Every finding on record at Four Corners Regional Care Center

Based on observation, interview, and record review, the facility did not ensure that the resident's environment remained as free of accident hazards as was possible; and that the resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 7 out of 39 samples residents, residents that had falls with injuries did not have interventions implemented to prevent future falls with injuries, a resident sustained an injury during cares provided by staff that resulted in the resident rolling out of bed, a resident that was provided a one on one with staff had falls with injuries, and residents that required a two person Hoyer lift had staff only use one person. Resident identifiers: 17, 19, 23, 29, 41, 52, and 296. Finding included: 1. Resident 41 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included other pulmonary embolism without acute cor pulmonale, type 2 diabetes mellitus with diabetic neuropathy, atherosclerotic heart disease, unspecified disorientation, essential hypertension, and mixed hyperlipidemia. On 1/6/25 at 4:53 PM, an observation was made of resident 41. Resident 41 was observed to have a greenish-purple discoloration to her left cheek and around her left eye. Resident 41's medical record was reviewed on 1/6/25 through 1/9/25. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6. A score of 0 to 7 indicated severe cognitive impairment. A care plan Focus initiated on 7/9/24 and revised on 7/25/24 documented, [Resident 41] is at Moderate Risk for Falls per standardized fall scale. The care plan Goal initiated on 7/9/24, documented [resident 41] will be free of minor injury through the review date. The care plan Interventions included: a. Fall mat times one. Date initiated: 11/5/24, Revision on: 12/4/24. b. Fall 11/25/24: Tilt in space wheelchair d/t [due to] pt [patient] poor posture, trunk control. Date initiated: 12/4/24. c. Be sure bed was in lowest position and locked in place. Date initiated: 11/5/24. d. Keep room free of clutter and ensure objects the resident may need are within use. Date initiated: 7/25/24. e. Monitor for any changes in mental, emotional, or physical condition. Monitor medications for side effects that could contribute to a fall. Date initiated : 7/25/24. f. (High Risk) Assess need for laboratory test to rule out hypo-hyperglycemia, abnormal electrolytes, urinary tract or other types of infections and hemoglobin/hematocrit to assess for anemia. Date initiated: 7/9/24. g. (High Risk) Encourage the resident to wait for assistance. Anticipate needs by assessing normal routines and times of increase risk. Provide routine scheduling for bathroom use. Date initiated: 7/9/24 h. RESOLVED: 11/19/24, Certified Nursing Assistant (CNA) and Registered Nurse (RN) to check on patient more frequently, every 30 minutes rather than q two hours. Date initiated: 11/19/24 Revision on: 12/4/24 Resolved: 12/4/24. A care plan Focus initiated on 8/5/24, documented [Resident 41] has a behavior of crawling out of bed on hand and knees and crawling around on the floor looking for her belonging [sic] and going to the bathroom. does not use call light for staff assist. The care plan Goal initiated on 8/5/24, documented [resident 41] will remain safe and have preferences honored The care plan Interventions initiated on 8/5/24, were Assist in meeting resident's preferences as able. Notify applicable staff of resident's preference as able. A review of resident 41's progress notes revealed the following: a. On 7/1/24 at 3:17 PM, a nurses note documented, At 1425 [2:25 PM] aide reports that patient had fallen at side of bed hitting head on side rail has a small bump of 3 mm [millimeter] on right upper eyebrow. she is moving arms and legs she require minimal assist when getting up. Dr [doctor] [name redacted] notified. b. On 7/17/24 at 4:02 PM, a nurses note documented, notified that resident was on the floor in her room assessment was done has a bump on the top of her she [sic] stated that she fell trying to get to the bathroom is moving all extremities with out any problems Neuro [neurological] checks started. c. On 7/23/24 at 6:19 PM, a nurses note documented, Alerted by CNA that dietary aide went into room passing snacks and resident slid out of bed onto floor. Assisted resident to wheelchair and assessed for injuries. No injuries noted. d. On 9/23/24 at 2:30 PM, a nurses note documented, Nurse called to resident room. Resident lying on the right side on the floor. Nurse assessed resident and complains of pain on the right side of the head and right side of pelvic. Nurse asked resident what she was trying to do, Resident claims she was trying to transfer self from bed to WC [wheelchair] and the WC went running from resident. LPN [Licensed Practical Nurse] assisted resident back into WC. Neuros were started. e. On 11/15/24 at 1:30 AM, a nurses note documented, Patient yell out for help. Aide check on patient and found her on the floor. Patient had an unwitnessed fall. Patient rolled from bed. Patient was face down, body half off bed onto floor, both lower extremities twisted and caught on side rail, laying on her right arm and bed was in lowest position, upon LN [licensed nurse] entering patient's room. Assist patient back onto bed after Neurologic assessment, and VS [vital signs] started. B/P [blood pressure]= 141/90, P [pulse]= 69, R [respirations]= 16, T [temperature]= 97.7, O2sat [oxygen saturations]= 95% on RA [room air]. Noted hematoma to left side top of head, patient alert with some confusion noted, Right pupil size 6 and non-reactive, left pupil size 3 and reactive, can follow my finger with left eye, follows simple commands, ask patient if she has any pain? She stated, 'my head hurts and my body hurts,' Pain level right now? she said, '7', 7/10 pain level. Moves all extremities. Tylenol 650 mg [milligrams] given for pain to body and headache. Patient sent to ER [emergency room ] for further evaluation @ [at] 0200 [2:00 AM], . f. On 11/15/24 at 5:37 AM, a nurses note documented, [local hospital] called with update. Patient going to be flown out to [hospital name redacted] in [city name redacted]. Patient has a minor brain bleed. Will let on coming LN know patient's status. g. On 11/18/24 at 4:55 PM, an interdisciplinary team (IDT) note documented, IDT Review: Reviewed fall 11/15/24, patient was sleeping in bed and was checked on during normal rounds by CNA and was found by CNA on floor with hematoma front and top of head. Patient neuro checks done and pupils noted to be unequal. Patient transportedto [sic] ER at [local hospital] via EMS [emergency medical services] and subsequently flown out to higher level of care. Findings are frequently turns around to sleep with head at the FOB [foot of bed], sleeps with body half on and half off the bed with feet on mat. Does not utilize call light although she is frequently reminded to do so. Resident has increased confusion NOC [nocturnal] and has hallucinations including 'dead people' men 'flying through the room and out the window'. Initial intervention: send to ER, was flown to different location and was admitted . A pressure call light mat was placed on her bed, and will alert staff to check on her if pressure is taken off of the mat. Alarm has been placed at the nurses station. All staff has been shown and trained on how this mat works for this patient. h. On 11/25/24 at 3:57 PM, a nurses note documented, Heard screaming coming from hall 2 and when investigated found resident face down on floor in front of her wheelchair. With the help of staff resident was assisted back up to wheelchair. VS, FSBS [fasting blood sugar], and neuro checks were completed. DON [Director of Nursing] and ADON [Assistant Director of Nursing] were notified and it was decided that resident would be taken to the ER for evaluation. i. On 11/26/24 at 4:23 AM, a nurses note documented, PT has been supervised all night due to her rolling around in her bed and attempting to stand without assistance. Pt is a HIGH fall risk and has not had any sleep during the night. j. On 11/26/2024 at 3:01 PM, an IDT note documented, IDT Review: . Patient recently has declined quickly to a state of being non-verbal and restless. Resident is on coumadin therapy. Resident is WC bound and becomes agitated at night, restless and often gets out of bed at night. Patient was heard calling for help and in her room during the afternoon and was found to have fallen from her WC forward motion, appeared to be face down. Patient was lifted to a sitting position with help of RN, DON, ADON and two CNA's. Patient assessed and did not appear to have any new bruising, abrasions, or other injuries. Resident did not complain of pain. Resident is on blood thinning medications and was sent to the ER as a precautionary measure. A WC that tilts back will be implemented to assess if the resident does better in this position and can be comfortable close to the nurses station. k. On 1/5/25 at 7:44 PM, a nurses note documented, 1855 [6:55 PM] resident up in w/c to come for supper had just been brought from dining room to foyer resident leaned forward to pick up something on floor and fell from w/c landed on left side and hit left side of forehead on floor resident was assisted to lay on back RN did assessment resident is alert and responsive. resident to be sent to ER to be evaluated due to history of brain bleed and being on coumadin. resident had refused pm medication no coumadin given. 1900 [7:00 PM] 911 called and resident sent to ER at 1935 [7:35 PM]. l. On 1/6/25 at 9:24 AM, an IDT note documented, IDT Review: Resident has history of dementia, hallucinations and falls in the near past. This day resident was not in her normal wheelchair due to the resident having had a large BM [bowel movement] that made it necessary to wash the wheelchair. Resident was placed in another WC temporarily. Resident was placed at the nurses station with many other residents in the common area. Resident fell forward from her chair. Other residents that witnessed the fall reported it looked as if she was reaching for something and lost her balance. Resident did hit her head on the right side, as well as her shoulder. Several people were there to help her up and to take VS immediately. VS were WNL [within normal limits] and resident C/O [complaining of] pain in areas where she reports pain often. Due to resident being on warfarin the ambulance was called and resident transported to [hospital name redacted] as a precautionary measure. Resident was sent back to [facility] with CT [computed tomography] Scan results sent to facility. A review of IDT word documents provided by the facility revealed the following: a. Name: [Resident 41]. Date of Event: 7/17/2024. Preventive measures prior to event: assisted with all adls [activities of daily living] as needed daily, medications administered per orders. Risk Factors: forgetfulness, poor safety awareness, impulsive. The following areas reviewed: Cognition Impairment: yes, intermittent confusion and forgetfulness. Summary of event: [resident 41] was found on the floor in her room, she stated that she fell trying to get to the bathroom and reported that she hit her head on the dresser. No injuries noted. Rehab/RNA [Restorative Nursing Assistant] Program: no. Medication Regimen Review: no issues found. Diagnostic Tests/Labs: no. Pain: Bowel & Bladder Incontinence: occasional Root Cause: Interventions: