Every finding on record at Avir at Weatherford

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility kitchen reviewed for kitchen sanitation. The facility failed to ensure foods were properly stored, labeled, and dated in the refrigerator and freezer.The facility failed to ensure the floors in the pantry and back hallway were kept clean to avoid buildup of grease, dirt, and dust in the faculty's only pantryThe facility failed to keep the kitchen area maintained in a clean manner to keep the floors, food surfaces, and cooking areas free of debris.The facility failed to ensure the stove was maintained in a clean manner to avoid liquid from seeping from underneath, maintain the drip pans in a safe manner, and keep the back drop free of grease and food splatter.The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling and serving food. The facility failed to ensure kitchen staff did not touch food directly with their hands.The facility failed to ensure kitchen staff used hairnets properly to secure hair was not exposed while in the kitchen. These failures could place residents at risk of cross contamination and food borne illness.The findings include: During an observation on 02/10/2026 at 11:04 a.m., when checking the the side-side stand up refrigerator on the back wall of the kitchen, observed a white, Styrofoam container without a label or date on the outside of the container that held a gray substance in a liquid. The Dietary Manager threw the food away. A large Ziplock bag that contained sliced turkey with no label, date, or use by date was observed. During an observation on 02/10/2026 at 11:10 a.m., observed two (2) plastic bags of yellow sliced bread with no label, date, or use by date in the large side-by-side freezer, located on the back wall of the kitchen and three (3) clear bags of small green brussels sprouts with no label, date, or use by date. The Dietary Manager threw the bags out. There was a clear plastic bag with small, yellow pancakes that contained ice crystals inside the bag, with no label, date, or use by date. During an observation on 02/10/2026 at 11:15 a.m., when checking the large side-by-side stand up refrigerator located in the front of the kitchen, observed a plastic container of purple jelly with no label, date, or use by date on the container, the lid was not properly sealed. The Dietary Manager attempted to seal the container, but the lid would not fit the container properly with an accurate seal. During an observation on 02/10/2026 at 11:20 a.m., in the pantry observed a large plastic container of corn flakes and a large container of fruit loop cereal with the lids not properly sealed. The Dietary Manager attempted to put the lids on the plastic containers, but both lids would not fit the containers properly with an accurate seal. The pantry floor was black in the middle area, and the tiles were lighter under the shelves. The floor was sticky and had several scuffs in the black substance. The substance was in the hall outside the pantry to the outside back door. During an observation on 02/10/2026 at 11:22 a.m., observed a liquid substance that came from under the back of the stove located in the kitchen. The substance felt greasy and was a cloudy color. In between the stove and fryer was buildup of grease that contained particles of an unknown substance. The window sill above the sink had stains and dirt build up. An industrial toaster with a large amount of toast crust build up was caked on the bars of the top and bottom trays. There was burnt stains on the back of the stove, which was greasy to the touch, when pulled out, the stove trap contained a black crusty substance on old, used tinfoil. During an observation on 02/10/2026 at 11:29 a.m., observed the [NAME] removed her gloves and put on a new pair without washing her hands after she picked up clean plates and continued to scoop food out of the containers at the serving table. During an observation on 02/10/2026 at 11:31 a.m., observed a tray on a shelf that held dishes that contained crumbs of an unknown source beside clean dishes that were to be used for service on a shelf located on the back wall of the kitchen. During an observation on 02/10/2026 at 11:35 a.m., observed the Dietary Aide cut the plastic wrap off a pumpkin pie, walk to the sink and rinse the scissors off under the faucet, then walked back to the food preparation table located in the middle area of the kitchen. The Dietary Aide picked up five (5) card board pie boxes and walked over to a 55-gallon trash container, picked up the lid and threw the boxes inside and replaced the lid. The Dietary Aide walked back to the prep table and picked up a stack of glasses and began placing the glasses on a serving tray. The Dietary Aide wore the same gloves, did not wash her hands, or change gloves. During an observation on 02/10/2026 at 11:39 a.m., observed the Dietary Aide pick up a stack of cups while wearing gloves, rubbed her left ear and pushed her hair back, then continued to place cups on a serving tray. Observed the Dietary Aide's hairnet did not fit properly. Observed a large amount of hair that hung out of the hair net with several strands that hung down approximately three (3) inches on the left side. The hair net exposed approximately two (2) inches of hair across her temple. During an observation on 02/10/2026 at 12:00 p.m., at the holding station, observed the [NAME] picked up a bread roll with her gloved hand and placed on a plate. The [NAME] took her gloves off and put on a new pair without washing her hands. The [NAME] pushed the serving cart with trays toward the door then walked back to the holding station. The [NAME] removed several plates from the plate holder, with her thumb and forefinger touching the eating surface and placed down the serving line. The [NAME] placed her full hand on the eating surface of the plates, touched the side of her nose, and placed her hand, full palm across the eating surface of the plate. The [NAME] did not change gloves or wash her hands. During an observation on 02/10/2026 at 12:10 p.m., at the serving station, observed the [NAME] scratched her nose on her sleeve, picked up new plates and placed them on the serving station. The [NAME] went over to the stove and picked up a pan of dinner rolls and placed them by the serving station. The [NAME] picked up a roll with her gloved hand and placed the roll on a serving plate. During an observation on 02/10/2026 at 12:30 p.m., at the serving station, observed the [NAME] scooped broccoli on to a plate and used her thumb and forefinger to touch the broccoli on the outside of the plate. The [NAME] touched the broccoli multiple times. During an interview on 02/10/2026 at 1:15 p.m., the [NAME] said she was trained on proper sanitation but forgot to wash her hands. The [NAME] said if she touch something like a surface, she should wash her hands. The [NAME] said she was trained to wash her hands in between changing gloves. The [NAME] said she normally did but forgot today. The [NAME] said she also knew she was not supposed to touch food with her hands. The [NAME] said she normally put vegetables like broccoli in small bowls but during the observation, she touched the broccoli to keep it from falling off the plate. The [NAME] said the facility was running low on dishes. The [NAME] said a negative consequence of not washing her hands could be cross-contamination and bacteria. The [NAME] said she followed a cleaning schedule, and she had a list of tasks she was responsible to complete. The [NAME] did not give an explanation for why the tasks had not been completed. The [NAME] said she was responsible to ensure food was labeled and dated. The [NAME] said she was also responsible to throw out food that was outdated. The [NAME] said this was necessary to keep the food from spoiling and others eating contaminated food. During an interview on 02/10/2026 at 1:32 p.m., the Dietary Aide said she had been trained on proper hand washing but did not wash her hands due to her nerves. The Dietary Aide said she was not aware she was supposed to wash her hands when she changed gloves and would do so in the future. The Dietary Aide said a negative consequence of not washing her hands could be bacteria, germs, or cause the residents to become sick. The Dietary Aide said she normally covered her hair with her hairnet, but the hairnet would rise up and expose her hair. The Dietary Aide said not covering all her hair could cause hair to drop into the food. The Dietary Aide said all staff were responsible to clean the kitchen and if she noticed a food item in the refrigerator or freezer that was not dated, she would throw it out. During an interview on 02/12/2026 at 9:52 a.m., the Dietary Manager said the kitchen had been short staffed and the staff's actions did not meet her expectations. The Dietary Manager said touching the trash can lid, touching hair, or face and not washing their hands was unacceptable. The Dietary Manager said the staff should be aware of the need to wash their hands when changing gloves and she said this did not meet her expectations. The Dietary Manager said unlabeled food was unacceptable because the food could be expired or could cause illness. The Dietary Manager said staff should never touch food with their hands and she said this was something she would train the staff on. The Dietary Manager said the overall cleanliness of the kitchen needed improvement and was unacceptable. The Dietary Manager said before she was hired, the kitchen did not have a cleaning schedule. The Dietary Manager said the unacceptable practices would affect the quality of the food and could cause cross-contamination and could make anyone who ate out of the kitchen ill. The Dietary Manager said the floor of the pantry was a dark color because the floor had not been cleaned. She said she mopped the floor after the observation and the tiles were lighter in color. The Dietary Manager said the lack of not mopping in the pantry area was unacceptable to her. The Dietary Manager said the kitchen staff are responsible for cleaning and mopping the floors. The Dietary Manager said she was new to her position and was still in the process of developing a cleaning schedule. The Dietary Manager said before she took the position, there was no cleaning schedule posted. During an interview on 02/12/2026 at 3:58 p.m., the Administrator said she was disappointed with the issues found with the kitchen and the issues were unacceptable. The Administrator said touching food, not washing hands, and an unclean environment could cause cross contamination. The Administrator said the facility was responsible for a very fragile environment and the issues were unacceptable and needed to be addressed. Record review of the facility's policy, Food Storage, dated 2023, revealed food would be stored in an area that was clean, dry, and free from contaminants. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products or opened packages. All containers or storage bags must be legible and accurately labeled and dated. Leftover food should be stored in covered containers and clearly labeled and dated before being refrigerated. Record review of the facility's policy, Cleaning and Sanitation of Dining and Food Service Areas, dated 2023, revealed a cleaning schedule would be posted for all cleaning tasks, and staff would initial the as completed. Staff would be held accountable for cleaning assignments. Record review of the facility's policy, Sanitization, dated 11/2022, revealed the all kitchens, kitchen areas, and dining areas were kept clean. All equipment, food contact surfaces and utensils are cleaned using heat or chemical sanitizing solutions. Record review of the facility's policy, Hand Washing, dated 2023, revealed employees would wash their hands as frequently as needed throughout the day using proper hand washing procedures. Hands and exposed portions of arms should be washed immediately before engaging in food preparation:a. when entering the kitchen at the start of the shiftb. after touching bare human body parts other than clean hands wristf. after handling soiled equipment or utensilsg. during food preparation, as often as necessary to remove soil or contamination and prevent cross contamination when changing tasksi. before donning disposable gloves for working with food and after gloves are removed.

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #3) reviewed for freedom from physical restraints. 1. The facility failed to obtain documentation and/or consent identifying the medical symptoms being treated and an order for a pommel cushion for Resident #3's pommel cushion.2. The facility failed to ensure Resident #3's movement was not restricted, due to a pommel cushion This failure could place residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control). Findings include: Record review of Resident #3's electronic face sheet, dated 02/12/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a reentry admission on [DATE]. Resident #3 had diagnosis which included: Dementia, malnutrition, anxiety disorder, depression, hypertension (high blood pressure) and dysphasia (unable to talk) Record review of Resident #3's Quarterly MDS, dated [DATE], revealed the BIMS score was blank. Further review of the MDS, revealed: Section E: Behavior: E0100. Potential Indicators of Psychosis: Z. None of the above (delusions or hallucinations). E0200. Behavioral Symptoms: A. Physical behavior symptoms directed towards others - behavior of this type occurred 1 to 3 days, B. Verbal behaviors symptoms directed towards others - behavior not exhibited, C. Other behavioral symptoms not directed towards others - behavior not exhibited. E0900: Wandering - 1 (Behavior of this type occurred 1 to 3 days). Section GG: Functional Abilities. GG 0122: Mobility Devices C. Wheelchair Section P0100: Physical Restraints and Alarms: Not used. Record review of Resident #3's consents, on 02/12/2026, revealed no evidence of a signed consent for the pommel cushion. Record review of Resident #3's progress notes, dated 01/02/2026, revealed Nursing Note Text: Resident is no longer sliding to the edge of the chair seat after pummel cushion installation. Record review of Resident #3's progress notes, dated 01/05/2026, revealed; Note Text: IDT Met and discussed root cause of fall. resident continues to lack safety awareness and attempts to get up frequently and falls. Pommel seat applied to wheelchair. During an observation on 02/11/2026 at 11:10 AM, revealed Resident #3 was sitting in a wheelchair at the nurse's station. He had a pommel cushion in his chair. During an interview on 02/12/2026 at 1:37 PM, revealed Resident #3's Representative stated she went to see Resident #3 and asked the nurse what the pummel was for, the nurse explained to her it was used to keep him from falling out of his wheelchair. She stated she had not signed a consent nor had she been called prior to the facility placing it in his wheelchair. During an interview on 02/12/2026 at 1:52 PM, the DON stated Resident #3 fell so much they had to figure out some other process to prevent him from falling. She stated the facility tried other things and had to resort to the pummel and used this for his safety. The DON stated this was to prevent Resident #3 from continuing to fall out of his wheelchair. The DON stated she did not consider this to be a restraint and therefore did not feel there needed to be consent. She stated, the pummel should have an order in Resident #3's medical chart from the physician. During an interview on 02/12/2026 at 2:21 PM, Resident #3's primary Doctor stated she was not notified of the pommel cushion, until today when the DON called, after the pummel cushion was in place. The Doctor stated he was aware of it, at times, but at other times wasn't. She stated she was aware of the pommel cushion when she spoke to the DON earlier in the afternoon (02/12/2026) and asked if there were any concerns. The Doctor stated to her it may be a concern because it was considered a restraint and was not aware it was put in place. She stated his family should have been notified prior to putting the pommel in place since it was considered a restraint. The Doctor stated since it was considered a restraint there also needed to be a consent that told them of the risks and the benefits of using it. She stated preventing him from being hurt or injuring himself was a big deal, but if it was considered a restraint and his family should have be aware. During an interview on 02/12/2026 at 2:42 PM, the ADON stated she considered the pommel cushion a restraint. She stated the policy was to speak to the physician and attain an order prior to placing the pommel cushion in Resident #3's wheelchair. During an interview on 02/12/2026 at 4:07 PM, the DON stated the staff failed to put the order in the electronic record. The physician order should have been placed in the electronic medical record prior to the pommel cushion being in use. She stated the MDS, DON, ADON and the physician were responsible for monitoring this type of restraint. The DON stated the Doctor should have been consulted for the order prior to being used. She stated she felt the pommel cushion was discussed with the doctor prior to being used and was the last alternative to keep him from getting out of his wheelchair and falling. The DON stated there was no consent for the pommel cushion, and if she considered it a restraint there would have been a consent. She stated the failure occurred with not being more thorough with the IDT and having a better checks and balance in place for monitoring and for all nursing staff to have performed a better job. Record review of the facility's policy Use of Restraints, dated 2001, revealed; Policy statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff. Convenience stores for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing reevaluation for the need for restraints will be documented.Policy Interpretation and Implementation; Physical restraints are defined as a manual method or physical or mechanical device, material or equipment attached or Adjacent to the residence body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to 1's body.The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot move a device in the same manner in which the staff applied it, given that residence physical condition. (I. E., rather than climbed over, and this restricts his or her typical ability to change position or place, That device is considered a restraint.A description of the residence. Medical symptoms. (i.e., An indication of the characteristic of a physical or psychological condition) that warranted the use of restraints;.

Based on observation, interview and record review the facility must ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary trach infections for 1 of 24 (Resident #8) residents reviewed for incontinent care. The facility failed to ensure CNA C performed proper peri-care (incontinent care) for Resident #8. This failure could place residents at risk of infections from incontinent care.Findings include: Record review of Resident #8's face sheet, dated 12/04/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had medical diagnoses which included fracture of the left femur, protein-calorie malnutrition, urinary tract infection, history of falling, anxiety disorder and schizoaffective disorder. Record review of Resident #8's Annual MDS, dated [DATE], revealed in Section C - C0500, a BIMS score of 05, which indicated the resident was severely cognitively impaired. Section H - Bladder and Bowel- revealed for toileting hygiene Resident #8 was frequently incontinent. Record review of Resident #8's Comprehensive Care Plan, dated 11/16/2025, revealed the following focused areas: The resident has bladder incontinence r/t dementia. During an observation on 02/11/2026 at 10:11 AM of incontinent care by CNA C on Resident #8 revealed CNA C wiped Resident #8 from back to front. CNA C was also observed wiping, folding and re-wiping the resident with the same wipe. During an interview on 02/11/2026 at 10:40 AM, CNA D stated while doing peri-care CNAs should use one swipe per wipe. She stated if done incorrectly it could have led to infections such as UTIs as well as the cleanliness of the resident. She stated it was the facility policy. During an interview on 02/12/2026 at 8:30 AM, CNA C stated folding and wiping x's 2 is what she was taught and what she had always done unless the resident had a bowel movement, then she would start cleaning in the front. She stated she did not know what the facility policy was and went by what she was taught in school. She stated if each wipe was not changed in between, if not careful, it could cause residents to have an infection. During an interview on 02/12/2026 at 10:27 AM, the DON stated the facility policy for Peri-care was one wipe one swipe and not fold the wipe and not to re-use the wipe at any time. She stated the last training for peri care to her aids was in January of 2026. The DON stated the charge nurses, DON and ADON were ultimately responsible for monitoring the aids that they performed peri care correctly. The DON stated if not performing peri care correctly it could have caused infection. She stated the failure occurred due to staff having not followed through with how they had been taught, per the facility policy. Record review of the facility's policy Perineal Care, dated 2001, revealed: PurposeThe purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents' condition.Steps in the Procedure.FEMALE1. Follow below:Cleanse the peri area with wipes going Front to Back/Clean to DirtySeparate the labia (clean to dirty)Use a new wipe with each strokeWipe one side, wipe the other side, wipe down the center and then once from hip bone to hip bone.

Based on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 6 medication carts (cart #1) reviewed for medication storage.The facility failed to ensure medication cart #1 was locked and secured while unattended.This failure could place residents at risk of a drug diversion. Findings include:During an observation on 02/10/2026 at 10:55 AM, on south side of the facility, across from the nurses' station, revealed the overflow medication cart (Cart #1) was unlocked and unattended. One male resident in a wheelchair approximately four feet from Cart #1 was observed. The medication cart contained blister packs of blood pressure medications, anti-diabetic medications, diuretics, potassium supplements, anti-platelet medications and blood thinners.During an interview on 02/10/2026 at 11:00 AM, LVN B stated Cart #1 was new and only had overflow medications stored in the cart. The LVN stated she was responsible for ensuring Cart #1 was locked when not in use. The LVN stated she got called to the secure unit and forgot to lock the medication cart. The LVN stated if a resident opened the medication cart, they could have possibly taken a medication that was not intended for them and could have caused them to have a negative reaction. The LVN stated she monitored for ensuring the medication cart was locked when not in use.During an interview on 02/12/2026 at 12:00 PM, the DON stated the medication carts should have been locked when not in use. The DON stated if a medication cart was unlocked and unattended a resident, visitor or staff could steal or ingest a medication that was not meant for them and possibly have an adverse reaction. The DON stated the nurses should have monitored the medication carts to ensure they were locked when not in use. The DON stated she did not have a set routine to monitor the medication carts. The DON stated because she was not present when this occurred, she did not know how this failure occurred.Record review of the facility's policy titled Medication Labeling and Storage Policy statement, dated 2001, revealed The facility stores all medications and biologicals in locked compartments under the proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and ImplementationMedication Storage1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on interview and record review the facility failed to inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident became eligible for Medicaid of the items and services that were included in nursing facility services under the State plan and for which the resident may not be charged, those other items and services that the facility offered and for which the resident may be charged, and the amount of charges for those services, and inform each Medicaid-eligible resident when changes were made to the items and services for 2 of 3 residents (Resident #6 and Resident #32) reviewed for resident rights. The facility failed to ensure Residents #6 and Resident #32 were given a paper copy of the NOMNC (notice of Medicare non coverage) with information on how to appeal the decision when residents were discharged from skilled services at the facility prior to covered days being exhausted.This failure could place residents at risk for not being aware of their right to appeal the decision to end Medicare coverage for skilled services, changes to provided services, and their financial responsibilities. Findings include:1. Record review of Resident #6's NOMNC (Notice of Medicare Non-Coverage), dated 08/06/2025 revealed no evidence of a signature by the resident or resident representative. The effective date of coverage of the current Medicare services will end on 08/08/2025. A written note stated verbal NOMNC given to POA at a phone number on 08/06/2025 due to resident diagnosis of cognitive impairment. Record review on 02/12/2026 of Resident #6's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnosis which included Metabolic Encephalopathy, Seizures or convulsions and Spastic Quadriplegic Cerebral Palsy. Record review of Resident #6's quarterly MDS, dated [DATE], revealed Section C, cognitive patterns, BIMS score 99, which indicated severely impaired cognition. Resident #6 Therapy services for at least 15 minutes a day on one or more days in last 7 days: Speech-Language Pathology and Audiology Services, Occupational Therapy and Physical Therapy.Record review of Resident #6's Care Plan, dated 01/07/2026 revealed the resident had limited physical mobility related to contractures. Intervention PT, OT referrals as ordered.Record review of Resident #6's Physician orders, dated 02/01/2026, revealed an order written 01.21.2026 Continue OT services for modalities 3 times a week times 4 weeks. PT ordered for therapeutic activities, therapeutic exercises, neuromuscular re-education and group therapy 3 times week times 8 weeks beginning 12.02.2025.Record review of Resident #32's NOMNC, dated 12.31.2025, revealed no evidence of a signature on the form. The effective date coverage of Medicare Services will end 01.02.2026. A written note on the form stated verbal notification given to son 12.31.2025 at 4:25 PM.Record review of Resident #32's electronic face sheet revealed [AGE] year-old-male admitted on 12.23.2025 with the following diagnosis Hyperkalemia , Acute respiratory failure with hypoxia (insufficient supply of oxygen), muscle weakness, Encephalopathy (Brain dysfunction).Record review of Resident #32's MDS dated [DATE], revealed Section C, cognitive patterns, BIMS score 15, which indicated cognitively intact cognition. Section O-Special Treatment, Procedures, Programs. ST 273 minutes of therapy. OT 300 minutes of therapy. PT 320 minutes of therapy.Record review of Resident #32's care plan, dated 01/06/2026, focus-The resident has an ADL self-care performance deficit related to Musculoskeletal deficit. Intervention-PT/OT evaluation and treatment as per physician orders.Record review of Resident #32's physician orders, dated 02/01/2026, revealed Admit to facility for Medicare part A skilled services. PT/OT/ST to evaluate and treat.During a telephone interview on 02/12/2026 at 1:38 PM, LPN A-MDS coordinator stated she gave verbal notification to Resident #6' POA of beneficiary notification and NOMNC information. The LPN stated she gave verbal information to Resident #32's family member. LPN A stated she verbally told them she would leave a copy of the form in the resident's room for them to pick up when they visited. LPN A stated she did not document on the form that a copy was left in the room or if the representative/POA had picked it up .During a telephone interview on 02/12/2026 at 1:57 PM, Resident #32's family representative stated he remembered someone called him and told him about Resident running out of skilled days, but they never gave him a form, and he never saw one in Resident #32's room, and he never signed anything. During an interview on 02/12/2026 at 3:45 PM, the ADMN stated the preferred method was actual written consent, unless it's a situation where the family was out of state and were not able to come in and sign. The ADMN stated she was not aware of there being no signatures on the NOMNOC. The ADMN stated her expectations were the NOMNOCs be completed. The ADMN stated the Social Worker, business office and the MDS coordinator were responsible for getting the form signed in person by the resident or the resident's representative. The ADMN stated at the very least the form should have been discussed with the responsible party over the phone. The ADMN stated ultimately the failure came back to her. The ADMN stated the harm to the residents could have been the residents did not have time to prepare for discharge from therapy and would not be aware of the appeals process. Record review of the facility's policy titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices not dated revealed: Residents are informed in advance when changes will occur to their bills. Policy Interpretation and Implementation: Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) IF the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. Notice of Medicare Non-Coverage (CMS form 10123) If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage is issued to the resident at least two calendar days before benefits end. The Notice of Medicare Non-Coverage informs the residents of the pending termination of coverage and of his/her right to an expedited review by a Quality Improvement Organization.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse and neglect for one of seven (Resident #1) residents reviewed for abuse. On 10 /11/25 CNA A dragged Resident # 1 by her ankles approximately 40 feet down the hallway in the memory care unit when Resident # 1 refused to allow CNA A to perform incontinent care. The noncompliance was identified as PNC. The IJ began on 10/11/25 and ended on 10/16/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of serious physical injuries, fear and emotional trauma, decline in health and a decreased quality of life.Findings included:Record review of Resident #1's face sheet, dated 12/30/25, revealed she was a [AGE] year-old female admitted on [DATE]. She resided on the memory care unit and had the following diagnoses: vascular dementia (occurs when damaged blood vessels reduce oxygen and nutrient flow to the brain, impairing memory, thinking, and behavior ), anxiety disorder, peripheral vascular disease ( peripheral vascular disease is a slow and progressive circulation disorder caused by narrowing, blockage or spasms in blood vessels), osteoarthritis of bilateral knees (degeneration of joint cartilage and the underlying bone which causes pain and stiffness especially in the hip, knee, and thumb joint), and lipodermatosclerosis (chronic inflammatory condition of the skin where the lower legs harden and thicken due to poor blood flow). Record review of Resident # 1's admission MDS, dated [DATE], reflected that she was incontinent of bowel and bladder and had a BIMS of four, (severe cognitive impairment), displayed wandering behaviors, inattention, disorganized thinking, and did not resist care or display behavioral symptoms or aggression toward others. Record review of the Care Plan, problem which was initiated and revised on 11/16/25, reflected Resident #1 had a problem of mixed bladder incontinence and an intervention was initiated on 11/16/25 to check the resident for incontinence every two hours. It also reflected that she had the problem of ADL self-performance deficit, initiated 10/16/25, with interventions that were also initiated on 10/16/25. Resident #1 required assistance of one staff to use the toilet and required total assistance with transfers but did not specify how many CNAs were required to assist with transfers. The care plans were updated on 10/15/25 after the incident on 10/11/25 to reflect that the resident resisted care and had the potential to be physically aggressive with staff. The care plan was revised on 10/16/25 to include: allow the resident to make decision about treatment regime to provide a sense of control, give clear explanation to all care activities, if resident resists with adl's leave and return in five to ten minutes and try again Record review of CNA A's timecard reports reflected CNA A worked:10/11/25: 6:00 a.m.- 2:21 p.m.10/12/25: 6:36 a.m. - 2:10 p.m.Record review of daily staffing schedule, dated 10/11/25, reflected CNA A was the only CNA assigned to the memory care unit from 6:00 a.m. - 2:00 p.m. on 10/11/25. Record review of the daily staffing schedule, dated 10/12/25, reflected CNA A worked 6:00 a.m. to 2:00 p.m. on the north side (the opposite side) of the building. It is unknown if CNA had contact with or was in the same space as, Resident #`1 at any point during this shift. Record review of CNA A's employe file reflected CNA A was not suspended until 10/12/25 after completing her shift and was terminated on 10/16/25. The record reflected The Investigation proved she did not follow policy and procedure. Record review of the facility's policy titled Abuse, Neglect, and Misappropriation Prevention Program dated revised April 2021, reflected the following: Residents have the right to be free from abuse and neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and chemical restraint not required to treat the resident's symptoms. The program consists of a facility wide commitment and resource allocation to support the following objectives.1.Protect residents from abuse, neglect exploitation, or misappropriation of property by anyone including facility staff, other residents, family members, staff from other agencies, friends, visitors.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. During an observation and an attempted interview on 12/30/25 at 2:00 PM Resident # 1 was sitting in the sitting area of the memory care unit. Resident #1 made eye contact but would not answer direct questions or engage in conversation. She was well groomed, and well dressed, and had no odors. There was no visible bruising. During an interview on 12/30/25 at 3:00 p.m., LVN D stated on 10/11/25 around 6:00 a.m., CNA A reported that Resident #1 was acting up, was dirty and refused to be changed. She stated she went to the memory care unit and saw Resident #1 sitting in a chair and Resident #1 smelled of feces. She stated CNA A was standing in front of her talking loudly to Resident #1. She stated CNA A tried to get Resident #1 to get up and stop yelling. Resident #1 refused to get up and continued to yell. LVN D stated CNA A then reached underneath Resident #1's arms and attempted to pick her up from the chair and Resident #1 grabbed the chair to resist. Resident # 1 slid down to the ground. She stated CNA A, then grabbed Resident #1's ankles and dragged her on the floor down the hall to her room. She stated Resident #1 was screaming, yelling, and resisting CNA A as she dragged her down the hallway. LVN D stated she did not intervene because she was shocked to see the incident and also stated CNA A was so agitated that she was afraid she would aggravate the situation further if she intervened before they got to Resident #1's room. She stated CNA C arrived at that time and she told CNA C to take over Resident #1's care from CNA A. She stated she told CNA A to go off the hall and take a break, and she left the memory care unit. LVN D stated she was the night shift charge nurse when this incident happened, and she was getting ready to go off duty. LVN D stated again she did not intervene because CNA A was a large woman and was terribly upset which made her hesitant to approach her for fear she would increase CNA A's agitation. LVN D stated she the abuse coordinator/administrator of the incident. She stated she also notified the physician and the responsible party. During an interview with Resident #1's responsible party, he stated he was notified of the incident of alleged abuse, but he did not remember who notified him or the date he was notified. During an interview on 12/30/25 at 3:40 p.m., CNA B stated she went outside the memory care unit a little after 5 :00 a.m. to ask CNA A for assistance. CNA A came into the unit and started screaming at Resident #1 to get up, and told her she had until the count of three to get up. CNA B stated Resident #1 was sitting in a gray chair by the television. CNA B stated she saw CNA A grab Resident #1 and pick her up out of her chair and lower her onto the floor. She stated CNA A then grabbed Resident #1 by the ankles and dragged her, while she laid on the floor, from the gray chair in the lobby to her room down the hallway. She stated when they got to the room CNA C and herself intervened at that time and took over Resident #1's care, as they were told to do by LVN D. She stated she did not immediately intervene on the behalf of Resident #1 as she had been trained to do by the facility. She also stated she did not notify the abuse coordinator/administrator because she thought LVN D notified the administrator/abuse coordinator. During an interview on 12/31/25 at 10:00 a.m., CNA A stated she no longer worked at the facility and did work her entire shift on the memory care unit on 10/11/25. CNA A stated when she arrived at the facility on 10/11/25, it was a little after 5:00 a.m She stated CNA B came to her and told her Resident #1 was out of control. She stated CNA B told her Resident #1 needed to be changed but refused. She stated Resident #1 was yelling and screaming. CNA A stated she told Resident #1 she needed to get up from the chair and let CNA B change her brief. She stated Resident #1 would not get up from the chair, and she tried to assist her to stand and at that time Resident #1 threw herself out of the chair and kicked at her wrapped her arms around CNA A's legs. She stated she took Resident #1's arms off her legs and Resident #1 continued to kick at her . CNA A stated there were a lot of residents around and she was afraid for those residents' safety, so she grabbed Resident #1's legs and pulled her to her room. She stated CNA B, CNA C, and LVN D were there, but did not try to help her. She stated LVN D was the nurse, and she just stood there and watched the whole thing . She stated she worked the full shift on the memory care unit on 10/11/25 and worked again on 10/12/25 for eight hours before she was suspended . She stated she was terminated on 10/16/25 as a result of this allegation of abuse. and was currently employed as a CNA at another nursing facility. In an interview on 12/31/25 at 3:00 p.m., the Administrator stated on 10/14/25 she viewed a video of the incident that occurred on 10/11/2025 that was recorded by the facility's electronic monitoring system. She stated the facility had recently undergone a change of ownership, and she was hired in August as the Administrator, but had worked as a marketer in the facility since 2016. She stated she viewed the video with the former DON and the ADON, and after she saw the film, she reported the incident to the police and the state and federal authorities. She stated she did not report the allegation before she saw the video because she was not sure it actually happened until she viewed the video. In an interview on 12/31/25 at 4:00 p.m., the Police Detective that responded to the facility's report on 10/15/25 stated another officer recorded the facility's video recording of the incident that occurred on 10/11/25 as he watched the video by using his work phone on 10/15/25. The Detective stated while watching the video, he observed CNA A drag Resident #1 down the hallway by her ankles. During an observation on 1/9/25 at 2:00 PM of a video dated 10/11/25 at 5:19 a.m., which was in the possession of the police department it was revealed Resident # 1 was sitting in a chair in the lobby area of the memory care unit. The observation revealed there were six other unidentified residents visible in the area. LVN D was standing behind Resident #1, and did not intervene, while CNA A was standing over Resident #1 pointing and shaking her finger in the face of Resident #1. The observation further revealed Resident #1 was looking up at CNA A and did not resist or strike out at CNA A. Further observation revealed CNA A grabbed Resident #1 under her arms and lifted her up while Resident #1 held on to the arms of the chair. The observation revealed CNA A jerked Resident #1 up and Resident #1 fell to the floor and CNA A immediately grabbed Resident #1 by the right leg and began dragging her. The observation also revealed CNA A then grabbed Resident #1's other ankle and dragged Resident #1 on her back down the hallway to her room and then halfway inside the door, at which point, the video ended. CNA A, CNA B, CNA C, and LVN D were observed standing calmly in the video and no one intervened to protect Resident #1. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. Review of the plan reflected:1. Resident # 1 received a skin assessment on 10/11/25 which reflected no open areas or bruising. Responsible party, Ombudsman, and Medical Director notified. Police were notified on 10/15/25. CNA A reassigned on 10/12/25 and suspended pending investigation for the allegation of abuse on 10/12/25. 2. All residents in the secured unit were given a skin assessment on 10/15/25. Interviewable residents were given a safe survey and residents unable to answer safe survey questions were given a skin assessment 10/15/25. There were no findings related to suspected abuse. 3. Education provided by the [NAME] President of Clinical Operations to the designated educators (managers) on the following for all staff members to include the Administrator, Assistant Director of Nursing, Social Services, Activity director, and the Wound Care Nurse, over the following Abuse and neglect, De-escalation, Aggressive Behavior, and Mental Health Management, Resident Rights, and dignity. A competency test was given to all staff after the in-service. Completed 10/15/25. 4. Education provided to all staff by the designated educators (managers)on the following for all staff members to include the Administrator, Assistant Director of Nursing, Social Services, Activity director, and the Wound Care Nurse, over the following by the [NAME] President of Clinical Operations. Abuse and neglect, De-escalation, Aggressive Behavior, and Mental Health Management, Resident Rights, and dignity. A competency test was given to all staff after the in-service. Completed 10/15/25. 5. Five staff and five residents interviewed weekly for four weeks, to ensure any allegations of abuse were reported by the education department (managers). Any concerns noted during the interviews will be immediately addressed and reported to the administrator. Persons responsible for interviews will be Department Heads or designee. 10/16/25 completed. 6. Progress notes and incident reports will be reviewed during morning clinical meetings and by the weekend supervisor to ensure any documented abuse or potential abuse was reported to the administrator or abuse coordinator and to HHSC per regulation. ADON, Wound Care Nurse, Weekend Supervisor and or Designee. 10/16/25 completed 7. Ad Hoc QAPI with the Medical Director regarding the alleged incident and the facility's plan for compliance with regulations. completed 10/15/25 Verification:1. An Action Plan was developed, and an Ad Hoc meeting was conducted with the Medical Director on 10/15/25.-Verified by surveyor: Record review and Medical Director interview on 12/31/25 at 4:00 p.m. 2.Resident #1 received a skin assessment with no injuries identified related to the incident and was observed at baseline without distress.-Verified by surveyor: Record review on 12/31/25 of skin assessment for 10/11/25 after incident and interview with LVN E on 12/31/25 at 2:30 p.m 3.A psychiatric note dated 11/20/25 documented the resident had no recollection of the incident and no behavioral changes were observed.-Verified by surveyor by Record review on 12/31/25. 4.Responsible Party, Police, Ombudsman, and Medical Director were notified. -Verified: Interviews on 12/30/25 between 12:00 p.m. and 4:00 p.m. with Resident #1's party responsible, Police Detective, and Medical director. 5.CNA A was reassigned verified on 10/11/25 and suspended pending investigation on 10/12/25 after working full shifts on 10/11/25 and 10/12/25. CNA A was terminated on 10/15/25 by the former DON as a result of the alleged abuse -Verified 12/31/25 and 1/8/26 by review of personnel files: Interview with CNA A on 12/31/25 at 10:00 a.m. 6.CNA A, CNA B and LVN D received education and disciplinary action and were subsequently terminated. -Verified: Record review of employee files and interviews revealed CNA A was suspended on 10/12/25 after 3:00 p.m. when she completed her shift. CNA A stated in an interview on 12/31/25 at 10:00 a.m. she was terminated on 10/15/25. LVN D was given disciplinary counseling by the Administrator on 10/21/25 and educated that she should have immediately intervened on 10/11/25. She self-terminated on 10/21/25. CNA B was given a written counseling by the ADON for failure to follow facility/company practices and procedures on 10/15/25. She self-terminated after she was counseled and finished her shift on 10/15/25. -CNA C was given a written warning on 10/15/25 by the ADON for failure to follow facility policy and report immediately; and always stop the aggressor and try to diffuse the situation. She stated she was in-serviced by ADON on abuse-related education and completed competency testing prior to working her next shift. Verified by record review of employee files and training records. 7. All residents on the secured unit received skin assessments on 10/15/25. -Verified: Record review on 1/2/26. There were no skin concerns. 8. Forty-two (42) residents able to answer safe survey questions. Department Heads conducted a safety questionnaire; no concerns identified. Thirty-four (34) residents unable to respond received skin assessments. Safe surveys were started and completed on 10/15/25. The skin assessments were started on 10/11/25 and completed on 10/17/25. -Verified: Interviews with Residents #'s 1 - 10 on 12/31/25 between 12:00 p.m. and 5:00 p.m. 9.Leadership staff received education by V/P of Clinical Operations on Abuse and Neglect, De-escalation, Aggressive Behavior, Mental Health Management, Resident Rights, and Dignity on 10/15/25.-Verified: Training records reviewed on 1/2/26. Interviews with ADON, DON, RNC, and VPO on 1/2/26 10.The Administrator received counseling from VPO and RNC for failure to appropriately investigate the allegation and suspend the alleged perpetrator immediately; and was instructed that all abuse allegations must be investigated and reported. -Verified: Record review of counseling in employee file on 12/31/25. Counseling occurred on 10/25/25 by VPO. 11.All staff received abuse-related education by department heads that had been educated by the RNC and VPO on 10/15/25 and completed competency testing prior to working their next shift. -Verified: Sign-in sheets, post-tests, and staff A, B, C, D, E, F, G, H, I, J interviews on 12/31/25 between 8:00 a.m. and 5:30 p.m. different shifts and positions. 12.The facility implemented weekly interviews by Department Heads of five staff and five residents for four weeks beginning 10/16/25 to monitor abuse reporting compliance.Surveyor Verified: Documentation review and interviews with ten staff members D, E, F, G, H, I, J, K, L, M, and seven, Residents #'s 2, 3, 4, 5, 6, 7, 8 on 12/31/25. 13. Daily review of progress notes and incident reports by the DON or weekend supervisor was implemented to ensure timely reporting to the Administrator/Abuse Coordinator and HHSC.-Verified: Staff interview with RN J on 12/31/25. DON and Administrator stated process involves going over them, signing off on them, and handing them to the administrator. 14.An ad hoc QAPI review was conducted with the Medical Director on 10/15/25. -Verified: Record review on 12/31/25.

