Every finding on record at Bell Avenue Nursing Center

Based on record review and interview, the facility failed to conduct a comprehensive assessment within 14 calendar days of admission for 2 (#104 and #205) of 13 sampled residents reviewed for comprehensive assessments. The administrator reported 51 residents resided in the facility. Findings: A MDS Completion and Submission Timeframes policy, dated July 2017, read in part, Our facility will conduct and submit resident assessments with current federal and state submission timeframes. 1. Resident #104 had diagnoses which included acute osteomyelitis, right tibia and fibula, encounter for closed fracture with nonunion, and chronic obstructive pulmonary disease. Resident #104's entry assessment, dated 03/08/25, showed an admitted [DATE]. Resident #104's admission/5-day Medicare assessment, dated 03/15/25, showed to be in progress. On 03/26/25 at 9:47 a.m., the MDS coordinator reported they did not complete the admission/5 day-Medicare assessment for Resident #104. They reported they had been out sick. 41873 2. Resident #205 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus. Resident #205's admission assessment, dated 03/13/25, showed to be in progress. On 03/26/25 at 9:47 a.m., the MDS coordinator reported they had not completed the admission assessment for Resident #205 and the assessment was late.

Based on record review and interview, the facility failed to ensure assessments were accurate for 2 (#37 and #46) of 2 sampled residents reviewed for anticoagulant therapy. The administrator reported 51 residents resided in the facility. Findings: The facility had no policy for coding medication on MDS assessments. 1. Resident #37 had diagnosis which included cerebrovascular accident. A physician order, dated 05/09/24, showed to give the clopidogrel bisulfate (antiplatelet medication), 75 mg by mouth one time a day for cerebrovascular accident. The physician orders contained no anticoagulant medication. A quarterly assessment, dated 12/24/24, showed resident #37's cognition was moderately impaired with a BIMS score of 11. The assessment showed anticoagulant medication and no antiplatelet medication. 2. Resident #46 had diagnosis which included stroke. A physician order, dated 10/15/24, showed to give clopidogrel bisulfate oral tablet 75 mg, one tablet by mouth one time a day for previous stroke and Aspirin (an antiplatelet prevention medication) 81 mg, one capsule by mouth one time a day for cerebrovascular accident prevention. The physician order contained no anticoagulant medication use. A significant change assessment, dated 02/17/25, showed Resident #46's cognition was severely impaired with a BIMS score of 06. The assessment showed anticoagulant and antiplatelet medication use. On 03/26/25 at 10:43 p.m., the MDS coordinator reported they had always coded clopidogrel bisulfate as an anticoagulant and not an antiplatelet on the MDS. The MDS coordinator reported they documented aspirin as an antiplatelet. On 03/26/25 at 10:48 a.m., the MDS coordinator reported they checked the Centers for Medicare and Medicaid Services (CMS) website and confirmed that clopidogrel bisulfate was coded wrong and should have been coded as an antiplatelet for Resident #37 and Resident #46.

Based on observation, record review, and interview, the facility failed to follow physician orders related to insulin administration for 1 (#205) of 3 sampled residents reviewed for insulin administration. The DON reported 11 residents received insulin at the facility. Findings: On 03/25/25 at 4:48 p.m., LPN #1 was observed to prepare supplies and obtain a FSBS for Resident #205. The FSBS was 367 mg/dl. They administered 10 units of Humalog. They did not document a follow-up for the high blood sugar reading. An Obtaining a Fingerstick Glucose Level policy, dated October 2011, read in part, Verify that there is a physician's order for this procedure. An Insulin Administration policy, dated September 2014, read in part, Check blood glucose per physician order or facility protocol. Resident #205's care plan, dated 03/07/25, showed the resident had diabetes mellitus and to administer diabetes medication as ordered and monitor for side effects and effectiveness. Resident #205's physician order, dated 03/17/25, showed a sliding scale for insulin. The order showed to inject 10 units of Humalog insulin for a FSBS between 351 mg/dl and 450 mg/dl every 60 minutes. The order showed to Redose every 60 minutes until less than 300 and notify primary care physician if not less than 400 mg/dl after three doses, call the primary care physician. On 03/26/25 at 10:44 a.m., the DON was asked about the FSBS readings recorded on 03/25/25 as 354 mg/dl and 367 mg/dl. They stated the nurse should have rechecked them and did not recheck them or document in the nurse's note. The DON stated the nurse did not follow the physician orders. The DON reported LPN #1 was not available today for interview. On 03/26/25 at 1:07 p.m., LPN #3 was asked about a FSBS recorded for Resident #205 on 03/21/25 as 401 mg/dl and 353 mg/dl. They stated they did not document in the nurse's note, but they knew they rechecked the residents blood sugar. They reported they were aware of the physician orders to check the FSBS every 60 minutes and to notify the physician.

