Every finding on record at Bride Brook Rehabilitation & Nursing Center

Based on observation, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #5) who required assistance for nail care, the facility failed to ensure the resident's nails were clean and trimmed. The findings include: Resident #5's diagnoses included rheumatoid arthritis, lupus, and repeated falls. The quarterly MDS assessment dated [DATE] identified Resident #5 was cognitively intact, had no behaviors, required touching assistance for personal hygiene, was a partial to moderate assistance for toileting, bathing, lower body dressing, and was independent for eating, and oral hygiene. The assessment further identified the resident was able to ambulate using a walker and was dependent when using a wheelchair. The care plan dated 2/12/25 identified Resident #5 had a self-care deficit related to generalized weakness and impaired mobility, which required assistance with personal hygiene, bathing, nail care and transfers. It also indicated the resident was visually impaired, wore glasses and had interventions that included assistance with personal hygiene and nail care. Resident #5's Care Card (utilized by nurses' aides to guide care) identified his/her shower day was on Wednesday's and Saturdays on the 7-3 shift. Review of the weekly skin checks-body audits completed for February 2025; March 2025 & April 2025 did not identify any concerns with Resident #5's nails. Observation on 4/15/25 at 10:30 AM identified Resident #5's right- and left-hand ring fingers and pinky fingernails were 0.6 inches long with debris noted underneath the nails. The occupational therapy progress note dated 4/18/25 identified Resident #5's Self-Care Score was an 8 out of 12. (score 0-12, 12 is the highest functioning). Interview on 4/22/25 at 12:59 PM with Resident #5 identified he/she had not refused nail care and was unable to recall the last time his/her fingernails were cleaned, cut and filed and noted that it would be nice if they were a little shorter. Observation on 4/22/25 at 1:03 PM of Resident #5's fingernails, identified three fingers on the right hand were contracted (turned inward toward the palm of the hand), as well as the fingers on the left hand. The right-hand pointer fingernail and second fingernail on the right hand had black/brown color debris under them. Also observed the pointer finger on the left hand had debris under it. The nails were 0.6-0.7 inches long. Interview on 4/22/25 at 1:04 PM with the recreation staff on the second floor (recreation office), indicated they provide nail care for residents. They can clean the nails and paint them. Recreation staff were not allowed to cut any resident's fingernails. If or when they need to be cut, they update the nursing staff, the staff person further identified there was also an individual who could be hired to provide professional manicures if any of the residents are interested. The facility staff would coordinate with the manicurist, resident or family, for payment from the resident's account. None of the recreational staff could recall if or when they had provided nail care to Resident #5. Interview on 4/22/25 at 1:06 PM with the unit nurse (RN #4) indicated she was unsure if there was a policy regarding nail care. She further identified that if a resident's nails appeared to need grooming, they would then be cleaned and filed. RN #4 identified that nail care would also be provided upon request. Upon learning that Resident #5's nails were long with debris, RN #4 identified the nails would be cleaned and cut that day. Interview on 4/23/25 at 10:55 AM with the DNS, Administrator and RN #3 (Regional Clinical Manager) identified Resident #5 refused nail care on 4/20/25. Residents are scheduled for biweekly showers, unless they prefer weekly showers. The nail care task is attached to one of the weekly showers, there by triggering the staff to complete nail care on one of the shower days. When a resident refuses a shower or nail care, the staff should update the floor nurse, the nurse would then speak to the resident regarding the refusal. The DNS further identified that residents are reapproached when they refuse nail care. The Administrator identified that residents have the right to refuse care or nail care and showers. Following the interviews with the DNS, and Administrator, Subsequent to the interview with the DNS and the Administrator, a request for documentation of Resident #5's refusals of nail care and completed nail care. A nail care flow sheet was provided by the facility that identified the refusal of nail care on 4/20/25. It also indicated the resident received nail care on 3/20/25, 4/1/25, 4/6/25 and 4/13/25. Observation on 4/23/25 at 11:11 AM identified Resident #5 in the bathroom with a recreational staff member washing his/her hands, after which Resident #5's nails appeared clean and trimmed. Interview on 4/23/25 at 11:12 AM with Resident #5, identified he/she was happy with his/her shorter and cleaned nails. He/she further identified the staff were welcome to provide him/her with nail care any time. Review of the activities of daily living policy dated 2024 directed, that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene.

Based on review of clinical records, review of facility policy, and interviews for one sample resident (Resident #61) reviewed for skin condition, the facility failed to ensure treatment to a wound was provided timely and for one of five sampled residents (Resident #83) reviewed for unnecessary medication the facility failed to ensure that physician's orders were implemented and completed as prescribed by the physician. The findings include: 1. Resident #61 was readmitted to the facility on [DATE] with diagnoses that included foot drop, arterial disease, muscle wasting and atrophy. The admission nurse's note dated 1/3/25 at 9:16 PM identified Resident #61 was alert and oriented, had a left second toe amputation and the left third toe had a scabbed area that measured 0.5 centimeters (cm) in length by 0.5 cm in width. The 5-day MDS assessment dated [DATE] identified Resident #61 had intact cognition and required extensive assistance with toileting, personal hygiene, bed mobility, and transfers. The care plan dated 1//11/25 identified Resident #61 had actual skin impairment related to arterial disease to the left first toe, third toe, and second toe amputation. Care plan interventions directed to administer treatment per physician's order, and podiatry consult as needed. Review of the January 2025 monthly Treatment Administration Record (TAR) identified the first recorded treatment to the left third toe was on 1/11/25, Which was 8 days after it was first identified on 1/3/25. Review of physician's orders from 1/3/25 to 1/10/25 failed to identify an active physician's treatment order to the left third toe. The physician's orders dated 1/11/25 directed to administer Xeroform to the wound base and cover with dry clean dressing to the left and third toe daily. Review of the weekly wound evaluation by RN #2 (wound nurse) dated 1/24/25 identified Resident #61 had an arterial open wound to the left medial third toe on 1/3/25. The wound measurement recorded as 0.5 cm in length by 0.5 cm in width by 0.3 cm in depth with a small amount of serosanguineous drainage. The wound bed was identified with 50 percent slough (dead tissue) and 50 percent granulation (healthy tissue). The wound assessment also identified a treatment of Xeroform to the left third toe daily. Interview with RN #2 (wound nurse) on 4/22/25 at 12:45 PM identified that she was responsible for administering the daily treatment and monitoring the healing of the wound. She also identified that any open wound would have an active physician's treatment order, and it would also be documented in the TAR when the treatment was administered on the day of the onset of the wound. She identified Resident #61 had a chronic arterial wound to the left third toe related to the arterial disease. She identified that Resident #61 third toe was noted open on 1/3/25 and she obtained a Xeroform treatment to the left third toe. She further identified that first recorded treatment administered to Resident #61 left third toe was on 1/11/25 and she identified that she forgot to transcribe the treatment in the physician's order. Interview with the DNS on 4/23/24 a 10:00 AM identified RN #2 is responsible for ensuring treatment is included in the physician's order when there was a noted open wound. Review of physician's order with the DNS for Resident #61 open wound to the left third toe that was first identified on 1/6/25 and she could not find a treatment was administered in the physician's order. She further identified that Resident #61 should have a physician's treatment order when it was noted on 1/3/25. The Wound Treatment Management facility policy identified that the facility would provide an evidence-based treatment in accordance with the current standards of practice and physician orders. The facility policy also identified that the license nurse would notify the physician to obtain a treatment, and treatment would be documented on the TAR and/or in electronic medical records. 2. Resident #83's diagnoses included generalized anxiety disorder, delusional disorder, depressive disorder, and dementia. The 5-day MDS assessment dated [DATE] identified Resident #83 had moderate cognitive impairment, required extensive assist with transfers, dressing and personal hygiene, and utilized anti-psychotic (used for managing mental health disorders) medication. The care plan dated 11/15/24 identified Resident #83 used psychotropic medication to help manage his/her delusional disorder. The care plan interventions directed to administer medication as per physician's orders, monitor and record targeted behavior, monitor for adverse reaction of psychotropic medication, and psychiatry follow-up as needed. Review of physician's order dated 12/3/24 directed to administer Zyprexa 15 mg (anti-psychotic medication) by mouth at bedtime related to delusional disorder. Review of physician's order dated 12/9/24 directed to obtain orthostatic blood pressure (check resident blood pressure while lying, sitting, and standing) for resident on a new dose or dose change of anti-psychotic medication once weekly in 4 weeks. Review of the Treatment Administration Record (TAR) for December 2024 identified Resident #83 orthostatic blood pressure was signed off by the nurse as completed on 12/10/24, 12/17/24, 12/24/24, and 12/31/24; however, a review of Resident #83's clinical record failed to identify the orthostatic blood pressures were taken as ordered by the physician on 12/10/24, 12/17/24, 12/24/24, and 12/31/24 (missed 4 out 4 opportunities). Interview with RN #1 (7-3 charge nurse) on 4/22/25 at 10:15 AM identified that the charge nurse was responsible for obtaining and assessing the orthostatic blood pressure. She identified that the orthostatic blood pressure should include the blood pressure while a resident was lying, sitting and standing with 5 minutes apart each time. She also identified that the orthostatic blood pressure would be recorded in the vital sign section and indicated the resident position when the blood pressure was taken. She identified Resident #83 had a physician's order for orthostatic blood pressures because of the dosage change of the Zyprexa medication. She also identified that she worked on 12/17/24 and signed off that the orthostatic blood pressure was completed but she could not identify why the orthostatic blood pressure was not recorded properly in the vital sign record. She further identified Resident #83 was capable of standing with assistance and his/her orthostatic blood pressure should include while lying, sitting, and standing. Interview with the DNS on 4/22/25 at 10:40 AM identified that orthostatic blood pressure would be obtained by a nurse to ensure that resident was free from the adverse reaction related to the use of psychotropic medication. She identified that blood pressure would be taken while a resident was lying, sitting and standing to complete the physician's order for orthostatic blood pressure unless a resident was unable to stand up. She identified Resident #83 was capable of standing with assistance so the orthostatic blood pressure should have been taken while lying, sitting, and standing. Review of the Consulting Physician/Practitioner Orders identified that the facility would meet all current standards of nursing practice in accepting, transcribing and executing doctor's orders to ensure compliance with current standards of nursing practice a ensure the resident's needs are met.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for pain management, the facility failed to ensure a complete and accurate medical record regarding physician notification with a change in status. The findings include: Resident #1's diagnoses included fracture of the shaft of the left femur (straight part of the thigh bone running from below the hip to the knee) and age-related osteoporosis (weak and brittle bones). The Resident Care Plan (RCP) dated 12/4/24 identified that Resident #1 had acute pain with interventions that included for staff to notify the physician if interventions are unsuccessful, or if the current complaint is a significant change from the resident's past experience of pain. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of nine (9) indicative of moderately impaired cognition and required substantial assistance for showering and was dependent on staff for bed mobility and transfers. A physician's order dated 12/3/24 directed to administer Oxycodone ( a narcotic pain medication) 5 milligrams (mg) by mouth every four (4) hours as needed for pain. A physician's order dated 12/6/24 directed to administer Acetaminophen ( over the counter pain medication) 1000 milligrams (mg) by mouth three times a day for pain. Review of the Medication Administration Record (MAR) for December 2024 identified that Resident #1 was administered the Oxycodone 5 mg on 12/4/24 at 9:32 PM for a reported pain level of four (4) out of ten (10), on 12/9/24 at 10:12 AM for a reported pain level of five (5) out of ten (10), on 12/10/24 at 2:10 AM for a reported pain level of six (6) out of ten (10), on 12/10/24 at 4:12 PM for a reported pain level of seven (7) out of ten (10), on 12/10/24 at 9:57 PM for a reported pain level of eight (8) out of ten (10), on 12/11/24 at 4:43 AM for a reported pain level of nine (9) out of ten (10) and on 12/11/24 at 10:00 AM for a reported pain level of eight (8) out of ten (10). All the aforementioned pain levels had follow up documentation that the pain was relieved. The MAR further identified that the Oxycodone 5 mg was ineffective at controlling the resident's pain on 12/10/24 at 4:12 PM, on 12/11/24 at 4:43 AM and on 12/11/24 at 10:00 AM. A nurse's follow-up note written by LPN #1 and dated 12/10/24 at 9:57 PM (5-hours and 45-minutes after the administration) identified that the 4:12 PM Oxycodone 5 mg dose was ineffective with a follow-up pain level of seven (7) out of ten (10). A nurse's follow-up note written by RN #5 and dated 12/11/24 at 7:29 AM (2-hours and 46-minutes after the administration) identified that the 4:43 AM dose of Oxycodone 5 mg was ineffective with a follow-up pain level of eight (8) out of ten (10). A nurse's note written by RN #5 and dated 12/11/24 at 11:05 AM (1-hour and 5-minutes after the administration) identified that the 10:00 AM dose of Oxycodone 5 mg was ineffective with a follow-up pain level of eight (8) out of ten (10). Review of nurse's notes identified that the provider wasn't notified of Resident #1's unrelieved pain on 12/10/24 at 4:12 PM that was unrelieved by the Oxycodone 5 mg until 12/11/24 at 12:55 PM. A Change in Condition assessment dated [DATE] at 12:55 PM identified that Resident #1 was noted with constant pain with minimal relief from the as needed Oxycodone and scheduled Acetaminophen. New orders were obtained to send the resident out for to the hospital for an x-ray and/or CT scan (detailed cross-sectional x-ray images of a specified body part) for comparison to the previous imaging. Interview with MD #1 on 2/5/25 at 12:49 PM identified that although he was unsure of the time, the facility notified him on 12/10/24 that Resident #1 was having increasing pain that was unrelieved by the as needed Oxycodone 5 mg. He reported that since the resident also had scheduled Acetaminophen three times daily and the Oxycodone 5 mg was available to be given every four (4) hours, he addressed the pain management the next day on 12/11/24, and increased the Oxycodone to 10 mg. Interview with the DNS on 2/5/25 at 1:08 PM identified that the provider should have been notified as soon as it was identified that the Oxycodone 5 mg was ineffective. She stated she reached out to RN #6 (Nursing Supervisor) who reported to her that she reached out to MD #1 and he identified that he'd address the change the following day, but stated her expectation was that all change in conditions and provider notifications be documented in the clinical record timely, and she was unsure why there was no documentation in the record when the change was identified. Further, she reported that the facility has a paper 'Change in Condition' provider communication book and stated she would check the book to see if there were any entries notating that the provider was notified. Interview with LPN #1 (evening nurse on 12/10/24) on 2/5/25 at 2:24 PM identified that she could not recall any details regarding the incident but reported that if a resident had pain that was unrelieved by pain medication or other interventions, she would have notified the Nursing Supervisor when she identified the change. Additionally, she identified that nursing should be following up on a resident's pain within an hour of medication administration and documenting the follow-up pain level, stating she was unsure when she followed-up or why the documentation from the 4:12 PM administration was over five (5) hours later. Interview with RN #5 on 2/5/25 at 3:24 PM identified that although she could not recall the time, and did not do an assessment, she reported that she notified MD #1 on 12/10/24 when she was notified by LPN #1 that Resident #1's pain medication was ineffective. She identified that MD #1 is cautious with narcotic medications and stated he would address Resident #1's pain management the next day, stating he did not give any orders or offer any alternatives until the resident was seen. RN #5 reported that she communicated with LPN #1 that MD #1 stated he would see the resident the next day, identifying that LPN #1 should have documented the change and the provider notification. Although attempted, an interview with RN #4 was not obtained. Review of the Documentation in the Medical Record policy (undated) directed, in part, that each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations and services provided in the resident's medical record in accordance with state law and facility policy and the documentation shall be completed in a timely manner. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or response to care.