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse of residents for 1 (Resident #1) of 7 residents reviewed for resident abuse. The facility failed to implement their policy and procedures to ensure Resident #1 was free from abuse when the facility failed to protect Resident #1 from CNA A on 10/11/25, when CNA A grabbed Resident # 1 by the ankles and dragged her approximately 40 feet down the hallway on the floor of the memory care unit. The facility failed to ensure staff immediately reported suspicions of abuse to the Abuse Coordinator when staff members CNA B, CNA C, and LVN D witnessed the abuse and failed to report or intervene immediately. The facility failed to immediately suspend alleged perpetrators of abuse when the facility allowed the alleged perpetrator to work 8.35 hours on 10/11/25 after the incident occurred and 7.57 hours on 10/12/25, before she was suspended. The noncompliance was identified as PNC. The IJ began on 10/11/25 and ended on 10/16/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of serious physical injuries, emotional trauma, decline in health and a decreased quality of life.Findings included: Record review of Resident #1's face sheet, dated 12/30/25, revealed she was a [AGE] year-old female initially admitted the facility on 10/2/25. She resided on the memory care unit and had the following diagnoses: vascular dementia (occurs when damaged blood vessels reduce oxygen and nutrient flow to the brain, impairing memory, thinking, and behavior), anxiety disorder, peripheral vascular disease (peripheral vascular disease is a slow and progressive circulation disorder caused by narrowing, blockage or spasms in blood vessels), osteoarthritis of bilateral knees (degeneration of joint cartilage and the underlying bone which causes pain and stiffness especially in the hip, knee, and thumb joint), lipodermatosis ( chronic inflammatory condition of the skin where the lower legs harden and thicken due to poor blood flow). Record review of Resident # 1's admission MDS, dated [DATE], reflected that she was incontinent of bowel and bladder and had a BIMS of four, (severe cognitive impairment), displayed wandering behaviors, inattention, disorganized thinking, and did not resist care or display behavioral symptoms or aggression toward others. Record review of the Care Plan, problem which was initiated and revised on 11/16/25, reflected Resident #1 had a problem of mixed bladder incontinence and an intervention was initiated on 11/16/25 to check the resident for incontinence every two hours. It also reflected that she had the problem of ADL self-performance deficit, initiated 10/16/25, with interventions that were also initiated on 10/16/25. Resident #1 required assistance of one staff to use the toilet and required total assistance with transfers but did not specify how many CNAs were required to assist with transfers. The care plans were updated and revised on 10/15/25 after the incident occurred on 10/11/25 to reflect that the resident resisted care and had the potential to be physically aggressive with staff. The care plan was revised on 10/16/25 to include: allow the resident to make decision about treatment regime to provide a sense of control, give clear explanation to all care activities, if resident resists with adl's leave and return in five-ten minutes and try again Record review of CNA A's timecard reports showed CNA A worked:10/11/25: 6:00 a.m. - 2:21 p.m.10/12/25: 6:36 a.m.- 2:10 p.m. Record review of daily staffing schedule for 10/11/25 showed that CNA A was the only CNA that worked the memory care unit from 6 a.m. - 2 p.m. Record Review of the daily staffing schedule for 10/12/25 showed that CNA A worked 6 a.m.-2 p.m. on the north side (the opposite side) of the building. Record review of CNA A's employe file reflected CNA A was not suspended until 10/12/25 after completing her shift and was terminated on 10/16/25. The record reflected The Investigation proved she did not follow policy and procedure. Record review of the incident investigation worksheet reflected that the incident was not reported to state authorities until 2/15/25. Record Review of the police report reflected that a police report was filed by the facility administrator three days after the alleged abuse occurred on 10/15/25 at 2:19 p.m Review of the facilities policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, stated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.Policy Interpretation and ImplementationReporting Allegations to the Administrator and AuthoritiesIf resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:1. The state licensing/certification agency responsible for surveying/licensing the facility;The local/state ombudsman;The resident's representative;Adult protective services (where state law provides jurisdiction in long-term care);Law enforcement officials;The resident's attending physician; andThe facility medical director. Immediately is defined as:1. within two hours of an allegation involving abuse or resulting in serious bodily injury; orwithin 24 hours of an allegation that does not involve abuse or result in serious bodily injury.Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone.Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. During an interview on 12/30/25 at 12:00 p.m., the administrator stated the incident with CNA A and Resident #1 occurred on 10/11/25 between 5:30 a.m. and 6:00 a.m and she was not informed until a little after 8:00 a.m. on 10/11/25 which was a Saturday. LVN D informed her of the incident at about 11:00 a.m She stated this was three hours after the incident occurred. She stated she started the investigation of the incident and began to get witness statements to find out if in fact abuse had occurred. She stated she did not report the incident at this time because she did not have any facts. She stated the incident seemed inappropriate, but she did not immediately report it because it just did not scream out in black and white that abuse had occurred, or if it was just inappropriate behavior by the employee. She stated she tried to contact the former DON, at the time that she was called, but she did not answer her phone until at least 5 hours later. She stated the incident occurred on the weekend, and the DON was coming into work that evening. She stated when the DON returned her call, she stated she would go on in and start the investigation. The administrator stated she came in and started interviews with staff and in-services on abuse and customer service. The administrator stated she told the DON to move CNA A off the hallway. She stated she determined it was appropriate to move the aide off of the hall on the 10/11/25 because they had nothing concrete that abuse occurred. She stated CNA A was suspended on the 12th and terminated on the 16th. She stated she determined on Tuesday the 14th of October that it was reportable and she called the incident in to state and federal authorities and did a self-report. She stated she also reported it to the police at this time. During an Interview on 12/30/25 at 1:30 p.m., the former DON stated on Saturday, 10/11/25 at approximately 12:00 p.m., she received a call from the Administrator, who described the incident as a near miss for abuse; and stated corporate determined it was highly inappropriate behavior rather than abuse. On Sunday, 10/12/25 at approximately 2:45 a.m. while she was working overnight CNA B and CNA C approached the DON stating that on 10/11/25 around 5:30 a.m., CNA A had grabbed Resident #1 out of a chair and dragged her down the hallway by her feet. They expressed concern that the incident was not being handled appropriately. The DON stated at 3:03 a.m. on 10/12/25, she texted the administrator regarding staff concerns of abuse. The DON stated she obtained written statements from the staff involved. She stated these statements consistently and described CNA A grabbing the resident, dropping her to the floor, and dragging her by her feet . She also stated she emailed the statements to the administrator, RNC (RN Consultant, and VPO (Vice President of Operations at 4:40 p.m. on 10/12/25. She stated the Administrator instructed her to suspend CNA A at that time. The DON further stated that on 10/13/25 she discussed the need to self-report the allegations of abuse to the state and local authorities with the Administrator, and the Administrator stated corporate instructed her not to self-report. The DON stated that due to her continued concerns that the allegation of abuse had not yet been reported to state and local authorities, she also contacted the corporate leadership (VPO) to report her concerns. During an interview on 12/30/25 at 3:00 p.m., LVN D stated on 10/11/25 around 6:00 a.m., CNA A reported that Resident #1 was acting up, was dirty and refused to be changed. She stated she went to the memory care unit and saw Resident #1 sitting in a chair and Resident #1 smelled of feces. She stated CNA A was standing in front of her talking loudly to Resident #1. She stated CNA A tried to get Resident #1 to get up and stop yelling. Resident #1 refused to get up and continued to yell. LVN D stated CNA A then reached underneath Resident #1's arms and attempted to pick her up from the chair and Resident #1 grabbed the chair to resist CNA A and then Resident # 1 slid down to the ground. She said CNA A, then grabbed Resident #1's ankles and dragged her on the floor down the hall to her room. She stated Resident #1 was screaming, yelling, and resisting CNA A as she dragged her down the hallway. LVN D stated she did not intervene because she was shocked to see the incident and also stated CNA A was so agitated that she was afraid she would aggravate the situation further if she intervened before they got to Resident #1's room. She stated CNA C arrived at that time and she told CNA C to take over Resident #1's care from CNA A. She stated she told CNA A to go off the hall and take a break, and CNA A left the memory care unit. LVN D stated she was the night shift charge nurse when this incident happened, and she was getting ready to go off duty. LVN D stated she did not intervene because CNA A was a large woman and was terribly upset which made her hesitant to approach her. LVN D stated she did notify the abuse coordinator/administrator of the incident. She stated she also notified the physician and the responsible party. She stated she did not remember the time that she called the administrator, but she knew that it was close to 11:00 a.m. before she ever left the building that morning. During an interview on 12/30/25 at 3:40 p.m., CNA B stated she went outside the memory care unit a little after 5:00 a.m. to ask CNA A for assistance. CNA A came into the unit and started screaming at Resident #1 and told her she had until the count of 3 to get up. CNA B stated Resident #1 was sitting in a gray chair by the television. CNA B stated she saw CNA A grab Resident #1 and pick her up out of her chair and lower her onto the floor. She stated CNA A then grabbed Resident #1 by the ankles and dragged her, while she laid on the floor, from the gray chair in the lobby to her room down the hallway. She stated when they got to the room CNA C and herself intervened at that time and took over Resident #1's care, at the direction of LVN D. She stated she did not immediately intervene on the behalf of Residet#1 as she had been trained to do by the facility. She stated she did not notify the abuse coordinator/administrator because she thought LVN D notified the administrator/abuse coordinator During an interview on 12/31/25 at 10:00 a.m. CNA A stated she no longer works at the facility and did work on 10/11/25. State when she arrived at the facility on 10/11/25 a little after 5:00 a.m. that CNA B came to her and told her Resident #1 was out of control. She stated CNA B told her Resident #1 needed to be changed but had refused. She stated Resident #1 was yelling and screaming. CNA A stated she told Resident #1 she needed to get up from the chair and let her change her brief. She stated Resident #1 would not get up from the chair, and she tried to assist her to stand and at that time Resident #1 threw herself out of the chair and kicked at her and had her arms wrapped around her legs. She stated she took Resident #1's arms off her legs and Resident #1 continued to kick. CNA A stated there were a lot of residents around and she was afraid for those residents safety, so she grabbed Resident #1's legs and pulled her on the floor to her room by her ankles. She stated CNA B, CNA C, and LVN D were there didn't try to help her. She stated LVN D was the nurse, and she just watched the whole thing. she stated she worked the full shift on the memory care unit on 10/11/25 and worked again on 10/12/25 for 8 hours before she was suspended. She stated she was terminated on 10/16/25 due to this allegation of abuse, and was currently employed as a CNA at another nursing facility. In an interview on 12/31/25 at 3:00 p.m., the Administrator stated she viewed a video on 10/14/25 that was recorded by the facilities electronic monitoring system that captured the incident on video. She stated the facility had recently undergone a change of ownership, and she had just recently been hired as the Administrator. She stated she viewed the video with the former DON, and the ADON when she became aware and after she saw the film she reported the incident to the police and the state and federal authorities. She stated the film was no longer available at the facility as the system only retained the video in the system for about a week. She stated the facility immediately began the following corrections / interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. Review of the plan reflected: 1. Resident # 1 received a skin assessment on 10/11/25. Responsible party, Responsible party, Ombudsman, and Medical Director notified. Police notified on 9/14/25.CNA reassigned on 9/12/25 and suspended pending investigation for the allegation of abuse on 10/12/25. 2. All residents in the secured unit were given a skin assessment on 10/15/25. Interviewable residents were given a safe survey and residents unable to answer safe survey questions were given a skin assessment 10/15/25. 3. Education provided to the designated educators (managers) on the following for all staff members to include the Administrator, Assistant Director of Nursing, Social Services, Activity director, and the Wound Care Nurse, over the following by the [NAME] President of Clinical Operations. Abuse and neglect, De-escalation, Aggressive Behavior, and Mental Health Management, Resident Rights, and dignity. A competency test was given to all staff after the in-service. Completed 10/15/25. 4. Education provided to all staff by the designated educators ( managers) on the following for all staff members to include the Administrator, Assistant Director of Nursing, Social Services, Activity director, and the Wound Care Nurse, over the following by the [NAME] President of Clinical Operations. Abuse and neglect, De-escalation, Aggressive Behavior, and Mental Health Management, Resident Rights, and dignity. A competency test was given to all staff after the in-service. Completed 10/15/25. 5. Five staff and five residents interviewed weekly for 4 weeks, to ensure any allegation of abuse has been reported by the education department. Any concerns noted during the interviews will be immediately addressed and reported to the administrator. Persons responsible for interviews will be Department Heads or designee. 10/16/25 completed. 6. Progress notes and incident reports will be reviewed during morning clinical meetings and by the weekend supervisor to ensure any documented abuse or potential abuse has been reported to the administrator or abuse coordinator and has been reported to HHSC per regulation. ADON, Wound Care Nurse, Weekend Supervisor and or Designee. 10/16/25 completed 7. Ad Hoc QAPI with the medical Director regarding the alleged incident and the facilities plan to be in compliance with regulations. 12/25/25 Verification:1.An Action Plan was developed, and an ad hoc meeting was conducted with the Medical Director on 10/15/25.-Verified by surveyor: Record review and Medical Director interview on 12/31/25 at 4:00 p.m. 2.Resident #1 received a skin assessment with no injuries identified related to the incident and was observed at baseline without distress.-Verified by surveyor: Record review on 12/31/25 of skin assessment for 10/11/25 after incident and Interview with LVN E on 12/31/25 at 2:30 p.m 3.A psychiatric note dated 11/20/25 documented the resident had no recollection of the incident and no behavioral changes were observed.-Verified by surveyor by Record review on 12/31/25. 4.Responsible Party, Police, Ombudsman, and Medical Director were notified. -Verified: Interviews on 12/30/25 between 12:00 and 4:00 p.m. with interviews with the party responsible, Police Detective, and Medical Director. 5.CNA A was reassigned on 10.11.25 and suspended pending investigation on 10/12/25 after working full shifts on 10/11/25 and 10/12/25. CNA A was terminated on 10/15/25 By the former DON. -Verified 12/31/25 and 1/8/26 by review of personnel files: Interview with CNA A on 12/31/25 at 10:00 p.m. 6.CNA B and LVN D received education and disciplinary action and were subsequently terminated. -Verified: Record review of employee files and interviews revealed CNA A was suspended on 10/12/25 after 3 p.m. when she completed her shift. CNA A stated in an interview on 12/31/25 at 10:00 a.m. she was terminated on 10/15/25. LVN D was given disciplinary counseling by the Administrator on 10/21/25 and educated that she should have immediately intervened on 10/11/25. She self-terminated on 10/21/25. CNA B was given a written counseling by the ADON for failure to follow facility/company practices and procedures on 10/15/25. She self-terminated after she was counseled and finished her shift on 10/15/25.-CNA C was given a written warning on 10/15/25 by the ADON, for failure to follow facility policy and report immediately; and always stop the aggressor and try to diffuse the situation. She stated she was in-serviced by ADON on abuse-related education and completed competency testing prior to working her next shift. 7.All residents on the secured unit received skin assessments on 10/15/25. -Verified: Record review on 1/2/26. 8. Forty-two (42) Residents able to answer safe survey questions. Department Heads conducted a safety questionnaire; no concerns identified. Thirty-four (34) Residents unable to respond received skin assessments. Safe surveys were started and completed on 10/15/25. The skin assessments were started on 10/11/25 and completed on 10/17/25.-Verified: Interviews with residents #'s one thru ten on 12/31/25 between 12 p.m. and 5 p.m. 9.Leadership staff received education by V/P of Clinical Operations on Abuse and Neglect, De-escalation, Aggressive Behavior, Mental Health Management, Resident Rights, and Dignity on 10/15/25.-Verified: Training records reviewed on 1/2/26. Interviews with ADON, DON, RNC, and VPO on 1/2/26 10.The Administrator received counseling from VPO and RNC for failure to appropriately investigate the allegation and suspend the AP immediately; and was instructed that all abuse allegations must be investigated and reported. -Verified: Record review of counseling in employee file on 12/31/25. Counseling occurred on 10/25/25 by VPO. 11.All staff received abuse-related education by department heads that had been educated by the RNC and VPO on 10/15/25 and completed competency testing prior to working their next shift. -Verified: Sign-in sheets, post-tests, and staff A, B, C, D, E, F, G, H, I, J interviews on 12/31/25 between 8 and 5:30 p.m. different shifts and positions. 12.The facility implemented weekly interviews by Department Heads of 5 staff and 5 residents for four weeks beginning 10/16/25 to monitor abuse reporting compliance. Surveyor Verified: Documentation review and interviews with ten staff members D, E, F, G, H, I, J, K, L, M, and seven residents #'s 2, 3, 4, 5, 6, 7, 8, on 12/31/25. 13.Daily review of progress notes and incident reports by the DON or weekend supervisor was implemented to ensure timely reporting to the Administrator/Abuse Coordinator and HHSC.-Verified: Staff interview with RN J on 12/31/25 DON, And Administrator, stated process involves going over them, signing off on them, and handing them to the administrator. 14.An ad hoc QAPI review was conducted with the Medical Director on 10/15/25. -Verified: Record review on 12/31/25.

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature as evidenced by a sample tray tested on [DATE]. This failure could affect the residents who ate food from the facility's kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served. The findings included: During an interview on 11/12/2024 at 10:16 AM, Resident #45 stated the food was not good and was cold. He stated the dietary offered a substitute, but it was not good. During an interview on 11/12/2024 at 10:49 AM, Resident #46 stated the facility had a new cook and nothing tasted good. He stated he was on a mechanical diet being ground up and nothing tasted right. During an observation on 11/12/2024 at 1:10 PM the test tray was on the hall cart, at 1:15 PM, the test tray was in the conference room with DM to temp and test for palatability. The temperatures of test tube revealed: 1. Chicken [NAME] 126 degrees 2. [NAME] Beans 118 degrees 3. Hot Apple dessert 82.9 During an interview on 11/12/2024 at 1:20 PM, the DM stated the temperatures were not warm enough to sustain the palatability. She stated the dining room trays were most likely cold as well since they were served last. She stated the failure could have been due to the [NAME] not stirring the food and getting from the top of the pan, and not the bottom. She stated the vegetables should have been served in a bowl to retain the heat as well as the juice of the beans made the roll soggy. The DM stated the apples were not served hot with the low temperature playing the major part as not being palatable. She stated she felt the cook had not seasoned the sauce after being advised to do so. The DM stated could have affected the residents with them not eating which could have causes them not to get receiving proper nutrition which could have caused weight loss or depression. She stated the [NAME] was responsible as well as her as the DM since she monitored her in the taking of temperatures. The DM stated she monitored 2-3 times a week. She stated her expectations were for meals to be prepared according to the recipe as well as residents be provided their choices. The DM stated the failure was a combination of staff needing more education, with 3 of her staff having trained and not performed what they learned. During an interview on 11/14/2024 at 2:15 PM the ADMN stated she could not answer how unpalatable food could have affected the residents. She stated, the cold food should be cold, and the hot food should be hot. The ADMN stated the DM monitored the temperatures and palatability of the food, with herself as the ADMN monitored the DM. She stated she usually monitored daily. The ADMN stated the last time she had entered into the kitchen was a week ago having done a quick look around due to a morning meeting. She stated her expectations was that the food have the correct seasonings, with the temperatures being correct. The ADMN stated the plate warmer may had not been working correctly possibly could have been where the failure occurred, but she wasn't there or observe and could not say. Record review of facility policy Test Trays, dated 2018 revealed the following [in-part]: Policy: The facility recognizes the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable and served at the correct temperatures. Record review of facility policy Food and Holding Service dated 2018 revealed the following [in-part]: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP guidelines. Procedure: 1. Serve all hot foods at a temperature of 135 F or greater and all cold food at 41 F or less.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. The facility failed to ensure kitchen staff followed proper hand hygiene during meal preparations. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: During an observation on [DATE] at 9:46 AM of the pantry was; 1 gallon of blended oil, unable to read the received date with no opened date. 1 16 oz. opened clear zip lock bag of marshmallows with no opened date. 1 5 lb. opened bag of potato chips with no opened date. 1 26 oz. opened bag of Dried Classic Mashed Potatoes in a clear zip lock bag with no opened date. 1 8 lb. opened container of Creole Seasoning with no opened date. 1 opened bag of hamburger buns with no opened date. 1 20 oz. opened loaf of bread with no opened date. 1 17 oz. opened container with the opened date unreadable. Expired food 1 6 lb. opened box container with a received date of [DATE] and no opened date. 1 8.1 oz can of Baking Powder with an expiration dated [DATE]. Refrigerator #1 1 clear container labeled [NAME] fruit with no use by date. 1 container labeled gravy dated ,d+[DATE] with no use by date. 1 clear zip lock bag labeled carrots with no use by date. 1 clear zip lock bag labeled taco meat and dated ,d+[DATE] with no use by date. 1 clear zip lock bag labeled eggs, dated [DATE] with no use by date. 1 clear zip lock bag labeled sausage, dated [DATE] with no use by date. 1 10 lb. opened and unsealed box of Sausage Patties with no opened date. 1 clear zip lock bag labeled Pork Chops, dated [DATE] with no use by date. 1 original clear bag labeled Sausage dated ,d+[DATE] with no use by date. Refrigerator #2 1 clear zip lock bag dated ,d+[DATE] with a head of (browning) lettuce. 1 clear zip lock bag dated ,d+[DATE] with (browning) shredded lettuce. 1 clear zip lock bag labeled cheddar cheese dated ,d+[DATE] and no use by date. 1 head of lettuce in original bag undated. 1 opened box and unsealed bag of Parsley dated ,d+[DATE] and appeared to be wilted. Freezer #1 1 clear zip lock bag unlabeled of what appeared to be French toast dated ,d+[DATE]. 1 opened box with an unsealed bag of Turkey Sausage dated [DATE]. 1 15 lb. opened box with an unsealed bag of Swai Fillet fish, undated. 2 sealed and unlabeled clear bags of what appeared to be frozen chicken, unlabeled and undated. During an observation on [DATE] at 11:06 AM the Dish Washer and [NAME] had not used proper hand hygiene when washing their hands, not using soap and scrubbing hands in the time required for proper sanitizing. During an interview on [DATE] at 2:40 PM the ADMN stated she expected her staff to wash their hands thoroughly and to know how long to not transmit any bacteria or cross contamination to the residents. She stated some residents had low immune systems therefore easier for them to get sick. The ADMN stated it was the DM's job to monitor. She stated her expectations were for the kitchen to be maintained. The ADMN stated the failure occurred with the DM and new staff, as they needed to be monitored as well as have an increased list of in-services for new staff. She stated all products that came into the kitchen should have been labeled and dated, which included, the received date and opened date prior to being placed on the shelves. The ADMN stated her expectations were to label, date, and rotate all products. During an interview on [DATE] at 9:23 AM, the DM stated all products were to be labeled with a received date and when opened. She stated when the product is opened and placed in another container, staff needed to label and place all dates needed on the product. The DM stated if the food product was a leftover in the refrigerator, there should have been a use by date of 3 days. She stated when the products were opened in the freezers, staff should have sealed the bag completely before closing the box. The DM stated the failure was with her staff getting in a hurry. She stated in not doing so, it could have affected the resident with the possibility of cross contamination which could have led to a food borne illness. The DM stated DM oversaw the kitchen and dining, but not often enough. She stated her expectations were to have all products labeled, dated and with the use by date when needed, as well as rotate products when needed. The DM stated the failure was with her and her staff having not followed regulations. The DM stated all staff also has been in-serviced as to how to wash their hands. She stated in not doing so, could have caused residents to become sick. She stated the DM monitored staff with in-services and observations. The DM stated, the failure was that staff were not following protocols and regulations of their in-services. Record Review of facility policy, Food Storage dated 2018, revealed: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry Storage rooms d. to ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated f. Where possible, leave items in the original cartons placed with the date visible. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that older items are used first. 2. Refrigerators .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 3. Freezers . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record Review of facility policy, Food Preparation and Handling dated 2018, revealed: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state, federal and US Food Codes and HACCP guidelines. 1. General Guidelines . b. Wash hands properly before beginning food preparation. C. Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly. Record Review of facility policy, General Kitchen Sanitation dated 2018, revealed: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 12. Make sure hand-washing facilities are easily accessible and supplied with soap and paper towels. Record Review of facility policy, Hand Washing dated 2018, revealed: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents All Nutrition & Food service employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness. Procedure: 1. Hand-washing stations . a. Make sure hand washing stations are located in food preparation areas to encourage employees to wash their hands frequently. b. Make sure there are hand washing stations in all areas that employees' hands may become contaminated, including food preparation areas, service areas, dishwashing areas and rest-rooms. c. Make sure all hand washing stations are equipped with the following i. Hot and cold running water. Ii. Hand cleaning liquid, powder, or bar soap. Iii. Individual, disposable towels, a continuous towel system that supplies the user with a clean towel or a heated-air hand-drying device. Iv. A receptacle for disposable towels. v. A sign that indicates employees must wash hands before returning to work. d. Sinks used for food preparation or washing utensils or a service sink or curbed cleaning facility used to dispose of mop water or similar wastes cannot be used as a hand-washing station. 2. Hands should be washed after the following occurrences: a. using the restroom b. Handling raw food (before and after) c. Touching the hair, face, or body d. sneezing or coughing e. smoking f. eating or drinking g. Handling chemicals h. taking out the garbage i. Clearing tables j. Touching clothing or aprons k. Touching unsanitized equipment, work surfaces, or wash cloths l. Assisting residents 3. Hand-washing steps . a. Wet hands and exposed arms with hot water at least 100* F. b. Apply soap c. scrub hands, exposed arms and fingernails for a minimum of 20 seconds being sure to apply a vigorous friction d. Rinse hands and exposed arms thoroughly under hot running water e. Dry hands and arms with a paper towel f. Turn off the faucet with the paper towel to avoid contaminating hands and discard towel. Review on [DATE] of the FDA Food Code 2022: Full Document accessed on [DATE] in annex 7 page 37, 38 revealed: Applicable Code Sections: ,d+[DATE].16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done.

Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs for 2 of 5 residents (Resident #'s 61 and 76) whose records were reviewed for psychotropic drugs, in that: 1. Resident #61 received an order for the antianxiety medication Valium PRN (as needed), and the order did not include an end date after 14 days. Valium was administered on 11/1/24, 11/2/24, 11/3/24, 11/4/24, 11/6/24, 11/8/24, 11/11/24, 11/12/24, 11/13/24, and 11/14/24 PRN. 2. Resident #76 had an order for the antipsychotic medication Seroquel was administered at bedtime11/1/24 thru 11/13/24 for a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety which was not an appropriate indication for use. This failure placed residents at risk for being over medicated or experiencing undesirable side effects and could cause a physical or psychosocial decline in health status. The findings included: Review of Resident # 61's Face Sheet (not dated) revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: - amyotrophic lateral sclerosis ( - dysphagia (difficulty swallowing) - major depressive disorder, recurrent - anxiety disorder. Review of Resident # 61's current physician orders, dated 11/14/24, revealed the following: -Diazepam gel 10 mg/ml Apply 1 ml topically to inner wrist and rub in well for anxiety Every 4 Hours - PRN (start date 5/9/24, order was last renewed on 10/28/24) there was not an end date. Review of Resident # 61's Medication Administration Records, dated 11/1/24 through 11/30/24, revealed Valium 10 mg topically every 4 hours prn was administered on 11/1/24, 11/2/24, 11/3/24, 11/4/24, 11/6/24, 11/8/24, 11/11/24, 11/12/24, 11/13/24, and 11/14/24 PRN. Review of Resident #61's Quarterly MDS Assessment, dated 8/21/24 revealed the resident had anxiety disorder, major depressive disorder, recurrent; and antianxiety medications were given during the 7-day review period. Review of Resident #61's comprehensive care plan, last revised on 8/19/24, revealed she was PASRR positive and was administered antianxiety and antidepressant medications. Review of the Pharmacy recommendations for the month of October of 2024 revealed the following recommendation to the physician by the pharmacy consultant: PRN psychotropic medications require a 14 day stop date. At that time physician will need to re-evaluate the need for the following Valium prn, duration greater than 14 days will need a physician rationale. The physician had signed the recommendation on 10/28/24 and written 14 days with no rationale. In an interview on 11/14/24 at 1:00 PM the ADON stated a prn psychotropic medication should not be ordered longer than 14 days without a stop date, or a rationale why the medication should be continued beyond the 14 days. Review of Resident # 76's Face Sheet (not dated) revealed an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: - Unspecified dementia, with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. - chronic kidney disease - unspecified dementia with psychotic disturbance, -delirium Review of Resident # 76's current physician orders, dated 11/14/24, revealed the following: -Seroquel 200 mg po at hs for unspecified dementia, with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. Review of Resident # 76's Medication Administration Records, dated 11/1/24, thru 11/30/24 revealed Resident # 76 received Seroquel 200 mg at hs 11/1/24 thru /11/13/24. Review of Resident #76's Admission MDS Assessment, dated 10/22/24 documented the resident did not meet the level 2 PASRR definition of mental illness, had no behavioral symptoms such as hallucinations or delusions or indicators of psychosis, she had no verbal or physical behavioral symptoms , had unspecified dementia without behavioral disturbances, and resident was currently taking an antipsychotic. Review of Resident # 76's comprehensive care plan, last revised in 10/20/24, revealed the following: - Problem: The resident requires psychotropic drugs for the treatment of depression, mood disorder, Behavior management. - Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. The resident will reduce the use of psychoactive medication through the review date. -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Consultant pharmacist to review medication regime monthly. Discuss with MD, family re ongoing need for use of medication. Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms. In an interview with the ADON on 11/14/24 at 1:10 PM she stated that Seroquel 200 mg at hs ordered for resident #71 did not have a diagnosis which would indicate the appropriate use of an antipsychotic. She stated that the diagnoses of unspecified dementia, with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety was not an indication for the use of an Antipsychotic. She stated that she and the DON were responsible for monitoring to ensure that residents had an appropriate diagnosis for the psychotropic medications they were prescribed. She stated a negative outcome of the use of antipsychotics and psychotropic medications in the elderly resident could be increased falls, confusion, and adverse events. In an interview on 11/14/24 at 1:35 PM the DON stated Resident #71 was admitted to the facility from another nursing facility and was on the Seroquel when she was admitted and the diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety was not an appropriate indication for use. She stated that an appropriate diagnosis would be schizophrenia, Huntington, or Tourette. She stated the facility could not request a diagnosis change, unless they could find out what the resident's past mental health history was. She stated she and the ADON do monitor new admissions before they come into the facility for their diagnosis and medication history. Review of the facility's policy and procedure for Medication Monitoring and Medication Management, dated 2007, revealed the following [in part]: It is the policy of this home to use antipsychotic medications per CMS guidelines and to perform dose reductions and monitoring as required by regulation, to promote the highest level of resident care and safety. DEFINITIONS 1. A gradual dose reduction is a tapering of the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether. 2. Behavioral interventions mean modification of the resident's behavior and/or the resident's environment, including staff approaches to care, to the largest degree possible to accommodate the resident's behavioral symptoms. 3. Clinically contraindicated means that a resident with an appropriate diagnosis for use who has had a history of recurrence of psychotic symptoms, which have been stabilized, with a maintenance dose of an antipsychotic drug without incurring significant side effects should not receive gradual dose reductions. In residents with organic mental syndromes, it means that a gradual dose reduction has been attempted twice in one year and that attempt resulted in the return of symptoms for which the drug was prescribed to a degree that a cessation in the gradual dose reduction, or a return to previous dose levels was necessary. 4. Specific Conditions for which antipsychotic drugs may be used: o Schizophrenia o Schizo-affective disorder o Delusional Disorder o Psychotic mood disorders (including mania and depression with psychotic features) o Acute psychotic episodes o Brief reactive psychosis o Schizophreniform disorder o Atypical psychosis o Tourette's disorder o Huntington's disease o Organic mental syndromes (including dementia and delirium) with associated psychotic and/or agitated behaviors: which have been quantitatively (number of episodes) and objectively (biting, kicking, scratching) documented which are not caused by preventable reasons which are causing the resident to: 1) Present a danger to her/himself or to others 2) Continuously scream, yell, or pace if these specific behaviors cause an impairment in functional capacity. 3) Experience psychotic symptoms (hallucinations, paranoia, delusions) not exhibited as dangerous behaviors or as crying, screaming, yelling, or pacing but which cause the resident distress or impairment in functional capacity 5. Conditions for Which Antipsychotic Drugs Should NOT Be Used (as an only indication): o Wandering o Poor self-care o Restlessness o Impaired memory o Anxiety o Depression (without psychotic features) o Insomnia o Unsociability o Indifference to surroundings o Fidgeting o Nervousness o Uncooperativeness o Agitated behaviors which do not represent danger to the resident or others. 1. Documenting the appropriate specific conditions for antipsychotic medication use: a. For resident's already receiving an antipsychotic medication that does not have an approved diagnosis listed in their medical record, the nursing staff and/or the consultant pharmacist will request a specific diagnosis for its use. b. For resident's who receive a new order for an antipsychotic medication, the nurse will request a specific diagnosis at the time the medication is ordered. c. The specific behavior(s) exhibited by the resident will be documented on the appropriate Clinical Software Monitoring Flow Sheet.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 (Resident #'s 7, 33, and 61) of 4 residents reviewed for infection control , in that: Agency LVN failed to intervene and practice EBP (enhanced barrier precautions) to protect resident's from MDRO'S by not donning a gown when caring for and administering medications to Resident #7 on 11/12/24 via his gastrostomy (an opening into the stomach through the abdominal wall to provide medication and nourishment) tube. The facility failed to intervene and practice EBP when caring for Resident # 33 who had a pressure area on her coccyx. The facility failed to intervene and practice EBP when caring for Resident # 61 a who had a foley catheter . These failures could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #7's electronic face sheet not dated reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: dysphagia (difficulty swallowing) hemiplegia (paralysis on one side of the body) cerebral infarct (stroke) diarrhea, and hypertension(high blood pressure). Record review of Resident # 7's Annual MDS, dated [DATE], reflected he had a BIMS of 15 (cognitively intact), received gastrostomy tube feedings, and that he was occasionally incontinent of bowel and bladder. Record review of Resident #7's comprehensive person-centered care plan reflected a last care conference date of 6/18/2024 reflected Problem: Feeding tube There was no Problem or intervention for enhanced barrier precautions. During an observation and interview on 11/12/2024 at 1:43 PM of Resident # 7's room revealed he did not have had a sign on his door or in his room which indicated he was on EBP. He stated the staff did not wear a gown when they provided care or administered his medications through his gastrostomy tube. During an observation on 11/13/24 at 3:20PM, Agency LVN entered Resident #7's room to administer his 3 PM medications which he received via gastrostomy tube (a tube placed through the abdominal wall and into the stomach). She wore gloves but did not put a gown on to administer the medication through the indwelling gastrostomy tube. After obtaining vital signs, the nurse prepared all medications as ordered to be given via the gastric tube route, she completed hand hygiene, and applied gloves. She paused the feeding pump, unscrewed the pump line from the gastric tube, placed the pump line hanging from the top of the IV pole, attached the appropriate syringe to patients' gastric tube and checked for residual fluid in the stomach. She then removed the plunger from the syringe and began administering medications via gravity feed one medication at a time mixed with 5ml water, followed by 15ml water flush between each medication. She re-attached the tube feed line to the gastric tube and restarted the tube feed pump. During an interview on 11/13/2024 at 03:25 PM with the Agency LVN, she stated she did not think about wearing a gown when she administered medication through the gastric tube for Resident #7, she stated cross contamination could result from improper use of PPE. She stated she was trained on the new EBP guidelines which included to wear a gown when working with a resident who had a wound or indwelling medical device. She stated she did not know if anyone was on EBP on the 100 hall on which she was assigned. She stated it was usually posted on the door of the resident's room at other facilities but at this facility she was informed in report of the resident's that require enhanced barrier precautions. She stated she did not receive any information on any of her residents requiring EBP. She stated a negative impact for residents that could occur if enhanced barrier precautions were not used on a resident that required their use, would be infection. She stated she had not had an in-service on EBP recently. Record review of Resident #33's electronic face sheet not dated reflected she was a [AGE] year-old female with a readmitted [DATE]. Her diagnoses included: dysphagia (difficulty swallowing) cerebral palsy (a congenital condition affecting the developing brain of an infant while in the womb. Damage affects the region of the brain in charge of motor skills. Movement and balance which can result in paralysis), contractures, and dysfunction of bladder. Record review of Resident # 33's Annual MDS, dated [DATE], reflected she had a had a long term and short-term memory problem and her cognitive skills for decision making were severely impaired, she had a stage 4 pressure ulcer ( open area involving muscle and bone) and was incontinent of bowel and bladder. Record review of Resident #33's comprehensive person-centered care plan reflected a problem start date of 11/14/24. Resident requires EBP (Enhanced Barrier Precautions) during contact care r/t(ex: chronic wounds, indwelling catheter, central lines, Infection). POA, refuses continued use of EBP while providing personal care. POA feels that staff using PPE upsets Resident # 33 and she wishes for it to be discontinued at this time. Risks and benefits of EBP explained and understanding voiced. Created: 11/14/2024 Approach: Staff is not required to use Enhanced Barrier Precautions; Staff to communicate refusal for EBP via POC/staff reports. Created: 11/14/24 During an observation on11/12/24 at12:30 PM it was noted that there was no enhanced barrier precautions sign noted outside or inside of Resident #33's room and no PPE other than a box of gloves available inside or outside the room. CNA C was observed performing Peri-care and she did not wear any PPE other than gloves to provide care to the resident. During an interview on 11/13/24 at 4:14 PM CNA C stated that she was not sure what EBP meant but does know that if a resident has their name on a blue tab outside the door she should wear gloves, gown, and mask if providing care including emptying catheter or changing residents. She stated that on 300 hall only Resident # 49 and Resident # 47 have blue names. CNA C stated I don't know what it could cause if don't wear PPE, I just know I am supposed to wear it when they have a blue tab. She then stated that Resident # 33 only requires gloves when providing care because her name is on a white tab outside door. 11/13/24 06:26 PM Interview with CNA B regarding EBP. She stated that she did not know what exactly that means. She stated that some residents with catheters have a blue name tag outside their door which meant staff should wear PPE such as gown, gloves, and mask to care for the resident. She stated that failure to do so could cause cross contamination to staff or others. During an interview on 11/14/24 at 3:11 PM the ADON stated Resident # 33's responsible party does not want her on EBP. She stated the RP works in LTC and just doesn't want it done. Review of Resident # 61's Face Sheet (not dated) revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function), dysphagia (difficulty swallowing, major depressive disorder, recurrent, and anxiety disorder. Record review of Resident # 61's Quarterly MDS, dated [DATE], reflected she had a BIMS of 15 (cognitively intact), had an indwelling catheter, and was incontinent of bowels at times. Record review of Resident #61's comprehensive person-centered care plan reflected a problem start created date 11/14/24 Resident requires EBP(Enhanced Barrier Precautions) during contact care r/t(ex: indwelling catheter) EBP discussed with resident and her mother. Res states she no longer wishes for staff to use PPE while providing care and states it makes her feel uncomfortable and she doesn't feel like it's necessary. Risks of infection re: long term indwelling catheter explained as well as benefits of EBP. Approach: Staff is not required to use Enhanced Barrier Precautions; Staff to communicate refusal for EBP via POC/staff reports. Created: 11/14/24 During an interview on11/13/24 04:15 PM Resident # 61 stated staff does not wear gowns when caring for her because she doesn't want them to wear gowns. She also stated that it was a waste of time for them and her to get (PPE)on and take PPE off In an interview on 11/14/24 at 2:50 PM the DON stated that the following residents were on Enhanced Barrier Precautions: Resident #'s 7, 49 and 47. The DON stated that it was her expectation that EBP should be followed during medication administration via tube for resident # 7. They should wash hands, gown and glove when administering meds for Resident 7. She stated, If he had a MDRO staff could transfer infection to someone else. The DON stated the staff knew what precautions to take and on which residents by use of in-services and the blue label. The DON said agency staff was also educated in the same way on EBP. She further added that she determines if EBP will be used by the following means: We ask the resident if they want the use of EBP and they can decline it. We talk to the family, their RP. DON Stated that the resident or RP both have the right to decline it. The DON stated she had started an inservice for staff on 11/13/24 with CMS Provider letter QSO 24-08-NH regarding the use of EBP. Record review of facility policy and procedure titled Infection Control, Precautions, Categories and Notices, dated revised March 2024, reflected in part: enhanced barrier precautions should be used in the following situations: when a resident is infected or colonized with CDC-targeted MDRO without a wound, indwelling medical device or secretions or excretions that are unable to be covered or contained; Has a wound or indwelling medical device without secretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO; and at the discretion of the facility when a resident is infected or colonized with a non-CDC targeted MDRO without a wound, indwelling medical device, or secretions, or excretions that are unable to be covered or contained; If they do not meet the criteria for contact precautions and have a wound or indwelling medical device, and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the boy that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen. Considerations 1. For residents for whom EBP are indicated, EBP is employed when performing the following high contact activities: 2. Dressing, bathing showering, transferring providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use (central line, urinary catheter, feeding tube tracheostomy tube/ventilator, wound care, and any skin opening that has a dressing. 3. Ensure PPE and alcohol-based hand rub or readily accessible to staff. Review of website https://www.cdc.gov/preventmdro on 11/13/24, revealed the following: Enhanced Barrier Protection Multi drug resistant organism transmission is common in skilled nursing facilities, contributing to substantial resident, morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident activities. EBP may be indicated when contact precautions do not apply for residents with any of the following: wounds or indwelling medical devices regardless of multidrug resistant organism colonization status.