Based on record review and interview, the facility failed to ensure accurate wandering risk scale assessments were completed for two (#2 and #3) of three residents sampled for accurate wandering risk scale assessments. The DON identified eight residents were at risk for wandering and elopement. Findings: The facility's Elopement and Wandering Residents policy, dated 01/13/21, read in part, Wandering is random or repetitive locomotion that may be goal directed (e.g., the person appears to be searching for something such as an exit) or non goal directed or aimless. The policy also read, The facility shall establish and utilize a systematic approach to monitoring and managing residence at risk for elopement or unsafe, wandering, including identification and assessment of risk, evaluations of hazards and risk, implementing interventions to reduce hazards and risk, and monitoring for effectiveness and modifying interventions when necessary. The policy also read, Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. 1. Resident #2 was admitted to the facility on [DATE] with diagnoses which included paroxysmal atrial fibrillation, type 2 diabetes, and unspecified dementia. A nurse's note for Resident #2, dated 11/21/23, read in part, Resident has been very upset about being in this facility and was crying stating [they] wanted to go home. Resident was at the front door trying to get outside and was shaking door handle trying to open it. This nurse tried to calm resident down and resident said [they] wanted to go for a walk outside. Took resident for a short wheel/walk in wheelchair outside on sidewalk. Resident calmed down after walk. Not too long after coming back inside, kitchen staff seen resident out in parking lot by herself. Staff was unaware how [they] got out the front door. This nurse and CNA went and got resident and resident again stated she wanted to go home and have [their] [family member] come get [them] and was crying. Got resident back into facility and contacted [their] [family member] to notify [them] of [their] behavior. Resident calm down and went and ate supper. Resident #2's comprehensive assessment, dated 01/31/24, documented the resident's cognition was moderately impaired and they required substantial to maximal assistance with activities of daily living. Resident #2's Wandering Risk Scale assessments dated, 02/01/24, 05/01/24, 07/26/24, and 10/23/24 documented the resident had no history of wandering and had no reported episodes of wandering in the past six months. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia with agitation, edema, and age related physical disability. Resident #3's quarterly assessment, dated 01/31/24, documented the resident's cognition was significantly impaired and they were independent for assistance with activities of daily living. Resident #3's incident note, dated 07/13/24, read in part, this resident was walking down the street toward [name withheld]. This nurse stopped resident and brought [them] back into the facility. This nurse asked resident if [they] knew the code to the front door. Resident stated, no, I snuck out the door behind someone. The facility's #1248 Elopement incident report, dated 07/13/24, read in part, Resident was observed by staff walking down the street to the store. Staff intervened and brought the resident back to the facility. Resident #3's Wandering Risk Scale assessment dated , 07/14/24, documented the resident had no history of wandering and has had no reported episodes of wandering in the past six months. Resident #3's nurse progress note, dated 08/03/24, read in part, resident was seen by resident [name withheld] jumping the fence in the back yard. The facility's #1319 Elopement incident report, dated 08/03/24, read in part, resident was seen by resident [name withheld] jumping the fence in the back yard. It also read, Resident is an elopement risk. Resident #3's Wandering Risk Scale assessments dated, 09/09/24 and 12/06/24, documented the resident had no history of wandering and has had no reported episodes of wandering in the past six months. On 12/17/24 at 2:30 p.m., the administrator stated Resident #2 was out front in eyesight on 11/21/23 and never left the property. They stated they were unsure how Resident #2 got out on 11/21/23, but was within eyesight on the front porch sidewalk area. The administrator stated Resident #3's exit was seeking was for cigarettes on 07/13/24 and on 8/03/24. The administrator was asked to review the Elopement and Wandering Residents policy, dated 1/13/21, and the SOM with Elopements and Wandering definitions. The administrator stated that based upon their review, the wandering assessments for Resident #2 and Resident #3 were not accurate because they documented no history of wandering and no wandering in the past six months. They stated there was a confusion as they thought all wandering should be aimless and they were not considering goal directed as wandering.