Based on clinical record review, interviews and review of facility policy for one (1) of three (3) residents (Resident #1) reviewed for resident rights, the facility failed to ensure a resident's privacy was protected. The findings included: Resident #1 had diagnoses of dementia, generalized anxiety disorder, and unspecified cerebrovascular disease. Review of the annual Minimum Data Set assessment dated [DATE] identified Resident #1 as severely cognitively impaired and required moderate assistance with oral hygiene and toileting hygiene, and supervision or touching assistance with eating. Review of Resident #1's care plan dated 6/26/24 identified a history of cerebrovascular accident/transient ischemic attacks with interventions that directed to ensure diet is the correct consistency to facilitate safe swallowing, monitor/document abilities for activities of daily living, assist as needed, and encourage the resident to do what he/she can do for his/herself. Interview with Person #1 on 9/17/24 at 9:32 AM identified he/she had witnessed that a Nurse Aide took a picture with h/her personal cell phone of a resident who had fallen a sleep with a sandwich in h/her mouth and sent it to another employee's personal cell phone (RN#1). Interview with RN #1 on 9/17/24 at 9:56 AM identified a photo of Resident #1, who appeared to be sleeping with a sandwich in her mouth, was sent to his/her personal cell phone on 8/20/24 as NA #1 requested guidance on what to do as the resident was refusing to give NA #1 his/her sandwich (although RN #1 was not working in the facility at the time the photo was taken and sent to h/her). RN #1 identified it was not appropriate to take a picture of Resident #1 to receive guidance, that it could have been explained via phone call, or by another staff member within the facility. RN #1 indicated he/she spoke with NA #1 regarding the photograph of Resident #1 that was taken and sent on 8/20/24 and informed him/her not to take photos of residents as it was a violation of the Health Insurance Portability and Accountability Act (HIPAA)( a privacy act that protects resident privacy). RN #1 further identified the facility's photograph policy directed a release to be signed for photos that were uploaded to the facility's Facebook page and during celebrations/events, however restricted photographs from being taken while a resident was receiving care. Interview with NA #1 on 9/17/24 at 10:52 AM identified he/she was feeding a sandwich to Resident #1 in the dining room on 8/20/24 and that the resident had fallen asleep as he/she was biting into the sandwich, the sandwich was hanging out of the resident's mouth. NA #1 indicated Resident #1 became agitated when he/she attempted to take the sandwich away from him/her, and not knowing what to do, had taken a picture of the resident, sent it to RN #1's personal cell phone (who was not working in the building at the time of the incident), and asked RN #1 what to do. NA #1 further identified he/she could possibly have explained the situation without sending a picture of the resident but felt sending the picture would provide a clearer understanding of the situation at hand. NA #1 indicated he/she did not take the picture to laugh or mock at the resident, show the picture of Resident #1 to any other staff, and deleted the picture right after texting RN #1 on the day of the incident. Interview with the Recreational Director on 9/17/24 at 12:01 PM identified photographs of residents were taken in relation to activities, programs and events and only of residents who had given consent (as was indicated on the Photo Consent Form). The Recreational director further identified photographs of residents were taken on the iPad as it had a secure application which the facility used for the taking and uploading of resident photographs. Interview with the ADNS on 9/17/24 at 12:01 PM identified that the photo was taken for a health related purpose and was not a privacy breach. Review of the Resident Admissions Agreement dated 9/19/22 identified the resident agrees to allow the Center to photograph or electronically record the resident as a means of identification or for health-related purposes only, that images and recordings of the resident shall otherwise be kept confidential, and that the Center would obtain written permission from the resident if it intends to use the image or recording for purposes other than those noted above. Review of the Resident's [NAME] of Rights policy directs the resident has the right to written, spoken, telephonic, and electronic communications including email and video communications and in internet research.

Based on clinical record review, observations, review of facility policy and interviews for three of six sampled residents (Residents #12, #35 and #521) reviewed for respiratory care, the facility failed to ensure that oxygen tubing was changed on a consistent basis, labeled, and dated. The finding include: 1. Resident #12's diagnoses included spastic quadriplegic cerebral palsy, vascular dementia, and cervical disc disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 had severe cognitive impairment, required total dependence for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Observation on 6/26/23 at 11:20 AM identified Resident #12 with oxygen in place via nasal cannula at 3 Liters via concentrator. The tubing was without the benefit of a label on the tubing that consisted of the date, time, and the initial of the individual who changed the tubing. Observation on 6/27/23 at 9:35 AM identified Resident #12 with oxygen in place via nasal cannula at 2 Liters via concentrator. The tubing was without the benefit of a label on the tubing that consisted of the date, time, and the initial of the individual who changed the tubing. Observation on 6/28/23 at 11:10 AM identified Resident #12 with oxygen in place via nasal cannula at 3 Liters via concentrator. The tubing was without the benefit of a label on the tubing that consisted of the date, time, and the initial of the individual who changed the tubing. Interview with RN #4 on 6/28/23 at 3:04 PM identified she was unsure when the oxygen tubing was last changed, she reviewed the MAR and there was no documentation indicating when the tubing had been changed. She could also not identify what the facility policy was regarding the changing of oxygen tubing and the labeling of the tubing. Interview with RN #3 on 6/28/23 at 3:18 PM identified the policy was to change the tubing when soiled. She could not provide information regarding the dating and labeling of the oxygen tubing and noted that she would need to refer to the DNS because the facility had conflicting policies. Review of the Oxygen Storage and Assembly policy Revised December 2021 directed when changed, tubing should be labeled with the date of the change and the initials of the person who changed it. 2. Resident #35's diagnoses included acute respiratory failure, acute pulmonary edema, and asthma. The significant change Minimum Data Set assessment dated [DATE] identified Resident #35 had intact cognition, and required limited assistance with bed mobility, and dressing, total dependence with transfers, extensive assistance toileting, and independent eating, The Resident Care Plan dated 5/24/23 identified the resident had asthma. Interventions directed oxygen as ordered by MD. A physician's order dated 5/12/23 directed to apply O2 to maintain sats >92%. Observations on 6/26/23 at 1:44PM and 6/28/23 at 2:14 PM, identified Resident #35 was actively utilizing oxygen via a concentrator and the tubing was not dated or labeled. Interview with RN #4 on 6/28/23 at 3:04 PM identified she was unsure when the oxygen tubing was last changed, she reviewed the MAR and there was no documentation indicating when the tubing had been changed. She could also not identify what the facility policy was regarding the changing of oxygen tubing and the labeling of the tubing. Interview with RN #3 on 6/28/23 at 3:18 PM identified the policy was to change the tubing when soiled. She could not provide information regarding the dating and labeling of the oxygen tubing and noted that she would need to refer to the DNS because the facility had conflicting policies. Review of the Oxygen Storage and Assembly policy Revised December 2021 directed when changed, tubing should be labeled with the date of the change and the initials of the person who changed it. 3. Resident #521's diagnoses included pneumonia, chronic pulmonary edema, pulmonary nodule, chronic respiratory failure, and systolic congestive heart failure. The admission Resident Care Plan dated 6/7/23 identified Resident #521 was at risk for Congestive Heart Failure (CHF). Interventions directed oxygen use as ordered and to monitor and notify the physician for any signs and symptoms of heart failure. A Physician's order dated 6/7/23 directed to change oxygen tubing when visibly soiled. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #521 was severely cognitively impaired and required extensive assist with a 1 person for bed mobility, transfers, and dressing. Observation on 6/26/23 at 11:13 AM of Resident #521's oxygen use, identified an oxygen nasal cannula tubing that was unlabeled and undated. Observation on 6/27/23 at 11:21 AM of Resident #521's with oxygen in place via nasal cannula and the tubing in place was unlabeled and undated. Interview with RN #4 on 6/28/23 at 3:04 PM identified she was unsure when the oxygen tubing was last changed, she reviewed the MAR and there was no documentation indicating when the tubing had been changed. She could also not identify what the facility policy was regarding the changing of oxygen tubing and the labeling of the tubing. Interview with RN #3 on 6/28/23 at 3:18 PM identified the policy was to change the tubing when soiled. She could not provide information regarding the dating and labeling of the oxygen tubing and noted that she would need to refer to the DNS because the facility had conflicting policies. Review of the Oxygen Storage and Assembly policy Revised December 2021 directed when changed, tubing should be labeled with the date of the change and the initials of the person who changed it. 47900 48879