neuro checks and vital signs per protocol, monitor x3 days for injuries r/t [related to] fall, . b. Name: [resident 41]. Date of Event: 7/23/2024. Preventive measures prior to event: assisted with adls daily, call light within reach, medications administered per orders. Risk Factors: confusion, forgetfulness, did not ask for assist with transfer, not wearing socks or shoes. The following areas reviewed: Cognition Impairment: yes confusion, poor memory recall. Summary of event: staff witnessed pt slide from the bed to the floor while attempting to transfer to wheelchair, pt remained in sitting position and landed on the floor on her bottom, checked for injuries and none found, pt stated her feet were slippery, she did not use call light for assist with transfer. Rehab/RNA Program:PT [physical therapy] and OT [occupational therapy]. Medication Regimen Review: no issues found. Diagnostic Tests/Labs: no. Pain: no. Bowel & [sic]; Bladder Incontinence: occasional. Root Cause: pt attempted self-transfer without staff assist and was not wear proper footwear. Interventions: educate staff to ensure pt has proper footwear on (non-slip socks, shoes) vital signs per fall protocol, checked for injuries. It should be noted that resident 41's care plan did not show any interventions for the falls on 9/23/24, 11/15/24, and 1/5/25. Additionally, no IDT was held for resident 41's falls on 7/1/24 and 9/23/24. On 1/7/25 at 1:31 PM, an interview was conducted with the Certified Nurse Assistant Coordinator (CNAC). The CNAC stated that resident 41 had declined mentally since she first arrived at the facility and did not remember to use the call light when needing assistance. The CNAC stated that resident 41 would crawl around on the floor and tried to get out of bed often. The CNAC stated that resident 41 was given a fall mat for the floor and her bed should be in the lowest position. The CNAC stated that resident 41 was dependent on staff for all cares. On 1/8/25 at 8:31 AM, an interview was conducted with LPN 2. LPN 2 stated that if a resident was a fall risk, then all interventions should be care planned. LPN 2 stated that she would not know what interventions a resident had unless it was documented in the care plan. On 1/8/25 at 8:46 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 41 was a fall risk. CNA 3 stated that resident 41 had a pad on her bed that would beep if she tried to get up. CNA 3 stated that resident 41 was dependent on staff for all cares and she was unable to ambulate on her own. CNA 3 stated that resident 41 required more frequent rounding than other residents due to the fall risk. On 1/8/25 at 9:50 AM, an interview was conducted with the DON. The DON stated that resident 41 liked to sleep with her head at the end of the bed and would bump her head on the foot board. The DON stated that resident 41's health had declined so a floor mat was placed next to the bed. The DON stated that resident 41 would sit slumped over in her wheelchair due to poor upper body control and would fall out of the wheelchair. The DON stated that resident 41 had done much better in the tilt wheelchair and had not fallen out of the tilt wheelchair. The DON stated that resident 41 now had a pressure alarm on her bed that would alarm if resident 41 tried to get out of bed. On 1/8/25 at 11:05 AM, an interview was conducted with LPN 1. LPN 1 stated that resident 41 was a fall risk and that she fell a lot. LPN 1 stated that the big bosses talked about the interventions for residents and she was not involved. LPN 1 stated that resident 41 was not cognitive enough to use a call light on her own. LPN 1 stated that she was not aware of what fall interventions resident 41 had. On 1/8/25 at 3:07 PM, an interview was conducted with the ADON. The ADON stated that if a resident had fallen they usually received a fall mat next to the bed. The ADON stated that the IDT team came up with specific fall interventions for each resident. The ADON stated that a physician's order would be placed for the intervention in the resident's medical record. The ADON stated that the MDS coordinator would add the intervention to the care plan and the Kardex for the CNA's. On 1/8/25 at 3:12 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that she updated care plans. The MDS Coordinator stated that she used to care plan for every fall but that became convoluted and now the care plan just reflected the date of the fall. The MDS Coordinator stated that she did not update the Kardex. The MDS Coordinator stated that the IDT tried to come up with interventions after every fall, but if there was not a new intervention the care plan would reflect to continue with the current interventions. The MDS Coordinator stated that IDT meeting notes used to be kept on a word document and not charted in the residents' medical records. On 1/8/25 at 3:20 PM, a follow-up interview was conducted with the DON. The DON stated that after every fall there was an IDT meeting held the next day. The DON stated that the MDS Coordinator updated the care plans for residents with new interventions after the IDT meetings. The DON stated that she would tell the staff verbally about what new fall interventions were put into place. The DON stated that she expected staff to know what fall interventions residents had and ensure they were being followed. On 1/8/25 at 4:02 PM, an interview was conducted with the Administrator (Admin) and Regional Nurse Consultant (RNC). The Admin stated that the IDT team tried to find out what the root cause for the fall was so that interventions for the falls made sense. The Admin stated that there needed to be an intervention put in place after every fall. The Admin stated that the DON was responsible for letting the floor staff know of the fall interventions for the residents. The Admin stated that resident 41 fell a lot. The Admin stated that a fall mat was placed on the floor next to resident 41's bed and was placed in the lowest position. The Admin stated that resident 41 received a new tilt wheelchair to help her stay up in the chair because resident 41 did not have good upper body control. The Admin stated that resident 41's latest fall out of a wheelchair was because resident 41 was placed in a normal wheelchair and not the tilt wheelchair. The Admin stated that she was not sure what staff member placed resident 41 in the wrong wheelchair. The Admin stated that she expected the floor staff to know what all interventions were for residents. The RNC stated that the new intervention after the fall on 1/5/25, was placed in risk management notes and had not been added to resident 41's care plan. The RNC stated the new intervention would include that resident 41 would need one on one monitoring if in a manual wheelchair. 43212 2. Resident 52 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease with dyskinesia, dementia, insomnia, monoplegia of upper limb, dysphagia, myalgia, and muscle spasms. Resident 52's medical record was reviewed on 1/6/25 through 1/9/25. A care plan Focus initiated on 7/31/19, documented [Resident 52] is High risk for falls r/t Parkinson's disease, poor safety awareness, impaired balance, impaired mobility, impulsiveness frequently taking all of his clothing out of the closet and drawers and throwing them on the floor. The Focus was revised and canceled on 12/27/23. No new fall interventions were implemented in 2023. An annual MDS assessment dated [DATE], revealed resident 52 had a BIMS score of 3, indicating significant cognitive impairment. The assessment also revealed resident 52 required one person extensive assistance for transfers, walking, and locomotion in the facility, and toileting. A fall risk assessment dated [DATE], determined that resident 52 was a high fall risk. On 2/10/23 at 6:44 PM, a Nurses note revealed, Note text: The patient is impulsive and has poor safety awareness, attempts to walk without assistance and forgets to use a wheelchair. [Resident 52] is monitored continuously for safety due to his hx [history] of falls resulting in trauma. Pt is continent of bowel and bladder. However, due to Parkinson's has accidents when he cannot move. [Resident 52] is learning safe transferring techniques and maintaining ROM [range of motion]. On 7/27/23 at 6:22 AM, a Nurses note revealed, Note text: Pt was up majority of the night attempting to rearrange his rooms furniture. Pt was very energetic and impulsive, in [sic] was unable to reason with the patient to lie down and rest. Pt was checked on throughout the night and was found moving his bed and climbing in and out of his closet. On 8/14/23 at 4:30 AM, a fall note revealed, Note text: Found patient trying to get into his closet with his pillows and blankets during pill pass at 0430 [4:30 AM]. Patient had dry blood around his right eye. Has bump to right side of right eyebrow with dry blood. Ask patient what happened? He replied, 'riding a horse.' I questioned- Horse? He replied, 'yes, I fell off the horse.' Patient had minimal swelling noted to right top of hand. Started Neuro checks and VS. Cleansed and left open to air. On 8/14/23 at 10:07 AM, a nurses note revealed, Note text: Dr. [name redacted] here this am to see resident due to unwitnessed fall during night. new order for x-ray of right hand. On 8/15/23 at 6:23 PM, a nurses note revealed, Note text: Results from XR [x-ray] right hand received. MD [Medical Director] notified at 1000 [10:00 AM]. No new orders at this time. Patient has had no c/o [complaints of] pain this shift. Patient was using right hand to feed himself during meals. On 9/14/23 at 6:02 PM, a nurses note revealed, Note text: Small laceration noted to pt L [left] eyebrow. Pt stated he had hit his head yesterday, but was unable to say where. Neuro assessment revealed no deficits. Site cleaned and left open. MD notified. Will continue to monitor. On 9/30/23 at 12:01 AM, a fall note revealed, Note text: I and another nurse were in another resident's room across the hall when an aide yelled that [resident 52] had fallen and she needed help. I went into the room and [resident 52] was lying on the floor with his arm stuck in-between where the bed meets the frame. We immediately started calling out [resident 52's] name to see if he was conscious which he responded to his name by grunting. The aide lifted his body and I dislodged his arm from the frame and where the bed meet. We sat him on the bed and I asked the aide to get the vital cart and I looked at his arm to check for injuries. I asked him if he had hit his head and he stated, 'yes.' We began neuro checks q [every] 15 mins [minutes] and I inspected his head for injuries which I did not notice any bruising on his arms or his head at that time. He had equal hand grasps, [NAME] [Pupils equal, round, reactive to light and accommodation] was not reactive to light and his pupils were pinpoint. He was able to move all extremities. His arm was red and an indentation was noticeable from where his arm was struck. On 10/4/23 at 9:28 PM, a nurses note revealed, Note text: patient was found on the floor, face down in his room approx [approximately] 2000 [8:00 PM]. He appeared to have hit his head on the corner of the dresser in his room. There was some fairly fresh bleeding. He was helped up onto the bed and when I asked how long he had been on the floor he very quietly said 'a while.' Neuro checks and VS were started immediately. He was not out of normal limits. He