetrators) were still around and worried when I came into her room that they were listening to us and were going to hurt us. R1 has not ate anything since Friday (10/18/19) morning. R1 was eating really good prior to this (10/17/1). R1 is just a completely different person. R1 and I would joke around back and forth. There is no joking now, R1 just seems to be upset all the time. All night last night she was saying her hands hurt. When I go in I'll rub the top of her hand to let her know I'm in the room with her. She grimaced when I lightly touched it and said her hand was really sore. Over the weekend (10/19-10/20/19) I didn't see her sleeping at all R1 was just constantly watching out the door. V3 confirmed that she felt this was potential abuse. V3 also stated that V4, V5, and V6 continued to work the rest of their shift (10/17/19), and that V3 was never interviewed by V1 or V2 (Director of Nursing) regarding the incident. R1's Behavior Monitoring event, dated 10/17/19 at 9:35 p.m. but recorded being completed on 10/18/19 at 2:36 p.m., documents, R1 upset not wanting to get wet adult brief changed and washed for bed, R1 also has bleeding gums and is not wanting her teeth out, hitting, grabbing, and scratching CNAs as they are trying to complete cares. On 10/22/19 at 1:15 p.m., V5 confirmed that she removed R1's dentures on the evening of 10/17/19, and stated, R1 was refusing to allow us to take her dentures out. The corners of her mouth were bleeding. We needed to get the dentures out. Then, afterwards R1 got really upset with me and started becoming combative, hitting, and scratching us (V5 and V6 CNAs). Even though R1 was combative we (V5 and V6) continued with her cares. V5 also confirmed she had never been removed from caring for R1 or any other residents. On 10/22/19 at 1:30 p.m., V6 stated, In report we were told that R1's dentures needed to come out. Obviously, we aren't going to leave the dentures in if there were sores even if R1 was refusing. R1 was trying to hit, punch, bite, and kick V5 while she was trying to get R1's dentures out. Then, the behaviors continued throughout the rest of her cares too. R1 kicked the crap out of both of us. We looked like we had been in a cat fight. R1 told us no and said, 'I'm leaving my dentures in.' We didn't know that R1's gums were bleeding. I didn't see any blood before or after we took the dentures out. V6 also confirmed she had never been removed from caring for R1 or any other residents. On 10/22/19 at 3:00 p.m., V4 (Licensed Practical Nurse) stated, I instructed V5 and V6 to take R1's dentures out (10/17/19). R1 was refusing to allow them (V5 and V6) to take her teeth out. R1 always doesn't want her dentures out. We can't even hardly be quick enough getting them out to clean them before she wants them back because she hates going without her dentures. V5 and V6 were covered in the scratches and marks because of getting R1's dentures out. R1's Skin Incident report, dated 10/17/19 and signed by V4 and V2, documents, Noted this a.m. 10/18/19 at 6:30 a.m. Skin incident: Left wrist bruising, right wrist and hand bruising, right elbow bruising, and left and right middle finger bruising. R1 reports, 'They were taking out my teeth. On 10/22/19 at 2:00 p.m., V12 (CNA) stated, During R1's bath on 10/18/19, R1 had bruising on both hands from about top of hand to mid forearm and left upper arm. R1 told me during her bath that morning that she was held down and her dentures were ripped out of her mouth. R1 said it was the girls from the night before. Right after the bath I reported this to V10 (Registered Nurse). I wasn't interviewed by anyone regarding this incident. On 10/22/19 at 2:15 p.m., V10 stated, V12 reported to me that R1 had bruising to the top of her bilateral wrists and that R1 had made a statement about someone taking R1's teeth when R1 didn't want them to. I called V2 to report this. V2 told me to get with V4 to figure out what happened. When V4 arrived at 2:00 p.m. that day I asked her to take care of R1's incident report. R1's Nurse's notes, dated 10/19/19 5:37 a.m., document, CNA noted bruises on R1 forearms yesterday at supper, but R1 was too uncooperative to assess them until now. Right hand has irregularly shaped red/purple bruise across top of hand, 10 cm (centimeters) x 12 cm. Left middle finger has purple bruise 4.5 cm in length extending from first knuckle to second knuckle. Left forearm has 4.5 cm x 3 cm red/purple bruise, the side of left index finger space between index finger and thumb has 3.5 cm x 5 cm dark purple bruise. R1's Behavior Monitoring events, dated 10/19/19 at 1:21 p.m., documents, Refusing cares, refusing to get up for meals or to eat meals brought to room. Angrily saying NO when asked is she wanted to get up or have a tray to her room. R1's Nurse's notes, dated 10/19/19 at 3:11 p.m., document, R1 did pinch one CNA and called them names. R1 also stated she wanted to kick them in the face and make them drink blood like she did. RN asked if she would like to get up for supper, even if she would like to stay in her room, resident declined stating she does not want to eat. R1's Nurse's notes, dated 10/19/19 at 6:27 p.m., document, RN noted several bruises to left and right arm. Right wrist has significant bruising and swelling, R1 also has bruising to back of right upper arm. Resident is very quiet during bath. R1 cried off and on during her bed bath and when asked what was wrong R1 replied, 'No, I do not want you to get hurt. They are probably listening with recording devices.' R1 refuses any medications or food stating, 'No' when offered something to eat. R1's Nurse's notes, dated 10/19/19 at 7:48 p.m., document, R1 refused bedtime medications. On 10/23/19 at 2:00 p.m., V9 (Registered Nurse) stated, Saturday (10/19/19) I worked 2:00 p.m. to 10:00 p.m. R1's right wrist was swollen and covered in bruising along with bruising on R1's left wrist. R1 cried frequently and was very terrified. R1 wasn't the normal R1 we know. R1 normally jokes and talks with staff, but this R1 was listening for every sound. Anytime R1 heard something in the hall, R1 would say, 'Who is that? Don't let them in here.' When she wasn't acting scared R1 would just stare at the wall. R1 did complain of her wrist hurting. These behaviors are different now, in the past some CNAs had issues with her complaining of getting up, but she would never refuse medications or food. R1 was never scared and paranoid. On Saturday, after I saw R1's wrist I called V1 and he told me at that point he was not aware of this situation. He was going to call V2 and call me back. V2 called me back 15 minutes later. V2 told me she was aware of it. V2 said V1 didn't call me back because I (V9) didn't know what was going on. So V2 decided to call me. V2 told me that R1 didn't want to take her dentures out, and when the staff tried R1 started hitting them (V5 and V6) and they put their arms up to block R1. That was how R1 got the bruises (according to V2). I told V2 that I was concerned about R1's wrists being swollen and not eating. V2 told me this was just R1's behaviors and not wanting to eat was all related to her [DIAGNOSES REDACTED]. On 10/22/19 at 10:55 p.m.,V8 (Registered Nurse) stated, On (10/20/19) I came into facility to sit with R1. R1 was in a different state of mind. She always knew who I was and talked to me about my son smiling when I came into room. She can be a very unhappy person but she always smiled at me. So different wise she wouldn't smile she just stared at me and was reluctant to talk at all. I didn't actually ask her what happened. She seemed to be very afraid of noises in the hallway R1 was always looking at the door. R1 seemed scared and had very few words. I saw the bruises on R1's hands. Something had happened to R1 for her to act this way, and it wasn't good. I sat with her for over an hour. At the end of the visit I went straight to the church where I knew I would find V1. I pulled him into a room at the church, and I spoke with him. I told V1 that I went to the facility and sat with R1 and R1's in a complete different state of mind. It appeared to me that something had happened. V1 told me he was aware of it and V2 was investigating it. I told him I'm not sure what they found out, but something has happened. V1 told me he would investigate it on Monday (10/21/19). On 10/26/19 at 2:15 p.m., V22 (CNA) stated, On Sunday (10/19/19) when we (staff) went in R1's room R1 kept saying shut the door shut the door they are going to get you too. R1 knew who we were. R1 