Based on clinical record review, facility documentation review, facility policy review and interviews for one of five sampled residents (Resident #112) reviewed for accidents, the facility failed to ensure the resident was transferred with the assistance of two staff as ordered, resulting in the resident sustaining a fall. The findings include: Resident #112 's diagnoses included cerebral infarction, hemiplegia, hemiparesis to right dominant side, aphasia, and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #112 had severe cognitive impairment, required extensive assist for bed mobility, toileting and hygiene and transfers. Assessment further noted Resident #112 was non ambulatory and utilized a wheelchair for mobility. The Resident Care Plan (RCP) dated 4/29/23 identified Resident # 112 was at risk for falls related to poor mobility, hemiplegia, stroke and other abnormalities of gait and mobility. Care plan intervention identified: anticipate and meet resident's needs, encourage use of proper footwear, and maintain clutter free environment. A physical therapy transfer evaluation dated 6/6/23 identified Resident #112 required extensive assistance of one person and stand by assistance of another person for stand pivot transfers with the use of enabler bar and wheelchair positioned on the resident's strong side. A reportable event report dated 6/12/23 identified NA #2 was transferred Resident #112 from his/her bed to the wheelchair, during which the resident lost his/her balance and was lowered to the floor. The nurse's note dated 6/13/23 at 5:28 AM identified Resident #112 was status post fall without injury with no complaints of pain/discomfort. A physical therapy transfer evaluation dated 6/13/23 identified Resident #112 would continue with extensive assist of one person and stand by assist of another person for stand pivot transfers with the use of enabler bar and wheelchair to the strong side. Interview with NA #2 on 6/29/23 at 10:20 AM identified that she lowered Resident #112 to the floor when he/she lost his/her balance during the transfer. She also identified that the care card indicated that Resident #112 was extensive assist of 1 person and used a rolling walker and wheelchair. She further identified that she transferred Resident # 112 alone. Interview with RN #5 on 6/29/23 at 10:50 AM identified that NA #2 transferred Resident #112 by herself when the resident should have been transferred with the assistance of two staff members, during which the resident lost his/her balance and was lowered to the floor. RN #5 further noted that she had instructed NA #2 to wait for a second person to assist her with transferring Resident #112 to the wheelchair. RN #5 also conveyed that NA #2 was a new employee and that she was educated following the incident. Interview with PT #1 on 6/29/23 at 11:15 AM identified that Resident #112 was extensive assist of 1 with stand by assist from a second person. He also identified that there should be a second person in the resident room prior to transfer. Interview with the DNS on 6/29/23 at 12:20 PM identified NA #2 should have followed Resident #112's transfer order and utilized the assistance of another staff person during the transfer. He further indicated that NA #2 was educated to follow resident transfer orders. Review of facility's Fall Prevention Program policy identified that each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falling.

Based on observations, clinical record reviews, interviews, and facility policy for two of three sampled residents (Resident #12, #73 and Resident #521) reviewed for respiratory therapy, the facility failed to follow a physician's order for a prescribed oxygen administration rate, failed to follow a physician's order to monitor oxygen saturation levels, and failed to have a protocol or policy to indicate settings for the titration of oxygen. The findings include: 1. Resident #12's diagnoses included spastic quadriplegic cerebral palsy, vascular dementia, and cervical disc disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 was severely cognitively impaired, and was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #12's care plan dated 4/24/19 identified Resident #12 had an altered respiratory status with interventions that included observing for signs and symptoms of respiratory distress and decreased pulse oximetry (low level of oxygen recorded in the blood). Observation on 6/26/23 at 11:20 AM identified Resident #12's nasal cannula (oxygen tubing) was connected to an oxygen concentrator and set at 3 Liters Per Minute (LPM). Observation on 6/27/23 at 9:35 AM identified Resident #12's nasal cannula was connected to an oxygen concentrator and set at 2 LPM. Observation on 6/28/23 at 11:10 AM identified Resident #12's nasal cannula was connected to an oxygen concentrator and set at 2 LPM. Review of the physician's orders from 3/14/23 to 6/9/23 directed Resident #12 to receive supplemental oxygen with the concentrator set at 2 LPM and daily oxygen saturation levels. Review of Resident #12's clinical record oxygen saturation documentation identified that for the period of 3/14/23 to 6/9/23 Resident #12 had oxygen saturation levels monitored 5 times for a total of 5 out of 87 opportunities or 82 missed opportunities. Interview with LPN #2 on 6/29/23 at 11:45 AM identified that there wasn't a physician's order in the Resident #12's chart to monitor oxygen pulse saturation levels. LPN #2 indicated that it was the responsibility of the Unit Manager to ensure oxygen pulse saturation monitoring was included on Resident #12's Kardex for residents who required continuous oxygen therapy. LPN #2 failed to indicate why there wasn't an order directing oxygen pulse saturation levels, as she had only been employed at the facility for 7 weeks. Interview with MD #1 on 6/29/23 at 12:45 PM identified that a physician's order directing oxygen flow rate was not needed. MD #1 expressed that nurses on the unit know to notify the physician if there is a change in the resident's respiratory condition and didn't see the need for a set oxygen flow rate for Resident #12. MD #1 indicated to refer to nursing on the issue of whether an order for monitoring oxygen saturation was needed. MD #1 further indicated that if the resident was stable there wouldn't be a need to check oxygen pulse saturation frequently. Review of the facility Oxygen Storage and Assembly policy provided by the facility failed to include oxygen pulse saturation monitoring and oxygen flow rates for residents who required oxygen therapy. Resident #73's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), muscle wasting and atrophy, and pulmonary nodule. 2. Resident #73's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), muscle wasting and atrophy, and pulmonary nodule. The quarterly MDS assessment dated [DATE] identified Resident #73 had moderate cognitive impairment, required limited assistance for bed mobility, transfers and personal hygiene, and required extensive assistance with dressing, bathing, and toileting. Resident #73's care plan for 4/2023 identified Resident #73 had an altered respiratory status with interventions that included observing for signs and symptoms of respiratory distress and decreased Pulse oximetry. Observation on 6/26/23 at 10:51 AM identified Resident #73 with oxygen in place via nasal cannula which was connected to an oxygen concentrator set at 2 liters. Observation on 6/27/23 at 9:30 AM identified Resident #73 with oxygen in place via nasal cannula connected to an oxygen concentrator set at 2 Liters. Observation on 6/28/23 at 11:05 AM identified Resident #73 with oxygen in place via nasal cannula connected to an oxygen concentrator set at 2.5 Liters. The current physician's orders in effect for the month of June (original date of 3/15/22) directed to titrate oxygen greater than 90% every shift. The order failed to direct the oxygen flow rate parameters and failed to direct oxygen saturation monitoring. A review of Resident #73's vital sign record for the period of 4/17/23 to 6/8/23 identified that the oxygen saturation rate was obtained only 10 times. Interview with LPN #2 on 6/29/23 at 11:45 AM identified that the physician's order to titrate oxygen greater than 90% every shift was not clear, and she could not explain what the order meant. LPN #2 further identified that there wasn't an order directing oxygen saturation monitoring for Resident #73. Review of the physician's orders following the interview with LPN #2 identified a physician's order dated 6/30/23 directing oxygen pulse saturation (Pulse Oximetry) daily every shift, and a physician's order dated 7/2/23 directed oxygen at 2 Liters via nasal cannula as needed. Interview with MD #1 on 6/29/23 at 12:45 PM identified that a physician's order directing oxygen flow rate was not needed for titration as the standards to keep oxygen pulse saturation greater than 90%. MD #1 expressed that nurses on the unit know to notify the physician if there is a change in the resident's respiratory condition and didn't see the need for a set oxygen flow rate for the resident. MD #1 indicated to refer to nursing on the issue of whether an order for monitoring oxygen saturation was needed. MD #1 further indicated that if the resident was stable there wouldn't be a need to check oxygen pulse saturation frequently. Review of the facility Oxygen Storage and Assembly policy provided by the facility failed to address oxygen pulse saturation monitoring and oxygen flow rate for residents on oxygen therapy. 3. Resident #521's diagnoses included pneumonia, chronic pulmonary edema, pulmonary nodule, chronic respiratory failure, and systolic congestive heart failure. The admission Resident Care Plan dated 6/7/23 identified Resident #521 was at risk for Congestive Heart Failure (CHF). Interventions directed oxygen use as ordered and to monitor and notify the physician for any signs and symptoms of heart failure. Physician's orders dated 6/7/23 directed to observe for signs of hypoxemia every shift, and to obtain oxygen saturation levels every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #521 was severely cognitively impaired and required extensive assist with a 1 person for bed mobility, transfers, and dressing. A Physician's order dated 6/22/23 directed to titrate (adjust up and down) oxygen to keep saturation levels (amount of oxygen recorded in the blood) above 90%. Observation on 6/26/23 at 11:13 AM identified Resident #521 was utilizing oxygen via a nasal cannula with the oxygen concentrator set to 0.5 liters per minute (LPM) Observation on 6/27/23 at 11:21 AM identified Resident #521's was utilizing oxygen via a nasal cannula with the oxygen concentrator set to 5 LPM. A nursing note dated 6/27/23 at 3:47 AM identified Resident #521 had a change in condition including a productive cough, congested lungs, shortness of breath, low grade fever, and an oxygen saturation level of 85-92% on 3 Liters Per Minute (LPM) of oxygen. The physician was notified and there were no news orders. A nursing note dated 6/27/23 at 12:26 PM noted an oxygen saturation of 91-93% on 4 LPM via nasal cannula. A nurse's transfer to the hospital summary note dated 6/27/23 at 5:57 PM identified Resident #521 had a congested productive cough and shortness of breath. The note further identified that the resident was coughing up moderate amounts of mucous, had an an oxygen saturation of 92% on 3 LPM of oxygen. Th e physician was called, and the resident was sent to the hospital to be evaluated. Interview with the DNS on 6/30/23 at 11:51 AM identified that the nursing staff of a resident in an acute situation would receive a standing oxygen order once the patient was stabilized. Interview with Physician #1 on 6/30/23 at 12:38 PM identified that although his orders directed to titrate oxygen to maintain an oxygen saturation above 90%, he did not identify a minimum or maximum amount of oxygen to be provided. Physician #1 was unable to describe a protocol as to how the facility staff nurses knew what oxygen levels were safe for each individual resident other than stating that they followed the standard. Further, Physician #1 indicated that there were orders for oxygen, but that the facility did not have the information written down anywhere, that it was not in a policy or protocol, and that maybe it was the facility practice, but that this was hard to judge. Additionally, Physician #1 indicated that he did not know how often facility staff nurses should be checking oxygen saturation rates and that was a nursing question. Interview with the DNS on 6/30/23 at 1:05 PM identified that he expected that staff caring for a newly admitted residents, when the situation was unknown, would be to check their oxygen saturation status as there are residents who will have moments of de-saturation (levels of oxygen decreasing). The DNS further stated that titration allows for turning the oxygen up or down and that if the goal was to get them discontinued from oxygen use, then they'd be checking their oxygen saturation levels more frequently. Although an oxygen titration policy or protocol was requested, the DNS identified that the facility did not currently have a policy or protocol. The facility failed to have a protocol or policy on the safe administration of titration for oxygen administration. 48879