Based on interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 1 of 24 residents (Resident #81) reviewed for advanced directives. The facility failed to have an Advanced Directive, Out of Hospital Do Not Resuscitate (OOHDNR) consent form which include a Representative and physician signature and License # in the electronic charting or Admission paperwork for Resident #81. This failure could affect residents by not having their preferences honored concerning advanced directives. Finding included: Record review of Resident #81's electronic face sheet dated [DATE] revealed Resident #81 was an [AGE] year-old female, admitted on [DATE] with DNR status and a diagnosis of Traumatic subdural hemorrhage without loss of consciousness (a collection of blood that takes place due to bleeding creating an enhanced pressure on the brain). Record review of Resident #81's physician's orders dated [DATE] revealed an order for DNR. Resident #81 electronic health record revealed: no evidence of an Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) form; there was also no evidence of documentation in Resident #81's progress notes relating to the DNR status. Record Review on [DATE] of Resident #81's hard copy chart revealed, a red DNR sheet with no OOH-DNR consent. During an interview on [DATE] at 4:26 PM the SW stated she had sent Resident #81's DNR paperwork, via email, to her representative via email two weeks prior and had not received it back. The SW stated the email was sent on the 29th of October with no return email. She stated she should have followed up with resident's representative for the OOH-DNR consent. The SW stated staff would follow the physicians order if there was a code and since Resident #81 was DNR status she would not be resuscitated. During an interview on [DATE] at 4:39 PM, the DON stated, Resident #81's Face sheet revealed she was a DNR status with no consent. She stated there may have been an actual DNR consent on her hard copy chart, or if she had a consent, it may have not been uploaded into the system. The DON stated the SW may have Resident #81's DNR. She stated the resident should not have been considered a DNR if the consent was not in the facility. She stated the SW was responsible for following up with consents, uploading them into the medical records, as well as placing the DNR status on the hard copy chart. The DON stated the negative affect on the resident was, if the resident was not truly a DNR they could expire with CPR not being performed and ultimately passing away. She stated the failure occurred with the family having not returned the consent form in a timely manner. She stated the consent form should have been back in the facility before the two weeks if it was truly what they had wanted. The DON stated her expectations was the DNR consent form should have been signed in a timely manner if those were their wishes. She stated it was not okay to have a verbal of family wishes without the consent. The DON stated she and her nursing staff would have gone first by the Face sheet and second look at the red DNR sign on the hard copy for guidance on what to do if a resident was to code. During an interview on [DATE] at 4:51 PM the ADMN stated the nursing staff can follow the physician order if there were a code while awaiting the DNR consent or if in transit. She stated the consent was really for EMT's. During an interview on [DATE] at 5:16 PM with, LVN-B stated if there happened to be a code on a resident, she would first look at the resident Face sheet under their picture as that would have been the quickest way to locate resident DNR status. She stated residents' charts (hard copies) also have the red DNR page as soon as you open their charts. During an interview on [DATE] at 5:21 PM, LVN C stated she would have looked first for residents DNR in their chart or the computer, but the most reliable would be their hard copy chart. LVN-C stated she staff should have looked in the front to see the red paper with red DNR signage, then she would have flipped it over to see there if there was a signed DNR. She stated the resident would not be considered a DNR status until the consent was in your hand. During an interview on [DATE] at 5:20 PM, RN-D stated when a patient was found unresponsive, she would have first checked resident electronic chart or the resident hard copy chart for resident's code status. She demonstrated that this information could be found in the resident's chart by pointing to the first red colored page in the chart that revealed Do Not Resuscitate (DNR). RN-D then flipped the colored folder over to display a signed DNR order and stated the DNR order would have directed her as to whether to perform resuscitation on the resident or not. She stated if there were no signed DNR present, she stated she would have Immediately started CPR. During an interview on [DATE] at 5:25 PM, RN-E stated when a resident was found unresponsive, she first thing she would have done would grab the crash cart and call for assistance. When asked how she would know if resident was to have been resuscitated, she states, I know my hospice patients. When asked for more information regarding how it was determined if other residents were to be resuscitated, she stated she would have checked their chart and if DNR, the first page would have displayed a red sign that revealed Do Not Resuscitate. RN-E identified where the DNR was at in the chart. When asked how she would have responded if a DNR was not present, she stated she would have checked the resident's chart for the small red icon DNR under the resident's picture in their electronic chart. She stated if she observed the printed red page Do Not Resuscitate and the small red icon in the resident electronic chart, it would have indicated in two areas that resident was a DNR status and would have been then she would have known not to provide CPR. Record Review on [DATE] of a blank Out of Hospital Do Not Resuscitate (OOH-DNR) Order Tx Dept. of State Health Services consent form, page 1, reads in part: This document becomes effective immediately on the date of execution for health care professionals acting in out of hospital settings. It remains in effect until the person is pronounced dead by an authorized medical or legal authority or the document is revoked. Resuscitation measures include cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, Defibrillation, advanced airway management, artificial ventilation. Comfort care will be given with a Representative and physician signature and License # in the electronic charting or Admission paperwork. The Physician Statement section and the final section instructs and reads in part, All persons who have signed above must sign, acknowledging the document has been properly completed. Record Review of page 2 of the Texas Out of Hospital Do Not Resuscitate form, Publication No EF,d+[DATE] revised [DATE], by the Texas Department of State Health Services titled Instructions for Issuing an OOH-DNR Order reads in part: IMPLEMENTATION: A competent adult person .or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section A-If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. Section B-If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, a guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating in section B. Section D if the person is incompetent and his/her attending physician has seen evidence of the person previously issued proper directive to physicians or observe the person competently issue and OH DNR order or a nonwritten manner, the physician may execute the order on behalf of the person signing and dating it in section D. In addition, the OOH-DNR order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either section B, C, or E, and if applicable have witnessed a competent adult person making an OOH-DNR order by nonwritten communication to the attending physician, who must sign in section D and also the physicians statement section. Record Review of the facility policy Advanced Directives Policy and Records, revised [DATE] revealed: Policy: It is the facility's policy to recognize and implement the resident's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives. Decisions Concerning Medical care and Valid Advance Directives: Facility agrees to honor: a. Decisions concerning medical care, including the right to accept and refuse treatment, when made in accordance with state law. b. Valid Advance Directives made in accordance with state law. The making of Advance Directives by the resident is not a precondition to admission; nor does the facility otherwise discriminate against a resident based on whether or not Advance Directives have been made.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 1 of 1 Treatment Cart observed for medication storage. The facility did not ensure the Treatment Cart was locked and secured on 11/13/24 on 300 hallway with resident present and no nurse present. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: Observation on 11/13/24 at 11:31 AM revealed the treatment cart was parked in the 300 hallway with a resident within 6 feet of the opened, unsecured cart. No nurse was in sight of the cart. Present in cart were medicated dressings, antiseptic ointment, triple antibiotic ointment, chlorhexidine gluconate solution antiseptic, Iodine swab sticks, adhesive remover, and wound cleanser. In an interview on 11/13/2024 at 11:37 AM the Treatment Nurse stated that she could not see treatment cart because she had walked 3 rooms down and into a resident room to speak with them. She stated that she normally locked her cart but failed to do so that time. She also stated that the expectation was to lock the cart and that she or any other nurse using the cart was responsible for locking it. She also stated that lack of locking cart would allow access for residents to get into the cart and gain access to the contents. She stated lots of things in this cart could harm the residents if ingested. There are creams, cleaners, and those orange sticks. There are also clippers and scissors that could hurt them. In an interview on 11/14/24 at 4:01 ADON stated that treatment cart should be locked when not in sight of nurse or in use. She also stated that anybody that had access with keys to the cart was responsible for ensuring that the cart was locked. She further stated that lack of locking the cart could result in A resident could get ahold of something that is not good for them. In an interview on 11/14/24 at 4:05 PM the DON stated that her expectation was for treatment cart to be locked when not in use or in sight by nurse responsible for cart. The DON stated that the nurse in charge of cart was responsible for locking cart. The DON stated that she and the ADON were ultimately responsible for monitoring cart security. She further stated that lack of locking treatment cart would allow resident access to cart contents and ability to ingest contents, put contents on skin, possibly be allergic to contents. Record review of policy Medication Storage- in the Home dated 12/2018 revealed the following [in-part]: POLICY: It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure, or misuse. PROCEDURE: 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (i.e., medication aides, etc.) are allowed access to medications. Medication rooms, carts, and medications supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchens reviewed. 1. The facility failed to ensure the floors weren't soiled with food particles and grease beneath the appliances and stainless-steel shelf units throughout the kitchen. 2. The facility failed to ensure two of two refrigerators did not have what appeared to be spilled milk, dried liquids, and food crumbs on the bottom shelf. These failures could place residents at risk for foodborne illness and a decline in health status. The findings include: Observations on 09/26/2023 at 9:40 AM, during the initial tour of the facility kitchen, revealed the following: - the floor was soiled with food debris and grease beneath shelves and appliances throughout the kitchen. - 2 of 2 refrigerators had what appeared to be spilled milk, dried liquids, and food crumbs on the bottom shelf. Observations on 09/26/2023 at 9:50 AM revealed daily cleaning logs, dated September 2023, used for all the kitchen cleaning duties revealed all cleaning duties for the morning had been completed and initialed by the kitchen staff who completed the cleaning. In an interview on 09/28/2023 at 10:40 a.m. with the Dietary Manager stated, her kitchen staff followed a cleaning schedule, but someone must have set a glass of milk on an open box, and it spilled and was not cleaned. She further stated, it's important that the kitchen counters, refrigerators, freezers, and equipment be clean to prevent foodborne illness. In an interview on 09/29/2023 at 3:35 p.m. the DON stated, her expectation was for the dietary department to follow the dietary department cleaning policy. In an interview on 09/29/2023 at 3:40 p.m. the Regional Consultant stated, his expectation was for the dietary department to follow their cleaning schedule per dietary department policy. Record review of the facility's Policy titled Refrigerators, Coolers and Freezers dated, October 1, 2018, revealed [in-part]: The facility will maintain refrigerators, coolers and freezers in a clean and sanitary manner to minimize the risk of food hazards. Refrigerators, coolers and freezers will be kept clean on a daily basis and will be thoroughly cleaned every month or more often as needed .

Based on observation, interview and record review the facility failed to ensure each resident had the right to a safe, clean, sanitary, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely on one of six hallways (Hallway 200) and the smoking area for areas reviewed for environment. 1. The facility failed to ensure Hallway 200 did not have a strong odor of urine. 2. The facility failed to ensure the smoking area did not have a foul odor with a large, uncovered bin filled with dirty laundry and a large, uncovered bin filled with trash within the smoking area. These failures could place residents at risk for a diminished quality of life and a diminished clean, homelike environment. The findings include: 1. In an observation during the initial tour on 09/26/23 at 11:24 AM, the entire Hallway 200 had a strong odor of urine. In an observation on 09/27/23 at 9:30 AM, Hallway 200 had a strong odor of urine which became stronger towards the end of the hallway. In an observation and interview on 09/28/23 at 10:50 AM, Hallway 200 had a strong odor of urine and progressively got stronger towards the end of the hallway. LVN A stated the hallway smelled at times but did not smell of urine to her. She stated the smell was from a resident who had a foul bowel movement. In an interview on 09/28/23 at 11:30 PM, Housekeeper B stated Hallway 200 smelled of urine most of the time. She said she believed it was coming from the resident in room [ROOM NUMBER]. She said when the resident left his room, she cleaned the resident's mattress and floors. In an observation and attempted interview on 09/28/23 at 11:35 PM, Resident #29 refused to be interviewed. His room was clean but smelled of urine. In an interview on 09/28/23 at 1:32 PM, the Maintenance Director stated he was aware of the odor on hallway 200. He said he thought it was coming from room [ROOM NUMBER]. He said he attempted to get rid of the smell and replaced the toilet, used charcoal and enzymes, and painted the walls, but it did not help. He did not think the resident was urinating on the floor. In an interview on 09/28/23 at 1:48 PM, Resident #61 who resided on the hallway said the hallway smelled most of the time and she kept her door closed due to odor. In an interview on 09/28/23 at 1:49 PM, Resident #54 stated she visits a friend on Hallway 200 and there was always a strong odor in the hallway. She said that was the reason why most of the residents on the hallway keep their door closed. In an interview on 09/28/23 at 3:45 PM, Resident #22 who resided on Hallway 200 said the smell was horrible at times. She kept her door closed due to the smell. 2. In an observation and interview of the smoking area on 09/28/23 at 1:48 PM, there were 6 residents smoking. Observed within the smoking area, there was a large, uncovered bin filled with bagged dirty laundry and there was a large, uncovered bin filled with mostly bagged trash that smelled. A staff member came into the smoking area and put 4 pizza boxes in the trash. In an interview with Resident #54 and Resident #61, who were sitting on the other side of the smoking area, said the bins were always there and they smelled, it was why they sat away from them. In an interview on 09/28/23 at 2:15 PM, the Medical Records Supervisor said she was filling in for the Housekeeping Supervisor and the bins were placed in the smoking area during COVID. It was where staff brought dirty laundry to be picked up by laundry and trash to be picked up by maintenance. In an interview on 09/28/23 at 2:27 PM, the Maintenance Director said the bins were placed in the smoking area during COVID. It was where staff brought dirty laundry to be picked up by laundry and trash to be picked up my maintenance. He said a negative outcome would be it would attract flies and pests. He said they put out bait for pests. The Maintenance Director stated there was no facility policy. The Administrator was not available for interview during the survey.

Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 residents (Resident #6) reviewed for accuracy of assessments. The facility failed to ensure Resident #6's MDS accurately reflected the resident hearing loss. This failure could place residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life. The findings include: Record review of Resident #6's, undated, Admission Record, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included: unspecified hearing loss unspecified ear, speech, and language development delay due to hearing loss, cerebral infarction (stroke), and hemiplegia non dominant side (paralysis on one side of the body). Record review of Resident #6's Annual MDS, dated [DATE], Section B revealed the resident was able to hear adequately. Record review of the resident's care plan revealed the resident had a communication problem related to a hearing deficit. The problem start date was 4/7/20, and a revision date of 9/23/23. During an observation and interview on 09/26/23 at 12:03 PM revealed Resident #6 communicated by typing on his laptop computer that he could not hear, and he did not use hearing aids. He could not speak clearly, and he preferred to use the laptop to communicate his needs. In an interview on 09/28/2023 at 10:40 AM, the MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated the Admission MDS for Resident #6 was not accurately descriptive of his hearing status. She stated she completed the assessment and was responsible for all MDS assessments in the facility and she failed to document Resident #6's Section B accurately because she was in a hurry and made a mistake. She stated she followed the guidelines of the RAI Manual to complete assessments. She stated it was her expectation the MDS be documented to accurately reflect the resident's status. She also stated failure to not complete the MDS accurately could result in the resident not receiving needed care and services. She stated she would make a correction to the MDS. Interview with the DON on 9/28/23, at 11:00 AM revealed the MDS Coordinator was responsible for accurately completing the MDS. She stated failure to accurately document the resident's status in the MDS could result in the resident not receiving needed care Record review of the RAI Manual section B, dated 10/2019, revealed in part: This section is intended to document the resident's ability to hear (with assistive hearing devices if used) understand and communicate with others and whether the resident experiences visual limitations or difficulties, related to diseases common in aged persons.

Based on observation, interview, and record review the facility failed to accurately assess each resident's status for 3 of 4 Residents (Resident #1, Resident #2 and Resident #3) reviewed for assessment accuracy in that: Residents #1, #2, and #3's Quarterly and Annual MDS, did not have accurate assessment for Section J (swallow) coded correctly. This failure could place residents at risk of not receiving the proper care and services due to inaccurate assessment. Finding included: Record review of Resident #1's Face Sheet, dated 07/37/2023, revealed Resident #1 was an [AGE] year-old male who was readmitted to the facility on [DATE] with a diagnosis of dysphasia (difficulty swallowing), cerebral infarction (stroke) high blood pressure, bipolar disorder (mood disorder in which mood alternates from manic to depression) and Dysarthria (difficulty speaking because the muscles you use for speech are weak) Review of Resident #1's annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 9 indicating moderate impaired cognition. Review of Resident #1's MDS Section (K) (Swallowing/Nutritional Status) on 07/03/2023 at 2:00 PM, K0100 (signs and symptoms of possible swallowing disorder) question Z. was checked (none of the above) meaning no swallowing deficit. Review of Resident #1's Care Plan dated 02/09/2022 revealed Resident #1 was at risk for swallowing problems, such as aspiration pneumonia, related to dysphagia following CVA (cardiovascular accident). Resident #1's intervention including serve thickened with each meal due to dysphasia. Review of Resident #1's Physician Orders dated 02/28/2023 revealed speech therapist to evaluate and treat. Review of the dietary schedule on 07/03/2023 at 1:10 PM provided by the Dietary Manager revealed Resident #1 required thickened liquid drinks. Review of Resident #2's revealed he was a [AGE] year-old-male admitted on [DATE] with the diagnoses of: Dysphagia following cerebral infarction, muscle wasting, cognitive cerebral deficit, and unspecific pain. Review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 13 indicating he was cognitively intact and able to make his needs know. Resident #2 was noted to require a therapeutic diet (honey thicken liquids) by the speech therapist. Review of Resident #2's MDS Section (K) (Swallowing/Nutritional Status) on 07/03/2023 at 2:00 PM, K0100 (signs and symptoms of possible swallowing disorder) question Z. was checked (none of the above) meaning no swallowing deficit. Review of Resident #2's Care Plan revised on 05/26/2023 revealed Resident #2 was at risk for swallowing problems, such as aspiration - Therapeutic Diet as evidenced by: Reg, Puree, Honey thick liquid. Review of Resident #3's undated face sheet revealed she was an[AGE] year-old-female admitted on [DATE] with the following diagnoses: dysphasia, unspecific pain, and unspecified dementia. Review of Resident #3's quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 15 indicating she was cognitively intact and able to make her needs know. Review of Resident #3's MDS Section (K) (Swallowing/Nutritional Status) on 07/23/2023 at 2:00 PM, K0100 (signs and symptoms of possible swallowing disorder) question Z. was checked (none of the above) meaning no swallowing deficit. Review of Resident #3's Care Plan on 07/06/2023 at 3:00 PM, revealed on 06/29/2023 revealed: Resident #3 is on a therapeutic diet, honey thickened liquids. During an interview on 07/06/2023 at 1:22 PM the MDS Coordinator revealed she goes by what the nurses tell her about the residents regarding swallowing. Surveyor asked since Resident #1, #2, #3 had barium swallow studies, diagnosis of dysphasia and orders for thicken liquids due to swallow issues why was section J in the MDS showing there was not a problem with swallowing. She said if you look at the questions A through D, which reflects the following questions: A. Loss of liquids/solids from the mouth (not checked) B. Holding food in mouth/cheeks or residual food in mouth after meals (not checked) C. Coughing or choking during meals or when swallowing medication (not checked) D. Complaint of difficulty or pain when swallowing (not checked) and Z. None of the above (checked). She said it does not meet the criteria for having difficulty swallowing. Continuing with the interview the surveyor asked if she has a policy regarding swallowing assessments. She said no, she goes by the MDS manual for guidance in how to assess residents regarding the swallowing section. She said she could not lie about the residents having swallowing problems. She said she wish she could the facility could have more reimbursement related to the residents having swallowing issues.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate accountability of controlled drugs on 4 of 4 medication carts. The Change-of-Shift Record of Control Substance Log for the 100/200, 400/500 medication carts were missing signatures. These failures could place residents receiving medications in the facility at risk for in-effective therapeutic outcomes, and drug diversion. The findings include: Record Review on 7/5/23 revealed nurses were in serviced on narcotic audit results training, drug diversion, narcotic Count, and med administration on 4/5/23. Record review on 7/5/23 of the Control Card Count revealed the sheets were missing signatures on the following dates and shifts.: May Station 100/200 - 5/6 off going shifts signatures missing June- 100/200 6/15 oncoming 10-6 shift, 6/16 off going signature 10/6 shift, 6/12 2-10 of going shift signature, 6/28 2-10 on coming signature and off going signature. 6/19/23 2-10 shift off going signature June Station 500/600 prn control drug count sheets: 6/1/23 6-2 oncoming shift signature and 6-2offgoing shift signature missing. 6/27/23, 6/28/23, 6/29/23 10-6 off going nurse signatures and on coming 10-6 shift signatures were missing. June 500/600 routine narcotics control drug count sheets: 6/10/23 6-2 oncoming shift nurse signature and 6/2/23 off going nurse shift signature, 6/27/23, 6/28/23, 6/29/23, 10-6 off going nurse signatures and on coming nurse 10-6 shift signatures, June 400/500 prn narcotics control drug count sheets: 6/27/23, 6/28/23, 1 off going nurse signatures and on coming 10-6 nurse signatures missing. June 500/600 routine narcotics control drug count sheets: 6/27/23, 6/28/23, 10-6 off going nurse signatures and 10 -6 on coming nurse signatures, June 400/500 routine narcotics control drug sheets: 6/27/23,6/28/23, 6/29/23 off going Nurse signature 10-6 missing, and 6/28/23 on coming nurse 10- 6am nurse signature missing. During an interview on 7/05/19 at 11:01 AM with the ADON, she said staff should be signing in and out when taking possession of the medication cart and be documenting medications in the MAR when they are signed out of the Narcotic Log. She said it is the responsibility of the charge nurse to monitor the sign in sheets as well as review they are being completed. She stated nurses were to count drugs at the beginning and end of their shift with the oncoming nurse, and both shifts should sign the log signifying that they accepted the count of the narcotics as correct, and they are accepting responsibility for the contents of the cart. During an interview with the DON on 7/05/23 at 11:30 am, she confirmed that the signatures were missing for the Control Drug Card Count for July 1, 2023. She verified there were missing signatures on the April, May, June, and July 2023 control drugs card count sheet. She confirmed she had in-serviced all nursing staff regarding counting and signing the count sheets stating that all narcotics were counted and reconciled at the beginning and end of each shift by the nurse coming on duty and the off going nurse. She said that staff should be signing the sign in and out narcotic log (Control Card Count) when they take possession of the cart. She stated the DON and ADON should be monitoring to see that it is done. She stated failure to count narcotics, could result in a drug diversion. Review of facilities Policy narcotic count revealed the following: It is the policy of this home that nursing staff must count narcotics at the beginning and end of each shift to ensure compliance with state and federal laws and regulations in the handling, storage, and record keeping of controlled substances. Procedure: The nurse coming on duty and the nurse going off duty must count and justify narcotics supply for each individual resident at the change of shift. Each nurse counting must record the date and his or her signature verifying the count is correct at the beginning and end of each shift. If the count is not correct the nurse going off duty is not to leave until the count is reconciled. Any discrepancy in the count is to be reported to the Director of Nurses promptly.

Based on observation, interview, and record review the facility failed to provide 3 of 3 residents (Resident #1, Resident #2 and Resident #3) the therapeutic diet prescribed by the attending physician. Physician orders required thicken liquids due to swallowing dysfunction (difficulty swallowing). The facility neglected to provide proper thickening for Resident #2 and Resident #3 drinks and allowing access to thin liquids for Resident #1. This failure could place residents at risk for health complications related to in adherence to prescribed diet order. Findings included: Review of Resident #1's undated Face Sheet revealed Resident #1 was an [AGE] year-old male who was readmitted to the facility on [DATE] with a diagnosis of dysphasia (difficulty swallowing), cerebral infarction (stroke) high blood pressure, bipolar disorder (mood disorder in which mood alternates from manic to depression) and Dysarthria (difficulty speaking because the muscles you use for speech are weak) Review of Resident #1's annual MDS assessment dated [DATE]/01/2023 revealed Resident #1 had a BIMS score of 9 indicating moderate impaired cognition. Review of Resident #1's MDS Section (K) (Swallowing/Nutritional Status) on 07/23/2023 at 2:00 PM, K0100 (signs and symptoms of possible swallowing disorder) question Z. was checked (none of the above) meaning no swallowing deficit. Review of Resident #1's Care Plan dated 02/09/2022 revealed Resident #1 was at risk for swallowing problems, such as aspiration pneumonia, related to dysphagia following CVA (cardiovascular accident) Resident #1's intervention including serve thickened with each meal due to dysphasia. Review of Resident #1's Physician Orders dated 02/28/2023 delegated speech therapist to evaluate and treat the therapeutic diet related to dysphagia Review of Speech Therapist notes dated 04/22/2022 revealed: Modified barium swallow conducted summary- The potential for aspiration or aspiration pneumonia risk found present in the Modified Barium Swallow study recommended thicken drinks. During an observation and interview on 07/03/2023 at 12:25 PM, Resident #1 was eating in his room with a tray placed on his bedside table. Resident #1 asked surveyor if he saw his thickened drink, he said he only sees his thickened cranberry juice he was drinking from. Observation by surveyor at this time saw 2 cups one with thin water (no thickener added as ordered) and one with thin tea (no thickener added as ordered) on his tray. Thickened cranberry juice was behind another cup of thin water. Surveyor moved the thin water behind the thickened cranberry juice making it available to Resident #1 and out of Resident #1's reach. During an interview and observation with DON standing outside of Resident #1's room on 07/03/2023 at 12:30 PM was notified of the thin drinks on Resident #1's tray. She said the thin drinks should not have been on his tray she said she would remove the thin drinks from his tray now. She said that there was a kitchen aide who was new and may have not known thin drinks should not be on his tray. She poured out the drinks and said that if the resident would drink the thin drink could potentially harm him. She said Resident #1 is aware he should not drink thin liquid. She said she thought the Dietary Manager was responsible for making sure the diets are correct. Review of Resident #1's tray card dated 07/03/2023 revealed Resident #1 received thickened liquids and the document related to special dietary needs indicated Resident #1 required thicken liquids. Review of the dietary schedule on 07/03/2023 at 1:10 PM provided by the Dietary Manager revealed Resident #1 required thickened liquid drinks ([NAME] that are thicken to the consistency of nectar). During an interview with the Speech Therapist on 07/05/2023 at 8:15 AM, she said a resident who has dysphasia and drinks thin liquids could be dangerous and cause aspiration (when food or liquid is breathed into the airways or lungs, instead of being swallowed). She said there has been a problem with Resident #1 receiving thin liquids last week and ice, she said there was a new dietary aide who put thin drinks on his tray last week. She said she was concerned about thickened drinks given to other residents as well. (Speech therapist did not discuss if she addressed the problem with anyone) During an interview on 07/05/2023 at 10:20 AM with the Administrator, DON and Speech Therapist attending revealed the Administrator said Resident #1 was able to let someone knows he was not supposed to drink thin liquids. The DON said she was there when surveyor told her thin liquids was on his tray and she poured it out. She said Resident #1 was able to tell someone he was not supposed to not drink thin liquids. She admitted that thin liquids should not have been on his tray to begin with. The DON said the dietary aide was new and that could have been the reason for the thin liquids on Resident #1's tray. She said the nurse (LVN A) caught thin liquids on Resident #1's tray last week. During an interview with Dietary Manager on 07/06/2023 at 9:45 AM said they have a new dietary aide who helped put the plated food on the trays and he may have put the thin drinks on Resident #1's tray last week and on Monday (7/03/2023) but the nurse (LVN A) caught it when he put the drinks on the tray last week. She said it may have occurred on Friday. She said she was alerted the dietary aide put in on Resident #1's tray Monday and said she was going to in-service the staff. She said the cooks were responsible for training on how to read the tickets and follow what the residents are supposed to have on their trays. She said the cooks are the responsible for making sure the dietary aides put the correct diets on the trays and relied on the cooks to monitor the meal tickets. She provided in-service with all kitchen staff related to p proper diet for the correct resident. During an interview on 07/06/2023 at 9:50 AM Cook #1 said that the cooks are responsible for training dietary aides on how to put the plates on trays following the tickets for each resident. She said she was on vacation on Monday (07/03/2023) and did not train the dietary aide. During an interview on 07/06/2023 at 10:00 AM Cook #2 said the cooks are supposed to train dietary aides on how to put the plates on trays following the meal tickets. She said the dietary aide was new and someone called in and she did not have the time to train the dietary aide and probably the reason for Resident #1 getting thin liquids on his tray. She said we normally do orientation and in-service but did not have time. Cook #2 admitted that someone with dysphasia and not getting the proper thickened drink could be harmful. Attempted to contact (LVN A) the nurse who intervened with Residents #1's tray with thin liquid was attempted on 07/06/2023 at 1:00 PM without success. Cook #2 said dietary aide called in on Wednesday 07/05/2023 (near start of his shift 5:00 AM) and did not show up today on 07/06/2023 or called in she said she assumed he quite. An attempt to call Dietary Aide for interview on 07/06/2023 at 11:00 AM was unsuccessful. Review of in-services regarding following meal tickets thin on 07/06/2023 at 10:05 AM was provided with all dietary staff being trained. Review of Resident #2's undated face sheet revealed he was a [AGE] year-old-male admitted on [DATE] with the diagnoses of: Dysphagia following cerebral infarction (difficulty swallowing due to muscle weakness caused by a stroke), muscle wasting, cognitive cerebral deficit, and unspecific pain. Review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 13 indicating he was cognitively intact and able to make his needs know. Resident #2 was noted to require a therapeutic diet (honey thicken liquids) by the speech therapist. Review of Resident #2's MDS Section (K) (Swallowing/Nutritional Status) on 07/23/2023 at 2:00 PM, K0100 (signs and symptoms of possible swallowing disorder) question Z. was checked (none of the above) meaning no swallowing deficit. Review of Resident #2's Care Plan revised on 05/26/2023 revealed Resident #2 was at risk for swallowing problems, such as aspiration - Therapeutic Diet as evidenced by: Reg, Puree, Honey thick liquids Record review of Resident #2's Physician Orders dated 03/03/2023 delegated speech therapist to evaluate and treat Resident #2 for therapeutic diet. Review of Resident #2's Modified Barium Swallow study conducted on 09/28/2022 revealed the following: Patient (Resident #2 appears to be at risk for aspiration and pneumonia. Diet recommendations: honey/thickened liquids. During an interview with Resident #2 on 07/03/2023 at 12:50 PM he said that the thickened drink was not thick enough and it has always been a problem and they (facility) always showing me the cartons and they say it shows to be honey thicken consistency. He said, he has never choked but that is not the issue, the issue is it is not correct. He said he told the Dietary Manager the DON and the ADON. Review of Resident #2's tray card dated 07/03/2023 revealed Resident #2 received honey thickened juice and the document related to special dietary needs indicated Resident #2 required honey thickened liquids. During an interview with the Speech Therapist on 07/05/2023 at 8:15 AM, she said a resident who has dysphasia and drinks thin liquids could be dangerous and cause aspiration. When it was revealed Resident #2 was complaining that the drinks he was receiving were not honey thickened she said if that was true it could be a problem. During an interview on 07/05/2023 at 10:20 AM with Administrator, DON and Speech Therapist attending revealed the Administrator said Resident #2 always said his drink were not thick enough and he was worried about aspiration. He is always having behaviors and it has gotten worse. She said the Dietary Manager has shown Resident #2 that the premade cartons show the drink is honey thicken. If it says that on the carton, then we trust it to be true. During an interview and observation on 07/03/2023 at 1:45 PM the Dietary Manager brought 1 pre-made carton of thicken juice and 1 carton of pre-made honey thicken to the conference room where the surveyors were conducting the survey. During observation both consistency of the juices appeared to be the same and confirmed by the dietary manager. She said she will talk to the manufacture about her concerns about the same consistence and again agreed there was no difference. She said if the drinks need to be thicker, they do have commercial thickener available to add to the drinks. During an interview with the Dietary Consultant on 07/05/2023 at 9:15 AM, he said that the premixed thickener was supposed to be accurate in the consistency related to the labeling. The problem could be that the cooks are not shaking it enough to mix the juices. He said the Dietary Manager talked to him about the consistency and was going to get with the manufacture. He said the facility has access to thickener if the consistence was not thick enough. He said they can provide measured containers with premixed thickener until the problems is solved, until then the thickener would be something to consider. Review of Resident #3's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the following diagnoses: dysphasia (difficulty swallowing), unspecific pain, and unspecified dementia. Review of Resident #3's quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 15 indicating she was cognitively intact and able to make her needs know. Review of Resident #3's quarterly MDS Section (K) (Swallowing/Nutritional Status) on 07/23/2023 at 2:00 PM, K0100 (signs and symptoms of possible swallowing disorder) question Z. was checked (none of the above) meaning no swallowing deficit. Review of Resident #3's Care Plan on 07/06/2023 at 3:00 PM, revealed on 06/29/2023 revealed: Resident #3 is on a therapeutic diet, honey thickened liquids. Record review of Resident #3's Modified Barium Swallow study on 02/16/2023 revealed the following: Recommendation moderately thicken honey liquids During an interview observation on 07/03/23 at 1:20 PM Resident #3 said, she is always not getting honey thickened drinks they seem too always be too thin. She said she has not coughed, or it is going gone down the wrong way, but it could. The trays were already picked up at this point and unable to verify meal ticket was accurate. During an interview on 07/05/2023 at 9:30 AM with the Administrator surveyor revealed Resident #1 had thin liquids on his tray, Resident #2 complained about his drinks were not thickened enough and Resident #3 complained about the drinks not being thick enough. She said that Resident #1 drinks could be caused by a new kitchen staff member may have not been aware thin liquids are not to be on his tray, Resident #1 is aware he should not drink thin liquids. She said Resident #2 always says his drinks are not thick enough he has behaviors (schizophrenia) (a mental disorder) that would explain the complaint. We have shown him the cartons with the labels on them and he still says it is not thick enough. She said Resident #3 has not mentioned any problems. When surveyor mentioned that she complained about the drinks not thick enough she said she would look into it. The surveyor also mentioned to the Administrator the proper assessment for her MDS section K (swallow assessment) said there were no problems with swallowing even though there was a diagnoses of dysphasia, diet including thicken drinks and a swallow study recommending honey thickened liquids. Administrator again said she would look into it. During a conference interview on 07/05/2023 at 10:30 AM with the Administrator, DON and Speech Therapist, said Resident #3 may have a swallow problem. When revealed by the surveyor that Resident #3's quarterly MDS dated [DATE] revealed she does not have a swallow even though she has a diagnosis of dysphasia, honey thicken liquid diet order and swallow study recommending honey thicken drinks they said they would look into it. List of Resident receiving thickened liquids provided by the Dietary Manager on 07/03/2023 at 11:20 AM revealed Resident #1 should receive thicken liquids. Resident #2 receive honey thicken liquids and Resident #3 receive honey thicken liquids. Review of facility undated policy titled; Thickened Liquids revealed the following: The facility will serve thickened liquids to all residents as ordered by the physician. .2. The Nutrition and Food Manager will record the ordered consistency on the resident's tray card. 3. The following consistency may be ordered. Thin - includes water, coffee 4. The speech therapist may order modified consistencies based on the resident's needs. Review of the website: https://intermountainhealthcare.org accessed on 07/10/23 at 7:00 PM revealed the description of thicken and honey thicken are as follows: Dysphagia - Liquid Consistency Thick Liquids Purpose of Diet: Thickened liquids are needed for people with swallowing problems to prevent breathing in liquids. Indications for Use: Thickened liquids are used to protect people who have had a stroke, head injury, cancer, etc. from pneumonia. Description of Diet: There are 3 levels of thickened liquids. These are nectar thick, honey thick, and spoon thick. o Nectar thick liquids are the consistency of apricot nectar. o Honey thick liquids are the consistency of honey.

Based on observations, interviews, and record reviews the facility failed to ensure assessments accurately reflected the resident's status for 9 of 9 residents (Resident #'s 18, 50,20, 17, 5, 28 35, 41, 47 ) reviewed for PASSR Evaluation. 1. Resident #18's Significant Change MDS dated [DATE] section A1500 indicated no, resident has not had a PE (PASSR Evaluation Assessment) and determined to have a serious illness. However, her PE (PASSR Evaluation Assessment by the Local Mental Health Authority or Local Intellectual Disability Authority) was documented as confirmed 12/11/18. 2. Resident #20's Annual MDS dated [DATE] section A1500 indicated: no, resident has not been evaluated by Level 2 PASRR and determined to have a serious illness. However, his PE (PASSR Evaluation) was documented as confirmed 02/20/2020. 3.Resident #50's Significant Change in Status MDS dated [DATE], indicated in section A1500 indicated: no, resident has not been evaluated by Level 2 PASRR and determined to have a serious illness. However, his PE (PASSR Evaluation) was documented as confirmed 02/26/2022. 4. Resident #17's Quarterly MDS dated [DATE], indicated in Section P0100 C. Limb Restraint, indicated used less than daily. 5. Resident #5's Admission MDS dated [DATE], Sections A1500 and A1510 revealed the following: A1500 Preadmission Screening and Resident Review was marked No and Section A1510 had none of the three boxes checked indicating Resident 5 had a serious mental illness 6. Resident #28's Admission MDS dated [DATE] Sections A1500 and A1510 revealed the following: A1500 Preadmission Screening and Resident Review was marked No and Section A1510 had none of the three boxes checked indicating Resident 28 had a serious mental illness. 7. Resident #35's MDS (minimal data set), dated 05/27/22, Section A 1500 indicated Resident #35 did not have a mental illness and did not progress to Section A 1550 which she had a mental illness 8. Resident #41 Admission MDS dated ,d+[DATE]/ 22 section A1500 indicated: no, resident has not been evaluated by Level 2 PASRR and determined to have a serious illness. However, his PE (PASSR Evaluation) was documented as confirmed in the long-term care portal. 9. Resident #47 -. Resident #41 Annual MDS dated [DATE] section A1500 indicated: no, resident has not been evaluated by Level 2 PASRR and determined to have. However, her PE (PASSR Evaluation) was documented as confirmed in the long-term care portal. These deficient practices could place residents at risk of inadequate care and services based on inaccurate assessment and place residents at risk of inaccurate information being transmitted to CMS which uses the data to shape future regulations and improve the quality of life and care for residents who live in nursing facilities. The findings included: Resident #18 Record review of Resident #18's face sheet, dated 07/28/2022, revealed a [AGE] year-old female with an initial admitted [DATE] and the latest return date of 04/27/2022. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #18's Significant Change in Status MDS dated [DATE] section A1500 indicated: No the resident had not been evaluated by PASSR and determined to have a serious mental illness and/or mental [CONDITION(S)] or a related condition Record review of Resident #18's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), dated 12/11/2018, indicated Yes for Mental Illness. His PE was documented as confirmed 12/11/2018 Observation and interview of Resident #18 on 07/26/2022 revealed the resident was alert and oriented but. She was lying in her bed watching TV. She said she had not received any additional counselling services or PASARR services. Resident # 20 Record review of Resident #20's face sheet, dated 07/28/2022, revealed a [AGE] year-old male with an initial admitted [DATE] and the latest return date of 05/18/2018. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #20's Annual MDS dated [DATE], Section A1500 indicated No, the resident had not been evaluated by PASRR and determined to have a serious mental illness and/or mental [CONDITION(S)] or a related condition. Record review of Resident #20's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), dated 02/20/2020, indicated Yes for Mental Illness. His PE was documented as confirmed 02/20/2020. Resident #50 Record review of Resident #50's face sheet, dated 07/28/2022, revealed a [AGE] year-old male with an initial admitted [DATE] and the latest return date of 05/10/2022. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #50's Significate Change in Status MDS, dated [DATE], Section A1500 indicated: No, the resident had not been evaluated by PAS and determined to have a serious mental illness and/or mental [CONDITION(S)] or a related condition. Record review of Resident #50's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), dated 2/21/2020, indicated Yes for Mental Illness. His PE was documented as confirmed 02/26/2020. Resident #17 Record review of Resident #17's face sheet, dated 07/28/2022, revealed an [AGE] year-old female with an initial admitted [DATE] and the latest return date of 04/16/2022. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #17's Quarterly Review MDS, dated [DATE], Section P0100 C. Limb Restraint, indicated used less than daily, the resident was being restrained. In an observation on 07/26/22 at 10:40 AM, Resident #17 refused to be interviewed but was observed lying in bed. The resident was not restrained nor was there any indications or devices that would be used to restrain the resident. In an interview with the ADON on 07/27/22 at 2:35 PM, she said the facility is a non-restraint facility. She said the Resident #17 has never been restrained. Resident #17 did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview with the DON on 07/28/22 at 2:22 PM, she said the facility is a non-restraint facility and Resident #17 had never been restrained. The MDS Coordinator no longer works at this facility who would have entered in that information. Resident #5 07/27/2022 Record review of Resident #5's electronic medical record revealed the following; Resident# 5 is a [AGE] year old female admitted on [DATE] with the following diagnoses; Unspecified dementia without behavioral disturbance (Primary, Admission), [CONDITION(S)], unspecified, Unspecified mood [affective] disorder, 07/27/2022 Record review of Resident #5's Admission MDS dated [DATE], Sections A1500 and A1510 revealed the following: A1500 Preadmission Screening and Resident Review was marked No and Section A1510 had none of the three boxes checked indicating Resident 5 had a serious mental illness. Resident #28 07/27/2022 Record review of Resident #28's electronic medical record revealed the following; Urinary tract infection, site not specified (Primary), Unspecified dementia without behavioral disturbance (Admission Anxiety disorder, Major depressive disorder, 07/27/2022 Record review of Resident #28's Admission MDS dated [DATE] Sections A1500 and A1510 revealed the following: A1500 Preadmission Screening and Resident Review was marked No and Section A1510 had none of the three boxes checked indicating Resident 28 had a serious mental illness. 07/27/2022 Record review of Resident #28's Annual MDS dated [DATE] revealed the following: A1500 Preadmission Screening and Resident Review was marked No and Section A1510 had none of the three boxes checked indicating Resident 28 had a serious mental illness. Resident #35 Record review of Resident #35's updated Face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's initial PASRR (Pre-Admission Screening and Resident Review) Dated 05/22/18 revealed Resident had a mental illness. Record review of Resident #35's MDS (minimal data set), dated 05/27/22, revealed a Brief Interview of Mental Status score of 13 (A score of 13 to 15 suggests the patient is cognitively intact), Section A 1500 indicated Resident #35 did not have a mental illness and did not progress to Section A 1550 which she had a mental illness Resident # 47 Record review of Resident #47's face sheet in the EMR, revealed a [AGE] year-old female with an initial admitted [DATE] and a readmitted [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of Resident #47's Annual MDS dated [DATE], Section A1500 indicated No, the resident had not been evaluated by PASRR and determined to have a serious mental illness and/or mental [CONDITION(S)] or a related condition Record reviews of Resident #47 's EMR and the long-term care portal documentation on 07/28/2022, revealed the resident's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), dated 12/07/2018, indicated yes for mental illness. Her PE section for mental Illness was documented as completed on 12/10/18. Section C documented the resident had the following Mental Illness Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview of Resident #47 on 07/27/2022 revealed the resident was alert and oriented. She stated did not remember how long she had been at the facility. Resident #41 Record review of Resident #41's face sheet in the EMR, revealed an [AGE] year-old female with an initial admitted [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record reviews of Resident #41 's EMR and the long-term care portal documentation on 07/28/2022, revealed the resident's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), dated 10/26/2021, indicated yes for mental illness. Her PE section C for mental Illness was documented as completed on 10/30/2021. Section C documented the resident had the following mental illness Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . (all are classified as mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #41 Admission MDS dated ,d+[DATE]/ 22 section A1500 indicated: no, resident has not been evaluated by Level 2 PASRR and determined to have a serious illness. However, his PE (PASSR Evaluation) was documented as confirmed in the long-term care porta During an interview with MDS Regional Consultant on 07/28/22 at 11:07 AM she stated she had been covering the MDS position for approximately two weeks. She stated the previous MDS nurse had resigned. Resident 41's Admission MDS dated 2//12/22, section A1500 and A1510 were marked no for Mental illness and this would be an inaccuracy. MDS nurse agreed that this was an MDS inaccuracy the resident did have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 03/24/2022 at 10:30 AM, the Administrator stated she was not aware there was a problem with the accuracy of the MDS's. She stated the MDS nurse was responsible for the accuracy of those documents and she should have filled them out correctly. She did not state how the residents could be affected by these inaccuracies. The MDS Regional Consultant and the Administrator were asked for a Policy on Resident Assessment. They provided a policy titled Care Plan-Resident. A policy on MDS assessments was not provided. During an interview with the Regional MDS Consultant on 7/28/2, She stated she followed the RAI (Resident Assessment Instrument Manual Manual) for information on completion of the MDS.