was put in his WC and taken into the dining room so he could safely eat his snack. The small wound on his forehead was cleaned and antibiotic ointment was placed on the wound with a band-aid. He did deny pain. He denies LOC [loss of consciousness]. An event/alert was created. The patient was seat belted into his WC due to him constantly getting up and attempting to walk. On 10/5/23 at 10:26 PM, an event/alert charting note revealed, Type of event: Unwitnessed fall. Assessment/Observations: Vital signs and neuros are stable. Patient was up walking around without wheelchair and fought staff when we tried to redirect him back to his wheelchair. Interventions: assisted patient into wheelchair and put the seatbelt on to help with decrease the occurrence of falls. Resident reaction to interventions: noncompliant. Improvement/Decline: stable. On 10/26/23 at 2:15 PM, a Skin/Wound note revealed, Note text: CNA approaches this nurse to report resident standing in room with a 'bloody gash' to his face. Upon inspection, injury is approximately 3 cm [centimeters] in length located at the distal end of L eyebrow. Area is cleaned, TAO [Troleandomycin] and bandage applied. Denies pain at site. Resident is questioned in regards to how injury occurred; points toward sink and cabinets only. VS WNL; 134/72, P 82, RR [respiratory rate] 17, T 98.2. Bed remains in low and locked position. Frequent rounding by staff continues. On 11/2/23 at 11:02 PM, a fall note revealed, Note text: CNA found patient on floor of room, with his door closed and it appeared that he had fallen from his wheelchair and hit his head on the door knob. He was alert and oriented, did nod yes when asked if he was in pain. His pupils are PERRLA motor function WNL for patient but he does have Parkinson's. Will begin neuro checks and VS protocol. On 8/14/23, a physician progress note revealed, . HPI [History and Physical Information]: [AGE] year-old nursing home resident who fell today and has pain and swelling in his right hand. He also had a small laceration on the side of his eyebrow.Physical exam: Patient appeared unchanged except for, very small laceration on the side of his eyebrow. Patient's right had had some mild swelling. The skin was intact. There was no ecchymosis . Assessment/plan: 1. Injury of hand- Right-patient will have an x-ray of the right hand will follow-up with results. It should be noted that fall interventions were not implemented after each fall. On 1/8/25 at 12:50 PM, an interview was conducted with the DON who stated every resident was evaluated for fall risk during the admission assessment. The DON did not know the frequency that residents were evaluated for falls. The DON stated falls were documented in the care plan. The DON stated after a resident fall, an IDT meeting would be held and the staff would go through the risk management process and try to figure out what the cause of the fall was. Interventions would be changed and documented in the resident's care plan. The DON stated staff checked on the residents at least every two hours. The DON stated recently staff had been checking hourly due to so many residents having falls. The DON stated during the night when resident doors were closed, the CNA would still peek into the room to check on the resident. On 1/8/25 at 2:39 PM, an interview was conducted with the Admin who stated if a resident had an unwitnessed fall it would be reported because staff did not know what happened. The Admin stated fall risk assessments were conducted on admission, post fall, and quarterly. The Admin stated after a resident sustained a fall, they would be monitored for several days afterwards. On 1/9/25 at 8:02 AM, an additional interview was conducted with the DON who stated resident 52 had bad Parkinson's and often got frozen. The DON stated resident 52 wanted to do everything by himself including feeding himself even though it was messy. The DON stated resident 52 was non-verbal, and could not walk although he thought he could. The DON stated resident 52 was in a wheelchair about 99% of the time. The DON stated resident 52 would sit on the side of his bed while in his room. The DON stated she thought resident 52 was an old bronco rider. The DON stated resident 52 was a fall risk in the sense that he had really bad Parkinson's. The DON stated she never saw resident 52 fall, but also was not in the facility much at the time resident 52 was a resident. The DON stated resident 52's bed was in the lowest position and at one point the staff moved all the furniture away from the bed. The DON stated resident 52 had a fall mat next to his bed. The DON stated staff padded everything with corners on it in his room to prevent resident 52 from bumping and injuring his head. The DON stated staff watched resident 52 like a hawk. The DON stated resident 52 was also moved close to the nurses station so he could be checked on more frequently. The DON stated both staff and residents checked on resident 52 frequently as resident 52 became increasingly impulsive and stubborn. The DON stated she was not included in the IDT meetings when resident 52 was in the facility. The DON stated she never looked at care plans, but staff would get text messages when new interventions were put into a resident's care plan. The DON stated she did not remember monitoring resident 52 for his behaviors and if resident 52 was freezing up more often, she would tell the ADON or the administrator. On 1/9/25 at 8:20 AM, an additional interview was conducted with the Admin who stated resident 52, at one time, had knee pads and a helmet to prevent injuries when he fell . The Admin stated after a while, resident 52 refused to wear the helmet. The Admin stated resident 52 slept most of the night, and staff would give him snacks during the day to keep him busy. The Admin stated resident 52 could not toilet independently, but tried occasionally. The Admin stated resident 52 was able to use the call light, but it was not always in line with when he needed care. The Admin stated their current DON did not participate in resident 52's care planning because she was not the DON at that time. The Admin stated the IDT meeting staff tried to put common sense interventions in place for resident 52. On 1/9/25 at 8:25 AM, an interview was conducted with the MDS Coordinator who stated she had been the coordinator for [AGE] years. The MDS Coordinator stated when changes were made to the care plan she was the person who put the information into the care plan. The MDS Coordinator stated when a resident had a fall, the fall would be discussed in the IDT meeting the following morning. The MDS Coordinator stated the IDT tried to put new interventions into the care plan every time a resident fell . The MDS Coordinator stated for resident 52, it was hard to find new things that could be put into place. The MDS Coordinator stated it was difficult adding actual falls each time, putting interventions in, and resolving the intervention. The MDS Coordinator stated the nurse on the floor would do the risk management documentation at the time of a fall and she would look each morning to see if there had been any events for the IDT meeting. The MDS Coordinator stated the DON was responsible for writing the note about the incident, and then the incident note would be scanned into the resident's medical record. The MDS Coordinator stated resident 52 was a high fall risk. The MDS Coordinator stated they were always trying to put new things into resident 52's care plan and put every thing they could think of. The MDS Coordinator stated the only CNA's that would remember resident 52 would be working at night. On 1/9/25 at 8:55 AM, an interview was conducted with CNA 5 who stated if she came upon a resident who had sustained an unwitnessed fall, she would ask the resident if they knew how they fell , how long they had been down, and if they hit their head. CNA 5 also stated she would contact a nurse to have the resident evaluated. CNA 5 stated she would ensure the resident's bed was lowered to the floor so they did not fall again, and put a protective padding down so if another fall was sustained, the resident would have a soft landing area. CNA 5 stated she would check the resident's vital signs after the nurse had assessed the resident. CNA 5 stated she found out how much assistance the resident needed by looking in the area of the resident's chart where nurses were able to leave notes for them. On 1/9/25 at 9:07 AM, an interview was conducted with the Medical Records (MR) staff who stated resident 52 had Parkinson's and dementia. The MR stated resident 52 would get up and walk, and then his legs would freeze up on him and he would fall to his knees, then get back up and went. The MR stated resident 52 had hallucinations quite a bit, and would fall a lot. The MR stated resident 52 was very impulsive and would jump up and start walking. The MR stated resident 52 was more confused at night. The MR stated the IDT and the MDS Coordinator were the staff who would [TRUNCATED]

Based on observation and interview, the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistant, and resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Specifically, the nurse staffing data was not posted on a daily basis and the nurse staffing data was not complete. Findings included: On 1/6/25 at 4:21 PM, an observation of the nurse staffing information was completed. The nurse staffing information was dated 1/5/25, and did not include the actual hours of the licensed and unlicensed nursing staff. On 1/8/25 at 8:00 AM, an observation of the nurse staffing information was completed. The nurse staffing information was dated 1/5/25, and did not include the actual hours of the licensed and unlicensed nursing staff. On 1/8/25 at 9:14 AM, an interview was conducted with the Director of Nursing (DON). The DON stated Medical Records (MR) was responsible to post the nurse staffing information. The DON stated MR worked Sunday through Thursday and was not sure who did the post when she was off. On 1/8/25 at 9:18 AM, an interview was conducted with MR. MR stated she was responsible for posting the nurse staffing information. MR stated she worked Sunday through Wednesday and on Sundays she worked on the floor as a nurse and was not always able to post the nurse staffing information. On 1/9/25 at 10:13 AM, an interview was conducted with the Administrator (Admin). The Admin stated she was not aware that the nurse staffing information had to be posted.