Every finding on record at Bethany Home Association

Based on observation, record review, and interview, the facility failed to maintain an in-service training program for Certified Nurse Aide (CNA) M, specific to the needs of the resident population. Findings included:- Review of CNA M's in-service education totals revealed CNA M did not complete Psychosocial Needs of the Older Adult scheduled to be completed 02/28/2026, Abuse Prevention in Persons with Dementia scheduled to be completed 03/31/2026, and Challenging Behaviors: Care and Interventions for Individuals Experiencing Dementia scheduled to be completed 05/31/2026. On 07/14/2026 at 11:30 AM, Administrative Nurse D verified CNA M had not completed her mandatory CNA trainings Abuse Prevention with Persons with Dementia, Challenging Behaviors: Care and Interventions for Individuals Experiencing Dementia, and Psychosocial Needs of an Older Adult. Administrative Nurse D stated the education was due at the end of the month they were assigned. Upon request, the facility did not provide a CNA Education Policy.

Based on record review, interview, and observation, the facility failed to ensure Resident (R) 1, who was severely cognitively impaired and on hospice, remained free from staff to resident abuse. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of malignant (a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) melanoma (a serious type of skin cancer) of overlapping skin sites, hyperlipidemia (condition of elevated blood lipid levels), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and traumatic subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain). The Significant Change in Status Minimum Data Set (MDS), dated 06/29/2026, documented R1 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R1 required setup/cleanup assistance for eating. The MDS documented R1 required moderate to substantial staff assistance with all other activities of daily living (ADLs). The MDS documented R1 did not have any swallowing difficulty or a mechanically altered diet. The Functional Abilities Care Area Assessment (CAA), dated 06/16/2026, documented R1 required staff assistance with dressing, personal hygiene, and bathing. The CAA documented R1 could dress her upper body with minimal staff assistance but needed extensive staff assistance with dressing her lower body. The CAA documented R1 could ambulate and transfer with her walker with stand-by assistance to minimal staff assistance of one person. The Cognitive Loss/Dementia CAA, dated 06/16/2026, documented R1 had a memory problem, was hard of hearing, and could make her needs known. The CAA documented R1 had a diagnosis of depression and preferred to stay in her room most of the day. R1's Care Plan, initiated 05/20/2026, documented R1 required assistance with bed mobility, dressing, grooming, mobility, toileting, and transfer. R1's care plan documented R1 could make food choices, was on a regular diet, and required cueing to feed herself (06/05/2026). The care plan documented R1 was on hospice care due to malignant melanoma, and hospice and the facility staff would provide R1 with the highest standards of care concerning R1's physical, mental, psychosocial, and spiritual comfort, and well-being. The care plan documented staff would provide R1 support during R1's dying process (06/12/2026). The Nutrition/Dietary Note, dated 06/16/2026, documented R1 was on a regular diet, ate meals in her room, was able to make food choices, was assisted with set-up, and was able to feed herself. The Facility Incident Report, dated 07/10/2026, documented Administrative Nurse D was notified on 07/01/2026 by the CNA instructor that one of her students, Nurse Aide (NA) N, had observed Certified Nurse Aide (CNA) M forcefully feeding mandarin oranges to R1 in her room on 06/30/2026. CNA N stated R1 was not chewing the mandarin oranges, and CNA M continued to feed her. NA N reported that when CNA M got R1 up to use the bathroom, CNA M grabbed R1 by the arm forcefully to get her up. CNA O's Notarized Witness Statement, dated 07/10/2026, documented CNA O had witnessed CNA M feeding R1 quickly without pause and did not allow R1 long enough breaks to chew and swallow her food. NA N's Notarized Witness Statement, dated 07/13/2026, documented on 06/30/2026, NA N observed CNA M rapidly feed R1 without allowing R1 breaks to breathe or chew. NA N stated this caused R1 to gag as too much food was in her mouth. NA N stated throughout the day, she observed CNA M did not handle the resident with care but pulled on the resident's arms. On 07/14/2026 at 09:20 AM, observation revealed R1 lay in bed with the lights off. R1 slept. R1 had oxygen on. On 07/14/2026 at 11:00 AM, observation revealed R1 lay in bed with her eyes open. This surveyor went into R1's room. R1 had cloudy, blank eyes. R1 did not look at this surveyor. R1 weakly whispered, Help. On 07/14/2026 at 09:30 AM, CNA P stated she had not really seen CNA M be abusive when she had worked with CNA M, but CNA M always seemed rushed, as if she was trying to get tasks done as quickly as possible and did not take time with residents. On 07/14/2026 at 10:30 AM, R3 stated CNA M had pushed him down into his chair several times when she provided him care. On 07/14/2026 at 11:30 AM, Administrative Nurse D stated she did not find out about the incident until 07/01/2026 when the CNA instructor notified her. Administrative Nurse D stated CNA M had been working at the facility for twenty-four years, and she had even worked with CNA M when she was a CNA. Administrative Nurse D stated CNA M had been suspended pending investigation. Administrative Nurse D stated during the investigation more things came up, which indicated CNA M needed to be terminated. Administrative Nurse D stated after she was notified of the incident, she brought CNA M into the office, and CNA M stated she did not think she had been too rough, and R1 needed to eat. Administrative Nurse D told CNA M staff were never to force-feed residents. Administrative Nurse D stated CNA M refused to write a witness statement. Administrative Nurse D stated she had talked with NA N and CNA O and told them if anything like this happened, they needed to report it immediately. Administrative Nurse D verified CNA M had not completed her mandatory CNA trainings Abuse Prevention with Persons with Dementia, Challenging Behaviors: Care and Interventions for Individuals Experiencing Dementia, and Psychosocial Needs of an Older Adult. Administrative Nurse D stated the education was due at the end of the month they were assigned. The facility's, Abuse, Neglect, and Exploitation Policy, dated 04/22/26, documented the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of property and exploitation by: Identifying, correcting, and intervening in situations in which abuse, neglect, or exploitation is more likely to occur with the deployment of qualified registered, licensed, and certified staff on each shift that meets the needs of the residents, and assure that staff have knowledge of the individual care needs and behavioral symptoms.

Based on record review, interview, and observation, the facility failed to ensure staff reported allegations of staff to resident abuse immediately to the administrator as required. Findings included:- The Facility Incident Report, dated 07/10/2026, documented Administrative Nurse D was notified on 07/01/2026 by the Certified Nurse Aide (CNA) instructor that one of her students, Nurse Aide (NA) N, had observed Certified Nurse Aide (CNA) M forcefully feeding mandarin oranges to R1 in her room on 06/30/2026. CNA N stated R1 was not chewing the mandarin oranges, and CNA M continued to feed her. NA N reported that when CNA M got R1 up to use the bathroom, CNA M grabbed R1 by the arm forcefully to get her up. CNA O's Notarized Witness Statement, dated 07/10/2026, documented CNA O had witnessed CNA M feeding R1 quickly without pause and did not allow R1 long enough breaks to chew and swallow her food. NA N's Notarized Witness Statement, dated 07/13/2026, documented on 06/30/2026, NA N observed CNA M rapidly feed R1 without allowing R1 breaks to breathe or chew. NA N stated this caused R1 to vomit as too much food was in her mouth. NA N stated throughout the day, she observed CNA M did not handle the resident with care but pulled on the resident's' arms. On 07/14/2026 at 09:20 AM, observation revealed R1 lay in bed with the lights off. R1 slept. R1 had oxygen on. On 07/14/2026 at 11:00 AM, observation revealed R1 lay in bed with her eyes open. This surveyor went into R1's room. R1 had cloudy, blank eyes. R1 did not look at this surveyor. R1 weakly whispered, Help. On 07/14/2026 at 09:30 AM, CNA P stated she had not really seen CNA M be abusive when she had worked with CNA M, but CNA M always seemed rushed, as if she was trying to get tasks done as quickly as possible and did not take time with residents. On 07/14/2026 at 10:30 AM, R3 stated CNA M had pushed him down into his chair several times when she provided him care. On 07/14/2026 at 11:30 AM, Administrative Nurse D stated she did not find out about the incident until 07/01/2026 when the CNA instructor notified her. Administrative Nurse D stated CNA M had been working at the facility for twenty-four years, and she had even worked with CNA M when she was a CNA. Administrative Nurse D stated CNA M had been suspended pending investigation. Administrative Nurse D stated she had talked with NA N and CNA O and told them if anything like this happened, they needed to report it immediately. The facility's, Abuse, Neglect, and Exploitation Policy, dated 04/22/26, documented the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of property and exploitation by: Identifying, correcting, and intervening in situations in which abuse, neglect, or exploitation is more likely to occur with the deployment of qualified registered, licensed, and certified staff on each shift that meets the needs of the residents, and assure that staff have knowledge of the individual care needs and behavioral symptoms.

Based on record review and interviews, the facility failed to ensure agency staff received the required infection control training. Findings included:- On 06/09/26 at 01:40 PM, a review of the training provided by the facility for agency Certified Nurse Aide (CNA) M, CNA N, CNA O, and CNA P revealed the following:The facility was unable to provide documentation that CNA M had completed infection control training. The facility was unable to provide documentation that CNA N had completed infection control training. The facility was unable to provide documentation that CNA O had completed infection control training. The facility was unable to provide documentation that CMA P had completed infection control training.On 06/09/26 at 01:51 PM, Administrative Nurse D stated the two agency providers the facility utilized for staffing had stated they ensured their staff had the required education. The facility failed to provide a policy related to ensuring all staff had received the required staff education as requested on 06/10/26.

