Every finding on record at Ayers Nursing Home

Based on record review and interview, the facility failed to protect a resident from verbal abuse for 1 (#1) of 3 sampled residents reviewed for staff abuse. The DON identified 72 residents resided in the facility.Findings: A policy titled Resident Abuse and Neglect Policy and Procedure, dated 02/24/20, read in part, ensure all residents are free from mistreatment, neglect, abuse .reporting, recognizing, and free from reprisal .recognize burnout, frustration or stress related issues .how and whom they may report concerns to, such as incidents and grievances without fear of retribution .no staff member is exempt from being reported. A final incident report, dated 07/20/26, showed an abuse allegation against LPN #1. The report showed LPN #1 was yelling and screaming at Resident #1 who had spit in the face of CNA #1. As of Monday, 07/20/26, after LPN #1 had completed their shift, they were placed on suspension. On 07/23/26 staff were educated on the importance of protecting residents from abuse by staff, other residents, family, and any other visitor. The report showed staff were advised they could go to the administrator or DON anytime. If the staff felt like there could be retaliation they were to report it. On 07/21/26 a written statement from Resident #2, read in part, LPN #1 liked to argue with them and really just seemed kind of rude. No bedside manner. On 07/22/26 a written statement from Resident #11, read in part, heard LPN #1 yelling, but did not who it was, but that person was being told they could go to jail for that shit. On 7/22/26 at 1:27 p.m., the administrator stated when CNA #1 went around the corner with Resident #1, the resident was saying hateful things and spit in the face of CNA #1. The administrator stated LPN #1 got up and told Resident #1 it was unacceptable. They stated a lot of people heard LPN #1 yelling at Resident #1. On 07/24/26, a written statement from Resident #6, read in part, [LPN #1] seemed cranky and got verbal with Residents. On 07/24/26, a written statement from Resident #12, read in part, [LPN #1] was always rude to me .I heard them yelling a few nights ago, but I don't know who or what is was about. On 07/24/26, a written statement from Resident #13, read in part, [LPN #1] was mean to me .that's how they thought it was supposed to be. On 07/29/26 at 9:44 a.m., an anonymous resident stated they had heard LPN #1 speak hateful to residents at night. On 07/29/26 at 2:45 p.m., the power of attorney for Resident #1 stated they thought the situation on 07/20/26 was handled exceptionally well. They stated, I was thankful, that's why I put them over there because I knew they would take care of them. On 07/29/26 at 4:03 p.m., LPN #1 stated the morning of 07/20/26, CNA #1 was ambulating Resident #1 with their rolling walker to the shower room. LPN #1 stated Resident #1 started calling CNA #1 names and spit on them. LPN #1 stated as charge nurse, I tried to intervene and deescalate the situation. LPN #1 stated their hands were on the u-shaped bar of the rolling walker, leading Resident #1 into the shower room. LPN #1 stated, I did not touch [them] once. LPN #1 stated they had bent forward trying to get eye level with Resident #1 so they could see them. LPN #1 stated they told Resident #1 they could not be doing that. On 07/30/26 at 5:07 a.m., CNA #1 stated LPN #1 told Resident #1, You can not spit on my staff like that. That is against the law. You could go to jail for that. It will not be tolerated. CNA #1 stated it sounded like scolding. CNA #1 stated LPN #1 asked them to close the door then stated to Resident #1, We're not in the view of the camera now [explicit language]. On 07/30/26 at 7:29 a.m., housekeeper #1 stated they overheard LPN #1 state, We're no longer in camera view. CNA #1 shut the door. On 07/30/26 at 7:36 a.m., the housekeeping supervisor stated at the shower room CNA #1 and LPN #1 were talking and Resident #1 told them to shut up. LPN #1 told Resident #1 they would not talk to anyone like that and look at me when I'm talking to you. On 07/30/26 at 8:46 a.m., the DON stated the owner, administrator, and themself had asked during the resident council about abuse for feedback, but no resident had any complaints. The stated, The administrator had interviewed a lot of them. On 07/30/26 at 9:09 a.m., the administrator was asked about the outcome of their investigation. They stated they had spoken with the owner and from everything they investigated and reviewed as a team, there was a problem with LPN #1. The administrator stated residents and staff were scared of LPN #1, but nobody said anything. On 07/30/26 at 11:09 a.m., CNA #3 stated they heard LPN #1 yelling. They knocked on the shower door and opened the door. LPN #1 was standing in front of Resident #1 and their walker with their hands on the bilateral wrists of Resident #1. They asked, Do I need to strip their bed? LPN #1 stated, Yeah you're going to strip their [explicit language] bed because they're not going back to [explicit language] in bed. CNA #3 stated LPN #1 slapped the hand of Resident. LPN #1 was yelling at Resident #1.