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer, walk-in refrigerator, and dry food storage room were open to the air and several areas throughout the kitchen had floor tiles that were damaged. Findings included: On 1/6/25 at 1:50 PM, an initial walk-through of the kitchen was conducted. In the walk-in refrigerator, three containers with green lids were observed to be without labels or dates. The tall container contained a thin, creamy liquid. One of the short containers contained a meat patty, and the other short container contained what appeared to be sliced meat. In the walk-in freezer, a box of cinnamon roll dough was found to be open to air. In the dry storage room, a box of bacon bits was open to air. An observation in the dish machine area revealed a large area from the drain on the floor to under the dish machine that had damaged floor covering and the cement was exposed. On 1/8/25 at 11:27 AM, a second walk-through of the kitchen was conducted. In the walk-in freezer, a package of baked biscuits was open to air and a box of cookie dough was open to air. In the dry storage room, a box of dry lasagna noodles was found to be open to air. The floor covering near the three sink area was chipped and the cement was exposed. The floor covering by the walk-in refrigerator was damaged and the cement was exposed. The floor covering by the food preparation area was damaged and the cement was exposed. The floor covering by the bulk storage containers was damaged, and the floor covering under the fire extinguisher was damaged. On 1/9/25 at 10:28 AM, an interview was conducted with the Dietary Manager (DM) who stated when food deliveries were made, food was initially put into the refrigerator, freezer, and dry storage areas. The DM stated after taking temperatures on the milk that was delivered, the boxed items were put away as soon as possible in their respective areas. The DM stated as food items were put away, the staff member should be putting the delivery date on the container. The DM stated when the container was opened, an open date should be put on the container and a use by date also put on the container. The DM stated she also had a reference book that she referred to so the proper expiration date could be documented on the food item. The DM stated if food was not stored correctly, the food quality decreased. The DM stated if she found a food item that was not stored properly, she would get rid of it. The DM stated she tried to conduct in-services with the dietary staff monthly to educate them about what was expected in the kitchen. The DM stated kitchen staff had been requesting repairs to the floor in the kitchen for years. The DM stated she had discussed the floor with the current Administrator. The DM stated the previous Administrator was going to have the floor replaced, but it never got done. The DM stated having rough surfaces on the floor, and open cement was a contamination issue. The DM stated the consultant Registered Dietitian (RD) came to the facility every three months. The DM stated when the RD came to the facility he would conduct a kitchen audit, including sanitation reviews, and would meet with her when finished. The DM stated the RD would email the audit to her and she would correct the necessary items. The DM stated the Administrator and the Assistant Director of Nursing were involved in making sure corrections from the audit were maintained.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 5 out of 39 sampled residents, a residents feeding tube was not capped when not in use, staff did not wear Personal Protective Equipment (PPE) while providing high contact care for residents on Enhanced Barrier Precautions (EBP), staff were not performing hand hygiene between resident care, and the Hoyer lift was not sanitized between resident use. Resident identifiers: 5, 19, 23, 29, and 348. Findings included: 1. Resident 348 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, encounter for surgical aftercare following surgery on the nervous system, hemiplegia, traumatic subarchnoid hemorrhage with loss of consciousness, gastrostomy status, pressure ulcer of right buttock stage 2, essential hypertension, and alcohol abuse. On 1/6/25 at 2:50 PM, an observation was made of resident 348. Resident 348 had a feeding tube running. Resident 348's room did not have an EBP sign posted. On 1/7/25 at 11:43 AM, an observation was made of resident 348. Resident 348 was observed to be sitting up near the nurses station in a wheelchair. Resident 348 was disconnected from her tube feeding. On 1/7/25 at 11:44 AM, an observation was made of resident 348's feeding tube. Resident 348's feeding tube did not have a cap connected to the end of the line. On 1/8/25 at 8:39 AM, an observation was made of an EBP sign on resident 348's door. On 1/8/25 11:33 AM, an observation was made of Licensed Practical Nurse (LPN) 1 unhooking resident 348 from her tube feed. LPN 1 was not wearing a gown when she provided cares to resident 348. On 1/8/25 11:39 AM, an observation was made of resident 348's feeding tube. Resident 348's feeding tube was not capped on the end of the line. On 1/8/25 at 2:59 PM, an observation was made of resident 348's tube feed not running and the feeding tube was not capped on the end of the line. On 1/7/25 at 03:38 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 348 was getting out of bed more often and her tube feedings were paused. The ADON stated resident 348's feeding tube should be cleaned daily with soap and water. The ADON stated that the feeding tube should be capped on the end of the line when not in use. The ADON stated that resident 348 did not have any transmission precautions for a gastrostomy tube. On 1/8/25 at 8:53 AM, a follow up interview was conducted with the ADON. The ADON stated that she did some research and found out that tube feedings required EBP. The ADON stated that she placed an EBP sign on resident 348's door. On 1/8/25 at 8:55 AM, an interview was conducted with LPN 1. LPN 1 stated that resident 348's feeding tube was cleaned daily with wipes. LPN 1 stated that when resident 348's tube feed needed to be disconnected, she would unhook the tube and flush the tube. LPN 1 stated that she would then hang the tube on a clamp. LPN 1 stated she would only wear gloves when she provided care for resident 348. On 1/8/25 at 9:48 AM, and interview was conducted with the Director of Nursing (DON). The DON stated that a Certified Nursing Assistant (CNA) would alert the nurse when a resident needed to be unhooked from their tube feed. The DON stated that she expected the nursing staff to at least wear gloves when they performed cares for a resident with a tube feed. The DON stated that when disconnected the feeding tube should be clamped and plugs placed on the end of the line. On 1/8/25 at 2:11 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that she only wore gloves when providing cares for resident 348 and that resident 348 did not have any precautions. 44640 2. On 1/6/25 at 4:14 PM, an observation was made of CNA 4. CNA 4 took the Hoyer lift from resident 5's room to resident 29's room. The Hoyer lift was not cleaned prior to resident use. Resident 29 was placed in a wheelchair using the Hoyer lift. The Hoyer lift was not sanitized after use. No Hand Hygiene (HH) was observed after resident cares. On 1/6/25 at 4:21 PM, an observation was made of CNA 4. CNA 4 took the Hoyer lift from resident 29's room into resident 23's room and stated, Hey [resident name redacted] you ready to get up? The Hoyer lift was not observed to be cleaned prior to use. Resident 23 was placed in a wheelchair from his bed. The Hoyer lift was not sanitized after use. Resident 23 was observed to be on EBP. No HH was observed after resident cares. On 1/6/25 at 4:32 PM, an observation was made of CNA 4. CNA 4 took the Hoyer lift from resident 23's room into resident 19's room. Resident 19 was observed to be lying in bed, CNA 4 closed the door. Upon opening the door, resident 19 was in a wheelchair with the Hoyer sling underneath him. The Hoyer lift was not observed to be sanitized after use. No HH was observed after resident cares. On 1/6/25 at 5:10 PM, an interview was conducted with CNA 4. CNA 4 stated he was the only CNA down the 400 hallway, it was a pretty busy hallway and he was able to complete most of the task by himself. On 1/7/25 at 11:15 AM, an observation was made of CNA 4. CNA 4 took the Hoyer lift into resident 29's room. Resident 29 was observed to by lying in bed. Resident 29 was observed to be brought out of the room in a wheelchair. The Hoyer lift was not sanitized after use. No HH was used after resident cares. On 1/7/25 at 11:24 AM, an observation was made of CNA 4. CNA 4 took the Hoyer lift into resident 23's room. Resident 23 was observed to by lying in bed prior to the door closing. Resident 23 was observed to be brought out of the room in a wheelchair. The Hoyer lift was not sanitized after being used in resident 23's room. No HH was observed after resident cares. On 1/7/25 at 11:32 AM, an observation was made of CNA 4. CNA 4 took the Hoyer lift into resident 19's room. Resident 19 was observed to by lying in bed prior to the door closing. Resident 19 was observed to be brought out of the room in a wheelchair. The Hoyer lift was not sanitized after being used in resident 19's room. No HH was observed after resident cares. On 1/7/25 at 1:49 PM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated the Hoyer lifts were cleaned everyday but she was not sure if it was recorded anywhere. NA 1 stated hand hygiene was done before and after resident cares. On 1/7/25 at 2:31 PM, an interview was conducted with CNA 4. CNA 4 stated that basically, he can use the Hoyer lift on some of these guys by myself. CNA 4 stated he was the only CNA down the 400 hallway so he did it himself without any help. CNA 4 stated the Hoyer lifts were cleaned every night shift, he thought. CNA 4 stated that he did not clean the Hoyer lifts. CNA 4 stated everyone should clean their hands after they help the residents. On 1/7/25 at 2:50 PM, an interview was conducted with the CNAC. The CNAC stated the Hoyer lift was cleaned by housekeeping but she was not sure how often. The CNAC stated the staff were expected to clean their hands with sanitizer or by washing them after each resident's cares. On 1/8/25 at 10:08 AM, an interview was conducted with Housekeeper (HSK) 1. HSK 1 stated they did not have regularly scheduled cleaning that they were in charge of for the Hoyer lifts. HSK 1 stated she would wipe the Hoyer lift down if she saw that it was dirty but she did not clean them routinely. On 1/8/25 at 11:00 AM, an interview was conducted with the Administrator (Admin). The Admin stated the Hoyer lift should be cleaned in between each resident use. The Admin stated the staff should always keep their hands clean. On 1/8/25 at 4:44 PM, an interview was conducted with the DON. The DON stated the staff should be cleaning the Hoyer lifts in between each resident usage and if they were dirty. The DON stated there were some resident rooms with EBP so we need to make sure they were being cleaned, especially if the Hoyer lifts were used in those rooms. The DON stated she encouraged the staff to wash their hands with soap and warm water after caring for the residents but if they could not do that then hand sanitizer should be used. 3. On 1/6/24 at 4:21 PM, an observation was made of CNA 4. CNA 4 entered resident 23's room with the Hoyer lift, CNA 4 did not don PPE. Signage on the door documented the resident was on EBP and Everyone needed to wash hands, wear gloves and a gown when performing high contact resident activities. Which included: dressing, transferring, providing hygiene, device care . Resident 23 was observed to by lying in bed. No PPE was observed outside of the resident's room. CNA 4 was observed to then exit resident 23's room with the resident who was now in a wheelchair. No HH was performed. On 1/7/24 at 11:24 AM, an observation was made of CNA 4. CNA 4 entered resident 23's room with the Hoyer lift, CNA 4 did not don PPE. Resident 23 was observed to by lying in bed. No PPE was observed outside of the resident's room. EBP signage was in place. CNA 4 was observed to then exit resident 23's room after cares with resident 23 now in a wheelchair. No HH was performed.