refused to eat or drink anything. R1 had not been out of bed at that point since Thursday (10/17/19) night. We provided cares and R1 was horrible. R1's eyes were bugging out but she wouldn't look at us at all. R1 acted traumatized. R1 didn't want us to even touch her. This is not behaviors, R1 is scared to death. R1 was unhappy at times but never like this before. Monday (10/20/19 and Tuesday (10/21/19) night I checked in on her and she still acted scared. Please believe me these are not behaviors this is not R1. Crying V22 stated, Nothing like this should have ever happened, with tears in her eyes and lip trembling. V22 stated, If a resident refuses you walk out let the nurse know. R1 is in her right mind to know that she can refuse to take her teeth out. There's no reason why she can't leave them in. They use lots of glue on her upper dentures, and you have to pry them out. I can't imagine them trying to get them out while she is fighting them. R1's Behavior Monitoring events, dated 10/22/19 2:27 a.m., documents, Worried facial expression, when awake/questions all movement and noises in the room. On 10/23/19 at 10:35 a.m., R1 was asked by this surveyor if R1 was experiencing pain. R1 stated she did not want to talk to this surveyor. This surveyor reassured R1 that it was safe to talk to me. With tears in her eyes, R1 stated to me, You weren't here when I needed you, and R1 asked the surveyor to leave the room. R1's Behavior Monitoring events, dated 10/23/19 at 1:47 p.m., documents, (R1) refusing cares, meals, drinks. When asked questions gives very short, terse answers. If directly asked in anyway what she is upset about will either not respond or say, 'If you don't know, I'm not telling you.'' During this investigation, interviews with V3 (CNA), V7 (CNA), V10 (Registered Nurse), V11 (Registered Nurse), V12 (CNA), and V20 (CNA) confirmed that R1 made the same allegation to each of these staff members that R1 was held down and her dentures were ripped out of her mouth. V1 also confirmed that V2 was aware of R1 making this statement also. R1's Medication Administration History, dated 10/1-10/23/19, document that up until 10/19/19 R1 was receiving her medications on a regular basis. The history also documents that R1 was refusing to take her medications on 10/19-10/23/19. On 10/23/19 at 2:30 p.m., V30 (Dietary Manager) provided R1's Food Intake Record, dated 10/19. R1's Food Intake Record documented that R1 has had no intake of meals since supper of 10/17/19. V30 stated, R1 has not eaten anything since supper on 10/17/19 according to this intake record. On 10/22/19 at 12:30 p.m., V2 stated, On Friday morning (10/18/19) V10 reported that R1 had bruising on her hands. R1's hands were swollen and bruised. I looked up her behavior monitoring, and R1 had a behavior incident the night before (10/17/19). I had a conversation with them (V4, V5 and V6) and asked what happened (on 10/17/19) they stated that R1 was hitting the side rails during cares. V5 and V6 had abrasion from R1. R1 was flailing her arms and hitting her side rails. R1 was refusing to have her dentures taken out, but she needed her teeth out. V9 called me (10/19/19) reporting R1's bruising On 10/21/19, V19 (R1's family) reported to me that R1 had been held down during cares at some point, and that V19 was concerned about R1's bruising. V2 also stated, Had a staff member called me and said we have an abuse allegation then I would have done an abuse investigation. No staff ever made the statement that this was an abuse allegation. I never felt like this was potential abuse so I didn't investigate it as abuse. I only interviewed R1 and the three staff members involved and all of the staffs' stories were the same. No other residents were interviewed. So I decided this was behavioral and did no further investigating. On 10/22/19 at 11:45 a.m., V1 stated, The first time I was aware of R1's situation is when I got a phone call Saturday (10/19/19) night regarding the bruising from V9. I contacted V2 who said she did a skin incident investigation. V2 was aware of the bruising Friday morning when it was reported to her. R1 has side rails on her bed and she fights cares. V5 and V6 had a rough time providing cares on Thursday night. V2 interviewed V4, V5, and V6 and they all had same explanation. R1 told V2 that the staff held her down to take her teeth out. We did not do an abuse investigation. At this time, this surveyor reported R1's bruising and pain to R1's bilateral wrists and hands, and R1's potential abuse allegation that R1 made on 10/22/19 at 11:35 a.m. On 10/23/19 at 1:10 p.m., V14 (Social Services Director) stated, At times during cares, R1 would occasionally get agitated and refuse cares (prior to 10/17/19). R1 would yell and call people names. R1 hasn't been coming out for meals, and she was typically a person who would come out for all meals. This week, R1 has been refusing to eat, refusing medications, refusing cares, and refusing to allow housekeepers to clean her room. The behaviors of being fearful of the staff and paranoid that someone is going to hurt her are new behaviors for R1. Also, the refusing to get out of bed and to eat are also new. R1 didn't have these behaviors before. V14 also stated, With R1's statement and the presenting of bruising I would consider this a potential abuse allegation that should be investigated. I'm apart of the abuse team and we did not do an investigation on this. No perpetrators were removed, however, if a staff member is accused of potential abuse they should be immediately removed from the facility. On 10/28/19 at 2:45 p.m., V1 stated, Signs to look for abuse in a resident are excessive bruising or a resident make certain comments about their safety here. We treat each comment like that from residents seriously regardless of their mental capacity. We would treat all of those as potential abuse and investigate them. Injury of unknown origin is investigated right away as abuse. Potential perpetrators are removed from the facility immediately. The first thing you do is remove the staff member from the situation and the building. V1 also stated, Usually I determine if an allegation should be investigated as potential abuse or sometimes V2. The staff member does not have to tell me they think its an abusive situation for us to investigate it as abuse. I make this judgement. Based on what the staff tell me if it's obviously an abusive situation I will investigate it. If it's obvious with the resident's statement also. It's not the staffs' job to identify that its abuse. It's their job to report to me what they have seen, heard, or witnessed. Later in the day (10/18/19), V2 told me that she was investigating new bruising on R1's hand. I don't look at this as abuse because V2 knew where these bruises came from based on her investigation that she did on Friday (10/18/19). The phone call I got from V9 Saturday evening was the first time I heard that R1 was claiming that she was held down during cares. At that point I called V2 and asked her thoughts on this. V2 did her investigation on Friday and she was very insistent that she received the bruising from hitting her hands on the side rails during cares. So at that point I didn't consider that abuse. On 10/20/19, V8 asked if I knew what was wrong with R1 and I told her I was aware of her fighting cares. V8 told me there was more I needed to know. V8 told me that R1 had told V8 that R1 was held down. I told V8 I had heard that, and that V2 and I were investigating that. V1 also confirmed that no staff were ever removed from duty, and that at no point the facility felt like these allegation were potential abuse because of the initial skin investigation that V2 performed on 10/18/19. Therefore, no abuse investigation has been completed at all as of today (10/28/19) On 10/28/19 at 3:30 p.m., V2 stated, The definition of abuse is a willful act to make someone either be injured physically, verbally, sexually, psychologically, or neglect. They are purposely trying to harm someone. Signs that a resident may be being abused are a resident is withdrawn, has bed sores, filthy, has drastic change in behavior, crying a lot when they normally don't, bruises in areas of private areas or unexplained bruises. Injury of unknown origin is investigated as abuse immediately. If a staff member finds someone abusing a resident they should remove them immediately from the resident and the building. If I was notified of abuse happening potentially I would come in and remove the perpetrator