Based on record review and interview, the facility failed to provide an environment free from abuse for two (#7 and #8) of five sampled residents reviewed for resident-to-resident abuse. The Administrator identified 56 residents resided in the facility. Findings: An 'Abuse Prevention Program' policy, revised September 2015, read in parts, .It is the policy of the facility to prohibit abuse .The facility will investigate allegations and reported incidents .The investigation will include preventative measures when possible to prevent reoccurrence .Examples of plans of action may include a change in care, a change in medication . 1. Resident #6 A document titled Annual MDS Assessment, dated 06/24/24, Resident #6 cognition was severly impaired. The assessment further indicated Resident #6 was independent with transfer. Resident #6 was able to ambulate with assistance with a walker and wheel chair. A Physician's Order, dated 04/03/24, documented Resident #6 was started on Provera 2.5mg by mouth daily. A document titled Progress Notes, documented four occurrences of inappropriate behavior by Resident #6 towards female residents on the following days: 03/31/24, 04/01/24, 04/08/24 & 04/19/24 A document titled Psychiatric Progress Note, dated 04/17/24, Resident #6 was starte on Provera 2.5mg to reduce testosterone levels. A document titled Psychiatric Progress Note, dated 05/18/24, documented to increase Provera 2.5mg to Provera 5mg twice a day. Then to follow-up in 3 - 4 weeks. The medication administration record, dated 05/18/24 - 08/22/24, contained no documentation Resident #6 received Provera 5mg twice a day. There was no documentation to indicate that a follow-up was completed in 3-4 weeks. There was no documentation to indicate Resident #6's Provera was increased to 5mg twice a day. Resident #6 careplan, dated 03/31/24, documented Resident #6 had become more focused on women and thinking of sexual urges. It was documented Resident #6 touched another residents breast without consent. A careplan entry, dated 04/19/24, documented Resident #6 touched another residents breast and was slapped. A progress note, dated 04/21/24, documented four occuraences of inappropriate behavior by Resident #6 towards female residents on the following days: 04/21/24, 04/26/24, 04/29/24 & 08/21/24 There was no documentation to indicate that Resident # 6 careplan was updated. 2. Resident #7 had diagnoses that included senile degeneration of the brain and dementia. A 'Functional Abilities and Goals' assessment, dated 06/19/24, documented Resident #7 was wheelchair dependent and required substantial/maximum assistance for ADL's. Nurse Progress Note, dated 03/31/24 1:13 p.m., documented Resident #6 was observed with Resident #7 in a corner groping her breasts. 3. Resident #8 had diagnoses that included vascular dementia and aphasia. A 'Functional Abilities and Goals' assessment, dated 07/10/24, documented Resident #7 was wheelchair dependent and required assistance for ADL's. Nurse Progress Note for Resident #6, dated 04/19/24 8:15 p.m., documented Resident #6 was reported to have approached Resident #8, asked resident to lift their shirt and then tried to reach forward and grab Resident #8's breasts. A Psychiatric Progress Note for Resident #6, written 04/17/24, documented an order to increase Resident #6's Provera to 5mg BID to decrease testosterone due to continued exhibition of sexual behaviors towards other residents. There was no documentation that this order was carried out. A Psychiatric Progress Note for Resident #6, written 05/15/24, documented another order to increase Resident #6's Provera to 5mg BID. There was no documentation that this order was carried out. On 08/20/24 at 2:52 p.m., CNA #1 reported that Resident #6 had a problem with inappropriate touching, and staff were instructed to keep them away from the females, especially the ones that could not speak. On 08/21/24 at 1:10 p.m., the Administrator reported to this surveyor that Resident #6 was observed in the dining room during lunch today sitting beside Resident #8 and touching their breast. On 08/21/24 at 3:45 p.m., the DON was asked to review these incidents involving Resident #7 and Resident #8, along with four other documented incidents of inappropriate sexual behaviors exhibited by Resident #6 towards unnamed residents. When asked what interventions had been put into place to protect residents from Resident #6's inappropriate sexual behaviors, they stated Resident #6 was placed on medication to decrease their testosterone on 04/02/24. The DON was asked if the orders, written by Physician #1 on the psychiatric MD progress notes on 04/17/24 and 05/15/24, to increase Resident #6's Provera due to continued exhibition of sexual behaviors towards other residents had been carried out. The DON stated they were not aware of these orders. The DON was asked to review the above psychiatric progress notes and acknowledged the orders had not been forwarded to the Medical Director for approval. On 08/21/24 at 4:26 p.m., Physician #1 was asked if they had been notified of Resident #6's repeated inappropriate sexual behaviors that occurred today. They stated no. Physician #1 was asked if they were aware the orders written on 04/17/24 and 05/15/24 to increase Resident #6's Provera dose to decrease testosterone was never carried out. They stated no. Physician #1 was asked if these medication increases could have helped in preventing the abuse from reoccurring. They stated maybe.

Based on record review and interview, the facility failed to ensure incident reports were created for documented incidents of inappropriate sexual behavior by one (#6) of five sampled residents reviewed for resident-to-resident abuse. The Administrator identified 56 residents resided in the facility. Findings: A 'Resident-to-Resident Altercations' policy, revised August 2011, read in parts, .If two residents are involved in an altercation, staff will .Complete an 'Report of Incident/Accident' form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record . A Nurse Progress Note, dated 04/01/24 at 9:23 a.m., documented Resident #6 was observed in the back of dining room with an unnamed female resident and had his penis exposed. A Nurse Progress Note, dated 04/08/24 at 4:00 p.m., documented Resident #6 was observed hugging and what appeared trying to kiss an unnamed female resident. A Nurse Progress Note, dated 04/21/24 at 8:35 p.m., documented Resident #6 wrote an unnamed female resident an inappropriate note and left it in her room while she wasn't there. A Nurse Progress Note, dated 04/29/24 at 5:51 p.m., documented Resident #6 left an inappropriate note in another unnamed female resident's room. There was no 'Report of Incident/Accident' form completed for either of the incidents listed above. Neither of the incidents were reported to OSDH or any other state agency. On 08/22/24 at 10:58 a.m., the DON was asked what the policy was for documenting incidents of sexually inappropriate behavior between residents. They stated that an internal report should be done and, if warranted, a report should be submitted within two hours to OSDH and other state agencies notified as needed. The DON was asked if an internal incident report had been completed for either of the incidents listed above. She stated no. The DON was asked if either of the incidents listed above warranted reporting to OSDH or other state agencies. They stated they were not sure.