Based on observation, interview, and record review, the facility failed to ensure adequate infection control practices related to urinary catheter (tube inserted into the bladder to drain urine) care, hand hygiene, and the sanitary storage of respiratory equipment. Findings included:- On 06/08/26 at 08:13 AM, Resident (R)38's nasal oxygen cannula laid coiled on his bed. R38's oxygen nasal was not in a sanitary container. On 06/08/26 at 01:00 PM, an observation revealed R18's catheter bag was located on the trash can next to his recliner. There was no privacy bag. On 06/09/26 at 08:25 AM, observation revealed R18's catheter bag hung on the trash can beside his recliner. There was no privacy bag over the indwelling catheter bag, On 06/09/26 at 10:42 AM, R21's oxygen nasal cannula laid on R21's bed. R21's nasal cannula was not contained in a sanitary manner. On 06/09/26 at 02:25 PM, observation revealed R18 sat in his recliner with his feet up. His catheter bag laid on the floor without a privacy bag. On 06/10/26 at 12:40 PM, Certified Medication Aide (CMA) R said staff usually place the catheter bag in the trash can after they place a trash bag. On 06/10/26 at 12:40 PM, Licensed Nurse (LN) G said the catheter bag should be inside the trash can and the bag should never be on the floor. R18's preferences should be on the care plan. On 06/10/26 at 12:40 PM, Administrative Nurse D expected staff to ensure catheter bags were not on the floor and said the staff should wash their hands between the dirty and the clean. The facility policy General Infection Control and Employee Health SOP undated the facility facilitates safe care by establishing and maintaining an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable disease and infection.

Based on observation, record review, and interview, the facility failed to ensure Resident (R)47's call light was within his reach to enable him to call for staff assistance. Findings Included:- R47's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin.The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R47 needed setup or cleanup assistance with eating and supervision or touching assistance with oral hygiene and toileting. The MDS documented R47 had no falls during the observation period.R47's Falls Care Area Assessment (CAA) dated 04/02/2026 documented R47 was alert to self, his speech was clear, and was able to verbalize his needs, and he usually understands others. The CAA documented R47 did not attend activities. The CAA documented R47 had not had a fall in 90 days.R47's Care Plan documented:10/14/2024-R47 was a high risk for falls related to confusion, deconditioning, gait, and balance problems.04/06/2026-Staff were to anticipate and meet R47's needs. Staff were to ensure R47's call light was within his reach and encourage R47 to use the call light as needed. Staff were to respond promptly to all requests for assistance.On 06/09/2026 at 08:39 AM, R47 sat in his recliner chair with his bedside table in front of him. R47 was unable to find his call light.On 06/10/2026 at 11:36 AM, R47 sat in his blue chair with his bedside table in front of him. R47 stated he did not know where his call light was.On 06/09/2026 at 11:30 AM, Certified Nurse Aide (CNA)Q stated call lights should be placed on the person or clipped to the chair. CNA Q stated R47 was unable to reach his call light and would clip R47's call light on his blue chair. CNA Q informed R47 of placement of his call light.On 06/10/2026 at 12:36 AM, Licensed Nurse (LN)G stated call lights should always be within the resident's reach. She stated the call light should be clipped to the chair or placed across his lap.On 06/03/2026 at 01:31 PM, Administrative Nurse D stated call lights should be within the resident's reach, if the resident was in their room.The facility's Call Light, Accessibility and Timely Response policy undated, documented the purpose of the policy was to ensure the facility was adequately equipped with a call light at each resident's bedside, toilet and bathing facility, to allow residents to call for assistance. Call light would directly relay to staff members or centralized location to ensure appropriate response.

Based on observation, record review, and interviews, the facility failed to ensure Resident (R)66 had an appropriate indication, or a documented physician rationale, which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorders characterized by a gross impairment in reality testing). Findings included:- R66's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The MDS documented R66 needed setup or cleanup assistance with eating and oral hygiene, and partial/moderate assistance for bathing and toileting. The MDS documented R66 received an antianxiety (a class of medications that calm and relax people) and an antipsychotic medication during the observationR66s Psychotropic Use Care Area Assessment (CAA) dated 07/03/25 documented R66 had a diagnosis of Alzheimer's, dementia, depression and anxiety and R66 received an antipsychotic (Seroquel) and an antianxiety (Xanax) daily. R66's Care Plan documented:01/28/26-R66 received Seroquel related to major depressive disorder. Staff were to administer psychotropic medications as ordered by the physician, and staff were to monitor side effects and effectiveness every shift. Staff to monitor, document, and report any adverse reactions to psychotropic medications. 06/04/26-R66 received anti-anxiety medication Xanax related to anxiety. Staff were to administer anti-anxiety medication as ordered by the physician, and staff were to monitor side effects and effectiveness. Staff to monitor, document, and report any adverse reactions to anti-anxiety medication with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment thatR66's EMR under Orders documented the following physician order:Seroquel oral tablet 100milligrams (mg) (Quetiapine Fumarate)Give 100 mg by mouth two times a day related to major depressive disorder dated 09/24/25.R66's EMR lacked documentation of a physician's rationale which included the risk versus benefits for R66's Seroquel.On 06/09/26 at 09:22 AM, R66 sat in her chair in her room. R66 ate her breakfast consisting of eggs and toast.On 06/10/26 at 12:36 PM, License Nurse (LN)G stated all nurses take orders from physicians, she stated she had not questioned the physician's diagnoses for psychotropic medication. LN G stated if a diagnosis indication needed to be changed, the director of nursing would call the physician.On 06/10/26 at 12:47 PM, Administrative Nurse D stated she was aware R66 did not have the correct indication for her antipsychotic medication. She stated she had sent information to the physician and educated physicians on indications for long term care facilities for residents with dementia. She stated the facility documented the residents' behaviors or indications prior to placing a resident on psychotropic medication.The facility's Unnecessary Drugs and Psychotropic Drugs Standards of Practice undated documented each resident's entire drug regimen would be free from unnecessary drugs including drugs ordered in excessive does. for excessive duration, without adequate monitoring, and without adequate indications for use. Antipsychotic medications would not be given to residents who have not previously used the drugs unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the clinical record.

Based on observation, interview, and record review the facility failed to ensure an environment free of potential accident hazards for Resident (R) 14 when staff failed to use two staff during a Hoyer (full body mechanical lift) as required. Findings include:- R14's Physician's Orders dated 11/03/25 documented a diagnosis of vascular dementia (cognitive mental disorder characterized by failing memory and confusion) anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear).R14's Significant Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R14 required substantial to maximal assistance with eating and depended on staff for toileting and showers.R14's Quarterly MDS 5/07//26 revealed a BIMS score of five, which indicated severe cognitive impairment, and no other changes. R14''s Care Plan dated 01/17/25 and revised on 06/04/25 directed staff the resident was totally dependent on staff for transfers- sling lift one to two assist. On 06/08/26 at 08:35 AM, Certified Nurse Aide (CNA) NN obtained the Hoyer lift and proceeded to transfer R14 from the bed to the Broda (specialized wheelchair with ability to tilt and recline) chair without assistance from a second staff member. On 06/08/26 at 08:35 AM, in an interview, CNA NN said R14's Care Plan had the transfer as a one to two person assist and went on to say she had done by herself in the past. On 06/10/26 at 12:30 PM, Licensed Nurse (LN) G said that there needs to be two staff members during Hoyer lift transfers. On 06/10/26 at 12:50 PM, Administrative Nurse D stated she had obtained the information from teaching a CNA class that indicated one to two staff members can transfer a resident using the Hoyer lift but went on to say that the state regulation did say that two staff members are required to transfer a resident with a Hoyer. The facility policy Safe Resident Handling/Transfers dated 2/2006 it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them.

Based on interviews, observations, and record review, the facility failed to address a significant weight loss for Resident (R) 2, which had the potential for physical complications related to nutritional deficits. Findings included:- R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), ataxia (impaired ability to coordinate movement), dementia (a progressive mental disorder characterized by failing memory and confusion), and dysphagia (swallowing difficulty).The Significant Change Minimum Data Set (MDS) dated 04/27/26 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R2 had limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) to upper and lower extremities bilaterally. The MDS documented R2 required staff assistance with setup or clean-up during meals. R2's Nutritional Status Care Area Assessment (CAA) dated 05/11/26 documented he could make his food choices and feeds himself after being set up. R2's Care Plan documented the following interventions: 06/12/23 - He had a cushion to help with improved posture and positioning in the dining room.10/14/25 - Staff would obtain a weekly weight. 12/22/25 - He was a regular diet with thin consistency fluids.02/19/26 - He was independent with making food choices and was able to feed himself with set up assistance.R2's EMR under the Orders tab revealed the following physician orders:Regular diet with liquid consistency dated 08/17/22.R2's EMR under the Progress Notes tab revealed a Dietitian note dated 05/15/26 at 11:32 AM, documenting Dietitian Comments: registered dietician (RD) had reviewed R2's weight loss of 40 pounds in 90 days. R2 had recent hospitalization. He was alert with slurred speech. R2 was able to voice his food preferences. R2 was on a regular diet and was at risk of aspiration. R2 refused the offer of altered consistency. R2 reported he had wanted to lose weight and his appetite had decreased. He remained on a diuretic (a medication to promote the formation and excretion of urine) medication. RD documented he would continue current diet and R2 did not want to regain the weight.The facility was unable to provide a physician order for prescribed weight loss, which included safe weight loss parameters.On 06/09/26 at 11:38 AM, R2 sat in the dining room at the table and ate lunch without assistance.On 06/10/26 at 12:37 PM, Licensed Nurse (LN) G stated if a resident had a weight loss, she would reweigh the resident to verify there had been a loss. LN G stated she would check for edema, ask if the residents had problems with their teeth, and attempt to find the cause for the weight loss. LN G stated she would notify the physician of the weight loss. LN G stated the RD would review the weekly weights in the resident's EMR.On 06/10/26 at 12:50 PM, Administrative Nurse D stated R2 had some weight loss related to R2 edema. Administrative Nurse D stated the physician had not given an order for a prescribed weight loss program.The facility's undated Weight Monitoring policy, documented based on the resident's comprehensive assessment, the facility would ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise.