Based on review of the clinical record, facility documentation, facility policy, and interviews, for the one sampled resident, (Resident #570), reviewed for pain, the facility failed to notify the physician when the resident requested an increase in pain medication being administered. The findings include: Resident #570 has diagnoses included muscle wasting and a history of myocardial infarction (heart attack). The initial Nursing Admission assessment dated [DATE] identified Resident #570 was cognitively intact, required set up help for eating, supervision for transfers, and extensive assistance with dressing. The Resident Care Plan dated 6/20/23 identified that Resident #570 was at risk for falls, had generalized pain, and required assistance with activities of daily living. Interventions included Resident #570 should ask for assistance with mobility and staff should monitor and record the resident's pain. A physician's order dated 6/20/23 directed to observe and document pain every shift and to provide Resident #570 with regular strength Tylenol 325 milligrams (mg) to be given every 6 hours for pain. Interview and observation on 6/26/23 at 1:00 PM identified LPN #1, who was about to administer Resident #570's Tylenol, asked what s/he was being given. LPN #1 indicated that she was administering regular strength Tylenol. Resident #570 stated that s/he has been asking other staff for Extra Strength Tylenol (ES APAP), because that's what worked and what s/he had been taking at home. LPN #1 stated that she would notify the physician. Review of the nursing notes, physician orders, and Medication Administration Record (MAR) on 6/28/23 from 6/19/23 through 6/27/23 failed to identify that facility staff had addressed Resident #570's request for ES APAP. Interview on 6/28/23 at 1:45 PM with RN #2 identified that during medication pass with Resident #570 this morning, the resident requested ES APAP instead or regular strength Tylenol. RN #2 indicated that she had written the request in the Medical Directors Rounding Logbook and discussed the request with the RN supervisor. Interview and review of the physician's logbook on 6/28/23 at 1:54 PM with the Assistant Director of Nursing Services (ADNS) identified that she was the RN supervisor on 6/26/23, but LPN #1 had failed to notify her of Resident #570's request to change his/her Tylenol to ES APAP. Additionally, the ADNS reviewed the physician's logbook from 6/19/23 through 6/28/23 and failed find an entry requesting a change to Resident #570's Tylenol until RN #2 had written a request on 6/28/23. Interview on 6/29/23 at 12:03 PM with the Director of Nursing Services (DNS) identified that his expectation would be, following any resident request for changes in medication administration, the nurse would bring the request for the change to the physician who would then make the decision. Review of the Pain Management policy for the facility identified that communicating with the care team regarding pain management strategies was an important component of a successful pain management system. The facility failed to communicate Resident #570's request for further pain management interventions to ensure the physician could address Resident #570's pain.

Based on observation and interview, for 1 of 4 medication carts reviewed for medication storage, the facility failed to secure a controlled substance appropriately. The findings include: During inspection of the first floor medication cart on 6/30/23 at 2:06 PM, an opened, unlabeled (no resident name or date opened) single blister pack (medication package) labeled Oxycodone HCl 5 milligrams was noted. The opened blister pack contained 1/2 of a white pill. Interview with LPN #3 on 6/30/23 at 2:06 PM identified that she had not administered any Oxycodone to a resident during her shift. LPN #3 identified that the blister pack did not belong to a resident and appeared to have been taken from the facility's emergency narcotic supply. Additionally, LPN #3 identified that as a narcotic, it should not have been stored in the top medication drawer but should have been double locked in the narcotic box located within a drawer of the medication cart. Interview with the DNS on 6/29/23 at 2:45 PM identified he had investigated how the medication had been placed inappropriately in the medication cart. The DNS stated that a night nurse had removed the Oxycodone from the emergency supply of medications in the facility Omnicell (emergency drug supply container), broke the tablet in half and stored the remaining half in the top drawer of the cart. The DNS indicated that the remaining half tablet was not appropriately secured.

Based on observations, review of the clinical records, facility documentation review, facility policy review, and interviews for four of six residents (Resident #1, Resident #28, Resident #95 and Resident #300) reviewed for infection control, the facility failed to ensure the safe storage of prescribed medications. The findings include: 1. Resident #1 was admitted to the facility in 4/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS dated [DATE] identified Resident #1 was cognitively intact. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the Personal Protective Equipment (PPE) bin on 4/28/2021 at 1:45 PM located outside of Resident #1's room on the COVID Observation Unit identified an open box of [MEDICATION(S)] Suspension 50mcg/act with an open pack of disposable gowns inside the clean and unlocked personal protective equipment (PPE) bin. 2. Resident #28 was admitted to the facility in 4/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS dated [DATE] identified Resident #28 had severely impaired cognition. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply to itchy areas on back/butt topically every shift for itch for ten (10) days. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #28's PPE bin on 4/28/2021 at 1:50 PM located on the COVID Observation Unit outside of Resident #28's room identified three (3) tubes of [MEDICATION(S)] Cream and one (1) bottle of [MEDICATION(S)] Powder inside the clean and unlocked PPE bin. 3. Resident #95 was admitted to the facility in 4/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS dated [DATE] identified Resident #95 was cognitively intact. The care plan dated 4/23/2021 identified Resident #95 has [CONDITION(S)] and interventions directed to administer aerosol or bronchodilators as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administer two (2) puffs, inhale orally two times a day for [CONDITION(S)] and rinse mouth with water after each use. Observation of Resident #95's PPE bin on 4/28/2021 at 1:55 PM located on the COVID Observation Unit outside of Resident #95's room identified an open box of [MEDICATION(S)] HFA Aerosol 220 mcg/act together with an open pack of disposable gowns inside the clean and unlocked PPE bin. 4. Resident #300 was admitted to the facility in 4/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS dated [DATE] identified Resident #300 had moderate cognitive impairment. The care plan dated 4/23/2021 identified a problem of impaired visual function related to [CONDITION(S)] and interventions included to administer eye drops as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Instill one (1) drop in both eyes two times a day for [CONDITION(S)]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Instill one (1) drop in the left eye in the morning for [CONDITION(S)]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #300's PPE bin on 4/28/2021 at 2:00 PM located on the COVID Observation Unit outside of Resident #300's room identified an open box of [MEDICATION(S)] Solution 2 %, [MEDICATION(S)] Solution 0.5 % and [MEDICATION(S)] Solution 0.005 % together with an open pack of disposable gowns inside the clean and unlocked PPE bin . Interview and observation with RN #5 on 4/28/2021 at 2:05 PM identified she was aware the medications were stored in the unlocked PPE bins and not the medication cart in the case a resident tested positive for COVID-19, the medications would not contaminate the medication cart. Additionally, RN #5 indicated all medications should be stored in a locked area or cart. Interview with DNS on 4/28/21 at 2:10 PM identified medications needed to be in a locked area, however identified the medication was stored in the PPE bins to prevent COVID-19 cross-contamination in the medication cart should a resident test positive for COVID -19. Review of the storage and expiration dating of medications, biologicals, syringes and needles policy identified the facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on observations, review of the clinical record and staff interviews for one of fourteen residents (Resident #80) reviewed for dining services, the facility failed to ensure that a meal provided to a resident accommodated the resident's allergies, and intolerances. The findings include: Resident #80 was admitted to the facility with diagnoses that included [CONDITION(S)], mild cognitive impairment, and anxiety. The physician order dated 2/1/2021 and directed a regular diet. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified intact cognition and Resident #80 could eat by him/herself with set up help. Review of the Resident care plan (RCP) dated 4/13/2021 identified a list of food allergies that included avocado, banana, lettuce, melon. Additionally, the care plan identified a problem with nutrition and directed to administer diet as ordered. Observation and interview with Resident #80 on 4/30/2021 at 8:16 AM identified a breakfast tray on Resident #80's bedside table that contained strawberry banana yogurt (a food item on the allergy list), coffee cake, apple sauce, cottage cheese, a glass of milk and one packet of butter. The meal ticket located on the food tray directed a regular diet and indicated Resident #80 had food allergies to artificial sweetener, banana, melon, lettuce and avocado. Interview with Resident #80 on 4/30/2021 at 8:16 AM identified he/she received the strawberry banana yogurt, it was not the first time it had happened and Resident #80 was concerned that he/she receives items on her allergy list regularly, such as lettuce and strawberry, banana, and yogurt. Resident #80 identified she did not eat the strawberry banana yogurt, however, was frustrated and concerned for residents who had dementia and would not know if they received an item on their allergy list. Additionally, Resident #80 identified his/her allergy to banana was mild and caused a stuffy head, runny nose and nausea. Interview and observation with the Administrator, on 4/30/2021 at 8:22 AM, of the strawberry banana yogurt on Resident #80's tray identified she did not know why Resident #80 received strawberry banana yogurt on his/her breakfast tray. Observation and interview with the Food Service Director (FSD) on 4/30/2021 8:25 AM identified Resident #80 should not have had the strawberry banana yogurt on his/her tray and he did not know why it was placed on the tray. Additionally, Dietary Aide #1 was responsible to check the tickets and allergies located at the top of the meal ticket and place items on each tray according to the resident's diet, allergies and preferences. Interview on 04/30/2021 at 8:31 AM with Dietary Aide (DA) #1 identified that he grabbed the strawberry banana yogurt from the top tray and should have grabbed the strawberry yogurt from the bottom tray and did not pay attention. Additionally, although the meal ticket identified banana as an allergy, DA #1 identified he did not check the meal ticket or the allergy list because he passively thought about it and he had memorized many of the tickets because he does the job so often. Further, DA#1 indicated he should have checked the ticket and compared the ticket to what he was placing on the tray. Interview with FSD 4/30/2021 at 8:35 AM identified DA#1 should have checked the food tray ticket for allergies and place food on the tray that was listed on the ticket. Interview with NA #1 on 4/30/2021 at 8:50 AM identified she gave Resident #80 the breakfast tray with the strawberry banana yogurt and indicated she usually checked the meal tickets before giving residents their food, however she did not check Resident #80's meal ticket for allergies this morning and did not know why she did not check. Interview and review of the dietary annual competency dated 12/31/2020 with the FSD on 4/30/2021 at 11:55 AM identified DA #1 was inserviced to check allergies and food tray tickets prior to placing items on the tray, and this was documented under the safe handling of food demonstration. Interview with the DNS on 4/30/2021 at 1:30 PM identified NA #1 was responsible to compare the tray ticket to the items on the tray and double check, for textures and allergies before giving the food to the resident. Interview with the DNS on 05/04/2021 at 8:10 AM with the DNS identified the strawberry and strawberry banana yogurt container look very similar and the facility is not going to order the same brand of strawberry banana yogurt moving forward to avoid the same mistake in the future. Review of the facility policy entitled Diet History and Tray Card identified in part, that the purpose of the policy was to obtain diet history and food, beverage and meal preferences so that the resident receives food in accordance with preferences whenever possible. Although requested, the facility did not have a policy regarding the process for checking food trays on the unit after the trays left the kitchen. The facility policy entitled food Allergy policy and Procedure dated 4/30/2021 and signed by DA #1, identified in part, that is was the responsibility of every food service worker to read each resident's tray ticket in its entirety to ensure no food item is placed on the tray that the resident may be allergic. Additionally, residents who have food allergies listed on the tray ticket will be checked during tray line by the food service worker who places the meal on the tray before it leaves the kitchen. Review of a tray ticket check protocol dated 4/31/2021 subsequent to surveyor inquiry, identified the purpose was to ensure all meal trays are checked for accuracy, proper diet, and allergies before leaving the kitchen.