Based on observation, interview and record review, the facility failed to ensure residents were free from of any significant medication errors for one (Resident #1) of five residents reviewed for medications. 1. LVN A failed to administer the correct dose of MS ([MEDICATION NAME])[MEDICATION NAME] to Resident #1 on [DATE]. LVN A administered 180 mg of [MEDICATION NAME] to Resident #1 instead of the physician prescribed dose of 60 mg of [MEDICATION NAME], which was three times the prescribed dose. 2. LVN B failed to accurately transcribe Resident #1's physician's orders [REDACTED]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of removal. These failures placed the 51, residents who received narcotic medications at the facility, the 17 residents that resided on Hall 400 and Hall 500 at risk of not receiving the correct dosage or correct medication which could lead to life-threatening respiratory issues, and/or possibly death. Findings included: The hospital discharge medications record dated [DATE] for Resident #1 reflected [MEDICATION NAME] ([MEDICATION NAME] MG Tablet) 30 MG Tablet Controlled-release. Dose: 60 Milligram. Oral, Three Times a Day for Pain. This order was verified by LVN B via telephone with the Medical Director as an admission medication order for Resident #1. Resident #1's Physician Orders, dated [DATE] 8:13 p.m., reflected he was to receive [MEDICATION NAME]([MEDICATION NAME]) tablet ER 30 mg give three tablets by mouth three times a day for chronic pain. (This was the incorrect order that was transcribed incorrectly by LVN B.) Resident #1's Physician Orders, written by LVN B on [DATE] at 2:37 p.m., reflected [MEDICATION NAME] 30 mg tablet three tablets by mouth three times a day for chronic pain was discontinued due to incorrect order. This order was replaced with 60 mg one tablet by mouth three times a day. An interview on [DATE] at 2:45 p.m. with LVN B revealed Resident #1 was admitted to the facility on [DATE] between 7:00 p.m. - 8:00 p.m. She stated she verified Resident #1's admitting orders with Resident #1's Physician/Medical Director. LVN B stated she made an error on the admission orders [REDACTED]. She stated she did not realize her error until [DATE] when she reported for her shift, which was the 2:00 p.m. to 10:00 p.m. shift. When she spoke to the DON later in the shift about another issue and the transcription issue was then mentioned. LVN B said there had been no in-services or training regarding medication errors. LVN B said she documented her error on the medication summary for Resident #1 on [DATE]. Wolters Kluwer Nursing 2015 Drug Handbook, pages ,[DATE], reflected the following regarding MS Contin: .Nursing Considerations - Reassess patient's level of pain .30 minutes after giving orally. .-Monitor circulatory, respiratory, bladder, and bowel functions carefully. Drug may cause [MEDICAL CONDITION], urine retention, nausea, vomiting, ileus, or altered level of consciousness regardless of the route. Black Box Warning Life-threatening respiratory depression may occur with [MEDICATION NAME] use, even when drug has been used as recommended and not misused or abused. Proper dosing and titration are essential and [MEDICATION NAME] should only be prescribed by health care providers knowledgeable in the use of potent opioids for management of long-term pain. Monitor patients for respiratory depression, especially during initiation of [MEDICATION NAME] or after a dosage increase. Resident #1's Face Sheet, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #1's Initial Plan of Care, dated [DATE] and electronically signed on [DATE], reflected a care plan for pain which included the following intervention: Provide medication as ordered and document effectiveness results of medication administration. A progress note, written by LVN J and dated [DATE] at 2:20 a.m. revealed Resident #1 transferred from the facility by ambulance to the hospital due to pain. Resident #1's hospital Discharge Medication Information form, dated [DATE], reflected [MEDICATION NAME] 1 mg (pain medication) was administered via an intramuscular injection on [DATE] at 3:35 a.m. (resident returned to the facility with this form.) Resident #1's Nurse's Progress Notes, dated [DATE], revealed Resident #1 transferred to a Long Term Acute Care hospital on [DATE] at 5:35 p.m. Resident #1's [DATE] MAR reflected on [DATE] at 9:00 a.m., LVN A signed off that she administered three tablets of [MEDICATION NAME] 30 mg by mouth to the resident. (Interview with LVN A she confirmed she gave different dosage than what she actually signed she administered on the MAR.) Resident #1's Individual Control Drug Record for [MEDICATION NAME] 60 mg one tablet three times a day reflected LVN A signed off that she administered three 60 mg tablets of [MEDICATION NAME] (180 mg) to Resident #1 on [DATE] at 8:00 a.m. Review of the blister-pack label for Resident #1's [MEDICATION NAME], dated [DATE], reflected [MEDICATION NAME] ER 60 mg tablet, 1 tablet by mouth three times daily with a quantity of 30 tablets. An interview on [DATE] at 3:15 p.m. with LVN A revealed she administered the [MEDICATION NAME] Resident #1 shortly after he returned to the facility on [DATE] at 6:30 a.m., because the resident was hollering and crying due to pain. She stated she administered the wrong dose of [MEDICATION NAME] mg when she administered three tablets to Resident #1. LVN A stated LVN A stated she did not know if the resident had received any pain medication when he was in the hospital prior to her administering the 180 mg of MS Contin. She stated Resident #1 was on six liters of oxygen per minute via nasal cannula at that time. LVN A stated after she administered three tablets of [MEDICATION NAME] mg to Resident #1, but she charted [MEDICATION NAME] mg (90 mg) three tablets were given. LVN A revealed she read the label on the [MEDICATION NAME]-pack, after she had given the medication, and the label reflected [MEDICATION NAME] 60 mg give one tablet by mouth three times a day. She stated she realized she made a medication error after she administered the medication when she reviewed the MAR and blister-pack. LVN A stated she administered 180 mg of [MEDICATION NAME] to Resident #1 when she gave him three tablets of 60 mg each. She stated Resident #1's MAR reflected [MEDICATION NAME] 30 mg three tablets (90 mg), and the blister pack reflected [MEDICATION NAME] 60 mg one tablet by mouth three times a day. LVN A stated she immediately called the DON to report the medication error. LVN A did not specify why she called the DON first instead of calling the physician and informing the charge nurse. When the DON arrived at the facility, she stated they both went to check on Resident #1, and the resident was stable. She stated she called Resident #1's physician, and he was informed Resident #1 had received [MEDICATION NAME] mg by her error, and no new orders were received at that time. LVN A stated the physician came to the facility and assessed Resident #1, and no new orders were received. LVN A stated Resident #1 was awake and talking during the 6:00 a.m.-2:00 p.m. shift. During the interview LVN A stated she took vitals that she documented on her personal tablet. When asked why she did not document the vitals in Resident #1's clinical records, no answer was given. She shared the following handwritten vitals from her personal tablet that included the following information: 9:00 a.m. Blood Pressure-,[DATE]; heart rate-101 Temperature 98.6; 9:30a.m. Oxygen Saturation 97%; 10:30 a.m. - blood pressure ,[DATE]; (no time written) ,[DATE]; 12 noon- blood pressure-,[DATE]. (Although LVN A stated the vitals were from [DATE], there was no date.) LVN A stated she did not give Resident #1 any other pain medication during her shift. LVN A confirmed she documented on the [DATE] MARs for [DATE] at 9:00 a.m. that [MEDICATION NAME] 30 mg tablet, three tablets by mouth were administered which would have been a total of 90mg administered, but she actually administered a total of 180mg. LVN A stated she did not record on the MAR or in the progress notes the actual dose of [MEDICATION NAME](180 mg) that was administered to Resident #1. She stated she should have documented the medication error on the MAR and progress notes, but she did not explain why she did not document the error in the clinical record. She stated she did document on the individual control drug record that she administered three tablets of [MEDICATION NAME] 60 mg tablets (180 mg). LVN A did not state why there was no documentation regarding Resident #1's condition following the medication error was written in the clinical record. When asked about possible complications related to administering the 180 mg of MS Contin, LVN A stated a complication could be death. When asked how long Resident #1 should have been monitored for complications, LVN A did not know. LVN A also did not know Resident #1's diagnoses. She stated Resident #1 was on 6 liters of oxygen per minute via nasal cannula, and he remained stable after the medication error. She stated Resident #1 did not need to go to the hospital for monitoring because he remained stable. Review Resident #1's clinical record for [DATE] through [DATE] revealed no documentation reflecting that Resident #1 received 180 mg of [MEDICATION NAME] [DATE]. There also was no documentation reflecting that Resident #1 was monitored for adverse drug reactions following this significant medication error. io The DON stated on [DATE], when she saw Resident #1 after learning of the medication error, the resident was awake and talking. She stated she saw the resident one other time that day, and the resident was alright. The DON stated no monitoring of Resident #1 was performed nor did monitoring need to be performed. When asked how staff would know if Resident #1 experienced a significant change or complication, the DON did not respond. When asked if Resident #1 needed to have his heart rate, blood pressure, respirations or any central nervous system monitored, the DON did not respond. She stated she found some literature on general medication administration and had given this information to LVN A, and she was trying to determine what should be done. The DON stated LVN A had been placed on suspension on this date, [DATE], and she would not be completing her shift pending further investigation. An interview on [DATE] at 10:20 a.m. with the Medical Director, who was also Resident #1's physician, revealed he had been notified that Resident #1 was administered 180 mg of [MEDICATION NAME]. He stated he arrived to the facility within the hour of the call, and he assessed Resident #1 upon his arrival at the facility. His assessment revealed Resident #1 was stable and in no distress. He said he remained at the facility afterwards assessing and reviewing other residents. He said there were no concerns with Resident #1 during this time or afterwards. The Medical Director stated he was surprised Resident #1 did not go into distress. He said it was verified with the admitting nurse/ LVN B on admission and later clarified with the pharmacy that Resident #1 was to receive [MEDICATION NAME] 60 mg dosage by mouth three times a day. He said he did not understand how the error was made. He said the facility could not provide Resident # 1 with effective pain relief and Resident #1 was discharged to another facility at a later time on [DATE]. He said no changes were implemented after the medication error. He did not give orders for the resident to be monitored. He did specify that he was in the building for an extended period of time after he assessed Resident #1. An interview on [DATE] at 12:30 p.m. with the DON revealed she discussed medications thoroughly with her staff. The DON said on [DATE] she had looked in the closet and items stored in her office and had found some videos and tests that she did not know were there. She stated these items had not previously been used, and she did not know the content of the videos. The DON stated she would start making observations of the controlled narcotic medication count as this had not previously been done. The facility's current General Dose Preparation and Medication Administration policy and procedure, dated [DATE], reflected the following: .Verify each time a medication is administered that it is the correct medication, at the correct dose, i.e .Document the administration of controlled substances in accordance with Applicable law .Document necessary medication administration/ treatment information (e.g., when medications are opened, when medications are given i.e.,) on appropriate forms; i.e An IJ was identified on [DATE] at 12:00 p.m. The facility's Administrator, DON, and District Director of Clinical Services were notified at that time and a plan of removal was requested. The facility's plan of removal was accepted on [DATE] at 5:30 p.m. and contained the following: LVN A who was involved with the significant medication error was suspended on [DATE] at 11:31 a.m. LVN A will no longer be employed in the facility. LVN A self-terminated on [DATE]. The DON was suspended on [DATE]. The DON failed to investigate significant medication error, failed to counsel and suspend LVN A, failed to re-educate licensed nurses regarding medication management including medication errors and medication administration. The DON's failure to address the significant medication error resulted in the Immediate Jeopardy. The DON will no longer be employed in the facility effective [DATE]. LVN B admitted Resident#1 on [DATE]. LVN B transcribed resident's [MEDICATION NAME] order inaccurately. Discharge orders from the hospital reflected [MEDICATION NAME] 30 mg two (2) tablets three times a day. LVN B transcribed [MEDICATION NAME] 30 mg three (3) tablets three times a day. LVN B was counseled on [DATE], re-educated regarding medication Administration with competency based test, re-educated on transcription of new orders, re-educated on medication related issues with competency based test, re-educated on medication variance report, re-educated on narcotic medication administration, observed for medication administration. After further review, the inaccurate transcription contributed to the significant medication error committed by LVN A. LVN B will be suspended on August, 10, 2016 and will no longer be employed in the facility effective [DATE]. District Director of Clinical Services or designee will educate all Licensed Nurses regarding General Dose Preparation and Medication Administration A competency based test will be required to validate comprehension. These in-services and competency based tests will start on [DATE] at 6 p.m. and will be completed on [DATE]. Any licensed nurse that has not received this education and competency based test will not be allowed to work in the facility. District Director of Clinical Services or designee will monitor 100% compliance of these in-services and competency based tests. District Director of Clinical Services or designee will educate all Licensed Nurses regarding Significant Medication Related Errors. A competency based test will be required to validate comprehension. These in-services and competency based tests will start on [DATE] at 6 p.m. and will be completed on [DATE]. Any licensed nurse that has not received this education and competency based test will not be allowed to work in the facility. District Director of Clinical Services or designee will monitor 100% compliance of these in-services and competency based tests. District Director of Clinical Services or designee will educate all Licensed Nurses regarding completion of Medication Variance Report in an event of medication error. This report will include notification of responsible party, attending physician and notation on the 24 hour report. These in-services will start on [DATE] at 6 p.m. and will be completed on [DATE]. Any licensed nurse that has not received this education will not be allowed to work in the facility. District Director of Clinical Services or designee will monitor 100% compliance of these in-services. District Director of Clinical Services or designee will educate all Licensed Nurses regarding Narcotic Medication Administration. This in-service will start on [DATE] at 6 p.m. and will be completed on [DATE]. Any licensed nurse that has not received this education will not be allowed to work in the facility. District Director of Clinical Services or designee will monitor 100% compliance of this in-service. District Director of Clinical Services or designee will observe medication administration pass on all Charge Nurses. This observation will start on [DATE] at 6 p.m. and will be completed on [DATE]. Any charge nurse that has not completed this observation will not be allowed to work in the facility. District Director of Clinical Services or designee will monitor 100% compliance of these in-service. 100% audit of medication administration record against medication on hand will be completed by District Director of Clinical Services or designee. This audit will be completed on [DATE] at 11 p.m. New orders, new admissions and 24 hour report will be reviewed daily including weekends for completion and compliance. This process will be monitored for 100% compliance by District Director of Clinical Services or designee. Administrator will validate completion and compliance of these reviews. Administrator will report progress of this plan to the Quality Assurance performance Improvement Committee monthly. To verify the facility implemented their accepted Plan of removal interviews, observations and record review were conducted. An interview on [DATE] at 2:05 p.m. with the Medical Director revealed he was also Resident #1's attending physician. He stated he had been the facility's Medical Director since [DATE], and his role was to assist the facility with problem-solving and identifying ways to address issues. He stated all of the facility's policies and procedures were developed by corporate, and he was able to make requests; however, the final decision was made by corporate. He stated he was aware of the IJ had been identified at the facility, and he had already been in an impromptu QA meeting with the facility. He revealed he would be working with the facility on documentation and would review the policies and protocols. An interview on [DATE] at 1:40 p.m. with the Administrator revealed he conducted rounds during the week and talked with each resident to see if they had concerns or grievances. He stated he was made aware of a medication error on [DATE], while he was out of town. He stated the resident's physician was involved, and there was no harm to the resident. He added that the resident did not have to be hospitalized due to the medication error. When asked how the IJ came about, he stated the DON provided poor supervision. He stated the DON should have done more training, cart audits and individual corrections when she found issues. An interview on [DATE] at 12:30 p.m. with the DON revealed the plan in place to ensure the staff was competent in their skill to care for residents was to read the 24-hour summary every day on every resident. She stated if there had been any concerns with any residents she would follow-up and assess those residents daily. The DON stated she did daily rounds throughout the entire facility and saw every resident, and she could tell by looking at a resident or talking to a resident if something was going on or there was a concern. The DON stated the medication error for Resident #1 occurred when the resident complained of pain, and the discharge medication list from the hospital was used. The DON stated the problem occurred due to LVN B's inputting the hospital orders. The DON stated if administering 180 mg of [MEDICATION NAME] instead of 60 mg of [MEDICATION NAME] was a significant medication error then Resident #1 could have died from the error. She stated Resident #1 did not die and there was no harm to Resident #1 so she did not agree with it being a significant medication error. The DON stated Resident #1 was sent to a long term acute care hospital for pain management not because of the medication error. Review of the Medication Cart to Medication Administration Record Audit Findings, dated [DATE], revealed 32 out of 72 residents audited received medication orders to be clarified for various reasons including the strength and dosage of the medication, discontinued, and/or reordered. No adverse reactions were noted. The errors that were noted in the audit were being corrected or had been corrected during the audit. Review of the Narcotic Medication Audit, dated [DATE], revealed 28 errors noted during the audit. No adverse reactions were noted. The errors that were noted in the audit were being corrected or had been corrected during the audit. Observations of administration of medications on [DATE] by LVN D at 8:50 a.m.; LVN F at 9:15 a.m., LVN G at 11:07 a.m. LVN I at 11:21 a.m.; LVN M at 3:20 p.m.; LVN K at 3:45 p.m. revealed the staff completed medication administration for each resident appropriately. Interviews with eight nurses revealed the licensed nurses were knowledgeable about passing narcotic medications, medication error procedures, new admission orders [REDACTED]. The interviews were conducted with the following nurses: LVN C on [DATE] at 3:22 p.m., LVN D on [DATE] at 2:20 p.m., LVN E on [DATE] at 11:00 a.m., LVN H on [DATE] at 1:55 p.m., LVN I on [DATE] at 2:10 p.m., LVN J on [DATE] at 2:32 p.m., LVN K on [DATE] at 2:40 p.m., and LVN L on [DATE] at 10:00 a.m. On [DATE], the Administrator was notified the IJ was removed. The facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of removal. Review of the Narcotic Medication Audit dated [DATE] revealed 51 residents received Narcotics at the facility. Interview with the ADM on [DATE] at 4:45 p.m. revealed LVN A and LVN B covered/worked Hall 400 and part of Hall 500 (,[DATE]), but on different shifts. Review of the Resident Roster dated [DATE] and provided by the ADM on [DATE] revealed 17 residents resided on Hall 400 and Hall 500 (rooms ,[DATE]), at that time.