Based on interview and record review, the facility did not ensure that alleged violations involving abuse were reported immediately but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to officials including the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 6 out of 39 sampled residents, allegations of resident to resident abuse and injuries of unknown origin were not reported timely to the SSA or APS. In addition, allegations of resident to resident sexual abuse and neglect were not reported to the SSA or APS. Resident identifiers: 13, 17, 31, 36, 49, and 53. Findings included: 33215 1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hypertensive chronic kidney disease, asthma, heart failure, major depressive disorder, essential hypertension, and pressure ulcer stage two. On 1/6/25 at 2:56 PM, an interview was conducted with resident 13. Resident 13 stated she had a resident to resident incident in the dining room the other day. Resident 13 stated that one little old man that ate in the dining room was a little on the horny side and he gave resident 13 a big kiss on the mouth. Resident 13 stated the Assistant Director of Nursing (ADON) saw the incident and the Social Services Supervisor spoke to the male resident about the incident. Resident 13 stated it embarrassed her to pieces. Resident 13 stated that she thought he was going to do it again the other day but he did not. Resident 13 stated that she thought she was going to have to eat in her room to avoid the male resident. (Note: Resident 13 was unable to recall the male resident's name.) Resident 13's medical record was reviewed on 1/7/25 through 1/9/25. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 13 had a Brief Interview for Mental Status (BIMS) score of 12. A BIMS score of 8 to 12 indicated moderate cognitive impairment. On 1/7/25 at 2:09 PM, an interview was conducted with the Social Services Supervisor. The Social Services Supervisor stated that yes the kissing incident did happen in the dining room with resident 13 and resident 36. The Social Services Supervisor stated that she had reported the incident to the Administrator (Admin) because the incident was observed by a Certified Nursing Assistant (CNA) and the CNA reported the incident to the nurse. The Social Services Supervisor stated that the incident happened recently possibly within the last month. Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, chronic kidney disease, essential hypertension, senile degeneration of brain, legal blindness, and dorsalgia. Resident 36's medical record was reviewed on 1/7/25 through 1/9/25. A quarterly MDS assessment dated [DATE], documented that resident 36 had a BIMS score of 14. A BIMS score of 13 to 15 indicated intact cognition. On 1/8/25 at 8:17 AM, an interview was conducted with CNA 2. CNA 2 stated that she remembered the incident between resident's 13 and 36 and she had wrote a report and gave it to the ADON. CNA 2 stated she could not remember the day or time but she was thinking it was either lunch or dinner. CNA 2 stated she was taking a resident to the dinning room and had seen resident's 13 and 36 to her right out of her peripheral talking. CNA 2 stated that she heard a smooching sound like kissing and saw resident's 13 and 36 kissing and holding hands. CNA 2 stated that she told resident 36 hey. CNA 2 stated that she was shocked, she told the nurse right away, and wrote an incident report. CNA 2 stated that staff were told to observe the residents more often and make sure they were not sitting together in bingo or other activities. On 1/8/25 at 8:29 AM, an interview was conducted with the ADON. The ADON stated that she was standing at the nurses station by the medication cart when the CNA came out of the dining room and told her what happened. The ADON stated that she went into the dining room and resident 36 was still at resident 13's table and nothing was going on. The ADON stated that she stood by the table hoping that resident 36 would walk away. The ADON stated that after resident 36 walked away she asked resident 13 what happened and resident 13 stated that nothing happened. The ADON stated she asked resident 13 if she was sure nothing happened and resident 13 stated that she was fine. The ADON stated that resident 13 made a kissing sound and laughed. The ADON stated that resident 13 was child like about the incident. On 1/8/25 at 10:52 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was at the facility when the incident happened and the CNA came to her office and reported what had happened. The DON stated she did not talk to the residents but she knew about the situation. On 1/8/25 at 11:02 AM, an interview was conducted with the Admin. The Admin stated that they talked about the incident in morning meeting. The Admin stated that resident 13 was not quite sure if anything had happened and kind of giggled about the incident. The Admin stated that resident 36 stated the incident did not happen and kind of giggled about the incident. The Admin stated that yes the incident should have been reported to the SSA. The Admin asked if the incident should be reported even if the residents did not know anything about the incident? On 1/8/25 at 12:11 PM, a follow up interview was conducted with the Admin. The Admin stated if she received a statement regarding abuse, it would be an official statement of what happened and if the staff spoke to her it would be official. The Admin stated the time line for reporting to the SSA was two hours. The Admin stated she would start investigating the allegation right away. The Admin stated she would interview the person it happened to, the person who came upon the scene, people down the hall, the nurses, and other residents. The Admin stated that she would try to get a general idea if it was neglect, a systemic problem, or isolated. 2. Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease, nondisplaced intertrochanteric fracture of left femur, encounter for other orthopedic aftercare, senile degeneration of brain, dementia, mood disorder, visual hallucinations, essential hypertension, and history of falling. Resident 53's medical record was reviewed on 1/9/25. On 8/27/23 at 1:19 PM, a Nurses Note documented Note Text: Resident was in the dining hall when [resident 31] moved passed [sic] her and resident got out of her wheelchair to hit [resident 31] (Resident believes she has been sleeping with her husband) and fell , resident is crying and was wheeled back to room where she was checked for bruising, no bruising apparent, did not hit head, will continue to evaluate. On 8/27/23 at 5:28 PM, a Fall Note documented Note Text: 1330 [1:30 PM]-Patient resting in bed and appeared to want to be left alone, would not allow nurse to assess. Kept eyes closed and appeared to ignore presence of nurse. Denied pain medication at this time. Kept checking on patient, pt [patient] sleeping. 1416 [2:16 PM]-[name redacted] (daughter) notified of pt's fall and no injuries noted at this time, will continue to monitor. 1630 [4:30 PM]-Pt appeared to have calmed down. Tylenol 650 mg [milligrams] administered at this time. No bruising to BLE [bilateral lower extremities] noted. Pt c/o [complains of] pain to left hip/upper thigh region. Patient reports that she is not able to lift her leg. Patient grimacing and cries out when attempting to move left leg. DON notified at 1636 [4:36 PM]. Non-emergency transport called at 1640 [4:40 PM]. Report given to [name redacted] at [name redacted] ER [emergency room ] at 1648 [4:48 PM]. Attempted to update daughter, [name redacted] on pt's condition and transfer to ER but no answer at this time. Left a message to return phone call at 1652 [4:52 PM]. MD [Medical Director] updated on pts condition and transfer to ER at 1723 [5:23 PM]. Patient left facility at 1715 [5:15 PM]. On 8/27/23 at 6:49 PM, a Nurses Note documented Note Text: Patient had x-ray done, has a fractured femur (neck). MD notified at 1836 [6:36 PM]. Form 358 Facility Reported Incidents documented that staff became aware of the event on 8/27/23 at 1:19 PM. The Admin became aware of the event on 8/28/23 at 8:58 AM. The SSA was notified of the event on 8/28/23 at 10:49 AM, and APS was not notified. On 1/9/25 at 8:48 AM, an interview was conducted with the Admin. The Admin stated any time abuse was suspected we should be contacting APS. The Admin stated with the past two Administrators they were told if we had anything happen during the night it could wait until the next morning and discuss the incident during the morning meeting. The Admin stated she would get report in the morning meeting and would then report within two hours to the SSA. 43212 3. Resident 49 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia without behavioral disturbance, severe protein-calorie malnutrition, epilepsy, and insomnia. Resident 49's medical record was reviewed on 1/6/25 through 1/9/25. On 6/19/23 at 9:46 AM, a nurse's progress note revealed, Note text: resident noted to have c/o pain in right shoulder and arm. Dr. [Doctor] [name redacted] notified new order for x-ray of right shoulder and humerus. On 6/19/23 at 1:58 PM, a nurse's progress note revealed, Note text: notified by social services that resident did have a dislocated right shoulder and was sent to the ER. On 6/19/23 at 6:00 PM, a nurses progress note revealed, Note text: resident returned from ER right arm in a sling .new order for resident to keep right arm for support to decrease changes of dislocating. Form 358 Facility Reported Incidents documented that staff became aware of the incident on 6/19/23 at 9:14 AM. The Admin was notified on 6/21/23 at 9:00 AM. The SSA was notified of the incident on 6/21/23 at 7:56 PM. On 1/8/25 at 12:50 PM, an interview was conducted with the DON who stated the facility policy for reporting injuries of unknown origin was that when a nurse became aware of a resident's injury, after assessing for the safety of the resident, the nurse would notify the DON and the Admin. The DON stated the Admin was responsible for reporting to the SSA as soon as she was made aware of the incident. The DON stated if the incident happened during the day, the DON and the Admin would be notified verbally during the day. The DON stated if an incident happened during the night time hours, the DON and Admin would be notified the following day. The DON stated the Admin reported to the SSA as soon as she was made aware of the incident. On 1/8/25 at 1:16 PM, an interview was conducted with the Admin who stated if abuse was suspected she would report the incident within two hours. The Admin stated if abuse was not suspected, she would find out the next morning and then submit the report. The Admin stated she found out about incidents that happened during the night at the morning stand up meeting. The Admin stated all staff were aware that she was the abuse coordinator and who to report to. 44640 4. Resident 17 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, protein calorie malnutrition, dementia, unsteadiness on feet, foot drop of right foot, adult failure to thrive, sexual dysfunction, bilateral primary osteoarthritis of hip, and insomnia. Resident 17's medical record was reviewed on 1/6/25 through 1/9/25. A care plan focus of Activities of Daily Living (ADLs) Self-care deficits related to impaired cognition, hemiplegia, impaired mobility and balance documented that resident 17's strength, coordination, and mobility had deteriorated. He would maintain current level of function in ability to participate in adls through the review date of 10/24/24. With an intervention that included monitor resident and report any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. A nursing progress note dated 11/9/24 at 4:37 PM, documented, Heard resident yelling and swearing in his room around 1500 [3:00 PM]. Entered room and resident was lying on his back with head resting on drawers across from bed. Blood smear noted on drawer face. Assisted to wheelchair x [by] 3 staff members and assessed resident. There was 1/4 cm [centimeter] lac [laceration] to back of scalp and was no longer bleeding. Started frequent VS [vital signs] and neuro [neurological] checks. DON, ADON, Dr. [name redacted] and brother [name redacted] were notified. Exhibit 358 was not located in the abuse log provided by the facility. On 1/7/25 at 9:30 AM, an interview was conducted CNA 4. CNA 4 stated resident 17 had experienced some falls with injuries but had not had any recently. CNA 4 stated that when a resident was on a one on one that meant the staff member was always with the resident. On 1/9/25 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated the resident was on a one on one but she was unsure if the staff were with him when he had his falls, he fell a lot. LPN 2 stated that when he fell she did report it to the administration as she was supposed to with any incident like that. On 1/9/25 at 9:15 AM, an interview was conducted with the Admin. The Admin stated she may have reported the fall on 11/9/24, but she could not remember. The Admin stated that she probably did not report it because she did not think she needed to report anything unless it was a fracture. The Admin stated she did not have a report for the fall. The facility Resident Abuse Procedural Summary documented . REPORTING The supervisor will be responsible for taking immediate triage actions and once the resident's safety is insured, to report the abuse to the appropriate individuals along with the individual that discovered the incident. 1. All employees and contractors who suspect that a resident has been abused, such as yelled at or intimidated, pushed or hit, or sexually assaulted must IMMEDIATELY report their suspicions to the supervisor on duty in the facility. This also includes incidents when a resident or someone else tells you about possible abuse, and also includes whether the abuse may have happened from facility staff (which includes all employees of [name redacted] and its facilities, including corporate employees, officers and director), other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. 2. The same is true for suspected neglect, such as when a resident does not receive the care he or she should, if the resident's property is taken, if they have bruising or other injuries, or if they are being taken advantage of. 3. The Supervisor will be responsible to make sure the Administration and Director of Nursing is made aware of your concerns. 4. The Administrator and Director of Nursing will be responsible for reporting the concerns, as required by law, and conducting the investigation. 5. Any time you have a concern about possible abuse, you MUST bring your concern to the supervisor immediately. If you suspect that your supervisor has abused a resident, contact the Administrator or DNS [Director of Nursing Services] directly. Do not make the decision yourself about whether abuse may have occurred or not. You will not be retaliated against for reporting you [sic] concerns.