or have the charge nurse remove them and replace them with someone else. V2 also stated, The abuse committee makes the determination together as to whether an allegation is potential abuse. It's the staff's job to report the allegation properly not determine if it's abuse. Friday morning (10/18/19), V10 told me that R1 had new bruising and asked if I knew about them. I told her I would look into it. I looked into who provided R1's cares (10/17/19). I never spoke with V3, I didn't know she cared for R1 that night (10/17/19). I had a conversation with V4, V5, and V6 because they were assigned to care for R1 that evening and interviewed them to ask what happened they all stated that R1 was hitting her side rails during cares. Their stories were all the same. I spoke with V5 and V6 on 10/18/19, and I spoke with V4 when she got to the facility on [DATE] at 2:00 p.m. for her shift. I never suspected abuse, because I knew how the bruising occurred. The bruising was on her hands wrist and a few fingers. I determined the bruising was from hitting staff or the side rails or both. The V5 and V6 showed me their marks from R1 hurting them during cares. R1 told me R1 was held down and her dentures were ripped out. I know that V5 and V6 struggled to get R1's dentures out, but I think R1 was confused about being held down. I didn't interview any other residents or staff. V2 confirmed that at no point did she consider this a potential abuse allegation, so no abuse investigation was started. As a result, V4, V5, nor V6 had been removed from caring for R1 or any other residents at any time, and they have continued to work since the incident on 10/17/19. On 10/30/19 at 1:50 p.m., V2 provided the Nurse and CNA schedules, dated 10/2019. V2 confirmed that these schedules were accurate and up to date. The nurse scheduled documented that V4 worked the following shifts: 10/17/19, 10/18/19, 10/21/19, 10/22/19, 10/23/19, 10/24/19, 10/26/19, 10/27/19, 10/29/19, and 10/30/19 during 2nd shift with the hours of 2:00 p.m. to 10:30 p.m. specifically assigned to R1's hall for each of these shifts. The CNAs scheduled documented that V5 worked the following shifts: 10/17/19, 10/20/19, 10/22/19, 10/24/19, 10/29/19, and 10/30/19 on 2nd shift 2:00 p.m. to 10:30 p.m., and on 10/19/19 from 2:00 p.m. to 6:00 p.m. Of these seven shifts, V5 was specifically assigned to caring for R1 four shifts. The schedule also documents that V6 worked: 10/17/19, 10/21/19, 10/22/19, 10/24/19, 10/25/19, 10/28/19, and 10/29/19 on 2nd shift from 2:00 p.m. to 10:30 p.m., 10/18/19 from 4:00 p.m. to 10:00 p.m., 10/19/19 2:00 p.m. to 6:00 p.m., and 10/23/19 from 5:00 p.m. to 9:00 p.m. Of these ten shifts, V6 was specifically assigned to care for R1 six shifts. On 10/30/19 at 1:50 p.m., V2 stated, V4, V5, and V6 continue to care for R1. I never determined that any of the allegations were potential abuse. Therefore, there was no need to remove V4, V5, or V6 from caring for R1. V2 also confirmed that all three staff have been scheduled to care for R1 since the incident 10/17/19, and if they are not scheduled on R1's hall they still cover those halls during other staff members' break times. On 10/23/19 at 11:45 a.m., V24 (R1's Physician) stated, This incident could have been considered abuse, and yes the facility should have investigated it as such. On 10/29/19 at 11:35 a.m., V21 (Medical Director) stated, If there is a family complaint of potential abuse, true potential evidence of abuse, or a staff member reports potential abuse an abuse investigation should be started. I agree that R1's bruising and change of behaviors would warrant an abuse investigation. If R1 continues to refuse to eat, refuse cares, and refuse medications this could lead to her death. On 10/31/19 at 12:30 p.m., both V1 and V2 stated that the facility continued to not identify any potential abuse related to R1's abuse allegation, and that no abuse investigation had been started. 2. R2's Minimum Data Set (MDS) assessment dated [DATE] documents R2 is severely cognitively impaired. On 10/23/19 at 2:10pm, V9, Registered Nurse (RN), stated she was working on 10/6/19 when she heard V13, CNAs, yelling I'm tired of you (R2) treating me like s**t, this has to stop now! V9 stated she thought this was verbal abuse. V9 stated she notified V2, Director of Nursing (DON) after the incident occurred (after supper) and notified V1, Administrator, at the end of the shift (approximately 10:00pm) by leaving a voice mail. V9 stated V2 said that V2 had already reprimanded (V13) a week earlier on another similar issue. I (V9) asked (V2) if (V13) needed removed from the building and (V2) said that technically she should come in to handle it, but to do it right she was going wait until (V13) came in the next day on her day off. I left a message for (V1), and I never heard back from him. I never spoke with V1 or V2 about it again. They never interviewed me. V13 continued working that night. V13's personnel file documents V13 received a written warning on 5/9/19 for verbal outbursts, and documented If this or any other unprofessional behavior is witnessed including cussing in public areas, employee (V13) will be terminated on the spot. V13's file documents V13 was interviewed on 10/11/19 about the incident on 10/6/19, and V13 admitted that she did cuss, and that she shouldn't have. The facility's 2019 Payroll #22 and #23 document V13 worked the following dates and had access to all residents: 10/6/19, 10/8/19, 10/9/19, 10/10/19, 10/17/19, 10/18/19, 10/20/19, 10/22/19, 10/23/19, 10/24/19, 10/26/19, 10/27/19, 10/28/19. On 10/30/19 at 1:40pm, V2, DON, confirmed the dates/schedule V13 worked. V2 stated CNAs on both halls assist each other during breaks and meals so V13 could potentially care for all residents in the facility. On 10/23/19 at 3:10pm, V13 stated (R2) was being very rude to me. I (loudly) told her to quit treating me like s**t. I worked the rest of my shift (until 10pm). On 10/23/19 V1 and V2 were unable to provide documentation of notification of the alleged verbal abuse to the State Agency or an investigation for this incident. On 10/24/19 at 12:10pm, V1, Administrator, stated he did not remember if he was notified of the verbal allegation of abuse on 10/6/19, no abuse investigation was initiated for this incident, and V13 was not suspended pending an investigation. V1 stated this was not verbal abuse because (V13) said it in the hallway, as she was leaving R2's room, not directly facing R2. 3. R3's MDS assessment dated [DATE] documents R3 is cognitively intact and documents no behaviors. R3's current care plan documents R3 may refuse care at times and want specific staff to care for her. R3's Nursing Progress Notes document on 9/25/19 at 4:46am, R3 reported to V15, Certified Nursing Assistant (CNAs) the horrible way I am treated by certain staff. On 10/22/19 at 2:32pm V15, CNA, stated that on 9/25/19, R3 told V15 she (R3) was being bullied by V16, CN[NAME] V15 stated R3 reported R3 could hear V16 talking about her out in the hall outside her room and that she didn't feel safe here (at the facility) and would rather die than live like this. V15 stated she reported the allegation to V8, Registered Nurse (RN), and witnessed V8 immediately called V1, Administrator, and V2, Director of Nursing (DON), and leave voice mails for V1 and V2. V15 stated no one called to interview me, so I called (the facility) on Friday morning to see if V1 and V2 got the message. I was told they did and that they interviewed R3. I asked if they needed to talk to me and they said no. R3's Progress Notes dated 9/25/19 written by V8, RN, document the following: Immediate VM (voice mail) left for the DON and administrator called, left VM on office phone and called personal phone. On 10/22/19 at 12:50pm, V2, Director of Nursing (DON), stated I wasn't made aware of the incident until 9/26/19 (the next day), and I felt it was a behavior because R3 doesn't like to be cared for by ((Certified Nursing Assistants (CNA) with a different sexual orientation)). I have directed that V16, CNA, not care for R3 because of this. V16 answered a call light and knew she wasn't to care for R3, so she went to get someone else to care for her. I did not consider this an allegation of abuse, I did not interview other staff and residents. I considered this a behavior. I was not aware that (R3) had said she was treated horribly, that she had named staff and given examples of the 'horrible' treatment. On 10/22/19 at 12:55pm, V1, Administrator, stated he was not notified of R3's statements/allegations on 9/25/19, but he should have been notified immediately. V1 stated no investigation was initiated, no report sent to the State Agency, and V16, the alleged perpetrator, was not immediately removed from resident contact. The facility's 2019 Payroll #22 and #23 document V16, CNA, worked the following dates and had access to all residents: 9/25/19, 9/26/19, 9/28/19. 10/1/19, 10/2/19, 10/3/19, 10/4/19, 10/7/19, 10/8/19, 10/9/19, 10/10/19, 10/12/19, 10/13/19, 10/15/19, 10/16/19, 10/17/19, 10/18/19, 10/21/19, 10/22/19, 10/23/19, 10/24/19, 10/28/19, 10/29/19, 10/30/19. V2 stated CNAs on both halls assist each other during breaks and meals so V16 could potentially care for all residents in the facility. On 10/23/19 V1 and V2 were unable to provide evidence of reporting or an investigation for this incident.