Based on observation, interview and record review the facility failed to assure the accurate administering of all drugs and biologicals to meet the needs of one (Resident #1) of five residents reviewd for medications. 1. LVN A failed to administer the correct dose of MS (Morphine Sulfate) Contin ER to Resident #1 on 08/04/16. LVN A administered 180 mg of MS Contin ER to Resident #1 instead of the physician prescribed dose of 60 mg of MS Contin ER, which was three times the prescribed dose. 2. LVN B failed to accurately transcribe Resident #1's physician's orders [REDACTED]. An Immediate Jeopardy (IJ) was identified on 08/09/16. While the IJ was removed on 08/12/16, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of removal. These failures placed the 51, residents who received narcotic medications at the facility, the 17 residents that resided on Hall 400 and Hall 500 at risk of not receiving the correct dosage or correct medication which could lead to life-threatening respiratory issues, and/or possibly death. Findings included: The hospital discharge medications record dated 08/03/16 for Resident #1 reflected Morphine Sulfate (MS Contin 30 MG Tablet) 30 MG Tablet Controlled-release. Dose: 60 Milligram. Oral, Three Times a Day for Pain. This order was verified by LVN B via telephone with the Medical Director as an admission medication order for Resident #1. Resident #1's Physician Orders, dated 08/03/16 8:13 p.m., reflected he was to receive MS Contin (Morphine Sulfate) tablet ER 30 mg give three tablets by mouth three times a day for chronic pain. (This was the incorrect order that was transcribed incorrectly by LVN B.) Resident #1's Physician Orders, written by LVN B on 08/04/16 at 2:37 p.m., reflected MS Contin ER 30 mg tablet three tablets by mouth three times a day for chronic pain was discontinued due to incorrect order. This order was replaced with 60 mg one tablet by mouth three times a day. An interview on 08/09/16 at 2:45 p.m. with LVN B revealed Resident #1 was admitted to the facility on [DATE] between 7:00 p.m. - 8:00 p.m. She stated she verified Resident #1's admitting orders with Resident #1's Physician/Medical Director. LVN B stated she made an error on the admission orders [REDACTED]. She stated she did not realize her error until 08/04/16 when she reported for her shift, which was the 2:00 p.m. to 10:00 p.m. shift. When she spoke to the DON later in the shift about another issue and the transcription issue was then mentioned. LVN B said there had been no in-services or training regarding medication errors. LVN B said she documented her error on the medication summary for Resident #1 on 08/04/16. Wolters Kluwer Nursing 2015 Drug Handbook, pages 971-975, reflected the following regarding MS Contin: .Nursing Considerations - Reassess patient's level of pain .30 minutes after giving orally. .-Monitor circulatory, respiratory, bladder, and bowel functions carefully. Drug may cause hypotension, urine retention, nausea, vomiting, ileus, or altered level of consciousness regardless of the route. Black Box Warning Life-threatening respiratory depression may occur with morphine use, even when drug has been used as recommended and not misused or abused. Proper dosing and titration are essential and morphine should only be prescribed by health care providers knowledgeable in the use of potent opioids for management of long-term pain. Monitor patients for respiratory depression, especially during initiation of morphine or after a dosage increase. Resident #1's Face Sheet, dated 08/06/16, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #1's Initial Plan of Care, dated 08/03/16 and electronically signed on 08/05/16, reflected a care plan for pain which included the following intervention: Provide medication as ordered and document effectiveness results of medication administration. A progress note, written by LVN J and dated 08/04/16 at 2:20 a.m. revealed Resident #1 transferred from the facility by ambulance to the hospital due to pain. Resident #1's hospital Discharge Medication Information form, dated 08/04/16, reflected Dilaudid 1 mg (pain medication) was administered via an intramuscular injection on 08/04/16 at 3:35 a.m. (resident returned to the facility with this form.) Resident #1's Nurse's Progress Notes, dated 08/04/16, revealed Resident #1 transferred to a Long Term Acute Care hospital on [DATE] at 5:35 p.m. Resident #1's August 2016 MAR reflected on 08/04/16 at 9:00 a.m., LVN A signed off that she administered three tablets of MS Contin ER 30 mg by mouth to the resident. (Interview with LVN A she confirmed she gave different dosage than what she actually signed she administered on the MAR.) Resident #1's Individual Control Drug Record for MS Contin ER 60 mg one tablet three times a day reflected LVN A signed off that she administered three 60 mg tablets of MS Contin ER (180 mg) to Resident #1 on 08/04/16 at 8:00 a.m. Review of the blister-pack label for Resident #1's MS Contin ER, dated 08/04/16, reflected Morphine Sulfate ER 60 mg tablet, 1 tablet by mouth three times daily with a quantity of 30 tablets. An interview on 08/06/16 at 3:15 p.m. with LVN A revealed she administered the MS Contin to Resident #1 shortly after he returned to the facility on [DATE] at 6:30 a.m., because the resident was hollering and crying due to pain. She stated she administered the wrong dose of MS Contin 60 mg when she administered three tablets to Resident #1. LVN A stated LVN A stated she did not know if the resident had received any pain medication when he was in the hospital prior to her administering the 180 mg of MS Contin. She stated Resident #1 was on six liters of oxygen per minute via nasal cannula at that time. LVN A stated after she administered three tablets of MS Contin 60 mg to Resident #1, but she charted MS Contin 30 mg (90 mg) three tablets were given. LVN A revealed she read the label on the MS Contin blister-pack, after she had given the medication, and the label reflected MS Contin ER 60 mg give one tablet by mouth three times a day. She stated she realized she made a medication error after she administered the medication when she reviewed the MAR and blister-pack. LVN A stated she administered 180 mg of MS Contin ER to Resident #1 when she gave him three tablets of 60 mg each. She stated Resident #1's MAR reflected MS Contin ER 30 mg three tablets (90 mg), and the blister pack reflected MS Contin ER 60 mg one tablet by mouth three times a day. LVN A stated she immediately called the DON to report the medication error. LVN A did not specify why she called the DON first instead of calling the physician and informing the charge nurse. When the DON arrived at the facility, she stated they both went to check on Resident #1, and the resident was stable. She stated she called Resident #1's physician, and he was informed Resident #1 had received MS Contin 180 mg by her error, and no new orders were received at that time. LVN A stated the physician came to the facility and assessed Resident #1, and no new orders were received. LVN A stated Resident #1 was awake and talking during the 6:00 a.m.-2:00 p.m. shift. During the interview LVN A stated she took vitals that she documented on her personal tablet. When asked why she did not document the vitals in Resident #1's clinical records, no answer was given. She shared the following handwritten vitals from her personal tablet that included the following information: 9:00 a.m. Blood Pressure-109/72; heart rate-101 Temperature 98.6; 9:30a.m. Oxygen Saturation 97%; 10:30 a.m. - blood pressure 113/75; (no time written) 119/74; 12 noon- blood pressure-181/97. (Although LVN A stated the vitals were from 08/04/16, there was no date.) LVN A stated she did not give Resident #1 any other pain medication during her shift. LVN A confirmed she documented on the August 2016 MARs for 08/04/16 at 9:00 a.m. that MS Contin ER 30 mg tablet, three tablets by mouth were administered which would have been a total of 90mg administered, but she actually administered a total of 180mg. LVN A stated she did not record on the MAR or in the progress notes the actual dose of MS Contin (180 mg) that was administered to Resident #1. She stated she should have documented the medication error on the MAR and progress notes, but she did not explain why she did not document the error in the clinical record. She stated she did document on the individual control drug record that she administered three tablets of MS Contin ER 60 mg tablets (180 mg). LVN A did not state why there was no documentation regarding Resident #1's condition following the medication error was written in the clinical record. When asked about possible complications related to administering the 180 mg of MS Contin, LVN A stated a complication could be death. When asked how long Resident #1 should have been monitored for complications, LVN A did not know. LVN A also did not know Resident #1's diagnoses. She stated Resident #1 was on 6 liters of oxygen per minute via nasal cannula, and he remained stable after the medication error. She stated Resident #1 did not need to go to the hospital for monitoring because he remained stable. Review Resident #1's clinical record for 08/06/16 through 08/09/16 revealed no documentation reflecting that Resident #1 received 180 mg of MS Contin on 08/04/16. There also was no documentation reflecting that Resident #1 was monitored for adverse drug reactions following this significant medication error. An interview on 08/06/16 at 2:20 p.m. with the DON revealed LVN A contacted her via telephone to inform her that she administered the wrong dose of MS Contin ER (180 mg) to Resident #1 on 08/04/16 before 8:00 a.m. The DON stated she went to the facility after being notified of the medication error, and she observed Resident #1 sitting up in bed eating breakfast. She stated he talked freely with her and the staff and was stable. She stated she saw no concerns with Resident #1. She stated the Administrator was out-of-state, but he had been informed that LVN A made a medication error affecting Resident #1. When asked if Resident #1 was monitored following the medication error, the DON did not answer. She stated the physician assessed Resident #1 that day (08/04/16), and she was not informed of any complications. When asked about possible effects of administering 180 mg of MS Contin, the DON did not answer. When asked if staff had been given any directions for assessment and monitoring of Resident #1 after the significant medication error, the DON did not answer. She also did not respond when asked what time frame the resident should have been monitored for complications. The DON stated there were no problems with Resident #1, and he was sent out to another facility for treatment of [REDACTED]. She stated she talked with LVN A about the medication error. The DON revealed the medication error was made because the transcription for the MS Contin ER reflected to give three pills instead of two. The DON made no response to the dosage of MS Contin ER 60 mg ordered to be administered and not the number of pills to be given. The DON did not respond when asked if any clarification or reconciliation was completed after the medication error was made. The DON stated she had not documented the medication error, and she did not respond when asked why there was no documentation on the MAR or progress notes about the medication error. The DON stated the facility did not have a log for medication errors, and there may have been two insignificant medication errors during her tenure. The DON did not know of any risk factors Resident #1 had after receiving a triple dose of MS Contin. The DON stated no in-services or training had been provided to the staff after LVN A made the medication error. She stated the nurses took a medication test when they were hired. An interview on 08/09/16 at 12:30 p.m. with the DON revealed the facility had not provided any in-services or training to the staff after the medication error was made with Resident #1. She also confirmed there had not been any documentation regarding the medication error. The DON revealed she did not see the administration of MS Contin ER 180 mg as being a significant medication error when the order was for MS Contin ER 60 mg to be administered. She stated there was no adverse outcome for Resident #1. When asked what the adverse outcomes and risks would be for an overdose of MS Contin, she did not answer. When asked what monitoring system the facility had to address significant medication errors, the DON did not respond to the question. The DON stated on 08/04/16, when she saw Resident #1 after learning of the medication error, the resident was awake and talking. She stated she saw the resident one other time that day, and the resident was alright. The DON stated no monitoring of Resident #1 was performed nor did monitoring need to be performed. When asked how staff would know if Resident #1 experienced a significant change or complication, the DON did not respond. When asked if Resident #1 needed to have his heart rate, blood pressure, respirations or any central nervous system monitored, the DON did not respond. She stated she found some literature on general medication administration and had given this information to LVN A, and she was trying to determine what should be done. The DON stated LVN A had been placed on suspension on this date, 08/09/16, and she would not be completing her shift pending further investigation. An interview on 08/09/16 at 10:20 a.m. with the Medical Director, who was also Resident #1's physician, revealed he had been notified that Resident #1 was administered 180 mg of MS Contin ER. He stated he arrived to the facility within the hour of the call, and he assessed Resident #1 upon his arrival at the facility. His assessment revealed Resident #1 was stable and in no distress. He said he remained at the facility afterwards assessing and reviewing other residents. He said there were no concerns with Resident #1 during this time or afterwards. The Medical Director stated he was surprised Resident #1 did not go into distress. He said it was verified with the admitting nurse/ LVN B on admission and later clarified with the pharmacy that Resident #1 was to receive MS Contin ER 60 mg dosage by mouth three times a day. He said he did not understand how the error was made. He said the facility could not provide Resident # 1 with effective pain relief and Resident #1 was discharged to another facility at a later time on 08/04/16. He said no changes were implemented after the medication error. He did not give orders for the resident to be monitored. He did specify that he was in the building for an extended period of time after he assessed Resident #1. An interview on 08/09/16 at 12:30 p.m. with the DON revealed she discussed medications thoroughly with her staff. The DON said on 08/09/16 she had looked in the closet and items stored in her office and had found some videos and tests that she did not know were there. She stated these items had not previously been used, and she did not know the content of the videos. The DON stated she would start making observations of the controlled narcotic medication count as this had not previously been done. The facility's current General Dose Preparation and Medication Administration policy and procedure, dated January 2013, reflected the following: .Verify each time a medication is administered that it is the correct medication, at the correct dose, i.e .Document the administration of controlled substances in accordance with Applicable law .Document necessary medication administration/ treatment information (e.g., when medications are opened, when medications are given i.e.,) on appropriate forms; i.e An IJ was identified on 08/09/16 at 12:00 p.m. The facility's Administrator, DON, and District Director of Clinical Services were notified at that time and a plan of removal was requested. The facility's plan of removal was accepted on 08/10/16 at 5:30 p.m. and contained the following: LVN A who was involved with the significant medication error was suspended on August 9, 2016 at 11:31 a.m. LVN A will no longer be employed in the facility. LVN A self-terminated on August 9, 2016. The DON was suspended on August 9, 2016. The DON failed to investigate significant medication error, failed to counsel and suspend LVN A, failed to re-educate licensed nurses regarding medication management including medication errors and medication administration. The DON's failure to address the significant medication error resulted in the Immediate Jeopardy. The DON will no longer be employed in the facility effective August 10, 2016. LVN B admitted Resident#1 on August 3, 2016. LVN B transcribed resident's Morphine Sulfate order inaccurately. Discharge orders from the hospital reflected Morphine Sulfate 30 mg two (2) tablets three times a day. LVN B transcribed Morphine Sulfate 30 mg three (3) tablets three times a day. LVN B was counseled on August 9, 2016, re-educated regarding medication Administration with competency based test, re-educated on transcription of new orders, re-educated on medication related issues with competency based test, re-educated on medication variance report, re-educated on narcotic medication administration, observed for medication administration. After further review, the inaccurate transcription contributed to the significant medication error committed by LVN A. LVN B will be suspended on August, 10, 2016 and will no longer be employed in the facility effective August 10, 2016. District Director of Clinical Services or designee will educate all Licensed Nurses regarding General Dose Preparation and Medication Administration A competency based test will be required to validate comprehension. These in-services and competency based tests will start on August 9, 2016 at 6 p.m. and will be completed on August 10, 2016. Any licensed nurse that has not received this education and competency based test will not be allowed to work in the facility. District Director of Clinical Services or designee will monitor 100% compliance of these in-services and competency based tests. District Director of Clinical Services or designee will educate all Licensed Nurses regarding Significant Medication Related Errors. A competency based test will be required to validate comprehension. These in-services and competency based tests will start on August 9, 2016 at 6 p.m. and will be completed on August 10, 2016. Any licensed nurse that has not received this education and competency based test will not be allowed to work in the facility. District Director of Clinical Services or designee will monitor 100% compliance of these in-services and competency based tests. District Director of Clinical Services or designee will educate all Licensed Nurses regarding completion of Medication Variance Report in an event of medication error. This report will include notification of responsible party, attending physician and notation on the 24 hour report. These in-services will start on August 9, 2016 at 6 p.m. and will be completed on August 10, 2016. Any licensed nurse that has not received this education will not be allowed to work in the facility. District Director of Clinical Services or designee will monitor 100% compliance of these in-services. District Director of Clinical Services or designee will educate all Licensed Nurses regarding Narcotic Medication Administration. This in-service will start on August 9, 2016 at 6 p.m. and will be completed on August 10, 2016. Any licensed nurse that has not received this education will not be allowed to work in the facility. District Director of Clinical Services or designee will monitor 100% compliance of this in-service. District Director of Clinical Services or designee will observe medication administration pass on all Charge Nurses. This observation will start on August 9, 2016 at 6 p.m. and will be completed on August 10, 2016. Any charge nurse that has not completed this observation will not be allowed to work in the facility. District Director of Clinical Services or designee will monitor 100% compliance of these in-service. 100% audit of medication administration record against medication on hand will be completed by District Director of Clinical Services or designee. This audit will be completed on August 10, 2016 at 11 p.m. New orders, new admissions and 24 hour report will be reviewed daily including weekends for completion and compliance. This process will be monitored for 100% compliance by District Director of Clinical Services or designee. Administrator will validate completion and compliance of these reviews. Administrator will report progress of this plan to the Quality Assurance performance Improvement Committee monthly. To verify the facility implemented their accepted Plan of removal interviews, observations and record review were conducted. An interview on 08/09/16 at 2:05 p.m. with the Medical Director revealed he was also Resident #1's attending physician. He stated he had been the facility's Medical Director since 12/28/15, and his role was to assist the facility with problem-solving and identifying ways to address issues. He stated all of the facility's policies and procedures were developed by corporate, and he was able to make requests; however, the final decision was made by corporate. He stated he was aware of the IJ had been identified at the facility, and he had already been in an impromptu QA meeting with the facility. He revealed he would be working with the facility on documentation and would review the policies and protocols. An interview on 08/11/16 at 1:40 p.m. with the Administrator revealed he conducted rounds during the week and talked with each resident to see if they had concerns or grievances. He stated he was made aware of a medication error on 08/04/16, while he was out of town. He stated the resident's physician was involved, and there was no harm to the resident. He added that the resident did not have to be hospitalized due to the medication error. When asked how the IJ came about, he stated the DON provided poor supervision. He stated the DON should have done more training, cart audits and individual corrections when she found issues. An interview on 08/09/16 at 12:30 p.m. with the DON revealed the plan in place to ensure the staff was competent in their skill to care for residents was to read the 24-hour summary every day on every resident. She stated if there had been any concerns with any residents she would follow-up and assess those residents daily. The DON stated she did daily rounds throughout the entire facility and saw every resident, and she could tell by looking at a resident or talking to a resident if something was going on or there was a concern. The DON stated the medication error for Resident #1 occurred when the resident complained of pain, and the discharge medication list from the hospital was used. The DON stated the problem occurred due to LVN B's inputting the hospital orders. The DON stated if administering 180 mg of MS Contin ER instead of 60 mg of MS Contin ER was a significant medication error then Resident #1 could have died from the error. She stated Resident #1 did not die and there was no harm to Resident #1 so she did not agree with it being a significant medication error. The DON stated Resident #1 was sent to a long term acute care hospital for pain management not because of the medication error. Review of the Medication Cart to Medication Administration Record Audit Findings, dated 08/11/16, revealed 32 out of 72 residents audited received medication orders to be clarified for various reasons including the strength and dosage of the medication, discontinued, and/or reordered. No adverse reactions were noted. The errors that were noted in the audit were being corrected or had been corrected during the audit. Review of the Narcotic Medication Audit, dated 08/11/16, revealed 28 errors noted during the audit. No adverse reactions were noted. The errors that were noted in the audit were being corrected or had been corrected during the audit. Observations of administration of medications on 08/11/16 by LVN D at 8:50 a.m.; LVN F at 9:15 a.m., LVN G at 11:07 a.m. LVN I at 11:21 a.m.; LVN M at 3:20 p.m.; LVN K at 3:45 p.m. revealed the staff completed medication administration for each resident appropriately. Interviews with eight nurses revealed the licensed nurses were knowledgeable about passing narcotic medications, medication error procedures, new admission orders [REDACTED]. The interviews were conducted with the following nurses: LVN C on 08/11/16 at 3:22 p.m., LVN D on 08/12/16 at 2:20 p.m., LVN E on 08/12/16 at 11:00 a.m., LVN H on 08/12/16 at 1:55 p.m., LVN I on 08/12/16 at 2:10 p.m., LVN J on 08/11/16 at 2:32 p.m., LVN K on 08/12/16 at 2:40 p.m., and LVN L on 08/12/16 at 10:00 a.m. On 08/11/16, the Administrator was notified the IJ was removed. The facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of removal. Review of the Narcotic Medication Audit dated 08/11/16 revealed 51 residents received Narcotics at the facility. Interview with the ADM on 08/25/16 at 4:45 p.m. revealed LVN A and LVN B covered/worked Hall 400 and part of Hall 500 (500-506), but on different shifts. Review of the Resident Roster dated 08/10/16 and provided by the ADM on 08/11/16 revealed 17 residents resided on Hall 400 and Hall 500 (rooms 500-506), at that time.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care, for two (Residents #8 and #12) of 14 residents reviewed for pain management. 1. The facility failed to ensure Resident #12's physician-ordered pain medication, Tylenol-[MEDICATION NAME] Suspension 120-12 mg/5 ml, was administered and/or available on 07/11/16, 07/12/16, 07/13/16, 07/14/16, 07/15/16, 07/16/17, 07/17/16, 07/18/16, 07/19/16. The facility also failed to ensure the resident's hospice comfort pack was available to administer to the resident. This resulted in the resident's pain not being relieved and the resident exhibited restlessness. 2. The facility failed to ensure Resident #8's physician-ordered pain medication [MEDICATION NAME] APAP 5/325 mg was administered and/or available on 07/14/16, 07/15/16, 07/16/16, 07/17/16 and 07/18/16. Resident #8 reported experiencing severe, unrelieved pain on the days she did not receive her physician-ordered pain medications, which interfered with her ability to fully participate in her therapy program. These failures placed the 51 residents, who were on a pain management program, at risk for continued pain, distress, and a decreased quality of life. Findings included: 1. Resident #12's MDS assessment, dated 04/28/16, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #12's Comprehensive Care Plan, dated 05/03/16, reflected the resident had pain related to debility along with repeated falls, and the resident's pain was alleviated with both pharmacological and non-pharmacological interventions. The care plan reflected staff was to observe the resident for signs and symptoms of pain and contact the physician if the resident had unrelieved pain. Resident #12's Physician Orders, dated 07/11/16, reflected Tylenol-[MEDICATION NAME] Suspension 120-12 gm/5 ml as need for pain. Resident #12's July 2016 MAR indicated [REDACTED]. An observation on 07/18/16 at 9:05 a.m. revealed Resident #12 lying in bed with the head of his bed elevated. The resident was frail and was not responsive to verbal stimuli. An interview with LVN I at the time of the observation revealed the resident had end-stage [MEDICAL CONDITION], and he received hospice services. LVN I stated Resident #12 was primarily bedfast, and he was not eating or drinking and could no longer swallow pills. She stated the resident received intravenous fluids on 07/17/16 due to dehydration. An interview on 07/19/16 at 9:55 a.m. with Resident #12's family member revealed the resident just finished receiving intravenous fluids for dehydration the day before. The family member stated the resident was in pain and was waiting for the nurse to bring pain medication. The family member stated he/she hoped the medication had been delivered from the pharmacy because it had been a few days coming. At the time of this interview, Resident #12's legs, feet and head were in almost constant restless motion. The family member explained that the resident had significant pain that kept him from resting. An interview on 07/19/16 at 11:00 a.m. with LVN I revealed she did not have Resident #12's pain medication because the medication had not been delivered from the pharmacy. She stated the she was waiting on the comfort pack to be delivered since there resident was receiving hospice services, and she did not have any idea why the medication had not been delivered. A telephone interview on 07/19/16 at 12:17 p.m. with a Pharmacy Representative revealed the pharmacy did not have an order for [REDACTED]. An interview on 07/19/16 at 1:40 p.m. with the DON revealed Resident #12's Tylenol with [MEDICATION NAME] Suspension was ordered on [DATE], but it had not been delivered from the pharmacy. Also, the hospice agency had not delivered Resident #12's comfort pack. The DON stated she received a one-time only order for one Tylenol #3 tablet on 07/19/16 at 12:45 p.m., which was administered to the resident. She stated she would follow-up with the hospice agency. An interview on 07/20/16 at 11:00 a.m. with LVN I revealed she had received a one-time only order to administer one Tylenol #3 tablet by mouth to Resident #12 on 07/19/16. She stated at 2:08 p.m. when the medication was administered the resident's pain was assessed as an eight on a scale from one to ten. LVN I stated the resident was able to swallow the medication, and she thought it relieved his pain. She added she was still waiting for the hospice agency to deliver Resident #12's pain medications. An interview on 07/20/16 at 12:30 p.m. with LVN F revealed he called Resident #12's physician requesting something more for pain relief for Resident #12 on 07/11/16 because the [MEDICATION NAME] 50 mg was not effective in relieving the resident's pain. He stated the physician originally ordered Tylenol #3 tablets for the resident, but the resident was no longer able to swallow pills so he called the physician back. The order was then changed to Tylenol with [MEDICATION NAME] Suspension, and the physician stated he would fax the prescription to the pharmacy. LVN F stated the following day on 07/12/16 he called the physician again because the Tylenol with [MEDICATION NAME] Suspension had not been delivered from the pharmacy for Resident #12, and the physician said he would take care of it. LVN F stated he reported the issue to the DON on the third day 07/13/16, and she said she would take care of it. When he next worked on 07/15/16, LVN F stated the medication was still not available. He stated he did not follow-up any further because he thought the problem had been taken care of. Resident #12's Progress Notes dated 07/11/16 at 8:02 a.m. reflected LVN F documented a late entry which reflected a new order for Tylenol-[MEDICATION NAME] Suspension 12.5 ml every six hours as needed for pain. An interview on 07/21/16 at 2:15 p.m. with the Administrator revealed any concerns related to nursing he deferred to the DON because he really did not get into nursing. 2. Resident #8's MDS assessment, dated 07/05/16, reflected she was a [AGE] year-old female readmitted to the facility on [DATE] with an original admitted d 05/23/16. The resident's [DIAGNOSES REDACTED]. The resident was able to understand and be understood by others. The resident received a PRN pain medication regimen, and non-medication interventions for pain. The resident's pain was almost constantly present, limited her day-to-day activities, and limited her ability to sleep at night. Her pain rating was 6 on a scale of 0-10 with zero being no pain and ten as the worst pain imaginable. Resident #8's July 2016 Physician order [REDACTED]. Resident #8's Comprehensive Plan of Care, review date 05/24/16 with revision on 06/07/16, reflected the resident had chronic pain and joint pain. The care planned approaches included observing the resident's need for pain relief, periodically and with each medication pass; evaluating the effectiveness of pain interventions post medication administration; and notifying the physician of unrelieved pain. Resident #8's Physician Order, dated 06/30/16, reflected [MEDICATION NAME]-APAP 10/325 mg one or two tablets every four hours for pain related to chronic pain. An interview on 07/18/16 at 9:15 a.m. with Resident #8 revealed her pain medication, [MEDICATION NAME], had not been available since 07/14/16. Resident #8 stated she was in and had been in a lot of pain which was limiting her ability to fully participate in therapy. She stated the [MEDICATION NAME] relieved her pain, lasted longer, allowed her to push herself in therapy, and it did not sedate her. Although, she had not missed any of her therapy sessions she stated she was not fully able to participate when her pain was not controlled. Resident #8 stated she was aware she had [MEDICATION NAME] available for pain; however, she did not want to take [MEDICATION NAME] during the day because it sedated her so she preferred to only receive it at night. She stated the nurses knew she did not like to take the [MEDICATION NAME] during the day so they offered her a heat pack which did nothing to relieve her pain. Resident #8 said she was hoping to be discharged home a the end of this week because she would be able to better manage her pain at home. An interview on 07/18/16 at 9:20 a.m. with LVN I, who was a charge nurse for Resident #8, revealed Resident #8 did not have any [MEDICATION NAME] available, and she was not certain how long the medication had not been available. LVN I explained that they sometimes had problems with the physicians signing the triplicate prescriptions for narcotics, and the pharmacy would not deliver narcotic medications without a physician's signature. LVN I stated she had not called the pharmacy to see why the [MEDICATION NAME] for Resident #8 had not been delivered. She stated she could offer Resident #8 [MEDICATION NAME], but the resident only wanted to take the [MEDICATION NAME] at night. An interview on 07/18/16 at 1:50 p.m. with the facility's only ADON revealed LVN I informed her this morning that Resident #8's [MEDICATION NAME] was not available. After learning about the medication not being available this morning, she stated she contacted Resident #8's physician, and the PA would be sending the prescription to the pharmacy as soon as possible. The ADON stated she had no idea why Resident #8's [MEDICATION NAME] had not been delivered, and the nurses knew to reorder medications when there was only about a seven day supply left. She stated the nurses knew [MEDICATION NAME] was available in the facility's emergency kit, and they should have given Resident #8 the pain medication. An interview on 07/18/16 at 2:10 p.m. with the DON and ADON revealed the DON just heard about Resident #8's [MEDICATION NAME] not being available from LVN H, and she did not understand why the medication was not available. She stated she would follow-up with the pharmacy. The DON stated the facility's emergency kit had [MEDICATION NAME] 10/325 mg available, and it should have been given. She stated the nurses just received an in-service regarding medications, and LVN I received orientation training just last week, which included pharmacy procedures. The DON stated she would provide another in-service today for the nurses regarding medications. The ADON added she had just learned from Resident #8 that the resident had a [MEDICATION NAME] pump implanted in her abdomen, which was delivering [MEDICATION NAME] according to her Pain Management Clinic's programming. The DON stated she was unaware the resident had the [MEDICATION NAME] pump. An interview on 07/18/16 at 2:50 p.m. with LVN C revealed the nurses reordered medications when the last row of medications on the bubble pack remained. LVN C revealed she was working on 07/14/16, but she could not recall if she gave Resident #8 [MEDICATION NAME] or if she reordered the medication. She stated she usually gave Resident #8 [MEDICATION NAME] on her shift because that was what the resident usually requested at night. LVN C stated the nurses had on-going problems with pharmacy orders not being delivered. An interview on 08/04/16 at 1:45 p.m. with LVN C revealed she was the nurse who admitted Resident #8 to the facility on [DATE], which included conducting a head-to-toe assessment of the resident. She stated when she assessed the resident's bowel sounds she palpated the outer four quadrants of the resident's abdomen, but she did not palpate the midline of the abdomen. LVN C stated she missed the [MEDICATION NAME] pump implanted in the resident's abdomen, and Resident #8 did not disclose to her she had a [MEDICATION NAME] pump at anytime during her stay. LVN C stated she was not aware of the [MEDICATION NAME] pump implant until the DON informed her on 07/21/16. LVN C denied calling the resident's physician or the Pain Management Clinic about the [MEDICATION NAME] pump after learning about it on 07/21/16. She stated she also did not document anything about the [MEDICATION NAME] pump in the resident's clinical record, and the resident's care plan was not updated in regards to the implanted [MEDICATION NAME] pump. LVN C stated she did not palpate Resident #8's abdomen until the resident's date of discharge on 07/23/16. Resident #8's July 2016 MAR indicated [REDACTED]. An interview on 07/19/16 at 12:17 p.m. with a Pharmacy Representative revealed the facility's emergency kit contained [MEDICATION NAME] 10/325 mg and was available for use. An interview on 07/20/16 at 9:30 a.m. with LVN G revealed she was the charge nurse for Resident #8 on the night shift from 07/14/16 through 07/17/16. LVN G stated Resident #8 had complained of pain at a level of eight of a scale of zero to ten, but the resident's [MEDICATION NAME] was not available. She stated she was aware the medication was available in the emergency kit; however, she decided to administer [MEDICATION NAME] instead which was effective in relieving the resident's pain. LVN G stated if Resident #8 had no alternative pain medication then she would have called the pharmacy for the code to the emergency kit. She stated for more than a month the residents' refill medications had not been delivered as usual by the pharmacy. An interview on 07/20/16 at 12:30 p.m. with LVN F revealed he was the weekend double charge nurse for Resident #8 on 07/15/16-07/17/16. LVN F stated Resident #8 did not have any [MEDICATION NAME], and he was aware that medication was available in the facility's emergency kit. He stated when Resident #8 complained of pain he just gave her [MEDICATION NAME] on 07/17/16. Review of Resident #8's Nurse's Notes for 07/14/16 through 07/18/16 revealed no documentation reflecting the resident's [MEDICATION NAME] was not available for administration. The facility's current New Orders for Schedule III-V Controlled Substances policy and procedure, revised 01/01/13, reflected the following: .Procedure: 1. For all Schedule III-V controlled substance medication orders, the facility must provide to the pharmacy: 1.1 A written prescription signed by a practitioner, or, 1.2 A fax of a written, signed prescription transmitted by the practitioner or the practitioner's agent to the pharmacy, or, 1.3 An oral prescription communicated by the practitioner or the practitioner's pharmacist. 2. Schedule III-V controlled substance orders should be communicated to the Pharmacy as follows: 2.1 Facility should ensure that written medication orders are legible when faxed to the Pharmacy 2.2 If the medication is needed before the next scheduled delivery, Facility staff should indicate the exact time by which the medication is needed. 2.3 If the controlled substance is needed before the Pharmacy can make arrangements for a timely delivery, Facility must fax a request to remove a controlled substance from the Facility's Emergency Medication Supply to the pharmacy. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the Administrator on 07/20/16, reflected 51 residents received pain management.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures to assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for two (Residents #8 and #12) of fourteen residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #12's physician-ordered pain medication, Tylenol-Codeine Suspension 120-12 mg/5 ml, was administered and/or available on 07/11/16, 07/12/16, 07/13/16, 07/14/16, 07/15/16, 07/16/17, 07/17/16, 07/18/16, 07/19/16. The facility also failed to ensure the resident's hospice comfort pack was available to administer to the resident. This resulted in the resident's pain not being relieved and the resident exhibited restlessness. 2. The facility failed to ensure Resident #8's physician-ordered pain medication Hydrocodone APAP 5/325 mg was administered and/or available on 07/14/16, 07/15/16, 07/16/16, 07/17/16 and 07/18/16. Resident #8 reported experiencing severe, unrelieved pain on the days she did not receive her physician-ordered pain medications, which interfered with her ability to fully participate in her therapy program. These failures placed the 51 residents, who were on a pain management program, at risk for continued pain, distress, and a decreased quality of life. Findings included: 1. Resident #12's MDS assessment, dated 04/28/16, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #12's Comprehensive Care Plan, dated 05/03/16, reflected the resident had pain related to debility along with repeated falls, and the resident's pain was alleviated with both pharmacological and non-pharmacological interventions. The care plan reflected staff was to observe the resident for signs and symptoms of pain and contact the physician if the resident had unrelieved pain. Resident #12's Physician Orders, dated 07/11/16, reflected Tylenol-Codeine Suspension 120-12 gm/5 ml as need for pain. Resident #12's July 2016 MAR indicated [REDACTED]. An observation on 07/18/16 at 9:05 a.m. revealed Resident #12 lying in bed with the head of his bed elevated. The resident was frail and was not responsive to verbal stimuli. An interview with LVN I at the time of the observation revealed the resident had end-stage Alzheimer's disease, and he received hospice services. LVN I stated Resident #12 was primarily bedfast, and he was not eating or drinking and could no longer swallow pills. She stated the resident received intravenous fluids on 07/17/16 due to dehydration. An interview on 07/19/16 at 9:55 a.m. with Resident #12's family member revealed the resident just finished receiving intravenous fluids for dehydration the day before. The family member stated the resident was in pain and was waiting for the nurse to bring pain medication. The family member stated he/she hoped the medication had been delivered from the pharmacy because it had been a few days coming. At the time of this interview, Resident #12's legs, feet and head were in almost constant restless motion. The family member explained that the resident had significant pain that kept him from resting. An interview on 07/19/16 at 11:00 a.m. with LVN I revealed she did not have Resident #12's pain medication because the medication had not been delivered from the pharmacy. She stated the she was waiting on the comfort pack to be delivered since there resident was receiving hospice services, and she did not have any idea why the medication had not been delivered. A telephone interview on 07/19/16 at 12:17 p.m. with a Pharmacy Representative revealed the pharmacy did not have an order for [REDACTED]. An interview on 07/19/16 at 1:40 p.m. with the DON revealed Resident #12's Tylenol with Codeine Suspension was ordered on [DATE], but it had not been delivered from the pharmacy. Also, the hospice agency had not delivered Resident #12's comfort pack. The DON stated she received a one-time only order for one Tylenol #3 tablet on 07/19/16 at 12:45 p.m., which was administered to the resident. She stated she would follow-up with the hospice agency. An interview on 07/20/16 at 11:00 a.m. with LVN I revealed she had received a one-time only order to administer one Tylenol #3 tablet by mouth to Resident #12 on 07/19/16. She stated at 2:08 p.m. when the medication was administered the resident's pain was assessed as an eight on a scale from one to ten. LVN I stated the resident was able to swallow the medication, and she thought it relieved his pain. She added she was still waiting for the hospice agency to deliver Resident #12's pain medications. An interview on 07/20/16 at 12:30 p.m. with LVN F revealed he called Resident #12's physician requesting something more for pain relief for Resident #12 on 07/11/16 because the Tramadol 50 mg was not effective in relieving the resident's pain. He stated the physician originally ordered Tylenol #3 tablets for the resident, but the resident was no longer able to swallow pills so he called the physician back. The order was then changed to Tylenol with Codeine Suspension, and the physician stated he would fax the prescription to the pharmacy. LVN F stated the following day on 07/12/16 he called the physician again because the Tylenol with Codeine Suspension had not been delivered from the pharmacy for Resident #12, and the physician said he would take care of it. LVN F stated he reported the issue to the DON on the third day 07/13/16, and she said she would take care of it. When he next worked on 07/15/16, LVN F stated the medication was still not available. He stated he did not follow-up any further because he thought the problem had been taken care of. Resident #12's Progress Notes dated 07/11/16 at 8:02 a.m. reflected LVN F documented a late entry which reflected a new order for Tylenol-Codeine Suspension 12.5 ml every six hours as needed for pain. An interview on 07/21/16 at 2:15 p.m. with the Administrator revealed any concerns related to nursing he deferred to the DON because he really did not get into nursing. 2. Resident #8's MDS assessment, dated 07/05/16, reflected she was a [AGE] year-old female readmitted to the facility on [DATE] with an original admitted d 05/23/16. The resident's [DIAGNOSES REDACTED]. The resident was able to understand and be understood by others. The resident received a PRN pain medication regimen, and non-medication interventions for pain. The resident's pain was almost constantly present, limited her day-to-day activities, and limited her ability to sleep at night. Her pain rating was 6 on a scale of 0-10 with zero being no pain and ten as the worst pain imaginable. Resident #8's July 2016 Physician order [REDACTED]. Resident #8's Comprehensive Plan of Care, review date 05/24/16 with revision on 06/07/16, reflected the resident had chronic pain and joint pain. The care planned approaches included observing the resident's need for pain relief, periodically and with each medication pass; evaluating the effectiveness of pain interventions post medication administration; and notifying the physician of unrelieved pain. Resident #8's Physician Order, dated 06/30/16, reflected Hydrocodone-APAP 10/325 mg one or two tablets every four hours for pain related to chronic pain. An interview on 07/18/16 at 9:15 a.m. with Resident #8 revealed her pain medication, Hydrocodone, had not been available since 07/14/16. Resident #8 stated she was in and had been in a lot of pain which was limiting her ability to fully participate in therapy. She stated the Hydrocodone relieved her pain, lasted longer, allowed her to push herself in therapy, and it did not sedate her. Although, she had not missed any of her therapy sessions she stated she was not fully able to participate when her pain was not controlled. Resident #8 stated she was aware she had Dilaudid available for pain; however, she did not want to take Dilaudid during the day because it sedated her so she preferred to only receive it at night. She stated the nurses knew she did not like to take the Dilaudid during the day so they offered her a heat pack which did nothing to relieve her pain. Resident #8 said she was hoping to be discharged home a the end of this week because she would be able to better manage her pain at home. An interview on 07/18/16 at 9:20 a.m. with LVN I, who was a charge nurse for Resident #8, revealed Resident #8 did not have any Hydrocodone available, and she was not certain how long the medication had not been available. LVN I explained that they sometimes had problems with the physicians signing the triplicate prescriptions for narcotics, and the pharmacy would not deliver narcotic medications without a physician's signature. LVN I stated she had not called the pharmacy to see why the Hydrocodone for Resident #8 had not been delivered. She stated she could offer Resident #8 Dilaudid, but the resident only wanted to take the Dilaudid at night. An interview on 07/18/16 at 1:50 p.m. with the facility's only ADON revealed LVN I informed her this morning that Resident #8's Hydrocodone was not available. After learning about the medication not being available this morning, she stated she contacted Resident #8's physician, and the PA would be sending the prescription to the pharmacy as soon as possible. The ADON stated she had no idea why Resident #8's Hydrocodone had not been delivered, and the nurses knew to reorder medications when there was only about a seven day supply left. She stated the nurses knew Hydrocodone was available in the facility's emergency kit, and they should have given Resident #8 the pain medication. An interview on 07/18/16 at 2:10 p.m. with the DON and ADON revealed the DON just heard about Resident #8's Hydrocodone not being available from LVN H, and she did not understand why the medication was not available. She stated she would follow-up with the pharmacy. The DON stated the facility's emergency kit had Hydrocodone 10/325 mg available, and it should have been given. She stated the nurses just received an in-service regarding medications, and LVN I received orientation training just last week, which included pharmacy procedures. The DON stated she would provide another in-service today for the nurses regarding medications. The ADON added she had just learned from Resident #8 that the resident had a morphine pump implanted in her abdomen, which was delivering morphine according to her Pain Management Clinic's programming. The DON stated she was unaware the resident had the morphine pump. An interview on 07/18/16 at 2:50 p.m. with LVN C revealed the nurses reordered medications when the last row of medications on the bubble pack remained. LVN C revealed she was working on 07/14/16, but she could not recall if she gave Resident #8 Hydrocodone or if she reordered the medication. She stated she usually gave Resident #8 Dilaudid on her shift because that was what the resident usually requested at night. LVN C stated the nurses had on-going problems with pharmacy orders not being delivered. An interview on 08/04/16 at 1:45 p.m. with LVN C revealed she was the nurse who admitted Resident #8 to the facility on [DATE], which included conducting a head-to-toe assessment of the resident. She stated when she assessed the resident's bowel sounds she palpated the outer four quadrants of the resident's abdomen, but she did not palpate the midline of the abdomen. LVN C stated she missed the morphine pump implanted in the resident's abdomen, and Resident #8 did not disclose to her she had a morphine pump at anytime during her stay. LVN C stated she was not aware of the morphine pump implant until the DON informed her on 07/21/16. LVN C denied calling the resident's physician or the Pain Management Clinic about the morphine pump after learning about it on 07/21/16. She stated she also did not document anything about the morphine pump in the resident's clinical record, and the resident's care plan was not updated in regards to the implanted morphine pump. LVN C stated she did not palpate Resident #8's abdomen until the resident's date of discharge on 07/23/16. Resident #8's July 2016 MAR indicated [REDACTED]. An interview on 07/19/16 at 12:17 p.m. with a Pharmacy Representative revealed the facility's emergency kit contained Hydrocodone 10/325 mg and was available for use. An interview on 07/20/16 at 9:30 a.m. with LVN G revealed she was the charge nurse for Resident #8 on the night shift from 07/14/16 through 07/17/16. LVN G stated Resident #8 had complained of pain at a level of eight of a scale of zero to ten, but the resident's Hydrocodone was not available. She stated she was aware the medication was available in the emergency kit; however, she decided to administer Dilaudid instead which was effective in relieving the resident's pain. LVN G stated if Resident #8 had no alternative pain medication then she would have called the pharmacy for the code to the emergency kit. She stated for more than a month the residents' refill medications had not been delivered as usual by the pharmacy. An interview on 07/20/16 at 12:30 p.m. with LVN F revealed he was the weekend double charge nurse for Resident #8 on 07/15/16-07/17/16. LVN F stated Resident #8 did not have any Hydrocodone, and he was aware that medication was available in the facility's emergency kit. He stated when Resident #8 complained of pain he just gave her Dilaudid on 07/17/16. Review of Resident #8's Nurse's Notes for 07/14/16 through 07/18/16 revealed no documentation reflecting the resident's Hydrocodone was not available for administration. The facility's current New Orders for Schedule III-V Controlled Substances policy and procedure, revised 01/01/13, reflected the following: .Procedure: 1. For all Schedule III-V controlled substance medication orders, the facility must provide to the pharmacy: 1.1 A written prescription signed by a practitioner, or, 1.2 A fax of a written, signed prescription transmitted by the practitioner or the practitioner's agent to the pharmacy, or, 1.3 An oral prescription communicated by the practitioner or the practitioner's pharmacist. 2. Schedule III-V controlled substance orders should be communicated to the Pharmacy as follows: 2.1 Facility should ensure that written medication orders are legible when faxed to the Pharmacy 2.2 If the medication is needed before the next scheduled delivery, Facility staff should indicate the exact time by which the medication is needed. 2.3 If the controlled substance is needed before the Pharmacy can make arrangements for a timely delivery, Facility must fax a request to remove a controlled substance from the Facility's Emergency Medication Supply to the pharmacy. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the Administrator on 07/20/16, reflected 51 residents received pain management.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #14) of 18 residents reviewed for care, was free of interference and coercion from the facility in exercising her rights. Resident #14 was confined to her bed for three years with full padded side rails due to the demands of her MPOA. Resident #14 voiced many times that she wanted out of bed and she tried to climb out of bed. Resident #14 was forced to have her hair cut short against her will. Resident #14 begged the beautician not to cut her hair so short. Her MPOA said it did not matter what Resident #14 wanted. She had not received showers, only bed baths. Resident #14 was not allowed to attend activities, socialize with her peers, or eat with her peers. These failures resulted in Resident #14 having a decline physically, mentally, and psychosocially. She was sad and anxious. Resident #14 was no longer able to walk as she did when she was first admitted to the facility and she required more assistance with activities of daily living. She was talking about being with her husband who was no longer living and she was talking about needing to go to work. She no longer wanted to watch/hear the television. She wanted to "just sleep." These failures could affect the other two residents, who were bedfast, by placing them at risk of a physical decline, mental decline, and psychosocial decline and being in bed against their will. Findings included: Review of Resident #14's Medical Power of Attorney Disclosure Statement dated 03/19/07 revealed, "...Except to the extent you state otherwise, this document gives the person you name as your agent authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself... Your agent's authority begins when your doctor certifies that you lack the competence to make health care decisions. Your agent is obligated to follow your instructions when making decisions on your behalf... Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so and treatment cannot be given to you or stopped over your objection...." Review of Resident #14's admission MDS assessment dated [DATE] revealed the resident required limited assistance from one staff member for walking in her room and in the corridor, for moving between locations, for dressing, toilet use, and for personal hygiene. Resident #14 spent an average of one third to two thirds of her time in activities, and enjoyed exercise, sports, music, watching television and talking. Resident #14 did not have any restraints. Resident #14 used a wheelchair for her primary mode of locomotion, but also used a cane/walker/and or/crutch. Resident #14 was not bedfast. Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/29/07 revealed, "...May DC wander guard d/t (due to) bed bound...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/11/08 revealed, "...Please do not move or place this resident out of bed...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 07/07/09 revealed, "...Resident-not to be moved out of bed...." Review of Resident #14's Comprehensive Plan of Care dated 08/04/10, and updated 06/03/11 revealed, "Res. Has dementia and res. Stays in bed most of the day per POA (power of attorney) request...." According to the MDS assessment dated [DATE], Resident #14 was an [AGE] year-old female, admitted to the facility on [DATE] from an acute hospital, with [DIAGNOSES REDACTED]. Resident #14 usually understood others, missed some part/intent of message but comprehended most conversation, had a memory problem and was severely impaired for cognitive skills for daily decision-making. Resident #14 was at risk for developing pressure ulcers, and had a pressure relieving device on her bed. Resident #14 had side rails up every day. Resident #14 required total assistance from two or more staff for bed mobility, dressing, toilet use and personal hygiene. Resident #14 did not receive restorative nursing for passive or active range of motion, bed mobility, transfers, walking, dressing and/or grooming. She did not receive Psychological Therapy within the seven days of the assessment period. The resident did not present with inattention or disorganized thinking. Resident #14 did not move from a seated to a standing position, walk or transfer from one surface to another surface. Resident #14 did not use a cane/crutch, walker, or a wheelchair, per a recent quarterly MDS assessment dated [DATE]. Interview with LVN J on 06/14/11 at 10:05 a.m. revealed Resident #14 was bedfast and not allowed out of bed due to [MEDICAL CONDITION]. Resident #14 had a physician's orders [REDACTED]. The resident rarely had visitation by friends and was never visited by relatives. Resident #14 had a decline in ADLs, and never took part in activities. The resident's mattress was a pressure relieving mattress, and full padded side rails were up bilaterally blocking the resident's view of the room when in a supine position. Observation of Resident #14 revealed she was sleeping and scooted down in bed with both of her feet hanging out from between the left full side rail and the foot of the bed. Interview on 06/15/11 at 2:40 p.m. with the SW revealed Resident #14 had been confined to her bed for a minimum of three years. Resident #14's MPOA refused to allow the resident out of bed. Resident #14 had a physician's orders [REDACTED]. When asked why the resident was ordered bed bound, the SW revealed it was due to [MEDICAL CONDITION] activity that had not occurred since she had been employed at the facility approximately two years earlier. The SW stated attempts to talk to MD G about allowing Resident #14 out of bed had been futile. The SW revealed she did not know what to do and asked the surveyor if she should call the situation in to "the state," since she had informed the DON and the ADM on many occasions and nothing had been done. Interview on 06/15/11 at 3:05 p.m. with Resident #14 revealed when she was asked if she liked to stay in bed all the time, the resident frowned, shook her head no and said, "No, I'm going to work." Observation on 06/16/11 at 8:09 a.m. revealed Resident #14 lying on her back with padded full side rails up bilaterally, and the privacy curtain pulled between the resident and her roommate. Interview with Resident #26 on 06/16/11 at 8:12 a.m. revealed she was Resident #14's roommate. She revealed Resident #14 had "been saying she wants to get out of that bed, she's been saying it a lot lately. She stays in that bed day in and day out. I don't know how she stands it." Interview on 06/16/11 at 8:20 a.m. with CNA K revealed she had cared for Resident #14 for the last three days. She had not witnessed Resident #14 having any [MEDICAL CONDITION] activity. CNA K revealed she knew Resident #14 wanted to get out of bed because the resident told her she needed to get out of bed to go to work or to have lunch with her husband. CNA K stated Resident #14 seemed anxious during those times. Interview on 06/16/11 at 10:15 a.m. with the SW revealed she attended the monthly QA meetings along with the Medical Director, the DON, the ADM, and the AD. Resident #14 had never been discussed in the meetings she had attended. The SW revealed she would have been "happy" to share the information regarding Resident #14 in the QA meetings, but she "didn't know" she could bring it up. The ADM "doesn't ask for my input." The SW revealed she had informed the ADM about her concerns regarding Resident #14's bed bound status "ten times a month," and the DON was always asked to accompany her whenever she told the ADM her concerns about residents. The SW revealed, "They (the DON and ADM) just don't do anything about it." The SW revealed she had voiced her concerns regarding Resident #14 in multiple stand-up meetings. The SW stated Resident #14 appeared sad on many days. Resident #14 had declined cognitively. In recent months, she had talked more about her dead husband and wishing to see him. The SW revealed a few weeks ago when Resident #14 had a hair cut, the beautician was very upset and told the SW how Resident #14's MPOA insisted the beautician shave Resident #14's hair. When the beautician was cutting her hair, Resident #14 was crying and saying, "Please don't shave my head." Interview on 06/16/11 at 11:40 a.m. with ADON B revealed she had worked for the facility for approximately six years and had cared for Resident #14 since she entered the facility. ADON B revealed she had never witnessed Resident #14 having a [MEDICAL CONDITION] or a [MEDICAL CONDITION] spell. ADON B revealed only one time had she heard about the resident having a [MEDICAL CONDITION] episode, and it was when the resident was gotten out of bed after "a few months" of being confined to bed most of the time. ADON B revealed before there was a doctor's order for Resident #14 to remain in bed, the staff rarely got the resident out of bed, because Resident #14's MPOA insisted the resident remain in bed. The MPOA was at the facility daily and told the staff if they got the resident out of bed she would call MD G and tell him. ADON B revealed Resident #14 could carry on a conversation and answer questions appropriately. ADON B revealed, "She hasn't been deemed incompetent ... I'm not (MPOA's) favorite person because we've gone around and around about this issue ... Sometimes when you go in (Resident #14's room) she seems sad ... All she does is sleep now, she's so de-conditioned. She doesn't even want the noise of the TV on." When asked if Resident #14 experienced nausea and/or vomiting often, ADON B revealed the resident would not complain of nausea and vomiting, it was the MPOA who complained. ADON B revealed she had only seen what appeared to be "phlegm." ADON B revealed she talked to MD G about allowing Resident #14 out of her bed, but he would not do it. Once he replied with, "You have an order." Interview on 06/16/11 at 12:10 p.m. with LVN J revealed she had worked at the facility for one year, and had cared for Resident #14 for the last three to four months. LVN J revealed Resident #14 had to stay in bed or she would faint. LVN J stated she heard MD G say the resident had to stay in bed because she had [MEDICAL CONDITION]. LVN J stated Resident #14 sat up in bed to eat with her head of the bed at a "45 to 90 degree" angle. She stated she had not witnessed Resident #14 faint or have a problem with sitting up in bed. Resident #14's MPOA told LVN J Resident #14 had [MEDICAL CONDITION] before the resident was admitted to the facility and "it's just progressed." LVN J revealed after Resident #14's care plan meeting on 06/15/11 the MPOA said, "It would be a cold day in hell before she (Resident #14) gets out of bed." LVN J revealed Resident #14 seemed sad about two weeks ago. Resident #14 told LVN J, "I need to get out of here, I feel like I'm going crazy." Again, about a week ago, Resident #14 told LVN J she "needed to get out of here." Interview on 06/16/11 at 3:00 p.m. with MD G revealed, when he was asked what the reason was for confining Resident #14 to her bed for three years he stated, "She doesn't want to get up. She throws up. She hardly takes any medication, only Tylenol. She flatly refuses. I told her she should get up and go to lobby and she refused." When MD G was asked when this conversation took place with Resident #14, he revealed it had been longer than six months ago. MD G revealed anytime the resident had attempted to get up she vomited, and he was not sure if it was psychological or not. MD G revealed the last attempt to get Resident #14 out of bed was more than six months ago. MD G revealed he had not referred Resident #14 to a [MEDICATION NAME] or to a neurologist for a consultation. Resident #14 was seen three years ago by a psychiatrist, but "was stopped." Resident #14 had not been seen by a psychiatrist, "because of her improvement since three years ago. She eats by herself, and she has no bed sores." MD G denied knowledge about Resident #14's feelings of sadness or anxiousness. MD G revealed he wrote the order to stay in bed, because the facility "got me to write the order because of what the resident expressed." MD G revealed he was not opposed to staff getting Resident #14 out of bed. "If staff got her up then that's okay." When MD G was asked how staff would know it was okay to get Resident #14 out of bed, when they had an order saying not to get the resident out of the bed, he remained silent. MD G revealed the staff talked to him about Resident #14 "two or three weeks ago." MD G did not reveal the details of the conversation with staff or who he talked to. MD G stated, "She (Resident #14) knows what she wants and what she doesn't want. So in that way she's competent, but other times she doesn't know why she's in the facility. She has periods of confusion. She has a Medical Power of Attorney. I haven't made any attempts to deem her incompetent. I haven't put it in writing." MD G revealed, "I' m going to check on her and talk and see what she expresses." When MD G was asked what his goals were for Resident #14 he stated, "Keep stable condition, she's just on one medication." When MD G was asked what the risks were if Resident #14 got out of bed, he stated, "Vomiting and self wishes." When MD G was asked what the risks were if Resident #14 remained in bed, he stated, "[MEDICAL CONDITION]." When MD G was asked if the resident was at risk for developing a [MEDICAL CONDITION] embolism, he revealed she was at risk. MD G revealed he would not come to see the resident until 06/21/11. Review of Resident #14's Medical Power of Attorney dated 03/19/07 revealed, "...I hereby require my agent to direct my physician to comply with any valid Directive to Physicians (or similar document) which I may have heretofore executed or which I my hereafter execute. My agent is not authorized to direct my physician in a manner which would contradict any such valid Directive to Physicians (or similar document)...." Review of Resident #14's Directive to Physicians and Family or Surrogates dated 03/19/07 revealed, "...I, (Resident #14), recognize that the best health care is based upon a partnership of trust and communication with my physician. My physician and I will make health care decisions together as long as I am of sound mind and able to make my wishes known...." Interview on 06/16/11 at 4:25 p.m. with the ADM revealed, when he was asked what his knowledge was of Resident #14, he revealed she had a MPOA who was "adamant" about keeping her in bed. The resident's name had not come up often because she had not had a change in condition. The ADM stated he had heard the resident wanted to get out of bed in some stand up meetings. The ADM revealed Resident #14 might want to get out of bed, while others did not want her to, but the resident must be protected. When the ADM was asked if he ever asked the resident if she wanted to get out of bed, he stated he had not. When the ADM was reminded Resident #14 had been confined to her bed for over three years, he replied, "Hearing that makes me feel real bad." The ADM denied any staff had expressed their concerns of Resident #14 being confined to bed. "If they did I don't remember." The ADM revealed no one told him the resident was made to stay in bed. The ADM revealed staff "may have made passing comments," about Resident #14 staying in bed. The ADM revealed he thought there was "an intimidation factor" involved, and "confusion" about the MPOA's "power." The ADM was informed by the surveyor there was no documentation to be found in Resident #14's clinical record indicating the resident was deemed incompetent by a court of law or by a physician. The ADM revealed he would look into it. The ADM revealed the facility was trying to get a care plan meeting scheduled for the following day for Resident #14. Interview with the DON on 06/16/11 at 5:20 p.m. with the ADM present, revealed the DON began employment at the facility on 01/08/08. The DON was aware since the beginning of her employment Resident #14's MPOA had requested Resident #14 remain in bed, and the MPOA had talked to MD G about it. The DON stated the MPOA wanted Resident #14 to stay in bed due to [MEDICAL CONDITION] occurring when the resident was moved out of bed. When the DON was asked if she was aware of any [MEDICAL CONDITION] activity experienced by Resident #14, she revealed she was not aware of any [MEDICAL CONDITION] activity. The DON revealed MD G had written the order for Resident #14 to stay in bed due to [MEDICAL CONDITION] and vomiting when the resident sat up. The DON revealed three years ago she suggested to Resident #14's MPOA that the resident should be allowed to get out of bed. The DON stated she suggested letting Resident #14 get out of bed several times to her MPOA and to her nurses. The DON denied ever speaking to MD G about allowing Resident #14 out of her bed. When the DON was asked when did the decision of a MPOA supersede a resident's right, she replied, "If it's egregious as in this case I refer back to the physician's orders [REDACTED].#14's confinement to bed, she replied, "Not in the last two to three weeks." The DON revealed, "CNAs have made comments," but there were no specific conversations with any staff voicing their concerns about Resident #14's confinement to bed for three years. When the DON was asked why Resident #14's MPOA was able to dictate to the staff about the resident's confinement to bed for three years, she remained silent. The DON stated she had attended the last few minutes of Resident #14's most recent care plan meeting with the MPOA. The DON also stated the SW was present and there was a discussion about allowing the resident to get out of bed. The DON revealed she told the MPOA how the resident stayed in the bed all the time looking at the same four walls, and the MPOA responded with, "Well, she has Dementia." The MPOA stated during the care plan meeting, "If you get her out of bed, and if she dies two months later, I will sue you." The DON revealed she told the ADM about the care plan meeting. The DON stated in the last four to five months the MPOA requested a "buzz cut" for Resident #14. The SW talked to Resident #14, and the resident did not want it cut, but the MPOA wanted it cut, so Resident #14 got a "buzz cut." When the DON was asked if hair cuts fell under the decision-making of a MPOA, she replied, "I don't believe so." The DON stated, "I went to talk to her about it, and she had her eyes closed." When the DON was asked why she thought no one had intervened to allow Resident #14 out of bed, she stated, "I don't believe it was complacency. I believe it was a frustration and resignation, and there wasn't anything done. I'm speaking for myself." When the surveyor asked the DON what her role was in her position as the facility's DON, she stated, "In addition to the clinical aspect, I address psychosocial issues, and I'm a liaison and advocate for the residents." Observation on 06/17/11 at 9:15 a.m. revealed Resident #14 was lying on her back with the head of the bed at approximately 30 degrees. The resident was sleeping with the privacy curtain closed between her and her roommate. The resident's hair was approximately one inch in length. Full padded side rails remained up bilaterally. Interview on 06/17/11 at 9:30 a.m. with ADON B revealed she talked to Resident #14 the night before about her meal preferences, and the resident told her she did not like onions or cold cereal. ADON B revealed Resident #14 was very appropriate in her answers to ADON B's questions. Interview on 06/17/11 at 10:00 a.m. with Resident #14 revealed, when the surveyor asked the resident if she like her hair cut short she looked at the surveyor and stated, "Well, no. Would you?" Interview on 06/17/11 at 10:30 a.m. with CNA L revealed except for approximately ten months, she worked at the facility since the year 2003. CNA L had always taken care of Resident #14 "most of the time." CNA L revealed upon Resident #14's admission, she was getting out of bed and was talking more than at the present time. Resident #14's last shower was "almost four years ago." CNA L revealed the resident only fainted one time that she knew of and she did not witness the [MEDICAL CONDITION] spell. CNA L revealed the full side rails were up on Resident #14's bed to keep her in bed. "She was always trying to get up and get out of bed. If they hadn't been on she would have gotten up." CNA L revealed Resident #14's MPOA told her the resident was not allowed out of the bed, "Doctor said." Resident #14 "always wants to get up. At least one to two times a week." CNA L stated Resident #14 would say, "I'm just ready to get up and get dressed." Resident #14 appeared to be anxious when she wanted out of bed. Before CNA L left her employment with the facility for ten months, Resident #14 often scooted to the end of the bed and put her feet out at the corner. CNA L would ask her what she was doing and Resident #14 would say, "I'm just trying to get up." CNA L returned to work at the facility in March 2011. Resident #14's MPOA told CNA L recently she wanted to be "the first one called if she gets up." CNA L revealed she thought because of Resident #14's MPOA, "She's accepted she can't get up and that's why she doesn't try to get up." CNA L revealed Resident #14 doesn't have activities, "at all." Resident #14 "doesn't even watch TV or want it on." Resident #14 told CNA L, "Just let me sleep." CNA L revealed Resident #14 was able to bear weight before she was ordered to stay in bed. "We rarely got her out of bed before there was a doctor's order." Resident #14's MPOA "didn't want her out of bed." Interview on 06/17/11 at 1:00 p.m. with the facility's current beautician revealed Resident #14's MPOA came to the beautician and told her she wanted Resident #14's hair "all off. I want it real dikey-shaved off." The beautician revealed she did not cut Resident #14's hair as short as she was instructed to cut it. She stated Resident #14 "begged me the whole time not to cut her hair off." Later Resident #14's MPOA came to the beautician and told her she did not cut it the way she told her to cut it. The beautician told Resident #4's MPOA, "She begged me not to cut it the whole time, she was very upset." The MPOA told the beautician, "She doesn't know what she wants. I'm not paying for her hair to be cut more than once a year." The beautician revealed she would not cut a resident's hair that short if they did not want it that short. The beautician stated Resident #14 "didn't deserve that. She deserves a little bit of dignity. Hair cuts cost $15, Come on." The beautician revealed she had been the only beautician since September 2010 and that was the first time she had cut Resident #14's hair. Interview on 06/17/11 at 1:15 p.m. with CNA M revealed she assisted the beautician when she cut Resident #14's hair. Resident #14 was very upset and kept telling the beautician she did not want her hair cut. CNA M stated Resident #14's MPOA wanted it cut short. Resident #14's hair was cut "around a month ago." The MPOA complained Resident #14's hair was not short enough. CNA M stated Resident #14 had been requesting to get out of bed "a lot for about two months. Almost every time you go in there she wants to get out of bed. She scoots to the end of the bed, because she's trying to get out. When she tries to get out of bed she's acting anxious." Interview on 06/17/11 at 1:30 p.m. with the SW revealed Resident #14 had her hair "buzzed twice" that she knew of. The first time was with another beautician, and she shaved it. The SW stated Resident #14's MPOA requested that it be shaved. After the last hair cut, the SW revealed she went to Resident #14 and asked her about her hair cut. Resident #14 told the SW she "didn't want it like this." The SW revealed she "went directly" to the ADM and asked the DON to accompany her, which she did. The SW informed the DON and the ADM what had happened with Resident #14's hair. The SW asked the DON during the most recent care plan meeting for Resident #14 if she was going to report her concerns for Resident #14 to DADS. The DON told the SW she would talk to the ADM about "reporting it." When the SW was asked if she thought to report her concerns to DADS, she revealed, "There is a chain of command of calling in a complaint." She reported her concerns to the DON, who reported to the ADM. The ADM told the SW about another social worker who had called a complaint in and lost her job. The SW revealed she told the ADM it was not a complaint against MD G, but Resident #14 needed to be out of bed. The SW stated, "My regret is I didn't go ahead and call state." The SW stated she was told by the DON and the ADM, "We have an order and that's the way it is, and (MPOA) wants it." The SW stated she asked if Resident #14 could be rolled out into the hall while in her bed, but was told the bed would not fit through the door. The SW revealed she asked MD G, "Do I get to get her out of bed today?" MD G "just shakes his head no." The SW revealed a care plan meeting for Resident #14 was scheduled for today, and she was not invited to attend because the MPOA was going to attend and might get defensive if the SW was there. Interview on 06/17/11 at 2:20 p.m. with the facility's Medical Director revealed he had been the facility's Medical Director since March 2010. He stated as the Medical Director he attended the monthly QA meetings, made sure resident care policies were implemented, he was available to the nursing facility for their issues and he was a liaison between the facility and the residents. When asked by the surveyor how he ensured other physicians at the facility were caring for and treating the residents appropriately, the Medical Director revealed, "That falls on the nursing facility, and they have to alert me. Standard of care has to be met." The Medical Director stated he first learned of the issues surrounding Resident #14 yesterday. The Medical Director stated, "Looking back I should have been told about (MPOA) and her role, and more about the resident. It makes it tough hearing about the demands that were made. Tough for the nursing facility when trying to make people happy. There were threats of lawsuit. You can't give into demands that aren't reasonable and demands that make no sense." When the Medical Director was asked by the surveyor if he thought it was unreasonable to have a resident stay in bed when the resident was asking to get up, he replied, "Yes, I have a problem with that." The Medical Director revealed the risks of staying in bed included infections, decubitus ulcers, and blood clots. "Those are the big ones I think of first. " Observation on 06/17/11 at 2:10 p.m. revealed Resident #14 was in her Geri chair sitting in the hall. The resident was calm and without distress. The resident was smiling and talking to her MPOA. The MPOA was asking the resident if she would like for her to bring her some food. Resident #14 stated, "I want a hamburger with French fries and water." The MPOA asked the resident what color of cup she would like her to bring. Resident #14 said, "White." The MPOA stated, "Why white? How about red, green or blue?" Resident #14 stated, "I like white." The MPOA stated, "I don't think they have white." Resident #14 stated, "Well, then I'll take green." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "...N.O. To have resident OOB (out of bed), sitting up in Geri-chair as tolerated. The First Three Days, maximum from 15 to 20 minutes as tolerated...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "Order clarification: N.O. to D/C order To 'Do Not Move or Place Pt. out of bed QD (everyday)...." Review of Resident #14's SOCIAL PROGRESS NOTES dated 07/21/09 revealed, "Met w/(DON, ADM) ... in regards to (Resident #14) and her quality of life, or lack there of, while she remains in bed 24/7. I have discussed my concerns w/these staff members and requested an evaluation from therapy. A psych consult has been recommended and I will request an order to be written for a psych consult...." Review of Resident #14's SOCIAL PROGRESS NOTES revealed, " 06/02/10 ... (MPOA) remains w/o concern that resident stays in bed. (MPOA) visits 2-3 times per month. Resident has no other contact w/family or friends. Resident remains alert ... 09/12/2010 ... Resident remains isolated in her room @ the request of her poa (MPOA)... she is kept from socialization ... She is alert and oriented to self. She has requested numerous times to get out of bed...." Review of Resident #14's SOCIAL PROGRESS NOTES revealed, "01/05/11 ... Resident remains in bed, flat on her back, receives bed baths and is w/o socialization of her peers. Her only socialization is the nurses and aids who visit her room and tend to her medical needs. I have concern and have voiced my concerns w/(MD G) and Administrator. (MPOA) is aware of my concerns and becomes extremely rude and irritable when I address these concerns. Review of SOCIAL PROGRESS NOTES dated 05/10/11 revealed, "...I asked (MPOA) if she was aware that resident did not want her hair buzzed. (MPOA) became very upset and told me it did not matter what resident wanted I informed (MPOA) that it does matter and the beautician should not have cut her hair. I informed (MPOA) it is very important what (Resident #14) wants. I explained to (MPOA) that (Resident #14) was begging the beautician to not cut her hair off. (MPOA) asked me to stop hassling her and this was not up for debate...." Review of SOCIAL PROGRESS NOTES dated 06/15/11 revealed, "... commented 'I knew I was coming into a snake pit.' I explained to (MPOA) that because resident is kept isolated and has been a prisoner here, unable to socialize, participate in activities, breathe fresh air I believe this is abusive. I also reiterated my concern about having residents head nearly shaved, knowing this upsets (Resident #14) and denying her dental care is all very neglectful and abusive. I explained to her that despite her (Resident #14) cognitive demise resident has rights to a better quality of life, free from abuse....I described this situation as sad and pathetic and extremely unfair. (MPOA) commented, 'If you get her out of bed, its your ass and I will have an attorney up.' I replied that's fine ... (MPOA) remained unconcerned and left the meeting voicing her opinion to staff. (DON) was present for a portion of this care plan and she states she will inform (Administrator) of this griev. (grievance)...." Review of the facility's current identified policy for Resident Rights dated June 2008 revealed, "...Policy The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility... Facility staff will assist residents in exercising their rights. Facility staff will not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her rights... Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety...." The CMS Form 672 signed by the DON and dated 06/14/11 reflected a census of 87 residents with three residents identified as bedfast all or most of the time.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #14) of 18 residents reviewed for care, was free from involuntary seclusion, and physical and mental abuse. Resident #14 was confined to her bed for three years with full padded side rails due to the demands of her Medical Power of Attorney (MPOA). Resident #14 voiced many times that she wanted out of bed and she tried to climb out of bed. Resident #14 was forced to have her hair cut short against her will. Resident #14 begged the beautician not to cut her hair so short. Her MPOA said it did not matter what Resident #14 wanted. She had not received showers, only bed baths. Resident #14 was not allowed to attend activities, socialize with her peers, or eat with her peers. These failures resulted in Resident #14 having a decline physically, mentally, and psychosocially. She was sad and anxious. Resident #14 was no longer able to walk as she did when she was first admitted to the facility and she required more assistance with activities of daily living. She was talking about being with her husband who was no longer living and she was talking about needing to go to work. She no longer wanted to watch/hear the television. She wanted to "just sleep." These failures could affect the other two residents, who were bedfast, by placing them at risk of a physical decline, mental decline, and psychosocial decline and being in bed against their will. Findings included: Review of Resident #14's Medical Power of Attorney Disclosure Statement dated 03/19/07 revealed, "...Except to the extent you state otherwise, this document gives the person you name as your agent authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself... Your agent's authority begins when your doctor certifies that you lack the competence to make health care decisions. Your agent is obligated to follow your instructions when making decisions on your behalf... Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so and treatment cannot be given to you or stopped over your objection...." Review of Resident #14's admission MDS assessment dated [DATE] revealed the resident required limited assistance from one staff member for walking in her room and in the corridor, for moving between locations, for dressing, toilet use, and for personal hygiene. Resident #14 spent an average of one third to two thirds of her time in activities, and enjoyed exercise, sports, music, watching television and talking. Resident #14 did not have any restraints. Resident #14 used a wheelchair for her primary mode of locomotion, but also used a cane/walker/and or/crutch. Resident #14 was not bedfast. Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/29/07 revealed, "...May DC wander guard d/t (due to) bed bound...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/11/08 revealed, "...Please do not move or place this resident out of bed...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 07/07/09 revealed, "...Resident-not to be moved out of bed...." Review of Resident #14's Comprehensive Plan of Care dated 08/04/10, and updated 06/03/11 revealed, "Res. Has dementia and res. Stays in bed most of the day per POA (power of attorney) request...." According to the MDS assessment dated [DATE], Resident #14 was an [AGE] year-old female, admitted to the facility on [DATE] from an acute hospital, with [DIAGNOSES REDACTED]. Resident #14 usually understood others, missed some part/intent of message but comprehended most conversation, had a memory problem and was severely impaired for cognitive skills for daily decision-making. Resident #14 was at risk for developing pressure ulcers, and had a pressure relieving device on her bed. Resident #14 had side rails up every day. Resident #14 required total assistance from two or more staff for bed mobility, dressing, toilet use and personal hygiene. Resident #14 did not receive restorative nursing for passive or active range of motion, bed mobility, transfers, walking, dressing and/or grooming. She did not receive Psychological Therapy within the seven days of the assessment period. The resident did not present with inattention or disorganized thinking. Resident #14 did not move from a seated to a standing position, walk or transfer from one surface to another surface. Resident #14 did not use a cane/crutch, walker, or a wheelchair, per a recent quarterly MDS assessment dated [DATE]. Interview with LVN J on 06/14/11 at 10:05 a.m. revealed Resident #14 was bedfast and not allowed out of bed due to [MEDICAL CONDITION]. Resident #14 had a physician's orders [REDACTED]. The resident rarely had visitation by friends and was never visited by relatives. Resident #14 had a decline in ADLs, and never took part in activities. The resident's mattress was a pressure relieving mattress, and full padded side rails were up bilaterally blocking the resident's view of the room when in a supine position. Observation of Resident #14 revealed she was sleeping and scooted down in bed with both of her feet hanging out from between the left full side rail and the foot of the bed. The privacy curtain was pulled between Resident #14 and her roommate. Interview on 06/15/11 at 2:40 p.m. with the SW revealed Resident #14 had been confined to her bed for a minimum of three years. Resident #14's MPOA refused to allow the resident out of bed. Resident #14 had a physician's orders [REDACTED]. When asked why the resident was ordered bed bound, the SW revealed it was due to [MEDICAL CONDITION] activity that had not occurred since she had been employed at the facility approximately two years earlier. The SW stated attempts to talk to MD G about allowing Resident #14 out of bed had been futile. The SW revealed she did not know what to do and asked the surveyor if she should call the situation in to "the state," since she had informed the DON and the ADM on many occasions and nothing had been done. Interview on 06/15/11 at 3:05 p.m. with Resident #14 revealed when she was asked if she liked to stay in bed all the time, the resident frowned, shook her head no and said, "No, I'm going to work." Observation on 06/16/11 at 8:09 a.m. revealed Resident #14 lying on her back with padded full side rails up bilaterally, and the privacy curtain pulled between the resident and her roommate. Interview with Resident #26 on 06/16/11 at 8:12 a.m. revealed she was Resident #14's roommate. She revealed Resident #14 had "been saying she wants to get out of that bed, she's been saying it a lot lately. She stays in that bed day in and day out. I don't know how she stands it." Interview on 06/16/11 at 8:20 a.m. with CNA K revealed she had cared for Resident #14 for the last three days. She had not witnessed Resident #14 having any [MEDICAL CONDITION] activity. CNA K revealed she knew Resident #14 wanted to get out of bed because the resident told her she needed to get out of bed to go to work or to have lunch with her husband. CNA K stated Resident #14 seemed anxious during those times. Interview on 06/16/11 at 10:15 a.m. with the SW revealed she attended the monthly QA meetings along with the Medical Director, the DON, the ADM, and the AD. Resident #14 had never been discussed in the meetings she had attended. The SW revealed she would have been "happy" to share the information regarding Resident #14 in the QA meetings, but she "didn't know" she could bring it up. The ADM "doesn't ask for my input." The SW revealed she had informed the ADM about her concerns regarding Resident #14's bed bound status "ten times a month," and the DON was always asked to accompany her whenever she told the ADM her concerns about residents. The SW revealed, "They (the DON and ADM) just don't do anything about it." The SW revealed she had voiced her concerns regarding Resident #14 in multiple stand-up meetings. The SW stated Resident #14 appeared sad on many days. Resident #14 had declined cognitively. In recent months, she had talked more about her dead husband and wishing to see him. The SW revealed a few weeks ago when Resident #14 had a hair cut, the beautician was very upset and told the SW how Resident #14's MPOA insisted the beautician shave Resident #14's hair. When the beautician was cutting her hair, Resident #14 was crying and saying, "Please don't shave my head." Interview on 06/16/11 at 11:40 a.m. with ADON B revealed she had worked for the facility for approximately six years and had cared for Resident #14 since she entered the facility. ADON B revealed she had never witnessed Resident #14 having a [MEDICAL CONDITION] or a [MEDICAL CONDITION] spell. ADON B revealed only one time had she heard about the resident having a [MEDICAL CONDITION] episode, and it was when the resident was gotten out of bed after "a few months" of being confined to bed most of the time. ADON B revealed before there was a doctor's order for Resident #14 to remain in bed, the staff rarely got the resident out of bed, because Resident #14's MPOA insisted the resident remain in bed. The MPOA was at the facility daily and told the staff if they got the resident out of bed she would call MD G and tell him. ADON B revealed Resident #14 could carry on a conversation and answer questions appropriately. ADON B revealed, "She hasn't been deemed incompetent ... I'm not (MPOA's) favorite person because we've gone around and around about this issue ... Sometimes when you go in (Resident #14's room) she seems sad ... All she does is sleep now, she's so de-conditioned. She doesn't even want the noise of the TV on." When asked if Resident #14 experienced nausea and/or vomiting often, ADON B revealed the resident would not complain of nausea and vomiting, it was the MPOA who complained. ADON B revealed she had only seen what appeared to be "phlegm." ADON B revealed she talked to MD G about allowing Resident #14 out of her bed, but he would not do it. Once he replied with, "You have an order." Interview on 06/16/11 at 12:10 p.m. with LVN J revealed she had worked at the facility for one year, and had cared for Resident #14 for the last three to four months. LVN J revealed Resident #14 had to stay in bed or she would faint. LVN J stated she heard MD G say the resident had to stay in bed because she had [MEDICAL CONDITION]. LVN J stated Resident #14 sat up in bed to eat with her head of the bed at a "45 to 90 degree" angle. She stated she had not witnessed Resident #14 faint or have a problem with sitting up in bed. Resident #14's MPOA told LVN J Resident #14 had [MEDICAL CONDITION] before the resident was admitted to the facility and "it's just progressed." LVN J revealed after Resident #14's care plan meeting on 06/15/11 the MPOA said, "It would be a cold day in hell before she (Resident #14) gets out of bed." LVN J revealed Resident #14 seemed sad about two weeks ago. Resident #14 told LVN J, "I need to get out of here, I feel like I'm going crazy." Again, about a week ago, Resident #14 told LVN J she "needed to get out of here." Interview on 06/16/11 at 3:00 p.m. with MD G revealed, when he was asked what the reason was for confining Resident #14 to her bed for three years he stated, "She doesn't want to get up. She throws up. She hardly takes any medication, only Tylenol. She flatly refuses. I told her she should get up and go to lobby and she refused." When MD G was asked when this conversation took place with Resident #14, he revealed it had been longer than six months ago. MD G revealed anytime the resident had attempted to get up she vomited, and he was not sure if it was psychological or not. MD G revealed the last attempt to get Resident #14 out of bed was more than six months ago. MD G revealed he had not referred Resident #14 to a [MEDICATION NAME] or to a neurologist for a consultation. Resident #14 was seen three years ago by a psychiatrist, but "was stopped." Resident #14 had not been seen by a psychiatrist, "because of her improvement since three years ago. She eats by herself, and she has no bed sores." MD G denied knowledge about Resident #14's feelings of sadness or anxiousness. MD G revealed he wrote the order to stay in bed, because the facility "got me to write the order because of what the resident expressed." MD G revealed he was not opposed to staff getting Resident #14 out of bed. "If staff got her up then that's okay." When MD G was asked how staff would know it was okay to get Resident #14 out of bed, when they had an order saying not to get the resident out of the bed, he remained silent. MD G revealed the staff talked to him about Resident #14 "two or three weeks ago." MD G did not reveal the details of the conversation with staff or who he talked to. MD G stated, "She (Resident #14) knows what she wants and what she doesn't want. So in that way she's competent, but other times she doesn't know why she's in the facility. She has periods of confusion. She has a Medical Power of Attorney. I haven't made any attempts to deem her incompetent. I haven't put it in writing." MD G revealed, "I'm going to check on her and talk and see what she expresses." When MD G was asked what his goals were for Resident #14 he stated, "Keep stable condition, she's just on one medication." When MD G was asked what the risks were if Resident #14 got out of bed, he stated, "Vomiting and self wishes." When MD G was asked what the risks were if Resident #14 remained in bed, he stated, "[MEDICAL CONDITION]." When MD G was asked if the resident was at risk for developing a [MEDICAL CONDITION] embolism, he revealed she was at risk. MD G revealed he would not come to see the resident until 06/21/11. Review of Resident #14's Medical Power of Attorney dated 03/19/07 revealed, "...I hereby require my agent to direct my physician to comply with any valid Directive to Physicians (or similar document) which I may have heretofore executed or which I my hereafter execute. My agent is not authorized to direct my physician in a manner which would contradict any such valid Directive to Physicians (or similar document)...." Review of Resident #14's Directive to Physicians and Family or Surrogates dated 03/19/07 revealed, "...I, (Resident #14), recognize that the best health care is based upon a partnership of trust and communication with my physician. My physician and I will make health care decisions together as long as I am of sound mind and able to make my wishes known...." Interview on 06/16/11 at 4:25 p.m. with the ADM revealed, when he was asked what his knowledge was of Resident #14, he revealed she had a MPOA who was "adamant" about keeping her in bed. The resident's name had not come up often because she had not had a change in condition. The ADM stated he had heard the resident wanted to get out of bed in some stand up meetings. The ADM revealed Resident #14 might want to get out of bed, while others did not want her to, but the resident must be protected. When the ADM was asked if he ever asked the resident if she wanted to get out of bed, he stated he had not. When the ADM was reminded Resident #14 had been confined to her bed for over three years, he replied, "Hearing that makes me feel real bad." The ADM denied any staff had expressed their concerns of Resident #14 being confined to bed. "If they did I don't remember." The ADM revealed no one told him the resident was made to stay in bed. The ADM revealed staff "may have made passing comments," about Resident #14 staying in bed. The ADM revealed he thought there was "an intimidation factor" involved, and "confusion" about the MPOA's "power." The ADM was informed by the surveyor there was no documentation to be found in Resident #14's clinical record indicating the resident was deemed incompetent by a court of law or by a physician. The ADM revealed he would look into it. The ADM revealed the facility was trying to get a care plan meeting scheduled for the following day for Resident #14. Interview with the DON on 06/16/11 at 5:20 p.m. with the ADM present, revealed the DON began employment at the facility on 01/08/08. The DON was aware since the beginning of her employment Resident #14's MPOA had requested Resident #14 remain in bed, and the MPOA had talked to MD G about it. The DON stated the MPOA wanted Resident #14 to stay in bed due to [MEDICAL CONDITION] occurring when the resident was moved out of bed. When the DON was asked if she was aware of any [MEDICAL CONDITION] activity experienced by Resident #14, she revealed she was not aware of any [MEDICAL CONDITION] activity. The DON revealed MD G had written the order for Resident #14 to stay in bed due to [MEDICAL CONDITION] and vomiting when the resident sat up. The DON revealed three years ago she suggested to Resident #14's MPOA that the resident should be allowed to get out of bed. The DON stated she suggested letting Resident #14 get out of bed several times to her MPOA and to her nurses. The DON denied ever speaking to MD G about allowing Resident #14 out of her bed. When the DON was asked when did the decision of a MPOA supersede a resident's right, she replied, "If it's egregious as in this case I refer back to the physician's orders [REDACTED].#14's confinement to bed, she replied, "Not in the last two to three weeks." The DON revealed, "CNAs have made comments," but there were no specific conversations with any staff voicing their concerns about Resident #14's confinement to bed for three years. When the DON was asked why Resident #14's MPOA was able to dictate to the staff about the resident's confinement to bed for three years, she remained silent. The DON stated she had attended the last few minutes of Resident #14's most recent care plan meeting with the MPOA. The DON also stated the SW was present and there was a discussion about allowing the resident to get out of bed. The DON revealed she told the MPOA how the resident stayed in the bed all the time looking at the same four walls, and the MPOA responded with, "Well, she has Dementia." The MPOA stated during the care plan meeting, "If you get her out of bed, and if she dies two months later, I will sue you." The DON revealed she told the ADM about the care plan meeting. The DON stated in the last four to five months the MPOA requested a "buzz cut" for Resident #14. The SW talked to Resident #14, and the resident did not want it cut, but the MPOA wanted it cut, so Resident #14 got a "buzz cut." When the DON was asked if hair cuts fell under the decision-making of a MPOA, she replied, "I don't believe so." The DON stated, "I went to talk to her about it, and she had her eyes closed." When the DON was asked why she thought no one had intervened to allow Resident #14 out of bed, she stated, "I don't believe it was complacency. I believe it was a frustration and resignation, and there wasn't anything done. I'm speaking for myself." When the surveyor asked the DON what her role was in her position as the facility's DON, she stated, "In addition to the clinical aspect, I address psychosocial issues, and I'm a liaison and advocate for the residents." Observation on 06/17/11 at 9:15 a.m. revealed Resident #14 was lying on her back with the head of the bed at approximately 30 degrees. The resident was sleeping with the privacy curtain closed between her and her roommate. The resident's hair was approximately one inch in length. Full padded side rails remained up bilaterally. Interview on 06/17/11 at 9:30 a.m. with ADON B revealed she talked to Resident #14 the night before about her meal preferences, and the resident told her she did not like onions or cold cereal. ADON B revealed Resident #14 was very appropriate in her answers to ADON B's questions. Interview on 06/17/11 at 10:00 a.m. with Resident #14 revealed, when the surveyor asked the resident if she like her hair cut short she looked at the surveyor and stated, "Well, no. Would you?" Interview on 06/17/11 at 10:30 a.m. with CNA L revealed except for approximately ten months, she worked at the facility since the year 2003. CNA L had always taken care of Resident #14 "most of the time." CNA L revealed upon Resident #14's admission, she was getting out of bed and was talking more than at the present time. Resident #14's last shower was "almost four years ago." CNA L revealed the resident only fainted one time that she knew of and she did not witness the [MEDICAL CONDITION] spell. CNA L revealed the full side rails were up on Resident #14's bed to keep her in bed. "She was always trying to get up and get out of bed. If they hadn't been on she would have gotten up." CNA L revealed Resident #14's MPOA told her the resident was not allowed out of the bed, "Doctor said." Resident #14 "always wants to get up. At least one to two times a week." CNA L stated Resident #14 would say, "I'm just ready to get up and get dressed." Resident #14 appeared to be anxious when she wanted out of bed. Before CNA L left her employment with the facility for ten months, Resident #14 often scooted to the end of the bed and put her feet out at the corner. CNA L would ask her what she was doing and Resident #14 would say, "I'm just trying to get up." CNA L returned to work at the facility in March 2011. Resident #14's MPOA told CNA L recently she wanted to be "the first one called if she gets up." CNA L revealed she thought because of Resident #14's MPOA, "She's accepted she can't get up and that's why she doesn't try to get up." CNA L revealed Resident #14 doesn't have activities, "at all." Resident #14 "doesn't even watch TV or want it on." Resident #14 told CNA L, "Just let me sleep." CNA L revealed Resident #14 was able to bear weight before she was ordered to stay in bed. "We rarely got her out of bed before there was a doctor's order." Resident #14's MPOA "didn't want her out of bed." Interview on 06/17/11 at 1:00 p.m. with the facility's current beautician revealed Resident #14's MPOA came to the beautician and told her she wanted Resident #14's hair "all off. I want it real dikey-shaved off." The beautician revealed she did not cut Resident #14's hair as short as she was instructed to cut it. She stated Resident #14 "begged me the whole time not to cut her hair off." Later Resident #14's MPOA came to the beautician and told her she did not cut it the way she told her to cut it. The beautician told Resident #4's MPOA, "She begged me not to cut it the whole time, she was very upset." The MPOA told the beautician, "She doesn't know what she wants. I'm not paying for her hair to be cut more than once a year." The beautician revealed she would not cut a resident's hair that short if they did not want it that short. The beautician stated Resident #14 "didn't deserve that. She deserves a little bit of dignity. Hair cuts cost $15, Come on." The beautician revealed she had been the only beautician since September 2010 and that was the first time she had cut Resident #14's hair. Interview on 06/17/11 at 1:15 p.m. with CNA M revealed she assisted the beautician when she cut Resident #14's hair. Resident #14 was very upset and kept telling the beautician she did not want her hair cut. CNA M stated Resident #14's MPOA wanted it cut short. Resident #14's hair was cut "around a month ago." The MPOA complained Resident #14's hair was not short enough. CNA M stated Resident #14 had been requesting to get out of bed "a lot for about two months. Almost every time you go in there she wants to get out of bed. She scoots to the end of the bed, because she's trying to get out. When she tries to get out of bed she's acting anxious." Interview on 06/17/11 at 1:30 p.m. with the SW revealed Resident #14 had her hair "buzzed twice" that she knew of. The first time was with another beautician, and she shaved it. The SW stated Resident #14's MPOA requested that it be shaved. After the last hair cut, the SW revealed she went to Resident #14 and asked her about her hair cut. Resident #14 told the SW she "didn't want it like this." The SW revealed she "went directly" to the ADM and asked the DON to accompany her, which she did. The SW informed the DON and the ADM what had happened with Resident #14's hair. The SW asked the DON during the most recent care plan meeting for Resident #14 if she was going to report her concerns for Resident #14 to DADS. The DON told the SW she would talk to the ADM about "reporting it." When the SW was asked if she thought to report her concerns to DADS, she revealed, "There is a chain of command of calling in a complaint." She reported her concerns to the DON, who reported to the ADM. The ADM told the SW about another social worker who had called a complaint in and lost her job. The SW revealed she told the ADM it was not a complaint against MD G, but Resident #14 needed to be out of bed. The SW stated, "My regret is I didn't go ahead and call state." The SW stated she was told by the DON and the ADM, "We have an order and that's the way it is, and (MPOA) wants it." The SW stated she asked if Resident #14 could be rolled out into the hall while in her bed, but was told the bed would not fit through the door. The SW revealed she asked MD G, "Do I get to get her out of bed today?" MD G "just shakes his head no." The SW revealed a care plan meeting for Resident #14 was scheduled for today, and she was not invited to attend because the MPOA was going to attend and might get defensive if the SW was there. Interview on 06/17/11 at 2:20 p.m. with the facility's Medical Director revealed he had been the facility's Medical Director since March 2010. He stated as the Medical Director he attended the monthly QA meetings, made sure resident care policies were implemented, he was available to the nursing facility for their issues and he was a liaison between the facility and the residents. When asked by the surveyor how he ensured other physicians at the facility were caring for and treating the residents appropriately, the Medical Director revealed, "That falls on the nursing facility, and they have to alert me. Standard of care has to be met." The Medical Director stated he first learned of the issues surrounding Resident #14 yesterday. The Medical Director stated, "Looking back I should have been told about (MPOA) and her role, and more about the resident. It makes it tough hearing about the demands that were made. Tough for the nursing facility when trying to make people happy. There were threats of lawsuit. You can't give into demands that aren't reasonable and demands that make no sense." When the Medical Director was asked by the surveyor if he thought it was unreasonable to have a resident stay in bed when the resident was asking to get up, he replied, "Yes, I have a problem with that." The Medical Director revealed the risks of staying in bed included infections, decubitus ulcers, and blood clots. "Those are the big ones I think of first." Observation on 06/17/11 at 2:10 p.m. revealed Resident #14 was in her Geri chair sitting in the hall. The resident was calm and without distress. The resident was smiling and talking to her MPOA. The MPOA was asking the resident if she would like for her to bring her some food. Resident #14 stated, "I want a hamburger with French fries and water." The MPOA asked the resident what color of cup she would like her to bring. Resident #14 said, "White." The MPOA stated, "Why white? How about red, green or blue?" Resident #14 stated, "I like white." The MPOA stated, "I don't think they have white." Resident #14 stated, "Well, then I'll take green." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "...N.O. To have resident OOB (out of bed), sitting up in Geri-chair as tolerated. The First Three Days, maximum from 15 to 20 minutes as tolerated...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "Order clarification: N.O. to D/C order To 'Do Not Move or Place Pt. out of bed QD (everyday)...." Review of Resident #14's SOCIAL PROGRESS NOTES dated 07/21/09 revealed, "Met w/(DON, ADM) ... in regards to (Resident #14) and her quality of life, or lack there of, while she remains in bed 24/7. I have discussed my concerns w/these staff members and requested an evaluation from therapy. A psych consult has been recommended and I will request an order to be written for a psych consult...." Review of Resident #14's SOCIAL PROGRESS NOTES revealed, " 06/02/10 ... (MPOA) remains w/o concern that resident stays in bed. (MPOA) visits 2-3 times per month. Resident has no other contact w/family or friends. Resident remains alert ... 09/12/2010 ... Resident remains isolated in her room @ the request of her poa (MPOA)... she is kept from socialization ... She is alert and oriented to self. She has requested numerous times to get out of bed...." Review of Resident #14's SOCIAL PROGRESS NOTES revealed, "01/05/11 ... Resident remains in bed, flat on her back, receives bed baths and is w/o socialization of her peers. Her only socialization is the nurses and aids who visit her room and tend to her medical needs. I have concern and have voiced my concerns w/(MD G) and Administrator. (MPOA) is aware of my concerns and becomes extremely rude and irritable when I address these concerns. Review of SOCIAL PROGRESS NOTES dated 05/10/11 revealed, "...I asked (MPOA) if she was aware that resident did not want her hair buzzed. (MPOA) became very upset and told me it did not matter what resident wanted I informed (MPOA) that it does matter and the beautician should not have cut her hair. I informed (MPOA) it is very important what (Resident #14) wants. I explained to (MPOA) that (Resident #14) was begging the beautician to not cut her hair off. (MPOA) asked me to stop hassling her and this was not up for debate...." Review of SOCIAL PROGRESS NOTES dated 06/15/11 revealed, "... commented 'I knew I was coming into a snake pit.' I explained to (MPOA) that because resident is kept isolated and has been a prisoner here, unable to socialize, participate in activities, breathe fresh air I believe this is abusive. I also reiterated my concern about having residents head nearly shaved, knowing this upsets (Resident #14) and denying her dental care is all very neglectful and abusive. I explained to her that despite her (Resident #14) cognitive demise resident has rights to a better quality of life, free from abuse....I described this situation as sad and pathetic and extremely unfair. (MPOA) commented, 'If you get her out of bed, its your ass and I will have an attorney up.' I replied that's fine ... (MPOA) remained unconcerned and left the meeting voicing her opinion to staff. (DON) was present for a portion of this care plan and she states she will inform (Administrator) of this griev. (grievance)...." Review of the facility's current identified policy for Resident Rights dated June, 2008 revealed, "...Policy The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility... Facility staff will assist residents in exercising their rights. Facility staff will not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her rights... Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety...." The CMS Form 672 signed by the DON and dated 06/14/11 reflected a census of 87 residents with three residents identified as bedfast all or most of the time.