Based on record review and interview, the facility failed to submit payroll based staffing information to CMS as required for the 3rd quarter of 2024. The administrator identified 69 residents resided in the facility. Findings: A PBJ Staffing Data Report - FY Quarter 3 2024, documented there was no data submitted for the third quarter. On 09/17/24 at 11:51 a.m., the BOM stated the staffing report for the 3rd quarter of 2024 had not been submitted to CMS as required.

Based on record review and interview, the facility failed to ensure diagnosis of a serious mental illness was reported to the OHCA for a level II PASRR evaluation for two (#3 and #48) of three sampled residents reviewed for PASRR. The DON identified 69 residents resided in the facility. Findings: An undated facility PASRR policy, read in part, Upon the receipt of a referral the designated staff will review the diagnosis and medication of the possible admission .If it is determined the referral requires a Level II PASRR due to a diagnosis and/or use of anti-psych meds, a Level II PASRR is initiated and transmitted to OHCA to determine approval for admission to LTC . 1. Res #3 was admitted to the facility on [DATE]. A Level I PASRR screen, dated 06/11/19, documented no diagnosis of a serious mental illness. Res #3's admission record, dated 08/31/22, documented on 05/07/21 the resident has a diagnosis of recurrent major depressive disorder, and on 05/13/21 the resident had a diagnosis of bipolar disorder. On 09/18/24 at 9:55 a.m., the DON and RN Consultant reported they did not have a policy for completing the PASRR screen. They stated staff had not contacted OHCA when resident #3 was diagnosed with new mental illness of recurrent major depressive disorder and bipolar disorder. 2. Res #48 was admitted to the facility on [DATE]. A Level I PASRR screen, dated 09/21/21, documented no diagnosis of a serious mental illness. Res #48's admission record, dated 09/21/21, documented on 09/13/21 the resident had diagnoses of recurrent major depressive disorder, anxiety disorder, and unspecified psychosis. On 09/19/24 at 9:34 a.m., the MDS Coordinator stated they were not aware a diagnosis of major depressive disorder would be considered a serious mental illness. They stated it should have been recorded on the PASRR Level I screen. On 09/19/24 at 9:42 a.m., the BOM stated resident #48's diagnosis of major depressive disorder should have been included on their 09/21/21 Level I PASRR screen.

Based on observation, record review, and interview, the facility failed to provide assessment and monitoring before and after dialysis treatments, and maintain ongoing communication with the dialysis center for one (#13) of one sampled resident reviewed for dialysis. The DON identified one resident who received dialysis treatments. A Policy for Care of Dialysis Residents in LTC Setting, dated September 2024, read in part, Purpose: To set a policy that will establish guidelines for best practices for End Stage Renal Disease and (ESRD)-Specific Resident care for dialysis residents. Our goal is to efficiently and effectively increase the quality of care of life for ESRD residents. We are focused on promoting resident-centered care, as well as resident and family engagement at the highest level possible. Findings: Res #13 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease stage 5, type 2 diabetes mellitus, retention of urine, and edema. A care plan, dated 02/28/23, documented the resident required dialysis related to renal failure. It was documented the facility would provide transportation and encourage the resident to go for scheduled treatments. It was documented to monitor the shunt to left forearm and palpate for thrill twice a day and as needed. It was documented the resident had a communication problem related to hearing deficit and unclear speech at times. An MDS assessment, dated 08/30/24, documented the resident was moderately impaired with cognition. It was documented the resident required dialysis treatments. On 09/16/24 at 11:27 a.m., resident #13 stated they went for dialysis treatments on Tuesday, Thursday, and Saturday. The resident's shunt was observed and they confirmed the dialysis center accessed it for treatments. On 09/17/24 at 3:15 p.m., RN #3 stated staff obtained the resident's vital signs on the day of dialysis and the nurse assessed the shunt for a thrill. The RN stated the resident was assessed and weighed at the dialysis center. The RN stated once a month the dialysis unit would draw labs and send the lab results back with the resident, along with any recommendations or requests for orders. The RN stated the nurse practitioner at the dialysis unit occasionally called the facility on Fridays to check in or make the facility aware of any changes. The RN stated they did not document on a communication form or share information with the dialysis unit, unless the dialysis unit called the facility to give a report. On 09/18/24 at 9:36 a.m., the DON stated the nurses obtained vital signs before and after resident #13 went to dialysis, but stated they did not have anything in place to ensure ongoing communication with the dialysis center before and after treatments.