Based on interview and record review, the facility in response to allegations of abuse, neglect, or mistreatment did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 13 out of 39 sampled residents, allegations of resident to resident sexual abuse, injuries of unknown origin, and neglect were not investigated or the allegations were not investigated thoroughly. Resident identifiers: 13, 17, 32, 36, 46, 47, 48, 49, 50, 52, 51, 54, and 55. Findings included: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hypertensive chronic kidney disease, asthma, heart failure, major depressive disorder, essential hypertension, and pressure ulcer stage two. On 1/6/25 at 2:56 PM, an interview was conducted with resident 13. Resident 13 stated she had a resident to resident incident in the dining room the other day. Resident 13 stated that one little old man that ate in the dining room was a little on the horny side and he gave resident 13 a big kiss on the mouth. Resident 13 stated the Assistant Director of Nursing (ADON) saw the incident and the Social Services Supervisor spoke to the male resident about the incident. Resident 13 stated it embarrassed her to pieces. Resident 13 stated that she thought he was going to do it again the other day but he did not. Resident 13 stated that she thought she was going to have to eat in her room to avoid the male resident. (Note: Resident 13 was unable to recall the male resident's name.) Resident 13's medical record was reviewed on 1/7/25 through 1/9/25. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 13 had a Brief Interview for Mental Status (BIMS) score of 12. A BIMS score of 8 to 12 indicated moderate cognitive impairment. On 1/7/25 at 2:09 PM, an interview was conducted with the Social Services Supervisor. The Social Services Supervisor stated that yes the kissing incident did happen in the dining room with resident 13 and resident 36. The Social Services Supervisor stated that she had reported the incident to the Administrator because the incident was observed by a Certified Nursing Assistant (CNA) and the CNA reported the incident to the nurse. The Social Services Supervisor stated that the incident happened recently possibly within the last month. Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, chronic kidney disease, essential hypertension, senile degeneration of brain, legal blindness, and dorsalgia. Resident 36's medical record was reviewed on 1/7/25 through 1/9/25. A quarterly MDS assessment dated [DATE], documented that resident 36 had a BIMS score of 14. A BIMS score of 13 to 15 indicates intact cognition. On 1/8/25 at 8:17 AM, an interview was conducted with CNA 2. CNA 2 stated that she remembered the incident between resident's 13 and 36 and she had wrote a report and gave it to the ADON. CNA 2 stated she could not remember the day or time but she was thinking it was either lunch or dinner. CNA 2 stated she was taking a resident to the dinning room and had seen resident's 13 and 36 to her right out of her peripheral talking. CNA 2 stated that she heard a smooching sound like kissing and saw resident's 13 and 36 kissing and holding hands. CNA 2 stated that she told resident 36 hey. CNA 2 stated that she was shocked, she told the nurse right away, and wrote an incident report. CNA 2 stated that staff were told to observe the residents more often and make sure they were not sitting together in bingo or other activities. On 1/8/25 at 8:29 AM, an interview was conducted with the ADON. The ADON stated that she was standing at the nurses station by the medication cart when the CNA came out of the dining room and told her what happened. The ADON stated that she went into the dining room and resident 36 was still at resident 13's table and nothing was going on. The ADON stated that she stood by the table hoping that resident 36 would walk away. The ADON stated that after resident 36 walked away she asked resident 13 what happened and resident 13 stated that nothing happened. The ADON stated she asked resident 13 if she was sure nothing happened and resident 13 stated that she was fine. The ADON stated that resident 13 made a kissing sound and laughed. The ADON stated that resident 13 was child like about the incident. On 1/8/25 at 10:52 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was at the facility when the incident happened and the CNA came to her office and reported what had happened. The DON stated she did not talk to the residents but she knew about the situation. On 1/8/25 at 12:11 PM, an interview was conducted with the Administrator (Admin). The Admin stated if she received a statement regarding abuse, it would be an official statement of what happened and if the staff talked to her it would be official also. The Admin stated the time line for reporting to the State Survey Agency (SSA) was two hours. The Admin stated she would start investigating the allegation right away. The Admin stated she would interview the person it happened to, the person who came upon the scene, people down the hall, the nurses, and other residents. The Admin stated that she would try to get a general idea if it was neglect, a systemic problem, or isolated. The abuse allegation was not reported to the SSA and an investigation was not conducted. 43212 2. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included left femur fracture, heart failure, asthma, iron deficiency anemia, and hypokalemia. Resident 46's medical record was reviewed on 1/6/25 through 1/9/25. On 5/24/23 at 12:25 PM, a Form 358 Facility Reported Incident was received by the SSA. The report documented, Resident was complaining of pain to left hip. After taking Ibuprofen, pain continued. Resident did not want to get back into bed. Assessment was given by MD [Medical Director] for further evaluation. Resident taken to ER [emergency room ] for x-ray. The incident report documented the resident sustained a fractured left hip with no change in behaviors until the pain started. The report also noted that the resident's odd behavior was refusing to get into bed. The report documented that no other agencies were notified of the resident's injury. On 5/30/23 at 1:45 PM, a Form 359 Follow-up Investigation Report was received by the SSA. The 359 report documented, Resident mentally is aware and would remember falls. Resident complained of pain in the left hip. [Resident 46] does not remember falling or hitting anything that would have broken her hip. The summary of witness and staff interviews stated, Nurse on shift, gave resident ibuprofen and the pain continued. Resident did not want to get into bed. After further evaluated, nurse contacted MD for further evaluation. The investigative summary revealed, Resident was transferred back from ER. Waiting on x-ray but hip has potential FX [fracture]. Resident given Eliquis Oral Tablet 2.5 MG [milligrams] (Apixaban); Give 1 tablet by mouth two times a day for ORIF [Open reduction and internal fixation] procedure for 42 days. The investigative finding stated, Inconclusive .injury source is unknown, and resident cannot remember the cause of injury. Corrective action included, Staff have been instructed to be quicker to call lights and inservice planned for falls and non-witnessed falls. On 1/8/25 at 1:21 PM, an interview was conducted with the Admin who stated she did not know how resident 46 fractured her hip. On 1/8/25 at 1:55 PM, an interview was conducted with the MDS Coordinator who stated the cause of resident 46's hip fracture was that she sat down onto the toilet really hard and after that began to complain of hip pain. It should be noted that additional investigation interviews and documentation was requested, but not provided. 3. Resident 47 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of brain, type 2 diabetes, dementia with moderate agitation, heart failure, peripheral vascular disease, atrioventricular block, osteoarthritis, and major depressive disorder. Resident 47's medical record was reviewed on 1/6/25 through 1/9/25. On 12/17/23 at 7:10 AM, Fall note: Note text: Aide reports to LN [licensed nurse] last rounds, patient found on floor. Initiate assessment. LN asked patient questions on his fall. Patient gestured he fell out of bed. Patient has a bump to top, back of head. Small skin tear, 1.5 cm [centimeters] x [by] 1.5 cm to right great toe. Site cleansed and applied band-aid. Patient moves all extremities. Denied pain. Got patient back in his bed and started neuro checks and vital signs. Neuro [neurological] checks and vital signs WNL [within normal limits]. MD notified. ADON notified. On 12/27/23 at 10:42 AM, a Form 359 Follow-up Investigation Report was received by the SSA. The report documented, No additional harm to the resident has occurred. The report also documented other agencies had not been notified. In the summary of the interviews with the resident it was documented, When [resident 47] was first found after the fall he gestured that he had fallen and was okay. When resident advocate went to talk to resident he did not remember the fall. The summary of interviews with witnesses revealed, Shift nurse stated that resident had fell and when they were helping the resident, back up and get comfortable. He was able to tell them what happened. The summary of interviews with responsible staff revealed, Shift nurse stated that resident had fell and when they were helping the resident, back up and get comfortable. He was able to tell them what happened. They were able to do neuros and vitals. Nurse was able to find a small skin tear on the toe, closed would with bandage. Under investigative summary it documented, Resident is at baseline and safe. The report documented the allegation was inconclusive as resident was able to gesture what happened however we could not exactly see how the resident fell . Corrective action taken stated, fall mat has been placed, we have also put resident on more frequent checks throughout the night. The plan for oversight included, increased training on residents that are not non-verbal or speak another language that is not common for most. It should be noted that additional investigative documentation was requested and not provided. 