Based on observation, interview and record review, it was determined the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, were reported immediately to the Administrator of the facility, and to other officials in accordance with State law through established procedures (including to the State survey and certification agency), and thoroughly investigated for one (Resident #14) of 18 residents reviewed for care. Resident #14 was confined to her bed for three years with full padded side rails due to the demands of her Medical Power of Attorney (MPOA). Resident #14 voiced many times that she wanted out of bed and she tried to climb out of bed. Resident #14 was forced to have her hair cut short against her will. Resident #14 begged the beautician not to cut her hair so short. Her MPOA said it did not matter what Resident #14 wanted. Resident #14 had not received showers, only bed baths. Resident #14 was not allowed to attend activities, socialize with her peers, or eat with her peers. The Social Worker reported the allegations multiple times to the Administrator, who was the Abuse Coordinator, and to the DON, but there was no investigation and the reports were not called in to the State survey and certification agency (DADS). These failures allowed the abuse and involuntary seclusion to continue, which resulted in Resident #14's physician decline, mental decline, and psychosocial decline. She was sad and anxious. Resident #14 was no longer able to walk as she did when she was first admitted to the facility and she required more assistance with her activities of daily living. She was talking about being with her husband who was no longer living and she was talking about needing to go to work. She no longer wanted to watch/hear the television. She wanted to "just sleep." These failures could affect the other two residents, who were bedfast, by placing them at risk of abuse, neglect, and involuntary seclusion. Findings included: Review of Resident #14's Medical Power of Attorney Disclosure Statement dated 03/19/07 revealed, "...Except to the extent you state otherwise, this document gives the person you name as your agent authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself... Your agent's authority begins when your doctor certifies that you lack the competence to make health care decisions. Your agent is obligated to follow your instructions when making decisions on your behalf... Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so and treatment cannot be given to you or stopped over your objection...." Review of Resident #14's admission MDS assessment dated [DATE] revealed the resident required limited assistance from one staff member for walking in her room and in the corridor, for moving between locations, for dressing, toilet use, and for personal hygiene. Resident #14 spent an average of one third to two thirds of her time in activities, and enjoyed exercise, sports, music, watching television and talking. Resident #14 did not have any restraints. Resident #14 used a wheelchair for her primary mode of locomotion, but also used a cane/walker/and or/crutch. Resident #14 was not bedfast. Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/29/07 revealed, "...May DC wander guard d/t (due to) bed bound...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/11/08 revealed, "...Please do not move or place this resident out of bed...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 07/07/09 revealed, "...Resident-not to be moved out of bed...." Review of Resident #14's Comprehensive Plan of Care dated 08/04/10, and updated 06/03/11 revealed, "Res. Has dementia and res. Stays in bed most of the day per POA (power of attorney) request...." According to the MDS assessment dated [DATE], Resident #14 was an [AGE] year-old female, admitted to the facility on [DATE] from an acute hospital, with [DIAGNOSES REDACTED]. Resident #14 usually understood others, missed some part/intent of message but comprehended most conversation, had a memory problem and was severely impaired for cognitive skills for daily decision-making. Resident #14 was at risk for developing pressure ulcers, and had a pressure relieving device on her bed. Resident #14 had side rails up every day. Resident #14 required total assistance from two or more staff for bed mobility, dressing, toilet use and personal hygiene. Resident #14 did not receive restorative nursing for passive or active range of motion, bed mobility, transfers, walking, dressing and/or grooming. Resident #14 did not did not receive Psychological Therapy within the seven days of the assessment period. The resident did not present with inattention or disorganized thinking. Resident #14 did not move from a seated to a standing position, walk or transfer from one surface to another surface. Resident #14 did not use a cane/crutch, walker, or a wheelchair, per a recent quarterly MDS assessment dated [DATE]. Interview with LVN J on 06/14/11 at 10:05 a.m. revealed Resident #14 was bedfast and not allowed out of bed due to [MEDICAL CONDITION]. Resident #14 had a physician's orders [REDACTED]. The resident rarely had visitation by friends and was never visited by relatives. Resident #14 had a decline in ADLs, and never took part in activities. The resident's mattress was a pressure relieving mattress, and full padded side rails were up bilaterally blocking the resident's view of the room when in a supine position. Observation of Resident #14 revealed she was sleeping and scooted down in bed with both of her feet hanging out from between the left full side rail and the foot of the bed. The privacy curtain was pulled between Resident #14 and her roommate. Interview on 06/15/11 at 2:40 p.m. with the SW revealed Resident #14 had been confined to her bed for a minimum of three years. Resident #14's MPOA refused to allow the resident out of bed. Resident #14 had a physician's orders [REDACTED]. When asked why the resident was ordered bed bound, the SW revealed it was due to [MEDICAL CONDITION] activity that had not occurred since she had been employed at the facility approximately two years earlier. The SW stated attempts to talk to MD G about allowing Resident #14 out of bed had been futile. The SW revealed she did not know what to do and asked the surveyor if she should call the situation in to "the state," since she had informed the DON and the ADM on many occasions and nothing had been done to. Interview on 06/15/11 at 3:05 p.m. with Resident #14 revealed when she was asked if she liked to stay in bed all the time, the resident frowned, shook her head no and said, "No, I'm going to work." Observation on 06/16/11 at 8:09 a.m. revealed Resident #14 was lying on her back with padded full side rails up bilaterally, and the privacy curtain pulled between the resident and her roommate. Interview with Resident #26 on 06/16/11 at 8:12 a.m. revealed she was Resident #14's roommate. She revealed Resident #14 had "been saying she wants to get out of that bed, she's been saying it a lot lately. She stays in that bed day in and day out. I don't know how she stands it." Interview on 06/16/11 at 8:20 a.m. with CNA K revealed she had cared for Resident #14 for the last three days. She had not witnessed Resident #14 having any [MEDICAL CONDITION] activity. CNA K revealed she knew Resident #14 wanted to get out of bed because the resident told her she needed to get out of bed to go to work or to have lunch with her husband. CNA K stated Resident #14 seemed anxious during those times. Interview on 06/16/11 at 10:15 a.m. with the SW revealed she attended the monthly QA meetings along with the Medical Director, the DON, the ADM, and the AD. Resident #14 had never been discussed in the meetings she had attended. The SW revealed she would have been "happy" to share the information regarding Resident #14 in the QA meetings, but she "didn't know" she could bring it up. The ADM "doesn't ask for my input." The SW revealed she had informed the ADM about her concerns regarding Resident #14's bed bound status "ten times a month," and the DON was always asked to accompany her whenever she told the ADM her concerns about residents. The SW revealed, "They (the DON and ADM) just don't do anything about it." The SW revealed she had voiced her concerns regarding Resident #14 in multiple stand-up meetings. The SW stated Resident #14 appeared sad on many days. Resident #14 had declined cognitively. In recent months, she had talked more about her dead husband and wishing to see him. The SW revealed a few weeks ago when Resident #14 had a hair cut, the beautician was very upset and told the SW how Resident #14's MPOA insisted the beautician shave Resident #14's hair. When the beautician was cutting her hair, Resident #14 was crying and saying, "Please don't shave my head." Interview on 06/16/11 at 11:40 a.m. with ADON B revealed she had worked for the facility for approximately six years and had cared for Resident #14 since she entered the facility. ADON B revealed she had never witnessed Resident #14 having a [MEDICAL CONDITION] or a [MEDICAL CONDITION] spell. ADON B revealed only one time had she heard about the resident having a [MEDICAL CONDITION] episode, and it was when the resident was gotten out of bed after "a few months" of being confined to bed most of the time. ADON B revealed before there was a doctor's order for Resident #14 to remain in bed, the staff rarely got the resident out of bed, because Resident #14's MPOA insisted the resident remain in bed. The MPOA was at the facility daily and told the staff if they got the resident out of bed she would call MD G and tell him. ADON B revealed Resident #14 could carry on a conversation and answer questions appropriately. ADON B revealed, "She hasn't been deemed incompetent ... I' m not (MPOA's) favorite person because we've gone around and around about this issue ... Sometimes when you go in (Resident #14's room) she seems sad ... All she does is sleep now, she's so de-conditioned. She doesn't even want the noise of the TV on." When asked if Resident #14 experienced nausea and/or vomiting often, ADON B revealed the resident would not complain of nausea and vomiting, it was the MPOA who complained. ADON B revealed she had only seen what appeared to be "phlegm." ADON B revealed she talked to MD G about allowing Resident #14 out of her bed, but he would not do it. Once he replied with, "You have an order." Interview on 06/16/11 at 12:10 p.m. with LVN J revealed she had worked at the facility for one year, and had cared for Resident #14 for the last three to four months. LVN J revealed Resident #14 had to stay in bed or she would faint. LVN J stated she heard MD G say the resident had to stay in bed because she had [MEDICAL CONDITION]. LVN J stated Resident #14 sat up in bed to eat with her head of the bed at a "45 to 90 degree" angle. She stated she had not witnessed Resident #14 faint or have a problem with sitting up in bed. Resident #14's MPOA told LVN J Resident #14 had [MEDICAL CONDITION] before the resident was admitted to the facility and "it's just progressed." LVN J revealed after Resident #14's care plan meeting on 06/15/11 the MPOA said, "It would be a cold day in hell before she (Resident #14) gets out of bed." LVN J revealed Resident #14 seemed sad about two weeks ago. Resident #14 told LVN J, "I need to get out of here, I feel like I'm going crazy." Again, about a week ago, Resident #14 told LVN J she "needed to get out of here." Interview on 06/16/11 at 3:00 p.m. with MD G revealed, when he was asked what the reason was for confining Resident #14 to her bed for three years he stated, "She doesn't want to get up. She throws up. She hardly takes any medication, only Tylenol. She flatly refuses. I told her she should get up and go to lobby and she refused." When MD G was asked when this conversation took place with Resident #14, he revealed it had been longer than six months ago. MD G revealed anytime the resident had attempted to get up she vomited, and he was not sure if it was psychological or not. MD G revealed the last attempt to get Resident #14 out of bed was more than six months ago. MD G revealed he had not referred Resident #14 to a [MEDICATION NAME] or to a neurologist for a consultation. Resident #14 was seen three years ago by a psychiatrist, but "was stopped." Resident #14 had not been seen by a psychiatrist, "because of her improvement since three years ago. She eats by herself, and she has no bed sores." MD G denied knowledge about Resident #14's feelings of sadness or anxiousness. MD G revealed he wrote the order to stay in bed, because the facility "got me to write the order because of what the resident expressed." MD G revealed he was not opposed to staff getting Resident #14 out of bed. "If staff got her up then that's okay." When MD G was asked how staff would know it was okay to get Resident #14 out of bed, when they had an order saying not to get the resident out of the bed, he remained silent. MD G revealed the staff talked to him about Resident #14 "two or three weeks ago." MD G did not reveal the details of the conversation with staff or who he talked to. MD G stated, "She (Resident #14) knows what she wants and what she doesn't want. So in that way she's competent, but other times she doesn't know why she's in the facility. She has periods of confusion. She has a Medical Power of Attorney. I haven't made any attempts to deem her incompetent. I haven't put it in writing." MD G revealed, "I' m going to check on her and talk and see what she expresses." When MD G was asked what his goals were for Resident #14 he stated, "Keep stable condition, she's just on one medication." When MD G was asked what the risks were if Resident #14 got out of bed, he stated, "Vomiting and self wishes." When MD G was asked what the risks were if Resident #14 remained in bed, he stated, "[MEDICAL CONDITION]." When MD G was asked if the resident was at risk for developing a [MEDICAL CONDITION] embolism, he revealed she was at risk. MD G revealed he would not come to see the resident until 06/21/11. Review of Resident #14's Medical Power of Attorney dated 03/19/07 revealed, "...I hereby require my agent to direct my physician to comply with any valid Directive to Physicians (or similar document) which I may have heretofore executed or which I my hereafter execute. My agent is not authorized to direct my physician in a manner which would contradict any such valid Directive to Physicians (or similar document)...." Review of Resident #14's Directive to Physicians and Family or Surrogates dated 03/19/07 revealed, "...I, (Resident #14), recognize that the best health care is based upon a partnership of trust and communication with my physician. My physician and I will make health care decisions together as long as I am of sound mind and able to make my wishes known...." Interview on 06/16/11 at 4:25 p.m. with the ADM revealed when he was asked what his knowledge was of Resident #14, he revealed she had a MPOA who was "adamant" about keeping her in bed. The resident's name had not come up often because she had not had a change in condition. The ADM stated he had heard the resident wanted to get out of bed in some stand up meetings. The ADM revealed Resident #14 might want to get out of bed, while others did not want her to, but the resident must be protected. When the ADM was asked if he ever asked the resident if she wanted to get out of bed, he stated he did not. When the ADM was reminded Resident #14 had been confined to her bed for over three years, he replied, "Hearing that makes me feel real bad." The ADM denied any staff had expressed their concerns of Resident #14 being confined to bed. "If they did I don't remember." The ADM revealed no one told him the resident was made to stay in bed. The ADM revealed staff "may have made passing comments," about Resident #14 staying in bed. The ADM revealed he thought there was "an intimidation factor" involved, and "confusion" about the MPOA's "power." The ADM was informed by the surveyor there was no documentation to be found in Resident #14's clinical record indicating the resident was deemed incompetent by a court of law or by a physician. The ADM revealed he would look into it. The ADM revealed the facility was trying to get a care plan meeting scheduled for the following day for Resident #14. Interview with the DON on 06/16/11 at 5:20 p.m. with the ADM present, revealed the DON began employment at the facility on 01/08/08. The DON was aware since the beginning of her employment Resident #14's MPOA had requested Resident #14 remain in bed, and the MPOA had talked to MD G about it. The DON stated the MPOA wanted Resident #14 to stay in bed due to [MEDICAL CONDITION] occurring when the resident was moved out of bed. When the DON was asked if she was aware of any [MEDICAL CONDITION] activity experienced by Resident #14, she revealed she was not aware of any [MEDICAL CONDITION] activity. The DON revealed MD G had written the order for Resident #14 to stay in bed due to [MEDICAL CONDITION] and vomiting when the resident sat up. The DON revealed three years ago she suggested to Resident #14's MPOA that the resident should be allowed to get out of bed. The DON stated she suggested letting Resident #14 get out of bed several times to her MPOA and to her nurses. The DON denied ever speaking to MD G about allowing Resident #14 out of her bed. When the DON was asked when did the decision of a MPOA supersede a resident's rights, she replied, "If it's egregious as in this case I refer back to the physician's orders [REDACTED].#14's confinement to bed, she replied, "Not in the last two to three weeks." The DON revealed, "CNAs have made comments," but there were no specific conversations with any staff voicing their concerns about Resident #14's confinement to bed for three years. When the DON was asked why Resident #14's MPOA was able to dictate to the staff about the resident's confinement to bed for three years, she remained silent. The DON stated she had attended the last few minutes of Resident #14's most recent care plan meeting with the MPOA. The DON also stated the SW was present and there was a discussion about allowing the resident to get out of bed. The DON revealed she told the MPOA how the resident stayed in the bed all the time looking at the same four walls, and the MPOA responded with, "Well, she has Dementia." The MPOA stated during the care plan meeting, "If you get her out of bed, and if she dies two months later, I will sue you." The DON revealed she told the ADM about the care plan meeting. The DON stated in the last four to five months the MPOA requested a "buzz cut" for Resident #14. The SW talked to Resident #14, and the resident did not want it cut, but the MPOA wanted it cut, and so Resident #14 got a "buzz cut." When the DON was asked if hair cuts fell under the decision-making of a MPOA, she replied, "I don't believe so." The DON stated, "I went to talk to her about it, and she had her eyes closed." When the DON was asked why she thought no one had intervened to allow Resident #14 out of bed, she stated, "I don't believe it was complacency. I believe it was a frustration and resignation, and there wasn't anything done. I'm speaking for myself." When the surveyor asked the DON what her role was in her position as the facility's DON, she stated, "In addition to the clinical aspect, I address psychosocial issues, and I'm a liaison and advocate for the residents." When the surveyor asked the DON and the ADM why the incident involving Resident #14's buzz cut was not reported to DADS as abuse, the DON remained silent and the ADM stated, "I don't know." Observation on 06/17/11 at 9:15 a.m. revealed Resident #14 lying on her back with the head of the bed at approximately 30 degrees. The resident was sleeping with the privacy curtain closed between her and her roommate. The resident's hair was approximately one inch in length. Full padded side rails remained up bilaterally. Interview on 06/17/11 at 9:30 a.m. with ADON B revealed she talked to Resident #14 the night before about her meal preferences, and the resident told her she did not like onions or cold cereal. ADON B revealed Resident #14 was very appropriate in her answers to ADON B's questions. Interview on 06/17/11 at 10:00 a.m. with Resident #14 revealed, when the surveyor asked the resident if she like her hair cut short, she looked at the surveyor and stated, "Well, no. Would you?" Interview on 06/17/11 at 10:30 a.m. with CNA L revealed except for approximately ten months, she worked at the facility since the year 2003. CNA L had always taken care of Resident #14 "most of the time." CNA L revealed upon Resident #14's admission, she was getting out of bed and was talking more than at the present time. Resident #14's last shower was "almost four years ago." CNA L revealed the resident only fainted one time that she knew of and she did not witness the [MEDICAL CONDITION] spell. CNA L revealed the full side rails were up on Resident #14's bed to keep her in bed. "She was always trying to get up and get out of bed. If they hadn't been on she would have gotten up." CNA L revealed Resident #14's MPOA told her the resident was not allowed out of the bed, "Doctor said." Resident #14 "always wants to get up. At least one to two times a week." CNA L stated Resident #14 would say, "I'm just ready to get up and get dressed." Resident #14 appeared to be anxious when she wanted out of bed. Before CNA L left her employment with the facility for ten months, Resident #14 often scooted to the end of the bed and put her feet out at the corner. CNA L would ask her what she was doing and Resident #14 would say, "I'm just trying to get up." CNA L returned to work at the facility in March 2011. Resident #14's MPOA told CNA L recently she wanted to be "the first one called if she gets up." CNA L revealed she thought because of Resident #14's MPOA, "She's accepted she can't get up and that's why she doesn't try to get up." CNA L revealed Resident #14 did not have activities, "at all." Resident #14 "doesn't even watch TV or want it on." Resident #14 told CNA L, "Just let me sleep." CNA L revealed Resident #14 was able to bear weight before she was ordered to stay in bed. "We rarely got her out of bed before there was a doctor's order." Resident #14's MPOA "didn't want her out of bed." Interview on 06/17/11 at 1:00 p.m. with the facility's current beautician revealed Resident #14's MPOA came to the beautician and told her she wanted Resident #14's hair "all off. I want it real dikey-shaved off ." The beautician revealed she did not cut Resident #14's hair as short as she was instructed to cut it. She stated Resident #14 "begged me the whole time not to cut her hair off." Later Resident #14's MPOA came to the beautician and told her she did not cut it the way she told her to cut it. The beautician told Resident #4's MPOA, "She begged me not to cut it the whole time, she was very upset." The MPOA told the beautician, "She doesn't know what she wants. I'm not paying for her hair to be cut more than once a year." The beautician revealed she would not cut a resident's hair that short if they did not want it that short. The beautician stated Resident #14 "didn't deserve that. She deserves a little bit of dignity. Hair cuts cost $15. Come on." The beautician revealed she had been the only beautician since September 2010 and that was the first time she had cut Resident #14's hair. Interview on 06/17/11 at 1:15 p.m. with CNA M revealed she assisted the beautician when she cut Resident #14's hair. Resident #14 was very upset and kept telling the beautician she did not want her hair cut. CNA M stated Resident #14's MPOA wanted it cut short. Resident #14's hair was cut "around a month ago." The MPOA complained Resident #14's hair was not short enough. CNA M stated Resident #14 had been requesting to get out of bed "a lot for about two months. Almost every time you go in there she wants to get out of bed. She scoots to the end of the bed, because she's trying to get out. When she tries to get out of bed she's acting anxious." Interview on 06/17/11 at 1:30 p.m. with the SW revealed Resident #14 had her hair "buzzed twice" that she knew of. The first time was with another beautician, and she shaved it. The SW stated Resident #14's MPOA requested that it be shaved. After the last hair cut, the SW revealed she went to Resident #14 and asked her about her hair cut. Resident #14 told the SW she "didn't want it like this." The SW revealed she "went directly" to the ADM and asked the DON to accompany her, which she did. The SW informed the DON and the ADM what had happened with Resident #14's hair. The SW asked the DON during the most recent care plan meeting for Resident #14 if she was going to report her concerns for Resident #14 to DADS. The DON told the SW she would talk to the ADM about "reporting it." When the SW was asked if she thought to report her concerns to DADS, she revealed, "There is a chain of command of calling in a complaint." She reported her concerns to the DON, who reported to the ADM. The ADM told the SW about another social worker who had called a complaint in and lost her job. The SW revealed she told the ADM it was not a complaint against MD G, but Resident #14 needed to be out of bed. The SW stated, "My regret is I didn't go ahead and call state." The SW stated she was told by the DON and the ADM, "We have an order and that's the way it is, and (MPOA) wants it." The SW stated she asked if Resident #14 could be rolled out into the hall while in her bed, but was told the bed would not fit through the door. The SW revealed she asked MD G, "Do I get to get her out of bed today?" MD G "just shakes his head no." The SW revealed, "Hindsight I should have called it in. It's abusive and neglectful." When asked why she did not call in her concerns to the state agency, she replied, "I'm not sure, several reasons. I called other social workers to see what they thought when the order came in (order for Resident #14 to remain in bed). The ADM is the abuse coordinator and he was told. I knew I wasn't supposed to lose my job but it crossed my mind. (ADM) is the one who always calls it in and I trusted the DON and (ADM)to call it in." The SW revealed a care plan meeting for Resident #14 was scheduled for today, and she was not invited to attend because the MPOA was going to attend and might get defensive if the SW was there. Interview on 06/17/11 at 2:20 p.m. with the facility's Medical Director revealed he had been the facility's Medical Director since March 2010. He stated as the Medical Director he attended the monthly Quality Assurance meetings, made sure resident care policies were implemented, he was available to the nursing facility for their issues and he was a liaison between the facility and the residents. When asked by the surveyor how he ensured other physicians at the facility were caring for and treating the residents appropriately, the Medical Director revealed, "That falls on the nursing facility, and they have to alert me. Standard of care has to be met." The Medical Director stated he first learned of the issues surrounding Resident #14 yesterday. The Medical Director stated, "Looking back I should have been told about (MPOA) and her role, and more about the resident. It makes it tough hearing about the demands that were made. Tough for the nursing facility when trying to make people happy. There were threats of lawsuit. You can't give into demands that aren't reasonable and demands that make no sense." When the Medical Director was asked by the surveyor if he thought it was unreasonable to have a resident stay in bed when the resident was asking to get up, he replied, "Yes, I have a problem with that." The Medical Director revealed the risks of staying in bed included infections, decubitus ulcers, and blood clots. "Those are the big ones I think of first. " Observation on 06/17/11 at 2:10 p.m. revealed Resident #14 was in her Geri chair sitting in the hall. The resident was calm and without distress. The resident was smiling and talking to her MPOA. The MPOA was asking the resident if she would like for her to bring her some food. Resident #14 stated, "I want a hamburger with French fries and water." The MPOA asked the resident what color of cup she would like her to bring. Resident #14 said, "White." The MPOA stated, "Why white? How about red, green or blue?" Resident #14 stated, "I like white." The MPOA stated, "I don't think they have white." Resident #14 stated, "Well, then I'll take green." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "...N.O. To have resident OOB (out of bed), sitting up in Geri-chair as tolerated. The First Three Days, maximum from 15 to 20 minutes as tolerated...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "Order clarification: N.O. to D/C order To 'Do Not Move or Place Pt. out of bed QD (everyday)...." Review of Resident #14's SOCIAL PROGRESS NOTES revealed, "01/05/11 ... have voiced my concerns w/(MD G) and Administrator. (MPOA) is aware of my concerns and becomes extremely rude and irritable when I address these concerns. Review of SOCIAL PROGRESS NOTES dated 05/10/11 revealed, "...I asked (MPOA) if she was aware that resident did not want her hair buzzed. (MPOA) became very upset and told me it did not matter what resident wanted... (MPOA) asked me to stop hassling her and this was not up for debate...." Review of SOCIAL PROGRESS NOTES dated 06/15/11 revealed, "... commented 'I knew I was coming into a snake pit.' I explained to (MPOA) that because resident is kept isolated and has been a prisoner here, unable to socialize, participate in activities, breathe fresh air I believe this is abusive. I also reiterated my concern about having residents head nearly shaved, knowing this upsets (Resident #14) and denying her dental care is all very neglectful and abusive. (MPOA) commented, 'If you get her out of bed, its your ass and I will have an attorney up.'... (DON) was present for a portion of this care plan and she states she will inform (Administrator) of this griev. (grievance)...." Review of the facility's identified current policy on Abuse & Neglect Prohibition dated February, 2010 revealed, "...Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion... The facility does not allow involuntary seclusion... Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish... Involuntary seclusion is defines as the separation of a resident from other residents or from his or her room or confinement to his or her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. The facility does not allow involuntary seclusion... Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse... is at risk... Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse... and to intervene as appropriate...The facility will conduct an investigation of any alleged abuse... in accordance with state law... The facility will report such allegations to the state, as per state regulation...The facility will protect residents from harm during the investigation... The facility will report all allegations and substantiated occurrences of abuse... to the state agency and law enforcement officials as designated by state law...." The CMS Form 672 signed by the DON and dated 06/14/11 reflected a census of 87 residents with three residents identified as bedfast all or most of the t