Based clinical record review, facility documentation review, facility policy review and interviews for two of four residents (Resident #16 and Resident #17) reviewed for abuse, the facility failed to ensure safeguards were in place to prevent misappropriate of controlled substances. The findings include: 1. Resident #16 was admitted to the facility in January 2020 under their Medicare Part A benefit, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #16 had moderately impaired cognition, had pain occasionally, and received pain medications as needed (PRN). The Resident Care Plan (RCP) dated 2/12/2020 identified a problem of pain related to chronic illness, recent surgery and abdominal wound. Interventions included to administer pain medications and evaluate the effectiveness of pain interventions. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #17 was admitted under their Medicare Part A benefit, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] identified Resident #17 was alert and oriented and had pain frequently. The RCP dated 3/26/2020 identified a problem of acute pain related to recent surgery. Interventions included to administer medication as ordered and evaluate the effectiveness of pain interventions every shift and as needed. a) Review of the facility investigation summary regarding missing narcotics, dated 3/25/2020, identified LPN #4 identified one of two medication cards of [MEDICATION(S)] belonging to Resident #16 was missing from the narcotic box. The white narcotic proof of use sheet was missing, however the yellow carbon copy proof of use sheet was found and verified the medication had been delivered from the pharmacy. The DNS reviewed staffing and the narcotic sign off sheets and discovered the number of counted cards changed on 3/23/2020 when RN #6 worked on the 3 PM to 11 PM shift (RN #6 had accounted for two (2) cards of [MEDICATION(S)] when the nurses before her accounted for three cards). Further, the investigation revealed a card of [MEDICATION(S)] for Resident #17 was noted missing the evening of 3/23/2020. RN #6 had worked on 3/23/2020, and the narcotic card count reflected two (2) cards of [MEDICATION(S)] when there should have been three cards. Review of a disciplinary action form dated 3/26/2020 identified RN #6 was terminated from employment for violating company rules; RN #6 had falsified documentation on a narcotic card count sheet and stole narcotic medication cards from the narcotic storage drawer. Review of an email dated 4/10/2021 identified the DNS notified Drug Control Agent #1 of the summary investigation report and supporting documentation. Additionally, The DNS informed drug control that he had reported the incident to the DPH licensing division 4/9/2021 and was waiting for a return call. Review of RN #6's employee file identified her employment was terminated on 3/26/2020. Interview with the DNS on 4/6/2021 at 8:45AM identified RN #6 stole a card of [MEDICATION(S)] from Resident #16 and was terminated. Additionally, the DNS identified he suspected RN #6 also stole a card of [MEDICATION(S)] from Resident #17, because the card count was identified as incorrect on 3/25/2020 when they had identified Resident #16's medication was missing, however both the original white and yellow carbon copy proof of use sheets were missing for Resident #17's [MEDICATION(S)]. b) Review of RN #6's employee file with the facility's Background Verification Manager (MGR) on 4/7/2021 at 11:19 AM identified RN #6's date of hire was 3/4/2020. The facility conducted a background check which identified potential negative information. The MGR indicated that RN #6 had a prior investigation conducted by another State's health department regarding the administration of [MEDICATION(S)] to a resident. The MGR sent a letter to the Administrator and DON on 3/17/2020 that indicated RN #6's background check identified a pending, open criminal case was confirmed, and RN #6 was conditionally approved to continue employment until the final court disposition. As part of the conditional approval, RN #6 was required to update and inform the company of all court dates and dispositions, and the next court date was noted as 3/23/2020. RN #6 was also directed to continue to comply with all facility policies and procedures. RN #6 was provided the opportunity to respond to the background check, and she indicated the case was related to an incident where she administered the medication as requested and ordered, however documented the wrong date in the narcotic book and the police were notified on behalf of the resident who alleged RN #6 stole the medication. Further, RN #6 identified she did not steal the medication and the investigation was completed. She indicated that there was no action against her license and the State's nursing board issued a clearance letter. The MGR identified that when an adverse background check is identified, an executive team reviews and discuss the report with the facility Administrator and DON to determine if they are comfortable moving forward with employment. Interview with the Administrator and DNS on 4/8/2021 at 8:45 AM identified they were not aware RN #6 had prior action pending against her license related to controlled substances. They indicted that if they had known they would have implemented monitoring and safeguards to limit RN #6's access to narcotics. Additionally, the Administrator identified a negative finding was identified during the background check process that was completed by the company verification manager and when RN #6 was provided an opportunity to appeal the finding she informed the Administrator and DNS that she was accused of not administering psych medication and documented that she gave the medication as ordered. Further, the facility knew a court case was pending, employment was approved conditionally, and RN #6 was required to inform the facility of all court dates and to disclose any details as they arose. The administrator identified she was not informed of the concerns by the MGR and indicated and there was no discussion to determine if the facility was comfortable moving forward with RN #6's employment. Review of the facility July 2018 policy entitled Abuse and Neglect Prohibition directed in part that each resident has the right to be free from misappropriation of resident property. Additionally, misappropriation of property meant the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Further, the policy identified the facility did not hire or otherwise engage individuals who have disciplinary action in effect against his or her professional license as a result of finding abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, facility documentation review, facility policy review and interviews for one of four residents (Resident #11) reviewed for abuse, the facility failed to implement the facility abuse policy for an allegation of resident mistreatment. The findings include: Resident #11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #11 had severely impaired cognition and required set up help to transfer and limited assistance of one person to walk. The Resident Care Plan (RCP) dated 9/26/2019 identified a behavior problem related to yelling, resistive to care, noncompliance with requesting assistance and combative with staff. Interventions included to approach and speak in a calm manner, anticipate needs and administer medications as needed. The nurse's note dated 10/5/2019 at 3:54 PM identified LPN #3 received a call from recreation requesting Resident #11 be removed from a bingo activity due to disruptive behaviors. When LPN #3 arrived at the activity, she observed Resident #11 was calm. When she attempted to remove Resident #11 from the activity, Resident #11 became combative, and recreation staff then directed to allow Resident #11 to remain in the activity and LPN #4 arrived in the activity to relieve LPN #3, and LPN #3 left the room. Review of facility documentation identified undated staff statements written by the DNS identified on Sunday 10/5/2019, recreation staff called LPN #3 to request she remove Resident #11 from a recreation activity because he/she was disrupting other residents. When LPN #3 attempted to bring Resident #11 out of the room, Resident #11 was agitated and stood up. The statement further identified that Resident #11 appeared unbalance when he/she stood up and LPN #3 placed her hands-on Resident #11's shoulders and guided him/her back down into the wheelchair. At that point LPN # 4 entered the room and took over attempts to de-escalate Resident #11, and sat with Resident #11 at the activity. Interview and review of facility documentation with the DNS on 4/6/2021 at 8:30 AM identified that LPN #4 had reported that he did not like the way LPN #3 treated Resident #11 when she attempted to remove Resident #11 from the activity on 10/5/2019. Additionally, the DNS indicated that an incident report was not completed because the DNS did not feel the treatment reported by LPN #4 was mistreatment. Interview with LPN #4 on 4/6/2021 at 12:24 PM identified that on 10/5/2019, LPN #3 yelled at Resident #11, grabbed his/her shirt and slammed Resident #11 into the wheelchair during an activity. Interview with RN #8 on 4/7/2021 at 9:08 AM identified that on 10/5/2019, LPN #3 notified him that when she was asked by recreation staff to remove Resident #11 from the activity room. RN #8 indicated that he then called LPN #4 regarding Resident #11, and LPN #4 informed him that LPN #3 had grabbed Resident #11 and slammed him/her down into the chair. Additionally, RN #8 identified he did a quick investigation and interviewed NA #4 who informed him that although LPN #3 not use excessive force, LPN #3 was loud and made a scene in front of the other residents. RN #8 indicated he notified the DNS that LPN #4 alleged LPN #3 slammed Resident #11 into the chair, and the DNS directed him to investigate the situation. RN #8 interviewed LPN #3 and NA #4 and assessed Resident #11's shoulders, waist and back and noted that he/she had good upper extremity range of motion and was not in any distress with no abnormalities identified. Further, RN #8 did not suspend LPN #3 pending an investigation because LPN #3 she had a habit of talking loudly, and he did not believe LPN #3 mistreated Resident #11. RN #8 indicated that he believed LPN #3 was trying to prevent a fall. Further, RN #8 did not feel the allegation was abuse or he would have removed LPN #3 from the floor. Interview with NA #4 on 4/7/2021 at 9:43 AM identified Resident #11 was trying to get out of his/her chair during an activity nearing the change of shift and LPN #3 pulled Resident #11 down into the chair by the shoulders to prevent him/her from falling and Resident #11 landed harshly. NA #4 identified she did not believe this was abuse because LPN #3 was trying to prevent a fall, however LPN #3 was loud, and used a hard tone. Interview with the DNS on 4/8/21 at 8:45 AM identified RN #8 did not notify him that LPN #4 alleged LPN #3 yelled at Resident #11 and slammed him/her into a chair. Interview with the DNS on 4/8/21 at 9:00 AM identified RN #8 notified him on 10/5/2019 that LPN #4 alleged LPN #3 yelled at Resident #11 and put Resident #11 back in the chair. The DNS identified he looked into the report the next day and determined LPN #3 raised her voice to get the attention of Resident #11 when he/she stood up, LPN #3 placed her hands on Resident #11's shoulders to prevent a fall. The DNS identified if RN #8 had determined that Resident #11 was mistreated, he would have completed an incident report, suspended LPN #3 and reported the allegation to the State Agency, however, RN #8 told him he did not think LPN #3 mistreated Resident #11. Review of the facility Abuse and Neglect Prohibition policy, dated July 2018, directed in part that each resident has the right to be free from abuse, mistreatment, corporal punishment, exploitation, and any form of physical or chemical restraint not required to treat the resident. Mistreatment was defined as inappropriate treatment or exploitation of a resident. The Policy further directed the facility will protect residents from harm during an investigation and the employee alleged to be involved will be interviewed and suspended immediately and will not be permitted to return to work until such investigation is unsubstantiated. The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin and misappropriation of property to the administrator, state survey agency, and law enforcement officials in accordance with state and federal law within 2 hours of the allegation. And the facility will conduct a timely investigation of any alleged abuse.