Based on observation, record review, and interview, the facility failed to ensure a medication rate of less than 5%. A total of 31 opportunities were observed during the medication pass with two errors identified. The total medication error rate was 6.45% related to two medications crushed without physician orders to crush the medications for two (#23 and #62) of nine sampled residents reviewed for medications. The administrator identified 69 residents resided in the facility. Findings: An undated document titled Drugs that should not be chewed or crushed, read in part, .Potassium Chloride .Enteric coated tablet designed to pass through the stomach whole and then dissolve in the intestines .Reasons for this type of formulation include: 1a. to prevent the destruction of the drug by stomach acid. 1b. to prevent irritation to the stomach. 1c. to achieve prolonged action . 1. Res #23's physician orders, dated 07/31/24, documented potassium chloride ER tablet 20 mEq. Give one tablet by mouth one time a day for supplement. The physician orders did not include an order to crush medications. On 09/17/24 at 8:20 a.m., a medication pass was conducted with ACMA #2. The ACMA administered one potassium chloride ER 20 mEq tablet to resident #23. They stated they were crushing their medication and mixing it with pudding. They stated the resident had thickened liquids with their meal. 2. Resident #62's physician orders, dated 09/09/24, documented potassium chloride ER tablet 20 mEq. Give one tablet by mouth one time a day for supplement. The physician orders did not include an order to crush medications. On 09/17/24 at 8:40 a.m., a medication pass was conducted with ACMA #2. They administered one potassium chloride ER 20 mEq tablet to resident #62. They stated they were crushing their medication and mixing it with pudding. On 09/17/24 at 3:02 p.m., the RN consultant stated the physician orders did not contain crush orders for resident #23 and resident #62. They stated the potassium chloride should not be crushed.

Based on observation, record review, and interview, the facility failed to have EBP in place for two (#13 and #57) of three sampled residents reviewed for infection prevention and control. The DON identified three residents who required EBP. Findings: The facility's infection control policy was reviewed and contained no documentation or guidance related to EBP. On 09/16/24 at 9:00 a.m., a tour of the facility was conducted. There was no signage or PPE supplies observed in place for residents who required EBP. On 09/16/24 at 3:15 p.m., the consulting RN stated they were not aware of the EBP requirement. They stated the facility did not have a policy or process in place. On 09/17/24 at 8:38 a.m., wound care was provided for resident #57. Nursing staff were observed to don PPE appropriately related to EBP. The staff stated they were not aware of EBP requirements. On 09/18/24 at 2:06 p.m., RN #1 was observed to provide catheter care for resident #13. The RN was observed to don gloves and a gown prior to care. The RN was asked if they were using EBP previously. They stated they were not. They stated they did not know anything about the requirement.

Based on observation and interview, the facility failed to ensure emergency call systems located near toilets were accessible by a resident lying on the floor in nine of 11 community bathrooms frequently used by residents. The DON stated 69 residents resided in the facility. Findings: On 09/18/24 at 1:40 p.m., community bathrooms used by residents were observed. Nine of the 11 bathrooms were observed to have a small switch on the wall near the toilet to activate the emergency call system and would not be accessible to a resident lying on the floor. 09/18/24 1:51 p.m. the DON stated not all the community bathrooms used by residents had a pull cord attached to the emergency call system switch near the toilet. They stated the emergency call system switch located near the toilets in the community bathrooms would not be accessible to a resident lying on the floor. The DON stated they did not know the reason all the call systems near the toilets were not equipped with a pull cord and the maintenance supervisor was on vacation. On 09/18/24 at 2:16 p.m., the DON stated the facility had no policy related to emergency call systems. They stated the administrator stated all emergency call systems in bathrooms used by residents had previously been equipped with pull cords and they were unsure of when they were removed.

Based on interview and record review, it was determined the facility failed to ensure nurse aides demonstrated competency of skills and techniques necessary to care for residents. The facility identified 73 residents resided in the facility. Findings: On 12/12/19 at 3:54 p.m., the director of nursing (DON) provided two certified nurse aide (CNA) competency checklists, both observed to be dated 12/06/18. The DON provided a list of employed CNAs and reported eight of the ten aides had not completed the required annual skills competency checklist.

Based on interview and record review, it was determined the facility failed to have a facility-wide assessment in place to determine resources required to care for the residents. The facility identified a census of 73 residents. Findings: On 12/12/19 at 2:58 p.m., facility records were reviewed for a facility assessment. The director of nursing (DON) and administrator (ADM) reported no knowledge of the requirement to have a facility assessment in place. The ADM reported a facility assessment had not been developed.