Based on record review and interview, the facility failed to establish a system of records of receipt and disposition, of controlled drugs, to enable an accurate reconciliation for one (#2) of one resident reviewed for disposition of controlled drugs upon discharge. The Resident Census and Conditions of Residents report, dated 04/19/23, identified 47 residents who resided in the facility. Findings: A Documentation of Transfers/Discharges, dated April 2007, read in parts, .All documentation concerning the transfer or discharge of a resident must be recorded in the resident's medical record .Documentation from the Care Planning Team concerning all transfers or discharges must include, as a minimum, and as they may apply .Disposition of medications . A Controlled Substance Administration & Accountability policy, dated 05/12/21, read in parts, .It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure .In all cases, the dose noted on the usage must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record .The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration . A blank Medication Release Form, not dated, read in parts, .Last Name of Resident, First Name, Physician, Medication, Rx number, Amount, Nurse, Responsible party, date. The amount of medication on discharge has been counted and is correct and I (responsible party) am responsible for all medications until they are returned to the facility . Resident #2's Quarterly Assessment, dated 02/03/23, documented the resident was cognitively intact. Resident #2's Plan of Care, dated 10/30/22, documented the resident had anxiety and pain. Resident #2's Discharge Instruction Form, dated 03/28/23 at 10:19 a.m., read in parts, .Medications blank, Medication List blank . There were no medications documented on the resident's discharge instruction form. A Progress Note, dated 03/28/23 at 4:57 p.m., read in parts, .Resident informed this Nurse that his family from .was here to pick him up and take him back to . All Resident's personal belongings, meds, insulin and narcs were sent with resident. Discharge summary complete . This progress note did not specify the drugs, nor quantity of controlled drugs, that were returned to the resident. The facility did not provide an accurate accounting of the controlled drugs when resident #2 was released to home. RN#1 created the progress note. Resident #2's Controlled Drug Record, read in parts, .03/28/23 .Hydrocodone-Acetaminophen 10-325 mg give 1 tablet by mouth three times daily .amount remaining 7 .03/28/23 .Diazepam 5 mg tablet give 1 tablet three times daily .amount remaining 17 .03/26/23 .Hydrocodone-Acetaminophen 7.5 mg-325 mg give 1 tablet by mouth three times daily as needed for pain .amount remaining 66 . A total of 90 controlled drugs were not accounted for in Resident #2's clinical record. On 04/19/23 at 10:43 a.m., the DON was asked about a signed medication discharge form for resident #2's narcotics. They stated the CMA witnessed the resident sign the sheet, but they were still looking for the form. On 04/19/23 at 10:47 a.m., RN#1 was asked about a signed medication discharge record for resident #2's narcotics. They stated the document was signed by the resident, but they did not retain a copy. They witnessed the resident sign it, but it did not make it to the resident's clinical record. RN #1 reported being the nurse who was responsible for the resident's discharge on 03/28/23. On 04/19/23 at 11:00 a.m., the DON was asked if the Discharge Summary included anything related to resident #2's medications. The DON stated, no, because there was nowhere to list it. The DON stated they print out the medication list and treatment list and review it with the resident. The DON was asked where would the resident sign for the narcotics to ensure accountability for the narcotics. The DON stated they thought staff had given the resident the original form, therefore, resident #2 would have the form. The DON was asked to provide the form which should have been in the clinical record to ensure accountability for resident #2's narcotics, and they provided a blank Medication Release Form. On 04/19/23 at 1:14 p.m., the DON was asked if they had located Resident #2's discharge medication form. The DON reported the form had not been located.

Based on record review, observation, and interview, the facility failed to obtain an appropriate rationale for a pharmacy recommended gradual dose reduction (GDR) for one (#4) of five residents whose records were reviewed for unnecessary medications. The Resident Census and Conditions of Residents, documented 38 residents resided in the facility and three residents were currently on antipsychotic medications. Findings: The facility's Consultant Pharmacist Reports policy, dated April 2015, read in parts, .Recommendations are acted upon and documented by the facility staff and/or the prescriber .Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . Resident #4 had diagnoses which included Schizophrenia, depression, anxiety, heart failure and diabetes. The resident's MDS Assessment, dated 11/24/21, documented the resident was cognitively intact. The assessment documented the resident received an antipsychotic, an antidepressant, and an antianxiety medication seven of seven days previous. The Monthly Behavior Monitoring Flowsheet for resident #4, dated January 2022, documented no behaviors for the month of January 2022. A Pharmacy Consultant Report for resident #4, dated 01/04/22, documented a recommendation for a GDR for Buspirone 10 mg TID, Cariprazine 6 mg QD, Cymbalta DR 60 mg QD, Latuda 120 mg QD, Lithium 300 mg BID, and Trintellix 10 mg QD. The physician response for the GDR recommendation, not dated, documented, Complex psychiatric patient under the care of a psychiatrist. Any objections to the medication regimen should be directed to the psychiatrist. The clinical record was reviewed and contained no documentation to indicate the resident was under the care of a psychiatrist at that time. The resident's Care Plan, dated 02/15/22, read in parts, .I am taking {Schizophrenia medications} on a routine basis to manage my Schizophrenia . Interventions .assess for continued need; if need continues, maintain on lowest possible effective dosage A Physicians Progress Note for resident #4, dated 09/02/22, documented Initial Psychiatric Evaluation. On 01/05/23 at 3:00 p.m., resident #4 was interviewed in her room and reported she felt like she was taking too many medications. The resident stated she had talked to her doctor about her medications but was told she needed all of her medications as currently ordered. On 01/05/23 at 4:30 p.m., the DON reported resident #4 did not have a consulting psychiatrist until September 2022. The DON reported no action was taken on the GDR recommendation in January 2022 because the resident didn't have a psychiatrist to review the medications.