4. Resident 49 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia without behavioral disturbance, severe protein-calorie malnutrition, epilepsy, and insomnia. Resident 49's medical record was reviewed on 1/6/25 through 1/9/25. Resident 49's physician orders included, X-ray of right shoulder and right humerus due to right upper extremity pain. one time only for 1 day no known injury. On 6/19/23 at 9:46 AM, Note text: resident noted to have c/o [Complains of] pain in right shoulder and arm Dr. [doctor] [name redacted] notified new order for x-ray of right shoulder and humerus. On 6/19/23 at 1:58 PM, Note text: notified by social services that resident did have a dislocated right shoulder and was sent to ER. A Form 358 Facility Reported Incident Report dated 6/21/23 at 7:56 PM, was received by the SSA. Resident 49 notified the shift nurse of pain in her right shoulder and could lift her arm. The nurse notified the MD and received an order for x-ray of right shoulder and humerous. Shoulder dislocation was documented as the injury that occurred. No other injury types were documented. There were no changes in resident 49's behavior. Steps taken to immediately ensure residents safety were, Resident was immediately, inspected by shift nurse and MD was notified of possible injury. Immediately taken to ER for x-ray. No witnesses were identified. No other agencies were notified. A Form 359 Follow-up investigation report was received on 6/27/23 at 3:24 PM by the SSA. The report documented, Dislocated shoulder at the time off [sic] of the event as updated information. No agencies were notified. Steps to investigate the incident included, Resident has no memory of the incident other than her shoulder began to have pain when being transported in the sling. The summary of interviews from responsible staff included, Shift believes that she was not placed properly in sling when being transported resulting in dislocated shoulder. Additional interview summary stated, Oversight staff believe that when being transferred on the lift, she was not properly lifted causing shoulder to be in pain. An investigation summary included, na [not applicable] at this time. The incident was inconclusive citing, could not verify if resident was in lift improperly or if other issues cause the injury. Corrective action taken included, Inservice on how to properly use the lifts when transferring a resident around the facility. Systemic actions included,Inservice on how to properly use the lifts when transferring a resident around the facility. aid will double up on resident that need extra care to make sure lift is done properly. Additional investigative documentation and inservice information was requested but not provided. On 1/8/24 at 2:04 PM, an interview was conducted with the Admin who stated she did not know the root cause of resident 49's shoulder dislocation. 5. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis affecting non-dominant side, vascular dementia, type 2 diabetes, protein-calorie malnutrition, major depressive disorder, congestive heart failure, hypoxemia, and iron deficiency anemia. Resident 51's medical record was reviewed on 1/6/25 through 1/9/25. On 6/24/24 at 7:41 PM, a nurses progress note revealed, Note text: resident c/o left hand pain, new order for xray. resident taken to [name redacted] for xray tolerated well. On 6/25/24 at 1:26 PM, a nurses progress note revealed, Note text: L [left] hand xray results received from [name redacted] hospital. No fx or dislocations noted. MD notified. No new orders at this time. On 6/25/24 at 10:45 AM, a Form 358 Facility Reported Incidents report was received by the SSA. The resident reported to the resident advocate [RA] that that lady grabbed her on the hand and wrist causing a bruise on her left hand. Resident 51 stated that her hand hurt. Resident 51 was unable to describe details of the person she was referring to or what exactly happened. The incident occurred on 6/23/24 at 4:45 PM, in the resident's bedroom. The report documented the resident was at baseline when describing changes in behavior. Steps taken to ensure the resident's safety was, Resident hand evaluated, xray scheduled. CNA on that shift will be moved to a different hall no suspected abuse. No witnesses were identified. No other agencies were notified. On 7/2/24 at 3:48 PM, a Form 359 Follow-up investigation report was received by the SSA. The report stated the resident was at baseline and did not sustain physical or mental harm. No agencies were notified of the incident. Steps taken to investigate the incident were documented as, Resident came to RA's office, with bruising on left hand. When asked what happened she said that lady grabbed my hand. When asked when it happened she said 'today'. [Resident 51] was unable to describe any individual. Witness interview summary included, upon investigation we spoke to shift aid, [initials redacted] who stated during the NOC [night] shift [resident 51] was on the call light multiple times requesting to changer [sic] her clothes. [Name redacted] was changing [resident 51] clothes when she felt a slight pinching on her arm, causing [name redacted] to jump from being startled. Resident was biting [name redacted] CNA arm and when she jumped from being startled, her hand hit [Resident 51] hand. Aid finish changing clothes and left the room. Summary of other resident interviews revealed, No residents had contact during noc shift. Summary of responsible staff interviews revealed,Speaking with RA she stated that [resident 51] has a pattern of accusing residents or staff of small things. However RA finds that most of these are lies and does not occur. A summary of the investigation related to the incident revealed, Resident sent out for xray. L hand xray results received from [name redacted] hospital. No fx or dislocations noted. MD notified. No new orders at this time. The conclusion of the investigation stated, Upon investigation we found that no abuse or neglect has taken place, staff reacted causing a slight bruising to resident. Resident at baseline. Corrective action taken included, Staff member has been moved to new hall, if staff member needs to go into [resident 51's] room, we currently are having her go with a second aid as a caution during this investigation. Implementation of corrective action stated, DON created a training on acting calm during all interactions with resident and to remain calm if situation like a bite happens. Steps to address systems stated, Training being planned to train staff on remaining calm in all interactions. On 1/8/25 at 2:30 PM, an interview was conducted with the Admin who stated the cause of resident 51's left had bruise had not been determined. The Admin stated staff members were being very deliberate and aware as a result of the incident. The Admin stated the staff member was moved to another area to ensure she was not triggering anything for the resident to cause behaviors. It should be noted that additional information regarding the investigation and actions taken was requested but not provided. 6. Resident 52 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease with dyskinesia, dementia, insomnia, monoplegia of upper limb, dysphagia, myalgia, and muscle spasms. Resident 52's medical record was reviewed on 1/6/25 through 1/9/25. On 8/14/23 at 3:43 PM, a Form 358 Facility Reported Incidents report was received by the SSA. The floor nurse reported, Found patient trying to get into his closet with his pillows and blankets during pill pass at 0430 [4:30 AM]. Patient had dried blood around his right eye. Has bump to right side of right eyebrow with dry blood. Asked patient what happened? He replied, 'riding a horse.' I questioned-Horse? He replied, 'yes', I fell off the horse.' Patient had minimal swelling noted to right top of hand. Started neuro checks and VS [vital signs]. Cleansed and left open to air. The report documented there were no changes in the resident's behavior and no witnesses to the fall. The report stated no other agencies were notified. On 8/21/23 at 11:08 AM, a Form 359 Follow-up Investigation Report was received by the SSA. Outcomes revealed, No additional harm or change in physical condition has occurred. The report stated the facility attempted to contact the resident's family, and as of 5:00 AM on 8/14/23, there was no answer from the resident's representative. In the interview with the resident, the report revealed, When I spoke to the resident, he does not remember the incident happening or what I am talking about. However, at the time of the incident he was riding a horse and fell off. He was found on the ground with all of his pillows and blankets. The summary of the witness interview revealed, Shift nurse-[name redacted] found [resident 52] on the ground during a room round/pill pass. Was trying to get into the closet and was on the ground. Patient stated he was riding a horse. He had dry blood, and bumps on the side of his eyebrow. A summary of the incident revealed, X-ray came back with no injuries. Patient has no pain in hand and face. In conclusion, the incident was, Inconclusive - resident was either dreaming or not in the correct mental state. Insufficient information to verify or refute anything. Corrective actions taken included, we are doing more frequent checks on room and specifically resident 52. We are doing another training on falls and how to mitigate them. Actions for oversight included, Shift nurses and admin clinical staff will monitor event and training to insure [sic] possible reduction of incidents. On 1/8/25 at 12:50 PM, an interview was conducted with the DON who stated that CNA's were the first line for information about the residents. The Regional Nurse Consultant (RNC) stated information was passed verbally, and they were encouraging staff to stop and watch the resident to get as much information as they could at the time of the event, and then alert the nurses. The RNC also stated that nurses passed information about the residents verbally as the next nurse came on shift. The RNC stated if a CNA became aware of a particular behavior for a resident they would put it in the point of care in the medical record so other staff members could see it. The RNC stated she was teaching nurses to look at the medical record Bell for updates. On 1/8/25 at 1:21 PM, an interview was conducted with the Admin who stated after submitting the Form 358 Facility Reported Incident, she would talk with the resident, the witness if there was one, and if no witness, the person who came upon the incident. The Admin then stated she would start interviewing staff and residents in the area. The Admin stated she would start implementing interventions to ensure the incident did not happen again. The Admin stated she documented all witness interviews that were conducted. The Admin stated she would have to call someone to see if an event was reportable. The Admin stated all residents were screened for fall risk upon admission, post fall, and quarterly. 