Based on record review and interview, it was determined the facility failed to develop a comprehensive care plan for three (#36, #47, and #57) of 19 residents whose care plans were reviewed. This had the potential to affect all 80 residents. Findings: 1. Resident #36 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 08/02/18, documented the resident was severely cognitively impaired and had received an anti-psychotic daily for the seven-day look back period prior to the assessment. The (MONTH) (YEAR) physician's orders [REDACTED]. The medication start date was 04/27/17. The most recent care plan had not documented the use of the [MEDICATION NAME]. On 10/10/18 at 4:40 p.m., the care plan coordinator was asked if the [MEDICATION NAME] should have been documented on the care plan. She stated, Yes. 2. Resident #47 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 07/18/18, documented the resident was moderately cognitively impaired. It documented the resident was totally dependent with bathing with one person assistance, extensive assistance with transfer and toilet use with two person assistance, extensive assistance with bed mobility, dressing, and hygiene with one person assistance, supervision with eating with set up only. It documented she had a range of motion limitation on one side in the lower extremities, and was frequently incontinent of bowel and bladder. The record contained no care plan information for rehabilitative services, which the resident had been receiving. On 10/11/18 at 11:41 a.m., The care plan coordinator was asked what care plan for therapies did resident #47 have on her care plan. She stated none. She was asked if she should have had therapies care planned for the resident. She stated she should have. 3. Resident #57 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/19/18, documented the resident's cognition was intact. He required extensive assistance with dressing and personal hygiene, He required supervision with all of his other activities of daily living. He was always continent of bowel and bladder. The resident had received an anti-anxiety and antidepressant daily on his 7 day look back period. The resident's monthly behavior flow sheets were reviewed for (MONTH) (YEAR) through (MONTH) (YEAR). There had been no behaviors of anxiety or depression documented. On 10/10/18 at 2:44 p.m., registered nurse (RN) #2 was asked if the resident was ever anxious. She stated, No he's pretty docile all the time. At 3:15 p.m., the social service director was asked if this resident has had any behaviors. She stated he had not had any behaviors since he went to the hospital over a year ago. The current physician's orders [REDACTED]. The resident's care plan was reviewed. There was no care plan for anxiety. On 10/11/18 at 11:19 a.m., the care plan coordinator was interviewed and asked about the resident having been on an anti-anxiety medication. She agreed he should have had a care plan for being on an anti-anxiety medication. At 12:39 p.m., the director of nursing was shown the above information. She was in agreement he should have had a care plan for the medication he was on. ·

Based on observation, record review and interview, it was determined the facility failed to follow proper infection control procedures while performing fingerstick blood sugar (fsbs) checks on residents for two (#6 and #230) of two residents observed who had received a fsbs check. This had the potential to affect 11 residents who received fsbs checks according to the assistant director of nurses. Findings: The facility's policy on glucometers documented, .Glucometer is to be cleaned thoroughly with recommended sanitizing wipe after each use . On 10/09/18 at 11:50 p.m., student practical nurse (SPN) #1 performed a fsbs check on resident #6. The SPN was not observed to have cleaned the glucometer used to check the fsbs after she checked the resident's fsbs. She placed it down on the cart. At 12:00 p.m., a fsbs check was performed by SPN #1 on resident #260. The glucometer was not observed to have been cleaned before or after the resident's fsbs check. At 12:05 p.m., licensed practical nurse #1, who was supervising SPN #1, was asked when the glucometer should have been cleaned. She stated every evening. At 12:15 p.m., the director of nurses was asked when the glucometer should have been cleaned. She stated after each use.

Based on record review and interview, it was determined the facility failed to develop an individualized care plan for residents with dementia for two (#24 and #36) of three residents reviewed for dementia. This had the potential to affect 49 residents with dementia according to the 'Resident Census and Conditions of Residents' form. Findings: 1. Resident #24 had a [DIAGNOSES REDACTED]. It documented the resident needed supervision for bed mobility, transfers, toilet use, and hygiene and limited assist with dressing and help in part with bathing with one person assistance, no range of motion limitations, and always continent of bowel and bladder. A care plan, dated 08/29/17, documented the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. It documented she needed assistance with some decision making. On 10/11/18 at 1:08 p.m., the care plan coordinator was asked what would a care plan for a resident with dementia consist of. She stated it would contain interventions such as to re-orient as needed, assist with activities of daily living, activities, and any other things the resident would need based on how bad their dementia was. The care plan for resident #24 was reviewed with her. She was asked if the care plan had been individualized for the resident. She stated is had not. 2. Resident #36 had a [DIAGNOSES REDACTED]. The quarterly assessment, dated 08/02/18, documented the resident was severely cognitively impaired and had a [DIAGNOSES REDACTED]. The resident's current care plan had not documented the [DIAGNOSES REDACTED]. On 10/10/18 at 4:40 p.m., the care plan coordinator was asked if the [DIAGNOSES REDACTED]. She stated, Yes.