The facility had a census of 75 residents. The sample included three residents, with one reviewed for a change of condition. Based on observation, record review, and interview, the facility failed to notify Resident (R) 1's representative when R1 had a change in condition. This deficient practice placed R1 at risk for a lack of required decision from her representative for treatment.Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and thrombophilia (blood disorder that makes the blood in your veins (blood vessels that carry oxygen filled blood towards the heart) and arteries (blood vessels that carry blood away from the heart) more likely to clot).R1's Quarterly Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of nine, which indicated moderately impaired cognition. The MDS documented R1 had no upper or lower extremity impairment and used a walker for mobility. The MDS documented R1 required supervision with transfers and ambulation 10 feet (ft).R1's Care Plan, revised 08/05/25, documented R1 required limited one staff assistance with mobility in the room with a walker. The Nurse's Note dated 07/12/25 at 10:34 PM documented the nurse observed R1 with vomiting and diarrhea throughout the day. Staff administered Maalox (antacid medication), 10 milliliters (ml), and two Imodium (over-the-counter medication used to treat diarrhea), 2 milligrams (mg), tablets to R1. Review of R1's clinical record revealed a lack of documentation. R1's representative was informed of the change in condition.The Nurse's Note dated 07/14/25 at 01:17 PM documented R1 had a rough weekend with nausea, vomiting, and diarrhea, and had a hard time transferring. The note documented R1 slept in, took her morning medications, got up for lunch, and ate some of her meal. The note documented staff checked her vitals, and they were within normal limits for R1. The nurse assessed R1's hand grasp, and they were equal on both sides. The note documented R1 had a hard time cutting up her meat, and the nurse notified the physician and R1's representative three days after R1's initial change in condition.On 09/02/25 at 10:22 AM, Administrative Nurse D verified a lack of documentation in R1's clinical record, regarding staff notifying the resident's representative of R1's change of condition on 07/12/25. Administrative Nurse D stated she would expect staff to notify the representative as soon as R1 had nausea, vomiting, and diarrhea.Upon request, the facility failed to provide a change in condition policy.

The facility had a census of 75 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to notify the physician regarding issues with red drainage from a urinary catheter (a tube inserted into the bladder to drain urine) and the lack of urine output for the night shift for one resident, Resident (R) 2. This placed the resident at risk for physical decline and urinary tract infections (UTI- infection in any part of the urinary system).Findings included:- The Electronic Medical Record (EMR) for R2 documented diagnoses of urinary retention (lack of the ability to urinate and empty the bladder), benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), and chronic kidney disease (a long term condition characterized by the gradual loss of kidney function over time).The admission Minimum Data Set (MDS) dated [DATE] documented R2 had intact cognition. R2 was dependent upon staff for assistance with toileting hygiene, transfers, and lower-body dressing. The MDS further documented R2 had a catheter and no UTIs during the observation period.The Quarterly MDS, dated 08/14/25, documented R2 had intact cognition. R2 was dependent upon staff for toileting hygiene, lower body dressing, and transfers. The MDS further documented R2 had a catheter and no UTIs during the observation period. R2's Care Plan dated 08/26/25, initiated on 11/27/24, directed staff to monitor for signs and symptoms of discomfort on urination and frequency, change the catheter as ordered by the physician, and monitor and document intake and output as per facility policy. The care plan further directed staff to monitor for pain/discomfort due to the catheter, monitor and report to the physician for signs and symptoms of UTIs, frequency, no output, altered mental status, and change in eating patterns. The Physician's Orders dated 02/16/25 directed staff to change the catheter using a 16 French, 10 cc (cubic centimeter) balloon, every one hour as needed, and on the night shift, every 30 days.The Nurse's Note dated 06/17/25, at 12:59 PM, documented that the nurse placed a 16 French catheter in the resident as it was due to be changed. The resident tolerated it well, and urine was returned once the catheter was inserted. The note further documented staff emptied out 600 milliliters (ml) of urine from the previous catheter and would continue to monitor.The Nurse's Note dated 06/18/25 at 02:41 PM, documented R2 complained of pain and little urine output. Nursing staff attempted to flush the catheter with 30 cc of sterile water, with no relief. Nursing staff attempted to advance the catheter with no output and removed 10cc of sterile water from the balloon. The catheter was removed, and a large amount of dark red drainage came out. The note further documented the nursing staff changed the catheter, and there was an immediate cloudy yellow return. Nursing staff inflated the bulb with 10 cc of sterile water per order, and the resident stated he felt better, but the red drainage continued.The Nurse's Note dated 06/18/25 at 07:34 PM, documented that R2's Foley catheter was changed yesterday, and then he complained of pain. The day shift staff changed the Foley catheter this morning, and a moderate amount of red drainage was noted, with some in the drainage bag as well. The resident stated he felt ok and the red drainage was probably caused by trauma.The Nurse's Note dated 06/19/25 at 08:52 AM, documented that nursing staff reported to the nurse that R2 had not had any urine output all night. The nurse went in and put in a new Foley catheter. When she removed the old Foley catheter, the nurse did notice some blood-tinged color. The note further documented that R2 tolerated it well, and the urine was yellow in the tube. The note documented that the nurse would continue to monitor. The EMR lacked documentation that the physician or responsible party was notified of the lack of urine output or the red drainage.The Nurse's Note dated 06/19/25 at 10:26 AM, documented that staff reported R2 had emesis (vomit) at breakfast. R2 stated he was nauseous and felt his medication caused this; no temperature was noted, and nursing staff would continue to monitor R2. The Nurse's Note dated 06/19/25 at 02:00 PM, documented that staff reported to the physician that R2 had increased drowsiness, was hard to arouse, had vital signs on the lower end, urine output and color, and the physician directed staff to send him to the emergency room for evaluation.The Nurse's Note dated 06/19/25 at 05:28 PM, documented R2's spouse reported that he was transferred from the local hospital to the hospital in [NAME], where he was admitted for a UTI.On 09/02/25 at 01:15 PM, R2 was in his room, in bed. His catheter bag was fastened to his bed. On 09/02/25 at 12:05 PM, Certified Nurse Aide (CNA) M stated she would contact the nurse if the resident did not act right or out of his normal behaviors. On 09/02/25 at 12:17 PM, Licensed Nurse (LN) G stated that if she had to change R2's catheter more than once in a short time, she would contact the physician. LN G further stated R2's spouse was very involved with his care, and she would make sure she was notified of any changes in his health. LN G further stated that nursing staff had recently been reeducated on when to contact the physician and responsible parties when there was a change in the status of residents.On 09/02/25 at 10:28 AM, Administrative Nurse D stated she would expect the physician to be notified if R2 had not had any output of urine in his catheter and any changes with the resident.The facility's Indwelling Catheter Protocol policy, dated 08/27/24, documented that every resident with an indwelling catheter would be reassessed by a licensed nurse every shift. Each resident with an indwelling catheter would be assessed for pain/discomfort related to the use of the catheter, and if any, the location of the pain/discomfort and what non-pharmacological interventions were attempted. If the bladder had been overly distended for a period of time, urine may become bloody. If clots are noted or bleeding appears excessively, notify the physician immediately.