Based on review of the clinical record, faculty documentation review, facility policy review and interviews for one of four residents (Resident #16) reviewed for abuse, the facility failed to report a missing narcotics to the police department and State Agency tiemly. The findings include: 1. Resident #16 was admitted to the facility in January 2020 under their Medicare Part A benefit, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #16 had moderately impaired cognition, had pain occasionally, and received pain medications as needed (PRN). The Resident Care Plan (RCP) dated 2/12/2020 identified a problem of pain related to chronic illness, recent surgery and abdominal wound. Interventions included to administer pain medications and evaluate the effectiveness of pain interventions. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #17 was admitted under their Medicare Part A benefit, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] identified Resident #17 was alert and oriented and had pain frequently. The RCP dated 3/26/2020 identified a problem of acute pain related to recent surgery. Interventions included to administer medication as ordered and evaluate the effectiveness of pain interventions every shift and as needed. Review of the facility investigation summary regarding missing narcotics, dated 3/25/2020, identified LPN #4 identified one of two medication cards of [MEDICATION(S)] belonging to Resident #16 was missing from the narcotic box. The white narcotic proof of use sheet was missing, however the yellow carbon copy proof of use sheet was found and verified the medication had been delivered from the pharmacy. The DNS reviewed staffing and the narcotic sign off sheets and discovered the number of counted cards changed on 3/23/2020 when RN #6 worked on the 3 PM to 11 PM shift (RN #6 had accounted for two (2) cards of [MEDICATION(S)] when the nurses before her accounted for three cards). Further, the investigation revealed a card of [MEDICATION(S)] for Resident #17 was noted missing the evening of 3/23/2020. RN #6 had worked on 3/23/2020, and the narcotic card count reflected two (2) cards of [MEDICATION(S)] when there should have been three cards. Review of a disciplinary action form dated 3/26/2020 identified RN #6 was terminated from employment for violating company rules; RN #6 had falsified documentation on a narcotic card count sheet and stole narcotic medication cards from the narcotic storage drawer. Review of an email dated 4/10/2021 identified the DNS notified Drug Control Agent #1 of the summary investigation report and supporting documentation. Additionally, The DNS informed drug control that he had reported the incident to the DPH licensing division 4/9/2021 and was waiting for a return call. Interview and review of facility documentation with the DNS on 4/8/2021 at 9 AM identified he did not report the incident to the police or the State Agency because he did not consider stealing narcotics to be misappropriation because Resident #16's stay was covered under his/her Medicare Part A benefit, and he indicated the medication belonged to and was paid for by the facility (Medicare Part A covered a flat rate for expenses related to the admission). Additionally, the DNS notified Drug Control and DPH licensure on 4/9/2021. He indicated that because no one at these agencies informed him that he needed to report to anyone else, he assumed further reporting was not required. Subsequent to surveyor inquiry, interview with the Administrator on 4/8/2020 at 8:45AM identified the police were notified of the missing narcotics on 4/7/2021 at approximately 4:30 PM. During an interview with the Administrator on 4/8/2020 at 11 AM identified the reason why the police wanted to be notified was so stolen drugs do not make it to the street. Review of the facility Inventory of Controlled Substances Policy directed in part that the facility should ensure that staff immediately report suspected theft or loss of controlled substances to their supervisor or manager for appropriate documentation, investigation, and timely follow-up in accordance with facility policy and applicable law. Review of the facility July 2018 policy entitled Abuse and Neglect Prohibition directed in part, that each resident has the right to be free from misappropriation of resident property. Additionally, misappropriation of property meant the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The Policy further directed the facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin and misappropriation of property to the administrator, state survey agency, and law enforcement officials in accordance with state and federal law. Review of Elder Justice Act requires the facility complete an incident report, and to report to law enforcement agencies and the State Agency a reasonable suspicion of a crime against any individual who is a resident or receives care from the facility, no later than 24 hours after forming the suspicion if the crime does not result in bodily injury and submit a summary within 5 days of the initial report.