Based on record review and interview, it was determined the facility failed to ensure a monthly drug regimen review was completed for one (#24) of six residents whose records were reviewed for unnecessary medications. This had the potential to affect all 80 residents. Findings: Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual assessment dated [DATE], documented the resident was severely cognitively impaired. It documented she needed supervision for bed mobility, transfer, toilet use, and hygiene and limited assist with dressing and help in part with bathing with one person assistance. It documented she had no range of motion limitations, was always continent of bowel and bladder and had received an anti-psychotic and antidepressant medication 7 of 7 days in the look back period. The resident record had not contained a monthly review of her medications for 02/2018, 03/2018, 04/2018, 06/2018, 08/2018, or 09/2018. on 10/15/18 at 10:25 a.m., the director of nursing was asked if a monthly medication review had been done for this resident for 02/2018, 03/2018, 04/2018, 06/2018, 08/2018, or 09/2018. She stated it did not look like one had been done.

Based on record review and interview, it was determined the facility failed to ensure pain medication effectiveness had been documented for one (#72) of three residents reviewed for pain management. This had the potential to affect 80 residents. Findings: The facility's policy and procedure for pain assessment was reviewed and documented the pain flow sheets would be completed for pain medications, which included documenting the residents' reports of the effectiveness of the medication. Resident #72 was admitted with [DIAGNOSES REDACTED]. The care plan, dated 02/05/18, documented the facility was to monitor/record/report to the nurse any complaint of pain or requests for pain treatment. A quarterly assessment, dated 08/05/18, documented the resident's cognition was intact and had received frequent pain management. The pain medication sheet documented the following was administered: 09/13/18 [MEDICATION NAME] (narcotic [MEDICATION NAME]) for pain at a level 7, no outcome documented, 09/13/18 [MEDICATION NAME] for pain at level 9, no outcome documented, 09/14/18 [MEDICATION NAME] for pain at level 8-9, no outcome documented, 09/14/18 [MEDICATION NAME] for pain at level 9, no outcome documented. On 10/11/18 at 9:53 a.m., certified medication aide #1 was asked the procedure to ensure pain management was documented. She stated the required pain management documentation was the resident's level of pain from 0 (being none) to 10 (the worst), administer medications per the physician's orders [REDACTED]. At 11:18 a.m., the assistant director of nursing was shown the resident's pain flow sheet and asked if the effectiveness of the administered pain medication had been documented. She stated, No.

Based on record review and interview, it was determined the facility failed to develop and implement a quality assurance and performance improvement (QAPI) plan for all 80 residents. Findings: The facility had systemic problems with their psychoactive medication use and bed rails. The QAPI committee failed to identify and/or correct the concerns. On 10/16/18 at 10:09 a.m., the director of nurses was asked if their QAPI committee should have identified the issues with their use of bed rails, gradual dose reductions of psychoactive medications, the use of psychoactive medications, the as needed use of psychoactive medication use, and their monthly pharmacy medication reviews. She stated they should have. She was asked if the QAPI committee had been effective in identifying these concerns. She stated it had not been.