Based on observation and interview, the facility failed to store food in a manner to ensure food service safety. The Director of Nursing reported 47 residents received meals from the facility kitchen. Findings: On 11/30/21 at 10:00 a.m., the kitchen was observed during the initial tour of the survey. Four, five-pound containers, of cottage cheese were observed in the refrigerator with a use-by date of 11/17/21. The dietary manager was present and reported the cottage cheese should have already been thrown away. One large Ziploc bag of sliced cheese was observed to be without an open or expiration date. The Dietary Manager (DM) reported the cheese should have been dated when placed in the refrigerator. Three small containers of onions and tomatoes were observed to be without labels or dates. Cook #1 stated she would start labeling and dating these items. The DM reported these are normally used on the same day they are sliced but stated they would start labeling the items to ensure proper storage and use-by dates.

Based on observation, interview and record review, it was determined the facility failed to provide treatment as needed for constipation for one (#1) of three residents reviewed for assessment, monitoring, and intervention. The facility identified 47 residents who resided in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A nurse note, dated 02/22/20, documented the resident was out of the facility with family. A nurse note, dated 02/27/20 at 10:52 a.m., documented the resident was assisted to a bedside commode. The note documented the resident was found to have bright red blood clots coming from rectum. The note documented the resident was transported to the emergency room and family was notified. The nurse notes documented the resident returned to the facility at 2:00 p.m. A nurse note, dated 02/27/20 at 3:15 p.m., documented the resident's family member reported to staff she was concerned about the resident's constipation. The note documented the family member had digitally removed feces from the resident's rectum on 02/22/20 while the resident was out of the facility with the family member. An emergency room report, dated 02/27/20, documented the resident was seen and treated for [REDACTED]. On 03/03/20 at 12:49 p.m., the resident's family member was interviewed and reported the resident had previously complained of her bottom hurting. The family member reported she had asked a nurse to check the resident and the nurse stated she would give the resident a suppository. The family member reported she took the resident home the following day and the resident told her she had not been given a suppository. The family member reported she took it upon herself to digitally remove hard stool from the resident's rectum. The family member reported the resident returned to the facility on [DATE] and was sent to theER on [DATE] for rectal bleeding. On 03/03/20 at 1:34 p.m., LPN #1 reported the resident's family member had previously requested the resident be checked related to rectal discomfort. The LPN reported she checked the resident and found what appeared to be reddened and swollen hemorrhoids. The LPN reported she did not provide treatment or care for the resident's complaints at that time. The LPN reported she did not remember documenting anything in the resident's clinical record related to the resident's complaints. The resident's clinical record for February 2020 was reviewed and contained no documentation related to the resident's complaints of constipation or rectal discomfort. On 03/04/20 at 9:30 a.m., the ADM and the DON were informed the nurse failed to intervene when the resident's bottom was swollen and sore and a family member had complained the resident was having rectal discomfort.

Based on observation, interview, and record review, it was determined the facility failed to ensure a family member was notified of a discontinued medication for one (#1) of three residents reviewed for notification of changes. The facility identified 47 residents who resided in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A MAR for September 2019 documented the resident would receive [MEDICATION NAME] acetate suppository, 25 mg PRN, for hemorrhoids. The MAR indicated [REDACTED]. The September nurses notes were reviewed and had no documentation the family had been notified when the medication had been discontinued. On 03/03/20 at 12:49 p.m., the resident's family member reported she had intervened when the resident complained of rectal pain. The family member reported she had asked a nurse to check the resident for impaction and the nurse reported the resident could be given a suppository. The family member reported she had not been told the suppositories had been discontinued. She stated she knew the facility had previously had an order for [REDACTED].>On 03/03/20 at 1:34 p.m., LPN #1 reported the resident's family member had asked her to check the resident's bottom. The LPN reported the resident had redness, soreness, and what appeared to be swollen hemorrhoids. The LPN reported she did not treat the resident with any medication. On 03/04/20 at 9:30 a.m., the ADM and DON were informed of the above findings. They agreed family members should be notified when a resident's medication has been discontinued.

Based on record review and interviews, it was determined the facility failed to ensure dementia training was provided during orientation for new employees for four (CNA #1, CNA #2, Cook #1 and Hoousekeeping #1) of five employee files reviewed. The director of nursing identified 19 residents with a [DIAGNOSES REDACTED]. Findings: 1. Cook #1 was hired on 08/01/19. A review of the employee on boarding training contained no documentation to indicate the cook received training on dementia. 2. Certified nurse aide (CNA) #1 was hired on 05/17/19. A review of the employee file contained documentation the CNA received dementia training on 05/30/19, two weeks after the aide started working directly on the floor with residents. 3. Housekeeper #1 was hired on 05/18/19. A review of the employee on boarding training contained no documentation to indicate the housekeeper received training on dementia. 4. CNA #2 was hired on 05/02/19. A review of the employee on boarding training contained no documentation to indicate the CNA received training on dementia. On 08/21/19 at 1:19 p.m., the business office manager stated he did not provide dementia training to non nursing personal, dietary, housekeeping and maintenance upon hire. He then stated the director of nursing (DON) might do something right away with the nursing staff. At 1:55 p.m., the DON stated the staff are provided dementia training every three months during in-services. She then stated all new nursing department employees received training through videos within two weeks from working on the floor. She then stated the training was not provided prior to the aides working the floor.