Based on review of clinical record review, facility documentation, facility policy and interview for 1 resident (Resident #2) who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Every shift. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition and required total assistance with personal hygiene. The care plan dated 4/16/20 identified Resident #2 had self-care deficits related to activity intolerance, impaired balance, [CONDITION(S)] and dementia. Interventions included to provide assistance with personal hygiene and oral care. Additionally, the care plan identified Resident #2 had a potential behavior problem related to history of being verbally aggressive, refusing care, exit seeking, combative, swearing at others, and yelling and repetitive questions. Interventions included to explain all procedures to the resident before starting and allow time to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Behavior health to evaluate and treat. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the May 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the [MEDICATION(S)] 25mg prn was not administered in May 2020. Review of the June MAR, 6/1/20 through 6/3/20 identified Resident #2 had no behavioral issues documented during the day or evening shifts, and on 6/3/20, the facility failed to document the resident ' s behavior. A Reportable Event Form dated 6/3/20 at 10:00 PM identified NA #1 was providing care when the resident became agitated and combative resulting in NA #1 attempting to hold back Resident #2's hands. Resident #2 was yelling at that time and LPN #2 went to investigate and interpreted the incident as NA #1 attempting to harm Resident #2. A written statement by LPN #2 dated 6/3/20 identified she was at the nurse's desk when she overheard Resident #2 yelling and went to investigate. LPN #2 indicated the bedroom door was halfway opened and she saw that NA #1 had both of Resident #2 ' s arms in his hands hitting the resident and pressing him/her down on the bed. Resident #2 was screaming. NA #1 turned his head and noted LPN #2 at the door. NA #1 immediately stated at that time Resident #2 was hitting him. LPN #2 indicated she did not want to confront NA #1 alone, so she immediately went to get LPN #1 who was assigned to Resident #2. LPN #2 and LPN #1 went to Resident #2's room and asked Resident #2 if he/she was ok. Resident #2 answered yes but something is wrong with this guy right here, pointing at NA #1. Both nurses assessed Resident #2 and no bruises or injury noted at that time. LPN #2 left and immediately reported the alleged incident to RN #2. LPN #2 indicated RN #2 interviewed both nurses and assessed Resident #2. LPN #2 indicated RN #2 notified the DNS. A written statement by NA #1 dated 6/3/20 identified LPN #2 assisted him in hoyering Resident #2 back into bed and LPN #2 left the room. NA #1 began performing care on Resident #2. Resident #2 became agitated and combative with NA #1. NA #1 attempted to redirect Resident #2 and held back the resident hands to avoid being hit and Resident #2 began to yell at NA #1. LPN #2 came to the door and NA #1 saw her and thought she was coming to help, and NA #1 told her that Resident #2 was trying to hit him. NA #1 saw that LPN #2 left and he continued to perform care and Resident #2 became less agitated and thanked him. LPN #2 and LPN #1 then entered the room. LPN #1 questioned him as to what was going on. NA #1 answered that nothing was going on and everything was ok which was also reiterated by Resident #2. A written statement by RN #2 dated 6/3/20 identified LPN #2 called and reported Resident #2 was yelling and she went to investigate and witnessed NA #1 punching Resident #2. LPN #2 reported that NA #1 saw her at the door and said stop hitting me to the resident. LPN #2 left and got LPN #1 and returned back to the room at which point Resident #2 was in bed and no longer yelling. RN #2 then called DNS and reported the alleged incident. RN #2 indicated she then went upstairs and assessed Resident #2 and interviewed both nurses and NA #1. RN #2 indicated she instructed NA #1 to stop performing care and leave the facility for the evening. RN #2 indicated she re-interviewed LPN #2 who now reported that NA #1 was holding onto both of Resident #2's hands and hitting the resident with his/her own hands. RN #2 indicated the DNS came and interviewed both nurses and the nurse aide. LPN #2 was interviewed by the DNS and RN #2 present at which point she stated, he was holding the residents arms with his hands and repeatedly pushing the arms down onto the resident body. As part of the investigation, interviews on 6/4/20 with 4 residents on the 3rd floor (who were cared for by NA #1) denied any issues with NA #1. A written statement by LPN #1 dated 6/4/20 identified he was taking care of a resident down another hallway when LPN #2 knocked on the door and asked if she can talk to him. LPN #1 indicated he went into the hallway and LPN #2 explained what transpired with NA #1. LPN #2 recounted that she heard Resident #2 yelling and had gone to investigate, and the door had been ajar and she could see NA #1 holding Resident #2's hands, but did not say that NA #1 was hitting Resident #2. Both nurses went to Resident #2 ' s room together and found NA #1 finishing providing care to Resident #2. LPN #1 indicated he asked NA #1 what was going on, and NA #1 answered nothing. LPN #1 questioned Resident #2 and he/she also replied nothing was going on and he/she was ok. A full body assessment performed identified no injury. LPN #1 and LPN #2 left the room and went back to the office where LPN #2 again reiterated what had transpired without mentioning that NA #1 had hit Resident #2. LPN #1 did not recollect Resident #2 saying something is wrong with this guy right here and pointing at NA #1 while in the room with LPN #2. Review of a disciplinary action record dated 6/5/20 identified NA #1 violated resident care standards when he continued to perform care on a resident after the resident had become agitated and combative and did not seek ssistance. Corrective action: NA #1 will always seek assistance and stop performing care on a resident that has become agitate and combative. The Summary Report dated 6/6/20 at 9:13 AM identified Resident #2 was not harmed and LPN #2's interpretation of the events could neither be substantiated nor unsubstantiated. Education provided to staff members on appropriate manner to care for residents who become agitated or combative with care. Education to be provided to staff members over the following week with weekly audits on education for 1 month. Other residents were interviewed whom had been under NA #1's care and no one verbalized any concerns with his care or performance. Education was provided to employees and care plan was updated The care plan revision dated 6/8/20 identified Resident #2 had a potential behavior problem related to history of being verbally aggressive, refusing care, exit seeking, combative, swearing at others, yelling and repetitive questions. Interventions initiated on 6/3/20 included Resident #2 triggers for becoming agitated or combative are related to performance of care. The behavior is de-escalated by leaving the resident in a safe environment and re-approach at a later time. Interview with the DNS on 4/1/21 at 2:52 PM identified he received a phone call from RN #2 who informed him of the alleged incident of abuse. The DNS indicated he immediately came back to the facility. RN #2 reported she had already removed NA #1 off the unit and NA #1 was in the waiting area downstairs. The DNS indicated he asked NA #1 to wait in order to get an interview and went to see Resident #2 and interviewed the resident. Resident #2 is alert and confused and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS indicated he saw that Resident #2 was alright and interviewed LPN #2, LPN #1, and all the nurse aides on the unit. The DNS indicated he interviewed NA #1. The DNS indicated his initial conclusion was a misunderstanding of what happened. NA #1 was sent home and was suspended pending conclusion of investigation. The DNS indicated on 6/4/20 he interviewed the alert and oriented residents that were on NA #1 assignment on 6/3/20 during the evening shift. There were only 4 residents that fell in that criteria and all of them stated they never had an issue with NA #1. The DNS indicated he called NA #1 to come in and had another discussion regarding the incident. The DNS indicated after all the interviews and his conclusion of what happened when NA #1 was providing care to Resident #2 who became combative with NA #1 and started yelling at NA #1. LPN #2 heard the yelling coming from Resident #2 room and went to investigate. The bedroom door was cracked not completely closed and LPN #2 looked into the room and saw NA #1 holding Resident #2 hands down on his stomach area. LPN #2 indicated she was scared of NA #1 and left to go get LPN #1. The DNS indicated LPN #2 did not follow the facility protocol by leaving the room and indicated LPN #2 should have asked NA #1 to leave the room. Interview with the DNS on 4/5/21 at 10:00 AM identified the facility protocol is if a staff member allegedly witnesses resident abuse, they are to make sure the resident is safe and then call the supervisor immediately. the DNS indicated that LPN #2 ' s statement changed from NA #1 holding Resident #2's hand down on his/her abdomen to NA #1 hitting the resident, and LPN #2 indicated she was afraid of NA #1. The DNS identified NA #1 had been in-serviced on how to deal with a combative resident and indicated he does not know why NA #1 did not walk away and re-approach and notified the nurse. Attempts to reach NA #1 were unsuccessful. Interview with LPN #2 on 4/5/21 at 11:52 AM identified NA #1 was a threat to everyone, and he would physically hit or punched himself in front of the staff. LPN #2 indicated she was at the nurse's desk when she heard Resident #2 screaming as if something was wrong. LPN #2 went to investigate and the bedroom door was halfway open. LPN #2 identified she observed NA #1 holding Resident #2's hands against his/her chest and hitting Resident #2 and pressing the resident's hands down towards his/her chest. LPN #2 indicated she observed NA #1 hitting Resident #2 on the upper body. NA #1 turned around and saw LPN #2 and NA #1 stopped. LPN #2 indicated she did not go into the room by herself because she was afraid NA #1 might come out of the room and hit her, so she left the room to call RN #2. LPN #2 indicated she went to go get LPN #1 who is a male nurse on the other unit. Both nurses went back into the resident's room. LPN #1 asked Resident #2 if he/she was alright and Resident #2 said he/she was ok and pointed at NA #1 and said something is wrong with him. NA #1 started saying Resident #2 was hitting him. LPN #2 indicated she told the supervisor (RN #2) what she observed, and RN #2 came to the unit and NA #1 was in another resident room. RN #2 told NA #1 he had to leave the building and NA #1 became verbally aggressive yelling and hitting himself in the hallway. NA #1 subsequently left the floor. Interview with RN #2 on 4/5/21 at 1:33 PM identified LPN #2 called and reported she observed NA #1 punching Resident #2. RN #2 indicated she immediately went to the 3rd floor and went to the resident ' s room and NA #1 was finishing care for Resident #2. NA #1 was placing the covers over the resident and he/she was not yelling at that time. RN #2 asked NA #1 to step out of the room and go to the dining room. RN #2 assessed Resident #2 who appeared to be fine and did not have any marks on his/her body. RN #2 indicated before she called the DNS, she asked LPN #2 what she saw and LPN #2 said she heard Resident #2 yelling and she went to the room and saw NA #1 holding Resident #2's arms on the resident's chest. And LPN #2 walked away to go and get LPN #1. RN #2 indicated on the phone LPN #2 indicated she saw NA #1 punching Resident #2. RN #2 indicated she went to ask NA #1 what transpired, and NA #1 stated he was performing care to Resident #2. NA #1 stated Resident #2 was fighting and he held Resident #2's arms to keep him/her from fighting. RN #2 indicated she called the DNS and told NA #1 to leave the unit and go downstairs in the waiting area. RN #2 indicated NA #1 seemed puzzled on why he had to leave the unit. RN #2 indicated LPN #2 did not follow the facility protocol to remove NA #1 from the room. Interview with LPN #1 on 4/5/21 at 2:11 PM identified he was on another unit in room [ROOM NUMBER] helping NA #3 when LPN #2 reported she saw NA #1 pinning down Resident #2 and heard NA #1 yelling at the resident. Both nurses went to resident room. LPN #1 asked NA #1 what was going on and NA #1 implied nothing is going on. LPN #1 also asked Resident #2 if he/she was ok and Resident #2 stated I am fine. LPN #1 and LPN #2 performed a body assessment and no bruises or marks was found. LPN #2 left the room to call RN #2. LPN #1 indicated he stayed with the resident. LPN #1 indicated NA #1 left the room. RN #2 came to the room and assessed Resident #2 and LPN #1 left the room at that point. The facility failed to ensure NA #1 stepped away and reproached Resident #2 when he/she became agitated and combative with care. Subsequently, Resident #2 was heard screaming during care and NA #1 was observed holding the resident's hands down.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #6) reviewed for quality of care, the facility failed to ensure the clinical record was complete and accurate to include physical assessments for urinary tract infection monitoring per physician orders, and for one of three residents (Resident # 11) reviewed for abuse, the facility failed to ensure the clinical record was complete and accurate to include a resident assessment after an allegation of mistreatment. The findings include: a) Resident #6 was admitted to the facility in August of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission MDS assessment dated [DATE] identified Resident #6 had moderately impaired cognition and required extensive assistance with toileting and was frequently incontinent of bladder. The care plan dated 08/29/19 identified that Resident #6 had a urinary tract infection (UTI) with interventions that included; toilet resident every two to three hours and as needed, administer antibiotic therapy as ordered, observe for side effects of medication and effectiveness of antibiotic therapy, observe vital signs per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview and review of the pre-printed MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation identified a missing assessment for the 3PM-11PM shift on 11/6/19 and the 7AM-3PM shift and the 3PM-11PM shift on 11/7/19. The DNS identified that the pre-printed MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . He further noted that the staff are required to document their findings on the pre-printed MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with LPN #3 on 04/06/21 at 1:30 PM identified that when a resident is on UTI watch, staff are required to document the absence or presence of symptoms on the pre-printed MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with RN #5 on 04/06/21 at 3:15 PM identified that she was aware that when a resident is on UTI watch, staff are required to document the absence or presence of symptoms on the pre-printed MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN #1 on 04/07/21 at 2:30 PM identified she was aware of the policy related to the documentation for a resident on UTI watch. LPN #1 verified she worked the 3PM-11PM shift on 11/6/19 but acknowledged that she may have forgotten to document her assessment on the pre-printed MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Although requested, the facility did not provide a policy related to clinical record documentation. b) Resident #11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #11 had severely impaired cognition and required set up help to transfer and limited assistance of one person to walk. The Resident Care Plan (RCP) dated 9/26/2019 identified a behavior problem related to yelling, resistive to care, noncompliance with requesting assistance and combative with staff. Interventions included to approach and speak in a calm manner, anticipate needs and administer medications as needed. The nurse's note dated 10/5/2019 at 3:54 PM identified LPN #3 received a call from recreation requesting Resident #11 be removed from a bingo activity due to disruptive behaviors. When LPN #3 arrived at the activity, she observed Resident #11 was calm. When she attempted to remove Resident #11 from the activity, Resident #11 became combative. Recreation staff then directed to allow Resident #11 to remain in the activity and LPN #4 arrived in the activity to relieve LPN #3, and LPN #3 left the room. Review of facility documentation/undated staff statements written by the DNS identified on Sunday 10/5/2019, recreation staff called LPN #3 to request she remove Resident #11 from a recreation activity because he/she was disrupting other residents. When LPN #3 attempted to bring Resident #11 out of the room, Resident #11 was agitated and stood up. The statement further identified that Resident #11 appeared unbalance when he/she stood up and LPN #3 placed her hands-on R#11's shoulders and guided her back down into the wheelchair. At that point LPN # 4 entered the room and took over attempts to de-escalate Resident #11 and sat with Resident #11 at the activity. Interview with LPN #4 on 4/6/2021 at 12:24 PM identified that on 10/5/2019 LPN #3 yelled at Resident #11, grabbed his/her shirt and slammed Resident #11 into the wheelchair during an activity. Review of the clinical record failed to identify a body assessment was documented on 10/5/2019 after the allegation that LPN #3 had her hands on Resident #11's shoulders. Interview with RN #8 on 4/7/2021 at 9:08 AM identified that on 10/5/2019, LPN #3 notified him that when she was asked to remove Resident #11 from the activity room. RN #8 indicated that he then called LPN #4 (second floor charge nurse) regarding Resident #11, and LPN #4 informed him that LPN #3 had grabbed Resident #11 and slammed him/her down into the chair. RN #8 assessed Resident #11's shoulders, waist and back and noted that he/she had good upper extremity range of motion and was not in any distress with no abnormalities identified. RM #8 indicated that he did not document the assessment because he was busy. Review of the facility Documentation Policy, dated February 2017, directed in part, that all facts and pertinent information related to an event, course of treatment, resident condition, response to care and deviation from standard treatment must be documented.