Based on record review and interview, it was determined the facility failed to ensure: ~an as needed medication was discontinued after 14 days for two (#2, #72) and, ~ justification for an anti-psychotic medication for one (#24) and, ~justification for an anti-anxiety medication for one (#57) and, ~gradual dose reductions were attempted for two (#36 and #59) of six residents whose records were reviewed for anti-psychotic unnecessary medications. This had the potential to affect 59 residents who received psychoactive medications according to the 'Resident Census and Conditions of Residents' form. Findings: 1. Resident #2 had [DIAGNOSES REDACTED]. An annual assessment, dated 09/13/18 documented the resident's cognition was intact. She required supervision for all of her activities of daily living. She was continent of bowel and bladder. A physician's orders [REDACTED]. The physician's progress note for (MONTH) (YEAR) had not documented anything in regard to the [MEDICATION NAME]. There was no follow up (f/u) for the PRN medication within 14 days and no physician's assessment with a rationale for it to have been continued. On 10/11/18 at 11:17 a.m., the assistant director of nursing was shown the order for [MEDICATION NAME] to be made PRN and no f/u had been done within the 14-day time frame. She stated, Ok, there's nothing we can do about it if the doctor changes a medication to PRN. At 11:21 a.m., the director of nursing (DON) was asked about the medication having been given over the 14-day period without a physician's assessment to have continued it. She stated the medication should have been discontinued or the physician should have given a rationale to have continued it. 2. Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 07/09/18, documented the resident was severely cognitively impaired. It documented she needed supervision for bed mobility, transfer, toilet use, and hygiene and limited assistance with dressing and help in part with bathing with one person assistance. It documented she had no range of motion limitations, was always continent of bowel and bladder and had received an anti-psychotic and an antidepressant medication 7 of the 7 days in the look back period. A care plan, dated 07/09/17, documented the resident used the antidepressant medication [MEDICATION NAME] and [MEDICATION NAME] (an anti-psychotic medication) related to depression. The staff were to administer the medications as ordered by the physician and were to monitor/document any side effects and the effectiveness every shift. A physician's orders [REDACTED]. On 10/15/18 at 10:25 a.m., the DON was asked why the resident was on an anti-psychotic medication. She stated she did not know. She was asked if the resident should be on the medication. She stated, No. 3. Resident #36 had a [DIAGNOSES REDACTED]. The quarterly assessment, dated 08/02/18, documented the resident was severely cognitively impaired and had a [DIAGNOSES REDACTED]. The (MONTH) (YEAR) physician's orders [REDACTED]. The medication start date was 04/27/17. There was no documentation in the clinical record of any behaviors from (MONTH) (YEAR) in the social service progress notes and none in the nurse's notes from (MONTH) (YEAR). The monthly (YEAR) psychologist notes had not documented any behaviors. On 10/10/18 at 10:25 a.m., registered nurse (RN) #1 and the assistant director of nurses were asked if the resident had behaviors. They both replied she had not had behaviors in a long time. A gradual dose reduction was documented to have been requested by the pharmacist on 05/25/18. The letter, with the physician's response, was unable to have been located by the DON. On 10/10/18 at 02:46 p.m., the DON was asked if the resident should have had a reduction attempt on her antipsychotic. She stated the medication should have been reduced. 4. Resident #57 had a [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/19/18, documented the resident's cognition was intact. He required extensive assistance with dressing and personal hygiene, He required supervision with all of his other activities of daily living. He was always continent of bowel and bladder. The resident had received an antianxiety and an antidepressant on his 7 day look back period. The resident's monthly behavior flow sheets for (MONTH) (YEAR) through (MONTH) (YEAR) had no behaviors of anxiety or depression documented. On 10/10/18 at 2:44 p.m., RN #2 was asked if the resident was ever anxious. She stated, No he's pretty docile all the time. At 3:15 p.m., the social service director was asked if the resident had any behaviors. She stated he had not had any behaviors since he went to the hospital over a year ago. The current physician's orders [REDACTED]. The clinical record had not documented the resident had a [DIAGNOSES REDACTED]. On 10/11/18 at 12:39 p.m., the DON was interviewed in regard to the resident's anti-anxiety medication. She stated he should not have been on an anti-anxiety medication without having a [DIAGNOSES REDACTED]. 5. Resident #59 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/21/18, documented the resident's cognition was intact, she required supervision for all of her activities of daily living. The resident was always continent of bowel and bladder. The monthly pharmacy consults were reviewed. They documented: Last change on [MEDICATION NAME] (anti-anxiety) 0.5 milligrams (mg) twice daily (BID) was 06/27/16, Last change on [MEDICATION NAME] (anti-psychotic) 80 mg four times daily was 01/13/17, Last change on [MEDICATION NAME] (anti-psychotic) 100 mg intramuscular was 03/10/16, Last change on [MEDICATION NAME] 1g Bid was 04/02/16, and Last change on [MEDICATION NAME] (antidepressant) 100 mg two at bedtime was 01/13/17 The monthly pharmacy consult, dated 10/20/17 documented, .the family will not allow mediation reductions . The monthly pharmacy consult, dated 08/27/18 documented, .Family won't allow change . On 10/10/18 12:42 PM The DON was interviewed and asked if a gradual dose reduction (GDR) had been recommended for the resident's anti-psychotic medications. She stated, No, because the family doesn't want them to be changed. The regulation was discussed and she was in agreement there should have been a GDR recommended for the resident's medications. 6. Resident #72 was admitted with [DIAGNOSES REDACTED]. The quarterly assessment, dated 08/05/18, documented the resident's cognition was intact and required supervision of activities of daily living, and had received an anti-anxiety medication daily for the past seven days. A physician's orders [REDACTED]. The order had not documented a stop date. The Medication Administration Record [REDACTED]. On 10/11/18 at 11:25 a.m., the DON was shown the above findings and agreed the medication should have been discontinued after fourteen days or a physician's assessment and rationale should have been obtained to continue the medication.