Based on observation, interview, and record review the facility failed to recognize the development of a pressure ulcer prior to the ulcer progressing into an unstageable pressure ulcer, failed to review and revise treatment interventions for the pressure ulcer, failed to follow Physician orders [REDACTED]. These failures resulted in R12 developing an unstageable pressure ulcer to the left heel which then increased in size. Findings include: On 3/18/14 at 1:40 p.m., R12 had a black/brown eschar, uncovered, unstageable pressure ulcer to left heel. On 3/17/14 at 12:45 p.m. and 3/18/14 at 1:40 p.m., R12 had a compression hose on the left foot. Events-Skin Integrity Assessment, dated 2/17/14, documents R12 developed an unstageable pressure ulcer to the left heel which measured 4cm (Centimeter) x 4cm and was covered in eschar (black necrosis). R12's Skin Integrity Events-Weekly skin log, dated 3/13/14, documents that R12's left heel pressure ulcer measurements increased to 6 cm x 5.5 cm, with necrotic tissue. R12's physician's orders [REDACTED]. R12's Current Physician Orders, dated 3/18/14, document a new order was received 2/28/14 to apply a compression stocking to right leg only. R12's Skin Care Plan, dated 1/21/14, documents R12 developed a blister to the left heel on 2/17/14. No new interventions were implemented on R12's skin care plan to treat and heal the blister (unstageable pressure ulcer), or to leave a compression stocking off of the left leg/foot, following the development of the ulcer. R12's Skin Care Plan documents an intervention, prior to the development of the unstageable pressure ulcer to the left heel, to turn and position R12 every two hours. R12's Skin Braden Scales, dated 10/9/13 and 1/8/14, document R12 is at minimal risk for developing pressure ulcers. R12's Vitals Report, dated 3/19/14, documents during the dates of 2/17/14 thru 3/18/14, R12 was not repositioned for longer than two hours and up to six hours on 90 occasions. On 3/20/14 at 11:30 a.m., Z3 (R12's Physician), stated "(R12) sits in the wheelchair all day crossing (R12's) feet, touching the ground. I can see how (R12) developed a pressure ulcer. (R12) is not at high risk for developing a pressure ulcer because (R12) eats good, pulses are fine, and has good circulation. I have not had any recent communication regarding the wound worsening. For (R12's) wound to heal, pressure needs to be taken off the heel. Wearing compression stockings on the affected leg would cause the pressure ulcer to worsen with increased friction." On 3/18/14 at 1:40 p.m., E11 (Registered Nurse) stated R12 should not have had a compression stocking on the left foot. On 3/19/14 at 12:05 p.m., E2 (Director of Nursing) stated, "Resident skin checks are done with tub baths and during partial baths. This could be weekly or two to three times a week. I would hope staff would discover a pressure ulcer at a stage one or two before it develops into an unstageable pressure ulcer. I would not expect a wound to worsen. We should have put preventative measures in place to prevent that. I am not sure why (R12) wound would worsen." On 3/19/14 at 12:15 p.m., E3 (Minimum Data Set/Care Plan Coordinator), stated "I would definitely say that (R12's) wound to left heel is a pressure ulcer." On 3/19/14 at 1:40 p.m., E2 (Director of Nursing), stated "Vitals report shows when they are toileted. Repositioning is done with toileting only, and this report is how our turn and reposition program is documented." On 3/19/14 at 2:00 p.m., E14 (Certified Nursing Assistant) and E7 (Licensed Practical Nurse) both stated R12 is not on a turning and repositioning program." On 3/20/14 at 9:50 p.m., E4 (Minimum Date Set Coordinator), stated "According to the care plan (R12) is on a turn and reposition program. This program is every two hours. R12 repositioning would be toileting time and repositioning in bed." On 3/20/14 at 11:25 a.m., E2 (Director of Nursing), stated "R12 should be toileted, which is (R12's)positioning, every two hours. According to the vitals report R12 has gone longer than two hours between positioning." On 3/20/14 at 11:30 a.m., E2 (Director of Nursing), stated "If his Braden score is at risk, but not high risk it would indicate (R12) should not have developed a pressure ulcer." Facility Assessing and Treating Pressure Ulcers and Skin Wounds policy, dated 3/18/14, documents to notify a Physician when a treatment is not effective. If no improvement in a wound is noted in two to four weeks, reevaluate treatment plan and notify physician. On 3/20/14 at 12:40 p.m., E16 (Registered Nurse-Wound Nurse), stated "(R12) heel is an unstageable pressure ulcer. We evaluate the effectiveness of a treatment about every two weeks and if wound is worsening we would notify the doctor immediately to change the treatment. I would not say that (R12) wound has worsened. If a wound gets larger I would say it has worsened." Facility Skin Impairment Prevention policy, dated 3/18/14, documents skin assessments will be done regularly thereafter when bathing, dressing or assisting the resident in the activities of daily living, being especially mindful of those residents who are high risk.

Based on record review and interviews the facility failed to prevent and monitor for the occurrence of a urethral tear to one of three sampled residents with continuous or intermittent urinary catheters. (R1) This failure caused an 1.5 inch erosion tear on the opening of R1's penis. Findings include: According to R1's on going physician's orders [REDACTED]. R1's Admission assessment and physician's orders [REDACTED]. R1's Nurse's notes dated 12/31/13 notes that an open area on R1's penis that was 1.5 inches long was observed and information was faxed to Z1 (R1's Attending Physician) office. On 1/17/14 at 12:45 P.M. Z1 stated that the first he heard about the 1.5 inch erosion tear on R1's penis was on 1/2/14 when he received a fax and gave orders for treatment. Z1 stated that this type of wound happens over a period of time and did not just happen over a week or two. Z1 stated that he referred R1 to be seen by a specialist (Z2 Urologist) for the urethral tear. On 1/17/14 at 11:40 A.M. Z2 stated that R1 was brought to his office on 1/13/14 regarding his Urethral tear. Z2 stated that tears like R1's happen over a long period of time. Z2 stated that these types of Urethral tears happen due to tension of the catheter causing pressure on the side of the Urethra. Z2 said that these types of Urethral tears can be avoided with proper anchoring of the tubing. Z2 stated that R1 is scheduled to have a Suprapubic catheter placed in on 1/22/14 due to the the Urethral tear. On 1/17/14 at 10:25 A.M., Z3 (R1's Wife) stated that she was called on 12/31/13 by E3 C.N.A. (Certified Nurse's Aide and R1's granddaughter) and informed that R1 had a 1.5 inch tear on the opening of his penis. Z3 stated that E3 said she had heard that the wound had been there for a long time. Z3 said that R1 was admitted with a indwelling catheter in June of 2012 and had no tearing to his Urethra at that time. Z3 stated that she then called E2 (Director of Nursing) and told her about the area on R1's penis, and that E2 had no idea that R1 had an open area on his penis. On 1/17/14 at 11:20 A.M. E2 confirmed that the first time that she had been notified about the open area on R1's penis was on 12/31/14 by Z3 per telephone call. E2 stated that the C.N.A.s are to perform catheter care twice a day and that the C.N.A.s should have reported this area on R1 at the very beginning when it first started. Z2 also stated that the Nurse's change the catheter monthly and that it should have been noted at that time also. R1's physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to implement preventative measures to prevent the development of a stage 3 pressure ulcer for R3. The facility failed to follow the wound care protocol and provide clean technique when treating a facility acquired stage 3 pressure ulcer for R3. The facility failed to provide treatment for [REDACTED]. E3 developed Stage I pressure ulcers on the left and right gluteal folds three days after admission and progressed to a Stage III after one month. Findings Include: 1. The physicians' order sheet for 2/1/11 - 2/28/11 document that R3 was admitted to this facility 12/29/10. The nurses notes of 1/1/11 document that R3 has two red areas on right and left gluteal inner folds which were treated with [MEDICATION NAME]. The nurses notes of 2/4/11 document that R3 has a Stage 3 covered with Slough on the gluteal folds. The nurses notes of 2/4/11 document that R3 refused a catheter which was ordered for wound healing. The nurses notes of 2/16/11 document that R3 accepted the catheter and it was placed. On 2/16/11 a physicians' order was received for a fecal collection bag to protect the wound from the BM, but the bag failed so it was not used. The facility Wound Care Protocol policy documents that for a" Stage 1 pressure ulcer -non blanchable redness of intact skin, remove cause of pressure, watch closely, reposition every 2 hours, off load, monitor weekly/skin nurse. Use cushion ex gel Spenco, air in wheelchair or special mattress, skin irritation: cleanse area with [MEDICATION NAME], apply skin repair cream or Moisture barrier cream twice a day and as needed til healed." The first person care plan dated 1/18/11 documents under skin: I was admitted with a stage II pressure ulcer on my buttocks. Please follow orders to help promote healing. Assess and monitor my skin condition daily with cares as well as during my baths. Provide for adequate hydration and nutrition, frequent repositioning and lubrication as needed to help promote circulation and promote skin health and integrity. Notify the physician if needed for further medical intervention. This care plan is inaccurate. The nurses notes document that R3 developed Stage I pressure ulcers on the left and right gluteal folds three days after admission. This care plan does not provide any direction or specific interventions to prevent or treat the pressure ulcers. On 2/7/11 R3 was sent to the wound clinic for treatment of [REDACTED]. According to the facility Wound Care Protocol this should have been implemented at the first sign of skin redness on 1/1/11 according to the nurses notes of this date. The facility treatment record of 2/10/11 documents that the Left Gluteal fold Stage III measured 3 cm by 1.3 cm by .8 cm., the Right Luteal fold Stage III measured 4.8 cm by 1.2 cm by .8 cm. The nurses notes document that R3 developed a blister on the left heel on 1/4/11, 3 cm by 4 cm intact, skin prep and observe was ordered. The aforementioned care plan does not address this blister or provide any direction for treatment. There are no interventions listed to remove cause of pressure. On 2/22/11 R3 was transferred from the wheelchair to the bed by two Certified Nurses Assistants. After they assisted R3 to bed, they changed the adult incontinence pad which was soiled with bowel movement. A dressing was observed in place with bowel movement on the dressing and on the two wounds. R3's wounds were cleansed and left open for the nurse to dress. On 2/23/11 at 11:00 AM, E17 (Registered Nurse) performed a dressing change for R3's left and right gluteal folds. E17 placed the basket with the clean dressings on the residents bed linen without preparing a clean field. E17 did not wash her hands, donned gloves and removed the dirty dressing from the wounds. E17 cleansed the bowel movement from the wounds with wound cleaner, placed the calcium alginate to wound beds and covered with clean dressing as ordered without changing dirty gloves and washing her hands between the dirty and the clean functions. On 2/23/11 at 1:30 PM, R3 stated that she had pressure ulcers before at a different facility and is at risk for developing them because she cannot control her bowel movement. R3 stated that she came to this facility to get stronger (physical therapy) so she can return back home. R3 stated that since this pressure ulcer has developed, she has to spend a lot of time in bed to keep pressure off of the pressure ulcer which does not help increase her strength. R3 stated that she is very unhappy because she can't return home yet. On 2/23/11 at 1:45 P.M., E2 (Director of Nurses) stated that the nurses were off loading R3 to promote healing of the pressure ulcer and have now placed a special mattress and a special cushion in her wheelchair. 2. On 2/22/11 at 10:00 AM, R5 stated that she has pain in her right ankle. The nurses notes from Jan and Feb. available in the residents record did not document anything regarding pain or a Stage I pressure ulcer on the right ankle. The Skin Assessment sheet of 12/17/10, 12/21/10, 1/6/11, 1/13/11 documents that a 3 cm blanchable area on right ankle with pain indicated. The Minimum (MDS) data set [DATE] documented a stage I pressure ulcer on right outer ankle, care plan initiated. The care plan dated 2/22/11 documents under the heading Skin: "I presently have a Stage I ulcer on my right outer ankle. It is pink and 3 cm in diameter. Please monitor and prevent pressure to the area as much as possible. Assess my skin with cares and tub baths. Provide fluids with and between meals to promote hydration. Encourage activity to promote circulation." On 2/23/11 at 2:00pm, E2 (Director of Nurses) stated that no treatment was being done on the stage I pressure ulcer and no assessment is done to investigate the cause of the pressure to protect the area and prevent the area from worsening. No evidence is found in the record to indicate that the facility Wound Care Protocol stated earlier is followed.

Based on observation, interview and record review, the facility failed to justify the need for antipsychotic medication above the recommended daily maximum dosage for the geriatric, with no attempt at reduction and no behaviors to support the use for R11, R7, R13 and R9 . four of twelve residents reviewed for psychoactive medications from a total sample of fifteen. The facility failed to assess and critically analyze behavior of resisting care and provide interventions before starting antipsychotic medication and failed to reduce the antipsychotic medication in the presence of adverse side effects(lethargy) for R10. One of twelve residents reviewed for psychoactive medications from a total sample of fifteen. Findings Include: The facility policy does not address how the facility will determine if a resident needs an antipsychotic, does not address reducing antipsychotic medications, and does not address assessing residents that are on antipsychotics for involuntary abnormal movements. Interview with E18 (Care Plans) stated on 03/01/11 at 10:00 a.m. that the facility just started doing the abnormal involuntary movement assessments on residents who are on antipsychotic/psychoactive medications. E18 stated she looks at the residents and reviews the charts but does not do the actual steps of testing for abnormal involuntary movements; just looks at them. 1. According to the current physicians' orders dated 2/1/11- 2/28/11, R10 is a [AGE] year-old -female with [DIAGNOSES REDACTED]. R10 has been receiving [MEDICATION NAME] 0.5 mg six times a week daily since 7/15/10, [MEDICATION NAME] 50 mg daily since 1/29/10, [MEDICATION NAME] 5 mg by mouth daily and [MEDICATION NAME] 5 mg Intramuscular daily since 9/17/10 and [MEDICATION NAME] 0.5 mg as needed. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurses signed out the [MEDICATION NAME] 5 mg orally all month, but the [MEDICATION NAME] 5 mg IM was only signed out as given on three days along with the oral dose. On 2/23/10 at 11:30 PM, E7(Minimum Data Set / Care Plan Coordinator) stated that the [MEDICATION NAME] 5 mg IM was to be given only if R11 refused to take it orally. E7 stated that R11 was confused so therefore she did not have the right to refuse the medication. E7 stated that none of R11's other medication was ordered IM if she refused oral. The Behavior Monitoring Records from 1/10 - 1/11 document that R10 is being monitored for striking out at staff and depression. These behavior monitoring sheets document that R 10 had behaviors of striking out a staff three days in 1/10, no behaviors in 2/10. 