The facility identified a census of 73 residents. Based on observation, record review, and interview, the facility failed to provide consistent Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all the residents who resided in the facility at risk of a lack of assessment and inappropriate care. Findings included: - A review of the facility's submitted Payroll Based Journal (PBJ) documented the facility had triggered for the Fiscal Year second quarter (January 1, 2025, to March 31, 2025) for four or more days within the quarter with no RN coverage for eight consecutive hours. Upon review of the facility's working schedule and daily posted staffing revealed that no accounted RN hours were posted for two days (04/27/25 and 05/11/25). The facility was not able to provide documentation for the two missing days of RN coverage as requested on 06/25/25. On 06/25/25 at 12:00 PM, Administrative Staff A stated the facility should not have any days without eight hours of consecutive RN coverage. Administrative Staff A stated he would provide supporting documentation, and if he could not find the supporting documentation, then the facility would get the deficient practice fixed. The facility lacked a policy regarding providing consistent RN coverage for eight consecutive hours a day, seven days a week.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella) and other waterborne pathogens. The facility further failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing high-contact care to Resident (R) 36. This placed the residents in the facility at risk for infectious disease. Findings Included: - On 08/13/24 at 03:00 PM, Maintenance Staff U verified he was not aware of any routine facility water management checks and verified the facility had some rooms presently unoccupied. Maintenance Staff U stated staff do not flush water in the unoccupied rooms. On 08/14/24 at 08:00 AM, Administrative Nurse D verified the facility lacked a system to check regarding standing water and potential growth inside the facility and lacked a system to mitigate the risk of Legionella. The facility's Legionella Water Management Procedure policy, dated 05/01/24, documented the purpose of the policy was to ensure as far as possible, all users of the facility are protected from the incidence of Legionnaire's disease. The Director of Environmental Services is responsible for all relevant details regarding roles and responsibilities and testing regimens contained in the policy and procedure. It is the policy of the facility to ensure that appropriate precautions for the control of Legionella bacteria are identified through the Legionella risk assessment process and appropriate control measures implemented to ensure, so far as is reasonably practicable, the health, safety, and welfare of residents, visitors, staff members, and volunteers. The minimum standards to be met included but not limited to: Carrying out suitable and sufficient Legionella assessments. Description of building water systems. Identification of areas where Legionella could grow and spread. Preparation of an action plan or written scheme for preventing or controlling the risk, where appropriate. (Inclusion in the plan of any area where medical procedures may expose residents to water mists including hydrotherapy and respiratory therapy services) Implementation. Management monitoring and recording of precautions to include regular inspection, microbiological monitoring, temperature checks, and flushing where appropriate. Plans to intervene when control limits are not met. Continuous monitoring of program compliance. Documentation of all monitoring. Seeking suitable advice and assistance from competent persons and Specialist consultants, where appropriate. Appointment of a person or persons to be managerially responsible for the water system at each premise. To otherwise meet the requirements of CMS Center for Clinical Standards and Quality/Survey and Certification Group, Survey and Certification letter 17-30, dated 02/2017 related to the requirement to reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease. The facility has established and maintained, an infection prevention and control group designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy further documented the requirements will be met by the following: inspection of water storage tanks, water would be measured at 86 degrees or below after two minutes of running, and hot water storage or distribution would be measured at 122 degrees at outlets after one minute of running. All cases of Legionella would be reported to the local health department and the State health departments. The facility failed to implement a water management program to test and manage waterborne pathogens placing the residents who resided in the facility at risk of contracting Legionella disease. 26768 - R36's Electronic Medical Record (EMR) documented diagnoses of bladder-neck obstruction and retention of urine (inability to empty the bladder completely). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R36 was independent with eating and required staff assistance for toileting hygiene and transfers. The MDS documented R36 had a urinary catheter. R36's Care Plan, dated 05/30/24, documented R36 had a urinary catheter and directed staff to administer antibiotics for a UTI when ordered by the physician, monitor for changes in mood, urine odor or color as well as pain, and general feelings of malaise (vague uneasy feeling of body weakness, distress or discomfort). The plan directed to change the catheter every two weeks and as needed and monitor intake and output per facility policy. Staff was to report to the physician signs and symptoms of a UTI such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns. The plan documented the resident was able to manage his catheter, and staff were to assist and provide support as the resident requested. An intervention dated 03/28/24 directed staff to provide enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care) for the urinary catheter with colonized proteus mirabilis (bacteria). Staff were to provide a sign on R36's door to alert staff of the need for EBP and update the report sheet with this information. Staff would clean their hands with alcohol sanitizer or wash with soap and water, then don the required personal protective equipment (PPE) before entering the resident's room for high-contact care activities. On 08/13/24 at 01:40 PM, observation revealed R36 sat in his recliner with the catheter drainage bag hung on the inside of the trash can with several used tissues. Certified Nurse Aide (CNA) N washed her hands and gloved but did not don a gown. CNA N then set the urinal canister inside the trash can on top of the used tissues. She held the catheter drainage bag over the canister and emptied it. She wiped the port with a moist wipe and then an alcohol pad. She collected 1400 milliliters of clear yellow urine which she dumped in the toilet. CNA N rinsed the urinal canister with water and stored it in a cabinet. When asked, CNA N stated she had never been told to wear a protective gown while emptying the catheter bag. On 08/13/24 at 01:52 PM, Administrative Nurse E verified staff were to wear PPE including gowns to provide catheter care and emptying of the catheter bag. She agreed it was not best practice to set the catheter bag inside a trash can with soiled tissues. On 08/14/24 at 09:50 AM, Administrative Nurse D verified staff were to wear PPE of gown and gloves while performing catheter cares. The facility's Enhance Barrier Precautions policy, undated, stated EBP would be implemented in addition to standard precautions when standard precautions do not prevent pathogen (any organism or agent that can produce disease) transmission. Clear signage would be placed on the door outside the resident room as well as inside the resident's room to identify the type of precautions and PPE to be used: gown and gloves during high contact care. The Infection Prevention Nurse would update the care plan, educate facility workers, resident, their representative, and their visitors PPE use and disposal. The facility failed to provide adequate infection prevention during care for R36's urinary catheter. This placed R36 at risk for infection.

The facility had a census of 70 residents. The sample included 18 residents with four reviewed for urinary catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, interview, and record review the facility failed to provide adequate catheter care per standards of practice for Resident (R)36's urinary catheter. This deficient practice placed R36 at risk for urinary tract infections (UTI- an infection in any part of the urinary system) and other catheter-related complications. Findings included: - R36's Electronic Medical Record (EMR) documented diagnoses of bladder-neck obstruction and retention of urine (inability to empty the bladder completely). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R36 was independent with eating and required staff assistance for toileting hygiene and transfers. The MDS documented R36 had a urinary catheter. R36's Care Plan, dated [DATE], documented R36 had a urinary catheter and directed staff to administer antibiotics for a UTI when ordered by the physician, monitor for changes in mood, urine odor or color as well as pain, and general feelings of malaise (vague uneasy feeling of body weakness, distress or discomfort). The plan directed to change the catheter every two weeks and as needed and monitor intake and output per facility policy. Staff was to report to the physician signs and symptoms of a UTI such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns. The plan documented the resident was able to manage his catheter, and staff were to assist and provide support as the resident requested. An intervention dated [DATE] directed staff to provide enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care) for the urinary catheter with colonized proteus mirabilis (bacteria). Staff were to provide a sign on R36's door to alert staff of the need for EBP and update the report sheet with this information. Staff would clean their hands with alcohol sanitizer or wash with soap and water, then don the required personal protective equipment (PPE) before entering the resident's room for high-contact care activities. The Progress Note, dated [DATE] at 10:12 PM, documented R36 reported he had lower body aches and chills. Staff checked his vital signs and noted an increased temperature and increased blood pressure. The resident reported increased confusion and began talking about a UTI four years prior where he could have died if he waited until morning. The note recorded the nurse recommended that R36 go to the emergency room as he was displaying symptoms of a UTI. His charge nurse immediately called his urologist's on-call number to advise them of the situation and they recommended sending the resident to the emergency room for evaluation. R36's EMR documented an unplanned discharge to an acute hospital on [DATE] and re-admission to the facility on [DATE]. The Progress Note, dated [DATE], recorded staff discussed all R36's lab results with him and discussed that R36 was colonized with bacteria and awaiting the urine culture. The note recorded that R36 stated that unless he was symptomatic, his urologist requested he not be treated with antibiotic therapy. The Physician Order, dated [DATE], directed staff to administer cefuroxime axetil (antibiotic) 500 milligrams (mg), twice daily for seven days for a UTI. R36's Urine Culture Lab, dated [DATE], documented abnormally high values for bacteria and identified proteus mirabilis as the organism. The Progress Note, dated [DATE] at 04:27 PM, R36 reported he had chills and just did not feel right; he asked to have his vital signs taken. His vital signs were within normal limits and he refused further assessment. The note recorded the resident requested a registered nurse (RN) come to see him and at 04:50 PM, an RN assessed R36's vital signs and identified a low-grade temperature with elevated blood pressure and shaking. The note documented R36 reported he had chills for the past ,d+[DATE] minutes and brain fog. The Progress Note, dated [DATE] at 10:55 AM, documented R36 returned to the facility from the hospital with a diagnosis of urosepsis (a condition where a urinary tract infection leads to a systemic infection that spreads throughout the body). The Progress Note, dated [DATE] at 10:55 AM, documented the physician called the facility and stated that R36's cultures grew back and because of his history he will have intravenous (IV-administered directly into the bloodstream via a vein) antibiotics every 12 hours for 10 days. The note directed to keep R36's catheter bag below the suprapubic line (insertion site on the abdomen) to prevent backflow and to not allow R36 to get in a whirlpool tub as this could cause infection. The Urologist Note, dated [DATE], documented R36 had two UTIs over the past few months and staff were to change the catheter every four weeks. The Physician Order, dated [DATE], directed staff to change the suprapubic catheter and replace the drainage bag with each catheter change. The urinal is to be replaced and dated with each catheter change. On [DATE] at 02:50 PM, R36 sat in his recliner in his room and stated his catheter bag was hung on the chair below bladder level. He stated staff emptied the bag usually at 06:00 AM and also around lunchtime. R36 stated he had a UTI in February and April this year and said he was able to tell when he needed to have that checked as he went from UTI to sepsis (systemic infection) very fast. On [DATE] at 01:40 PM, observation revealed R36 sat in his recliner with the catheter drainage bag hung on the inside of the trash can with several used tissues. Certified Nurse Aide (CNA) N washed her hands and gloved but did not don a gown. CNA N then set the urinal canister inside the trash can on top of the used tissues. She held the catheter drainage bag over the canister and emptied it. She wiped the port with a moist wipe and then an alcohol pad. She collected 1400 milliliters of clear yellow urine which she dumped in the toilet. CNA N rinsed the urinal canister with water and stored it in a cabinet. When asked, CNA N stated she had never been told to wear a protective gown while emptying the catheter bag. On [DATE] at 01:52 PM, Administrative Nurse E verified staff were to wear PPE including gowns to provide catheter care and emptying of the catheter bag. She agreed it was not the best practice to set the catheter bag inside a trash can with soiled tissues. On [DATE] at 09:50 AM, Administrative Nurse D verified staff were to wear PPE consisting of a gown and gloves while performing catheter care. The facility's Indwelling Urinary Catheter Care policy, undated, lacked guidance for emptying the drainage bag. The facility failed to provide adequate catheter care for R36's urinary catheter. This placed R36 at risk for further UTI and catheter-related complications.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 12 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization. This placed the resident at risk for unmet mental healthcare needs and impaired psychosocial well-being. Finding included: - R12's Electronic Medical Record (EMR) included diagnoses of post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings of sadness) urinary retention, and cardiac murmur. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R12 had intact cognition, no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or behaviors. R12 was independent with most functional abilities and mobility. The MDS recorded an active diagnosis of PTSD, depression, and anxiety disorder. R12 received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), and diuretic (medication to promote the formation and excretion of urine). The antipsychotic was received on a routine basis only; there was a gradual dose reduction (GDR) on 07/09/24 and no physician documented contraindication for GDR. The Psychotropic Care Area Assessment(CAA), dated 10/24/23, documented R12 received an antipsychotic and antidepressant for diagnoses of major depressive disorder and PTSD. R12 was seen routinely by a mental health practitioner. R12's Care Plan, dated 06/17/24, documented R12 had a mood problem related to a history of depression, PTSD, and generalized anxiety disorder. The care plan directed staff to administer medications as ordered, monitor and document for side effects and effectiveness, and assist the resident, family, and caregivers to identify strengths and positive coping skills, and to reinforce them. The Physician Order, dated 11/22/22, directed staff to administer clonazepam (antianxiety) 0.5 milligrams (mg) in the afternoon and at bedtime for verbal expressions of anxiety, religious doubts, and isolation related to PTSD. The Mental Health Medication Management note, dated 07/19/24, documented R12's PTSD was stable and a chronic condition, and clonazepam doses had not changed. On 08/13/24 at 01:31 PM observation revealed R12 sat in her recliner with her eyes closed. She was dressed and groomed for the day. On 08/13/24 at 02:58 PM, Certified Nurse Aide (CNA) M reported she was not aware of R12's PTSD diagnosis or was not aware of what R12's triggers were. On 08/13/24 at 04:21 PM, Licensed Nurse (LN) G reported she thought R12 had a diagnosis of PTSD but was not aware of R12's triggers. On 08/14/24 at 09:29 AM Social Service X reported the Trauma Informed Care Assessment had been done by social services staff. Social Service X reported knowledge of R12's PTSD diagnosis, which stemmed from when the resident was young. Social Service X reported R12's Care Plan lacked trauma triggers. On 08/14/24 at 10:26 AM, Administrative Nurse D reported R12's PTSD occurred many years back and the care plan is where that information including triggers for prevention of re-traumatization should be recorded. The facility's undated Standard of Practice for Trauma Informed Care policy, documented the facility would ensure the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for each resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The facility failed to ensure R12 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization. This placed the resident at risk for unmet mental healthcare needs.