Based on interview and record review, it was determined the facility failed to ensure showers were given according to the resident's shower schedules for two (#14, and #41) of 15 residents whose records were reviewed for activities of daily living. This had the potential to affect 51 residents who reside in the facility. Findings: 1. Resident #14 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/17/19, documented the resident's cognition was intact. She required extensive assistance with personal hygiene and was a one person physical assist with bathing. The resident's carnelian, dated 06/26/19, documented: F[NAME]US, I consider this my home I want staff to know my personal choices and preference. Interventions . My preferred choice of bathing is showering. On 08/20/19 at 11:01 a.m., during our screening process the resident was interviewed and she stated, I wash myself at night in bed because the staff do not give me a shower. On 08/21/19 at 11:09 a.m., the resident was asked again about her showers. She pulled out a notebook where she had documented when she did get a shower. The notebook documented she had a shower on (MONTH) 12th, 18th, and 31st. She had no showers in (MONTH) she had only cleaned herself up in bed. The facility shower log documented the resident was to receive a shower every Tuesday, Thursday and Saturday. The facility bath/shower follow up question report did not distinguish between a bath or a shower. The (MONTH) 2019 report documented she received a bath/shower on 07/02/19. There was no bath/shower documented again until 07/11/19. Out of 13 opportunities to receive a bath/shower on Tuesday, Thursday and Saturday in (MONTH) only 9 dates were documented. On 08/21/19 at 1:55 p.m., the director of nursing was informed of the above findings and that the resident had not been getting showers as scheduled but had only been cleaning herself up in bed. 2. Resident #41 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/30/19, documented the resident's cognition was intact. She required one person physical assist with bathing. On 08/20/19 at 9:20 a.m., during our screening process the resident was interviewed. She stated, I don't get showers but maybe once in awhile. It has not been very often and sometimes it's been a month or longer. I can't remember when I had my last shower. They will wash my back and my legs and give me a rag to wash the rest of myself, but I don't hardly ever get to take a shower. The facility shower log documented the resident was to receive a shower every Tuesday, Thursday and Saturday. The facility bath/shower follow up question report did not distinguish between a bath or a shower. The (MONTH) 2019 report documented the resident received a bath/shower on 07/02/19 and 07/04/19. There was no bath/shower documented on again until 07/11/19. Out of 13 opportunities to receive a bath/shower on Tuesday, Thursday and Saturday in (MONTH) only 10 opportunities were documented. On 08/21/19 at 10:30 a.m., certified nurses aide was asked about this resident not receiving showers and only washing up with a washrag. She stated, She's independent, we don't have to help her. On 08/21/19 at 2:05 p.m., the director of nursing was informed of the above findings and that the resident had not received showers as scheduled but had to clean herself up with a washrag most of the time.

Based on interview and record review, it was determined the facility failed to ensure the resident council meets on a regular basis. This had the potential to affect 51 residents who reside in the facility. Findings: On 08/20/19 at 10:12 a.m., a resident council meeting was held with nine residents. All nine residents stated they have not had monthly meetings in along time. Resident (Name deleted) stated, Staff appointed me as the president and I didn't even know what they were talking about. At 10:15 a.m., the social service director was asked if they meet on a regular basis. She stated, We are supposed to have them the end of every month but no one shows up so I just go room to room. At 10:26 a.m., the nine residents were asked if they knew about resident council meetings that were supposed to be held the end of the month. They all stated, No. They did not know about any resident council meetings being held. On 08/21/19 at 9:15 a.m., the social services director was interviewed and asked if the resident council meeting was on her monthly activities calendar. She stated, I looked back for several months and it is not on there. She was asked if a meeting was held starting with (MONTH) through (MONTH) 2019. She stated, I just went room to room talking with some of the residents. She provided documentation of her room to room visits from (MONTH) to July. The (MONTH) record was the only month that had documented six residents. She acknowledged meetings had not been held. She was in agreement the residents should be having a monthly resident council meeting. At 09:43 a.m., the director of nursing and the administrator were made aware there had been no resident council meetings for months. They were in agreement they should be having monthly meetings.

Based on interview and record, it was determined the facility failed to insure residents were informed as to where the required notices and contact information for the ombudsman was located at in the facility. This had the potential to affect 51 residents. Findings: On 08/20/19 at 10:12 a.m., a resident council meeting was held with nine residents. All nine residents stated they did not know where to locate the ombudsman's contact information and they did not know how to formally complain to the State about care they receive. On 08/21/19 09:43 a.m., the director of nursing and the administrator were were informed the residents in the resident council meeting did not know where to find the required information for the ombudsman or how to formally complain to the State. They stated they would have a meeting and show them where to find the information.

Based on interview and record review, it was determined the facility failed to ensure the residents were informed on how to file a grievance. This had the potential to affect 51 residents who reside in the facility. Findings: On 08/20/19 at 10:12 a.m., a resident council meeting was held with nine residents. The residents were asked if they know how to file a grievance. They all stated, No or shook their heads no. On 08/21/19 at 9:43 a.m., the director of nursing and the administrator were made aware that the nine residents in the resident council meeting did not know how to file a grievance. They said they would hold a meeting with the residents to let them know where to find the information and how to file a grievance and will let the residents know again each month in the resident council meetings.