3 days of striking at staff in 3/10, 1 day of striking at staff in 4/10, 1 day of striking at staff in 5/10, no behaviors 6/10, 3 days of striking at staff in 7/10, 6 days of striking at staff in 8/10, 13 days of striking at staff in 9/10, 4 days striking at staff 10/10, 3 days striking at staff 11/10, no behaviors 12/10, no behaviors 1/11, no behaviors 2/11. No behaviors of depression from 1/10 through 2/11. The Nurses Notes from 8/30/10 until present 2/11 document that R10 refuses medication at times, screaming and crying when blood drawn and when CNA's did cares and dressed resident, sleeping in dining room, did not eat or take medication. These nursing notes do not document that any assessment to rule out pain, or possible urinary tract infection or possible physical abnormalities was done before starting [MEDICATION NAME]. The behaviors that R10 is having a few days a month are all resisting care when staff are dressing, bathing or transferring R10. There is no documentation that a root cause analysis was done for these behaviors to rule out any physical or emotional cause for R10 resisting care. The first person Care Guide dated 2/15/11 documents that R10 is severely cognitively impaired, has poor vision(can identify objects). My hearing is highly impaired and my speech is mumbled. Speak to me in simple sentences, directly in my right ear. Observe me for indications of discomfort or distress and assist me as needed. Be observant for nonverbal indicators of distress/concern. Occasionally, I refuse to cooperate or interact with staff and become upset as staff attempts to assist me. This care plan does not address the use of [MEDICAL CONDITION] medications or any interventions used prior to starting antipsychotic medication such as assessing for pain using the non verbal scale, since the resisting care is when staff are attempting to move the resident(dressing, bathing, transferring). There is no plan to reduce these [MEDICAL CONDITION] medications. The care plan does not direct the care giver of the adverse side effects of these [MEDICAL CONDITION] medications(orthostatic blood pressure monitoring , CNS depression(ranging from drowsiness to coma), extrapyramidal movements. On 2/28/11 at 9:50 AM, E7 Minimum Data Set/ Care Plan Coordinator stated that they have not monitored for abnormal involuntary movements prior to 2/7/11 when they started the 3.0 MDS. No AIMS was initiated on start of the [MEDICATION NAME] to establish a baseline. E14(MDS/ Care Plans) stated that she started doing AIMS testing on 2/7/11 when she does the interview for the MDS. E14 stated that she has not been trained to administer the physical AIMS testing. E14 stated that she just looked at R11 and scored her all 0's because R10 was asleep in bed at the time of testing. On 2/23/11 at 1:30 PM R10 was sleeping in bed, still sleeping in bed at 2:30 PM, still sleeping in bed at 3:30pm. On 2/24/11 at 9:00 AM through 11:30 AM, R11 was observed in bed asleep and again from 1:30PM through 4:00 PM R11 was asleep in bed. On 2/28/11 at 8:45 AM, R10 was asleep in bed and remained asleep until 11:30 AM when she was observed sleeping in wheelchair in the main dining room. At 11:45 AM, R10 remained asleep at the assistive table with everyone else eating around her. At 12:00 PM, R10 was still asleep in the wheelchair at the assistive dining table. At 12:30 PM R11 was observed with eyes closed being fed by staff. R10 opened her mouth for food when staff spoke to her in her right ear but kept her eyes closed. There is no documentation in the nurses notes or care plan to indicate that R10's change in condition was assessed as a possible adverse side effect of the medication (lethargy) and that this change of condition was reported to the physician. The Drug Information Handbook for Nursing 2007, Appendix/OBRA Guidelines for Long Term Care documents that approved indications for use of an antipsychotic medication include: behaviors quantitatively and objectively documented, behaviors must be persistent, behaviors are not caused by preventable reasons, patient presents a danger to self or others, continuous crying or screaming if this impairs functional status. The Warning/Precautions for [MEDICATION NAME] document that patients with dementia-related behavioral disorders treated with atypical antipsychotics are at an increased risk of [MEDICAL CONDITION] adverse events and death compared to placebo. [MEDICATION NAME] is not approved for this indication. Life threatening arrhythmias have occurred with some neuroleptics. May induce orthostatic [MEDICAL CONDITION], use caution with history of cardiovascular disease. Overdosage/Toxicology: Signs and symptoms of overdose include CNS depression (ranging from drowsiness to coma) extrapyramidal movements, [MEDICAL CONDITION], slurred speech. Consider low dose for the elderly with close monitoring of orthostatic blood pressure. On 3/1/11 at 3:00 PM, E2(Director of Nurses) stated that "the physician does not listen when the nurses ask for a dose reduction. The physician stated that the R10 is doing well on this dose, so therefore does not want to attempt a reduction." 2. The current physician's orders [REDACTED]. According to this physicians' order, R11 is receiving [MEDICATION NAME] 100 mg three times a day, [MEDICATION NAME] 15 mg at bedtime, [MEDICATION NAME] 3 mg twice a day, [MEDICATION NAME] 0.25 mg three times a day as needed, [MEDICATION NAME] 50 mg every 4 hours as needed, Aspirin 81 mg and [MEDICATION NAME] 50 mg twice a day. The physician order [REDACTED]. The physicians' orders document that the [MEDICATION NAME] was steadily increased in 2008 and 2009 for R11. The physician's orders [REDACTED]. The Pharmacy Consultation of 9/7/10 requested a reduction attempt for the [MEDICATION NAME]. The physician replied: "Attempted to reduce in past with worsening problems, increased agitation, increased aggression." Review of the [MEDICATION NAME] from the start date until present, the [MEDICATION NAME] was reduced on 9/6/09 to 75mg three times a day and increased back to [MEDICATION NAME] 100mg three times a day on 9/16/09 and remained at this dose until present. R11's Behavior Monitoring Records dated 1/10 - 1/11 document that the behaviors being monitored for R11 are agitation, anxiety and pacing in chair. The only identified behaviors of agitation, anxiety and pacing were on 4/15/10 all three shifts and anxiety on 4/22/10 on second shift with no other behaviors identified for the other 11 months. The nurses notes from 6/12/10 available in the record does not document any behaviors to justify the use of antipsychotic medication. The 12/8/10 nursing note, "R11 seemed to be sleeping in the chair. When Certified Nurses Aid's attempted to transfer her,she was limp and had to be chair lifted to bed." The other nurses notes document that R11 is traveling around the facility in her chair with lap tray. On 2/24/11 at 12:30 PM, E14 stated that R11 is rolling around the facility in her chair with her lap tray in place continuously. On 2/23/11 form 12:30 PM thru 3:30 PM, R11 was laying in bed asleep. At 3:30 PM the CNA assisted R11 up to the bathroom. R11 was cooperative with assistance. The Drug Information Handbook for Nurses 2007 Appendix/OBRA Guidelines for Long-Term Care and The State Operations Manual both document that the maximum daily dosage for [MEDICATION NAME] should be 100 mg or less unless documentation exists to support the need for higher doses to maintain or improve functional status. R11 is receiving 300 mg daily with no behaviors to justify the use and no clinical justification from the physician to support the use of this high dose of [MEDICATION NAME]. The Adverse Side Effects listed for [MEDICATION NAME] are: orthostatic [MEDICAL CONDITION], agitation, dizziness, headache somnolence, anxiety, fever, anorexia, vomiting, dysarthria, back pain, weakness, tremor and akathisia(feeling of needing to move, unable to sit still.). The first person Care Guide dated 2/1/11 does not have a specific care plan for [MEDICAL CONDITION] medication with interventions listed to monitor for adverse side effects of these [MEDICAL CONDITION] medications or a reduction plan. Listed under the heading of Nursing Concerns and Medical History is documented: "I am at significant risk for injuring myself due to agitation: therefore, give medication as needed to reduce my risk for further injury. At times I am lethargic from medication given to ease my agitation." "I am at high risk for falls and elopement. Because of these risks