Based on observation, interview and record review, it was determined the facility failed to implement its written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for one (Resident #14) of 18 residents reviewed for care. Resident #14 was confined to her bed for three years with full padded side rails due to the demands of her Medical Power of Attorney (MPOA). Resident #14 voiced many times that she wanted out of bed and she tried to climb out of bed. Resident #14 was forced to have her hair cut short against her will. Resident #14 begged the beautician not to cut her hair so short. Her MPOA said it did not matter what Resident #14 wanted. Resident #14 had not received showers, only bed baths. Resident #14 was not allowed to attend activities, socialize with her peers, or eat with her peers. The Social Worker reported the allegations multiple times to the Administrator, who was the Abuse Coordinator, and to the DON, but there was no investigation and the reports were not called in to the State survey and certification agency (DADS), per the facility's policy. These failures allowed the abuse and involuntary seclusion to continue, which resulted in Resident #14's physician decline, mental decline, and psychosocial decline. She was sad and anxious. Resident #14 was no longer able to walk as she did when she was first admitted to the facility and she required more assistance with her activities of daily living. She was talking about being with her husband who was no longer living and she was talking about needing to go to work. She no longer wanted to watch/hear the television. She wanted to "just sleep." These failures could affect the other two residents, who were bedfast, by placing them at risk of abuse, neglect, and involuntary seclusion. Findings included: 1) Review of the facility's identified current policy on Abuse & Neglect Prohibition dated February, 2010 revealed, "...Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion... The facility does not allow involuntary seclusion... Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish... Involuntary seclusion is defines as the separation of a resident from other residents or from his or her room or confinement to his or her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. The facility does not allow involuntary seclusion... Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse... is at risk... Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse... and to intervene as appropriate... The facility will conduct an investigation of any alleged abuse... in accordance with state law... The facility will report such allegations to the state, as per state regulation... The facility will protect residents from harm during the investigation... The facility will report all allegations and substantiated occurrences of abuse... to the state agency and law enforcement officials as designated by state law...." 2) Review of Resident #14's Medical Power of Attorney Disclosure Statement dated 03/19/07 revealed, "...Except to the extent you state otherwise, this document gives the person you name as your agent authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself... Your agent's authority begins when your doctor certifies that you lack the competence to make health care decisions. Your agent is obligated to follow your instructions when making decisions on your behalf... Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so and treatment cannot be given to you or stopped over your objection...." Review of Resident #14's admission MDS assessment dated [DATE] revealed the resident required limited assistance from one staff member for walking in her room and in the corridor, for moving between locations, for dressing, toilet use, and for personal hygiene. Resident #14 spent an average of one third to two thirds of her time in activities, and enjoyed exercise, sports, music, watching television and talking. Resident #14 did not have any restraints. Resident #14 used a wheelchair for her primary mode of locomotion, but also used a cane/walker/and or/crutch. Resident #14 was not bedfast. Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/29/07 revealed, "...May DC wander guard d/t (due to) bed bound...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/11/08 revealed, "...Please do not move or place this resident out of bed...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 07/07/09 revealed, "...Resident-not to be moved out of bed...." Review of Resident #14's Comprehensive Plan of Care dated 08/04/10, and updated 06/03/11 revealed, "Res. Has dementia and res. Stays in bed most of the day per POA (power of attorney) request...." According to the MDS assessment dated [DATE], Resident #14 was an [AGE] year-old female, admitted to the facility on [DATE] from an acute hospital, with [DIAGNOSES REDACTED]. Resident #14 usually understood others, missed some part/intent of message but comprehended most conversation, had a memory problem and was severely impaired for cognitive skills for daily decision-making. Resident #14 was at risk for developing pressure ulcers, and had a pressure relieving device on her bed. Resident #14 had side rails up every day. Resident #14 required total assistance from two or more staff for bed mobility, dressing, toilet use and personal hygiene. Resident #14 did not receive restorative nursing for passive or active range of motion, bed mobility, transfers, walking, dressing and/or grooming. Resident #14 did not did not receive Psychological Therapy within the seven days of the assessment period. The resident did not present with inattention or disorganized thinking. Resident #14 did not move from a seated to a standing position, walk or transfer from one surface to another surface. Resident #14 did not use a cane/crutch, walker, or a wheelchair, per a recent quarterly MDS assessment dated [DATE]. Interview with LVN J on 06/14/11 at 10:05 a.m. revealed Resident #14 was bedfast and not allowed out of bed due to [MEDICAL CONDITION]. Resident #14 had a physician's orders [REDACTED]. The resident rarely had visitation by friends and was never visited by relatives. Resident #14 had a decline in ADLs, and never took part in activities. The resident's mattress was a pressure relieving mattress, and full padded side rails were up bilaterally blocking the resident's view of the room when in a supine position. Observation of Resident #14 revealed she was sleeping and scooted down in bed with both of her feet hanging out from between the left full side rail and the foot of the bed. The privacy curtain was pulled between Resident #14 and her roommate. Interview on 06/15/11 at 2:40 p.m. with the SW revealed Resident #14 had been confined to her bed for a minimum of three years. Resident #14's MPOA refused to allow the resident out of bed. Resident #14 had a physician's orders [REDACTED]. When asked why the resident was ordered bed bound, the SW revealed it was due to [MEDICAL CONDITION] activity that had not occurred since she had been employed at the facility approximately two years earlier. The SW stated attempts to talk to MD G about allowing Resident #14 out of bed had been futile. The SW revealed she did not know what to do and asked the surveyor if she should call the situation in to "the state," since she had informed the DON and the ADM on many occasions and nothing had been done to. Interview on 06/15/11 at 3:05 p.m. with Resident #14 revealed when she was asked if she liked to stay in bed all the time, the resident frowned, shook her head no and said, "No, I'm going to work." Observation on 06/16/11 at 8:09 a.m. revealed Resident #14 was lying on her back with padded full side rails up bilaterally, and the privacy curtain pulled between the resident and her roommate. Interview with Resident #26 on 06/16/11 at 8:12 a.m. revealed she was Resident #14's roommate. She revealed Resident #14 had "been saying she wants to get out of that bed, she's been saying it a lot lately. She stays in that bed day in and day out. I don't know how she stands it." Interview on 06/16/11 at 8:20 a.m. with CNA K revealed she had cared for Resident #14 for the last three days. She had not witnessed Resident #14 having any [MEDICAL CONDITION] activity. CNA K revealed she knew Resident #14 wanted to get out of bed because the resident told her she needed to get out of bed to go to work or to have lunch with her husband. CNA K stated Resident #14 seemed anxious during those times. Interview on 06/16/11 at 10:15 a.m. with the SW revealed she attended the monthly QA meetings along with the Medical Director, the DON, the ADM, and the AD. Resident #14 had never been discussed in the meetings she had attended. The SW revealed she would have been "happy" to share the information regarding Resident #14 in the QA meetings, but she "didn't know" she could bring it up. The ADM "doesn't ask for my input." The SW revealed she had informed the ADM about her concerns regarding Resident #14's bed bound status "ten times a month," and the DON was always asked to accompany her whenever she told the ADM her concerns about residents. The SW revealed, "They (the DON and ADM) just don't do anything about it." The SW revealed she had voiced her concerns regarding Resident #14 in multiple stand-up meetings. The SW stated Resident #14 appeared sad on many days. Resident #14 had declined cognitively. In recent months, she had talked more about her dead husband and wishing to see him. The SW revealed a few weeks ago when Resident #14 had a hair cut, the beautician was very upset and told the SW how Resident #14's MPOA insisted the beautician shave Resident #14's hair. When the beautician was cutting her hair, Resident #14 was crying and saying, "Please don't shave my head." Interview on 06/16/11 at 11:40 a.m. with ADON B revealed she had worked for the facility for approximately six years and had cared for Resident #14 since she entered the facility. ADON B revealed she had never witnessed Resident #14 having a [MEDICAL CONDITION] or a [MEDICAL CONDITION] spell. ADON B revealed only one time had she heard about the resident having a [MEDICAL CONDITION] episode, and it was when the resident was gotten out of bed after "a few months" of being confined to bed most of the time. ADON B revealed before there was a doctor's order for Resident #14 to remain in bed, the staff rarely got the resident out of bed, because Resident #14's MPOA insisted the resident remain in bed. The MPOA was at the facility daily and told the staff if they got the resident out of bed she would call MD G and tell him. ADON B revealed Resident #14 could carry on a conversation and answer questions appropriately. ADON B revealed, "She hasn't been deemed incompetent ... I'm not (MPOA's) favorite person because we've gone around and around about this issue ... Sometimes when you go in (Resident #14's room) she seems sad ... All she does is sleep now, she's so de-conditioned. She doesn't even want the noise of the TV on." When asked if Resident #14 experienced nausea and/or vomiting often, ADON B revealed the resident would not complain of nausea and vomiting, it was the MPOA who complained. ADON B revealed she had only seen what appeared to be "phlegm." ADON B revealed she talked to MD G about allowing Resident #14 out of her bed, but he would not do it. Once he replied with, "You have an order." Interview on 06/16/11 at 12:10 p.m. with LVN J revealed she had worked at the facility for one year, and had cared for Resident #14 for the last three to four months. LVN J revealed Resident #14 had to stay in bed or she would faint. LVN J stated she heard MD G say the resident had to stay in bed because she had [MEDICAL CONDITION]. LVN J stated Resident #14 sat up in bed to eat with her head of the bed at a "45 to 90 degree" angle. She stated she had not witnessed Resident #14 faint or have a problem with sitting up in bed. Resident #14's MPOA told LVN J Resident #14 had [MEDICAL CONDITION] before the resident was admitted to the facility and "it's just progressed." LVN J revealed after Resident #14's care plan meeting on 06/15/11 the MPOA said, "It would be a cold day in hell before she (Resident #14) gets out of bed." LVN J revealed Resident #14 seemed sad about two weeks ago. Resident #14 told LVN J, "I need to get out of here, I feel like I'm going crazy." Again, about a week ago, Resident #14 told LVN J she "needed to get out of here." Interview on 06/16/11 at 3:00 p.m. with MD G revealed when he was asked what the reason was for confining Resident #14 to her bed for three years, he stated, "She doesn't want to get up. She throws up. She hardly takes any medication, only Tylenol. She flatly refuses. I told her she should get up and go to lobby and she refused." When MD G was asked when this conversation took place with Resident #14, he revealed it had been longer than six months ago. MD G revealed anytime the resident had attempted to get up she vomited, and he was not sure if it was psychological or not. MD G revealed the last attempt to get Resident #14 out of bed was more than six months ago. MD G revealed he had not referred Resident #14 to a [MEDICATION NAME] or to a neurologist for a consultation. Resident #14 was seen three years ago by a psychiatrist, but "was stopped." Resident #14 had not been seen by a psychiatrist, "because of her improvement since three years ago. She eats by herself, and she has no bed sores." MD G denied knowledge about Resident #14's feelings of sadness or anxiousness. MD G revealed he wrote the order to stay in bed, because the facility "got me to write the order because of what the resident expressed." MD G revealed he was not opposed to staff getting Resident #14 out of bed. "If staff got her up then that's okay." When MD G was asked how staff would know it was okay to get Resident #14 out of bed, when they had an order saying not to get the resident out of the bed, he remained silent. MD G revealed the staff talked to him about Resident #14 "two or three weeks ago." MD G did not reveal the details of the conversation with staff or who he talked to. MD G stated, "She (Resident #14) knows what she wants and what she doesn't want. So in that way she's competent, but other times she doesn't know why she's in the facility. She has periods of confusion. She has a Medical Power of Attorney. I haven't made any attempts to deem her incompetent. I haven't put it in writing." MD G revealed, "I' m going to check on her and talk and see what she expresses." When MD G was asked what his goals were for Resident #14 he stated, "Keep stable condition, she's just on one medication." When MD G was asked what the risks were if Resident #14 got out of bed, he stated, "Vomiting and self wishes." When MD G was asked what the risks were if Resident #14 remained in bed, he stated, "[MEDICAL CONDITION]." When MD G was asked if the resident was at risk for developing a [MEDICAL CONDITION] embolism, he revealed she was at risk. MD G revealed he would not come to see the resident until 06/21/11. Review of Resident #14's Medical Power of Attorney dated 03/19/07 revealed, "...I hereby require my agent to direct my physician to comply with any valid Directive to Physicians (or similar document) which I may have heretofore executed or which I my hereafter execute. My agent is not authorized to direct my physician in a manner which would contradict any such valid Directive to Physicians (or similar document)...." Review of Resident #14's Directive to Physicians and Family or Surrogates dated 03/19/07 revealed, "...I, (Resident #14), recognize that the best health care is based upon a partnership of trust and communication with my physician. My physician and I will make health care decisions together as long as I am of sound mind and able to make my wishes known...." Interview on 06/16/11 at 4:25 p.m. with the ADM revealed, when he was asked what his knowledge was of Resident #14, he revealed she had a MPOA who was "adamant" about keeping her in bed. The resident's name had not come up often because she had not had a change in condition. The ADM stated he had heard the resident wanted to get out of bed in some stand up meetings. The ADM revealed Resident #14 might want to get out of bed, while others did not want her to, but the resident must be protected. When the ADM was asked if he ever asked the resident if she wanted to get out of bed, he stated he did not. When the ADM was reminded Resident #14 had been confined to her bed for over three years, he replied, "Hearing that makes me feel real bad." The ADM denied any staff had expressed their concerns of Resident #14 being confined to bed. "If they did I don't remember." The ADM revealed no one told him the resident was made to stay in bed. The ADM revealed staff "may have made passing comments," about Resident #14 staying in bed. The ADM revealed he thought there was "an intimidation factor" involved, and "confusion" about the MPOA's "power." The ADM was informed by the surveyor there was no documentation to be found in Resident #14's clinical record indicating the resident was deemed incompetent by a court of law or by a physician. The ADM revealed he would look into it. The ADM revealed the facility was trying to get a care plan meeting scheduled for the following day for Resident #14. Interview with the DON on 06/16/11 at 5:20 p.m. with the ADM present, revealed the DON began employment at the facility on 01/08/08. The DON was aware since the beginning of her employment Resident #14's MPOA had requested Resident #14 remain in bed, and the MPOA had talked to MD G about it. The DON stated the MPOA wanted Resident #14 to stay in bed due to [MEDICAL CONDITION] occurring when the resident was moved out of bed. When the DON was asked if she was aware of any [MEDICAL CONDITION] activity experienced by Resident #14, she revealed she was not aware of any [MEDICAL CONDITION] activity. The DON revealed MD G had written the order for Resident #14 to stay in bed due to [MEDICAL CONDITION] and vomiting when the resident sat up. The DON revealed three years ago she suggested to Resident #14's MPOA that the resident should be allowed to get out of bed. The DON stated she suggested letting Resident #14 get out of bed several times to her MPOA and to her nurses. The DON denied ever speaking to MD G about allowing Resident #14 out of her bed. When the DON was asked when did the decision of a MPOA supersede a resident's rights, she replied, "If it's egregious as in this case I refer back to the physician's orders [REDACTED].#14's confinement to bed, she replied, "Not in the last two to three weeks." The DON revealed, "CNAs have made comments," but there were no specific conversations with any staff voicing their concerns about Resident #14's confinement to bed for three years. When the DON was asked why Resident #14's MPOA was able to dictate to the staff about the resident's confinement to bed for three years, she remained silent. The DON stated she had attended the last few minutes of Resident #14's most recent care plan meeting with the MPOA. The DON also stated the SW was present and there was a discussion about allowing the resident to get out of bed. The DON revealed she told the MPOA how the resident stayed in the bed all the time looking at the same four walls, and the MPOA responded with, "Well, she has Dementia." The MPOA stated during the care plan meeting, "If you get her out of bed, and if she dies two months later, I will sue you." The DON revealed she told the ADM about the care plan meeting. The DON stated in the last four to five months the MPOA requested a "buzz cut" for Resident #14. The SW talked to Resident #14, and the resident did not want it cut, but the MPOA wanted it cut, and so Resident #14 got a "buzz cut." When the DON was asked if hair cuts fell under the decision-making of a MPOA, she replied, "I don't believe so." The DON stated, "I went to talk to her about it, and she had her eyes closed." When the DON was asked why she thought no one had intervened to allow Resident #14 out of bed, she stated, "I don't believe it was complacency. I believe it was a frustration and resignation, and there wasn't anything done. I'm speaking for myself." When the surveyor asked the DON what her role was in her position as the facility's DON, she stated, "In addition to the clinical aspect, I address psychosocial issues, and I'm a liaison and advocate for the residents." When the surveyor asked the DON and the ADM why the incident involving Resident #14's buzz cut was not reported to DADS as abuse, the DON remained silent and the ADM stated, "I don't know." Observation on 06/17/11 at 9:15 a.m. revealed Resident #14 lying on her back with the head of the bed at approximately 30 degrees. The resident was sleeping with the privacy curtain closed between her and her roommate. The resident's hair was approximately one inch in length. Full padded side rails remained up bilaterally. Interview on 06/17/11 at 9:30 a.m. with ADON B revealed she talked to Resident #14 the night before about her meal preferences, and the resident told her she did not like onions or cold cereal. ADON B revealed Resident #14 was very appropriate in her answers to ADON B's questions. Interview on 06/17/11 at 10:00 a.m. with Resident #14 revealed, when the surveyor asked the resident if she like her hair cut short she looked at the surveyor and stated, "Well, no. Would you?" Interview on 06/17/11 at 10:30 a.m. with CNA L revealed except for approximately ten months, she worked at the facility since the year 2003. CNA L had always taken care of Resident #14 "most of the time." CNA L revealed upon Resident #14's admission, she was getting out of bed and was talking more than at the present time. Resident #14's last shower was "almost four years ago." CNA L revealed the resident only fainted one time that she knew of and she did not witness the [MEDICAL CONDITION] spell. CNA L revealed the full side rails were up on Resident #14's bed to keep her in bed. "She was always trying to get up and get out of bed. If they hadn't been on she would have gotten up." CNA L revealed Resident #14's MPOA told her the resident was not allowed out of the bed, "Doctor said." Resident #14 "always wants to get up. At least one to two times a week." CNA L stated Resident #14 would say, "I'm just ready to get up and get dressed." Resident #14 appeared to be anxious when she wanted out of bed. Before CNA L left her employment with the facility for ten months, Resident #14 often scooted to the end of the bed and put her feet out at the corner. CNA L would ask her what she was doing and Resident #14 would say, "I'm just trying to get up." CNA L returned to work at the facility in March 2011. Resident #14's MPOA told CNA L recently she wanted to be "the first one called if she gets up." CNA L revealed she thought because of Resident #14's MPOA, "She's accepted she can't get up and that's why she doesn't try to get up." CNA L revealed Resident #14 doesn't have activities, "at all." Resident #14 "doesn't even watch TV or want it on." Resident #14 told CNA L, "Just let me sleep." CNA L revealed Resident #14 was able to bear weight before she was ordered to stay in bed. "We rarely got her out of bed before there was a doctor's order." Resident #14's MPOA "didn't want her out of bed." Interview on 06/17/11 at 1:00 p.m. with the facility's current beautician revealed Resident #14's MPOA came to the beautician and told her she wanted Resident #14's hair "all off. I want it real dikey-shaved off ." The beautician revealed she did not cut Resident #14's hair as short as she was instructed to cut it. She stated Resident #14 "begged me the whole time not to cut her hair off." Later Resident #14's MPOA came to the beautician and told her she did not cut it the way she told her to cut it. The beautician told Resident #4's MPOA, "She begged me not to cut it the whole time, she was very upset." The MPOA told the beautician, "She doesn't know what she wants. I'm not paying for her hair to be cut more than once a year." The beautician revealed she would not cut a resident's hair that short if they did not want it that short. The beautician stated Resident #14 "didn't deserve that. She deserves a little bit of dignity. Hair cuts cost $15. Come on." The beautician revealed she had been the only beautician since September 2010 and that was the first time she had cut Resident #14's hair. Interview on 06/17/11 at 1:15 p.m. with CNA M revealed she assisted the beautician when she cut Resident #14's hair. Resident #14 was very upset and kept telling the beautician she did not want her hair cut. CNA M stated Resident #14's MPOA wanted it cut short. Resident #14's hair was cut "around a month ago." The MPOA complained Resident #14's hair was not short enough. CNA M stated Resident #14 had been requesting to get out of bed "a lot for about two months. Almost every time you go in there she wants to get out of bed. She scoots to the end of the bed, because she's trying to get out. When she tries to get out of bed she's acting anxious." Interview on 06/17/11 at 1:30 p.m. with the SW revealed Resident #14 had her hair "buzzed twice" that she knew of. The first time was with another beautician, and she shaved it. The SW stated Resident #14's MPOA requested that it be shaved. After the last hair cut, the SW revealed she went to Resident #14 and asked her about her hair cut. Resident #14 told the SW she "didn't want it like this." The SW revealed she "went directly" to the ADM and asked the DON to accompany her, which she did. The SW informed the DON and the ADM what had happened with Resident #14's hair. The SW asked the DON during the most recent care plan meeting for Resident #14 if she was going to report her concerns for Resident #14 to DADS. The DON told the SW she would talk to the ADM about "reporting it." When the SW was asked if she thought to report her concerns to DADS, she revealed, "There is a chain of command of calling in a complaint." She reported her concerns to the DON, who reported to the ADM. The ADM told the SW about another social worker who had called a complaint in and lost her job. The SW revealed she told the ADM it was not a complaint against MD G, but Resident #14 needed to be out of bed. The SW stated, "My regret is I didn't go ahead and call state." The SW stated she was told by the DON and the ADM, "We have an order and that's the way it is, and (MPOA) wants it." The SW stated she asked if Resident #14 could be rolled out into the hall while in her bed, but was told the bed would not fit through the door. The SW revealed she asked MD G, "Do I get to get her out of bed today?" MD G "just shakes his head no." The SW revealed, "Hindsight I should have called it in. It's abusive and neglectful." When asked why she did not call in her concerns to the state agency, she replied, "I'm not sure, several reasons. I called other social workers to see what they thought when the order came in (order for Resident #14 to remain in bed). The ADM is the abuse coordinator and he was told. I knew I wasn't supposed to lose my job but it crossed my mind. (ADM) is the one who always calls it in and I trusted the DON and (ADM)to call it in." The SW revealed a care plan meeting for Resident #14 was scheduled for today, and she was not invited to attend because the MPOA was going to attend and might get defensive if the SW was there. Interview on 06/17/11 at 2:20 p.m. with the facility's Medical Director revealed he had been the facility's Medical Director since March 2010. He stated as the Medical Director he attended the monthly Quality Assurance meetings, made sure resident care policies were implemented, he was available to the nursing facility for their issues and he was a liaison between the facility and the residents. When asked by the surveyor how he ensured other physicians at the facility were caring for and treating the residents appropriately, the Medical Director revealed, "That falls on the nursing facility, and they have to alert me. Standard of care has to be met." The Medical Director stated he first learned of the issues surrounding Resident #14 yesterday. The Medical Director stated, "Looking back I should have been told about (MPOA) and her role, and more about the resident. It makes it tough hearing about the demands that were made. Tough for the nursing facility when trying to make people happy. There were threats of lawsuit. You can't give into demands that aren't reasonable and demands that make no sense." When the Medical Director was asked by the surveyor if he thought it was unreasonable to have a resident stay in bed when the resident was asking to get up, he replied, "Yes, I have a problem with that." The Medical Director revealed the risks of staying in bed included infections, decubitus ulcers, and blood clots. "Those are the big ones I think of first." Observation on 06/17/11 at 2:10 p.m. revealed Resident #14 was in her Geri chair sitting in the hall. The resident was calm and without distress. The resident was smiling and talking to her MPOA. The MPOA was asking the resident if she would like for her to bring her some food. Resident #14 stated, "I want a hamburger with French fries and water." The MPOA asked the resident what color of cup she would like her to bring. Resident #14 said, "White." The MPOA stated, "Why white? How about red, green or blue?" Resident #14 stated, "I like white." The MPOA stated, "I don't think they have white." Resident #14 stated, "Well, then I'll take green." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "...N.O. To have resident OOB (out of bed), sitting up in Geri-chair as tolerated. The First Three Days, maximum from 15 to 20 minutes as tolerated...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "Order clarification: N.O. to D/C order To 'Do Not Move or Place Pt. out of bed QD (everyday)...." Review of Resident #14's SOCIAL PROGRESS NOTES revealed, "01/05/11 ... have voiced my concerns w/(MD G) and Administrator. (MPOA) is aware of my concerns and becomes extremely rude and irritable when I address these concerns. Review of SOCIAL PROGRESS NOTES dated 05/10/11 revealed, "...I asked (MPOA) if she was aware that resident did not want her hair buzzed. (MPOA) became very upset and told me it did not matter what resident wanted... (MPOA) asked me to stop hassling her and this was not up for debate...." Review of SOCIAL PROGRESS NOTES dated 06/15/11 revealed, "... commented 'I knew I was coming into a snake pit.' I explained to (MPOA) that because resident is kept isolated and has been a prisoner here, unable to socialize, participate in activities, breathe fresh air I believe this is abusive. I also reiterated my concern about having residents head nearly shaved, knowing this upsets (Resident #14) and denying her dental care is all very neglectful and abusive. (MPOA) commented, 'If you get her out of bed, its your ass and I will have an attorney up.'... (DON) was present for a portion of this care plan and she states she will inform (Administrator) of this griev. (grievance)...." 3) The CMS Form 672 signed by the DON and dated 06/14/11 reflected a census of 87 residents with three residents identified as bedfast all or most of the time.