Based on interview and record review, it was determined the facility failed to ensure a careplan was updated when care changed for one (#14) of 15 residents whose careplans were reviewed. This had the potential to affect 51 residents who reside in the facility. Findings: Resident #14 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/17/19, documented the resident's cognition was intact. She required extensive assistance with personal hygiene and was a one person physical assist with bathing. The residents careplan, dated 06/26/19, documented TRANSFER: I have limited ability to stand (bear weight) to transfer. I need staff to assist me with all transfer to and from surfaces. I need two person to assist with transfers. I use the Hoyer lift with transfers. On 08/21/19 at 1:19 p.m., an observation was made of this resident being transferred by certified nurse aide #5 from her motorized scooter to her bed via a wooden slide board. The CNA placed a gait belt around the resident and then the resident wiggled herself over onto the board while the CNA was holding onto the gait belt. The CNA helped the resident wiggle herself on over onto the bed and then she removed the slide board and the resident layed down on her back and used the side rails to help straighten herself up. CNA #6 was in the room with her and did not help her. At 1:25 p.m., CNA #5 was asked why a Hoyer lift was not used. She stated the resident did not like the Hoyer lift. She was asked how long ago did they stop using the Hoyer lift. She stated it was around two months ago. On 08/22/19 at 12 :19 p.m., the assessment coordinator was asked about this resident's careplan documenting she uses a Hoyer lift. She stated the resident did not like the Hoyer lift so we switched over letting her use a slide board. She was in agreement the careplan should have been updated when this happened.

Based on observation, interview and record review, it was determined the facility failed to ensure activities of daily living were performed according to the residents' assessment and careplan for two (#14 and #46) of 15 residents whose functional status was reviewed. This had the potential to affect seven residents dependent for activities of daily living (ADL) as identified on the Resident Census and Conditions of Residents form. Findings: 1. Resident #14 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/17/19, documented the resident's cognition was intact. She required extensive assistance with transfers and was a two plus person physical assist with transferring. A careplan, dated 06/26/19, documented TRANSFER: I have limited ability to stand (bear weight) to transfer. I need staff to assist me with all transfer to and from surfaces. I need two person to assist with transfers. I use the Hoyer lift with transfers. On 08/21/19 at 10:50 a.m., certified nurse aide #5 (CNA) was asked how she transfers this resident. She stated with resident (name delete) I'm the only CNA on this floor. She stated with resident (name deleted) I figured out how to use a slide board to get her up by myself. On 08/21/19 at 1:19 p.m., an observation was made of this resident being transferred by CNA #5 from her motorized scooter to her bed via a wooden slide board. At 1:25 p.m., CNA #5 was asked why a hoyer lift was not used. She stated a Hoyer lift has not been used for around two months. At 1:55 p.m., the director of nursing was informed of the above findings and was in agreement there should have been two aides to transfer this resident. 2. Resident #46 was admitted with [DIAGNOSES REDACTED]. The care plan, dated 07/30/18, documented the resident preferred to have staff do nail care during a bath. An assessment, dated 08/08/19, documented the resident was dependent for bathing and hygiene. On 08/19/19 at 4:16 p.m., the resident was observed to have long jagged nails. He stated he had asked several staff for nail care and it had not been provided. On 08/20/19 at 11:24 a.m., the resident was observed to have long jagged nails. On 08/21/19 at 10:48 a.m., certified nurse aide #3 stated nail care was to be provided for residents during showers except for diabetic residents and the nurses do those. At 10:55 a.m., licensed practical nurse #2 stated nail care for diabetic residents was provided by nurses and should be documented on the treatment record. She reviewed the resident's record and stated it had not been done. At 10:58 a.m., the director of nursing was informed of the above findings and agreed nail care should have been provided by nurses and documented in the record.

Based on observation, record review and interview it was determined the facility failed to follow physician's order for one (#46) of 15 residents records reviewed. This had the potential to affect 51 residents. Findings: Resident #46 was admitted with [DIAGNOSES REDACTED]. The assessment, dated 08/08/19, documented the resident was independent with eating and had a mechanically altered diet. The care plan, dated 08/08/19, documented the resident with potential for alteration in nutrition related to dysphagia and therapy orders to evaluate and treat as indicated .nectar thick liquids. A physician's order, dated 08/08/19, documented the resident was to receive a regular diet, mechanical soft texture, with nectar thickened liquid consistency, change from thin liquid to nectar honey consistency for decreased risk of aspiration. On 08/20/19 at 7:45 a.m., the resident was observed during the breakfast meal with two glasses of milk and two cups of coffee. The resident was asked if the beverages had been thickened and he stated, No, it is regular. At 2:20 p.m., the resident was observed in his room with fresh ice water at bedside. At 2:22 p.m., certified medication aide (CMA) #1 stated the resident is given water with medications. At 2:47 p.m., CMA #2 stated the resident is given water to take medications. The Medication Administration Record, [REDACTED].nectar thickened liquid consistency, change from thin liquid to nectar honey consistency for decreased risk of aspiration. On 08/21/19 at 9:41 a.m., the speech therapy director was interviewed and stated according to the evaluation, dated 08/06/19, the resident had impaired swallowing and does need the thickened liquids at this time. At 9:45 a.m., the director of nursing was made aware of the above findings and stated the resident refused all thickened liquids. There was no documentation in the record of thickened liquids offered and refused. She agreed physician's order had not been followed and should have been documented when the resident refused.