I need frequent observation. I wear a monitoring alarm device to alert staff when I try to get up. I also sit in a "go chair" with a tray for agitation, safety and impaired cognition." There is no documentation in the care plan to indicate that the constant moving around the facility in the "Go Chair" was considered to be a possible side effect to the [MEDICATION NAME](akathisia.). On 2/28/11 at 9:50 AM, E7 Minimum Data Set/ Care Plan Coordinator stated that they have not monitored for abnormal involuntary movements prior to 2/7/11 when they started the 3.0 MDS. On 3/1/11, E14 (MDS / Care Plan Coordinator) stated that she does the AIMS test when she does the MDS interview. E14 stated that she has not been trained to do the physical AIMS test. There is no documentation that there is any plan to reduce this medication. There are no documented behaviors to support the use of the [MEDICATION NAME]. There is no clinical justification from the physician why R11 requires 3 times the maximum dosage recommended for the geriatric. The facility policy does not address how the facility will determine if a resident needs an antipsychotic, does not address reducing antipsychotic medications, and does not address assessing residents that are on antipsychotics for involuntary abnormal movements. Interview with E18 (Care Plans) stated on 03/01/11 at 10:00 a.m. that the facility just started doing the abnormal involuntary movement assessments on residents who are on antipsychotic/psychoactive medications. E18 stated she looks at the residents and reviews the charts but does not do the actual steps of testing for abnormal involuntary movements; just looks at them. 3. R7 was admitted on [DATE] with [DIAGNOSES REDACTED]. A year later after admission, R7 was started on [MEDICATION NAME] 3 mg (milligrams) for inappropriate sexual remarks per interview with E1 (Administrator) and E2 (Director of Nursing) at 3:00 p.m. on 02/24/11. E2 stated that R7 does not make many sexual remarks as she did when R7 was first admitted to the facility in 02/06/02. R7's 02/11 physician orders, and a pharmacy recommendation dated 12/08/10, documents R7 has been receiving [MEDICATION NAME] 3 mg since 09/03/03 (7 years and 5 months). E2 stated on 02/23/11 at 9:45 a.m. that R7 sees a psychiatrist about once a year at times. E2 stated that the psychiatrist is the one that ordered the [MEDICATION NAME] for R7 but was not notified of the recommendation. R7's physician was notified and declined to attempt to reduce the [MEDICATION NAME] because R7 has been stable and afraid that R7's behaviors (sexual remarks) may return. E2 stated R7 has postural (upper body) decline and most likely due to R7's [MEDICAL CONDITION] and decline in health. On 02/28/11 at 9:50 a.m., E 7 (Care Plan Coordinator) stated that there was is no previous abnormal body movements (AIMS) done on R7 until 02/07/11, so there is no previous AIMS testing to compare for abnormal body movements or postural changes. R7 was compliant with care. No verbal outbursts or inappropriate behaviors observed during care. During morning activities on 02/23/11 in the activity room, R7 did not display any behaviors and tends to lean to the side of the wheelchair. R7's physician (Z6) responded on the pharmacy Consultation Report dated 12/08/10 that R7 remain stable on the medication ([MEDICATION NAME]) and is having no side effects and needs to continue with the medication. The facility has not attempted to reduce the [MEDICATION NAME] since starting 09/03/03, has no justification for the use of an antipsychotic, and R7 was started on an above normal dose of [MEDICATION NAME] without justification. On 02/23/11, E2 faxed R7's physician another request to reduce the [MEDICATION NAME] per pharmacy recommendation and per concerns from IDPH and that there has been no attempts to reduce the [MEDICATION NAME] since 09/03/03. The physician documented that the physician will readdress this issue on his next visit and that R7 has been stable and doing well on the [MEDICATION NAME]. The physician also documented that he fears there may be a significant change if there is a reduction in the [MEDICATION NAME] dose. R7's behavior tracking records for December, 2010, January and February, 2011 documents R7's behavior is "making no sense". No other behaviors are listed and no other behaviors being displayed by R7 per the behavior tracking records. No other information provided showing R7 has been displaying other behaviors the past year. R7's Minimum (MDS) data set [DATE], R7 receives total assistance with bathing, dressing, feeding, is incontinent of bowel and bladder, and requires staff to wheel her in her wheelchair, and is not displaying any behaviors. R7's care plan documents R7 as being "demanding with cares, request the bedpan and to be repositioned quite often. Recent episodes of disorganized thinking which was most likely associated with urinary tract infection. The care plan also notes to observe for adverse side effects, behavior changes or oddities as these may be signs of impending psychotic episode and R7 at times seem to be staring into space related to R7's medical condition." R7's Minimum Data Set for 09/30/10 and 12/7/10 shows R7 is has not been displaying any behaviors. The Drug Information Handbook for Nursing 2007 documents to use [MEDICATION NAME] with caution in disorders with the Central Nervous System. Depression is a feature, may cause extrapyramidal symptoms, including pseudoparkinsonism, tardive dyskinesia, and to monitor for symptoms of confusion, obtundation, and postural instability The residents' physician provides a justification why the continued use of the drug and the dose of the drug is clinically appropriate. The justification should include a diagnosis, but not simply a diagnostic label or code but the description of symptom.. 4. R13 was admitted on [DATE] with [DIAGNOSES REDACTED]. In March, 2004, R13 was started on [MEDICATION NAME] 0.5 milligrams twice a day for behaviors of increased anxiety and hallucinations per a pharmacy recommendation record dated 09/07/10. R13's admission nursing assessment and initial care plan date 09/10/03 documents R13's behaviors as sociable and anxious. R13's current care plan dated 02/15/11 documents R7's behaviors as "often criticizing staff and saying unkind things to them or about their appearance, delusional, confused, restless at night, and is often wanting staff to call father on phone to come pick her up and annoyed and fearful that he cannot reach him. Reorienting makes her more upset and it is best to go along with what R13 is thinking. R13 becomes irritated if rushed, especially in the morning and may resist help with care and try to grab at staff and yell at them. Also, the care plan documents that R13 is often concerned about her dogs and has multiple health complaints; especially headaches and often calls out for help and ask for medicine. The care plan documents that R13 continues to receive medications to help her cope and documents for staff to observe R13 for adverse side effects. R13's care plan does documents that R13 has [MEDICAL CONDITION], Arthritis, and Migraine Headaches and needing to lie down and rest with a cloth covering her eyes", but the pain is not assessed as possibly causing R13's behaviors. A monthly Nursing summary record dated 01/11 documents that R13 has a history of [MEDICAL CONDITION], throbbing headaches, increased lethargy, increased confusion, and increased restlessness. The monthly nursing summary record also documents R13 was recently diagnosed with [REDACTED]. Nursing notes dated 10/17/10 documents R13 is "very lethargic, sleepy, refusing supper or medications, and can be aroused but will close eyes shortly after looking at you. Extensive assist with all cares. On 11/1/10, R13 was found on the floor next to the bed, and R13 stated she was looking for her 3 dogs. On 11/10/10, a lesion was removed on the left lateral thigh area. Nursing notes dated 11/20/10 at 06:00 document R13 is awake most of the night and at 05:00 R13 was wandering in halls and documents, "check the door; no bells please", and given a prn medication. On 12/8/10 nursing notes, R13 was given an [MEDICATION NAME] 0.5 milligram for restlessness. Remained restless and attempting to climb out of bed. Transferred to a wheelchair and obtained a 1 x 1 centimeter skin tear to the lower, left leg. On 02/23/11 at 1:45 a.m., E6 stated that R13's has behaviors at times during cares but if re-approached or different staff try will help. E6 stated that R13 