The facility had a census of 70 residents. The sample included 18 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure an approved indication for use or the required physician documentation as well as ongoing monitoring for effectiveness and the ongoing necessity for the use of antipsychotic drugs (class of medications used to treat psychosis and other mental-emotional conditions) and psychotropic (alters mood or thought) drugs for Resident (R)121 and failed to ensure a stop date for as needed (PRN) lorazepam (antianxiety drug) for R41. This deficient practice placed R41 and R121 at risk for unnecessary antipsychotic and psychotropic drugs and related side effects. Findings included: - R121's Electronic Medical Record (EMR) documented diagnoses including vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) without psychosis (any major mental disorder characterized by a gross impairment in reality perception). The Admission Minimum Data Set (MDS) was in process. R121's Care Plan, dated 8/14/24, directed staff to obtain periodic gradual dose reduction (GDR) evaluations by a pharmacist or the physician per Center for Medicare and Medicaid Services (CMS) guidelines. The Physician Order, dated 08/01/24, directed staff to administer quetiapine (antipsychotic) 25 milligrams (mg) at bedtime, and stated the diagnosis was pending. The Physician Order, dated 08/02/24, directed staff to administer sertraline (antidepressant) 50 mg, in the morning, and stated the diagnosis was pending. The Progress Note, dated 08/04/24 at 01:57 AM, documented R121 was slightly upset at being left here. Staff talked with R121 about her being a bus driver and was able to redirect her. The resident asked if she had to stay here forever now. R121 visited with another resident next door and then went to bed for the night. The Social Services Note, dated 08/06/24 at 01:43 PM, documented that R121 was upset at the time and confused as to why she was here and not at the other place. She became a bit angry, demanding answers as to what is going on. She was easily redirectable with assurances provided. She had very limited memory recall and was only oriented to person. She had difficulty tracking the entirety of the conversation. R121 stated that she becomes depressed and angry sometimes and felt lonely often. She had frequent visitors and interacted with other residents often. The Progress Note, dated 08/12/24 at 01:06 PM, documented that staff contacted the physician to report an increase in anxiety and tearfulness and were awaiting a return call. R121's progress notes and physician notes lacked notation of behaviors other than anxiety and depression. R121's behavior monitoring lacked a specific targeted behavior for the use of quetiapine and sertraline and documented no behaviors observed since admission. On 08/12/24 at 01:31 PM, observation revealed R121 independently ambulated out of her room with a walker and steady steps. R121 wore walking shoes, walked to the small commons area by a side exit, and sat down. She stated she had one fall where she slipped out of bed and had no injury. R121 stated she had been here at the facility for two weeks. On 08/13/24 at 07:58 AM, CMA T administered medications to R121. The CMA asked the resident if she took them whole or crushed and the resident reached out, took the medication cup, and took them whole, all at one time with water to follow. On 08/14/24 at 10:05 AM, Administrative Nurse D verified the physician had not given a diagnosis for the prescription for quetiapine and sertraline. She stated they had trouble getting answers back from her physician. During the interview, Administrative Nurse D received communication from the physician's office of the diagnoses: quetiapine for vascular dementia with psychosis and sertraline for depression. The facility's Psychotropic Medication Monitoring, policy, dated 06/07/2018, stated the facility would use and administer psychotropic medications appropriately to ensure the appropriate use, evaluation, and monitoring. Physician responsibilities included orders for psychotropic medication only for the treatment of specific medical or psychiatric conditions when the medication meets the needs of the resident to alleviate significant distress not met using non-pharmacological approaches. The physician would document the rationale and diagnosis for use and identify target symptoms. The policy stated upon admission of a resident with ordered psychoactive medication and a diagnosis of dementia, the nursing staff would obtain from the physician an approved diagnosis for the antipsychotic medications and a specific behavior for its use. The facility failed to ensure R121 had a CMS-approved indication for the use of quetiapine, or the required physician documentation and failed to monitor for targeted behaviors to determine the effectiveness and ongoing necessity of psychoactive medications. This placed the resident at risk of receiving unnecessary antipsychotic and psychotropic drugs. 27168 - R41's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dementia (progressive mental disorder characterized by failing memory, and confusion). R41's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R41 had severely impaired cognition. The MDS recorded R41 was dependent for most activities of daily living (ADL) and required extensive staff assistance. The MDS recorded R41 received an antianxiety and antidepressant medication during the observation period. R41's Care Plan, dated 06/11/24 recorded R41 received the antianxiety medication lorazepam (antianxiety medication) per physician order. The care plan documented the staff would monitor, document, and report as needed any adverse side effects to the medication such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, impaired thinking and judgment, memory loss, forgetfulness, nausea, slurred speech, and double vision. The Physician's Order, dated 06/22/24, directed the staff to administer lorazepam oral concentrate 1 milligram (mg)/milliliter (ml), Give 1.0 ml every two hours as needed for anxiety. The order lacked a stop date. R41's EMR lacked evidence of s specified duration which included a physician's rationale for the extended use. R41's Consultant Pharmacist monthly review completed on 07/17/24 documented that the pharmacist identified the PRN lorazepam with no stop date. The recommendation lacked a response. On 08/12/24 at 01:45 PM, observation revealed R41 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) in the living room area on the [NAME] Hall dressed in street clothes. R41's eyes were closed, and the resident held a stuffed dog. Continued observation revealed Certified Medication Aide (CMA) R administered the resident's morning medications. On 08/14/24 at 08:40 AM, Administrative Nurse D verified the resident received lorazepam PRN that lacked a stop date. The facility's Use of Psychotropic Drug Use policy, undated, documented the facility would make every effort to comply with State and Federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dosage, side effects, risk and/or benefits. The facility supports the appropriate use of psychopharmacological medications that are therapeutic and enabling for residents suffering from mental illness while recognizing that the use of psychopharmacological medications for dementia-related behaviors is inappropriate in most cases but rather the use of non-pharmacological interventions based on individual resident needs, preferences and routines is the most appropriate and first-line treatment for dementia-related behaviors. The facility failed to ensure R41's lorazepam had a 14-day stop date or specified duration placing R41 at risk for adverse side effects.