Based on observation, record review and interview, it was determined the facility failed to ensure a medication error rate of less than 5% for three (#39, #47 and #6) of nine sampled residents who were observed during the medication passes. Four errors were observed during 31 opportunities of medication administration. This resulted in a medication error rate of 12.9%. The facility identified 51 residents as receiving medications. Findings: The facility policy, titled Medication Administration Schedule, not dated, documented bedtime medications to be administered at 8:00 p.m. 1. On 08/21/19 at 8:21 a.m., a medication pass observation was observed with certified medication aide (CMA) #3. The CMA was observed to administer one 20 milligram (mg) tablet of [MEDICATION NAME] (a diuretic) to resident #39. The physician orders [REDACTED]. The Medication Administration Record [REDACTED]. At 9:45 a.m., CMA #3 was asked about the [MEDICATION NAME] order for two tablets. She stated the resident was to receive two 10 mg tablets to equal 20 mg. The CMA stated she did not realize the resident should have received two 20 mg tablets. At 9:45 a.m., licensed practical nurse (LPN) #6 was asked to review the physician's orders [REDACTED]. 2. On 08/21/19 at 9:00 a.m., a medication pass was observed with certified medication aide (CMA) #1. She was observed to administer one 5 mg tablet of [MEDICATION NAME] (for high blood pressure) by mouth to resident #47. The resident was to receive 1.5 tablets of 5 mg tablets to equal 7.5 mg. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. At 10:53 a.m., LPN #3 reviewed the physician's orders [REDACTED]. CMA #1 stated she did not see the MAR indicated [REDACTED]. 3. On 08/21/19 at 3:06 p.m., a medication pass was observed with CMA #4. She was observed to administer Magnesium Oxide (a supplement) 400 mg one tablet and [MEDICATION NAME] (for high cholesterol) 40 mg one tablet by mouth to resident #6. The Magnesium Oxide and [MEDICATION NAME] were to be administered at bedtime The physician's orders [REDACTED]. The MAR indicated [REDACTED]. At 3:25 p.m., LPN #6 reviewed the physician's orders [REDACTED]. On 8/21/19 at 3:57 p.m., the assistant director of nursing (ADON) reviewed the physician's orders [REDACTED]. She stated there was a glitch in their system that shows some medications ordered at bedtime show up earlier on the MAR. She was asked when the medications ordered at bedtime should be administered. The ADON stated anywhere from 7:00 p.m. to 11:00 p.m. At 4:05 p.m., the director of nursing was asked when medications ordered at bedtime should be administered. She stated anywhere from 7:00 p.m. to 11:00 p.m.

Based on record review and interview, it was determined the facility failed to ensure a resident was transferred from the bed in a manner to prevent injury. This affected one (#12) of one sampled resident who required cardiopulmonary resuscitation (CPR). The resident was being transferred prior to CPR and sustained a head injury during the transfer. The facility identified no other residents who required CPR in the prior 60 days. Findings: Resident #12 had [DIAGNOSES REDACTED]. An assessment dated [DATE] documented the resident was independent in cognitive skills for daily decision making. The assessment documented the resident required assistance with surface-to-surface transfers and utilized a wheelchair or walker for movement about the facility. The assessment documented the resident had no limitations to range of motion. The care plan dated [DATE] documented the resident required one person assistance for all transfers. The clinical record dated [DATE] documented the resident was found unresponsive with agonal (abnormal pattern) breathing and no pulse. The record documented the resident was to be resuscitated. The clinical record documented attempts were made to obtain a response from the resident by changing his position. Documentation from the referred specialty hospital revealed the resident had suffered a scalp hematoma. The documentation revealed no acute intracranial abnormalities were found and the resident was able to verbalize who he was, where he had been, and events in his past. The specialty hospital discharge summary documented the resident was alert, active, and oriented X2. The discharge summary documented the resident was discharged to hospice due to additional health concerns. On [DATE] at 2:20 p.m., licensed practical nurse #2 was asked to describe the above events. She stated she entered the room and found the resident unresponsive. She stated she moved him from the bed to the floor by placing her arms under his shoulders and knees. She stated her foot slipped during the transfer when the resident was approximately 6 inches off the floor. She stated she was aware the resident had hit his head on the floor and reported it immediately to the emergency medical service staff who arrived to transport the resident. On [DATE] at 10:15 a.m., the director of nurses (DON) was asked if proper policy had been followed to transfer the resident prior to CPR. She stated, No, that's why we did the mock codes (staff demonstrations of correct methods for administering CPR). The DON provided documentation of inservice on [DATE]. The staff were informed of the new policy, which documented two staff were always necessary prior to transfers during CPR. On [DATE] at 1:25 p.m., certified nurse aide (CNA) #1 stated she had received inservice on the transfer of residents prior to CPR. She stated two staff were required for transfer. At 2:20 p.m., LPN #5 was asked if she had received additional training on transferring residents prior to CPR. She stated two staff were required for the transfer. She stated she was aware of the placement of the crash cart and had received CPR training within the last year. Random interviews with direct care staff revealed they had received additional training in transferring residents prior to CPR. They stated they were to no longer to attempt transfers of a resident to the floor without assistance.