has medication the nurse will give if needed for R13's anxiety. E6 stated R13 has always been like this but does not get combative during cares; just real anxious. E6 stated that once R13 receives her cares and is up in her wheelchair, R13 is happier and likes to ambulate "baby steps" down the hall in her wheelchair. At 1:50 p.m. on 02/23/11, R13 was lying in a low bed in R13's room and was awake. R13 is very thin and has contracted fingers and hands bilaterally. R13 responded back with "hello" and began to talk but could not understand what R13 was saying. On 02/22/11 from 12:30 p.m. to 3:00 p.m. and on 02/23/11 from 9:30 a.m. to 11:30 a.m., R13 was not displaying any behaviors or yelling out. R13's Physician orders [REDACTED]. A physician follow-up report dated 01/31/11 documents R13 has dementia, and that hallucinations have stabilized, not as frequent. [MEDICAL CONDITION] ulcer disease and a history of [MEDICAL CONDITION] in August 2003. Also, notes R13 has Depression anxiety and [MEDICAL CONDITION] and managed on [MEDICATION NAME], and [MEDICATION NAME]. A pharmacy recommendation dated 09/13/10 recommends to reduce R13's [MEDICATION NAME] 0.5 milligrams because R13 has been on the [MEDICATION NAME] 0.5 milligrams for hallucinations and anxiety since 03/2004. The physician documents that a gradual dose reduction had been attempted but that R13's symptoms had returned. However, there are no records showing that have been any attempts to reduce R13's the [MEDICATION NAME] 03/2004 per record review, the pharmacy recommendation record, and per interview with E2 (Director of Nursing) on 02/23/11 at 3:00 p.m.. The physician did discontinue R13's [MEDICATION NAME] 75 milligrams that R13 has been taking since 11/09 per pharmacy recommendation on 11/09, but did not indicate why and did not reduce the [MEDICATION NAME]. An Initial Abnormal Body Movement (AIMS) test was not done on R13 when R13 was started on the [MEDICATION NAME] in 03/2004, and there has been no quarterly or annual AIMS testing done for R13 until 02/07/11. On 02/28/11 at 9:50 a.m., E 7 (Care Plan Coordinator) stated that testing for abnormal body movements (AIMS) being done until 02/07/11 so there is no previous AIMS testing to compare to. 5. Observed R9 to be alert and calmly sitting in his room, exhibiting no signs of anxiety or agitation on 2/22/11 at 11:47 am. R9 was observed to have a restraint (preventing rising from the wheelchair) and a chair alarm used in his wheelchair. Observed a certified nurse assistant, E10, wheeling R9 to the dining room. At reaching his table in the dining room, the restraint was removed and R9 remained in the wheelchair at the table. During this observation from 11:47 through 12:05 pm, R9 calmly received medication from the medication nurse and ate sparingly from his noon meal, before quietly wheeling himself out of the dining room unattended. As he reached the doorway leading out of the dining room, E10, CNA, reapplied the restraint on R9 ' s wheelchair before leaving him to return to the dining room. Resident was observed to be calm, non-agitated, nor exhibiting any increase in anxiety. Most other observations of R9 were resting in his a recliner or in bed with the lights turned low, at times calling out " Help me. " The History and Physical of 9/25/10 from a local hospital admission documents that R9 has [DIAGNOSES REDACTED]. Record review of the current physician orders [REDACTED]. R9 ' s Pharmacy Consultation Report of December 1 through 7, 2010 includes a [DIAGNOSES REDACTED]. It was also noted that he had a new onset Urinary Tract Infection which may have accounted for the increases in behaviors. With the increase in his as needed [MEDICATION NAME], he may no longer need the [MEDICATION NAME]. If [MEDICATION NAME] is to continue, federal nursing facility regulations require that antipsychotic agents only be used when one or more of the following conditions exists. " The physician ' s response: " (R9) Patient had Dementia with Behavior Disturbances as well. See 11/23/10 progress note- " Subjective: (R9) Patient seen today at request of staff. He is having increasing behaviors, loud, constant yelling for help, wanting up all the time. He is not sleeping more than 10-20 minutes at a time at night. He is sleeping some during the day. He has also been urinating frequently but with little output. He is unhappy most of the time. Z5, Physician, had given him an as needed [MEDICATION NAME] order which seems to help a little bit but is still not ideal. No other major concerns. Assessment/Plan: 1. Mild dementia with some behavioral issues and difficulty sleeping. Will increase his [MEDICATION NAME] to 25 mg (milligrams) at nighttime and see how this works for him. 2. Urinary frequency. Will get an urinary analysis with culture and sensitivity. Record review of the faxed request to Z3, attending physician, on 11/ 6 / 11, documents that R9 was started on [MEDICATION NAME] 12.5 mg at night with the following description of the resident's behavior. "Continues to yell out constantly all night. Even with [MEDICATION NAME] that's ordered as needed every 8 hours [MEDICATION NAME] sleep doesn't help!! Keeps others awake all night." The physician orders [REDACTED]. The [MEDICAL CONDITION] Medication Consent entry dated 1/25/11 documents that the [MEDICATION NAME] was increased to 50 mg two times a day and has continued at this dosage until present. Review of the [MEDICATION NAME] from the start date until present verified by E7, care plan coordinator/RN that there is no documentation of any attempt at a reduction. E7, RN, verified that historically, R9's [MEDICATION NAME] orders were increased to 25 mg at bedtime on 11/23/10, to 25 mg twice a day on 12/23/10, and to 50 mg twice a day on 1/25/11. R9's Behavior Monitoring Records dated 2/11 document that the behaviors being monitored for R9 are agitation, [MEDICAL CONDITION], and depression. The Drug Information Handbook for Nurses 2007 Appendix/OBRA (Omnibus Budget Reconcilliation Act) Guidelines for Long-Term Care and The State Operations Manual both document that the maximum daily dosage for [MEDICATION NAME] should be 100 mg or less unless documentation exists to support the need for higher doses to maintain or improve functional status. R9 is receiving the maximum dosage of 100 mg daily. The Adverse Side Effects listed for [MEDICATION NAME] are: orthostatic [MEDICAL CONDITION], agitation, dizziness, headache, somnolence, anxiety, fever, anorexia, vomiting, dysarthria, back pain, weakness, tremor and akathisia(feeling of needing to move, unable to sit still.) Interview with E2, Director of Nurse, E7 and E14, Care plan Coordinators, and E15, Nurse, Certified Nurse Assistants, E4 and E5, all confirmed that resident is not able to sit still during activity of daily living, like activities and dining and requested to be repositioned/toileted often when in his room. Nursing notes of 12/12/10 " Resident exhibited increased anxiety, yelling " help me. " When asked how we can help him, he asked for a bin and stated he felt like he was going to get sick. Basin given and resident vomited brownish colored, small emesis, as needed medication had been given shortly before emesis, medication not in emesis. " physician progress notes [REDACTED]. 10/8/10 " He has been requesting that staff get him up to the bathroom a lot. Doesn't always void much, sometimes not at all. Asking for frequent positioning changes, want to be put in his recliner, wants to be taken out of his recliner. When he gets to dinner, he wants to leave fairly quickly. Just increased confusion since his return. Never really got back to his baseline prior to when he was hospitalized . " 11/9/10 " ...(R9) seems to be just generally declining. He is not eating. ... He is generally weaker. " 1/27/11 " (R9) has just continued to decline overall. He is not eating as much. He has lost a lot of weight. Patient was sleeping in the chair when I saw him. He actually awakened and answered a few questions appropriately but states he had no problem. " The first person Care Guide dated 1/25/11 does not have a specific care plan for [MEDICAL CONDITION] medication with interventions listed how to monitor for adverse side effects or a reduction plan for the [MEDICATION NAME] use with alternative interventions to antipsychotic medication use. On 2/28/11 at 9:50 AM, E7 Minimum Data Set/ Care Plan Coordinator stated that they have not monitored for abnormal involuntary movements prior to 2/7/11 when they started the 3.0 MDS (Minimum Data Set).