Based on observation, interview and record review, it was determined the facility failed to care for one (Resident #14) of 18 residents reviewed for care, in a manner and in an environment that promoted maintenance and/or enhancement of her quality of life. Resident #14 was confined to her bed for three years with full padded side rails due to the demands of her Medical Power of Attorney (MPOA). Resident #14 voiced many times that she wanted out of bed and she tried to climb out of bed. Resident #14 was forced to have her hair cut short against her will. Resident #14 begged the beautician not to cut her hair so short. Her MPOA said it did not matter what Resident #14 wanted. Resident #14 had not received showers, only bed baths. Resident #14 was not allowed to attend activities, socialize with her peers, or eat with her peers. These failures resulted in Resident #14 having a decreased quality of life and a decline in her physical condition. She was sad and anxious. Resident #14 was no longer able to walk as she did when she was first admitted to the facility and she required more assistance with activities of daily living. She was talking about being with her husband, who was no longer living and she was talking about needing to go to work. She no longer wanted to watch/hear the television. She wanted to "just sleep." These failures could affect the other two residents, who were identified as bedfast, by placing them at risk of a decreased quality of life, anxiety, sadness, involuntary seclusion and not allowed to make any decisions. Findings included: 1) Review of Resident #14's Medical Power of Attorney Disclosure Statement dated 03/19/07 revealed, "...Except to the extent you state otherwise, this document gives the person you name as your agent authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself... Your agent's authority begins when your doctor certifies that you lack the competence to make health care decisions. Your agent is obligated to follow your instructions when making decisions on your behalf... Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so and treatment cannot be given to you or stopped over your objection...." Review of Resident #14's admission MDS assessment dated [DATE] revealed the resident required limited assistance from one staff member for walking in her room and in the corridor, for moving between locations, for dressing, toilet use, and for personal hygiene. Resident #14 spent an average of one third to two thirds of her time in activities, and enjoyed exercise, sports, music, watching television and talking. Resident #14 did not have any restraints. Resident #14 used a wheelchair for her primary mode of locomotion, but also used a cane/walker/and or/crutch. Resident #14 was not bedfast. Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/29/07 revealed, "...May DC wander guard d/t (due to) bed bound...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/11/08 revealed, "...Please do not move or place this resident out of bed...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 07/07/09 revealed, "...Resident-not to be moved out of bed...." Review of Resident #14's Comprehensive Plan of Care dated 08/04/10, and updated 06/03/11 revealed, "Res. Has dementia and res. Stays in bed most of the day per POA (power of attorney) request...." According to the MDS assessment dated [DATE], Resident #14 was an [AGE] year-old female, admitted to the facility on [DATE] from an acute hospital, with [DIAGNOSES REDACTED]. Resident #14 usually understood others, missed some part/intent of message but comprehended most conversation, had a memory problem and was severely impaired for cognitive skills for daily decision-making. Resident #14 was at risk for developing pressure ulcers, and had a pressure relieving device on her bed. Resident #14 had side rails up every day. Resident #14 required total assistance from two or more staff for bed mobility, dressing, toilet use and personal hygiene. Resident #14 did not receive restorative nursing for passive or active range of motion, bed mobility, transfers, walking, dressing and/or grooming. She did not receive Psychological Therapy within the seven days of the assessment period. The resident did not present with inattention or disorganized thinking. Resident #14 did not move from a seated to a standing position, walk or transfer from one surface to another surface. Resident #14 did not use a cane/crutch, walker, or a wheelchair, per a recent quarterly MDS assessment dated [DATE]. Interview with LVN J on 06/14/11 at 10:05 a.m. revealed Resident #14 was bedfast and not allowed out of bed due to [MEDICAL CONDITION]. Resident #14 had a physician's orders [REDACTED]. The resident rarely had visitation by friends and was never visited by relatives. Resident #14 had a decline in ADLs, and never took part in activities. The resident's mattress was a pressure relieving mattress, and full padded side rails were up bilaterally blocking the resident's view of the room when in a supine position. Observation of Resident #14 revealed she was sleeping and scooted down in bed with both of her feet hanging out from between the left full side rail and the foot of the bed. The privacy curtain was pulled between Resident #14 and her roommate. Interview on 06/15/11 at 2:40 p.m. with the SW revealed Resident #14 had been confined to her bed for a minimum of three years. Resident #14's MPOA refused to allow the resident out of bed. Resident #14 had a physician's orders [REDACTED]. When asked why the resident was ordered bed bound, the SW revealed it was due to [MEDICAL CONDITION] activity that had not occurred since she had been employed at the facility approximately two years earlier. The SW stated attempts to talk to MD G about allowing Resident #14 out of bed had been futile. The SW revealed she did not know what to do and asked the surveyor if she should call the situation in to "the state," since she had informed the DON and the ADM on many occasions and nothing had been done. Interview on 06/15/11 at 3:05 p.m. with Resident #14 revealed when she was asked if she liked to stay in bed all the time, the resident frowned, shook her head no and said, "No, I'm going to work." Observation on 06/16/11 at 8:09 a.m. revealed Resident #14 lying on her back with padded full side rails up bilaterally, and the privacy curtain pulled between the resident and her roommate. Interview with Resident #26 on 06/16/11 at 8:12 a.m. revealed she was Resident #14's roommate. She revealed Resident #14 had "been saying she wants to get out of that bed, she's been saying it a lot lately. She stays in that bed day in and day out. I don't know how she stands it." Interview on 06/16/11 at 8:20 a.m. with CNA K revealed she had cared for Resident #14 for the last three days. She had not witnessed Resident #14 having any [MEDICAL CONDITION] activity. CNA K revealed she knew Resident #14 wanted to get out of bed because the resident told her she needed to get out of bed to go to work or to have lunch with her husband. CNA K stated Resident #14 seemed anxious during those times. Interview on 06/16/11 at 10:15 a.m. with the SW revealed she attended the monthly QA meetings along with the Medical Director, the DON, the ADM, and the AD. Resident #14 had never been discussed in the meetings she had attended. The SW revealed she would have been "happy" to share the information regarding Resident #14 in the QA meetings, but she "didn't know" she could bring it up. The ADM "doesn't ask for my input." The SW revealed she had informed the ADM about her concerns regarding Resident #14's bed bound status "ten times a month," and the DON was always asked to accompany her whenever she told the ADM her concerns about residents. The SW revealed, "They (the DON and ADM) just don't do anything about it." The SW revealed she had voiced her concerns regarding Resident #14 in multiple stand-up meetings. The SW stated Resident #14 appeared sad on many days. Resident #14 had declined cognitively. In recent months, she had talked more about her dead husband and wishing to see him. The SW revealed a few weeks ago when Resident #14 had a hair cut, the beautician was very upset and told the SW how Resident #14's MPOA insisted the beautician shave Resident #14's hair. When the beautician was cutting her hair, Resident #14 was crying and saying, "Please don't shave my head." Interview on 06/16/11 at 11:40 a.m. with ADON B revealed she had worked for the facility for approximately six years and had cared for Resident #14 since she entered the facility. ADON B revealed she had never witnessed Resident #14 having a [MEDICAL CONDITION] or a [MEDICAL CONDITION] spell. ADON B revealed only one time had she heard about the resident having a [MEDICAL CONDITION] episode, and it was when the resident was gotten out of bed after "a few months" of being confined to bed most of the time. ADON B revealed before there was a doctor's order for Resident #14 to remain in bed, the staff rarely got the resident out of bed, because Resident #14's MPOA insisted the resident remain in bed. The MPOA was at the facility daily and told the staff if they got the resident out of bed she would call MD G and tell him. ADON B revealed Resident #14 could carry on a conversation and answer questions appropriately. ADON B revealed, "She hasn't been deemed incompetent ... I'm not (MPOA's) favorite person because we've gone around and around about this issue ... Sometimes when you go in (Resident #14's room) she seems sad ... All she does is sleep now, she's so de-conditioned. She doesn't even want the noise of the TV on." When asked if Resident #14 experienced nausea and/or vomiting often, ADON B revealed the resident would not complain of nausea and vomiting, it was the MPOA who complained. ADON B revealed she had only seen what appeared to be "phlegm." ADON B revealed she talked to MD G about allowing Resident #14 out of her bed, but he would not do it. Once he replied with, "You have an order." Interview on 06/16/11 at 12:10 p.m. with LVN J revealed she had worked at the facility for one year, and had cared for Resident #14 for the last three to four months. LVN J revealed Resident #14 had to stay in bed or she would faint. LVN J stated she heard MD G say the resident had to stay in bed because she had [MEDICAL CONDITION]. LVN J stated Resident #14 sat up in bed to eat with her head of the bed at a "45 to 90 degree" angle. She stated she had not witnessed Resident #14 faint or have a problem with sitting up in bed. Resident #14's MPOA told LVN J Resident #14 had [MEDICAL CONDITION] before the resident was admitted to the facility and "it's just progressed." LVN J revealed after Resident #14's care plan meeting on 06/15/11 the MPOA said, "It would be a cold day in hell before she (Resident #14) gets out of bed." LVN J revealed Resident #14 seemed sad about two weeks ago. Resident #14 told LVN J, "I need to get out of here, I feel like I'm going crazy." Again, about a week ago, Resident #14 told LVN J she "needed to get out of here." Interview on 06/16/11 at 3:00 p.m. with MD G revealed, when he was asked what the reason was for confining Resident #14 to her bed for three years he stated, "She doesn't want to get up. She throws up. She hardly takes any medication, only Tylenol. She flatly refuses. I told her she should get up and go to lobby and she refused." When MD G was asked when this conversation took place with Resident #14, he revealed it had been longer than six months ago. MD G revealed anytime the resident had attempted to get up she vomited, and he was not sure if it was psychological or not. MD G revealed the last attempt to get Resident #14 out of bed was more than six months ago. MD G revealed he had not referred Resident #14 to a [MEDICATION NAME] or to a neurologist for a consultation. Resident #14 was seen three years ago by a psychiatrist, but "was stopped." Resident #14 had not been seen by a psychiatrist, "because of her improvement since three years ago. She eats by herself, and she has no bed sores." MD G denied knowledge about Resident #14's feelings of sadness or anxiousness. MD G revealed he wrote the order to stay in bed, because the facility "got me to write the order because of what the resident expressed." MD G revealed he was not opposed to staff getting Resident #14 out of bed. "If staff got her up then that's okay." When MD G was asked how staff would know it was okay to get Resident #14 out of bed, when they had an order saying not to get the resident out of the bed, he remained silent. MD G revealed the staff talked to him about Resident #14 "two or three weeks ago." MD G did not reveal the details of the conversation with staff or who he talked to. MD G stated, "She (Resident #14) knows what she wants and what she doesn't want. So in that way she's competent, but other times she doesn't know why she's in the facility. She has periods of confusion. She has a Medical Power of Attorney. I haven't made any attempts to deem her incompetent. I haven't put it in writing." MD G revealed, "I' m going to check on her and talk and see what she expresses." When MD G was asked what his goals were for Resident #14 he stated, "Keep stable condition, she's just on one medication." When MD G was asked what the risks were if Resident #14 got out of bed, he stated, "Vomiting and self wishes." When MD G was asked what the risks were if Resident #14 remained in bed, he stated, "[MEDICAL CONDITION]." When MD G was asked if the resident was at risk for developing a [MEDICAL CONDITION] embolism, he revealed she was at risk. MD G revealed he would not come to see the resident until 06/21/11. Review of Resident #14's Medical Power of Attorney dated 03/19/07 revealed, "...I hereby require my agent to direct my physician to comply with any valid Directive to Physicians (or similar document) which I may have heretofore executed or which I my hereafter execute. My agent is not authorized to direct my physician in a manner which would contradict any such valid Directive to Physicians (or similar document)...." Review of Resident #14's Directive to Physicians and Family or Surrogates dated 03/19/07 revealed, "...I, (Resident #14), recognize that the best health care is based upon a partnership of trust and communication with my physician. My physician and I will make health care decisions together as long as I am of sound mind and able to make my wishes known...." Interview on 06/16/11 at 4:25 p.m. with the ADM revealed when he was asked what his knowledge was of Resident #14, he revealed she had a MPOA who was "adamant" about keeping her in bed. The resident's name had not come up often because she had not had a change in condition. The ADM stated he had heard the resident wanted to get out of bed in some stand up meetings. The ADM revealed Resident #14 might want to get out of bed, while others did not want her to, but the resident must be protected. When the ADM was asked if he ever asked the resident if she wanted to get out of bed, he stated he had not. When the ADM was reminded Resident #14 had been confined to her bed for over three years, he replied, "Hearing that makes me feel real bad." The ADM denied any staff had expressed their concerns of Resident #14 being confined to bed. "If they did I don't remember." The ADM revealed no one told him the resident was made to stay in bed. The ADM revealed staff "may have made passing comments," about Resident #14 staying in bed. The ADM revealed he thought there was "an intimidation factor" involved, and "confusion" about the MPOA's "power." The ADM was informed by the surveyor there was no documentation to be found in Resident #14's clinical record indicating the resident was deemed incompetent by a court of law or by a physician. The ADM revealed he would look into it. The ADM revealed the facility was trying to get a care plan meeting scheduled for the following day for Resident #14. Interview with the DON on 06/16/11 at 5:20 p.m. with the ADM present, revealed the DON began employment at the facility on 01/08/08. The DON was aware since the beginning of her employment Resident #14's MPOA had requested Resident #14 remain in bed, and the MPOA had talked to MD G about it. The DON stated the MPOA wanted Resident #14 to stay in bed due to [MEDICAL CONDITION] occurring when the resident was moved out of bed. When the DON was asked if she was aware of any [MEDICAL CONDITION] activity experienced by Resident #14, she revealed she was not aware of any [MEDICAL CONDITION] activity. The DON revealed MD G had written the order for Resident #14 to stay in bed due to [MEDICAL CONDITION] and vomiting when the resident sat up. The DON revealed three years ago she suggested to Resident #14's MPOA that the resident should be allowed to get out of bed. The DON stated she suggested letting Resident #14 get out of bed several times to her MPOA and to her nurses. The DON denied ever speaking to MD G about allowing Resident #14 out of her bed. When the DON was asked when did the decision of a MPOA supersede a resident's right, she replied, "If it's egregious as in this case I refer back to the physician's orders [REDACTED].#14's confinement to bed, she replied, "Not in the last two to three weeks." The DON revealed, "CNAs have made comments," but there were no specific conversations with any staff voicing their concerns about Resident #14's confinement to bed for three years. When the DON was asked why Resident #14's MPOA was able to dictate to the staff about the resident's confinement to bed for three years, she remained silent. The DON stated she had attended the last few minutes of Resident #14's most recent care plan meeting with the MPOA. The DON also stated the SW was present and there was a discussion about allowing the resident to get out of bed. The DON revealed she told the MPOA how the resident stayed in the bed all the time looking at the same four walls, and the MPOA responded with, "Well, she has Dementia." The MPOA stated during the care plan meeting, "If you get her out of bed, and if she dies two months later, I will sue you." The DON revealed she told the ADM about the care plan meeting. The DON stated in the last four to five months the MPOA requested a "buzz cut" for Resident #14. The SW talked to Resident #14, and the resident did not want it cut, but the MPOA wanted it cut, so Resident #14 got a "buzz cut." When the DON was asked if hair cuts fell under the decision-making of a MPOA, she replied, "I don't believe so." The DON stated, "I went to talk to her about it, and she had her eyes closed." When the DON was asked why she thought no one had intervened to allow Resident #14 out of bed, she stated, "I don't believe it was complacency. I believe it was a frustration and resignation, and there wasn't anything done. I'm speaking for myself." When the surveyor asked the DON what her role was in her position as the facility's DON, she stated, "In addition to the clinical aspect, I address psychosocial issues, and I'm a liaison and advocate for the residents." Observation on 06/17/11 at 9:15 a.m. revealed Resident #14 was lying on her back with the head of the bed at approximately 30 degrees. The resident was sleeping with the privacy curtain closed between her and her roommate. The resident's hair was approximately one inch in length. Full padded side rails remained up bilaterally. Interview on 06/17/11 at 9:30 a.m. with ADON B revealed she talked to Resident #14 the night before about her meal preferences, and the resident told her she did not like onions or cold cereal. ADON B revealed Resident #14 was very appropriate in her answers to ADON B's questions. Interview on 06/17/11 at 10:00 a.m. with Resident #14 revealed, when the surveyor asked the resident if she like her hair cut short she looked at the surveyor and stated, "Well no. Would you?" Interview on 06/17/11 at 10:30 a.m. with CNA L revealed except for approximately ten months, she worked at the facility since the year 2003. CNA L had always taken care of Resident #14 "most of the time." CNA L revealed upon Resident #14's admission, she was getting out of bed and was talking more than at the present time. Resident #14's last shower was "almost four years ago." CNA L revealed the resident only fainted one time that she knew of and she did not witness the [MEDICAL CONDITION] spell. CNA L revealed the full side rails were up on Resident #14's bed to keep her in bed. "She was always trying to get up and get out of bed. If they hadn't been on she would have gotten up." CNA L revealed Resident #14's MPOA told her the resident was not allowed out of the bed, "Doctor said." Resident #14 "always wants to get up. At least one to two times a week." CNA L stated Resident #14 would say, "I'm just ready to get up and get dressed." Resident #14 appeared to be anxious when she wanted out of bed. Before CNA L left her employment with the facility for ten months, Resident #14 often scooted to the end of the bed and put her feet out at the corner. CNA L would ask her what she was doing and Resident #14 would say, "I'm just trying to get up." CNA L returned to work at the facility in March 2011. Resident #14's MPOA told CNA L recently she wanted to be "the first one called if she gets up." CNA L revealed she thought because of Resident #14's MPOA, "She's accepted she can't get up and that's why she doesn't try to get up." CNA L revealed Resident #14 doesn't have activities, "at all." Resident #14 "doesn't even watch TV or want it on." Resident #14 told CNA L, "Just let me sleep." CNA L revealed Resident #14 was able to bear weight before she was ordered to stay in bed. "We rarely got her out of bed before there was a doctor's order." Resident #14's MPOA "didn't want her out of bed." Interview on 06/17/11 at 1:00 p.m. with the facility's current beautician revealed Resident #14's MPOA came to the beautician and told her she wanted Resident #14's hair "all off. I want it real dikey-shaved off." The beautician revealed she did not cut Resident #14's hair as short as she was instructed to cut it. She stated Resident #14 "begged me the whole time not to cut her hair off." Later Resident #14's MPOA came to the beautician and told her she did not cut it the way she told her to cut it. The beautician told Resident #4's MPOA, "She begged me not to cut it the whole time, she was very upset." The MPOA told the beautician, "She doesn't know what she wants. I'm not paying for her hair to be cut more than once a year." The beautician revealed she would not cut a resident's hair that short if they did not want it that short. The beautician stated Resident #14 "didn't deserve that. She deserves a little bit of dignity. Hair cuts cost $15. Come on." The beautician revealed she had been the only beautician since September 2010 and that was the first time she had cut Resident #14's hair. Interview on 06/17/11 at 1:15 p.m. with CNA M revealed she assisted the beautician when she cut Resident #14's hair. Resident #14 was very upset and kept telling the beautician she did not want her hair cut. CNA M stated Resident #14's MPOA wanted it cut short. Resident #14's hair was cut "around a month ago." The MPOA complained Resident #14's hair was not short enough. CNA M stated Resident #14 had been requesting to get out of bed "a lot for about two months. Almost every time you go in there she wants to get out of bed. She scoots to the end of the bed, because she's trying to get out. When she tries to get out of bed she's acting anxious." Interview on 06/17/11 at 1:30 p.m. with the SW revealed Resident #14 had her hair "buzzed twice" that she knew of. The first time was with another beautician, and she shaved it. The SW stated Resident #14's MPOA requested that it be shaved. After the last hair cut, the SW revealed she went to Resident #14 and asked her about her hair cut. Resident #14 told the SW she "didn't want it like this." The SW revealed she "went directly" to the ADM and asked the DON to accompany her, which she did. The SW informed the DON and the ADM what had happened with Resident #14's hair. The SW asked the DON during the most recent care plan meeting for Resident #14 if she was going to report her concerns for Resident #14 to DADS. The DON told the SW she would talk to the ADM about "reporting it." When the SW was asked if she thought to report her concerns to DADS, she revealed, "There is a chain of command of calling in a complaint." She reported her concerns to the DON, who reported to the ADM. The ADM told the SW about another social worker who had called a complaint in and lost her job. The SW revealed she told the ADM it was not a complaint against MD G, but Resident #14 needed to be out of bed. The SW stated, "My regret is I didn't go ahead and call state." The SW stated she was told by the DON and the ADM, "We have an order and that's the way it is, and (MPOA) wants it." The SW stated she asked if Resident #14 could be rolled out into the hall while in her bed, but was told the bed would not fit through the door. The SW revealed she asked MD G, "Do I get to get her out of bed today?" MD G "just shakes his head no." The SW revealed a care plan meeting for Resident #14 was scheduled for today, and she was not invited to attend because the MPOA was going to attend and might get defensive if the SW was there. Interview on 06/17/11 at 2:20 p.m. with the facility's Medical Director revealed he had been the facility's Medical Director since March 2010. He stated as the Medical Director he attended the monthly QA meetings, made sure resident care policies were implemented, he was available to the nursing facility for their issues and he was a liaison between the facility and the residents. When asked by the surveyor how he ensured other physicians at the facility were caring for and treating the residents appropriately, the Medical Director revealed, "That falls on the nursing facility, and they have to alert me. Standard of care has to be met." The Medical Director stated he first learned of the issues surrounding Resident #14 yesterday. The Medical Director stated, "Looking back I should have been told about (MPOA) and her role, and more about the resident. It makes it tough hearing about the demands that were made. Tough for the nursing facility when trying to make people happy. There were threats of lawsuit. You can't give into demands that aren't reasonable and demands that make no sense." When the Medical Director was asked by the surveyor if he thought it was unreasonable to have a resident stay in bed when the resident was asking to get up, he replied, "Yes, I have a problem with that." The Medical Director revealed the risks of staying in bed included infections, decubitus ulcers, and blood clots. "Those are the big ones I think of first." Observation on 06/17/11 at 2:10 p.m. revealed Resident #14 was in her Geri chair sitting in the hall. The resident was calm and without distress. The resident was smiling and talking to her MPOA. The MPOA was asking the resident if she would like for her to bring her some food. Resident #14 stated, "I want a hamburger with French fries and water." The MPOA asked the resident what color of cup she would like her to bring. Resident #14 said, "White." The MPOA stated, "Why white? How about red, green or blue?" Resident #14 stated, "I like white." The MPOA stated, "I don't think they have white." Resident #14 stated, "Well, then I'll take green." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "...N.O. To have resident OOB (out of bed), sitting up in Geri-chair as tolerated. The First Three Days, maximum from 15 to 20 minutes as tolerated...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "Order clarification: N.O. to D/C order To 'Do Not Move or Place Pt. out of bed QD (everyday)...." Review of Resident #14's SOCIAL PROGRESS NOTES dated 07/21/09 revealed, "Met w/(DON, ADM) ... in regards to (Resident #14) and her quality of life, or lack there of, while she remains in bed 24/7. I have discussed my concerns w/these staff members and requested an evaluation from therapy. A psych consult has been recommended and I will request an order to be written for a psych consult...." Review of Resident #14's SOCIAL PROGRESS NOTES revealed, " 06/02/10 ... (MPOA) remains w/o concern that resident stays in bed. (MPOA) visits 2-3 times per month. Resident has no other contact w/family or friends. Resident remains alert ... 09/12/2010 ... Resident remains isolated in her room @ the request of her poa (MPOA)... she is kept from socialization ... She is alert and oriented to self. She has requested numerous times to get out of bed...." Review of Resident #14's SOCIAL PROGRESS NOTES revealed, "01/05/11 ... Resident remains in bed, flat on her back, receives bed baths and is w/o socialization of her peers. Her only socialization is the nurses and aids who visit her room and tend to her medical needs. I have concern and have voiced my concerns w/(MD G) and Administrator. (MPOA) is aware of my concerns and becomes extremely rude and irritable when I address these concerns. Review of SOCIAL PROGRESS NOTES dated 05/10/11 revealed, "...I asked (MPOA) if she was aware that resident did not want her hair buzzed. (MPOA) became very upset and told me it did not matter what resident wanted I informed (MPOA) that it does matter and the beautician should not have cut her hair. I informed (MPOA) it is very important what (Resident #14) wants. I explained to (MPOA) that (Resident #14) was begging the beautician to not cut her hair off. (MPOA) asked me to stop hassling her and this was not up for debate...." Review of SOCIAL PROGRESS NOTES dated 06/15/11 revealed, "... commented 'I knew I was coming into a snake pit.' I explained to (MPOA) that because resident is kept isolated and has been a prisoner here, unable to socialize, participate in activities, breathe fresh air I believe this is abusive. I also reiterated my concern about having residents head nearly shaved, knowing this upsets (Resident #14) and denying her dental care is all very neglectful and abusive. I explained to her that despite her (Resident #14) cognitive demise resident has rights to a better quality of life, free from abuse....I described this situation as sad and pathetic and extremely unfair. (MPOA) commented, 'If you get her out of bed, its your ass and I will have an attorney up.' I replied that's fine ... (MPOA) remained unconcerned and left the meeting voicing her opinion to staff. (DON) was present for a portion of this care plan and she states she will inform (Administrator) of this griev. (grievance)...." Review of the facility's current identified policy for Resident Rights dated June, 2008 revealed, "...Policy The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility... Facility staff will assist residents in exercising their rights. Facility staff will not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her rights... Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety...." The CMS Form 672 signed by the DON and dated 06/14/11 reflected a census of 87 residents with three residents identified as bedfast all or most of the time.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two (Residents #14 and #3) of 18 residents reviewed for care and catheter care. 1. Resident #14 was confined to her bed for three years with full padded side rails due to the demands of her Medical Power of Attorney (MPOA). Resident #14 voiced many times that she wanted out of bed and she tried to climb out of bed. Resident #14 was forced to have her hair cut short against her will. Resident #14 begged the beautician not to cut her hair so short. Her MPOA said it did not matter what Resident #14 wanted. Resident #14 had not received showers, only bed baths. Resident #14 was not allowed to attend activities, socialize with her peers, or eat with her peers. These failures resulted in Resident #14's physical decline, mental decline, and psychosocial decline. She was sad and anxious. Resident #14 was no longer able to walk as she did when she first admitted to the facility and she required more assistance with her activities of daily living. She was talking about being with her husband who was no longer living and she was talking about needing to go to work. She no longer wanted to watch/hear the television. She wanted to "just sleep." These failures also affected Resident #14 by placing her at risk of infections, skin breakdown, blood clots, [MEDICAL CONDITION], and bone loss. These failures could also affect the other two residents, who were bedfast by placing them at risk of declines in their physical condition, mental state, psychosocial well-being, infections, skin breakdown, blood clots, [MEDICAL CONDITION], and bone loss. 2. Resident #3's indwelling urinary catheter tubing was observed unsecured. CNA H provided pericare/catheter care to Resident #3 without cleaning the catheter insertion site and without cleaning the head of the resident's penis. These failures could affect the nine residents who had a urinary catheter, including Resident #3 by placing them at risk for traumatic injury to the bladder/urinary tract and/or urinary tract infections. Findings included: 1) Review of Resident #14's Medical Power of Attorney Disclosure Statement dated 03/19/07 revealed, "...Except to the extent you state otherwise, this document gives the person you name as your agent authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself... Your agent's authority begins when your doctor certifies that you lack the competence to make health care decisions. Your agent is obligated to follow your instructions when making decisions on your behalf... Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so and treatment cannot be given to you or stopped over your objection...." Review of Resident #14's admission MDS assessment dated [DATE] revealed the resident required limited assistance from one staff member for walking in her room and in the corridor, for moving between locations, for dressing, toilet use, and for personal hygiene. Resident #14 spent an average of one third to two thirds of her time in activities, and enjoyed exercise, sports, music, watching television and talking. Resident #14 did not have any restraints. Resident #14 used a wheelchair for her primary mode of locomotion, but also used a cane/walker/and or/crutch. Resident #14 was not bedfast. Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/29/07 revealed, "...May DC wander guard d/t (due to) bed bound...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/11/08 revealed, "...Please do not move or place this resident out of bed...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 07/07/09 revealed, "...Resident-not to be moved out of bed...." Review of Resident #14's Comprehensive Plan of Care dated 08/04/10, and updated 06/03/11 revealed, "Res. Has dementia and res. Stays in bed most of the day per POA (power of attorney) request...." Review of the MDS assessment dated [DATE] revealed Resident #14 was an [AGE] year-old female, admitted to the facility on [DATE] from an acute hospital, with [DIAGNOSES REDACTED]. Resident #14 usually understood others, missed some part/intent of message but comprehended most conversation, had a memory problem and was severely impaired for cognitive skills for daily decision-making. Resident #14 was at risk for developing pressure ulcers, and had a pressure relieving device on her bed. Resident #14 had side rails up every day. Resident #14 required total assistance from two or more staff for bed mobility, dressing, toilet use and personal hygiene. Resident #14 did not receive restorative nursing for passive or active range of motion, bed mobility, transfers, walking, dressing and/or grooming. She did not receive Psychological Therapy within the seven days of the assessment period. The resident did not present with inattention or disorganized thinking. Resident #14 did not move from a seated to a standing position, walk or transfer from one surface to another surface. Resident #14 did not use a cane/crutch, walker, or a wheelchair, per a recent quarterly MDS assessment dated [DATE]. Interview with LVN J on 06/14/11 at 10:05 a.m. revealed Resident #14 was bedfast and not allowed out of bed due to [MEDICAL CONDITION]. Resident #14 had a physician's orders [REDACTED]. The resident rarely had visitation by friends and was never visited by relatives. Resident #14 had a decline in ADLs, and never took part in activities. The resident's mattress was a pressure relieving mattress, and full padded side rails were up bilaterally blocking the resident's view of the room when in a supine position. Observation of Resident #14 revealed she was sleeping and scooted down in bed with both of her feet hanging out from between the left full side rail and the foot of the bed. The privacy curtain was pulled between Resident #14 and her roommate. Interview on 06/15/11 at 2:40 p.m. with the SW revealed Resident #14 had been confined to her bed for a minimum of three years. Resident #14's MPOA refused to allow the resident out of bed. Resident #14 had a physician's orders [REDACTED]. When asked why the resident was ordered bed bound, the SW revealed it was due to [MEDICAL CONDITION] activity that had not occurred since she had been employed at the facility approximately two years earlier. The SW stated attempts to talk to MD G about allowing Resident #14 out of bed had been futile. The SW revealed she did not know what to do and asked the surveyor if she should call the situation in to "the state," since she had informed the DON and the ADM on many occasions and nothing had been done. Interview on 06/15/11 at 3:05 p.m. with Resident #14 revealed when she was asked if she liked to stay in bed all the time, the resident frowned, shook her head no and said, "No, I'm going to work." Observation on 06/16/11 at 8:09 a.m. revealed Resident #14 lying on her back with padded full side rails up bilaterally, and the privacy curtain pulled between the resident and her roommate. Interview with Resident #26 on 06/16/11 at 8:12 a.m. revealed she was Resident #14's roommate. She revealed Resident #14 had "been saying she wants to get out of that bed, she's been saying it a lot lately. She stays in that bed day in and day out. I don't know how she stands it." Interview on 06/16/11 at 8:20 a.m. with CNA K revealed she had cared for Resident #14 for the last three days. She had not witnessed Resident #14 having any [MEDICAL CONDITION] activity. CNA K revealed she knew Resident #14 wanted to get out of bed because the resident told her she needed to get out of bed to go to work or to have lunch with her husband. CNA K stated Resident #14 seemed anxious during those times. Interview on 06/16/11 at 10:15 a.m. with the SW revealed she attended the monthly QA meetings along with the Medical Director, the DON, the ADM, and the AD. Resident #14 had never been discussed in the meetings she had attended. The SW revealed she would have been "happy" to share the information regarding Resident #14 in the QA meetings, but she "didn't know" she could bring it up. The ADM "doesn't ask for my input." The SW revealed she had informed the ADM about her concerns regarding Resident #14's bed bound status "ten times a month," and the DON was always asked to accompany her whenever she told the ADM her concerns about residents. The SW revealed, "They (the DON and ADM) just don't do anything about it." The SW revealed she had voiced her concerns regarding Resident #14 in multiple stand-up meetings. The SW stated Resident #14 appeared sad on many days. Resident #14 had declined cognitively. In recent months, she had talked more about her dead husband and wishing to see him. The SW revealed a few weeks ago when Resident #14 had a hair cut, the beautician was very upset and told the SW how Resident #14's MPOA insisted the beautician shave Resident #14's hair. When the beautician was cutting her hair, Resident #14 was crying and saying, "Please don't shave my head." Interview on 06/16/11 at 11:40 a.m. with ADON B revealed she had worked for the facility for approximately six years and had cared for Resident #14 since she entered the facility. ADON B revealed she had never witnessed Resident #14 having a [MEDICAL CONDITION] or a [MEDICAL CONDITION] spell. ADON B revealed only one time had she heard about the resident having a [MEDICAL CONDITION] episode, and it was when the resident was gotten out of bed after "a few months" of being confined to bed most of the time. ADON B revealed before there was a doctor's order for Resident #14 to remain in bed, the staff rarely got the resident out of bed, because Resident #14's MPOA insisted the resident remain in bed. The MPOA was at the facility daily and told the staff if they got the resident out of bed she would call MD G and tell him. ADON B revealed Resident #14 could carry on a conversation and answer questions appropriately. ADON B revealed, "She hasn't been deemed incompetent ... I'm not (MPOA's) favorite person because we've gone around and around about this issue ... Sometimes when you go in (Resident #14's room) she seems sad ... All she does is sleep now, she's so de-conditioned. She doesn't even want the noise of the TV on." When asked if Resident #14 experienced nausea and/or vomiting often, ADON B revealed the resident would not complain of nausea and vomiting, it was the MPOA who complained. ADON B revealed she had only seen what appeared to be "phlegm." ADON B revealed she talked to MD G about allowing Resident #14 out of her bed, but he would not do it. Once he replied with, "You have an order." Interview on 06/16/11 at 12:10 p.m. with LVN J revealed she had worked at the facility for one year, and had cared for Resident #14 for the last three to four months. LVN J revealed Resident #14 had to stay in bed or she would faint. LVN J stated she heard MD G say the resident had to stay in bed because she had [MEDICAL CONDITION]. LVN J stated Resident #14 sat up in bed to eat with her head of the bed at a "45 to 90 degree" angle. She stated she had not witnessed Resident #14 faint or have a problem with sitting up in bed. Resident #14's MPOA told LVN J Resident #14 had [MEDICAL CONDITION] before the resident was admitted to the facility and "it's just progressed." LVN J revealed after Resident #14's care plan meeting on 06/15/11 the MPOA said, "It would be a cold day in hell before she (Resident #14) gets out of bed." LVN J revealed Resident #14 seemed sad about two weeks ago. Resident #14 told LVN J, "I need to get out of here, I feel like I'm going crazy." Again, about a week ago, Resident #14 told LVN J she "needed to get out of here." Interview on 06/16/11 at 3:00 p.m. with MD G revealed, when he was asked what the reason was for confining Resident #14 to her bed for three years he stated, "She doesn't want to get up. She throws up. She hardly takes any medication, only Tylenol. She flatly refuses. I told her she should get up and go to lobby and she refused." When MD G was asked when this conversation took place with Resident #14, he revealed it had been longer than six months ago. MD G revealed anytime the resident had attempted to get up she vomited, and he was not sure if it was psychological or not. MD G revealed the last attempt to get Resident #14 out of bed was more than six months ago. MD G revealed he had not referred Resident #14 to a [MEDICATION NAME] or to a neurologist for a consultation. Resident #14 was seen three years ago by a psychiatrist, but "was stopped." Resident #14 had not been seen by a psychiatrist, "because of her improvement since three years ago. She eats by herself, and she has no bed sores." MD G denied knowledge about Resident #14's feelings of sadness or anxiousness. MD G revealed he wrote the order to stay in bed, because the facility "got me to write the order because of what the resident expressed." MD G revealed he was not opposed to staff getting Resident #14 out of bed. "If staff got her up then that's okay." When MD G was asked how staff would know it was okay to get Resident #14 out of bed, when they had an order saying not to get the resident out of the bed, he remained silent. MD G revealed the staff talked to him about Resident #14 "two or three weeks ago." MD G did not reveal the details of the conversation with staff or who he talked to. MD G stated, "She (Resident #14) knows what she wants and what she doesn't want. So in that way she's competent, but other times she doesn't know why she's in the facility. She has periods of confusion. She has a Medical Power of Attorney. I haven't made any attempts to deem her incompetent. I haven't put it in writing." MD G revealed, "I' m going to check on her and talk and see what she expresses." When MD G was asked what his goals were for Resident #14 he stated, "Keep stable condition, she's just on one medication." When MD G was asked what the risks were if Resident #14 got out of bed, he stated, "Vomiting and self wishes." When MD G was asked what the risks were if Resident #14 remained in bed, he stated, "[MEDICAL CONDITION]." When MD G was asked if the resident was at risk for developing a [MEDICAL CONDITION] embolism, he revealed she was at risk. MD G revealed he would not come to see the resident until 06/21/11. Review of Resident #14's Medical Power of Attorney dated 03/19/07 revealed, "...I hereby require my agent to direct my physician to comply with any valid Directive to Physicians (or similar document) which I may have heretofore executed or which I my hereafter execute. My agent is not authorized to direct my physician in a manner which would contradict any such valid Directive to Physicians (or similar document)...." Review of Resident #14's Directive to Physicians and Family or Surrogates dated 03/19/07 revealed, "...I, (Resident #14), recognize that the best health care is based upon a partnership of trust and communication with my physician. My physician and I will make health care decisions together as long as I am of sound mind and able to make my wishes known...." Interview on 06/16/11 at 4:25 p.m. with the ADM revealed, when he was asked what his knowledge was of Resident #14, he revealed she had a MPOA who was "adamant" about keeping her in bed. The resident's name had not come up often because she had not had a change in condition. The ADM stated he had heard the resident wanted to get out of bed in some stand up meetings. The ADM revealed Resident #14 might want to get out of bed, while others did not want her to, but the resident must be protected. When the ADM was asked if he ever asked the resident if she wanted to get out of bed, he stated he had not. When the ADM was reminded Resident #14 had been confined to her bed for over three years, he replied, "Hearing that makes me feel real bad." The ADM denied any staff had expressed their concerns of Resident #14 being confined to bed. "If they did I don't remember." The ADM revealed no one told him the resident was made to stay in bed. The ADM revealed staff "may have made passing comments," about Resident #14 staying in bed. The ADM revealed he thought there was "an intimidation factor" involved, and "confusion" about the MPOA's "power." The ADM was informed by the surveyor there was no documentation to be found in Resident #14's clinical record indicating the resident was deemed incompetent by a court of law or by a physician. The ADM revealed he would look into it. The ADM revealed the facility was trying to get a care plan meeting scheduled for the following day for Resident #14. Interview with the DON on 06/16/11 at 5:20 p.m. with the ADM present, revealed the DON began employment at the facility on 01/08/08. The DON was aware since the beginning of her employment Resident #14's MPOA had requested Resident #14 remain in bed, and the MPOA had talked to MD G about it. The DON stated the MPOA wanted Resident #14 to stay in bed due to [MEDICAL CONDITION] occurring when the resident was moved out of bed. When the DON was asked if she was aware of any [MEDICAL CONDITION] activity experienced by Resident #14, she revealed she was not aware of any [MEDICAL CONDITION] activity. The DON revealed MD G had written the order for Resident #14 to stay in bed due to [MEDICAL CONDITION] and vomiting when the resident sat up. The DON revealed three years ago she suggested to Resident #14's MPOA that the resident should be allowed to get out of bed. The DON stated she suggested letting Resident #14 get out of bed several times to her MPOA and to her nurses. The DON denied ever speaking to MD G about allowing Resident #14 out of her bed. When the DON was asked when did the decision of a MPOA supersede a resident's right, she replied, "If it's egregious as in this case I refer back to the physician's orders [REDACTED].#14's confinement to bed, she replied, "Not in the last two to three weeks." The DON revealed, "CNAs have made comments," but there were no specific conversations with any staff voicing their concerns about Resident #14's confinement to bed for three years. When the DON was asked why Resident #14's MPOA was able to dictate to the staff about the resident's confinement to bed for three years, she remained silent. The DON stated she had attended the last few minutes of Resident #14's most recent care plan meeting with the MPOA. The DON also stated the SW was present and there was a discussion about allowing the resident to get out of bed. The DON revealed she told the MPOA how the resident stayed in the bed all the time looking at the same four walls, and the MPOA responded with, "Well, she has Dementia." The MPOA stated during the care plan meeting, "If you get her out of bed, and if she dies two months later, I will sue you." The DON revealed she told the ADM about the care plan meeting. The DON stated in the last four to five months the MPOA requested a "buzz cut" for Resident #14. The SW talked to Resident #14, and the resident did not want it cut, but the MPOA wanted it cut, so Resident #14 got a "buzz cut." When the DON was asked if hair cuts fell under the decision-making of a MPOA, she replied, "I don't believe so." The DON stated, "I went to talk to her about it, and she had her eyes closed." When the DON was asked why she thought no one had intervened to allow Resident #14 out of bed, she stated, "I don't believe it was complacency. I believe it was a frustration and resignation, and there wasn't anything done. I'm speaking for myself." When the surveyor asked the DON what her role was in her position as the facility's DON, she stated, "In addition to the clinical aspect, I address psychosocial issues, and I'm a liaison and advocate for the residents." Observation on 06/17/11 at 9:15 a.m. revealed Resident #14 was lying on her back with the head of the bed at approximately 30 degrees. The resident was sleeping with the privacy curtain closed between her and her roommate. The resident's hair was approximately one inch in length. Full padded side rails remained up bilaterally. Interview on 06/17/11 at 9:30 a.m. with ADON B revealed she talked to Resident #14 the night before about her meal preferences, and the resident told her she did not like onions or cold cereal. ADON B revealed Resident #14 was very appropriate in her answers to ADON B's questions. Interview on 06/17/11 at 10:00 a.m. with Resident #14 revealed, when the surveyor asked the resident if she like her hair cut short she looked at the surveyor and stated, "Well no. Would you?" Interview on 06/17/11 at 10:30 a.m. with CNA L revealed except for approximately ten months, she worked at the facility since the year 2003. CNA L had always taken care of Resident #14 "most of the time." CNA L revealed upon Resident #14's admission, she was getting out of bed and was talking more than at the present time. Resident #14's last shower was "almost four years ago." CNA L revealed the resident only fainted one time that she knew of and she did not witness the [MEDICAL CONDITION] spell. CNA L revealed the full side rails were up on Resident #14's bed to keep her in bed. "She was always trying to get up and get out of bed. If they hadn't been on she would have gotten up." CNA L revealed Resident #14's MPOA told her the resident was not allowed out of the bed, "Doctor said." Resident #14 "always wants to get up. At least one to two times a week." CNA L stated Resident #14 would say, "I'm just ready to get up and get dressed." Resident #14 appeared to be anxious when she wanted out of bed. Before CNA L left her employment with the facility for ten months, Resident #14 often scooted to the end of the bed and put her feet out at the corner. CNA L would ask her what she was doing and Resident #14 would say, "I'm just trying to get up." CNA L returned to work at the facility in March 2011. Resident #14's MPOA told CNA L recently she wanted to be "the first one called if she gets up." CNA L revealed she thought because of Resident #14's MPOA, "She's accepted she can't get up and that's why she doesn't try to get up." CNA L revealed Resident #14 doesn't have activities, "at all." Resident #14 "doesn't even watch TV or want it on." Resident #14 told CNA L, "Just let me sleep." CNA L revealed Resident #14 was able to bear weight before she was ordered to stay in bed. "We rarely got her out of bed before there was a doctor's order." Resident #14's MPOA "didn't want her out of bed." Interview on 06/17/11 at 1:00 p.m. with the facility's current beautician revealed Resident #14's MPOA came to the beautician and told her she wanted Resident #14's hair "all off. I want it real dikey-shaved off." The beautician revealed she did not cut Resident #14's hair as short as she was instructed to cut it. She stated Resident #14 "begged me the whole time not to cut her hair off." Later Resident #14's MPOA came to the beautician and told her she did not cut it the way she told her to cut it. The beautician told Resident #4's MPOA, "She begged me not to cut it the whole time, she was very upset." The MPOA told the beautician, "She doesn't know what she wants. I'm not paying for her hair to be cut more than once a year." The beautician revealed she would not cut a resident's hair that short if they did not want it that short. The beautician stated Resident #14 "didn't deserve that. She deserves a little bit of dignity. Hair cuts cost $15. Come on." The beautician revealed she had been the only beautician since September 2010 and that was the first time she had cut Resident #14's hair. Interview on 06/17/11 at 1:15 p.m. with CNA M revealed she assisted the beautician when she cut Resident #14's hair. Resident #14 was very upset and kept telling the beautician she did not want her hair cut. CNA M stated Resident #14's MPOA wanted it cut short. Resident #14's hair was cut "around a month ago." The MPOA complained Resident #14's hair was not short enough. CNA M stated Resident #14 had been requesting to get out of bed "a lot for about two months. Almost every time you go in there she wants to get out of bed. She scoots to the end of the bed, because she's trying to get out. When she tries to get out of bed she's acting anxious." Interview on 06/17/11 at 1:30 p.m. with the SW revealed Resident #14 had her hair "buzzed twice" that she knew of. The first time was with another beautician, and she shaved it. The SW stated Resident #14's MPOA requested that it be shaved. After the last hair cut, the SW revealed she went to Resident #14 and asked her about her hair cut. Resident #14 told the SW she "didn't want it like this." The SW revealed she "went directly" to the ADM and asked the DON to accompany her, which she did. The SW informed the DON and the ADM what had happened with Resident #14's hair. The SW asked the DON during the most recent care plan meeting for Resident #14 if she was going to report her concerns for Resident #14 to DADS. The DON told the SW she would talk to the ADM about "reporting it." When the SW was asked if she thought to report her concerns to DADS, she revealed, "There is a chain of command of calling in a complaint." She reported her concerns to the DON, who reported to the ADM. The ADM told the SW about another social worker who had called a complaint in and lost her job. The SW revealed she told the ADM it was not a complaint against MD G, but Resident #14 needed to be out of bed. The SW stated, "My regret is I didn't go ahead and call state." The SW stated she was told by the DON and the ADM, "We have an order and that's the way it is, and (MPOA) wants it." The SW stated she asked if Resident #14 could be rolled out into the hall while in her bed, but was told the bed would not fit through the door. The SW revealed she asked MD G, "Do I get to get her out of bed today?" MD G "just shakes his head no." The SW revealed a care plan meeting for Resident #14 was scheduled for today, and she was not invited to attend because the MPOA was going to attend and might get defensive if the SW was there. Interview on 06/17/11 at 2:20 p.m. with the facility's Medical Director revealed he had been the facility's Medical Director since March 2010. He stated as the Medical Director he attended the monthly QA meetings, made sure resident care policies were implemented, he was available to the nursing facility for their issues and he was a liaison between the facility and the residents. When asked by the surveyor how he ensured other physicians at the facility were caring for and treating the residents appropriately, the Medical Director revealed, "That falls on the nursing facility, and they have to alert me. Standard of care has to be met." The Medical Director stated he first learned of the issues surrounding Resident #14 yesterday. The Medical Director stated, "Looking back I should have been told about (MPOA) and her role, and more about the resident. It makes it tough hearing about the demands that were made. Tough for the nursing facility when trying to make people happy. There were threats of lawsuit. You can't give into demands that aren't reasonable and demands that make no sense." When the Medical Director was asked by the surveyor if he thought it was unreasonable to have a resident stay in bed when the resident was asking to get up, he replied, "Yes, I have a problem with that." The Medical Director revealed the risks of staying in bed included infections, decubitus ulcers, and blood clots. "Those are the big ones I think of first." Observation on 06/17/11 at 2:10 p.m. revealed Resident #14 was in her Geri chair sitting in the hall. The resident was calm and without distress. The resident was smiling and talking to her MPOA. The MPOA was asking the resident if she would like for her to bring her some food. Resident #14 stated, "I want a hamburger with French fries and water." The MPOA asked the resident what color of cup she would like her to bring. Resident #14 said, "White." The MPOA stated, "Why white? How about red, green or blue?" Resident #14 stated, "I like white." The MPOA stated, "I don't think they have white." Resident #14 stated, "Well, then I'll take green." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "...N.O. To have resident OOB (out of bed), sitting up in Geri-chair as tolerated. The First Three Days, maximum from 15 to 20 minutes as tolerated...." Review of Resident #14's PHYSICIAN's TELEPHONE ORDER dated 06/16/11 revealed, "Order clarification: N.O. to D/C order To 'Do Not Move or Place Pt. out of bed QD (everyday)...." Review of Resident #14's SOCIAL PROGRESS NOTES dated 07/21/09 revealed, "Met w/(DON, ADM) ... in regards to (Resident #14) and her quality of life, or lack there of, while she remains in bed 24/7. I have discussed my concerns w/these staff members and requested an evaluation from therapy. A psych consult has been recommended and I will request an order to be written for a psych consult...." Review of Resident #14's SOCIAL PROGRESS NOTES revealed, " 06/02/10 ... (MPOA) remains w/o concern that resident stays in bed. (MPOA) visits 2-3 times per month. Resident has no other contact w/family or friends. Resident remains alert ... 09/12/2010 ... Resident remains isolated in her room @ the request of her poa (MPOA)... she is kept from socialization ... She is alert and oriented to self. She has requested numerous times to get out of bed...." Review of Resident #14's SOCIAL PROGRESS NOTES revealed, "01/05/11 ... Resident remains in bed, flat on her back, receives bed baths and is w/o socialization of her peers. Her only socialization is the nurses and aids who visit her room and tend to her medical needs. I have concern and have voiced my concerns w/(MD G) and Administrator. (MPOA) is aware of my concerns and becomes extremely rude and irritable when I address these concerns. Review of SOCIAL PROGRESS NOTES dated 05/10/11 revealed, "...I asked (MPOA) if she was aware that resident did not want her hair buzzed. (MPOA) became very upset and told me it did not matter what resident wanted I informed (MPOA) that it does matter and the beautician should not have cut her hair. I informed (MPOA) it is very important what (Resident #14) wants. I explained to (MPOA) that (Resident #14) was begging the beautician to not cut her hair off. (MPOA) asked me to stop hassling her and this was not up for debate...." Review of SOCIAL PROGRESS NOTES dated 06/15/11 revealed, "... commented 'I knew I was coming into a snake pit.' I explained to (MPOA) that because resident is kept isolated and has been a prisoner here, unable to socialize, participate in activities, breathe fresh air I believe this is abusive. I also reiterated my concern about having residents head nearly shaved, knowing this upsets (Resident #14) and denying her dental care is all very neglectful and abusive. I explained to her that despite her (Resident #14) cognitive demise resident has rights to a better quality of life, free from abuse....I described this situation as sad and pathetic and extremely unfair. (MPOA) commented, 'If you get her out of bed, its your ass and I will have an attorney up.' I replied that's fine ... (MPOA) remained unconcerned and left the meeting voicing her opinion to staff. (DON) was present for a portion of this care plan and she states she will inform (Administrator) of this griev. (grievance)...."