Based on observation, record review, and interview, it was determined the facility failed to ensure bed rails had not been utilized as restraints for four (#7, #17, #47, and #65) of 12 residents reviewed for using bed rails. This had the potential to affect all 80 residents Findings: 1. Resident #7 was admitted with [DIAGNOSES REDACTED]. An annual assessment, dated 09/21/18, documented the resident had moderately impaired cognition, required limited assistance with bed mobility and transfers, and bed rails were used daily. The care plan, dated 06/21/18, documented the resident used side rails related to (r/t) confusion and the facility was to have ensured a valid consent was in the medical record prior to having initiated the use of the restraint. The clinical record had not documented a physician's orders [REDACTED]. On 10/08/18 at 9:43 a.m., the resident was observed in bed with two half bed rails in the up position. On 10/10/18 at 9:32 a.m., the resident was asked if she would have been able to lower the bed rails while in bed. She stated she did not think she could. On 10/10/18 at 3:24 p.m., certified nurse aide (CNA) #1 was asked if the bed rails were used while the resident was in bed. She stated, Yes, because she rolls, it's for her safety. 2. Resident #17 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 07/10/18, documented his cognition was moderately impaired. He required extensive assistance with transfers. He had no impairments to his upper or lower extremities, limiting his range of motion. No use of bed rails had been documented. The care plan had not documented the use of bed rails. On 10/08/18 at 2:35 p.m., the resident's bed had a full bed rail in the up position on the outer side that was not against the wall. He was lying in bed with his eyes closed. On 10/10/18 at 3:04 p.m., the resident was observed lying in bed with his eyes closed. The full bed rail away from the wall on his bed was in the up position. At 3:08 p.m., CNA #3 was asked why they had been using a full bed rail. He stated the rail was up because the resident tried to get up and could fall. On 10/11/18 at 4:20 p.m., the resident was lying in his bed with his eyes closed. The full bed rail away from his wall was in the up position. At 4:21 p.m., CNAs #2 and #4 were asked why the resident's bed rail had been up. They both stated it was because he would try to get up. At 4:27 p.m., licensed practical nurse (LPN) #1 was asked why the resident's bed rail was up. She stated he would try to get up. 3. Resident # 47 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 07/09/18, documented a new order had been received for a restraint due to the resident was getting out of bed and her bed was switched to a bed with full side rails. An admission assessment, dated 07/18/18, documented the resident was moderately cognitively impaired. It documented she required extensive assistance with transfers and toilet use with two person assistance, and extensive assistance with bed mobility. It documented she had a range of motion limitation on one side in the lower extremities and was frequently incontinent of bowel and bladder. A care plan, dated 07/19/18, documented the resident would have side rails up while in bed per the family's request and the resident would have shown understanding for safety with side rail use and the call light would be within reach. On 10/08/18 at 10:55 a.m., the resident was observed in bed with the bed having a full length bed rail in the up position. She was asked if she was able to get out of bed on her own. She stated she could sometimes. She was asked if the bed rails kept her from getting up. She stated the staff put them up sometimes so she can not get up. The clinical record had not contained a physician's orders [REDACTED]. On 10/15/18 at 10:49 a.m., CNA #4 was asked if the resident was able to get up on her own. She stated she could. She was asked if the resident could get up when the bed rails were up. She stated she could but did not know how she would get up. She stated the staff would find the resident up and the bed rails were up and they didn't know if she had climbed over them or around them somehow. At 1:59 p.m., the director of nurses (DON) was asked if bed rails had been used as a restraint for the resident. She stated apparently so. She was asked if the bed rails should have been used as a restraint. She stated, No. 4. Resident #65 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 09/05/18, documented the resident's cognition was severely impaired. He required extensive assistance with transfers. He had not ambulated. The bed rails were used less than daily under the physical restraint section. The care plan had documented he had impaired cognitive function/dementia or impaired thought processes r/t dementia and the resident used physical restraints (bed rails) r/t confusion. The goal for the use of the restraint was the resident would remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation or withdrawal. The restraint use would be minimized. The interventions documented for the use of the bed rails were: The facility was to anticipate and intervene for potential causes which had precipitated prior falls or accidents and ensure the resident was positioned correctly with proper body alignment while restrained. The care plan had also documented the resident was at a high risk for falls r/t confusion and gait/balance problems. On 10/08/18 at 2:35 p.m., the resident's bed had a full side rail in the up position on the outer side that was not against wall. He was lying in bed with his eyes closed. On 10/10/18 at 3:04 p.m., the resident was observed lying in bed with his eyes closed. The full side rail away from the wall on his bed was in the up position. At 3:08 p.m., CNA #3 was asked why they had been using a full side rail. He stated the rail was up because the resident had tried to get up and could fall. On 10/11/18 at 4:20 p.m., the resident was lying in his bed with his eyes closed. The full side rail away from his wall was in the up position. At 4:21 p.m., CNAs #2 and CNA #4 were asked why the resident's bed rail had been up. She stated it was because he would try to get up. At 4:27 p.m., licensed practical nurse (LPN) #1 was asked why the resident's bed rail was up. She stated he would try to get up.