The facility identified a census of 67 residents. Based on record review and interviews, the facility failed to ensure the availability of physician-ordered medications for Resident (R) 1. This deficient practice had the risk for physical complications and less than desired/therapeutic effects of prescribed medications for R1. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of paroxysmal atrial fibrillation (rapid, irregular heart beat) and hypertensive heart disease (long-term condition that develops in people who have high blood pressure) with heart failure (a progressive heart disease that affects pumping action of the heart muscles). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Activities of Daily Living (ADL)/Function Care Plan dated 03/24/23, directed R1 required limited to total assistance with ADLs. The Orders tab of R1's EMR documented an order with a start date of 07/15/23 for metolazone (diuretic medication that increases the amount of urine made and causes the body to get rid of excess water) 2.5 milligrams (mg) in the morning every other day for fluid overload. The Miscellaneous tab of R1's EMR revealed an order written by Consultant GG, dated 07/14/23 at 09:01 AM, for metolazone 2.5 mg every other day with a note that said the prescription was sent to the pharmacy. R1's Medication Administration Record (MAR) for July 2023, revealed metolazone 2.5 mg was not administered as scheduled on 07/15/23 and 07/17/23. The Notes tab of R1's revealed the following: A Communication with Physician note on 07/14/23 at 09:52 AM, documented a call was placed to Consultant GG's office regarding the order for metolazone. The medication was ordered from the pharmacy and the facility waited to hear back regarding the order for metolazone. An Orders- Administration Note on 07/15/23 at 08:26 AM, documented metolazone 2.5 mg was not administered due to waiting on medication from pharmacy. An Orders- Administration Note on 07/17/23 at 07:57 AM, documented metolazone 2.5 mg was not administered due to not being available. A Health Status Note on 07/17/23 at 11:19 AM, documented the nurse called the pharmacy to check on metolazone 2.5 mg and the pharmacy first stated they did not get the order. Pharmacy then stated they did receive it last week and left a message at the facility, but no one called back due to the doctor stating it was already sent to the pharmacy. The pharmacist checked and the medication was to be sent out that day. On 08/31/23 at 01:58 PM, Licensed Nurse (LN) G stated when a medication was ordered, the order was faxed to the pharmacy and if it did not come by the next day then the nurse called the pharmacy. She stated if the medication was in the emergency kit (E-kit) then it could be pulled from there. LN G stated the facility implemented a pharmacy communication in progress notes which was helpful to track communication between the facility and the pharmacy. She stated missing one dose was an acceptable amount of time a resident could go without a medication. On 08/31/23 at 02:08 PM, Administrative Nurse D stated when a medication was ordered, the doctor usually faxed the order straight to the pharmacy but if it came from an outside provider then the facility faxed the order to the pharmacy. She stated depending on the medication, it usually arrived that day or the next day. Administrative Nurse D stated new medications should have started as soon as they can and if the medication did not come in then the doctor was notified if the pharmacy did not have the medication. She stated after R1 missed the first dose, the nurse should have called the pharmacy to check on the medication. The facility's Pharmacy Services policy, last revised 09/06/00, directed the facility provided routine and emergency drugs to it's residents and ensured that all drugs were administered to residents in accordance with a physician's order and acceptable medical practice. The facility failed to ensure the availability of physician-ordered medications for R1. This deficient practice had the risk for physical complications and less than desired/therapeutic effects of prescribed medications for R1.

The facility identified a census of 63 residents with three reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to provide adequate supervision and failed to respond appropriately to door alarms to prevent an elopement (when a cognitively impaired resident leaves the facility without staff knowledge and /or supervision) for Resident (R)1. On 06/13/23 at approximately 02:05 PM, R1, a severely cognitively impaired resident at high risk for elopement, exited the facility's [NAME] door without staff knowledge and/or supervision. Prior to R1 exiting the building, a family member of another resident exited the same door with their resident and set off the alarm. Certified Medication Aide (CMA) R entered the code to cancel the alarm and, during that time, R1 walked out the door without CMA R's knowledge. CMA R did not check the area in response to the alarm or check to ensure all residents at risk for elopement were accounted for. R1 walked around the block and down the street approximately one block away from the facility until she encountered members of the community. The community members visited with R1 for a few minutes and then put her in their car and took her back to the facility. The facility staff did not know R1 was outside of the building until the community members alerted the facility staff of the incident. Staff went outside and verified R1 was a resident at the facility and staff accompanied R1 back into the building at 02:30 PM. The facility failures which resulted in an elopement placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The MDS documented R1 had exhibited verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) one to three days during the look back period. The MDS documented R1 had other behavioral symptoms not directed towards others (hitting or scratching self, pacing, disrobing in public, or verbal/vocal symptoms like screaming) for one to three days during the look back period. The MDS documented R1 exhibited wandering behavior during one to three days during the look back period. The MDS documented R1 required supervision of one staff for bed mobility, transfer, walking in her room, walking in the corridor, locomotion on and off of the unit, and personal hygiene. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/12/23, documented R1 could not participate in the BIMS, exhibited short- and long-term memory problems, often misunderstood communication from others, and displayed increased irritability with others. The CAA documented R1's activities of daily living (ADL) were supervised due to R1's impaired balance. The Fall CAA, dated 02/12/23, documented R1 had two falls during the last 90 days due to impaired balance with transitions. The Elopement Care Plan, dated 05/05/23, documented R1 would remain safe and directed staff to engage R1 in purposeful activity, provide clear and simple instructions, provide orientation to surroundings and environment, and Wander Guard (bracelet to alert staff when a resident gets close to an exit door) number 12 applied to her left wrist. The nursing staff were to verify the placement and function of the Wander Guard, every shift. The Elopement Assessment, dated 05/05/23, documented R1 had an elopement score of two which indicated R1 was at risk for elopement. The evaluation documented R1 expressed the desire to go home, packed belongings to go home, and/or stayed near exit doors. The evaluation documented R1's wandering behavior was patterned or goal-directed, likely to affect the safety or well-being of others and likely to affect the privacy of others. The Health Status Note, dated 05/05/23 at 10:12 AM, documented R1 was exit seeking with a packed bag and staff applied a Wander Guard. The Behavior Note, dated 05/06/23 at 10:59 AM, documented R1 was pacing and exit seeking that morning. R1 carried around her personal belongings, and cursed at staff when R1 did not get the answer she wanted. The Behavior Note, dated 05/06/23 at 01:57 PM, documented R1 changed her clothes and wrapped things in other clothes and carried it around with her. The Behavior Note, dated 05/06/23 at 09:07 PM, documented R1 tried to empty her room out and leave. The nurse redirected R1 back to her room but R1 continued to bring out her belongings. The Behavior Note, dated 05/07/23 at 09:43 AM, documented R1 was up and had two sacks full of her belongings at 07:00 AM. Staff were able to redirect R1 back to her room and placed the sacks in R1's closet and accompanied R1 to breakfast. R1 paced and would not sit still even in her room. R1 stated to staff she was moving out. The Alert Note, dated 06/13/23 at 02:40 PM, documented the receptionist alerted staff R1 got out of the facility and was brought back to the facility by personal car. R1's vital signs were obtained and recorded, and her skin was checked with no problems noted. R1 wore a purplish colored sweater and blue pants. The Alert Note, dated 06/13/23 at 02:52 PM, documented R1's Wander Guard was blinking red at that time. The Health Status Note, dated 06/13/23 at 03:02 PM, documented the nurse was notified at 02:29 PM that R1 exited the building. A community member observed R1 down the street and returned R1 to the facility by private vehicle. The temperature was 81 degrees and humid. R1 wore a purple sweater, black slacks, socks, and shoes. Staff notified the director of nursing immediately and initiated an investigation. The charge nurse observed R1's skin and reported no new skin areas. A charge nurse notified R1's primary care physician, hospice, and family. The facility's Information Technology (IT) employee checked the cameras in the facility for further information. R1's Wander Guard had a blinking red light, which indicated the battery was working and the Wander Guard was tested at the door and was in working order. Maintenance was notified to ensure all door checks were performed and maintenance confirmed the Wander Guard system was checked on all doors that morning and functioned properly. The Facility Incident Report, dated 06/21/23, documented on the afternoon of Tuesday, 06/13/23, R1 exited the facility without supervision at approximately 02:05 PM. R1 returned to the facility at 02:26 PM by private vehicle accompanied by two community members. One of the community members came into the building and notified the front receptionist she and her husband had R1 in their car. Medical records personnel notified nursing staff and went out to the car at 02:28 PM and confirmed R1 was a resident at the facility. Nursing staff accompanied R1 back into the building at 02:30 PM. The community member stated he was mowing his lawn when R1 stopped to talk to him. The community member and his wife conversed with R1 and then drove R1 back to the facility. R1 wore a purple sweater, black slacks, socks and shoes. Staff assessed R1's skin and found no issues. After reviewing the cameras, it was noted a family member took another resident out of the facility through the [NAME] door. CMA R then entered the code to clear the alarm to the [NAME] door and R1 walked behind CMA R out the door. On 06/21/23 at 10:30 AM, R1 sat in a resident led exercise group sleeping with her chin on her chest. Her Wander guard bracelet was on her left wrist. On 06/21/23 at 11:00 AM, CNA M stated R1 wandered and would exit seek frequently. On 06/21/23 at 12:00 PM, Administrative Nurse E stated that a lot of things went wrong on 06/13/23 including CMA R not checking to see if any residents had exited when canceling the door code, the resident's family not seeing R1 walking out of the building, and no one seeing R1 walking around the outside of the building. Administrative Nurse E stated CMA R had a plan for improvement in place that stated she should always evaluate which resident caused the alarm to sound and observe residents until the doors lock, and to always check surrounding, inside and outside, prior to overriding the alarm, to assure residents safety. On 06/21/23 at 12:30 PM, CMA R stated that she knew family just left out the [NAME] door with their resident and she figured the alarm went off because they left the door open too long, so she cleared the alarm. CMA R stated she did not see R1 exit behind her and did not go outside looking for any resident. CMA R stated she knows now to let the alarm continue to sound and stay by the door to ensure resident safety. On 06/21/23 at 02:00 PM, Administrative Staff A stated it was a perfect storm and everything that could have gone wrong, went wrong, and the facility was just happy R1 returned to the facility without any injury. The facility Elopement Policy, reviewed 06/14/23, documented all staff that hear an audible door alarm will respond immediately. A door alarm will never be reset until the source of the alarm has been identified and if a resident has exited through the door the alarm will be disengaged only after the resident has been re-directed back to a safe location or with appropriate supervision. The facility failed to provide adequate supervision and failed to respond appropriately to door alarms to prevent an elopement for R1 which placed R1 in immediate jeopardy. The facility implemented corrective actions to address the deficient practice including staff education regarding responding to door alarms, supervision of residents, and elopement protocols and policies. The facility Quality Assurance and Performance Improvement (QAPI) team evaluated the occurrences, identified causative factors, and implemented facility and individual performance improvement plans. The corrective actions were completed on 06/16/23, prior to the onsite survey event, therefore the deficient practice was cited as past noncompliance at the scope and severity of a J.