Based on observation, review of facility documentation and staff interviews, the facility failed to ensure a safe environment was maintained. The findings include: Observation during a tour of resident units on 6/7/20 at 8:30 AM identified a water temperature reading of 131.5 degrees Fahrenheit in room [ROOM NUMBER]. Subsequently, on 6/7/20 at 8:33 AM the water temperature in room [ROOM NUMBER] was found to be 130.5 degrees Fahrenheit with the water noted to be cloudy and brown before the color cleared after approximately three minutes. Interview with Registered Nurse (RN) #1 at 8:40 AM on 6/7/20 identified the Maintenance Director had been notified of the unsafe water temperatures. RN #1 further stated that staff were also nnformed, and all bathing/showering would be temporarily suspended to ensure the safety of the residents. Interview with the Director of Nursing Services (DNS) on 6/7/20 at 9:00 AM identified the facility's water system had been serviced during the previous week. The DNS stated that the resident rooms on the hallway where room [ROOM NUMBER] was located were currently unoccupied as part of the facility's Coronavirus Disease 2019 (COVID-19) infection prevention cohort strategy plan, and the sediment had probably occurred because the faucets were not in use. Interview and observation with Maintenance Staff #1 on 6/7/20 at 10:35 AM identified the water heating system's mixing valve required frequent adjustments. Subsequent water temperatures taken in rooms [ROOM NUMBERS] on 6/7/20 at 11:00 AM identified readings of 118.0 degrees F. Review of the facility's policy on Water Temperature Monitoring identified that faucets were to be checked throughout the facility every three days, and the recorded temperature for hot water supplied to faucets and shower heads which were accessible to facility residents should be in a range of 105 degrees Fahrenheit (F) to 120 degrees F. Review of the facility's Water Temperature Maintenance Logs identified that during the period from 5/5/20 through 6/4/20 water temperatures had been monitored daily except for weekends and holidays. Further review of the facility's water temperature logs and interview with the DNS on 6/7/20 identified all water temperatures taken from 5/5/20 through 6/4/20 were recorded at 118.0 degrees F. The DNS stated that water temperatures were monitored daily, and when indicated the mixing valve was immediately adjusted to achieve the desired temperature of 118.0 degrees F without the benefit of recording the actual water temperatures taken. On 6/7/20 the DNS further identified that the hot water system would be immediately repaired to ensure the water temperatures in areas accessible to the residents remained within a safe range at all times. The DNS subsequently stated the facility had found that a pressure releasing valve at the street level had been causing the problem and was being replaced. He further indicated that staff and residents were being informed of the possibility of elevated hot water temperatures through signs and verbal communication. He identified that water temperatures would be monitored multiple times a day until the temperatures were fully stabilized, and any necessary adjustments would be made immediately if indicated.

Based on a review of clinical records, interview and policy review, for one of four sampled residents reviewed for hydration (R#66), the facility failed to ensure sufficient care planning to meet the hydration needs and/or plans to meet the fluid needs of a newly admitted resident identified in the nutrition assessment. The finding includes the following: Review of the clinical record indicated that Resident #66 was admitted to the facility on [DATE] for respite care with [DIAGNOSES REDACTED]. Review of the care plan dated 11/04/16 identified the resident had a potential risk for fluid deficit related to confusion, dementia, dysphagia, and low body mass index with a goal that the resident will have adequate hydration levels evidenced by moist mucosa, adequate urinary output and supple skin. Interventions included to observe skin turgor, place fluids at bedside within reach, provide 6-8 ounces (oz) of fluid at each medication pass as tolerated, provide 6-8 oz of of extra fluid at each meal time as tolerated, and notify the physician on change of status as indicated. Review of the Registered Dietician (RD) assessment completed on 11/04/16 indicated that the resident's weight was 111.5 pounds (lbs). The note indicated that the resident was assessed with [REDACTED]. The resident's estimated fluid requirement was identified as 1,614 cc's per day (1 ml/kcal). Review of the physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the resident's flow sheets during the period of 11/03/16 through 11/14/16 identified that the documented fluid intake that the resident consumed during meals ranged from 200 cc's to 1000 cc's daily. The admission MDS dated [DATE] identified that the resident as severely cognitively impaired, non-ambulatory and was an extensive assist with eating. Interview with the RD on 2/02/17 at 1:15 PM indicated that there were no guidelines related to when staff should notify him/her of the resident's inability to meet the fluid goal but that s/he would expect after a few days s/he should be notified. Interview with the DNS on 2/2/17 at 11:00 AM indicated that s/he investigated the residents poor oral intake after being called by the acute care facility. The DNS stated the resident refused and/or was difficult to assist at times and the RD goal was difficult to meet based on the resident's behavior. Review of the acute care record dated 11/14/16 indicated that the resident presented to the ED with bruising and deformity of the left hip with shortening and external rotation. The resident had a BUN of 44 (normal 7-18), creatinine of 1.52 (0.55-1.02), sodium of 154 (136-145), chloride of 124 (98-107) and a glomerular filtration rate (GFR) of 31 (>60). The ED assessment indicated that the resident had extremely dry mucus membranes with cracked lips and appeared clinically quite dehydrated. The clinical impression was left [MEDICAL CONDITION], acute [MEDICAL CONDITION] secondary to dehydration, and urinary tract infection. Review of the Weight/Hydration policy indicated that the RD may visit with the resident, family and care staff regarding hydration status and acceptable interventions. However further review of the policy failed to reflect when the physician should be notified when the resident did not meet the daily estimated fluid needs and/or how the RD recommendations are communicated to the nursing staff and/or incorporated into the plan of care. According to the American Dietetic Association, a guideline for determining baseline daily fluids needs is to multiply the resident's body weight in kg times 25-30 cc (2.2 lbs = 1 kg), except for residents with renal or cardiac distress.

Based on a review of clinical records, facility documentation, interviews, and policy review for one of two sampled residents reviewed for injuries of unknown origin (Resident #66) the facility failed to ensure that nursing assessments and/or physician notification was documented in the clinical record. The finding includes the following: Review of the clinical record indicated that Resident #66 was admitted to the facility on [DATE] for respite care with [DIAGNOSES REDACTED]. The care plan dated 11/03/16 identified the resident had targeted behaviors that included in part, kicking and biting. Interventions included to modify the environment, check for discomfort, pain, notify the MD as needed, and two staff to care for the resident due to disruptive behaviors. Review of RN #1's note dated 11/13/16 at 6:47 PM indicated that the resident was moaning and screaming while asleep and Tylenol 650 mg was given with some relief. The note further reflected that the resident's left lower extremity (LLE) was very painful to movement and touch, screams out when touched with no falls or injuries noted and that the physician would evaluate. The record failed to demonstrate that a comprehensive assessment was completed and/or documented. The note authored by the DON dated 11/14/16 at 2:26 PM indicated that the physician was notified of the possible injury to the resident's left hip as acute pain was noted during therapy. The subsequent note at 2:33 PM identified that the physician was notified and a two-view x-ray was ordered. Review of the x-ray result dated 11/15/16 at 1:19 AM indicated that the resident had a left intertrochanteric fracture. A nurse's note dated 11/15/16 at 2:23 AM identified that the physician was notified of the x-ray results. And at 7:57 AM the resdient was on a medical leave of absence. The record failed to identify when the resdient was transported to the acute care hospital. Review of facility documentation and interview with RN #1 on 2/02/17 at 12:00 PM indicated that the resident was noted to be in pain on 11/13/16 and that the resident was acting differently and was not her/his self. The RN indicated that s/he left a notation in the MD notification book because s/he felt that it was not an emergency. Subsequent to surveyor inquiry, RN #4 (nursing supervisor) provided a typed statement to the facility dated 2/03/17 that identified s/he was called by RN #1 to assess the resident and provided specific details of her assessment including notification of the physician. Review of the Changes in Resident Condition policy indicated that staff should assess and document changes.

Based on clinical record reviews, review of facility documentation, review of facility policies and interviews for one of three sampled residents reviewed for injuries of unknown origin (R#101), the facility failed to complete thorough investigations. The findings included: 1. Resident #101's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified R#101 as severely cognitively impaired, had short and long-term memory problems, minimally depressed, exhibited no behaviors, and required total assistance with activity of daily living. The care plan dated 5/06/15 identified R#101 required extensive assistance with ADL's. Interventions included two staff members for completion of ADL, to ensure effective pain management prior to ADL activities, palm guard as per physician order, pad call light, provide passive range of motion and encourage active range of motion as tolerated, and out of bed to custom wheelchair per 24 - hour positioning plan. In addition the RCP identified the resident at risk for increased bleeding, bruising or injury related to use of anticoagulant therapy, R#101 receives Aspirin. Interventions included to observe for bleeding or increased bruising. a. A RE dated 6/24/15 at 8:00 AM identified R#101 with hematoma to right forehead and ecchymotic area to left eye lid. Review of the facility investigation failed to reflect that all staff members on duty prior to the identification of the injuries were interviewed to ascertain etiology of the hematoma to right forehead and ecchymotic area to left eye lid. b. A RE dated 6/25/15 at 10:00 PM identified R#101 with ecchymotic area to left forearm area measuring 2.5 centimeters (cm) by 2.3 cm. Review of facility investigation failed to reflect that all staff on duty prior to identification of the ecchymotic area to left forearm were interviewed. Interview and review of the staff statements regarding injury of unknown origin dated 6/24/15 and 6/25/15 with the DNS on 12/23/15 at 11:55 AM identified that the injuries of unknown origin sustained by R#101 on 6/24 and 6/25/2015 were investigated at the same time and a total of ten staff statement were obtained. Review of the facility 's Abuse and Neglect Policy identified that injury of unknown origin may occur as a result of abuse. Additionally, the facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance to state law.

Based on clinical record review, review of facility documentation, observations and interviews for one of three sampled residents ( R#241), the facility failed to provide care and services to prevent the development of a pressure ulcer and/or promote healing. The findings include: Resident #241's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified R#241 as cognitively intact, requiring extensive assistance with bed mobility and transfers, at risk for pressure ulcers and requiring a pressure reducing device in the bed and chair. An initial plan of care dated 10/13/13 identified a potential for skin problems with interventions to provide wound care/preventive skin care per order, perform skin checks weekly and turn and reposition frequently to decrease pressure. A RCP dated 10/20/13 identified R#241 required extensive assistance for completion of activities of daily living with the lower extremities with interventions that included to provide cueing with tasks and educate as needed. A care plan dated 11/18/13 identified a pressure ulcer to the left heel with interventions that included to provide a pressure reduction mattress to the bed, a pressure reduction cushion to the chair/wheelchair, turn and reposition in bed frequently for comfort and pressure reduction and provide pressure ulcer treatment as ordered. Physician orders [REDACTED]. A physician's orders [REDACTED]. Additionally, to apply a foam boot to the left lower extremity while in bed. A physician's orders [REDACTED]. physician's orders [REDACTED]. Apply [MEDICATION NAME] spray topically to both heels with AM and PM care. The facility's skin risk assessment tool used was the Braden scale. The risk assessment identified that scores less than 12 represented high risk for skin breakdown. Resident #241 risk assessments dated 10/13/13 identified a score of 21, on 10/20/13 a score of 19, on 11/3/13 a score of 18 and on 11/27/13 a score of 18. Observation of R#241's wound was conducted on 11/21/13 at 8:10 AM with the DNS and identified the left foot heel wound to be a partial filled blister. The blister was tan in color and on the planter aspect of the Achilles a flattened area of firm tissue contained two discolored areas. The discolored areas were tissue that was reddish purple in color. The superior area measured 1.0 cm x 1.0 cm and the inferior area measured 0.5 cm x 1.0 cm. Interview with R#241 on 11/21/13 at 9:55 AM identified that until the wound on his/her heel was discovered no other "apparatus" was used to keep his/her heels off the mattress including the use of pillows. Additionally Resident #241 identified that staff only woke him/her up to administer medication and could not recall ever being turned or repositioned while in bed prior to the discovery of the wound. Interview, observation and review of the clinical record with the Director of Nursing on 11/21/13 at 12:10 PM identified that Resident #241 was an extensive assist with bed mobility. The DNS identified that the cause of the of the blister on the left lower extremity could have been due to wearing his/her shoe and the [MEDICAL CONDITION] that R#241 presented with. The DNS identified that interventions were implemented on 10/25/13 that included to turn and position in bed, however, review of NA flow sheets identified this was not consistently done. Surveyor: Trombley-Norton, Lau