Based on observation, record review, and interview it was determined the facility failed to follow the care plan for one (#71) and also failed to update/revise care plans for one (#72) of 19 records reviewed. This had the potential to affect 80 residents. Findings: 1. Resident #71 had [DIAGNOSES REDACTED]. An annual assessment, dated 08/09/18, documented the resident required extensive assistance with activities of daily living. She had frequent pain and pain medication had been administered. She had two unstageable pressure ulcers. The care plan, revised on 10/01/18, had documented the resident was on pain medication therapy ([MEDICATION NAME] 5-325 milligrams every 6 hours as needed), she had chronic pain related to her wounds. The facility was to have administered her [MEDICATION NAME] medication as per the physician's orders [REDACTED]. On 10/11/18 at 10:11 a.m., the assistant director of nurses was observed to perform the physician's orders [REDACTED]. The resident had stated ouch every time the wounds themselves were touched during the treatment. At 10:30 a.m., certified medication aide #2 was asked if the resident had received pain medication. She stated the resident had received it that morning at 8:00 a.m. She asks for it every morning because she knows her treatment is going to be done. At 11:00 p.m., the assistant director of nurses was interviewed in regard to the resident's pain with wound care treatments and how she ensured pain medication was given per the physician's orders [REDACTED]. She was asked if the care plan had been followed since the treatment had been performed over two hours after the resident had received pain medication. She stated, No. 2. Resident #72 was admitted with [DIAGNOSES REDACTED]. The care plan, dated 02/05/18, documented the resident required tube feeding, the resident was dependent with tube feeding and water flushes. A physician's progress note, dated 02/22/18, documented the peg tube had been removed, dated 02/19/18, and a new order for a regular diet with regular texture was received. The quarterly assessment, dated 08/05/18, documented the resident's cognition intact, required supervision of all activities of daily living, and had received [MEDICAL CONDITION] therapy. A physician's progress note, dated 08/07/18 documented, .complete traumatic amputation of the left foot . The care plan had not documented goals or interventions related to the [DIAGNOSES REDACTED]. On 10/15/18 at 9:09 a.m., the director of nurses was shown the above findings and agreed the care plan had not been revised to reflect the resident's current status.

Based on record review and interview, it was determined the facility failed to ensure residents were given information about an advanced directive upon admission for two (#47 and #230) of 22 residents who were reviewed for advanced directives. This had the potential to affect all 80 residents. Findings: 1. Resident #47 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 07/18/18, documented the resident was moderately cognitively impaired. It documented the resident was totally dependent with bathing with one person assistance, extensive assistance with transfer and toilet use with two person assistance, extensive assistance with bed mobility, dressing, and hygiene with one person assistance, and supervision with eating with set up only. It documented she had a range of motion limitation on one side in the lower extremities, and was frequently incontinent of bowel and bladder. There was no advance directive information found in the resident's clinical records. 2. Resident #230 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 10/02/18, documented the resident was moderately cognitively impaired. It documented the resident required limited assistance with activities of daily living with one person assistance, had no range of motion limitations, and was occasionally incontinent of bladder and frequently incontinent of bowel. There was no advance directive information found in the resident's clinical records. On 10/11/18 at 2:30 p.m., the social services director was asked if the advanced directive information should have been provided to the residents on admission. She stated she was not aware she was supposed to have been doing these.

Based on record review and interview, it was determined the facility failed to ensure an admission assessment was completed within fourteen days of admission for one (#230) of 19 residents whose assessments were reviewed. This had the potential to affect all 80 residents. Findings: Resident #230 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/08/18 the assessment had not been completed yet. On 10/11/18 at 11:40 a.m., the minimum data set coordinator was asked if the assessment for resident #230 should have been completed by now. She stated it should have been and was late.