The facility identified a census of 60 residents. Based on record review and interview, the facility failed to ensure their Medical Director attended the Quality Assessment and Assurance (QAA) committee meetings at least quarterly. The deficient practice placed the residents of the facility at risk for decreased quality of care. Findings include: - On 03/15/23 at 09:50 AM, Administrative Nurse D provided examples of the QAA committee's performance improvement projects for the past year and sign in sheets of attending staff. The Medical Director of the facility had not attended any of the monthly meetings in 2022 and through the current date, 03/15/23. On 03/15/23 at 09:50 AM, Administrative Nurse D stated the Medical Director had not attended any of the QAA meetings for the past year. She stated the committee had provided their schedule to the Medical Director and asked if those times were okay for him to attend. On 03/15/23 at 01:05 PM, Administrative Staff A stated the Medical Director had not attended QAA meetings at least quarterly for the past two years. The undated Quality Assurance Performance Plan (QAPI) documented the QAPI committee would meet at least monthly and the Medical Director would attend the meeting in person at least quarterly. The facility failed to ensure their Medical Director attended the QAA committee meetings at least quarterly, placing the 60 residents of the facility at risk for decreased quality of care.

The facility had a census of 60 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety when staff used contaminated gloves to transfer food items from one container to another while preparing the three residents mechanical soft diets. This placed the residents at risk for foodborne illness. Findings included: - On 03/13/23 at 08:50 AM, observation, during preparation of the three residents mechanical soft diets, revealed Dietary Staff (DS) BB placed a glove on her right hand, retrieved a blender container, touched the counter and side of the blender, then picked up four individual Salisbury steaks one at a time, with the contaminated right gloved hand, and placed them into the blender. DS BB added unmeasured brown beef gravy with onions and mushrooms, using a large spoon, blended the items, then placed her same contaminated right gloved hand into the mixture and transferred it into a metal pan, then removed and discarded her glove. DS BB verified the above finding and stated she liked to use her hand to make sure the Salisbury steak was the right consistency. On 03/13/23 at 09:30 AM, Dietary Manager (DM) CC stated staff should use tongs to pick up meat and a spatula to transfer a food item from a blender to a container. The facility's Food Preparation-Employee Sanitary Practices Policy, undated, documented all employees should use proper utensils and gloves to handle food and avoid touching hands to mouth or face while preparing food. The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the 60 residents who resided in the facility and received their food from the facility kitchen. This placed the 60 residents at risk for foodborne illness.

The facility had a census of 84 residents. The sample included 3 residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to provide an environment free from abuse, when direct care staff B roughly transferred a resident. This deficient practice placed all residents in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 2/16/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 3, which indicated he/she had severely impaired cognition. The MDS documented the resident displayed physical behavior directed toward others, rejected care from staff, and had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The MDS documented the resident required extensive assistance from staff for bed mobility, transfers, eating, dressing, toileting and personal hygiene, and was totally dependent on staff for bathing. The resident used a walker and wheelchair for mobility, and received an antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication daily. The 11/26/16, significant change (CAA) Care Area Assessment for ADL's (activities of daily living) did not trigger. The 2/16/17 care plan documented the resident had a low BIMS score of 3, and required extensive assistance from staff for transfers. The care plan documented he/she may take several steps with transfers, and staff should cue him/her to move to the edge of the surface, and push up from the seat. The facility investigation report documented on 4/15/17, during the evening shift, the (DON) director of nursing received a call from the charge nurse, who was informed of an incident that occurred on 4/12/17 (3 days prior). Nurse Aide A stated he/she witnessed Nurse Aide B treat Resident #1 in a rough way, when he/she transferred him/her from the wheelchair to the recliner. The report documented the charge nurse immediately notified the DON, talked to Nurse Aide B and sent him/her home from the facility because of the allegation. The report documented the DON reported the allegation to the state agency on 4/15/17 at 7:56 PM via email. Review of the facility records documented Nurse Aide B (alleged perpetrator) was suspended from work on 4/15/17 at 6:55 PM, and terminated on 4/18/17. Review of Nurse Aide B's time sheet, documented he/she completed his/her shift on 4/12/17 and worked for approximately 3 hours after the incident, worked a full 8 hour shift on 4/14/17, and worked on 4/15/17 from 3:00 PM until 6:55 PM, when he/she was suspended from the facility. On 5/10/17 at 10:20 AM, observation revealed the resident, seated in his/her recliner, when staff entered the resident's room and asked if he/she needed to use the bathroom. Observation revealed the resident did not respond verbally, but he/she shook his/her head yes. Further observation revealed 2 staff members ambulated the resident to the bathroom, with use of a gait belt. On 5/9/17 at 3:10 PM, Nurse Aide A verified on 4/12/17, at approximately 8:00 PM, he/she and Nurse Aide B provided bed time care for Resident #1, when Nurse Aide A saw Nurse Aide B stand the resident up from his/her wheelchair, did not wait for the resident to get his/her balance to pivot, picked the resident up, and dropped him/her into the recliner, in a quick, fast manner. Nurse Aide A stated the resident said ouch, and he/she told Nurse Aide B he/she did not need to be so rough because he/she might hurt the resident. Nurse Aide A stated Nurse Aide B said the resident was not hurt, but Nurse Aide A told Nurse Aide B to leave the resident's room and he/she would finish cares and get the resident ready for bed. Nurse Aide A verified he/she did not report Nurse Aide B to the charge nurse because he/she just thought Nurse Aide B had a bad day. On 5/9/17 at 3:25 PM, Nurse Aide C stated he/she was not working at the time of Resident #'1's incident on the evening of 4/12/17 with Nurse Aide A and Nurse Aide B. Nurse Aide C stated Nurse Aide A told him/her on 4/15/17 that he/she was concerned about how rough Nurse Aide B had been with the resident on 4/12/17. After Nurse Aide C found out Nurse Aide A had not reported the incident, he/she notified the charge nurse of the incident. On 5/9/17 at 3:45 PM, Nurse D stated Nurse Aide C reported to him/her on the evening of 4/15/17, that Nurse Aide A witnessed Nurse Aide B was rough with Resident #1 on 4/12/17, but Nurse Aide A had not reported it. Nurse D stated he/she immediately notified Administrative Nurse E, talked with Nurse Aide B, and sent him/her home from the facility, and informed Nurse Aide B he/she could not come back to the facility until an investigation was completed. Nurse D stated he/she educated Nurse Aide A on the importance of reporting any allegation of abuse to the nurse, Administrative Nurse E, or the administrator immediately. On 5/9/17 at 4:30 PM, Administrative Nurse F stated he/she would have expected Nurse Aide A to report the incident to the charge nurse, Administrative Nurse E or the administrator, immediately after he/she witnessed it. Administrative Nurse F verified staff had not followed the facility's policy. On 5/10/17 at 8:45 AM, Administrative Nurse E stated Nurse Aide A should have reported the incident as soon as he/she witnessed it on 4/12/17, and verified Nurse Aide A had not followed the facility's policy for abuse, neglect and exploitation. On 5/10/17 at 10:40 AM, Administrative Staff G stated he/she would have expected staff to follow the facility's abuse policy, and report the incident immediately. The facility's 12/5/16 Abuse, Neglect, and Exploitation prevention policy documented all facility employees are educated that all alleged or suspected violation involving mistreatment, neglect, abuse or exploitation, including injuries of unknown origin, and involuntary seclusion, misappropriation of elder property are reported immediately to the director of nursing, assistant director of nursing, charge nurse, or the administrator, after the incident. The policy documented the director of nursing or the assistant director of nursing would ensure that all alleged or suspected violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of elder property, are investigated and reported immediately to the state agency. The policy documented any alleged perpetrator who is an employee of the facility, accused of alleged abuse, neglect, or exploitation will be immediately suspended from employment and will leave the employment property and not return to the property until the investigation by the facility is complete and the incident is resolved. The facility failed to provide an environment free from abuse, when Nurse Aide B transferred Resident #1 in a rough manner, he/she continued to work at the facility and provide care to the residents, placing all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 5/11/16, when they held an all staff in-service to re-educate staff on abuse, neglect and exploitation. This deficient practice remained at a scope and severity of an F.

The facility had a census of 84 residents. The sample included 3 residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to provide an environment free from abuse, when direct care staff B roughly transferred a resident. This deficient practice placed Resident #1 in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 2/16/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 3, which indicated he/she had severely impaired cognition. The MDS documented the resident displayed physical behavior directed toward others, rejected care from staff, and had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The MDS documented the resident required extensive assistance from staff for bed mobility, transfers, eating, dressing, toileting and personal hygiene, and was totally dependent on staff for bathing. The resident used a walker and wheelchair for mobility, and received an antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication daily. The 11/26/16, significant change (CAA) Care Area Assessment for ADL's (activities of daily living) did not trigger. The 2/16/17 care plan documented the resident had a low BIMS score of 3, and required extensive assistance from staff for transfers. The care plan documented he/she may take several steps with transfers, and staff should cue him/her to move to the edge of the surface, and push up from the seat. The facility investigation report documented on 4/15/17, during the evening shift, the (DON) director of nursing received a call from the charge nurse, who was informed of an incident that occurred on 4/12/17 (3 days prior). Nurse Aide A stated he/she witnessed Nurse Aide B treat Resident #1 in a rough way, when he/she transferred him/her from the wheelchair to the recliner. The report documented the charge nurse immediately notified the DON, talked to Nurse Aide B and sent him/her home from the facility because of the allegation. The report documented the DON reported the allegation to the state agency on 4/15/17 at 7:56 PM via email. Review of the facility's investigation regarding alleged abuse by Nurse Aide B to Resident #1 was investigated, Nurse Aide B was suspended on 4/15/17 while the facility investigated the allegation, and he/she was terminated for the rough transfer of Resident #1. On 5/10/17 at 10:20 AM, observation revealed the resident, seated in his/her recliner, when staff entered the resident's room and asked if he/she needed to use the bathroom. Observation revealed the resident did not respond verbally, but he/she shook his/her head yes. Further observation revealed 2 staff members ambulated the resident to the bathroom, with use of a gait belt. On 5/9/17 at 3:10 PM, Nurse Aide A verified on 4/12/17, at approximately 8:00 PM, he/she and Nurse Aide B provided bed time care for Resident #1, when Nurse Aide A saw Nurse Aide B stand the resident up from his/her wheelchair, did not wait for the resident to get his/her balance to pivot, picked the resident up, and dropped him/her into the recliner, in a quick, fast manner. Nurse Aide A stated the resident said ouch, and he/she told Nurse Aide B he/she did not need to be so rough, because he/she might hurt the resident. Nurse Aide A stated Nurse Aide B said the resident was not hurt, but Nurse Aide A told Nurse Aide B to leave the resident's room and he/she would finish cares and get the resident ready for bed. Nurse Aide A verified he/she did not report Nurse Aide B to the charge nurse because he/she just thought Nurse Aide B had a bad day. On 5/9/17 at 3:25 PM, Nurse Aide C stated he/she was not working at the time of Resident #'1's incident on the evening of 4/12/17 with Nurse Aide A and Nurse Aide B. Nurse Aide C stated Nurse Aide A told him/her on 4/15/17 that he/she was concerned about how rough Nurse Aide B had been with the resident on 4/12/17. On 5/9/17 at 3:45 PM, Nurse D stated Nurse Aide C reported to him/her on the evening of 4/15/17, that on 4/12/17, Nurse Aide A witnessed Nurse Aide B roughly transfer Resident #1. On 5/10/17 at 8:45 AM, Administrative Nurse E stated Nurse Aide B was suspended during the facility's investigation of the allegation of abuse against him/her. Administrative Nurse E verified Nurse Aide B was terminated after the investigation was completed. On 5/10/17 at 10:40 AM, Administrative Staff G stated the facility does not tolerate any type of abuse to the residents, and any staff member found to do so would be suspended until a thorough investigation is completed, and terminated if the abuse is substantiated. The facility's 12/5/16 Abuse, Neglect, and Exploitation prevention policy documented all elders of the facility would be free of physical, emotional, and sexual abuse, neglectful treatment, and misappropriation of funds and resources. The facility staff failed to provide an environment free from abuse, when direct care staff B transferred Resident #1 in a rough manner, which placed him/her in immediate jeopardy. The facility abated the immediate jeopardy on 5/11/16, when they held an all staff in-service to re-educate staff on abuse, neglect and exploitation. This deficient practice remained at a scope and severity of a G.

The facility had a census of 90 residents. The sample included 18 residents. Based on observation, record review and interview the facility failed to provide care and services to maintain the highest level of mental and psychosocial functioning for 1 of 1 residents reviewed for Behavioral and Emotional Status. (#100) Findings included: - Review of the medical record revealed the facility admitted Resident #100 on 11/27/14. The physician progress notes [REDACTED].#100 had [DIAGNOSES REDACTED]. Feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The admission (MDS) Minimum Data Set 3.0 assessment, dated 2/2/14, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. Further review of the MDS indicated the resident required extensive assistance with transfers and had no behaviors. The resident's mood score was 1 which indicated the resident had minimal depression ( abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The quarterly MDS, dated [DATE], revealed the resident had altered level of consciousness, trouble concentrating, feeling down and hopeless.Further review of the MDS revealed the resident had verbal and physical behaviors and a mood score of 3 which indicated the resident had moderate depression and he/she received an antidepressant medication daily. The [MEDICAL CONDITION] drug use (CAAs) Care Area Assessment Summary, dated 2/17/14, indicated the resident had a history of [REDACTED]. Further review of the CAA revealed the resident received an antidepressant and a medication for a mood disorder daily. The 4/24/14 care plan directed the staff to validate the resident's feelings, and administer medications as ordered. There was no care plan to instruct the staff regarding care of the resident for behaviors or mood disorder. The 3/11/14 physician's orders [REDACTED]. Review of the (MAR) medication administration records revealed from 4/1/14 through 6/25/14 the resident had refused the medication. The nurses note's behavior documentation revealed the following: 4/26/14 at 2:27 PM, Resident has little pleasure in doing things, resident stated," I am ready to die because heaven is a better place than it is here." Resident quiet and seems depressed recently. Often makes statements such as , " Why don't you just shoot me." 4/28/14 at 10:59 AM, appears angry, aggressive, an aide reported he/ she entered the resident's room and said , "Hi," and the resident responded, "you can just go to hell." 5/9/14 at 2:37 PM, the facility contacted, a mental health agency for an evaluation of the resident. 5/17/14 at 10:46 AM, an aide reported to the nurse that while asking the resident for his/her dinner order, he/she stated, "How about a room full of carbon monoxide?"( a poisonous gas). The resident then stated to aide , "I believe in death with dignity," " I should be able to do what I want with myself." An email was sent to the Social Service Director regarding resident's behavior. 5/31/14 at 2:07 AM, when an aide provided care for the resident, the resident raised his/her fist and asked the aide, " How about a fist in the face." On 5/16/14 at 12:30 PM, the mental health agency's evaluation stated the resident had behavior problems in judgment, irritability, anger, was easily annoyed by others, had a depressed mood and a feeling of helplessness. Further review of the psychiatric evaluation recommended the facility monitor medications prescribed for the resident for his/her depression and mood disorder, and the resident could benefit from individual therapy with focus on coping skills to reduce symptoms. Review of the medical record revealed a Social Services note, dated 4/30/14, which indicated Social Services had spoken with the resident's family regarding the resident's stay in the facility. Further review of the medical record revealed no further Social Service documentation regarding the resident's mood or behavior's, or the resident's adjustment to his/her facility. On 6/25/14 at 10:50 AM, observation revealed the resident, seated in his/her wheelchair, in his/her room, with his/her eyes closed, TV on, leaning to the right in his/her wheelchair. On 6/26/14 at 1:15 PM, observation revealed the resident lying on his/her bed with the TV on, and a nurse aide in his/her room. Further observation revealed the resident called out loudly to the nurse aide, "Get out of here !" On 6/26/14 at 9:40 AM, the resident stated to the surveyor, " I feel all closed in here, " " I need to talk to somebody." "I would be better off if I wasn't here." The resident displayed a flat affect.(outward, observable manifestation of a person ' s expressed feelings or emotions). On 6/26/14 at 9:55 AM, Nurse L verified the resident was depressed and refused to come out of his/her room. Nurse L also verified the resident had an evaluation from the mental health agency, but needs to be seen again. On 6/26/14 at 10:15 AM, Nurse Aide H verified the resident was always making comments that he/she wished he/she was not here, and he/she needed to die. Nurse Aide H stated the resident had asked for a gun before to end his/her life. On 6/26/14 at 1:30 PM, the resident stated to the surveyor," I wish I had a gun." " I am just no good to anyone." On 6/26/14 at 3:00 PM, Nurse Aide I verified the resident makes statements he/she would be better off dead. On 6/26/14 at 10:20 AM, Administrative Nurse D verified the resident has had increased behaviors and of depressed mood. Administrative Nurse D also verified the resident he/she was not aware the resident had been refusing his/her mood medication, and verified the resident needed to be seen by a psychiatrist. On 6/30/14 at 1:10 PM, the physician's office Nurse E verified the facility should have notified the physician regarding the resident's change in mood and behaviors, suicidal ideation (thoughts about or an unusual preoccupation with suicide associated with [MEDICAL CONDITION]) and refusal of medications for mood disorder. The 4/2004 facility policy for Psychosocial/Moods stated the facility would identify residents with psychosocial problems and or mood disorders, would provide the highest quality social interaction and level of mental health possible through staff intervention, professional evaluation and treatment. The facility failed to provide psychosocial and emotional support for Resident # 100 who recently was admitted to the nursing facility and demonstrated a decline in mood and behavior during his/her adjustment period as noted in increased isolation and suicidal ideation.