44640 7. Resident 17 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, protein calorie malnutrition, dementia, unsteadiness on feet, foot drop of right foot, adult failure to thrive, sexual dysfunction, bilateral primary osteoarthritis of hip, and insomnia. Resident 17's medical record was reviewed on 1/6/25 through 1/9/25. A nursing progress note dated 11/9/24 at 4:37 PM, documented, Heard resident yelling and swearing in his room around 1500 [3:00 PM]. Entered room and resident was lying on his back with head resting on drawers across from bed. Blood smear noted on drawer face. Assisted to wheelchair x 3 staff members and assessed resident. There was 1/4 cm lac [laceration] to back of scalp and was no longer bleeding. Started frequent VS and neuro checks. DON, ADON, Dr. [doctor] [name removed] and brother [name removed] were notified. Exhibit 359 was not located in the abuse log provided by the facility. For the allegation no investigation was provided by the facility. On 1/8/24 at 11:30 AM, an interview was conducted with resident 17. Resident 17 was not interviewable at the time and answers were indiscernible. On 1/9/25 at 8:45 AM, an interview was conducted with the DON. The DON stated the resident was on a one on one observation at the time of the fall and that she was not made aware of the incident or that the resident had been injured during the fall. On 1/9/25 at 9:15 AM, an interview was conducted with the Admin. The Admin stated she may have reported the fall on 11/9/24, but she could not remember. The Admin stated that she probably did not report it because she did not think she needed to report anything unless it was a fracture. The Admin stated she did not have a report on it or did not do an investigation for the incident. The Admin stated she now knows that she should have done an investigation for the incident. 47431 8. Resident 32 was admitted to the facility on [DATE] with diagnoses which included senile degeneration of brain, epilepsy, cardiomegaly, bilateral presbycusis, and bilateral age-related cataracts. Resident 32's record was reviewed on 1/6/25 through 1/9/25. On 4/19/24 at 7:05 PM, a Nurses Note documented Note Text: 1905: [7:05 PM] CNA to nurses station stating that resident is calling out in pain when attempting to remove socks and shoes. Nurse to resident room. Pt [patient] pointing to top of foot and speaking in Navajo. Pt tells CNA that he tripped and fell and now his foot hurts. CNA translating that Pt reports pain on top of left foot. Socks and shoes removed for comparison. Pt is guarded and yells out in pain. Swelling and 2x2 bruise to lateral left foot. 1920 [7:20 PM]: ER contacted and report given to ER nurse, [name redacted]. 1925 [7:25 PM]: Resident loaded in van and transported to ED [emergency department]. [Name redacted], CNA, accompanies to act as translator. 1930 [7:30 PM]: Arrived to ED, X-rays done with confirmation of fx, boot placed, and discharge instructions received. Ibuprofen 400 mg q [every] 4 hours PRN [as needed] and Tylenol 650 mg PO [by mouth] to be alternated for pain. Dr. [name redacted] is pt PCP [primary care physician] as well as ER MD [medical doctor]. 1033 [10:33 PM]: Arrived at care center. Boot to be worn during wake hours and removed while sleeping. Pt declines pain medication at this time. Will continue to monitor. On 4/20/23 at 3:25 PM, the facility reported to the SSA that on 4/19/23 at 7:15 PM, the Resident reported pain to his left foot. The Resident was assessed and increased bruising and pain were noted. The ER was contacted and the Resident was transported to ED. The ED evaluated the pain sight and completed an Xray. The Resident received Ibuprofen and Tylenol for pain. The Resident was placed in a boot. Resident is wearing boot during wake hours and removed while sleeping. No other agencies notified. (Note: Form 358 was not located in the abuse log provided by the facility.) For the allegation no investigation was provided by the facility. 9. Resident 48 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia, senile degeneration of brain, dislocation of right shoulder joint, multiple fractures of ribs, right side, and dislocation of right hip. Resident 48's record was reviewed on 1/6/25 through 1/9/25. On 12/3/23 at 5:30 AM, a Fall Note documented Note Text: Aide report, patient was found on floor at the foot of bed with her left arm caught in the bed (between mattress and foot board, of the bed), and laying face down by the bed. Wearing no clothes, but left sock and shoe on and had only sock on right foot. She said, 'I was going to go to the bathroom, but I got my arm caught in the bed. I didn't hit my head, I slowly went down to the floor. I didn't hurt myself any where else, but my left arm getting caught in the bed.' Assessment started, assist patient back to bed, Neuro checks and Vital signs started. MD notified. ADON notified. Patient responsible for self. Call light in easy reach. Will continue to monitor. On 12/3/23 at 7:00 PM, a Nurses Note documented Note Text: Left arm is bruised the whole arm. When she moves her arm no c/o pain. Will continue to monitor. Used both hands when eating today. Form 358 Facility Reported Incidents documented on the incident summary, Shift Aid, found resident on the floor, Leg and foot was stuck in the foot of the bed. Resident was naked, with only one shoe and one sock on. Aid ran to get nurse. Resident stated that she was going to go to the bathroom and caught her arm on the bed, stated she did not hit her head. Shift nurse check vitals and neuros, ADON, MD. Form 359 Facility Reported Incidents documented a summary of interviews with the alleged victim and/or the victim's responsible party revealed, Resident does not remember the details of the incident of the event as clear as she did at the time of the event. She just remembers trying to go to the restroom and then an aid finding her and helping. She states she 'is not hurt and is fine' No psychological harm or distress at this time. Summary of interviews with witnesses and staff responsible for oversight revealed, Aids states that she found resident - left arm stuck, facing face down on the bed. Resident was without clothes on. She immediately ran and got the nurse. Nurse was able to see the situation that the nurse on shift was able to get the resident in a proper position and make sure she was safe. Performed neuros and vitals. Conclusion: the situation is inconclusive, and insufficient evidence on how resident fell . Corrective Actions Taken: Changes to bed are being made to trying to mitigate potential falls. For the allegation on 12/3/23, no investigation was provided by the facility. On 3/31/24 at 7:16 PM, a Nurses Note documented Note Text: Aide came and got LN, aide found resident on the floor by her chair face down, resident was conscious and breathing, turned resident on side bruising on R [right] cheek and on R hand noted, resident was alert. Moved patient to the bed, cleaned and bandaged wounds and took vitals, initiated neuro checks all VS and neuro checks were normal at this time. Form 358 Facility Reported Incidents documented on the incident summary, On 03/31/2024 at 8:28 PM, the facility reported that on 03/31/2024 at 6:55 PM, the Resident had an unwitnessed fall out of her chair and was found by a CNA. The Resident had hit her face and slight bruising was noted on her face and wrist. The CNA was able to successfully get the Resident up and assessed. The Resident stated feeling safe and wanted to rest in bed. Neuro check was conducted and DON, Admin and MD were notified. The Resident's bed area was checked for potential items to cause a fall is not available at this time. Form 359 was not located in the abuse log provided by the facility. For the allegation on 3/31/24, no investigation was provided by the facility. On 1/8/25 at 3:09 PM, an interview was conducted with the Admin. The Admin stated that the facility was unable to provide investigations for Resident 48 regarding the events from 12/3/23 and 3/31/24. 10. Resident 50 was admitted to the facility on [DATE] with diagnoses senile degeneration of brain, epilepsy, and unilateral primary osteoarthritis, Left hip. Resident 50's records were reviewed between 1/6/25 through 1/9/25. On 12/3/23 at 2:00 AM, Fall Note documented Note Text: Aide report, patient on floor. Patient has laceration by left eyebrow and has a bump with skin tear on top of his nose. He said he fell off the bed and hit his nose on bed rail. Assessment started. Vital signs and neuro checks started. MD notified. ADON notified. Will notify Son in the morning after 8 am. Form 358 Facility Reported Incidents documented, Shift Aide found resident on the floor, with laceration by left eyebrow. Skin is elevated with a bump and a skin tear on his nose. Resident stated that he fell off the bed and hit his nose on the railing of the bed. Shift nurse performed vitals and neuros MD [Medical Doctor] and ADON [Assistant Director of Nursing] notified. Son notified in the late morning. Form 359 was not located in the abuse log provided by the facility. For the allegation on 12/4/23, no investigation was provided by the facility. On 1/8/25 at 3:09 PM, an interview was conducted with the Admin. The Admin stated that the facility was unable to provide the investigation for Resident 50 regarding the event on 12/4/23. 11. Resident 54 was admitted to the facility on [DATE] with diagnoses which included displaced bimalleolar fracture of left lower leg, type 2 diabetes mellitus, pressure ulcer of left heal, peripheral vascular disease, and urinary tract infection. Resident 54's record was reviewed on 1/6/25 through 1/9/25. Form 358 Facility Reported Incidents documented, Family stated that resident told her she had gotten up to use the restroom, that aid did not come quickly when she pressed the call light. She went to the restroom and upon returning to her bed se fell before entering the bed. After she had fallen, she was able to get back into bed.[TRUNCATED]

Based on observation, interview, and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident. Specifically, the facility staff were taping narcotic medications back into the medication cards. Findings included: On 1/8/25 at 8:00 AM, an observation was made of the facility Team 1 medication cart with Licensed Practical Nurse (LPN) 2. The following medications were observed in the medication cart: a. A multi dose medication card which held Oxycodone 5 milligram (mg) had the back of pocket numbers 26 and 27 that were opened with tape now closing them, there were no medications observed in the pockets. b. A multi dose medication card which held Hydrocodone - Acetaminophen 5-325 mg had the back of pocket number 34 that was opened with tape now closing it, there was no medication observed in the pocket. An immediate interview was conducted with LPN 2. LPN 2 stated the nurses would do the narcotic count at change of shift. LPN 2 stated the nurses waste narcotics in the sharps container and were not supposed to tape the medications back into the medication cards. On 1/8/25 at 8:18 AM, an observation was made of the facility Team 2 medication cart with LPN 1. The following medications were observed in the medication cart: a. A multi dose medication card which held Pregamblin 100 mg had the back of pocket number 44 that was opened with tape now closing it, there was no medication observed in the pocket. b. A multi dose medication card which held Hydrocodone 10/325 mg had the back of pockets 4, 5, 6, 10, 16, 23, 24, and 25 that were opened with tape now closing them, there were no medications observed in the pockets. On 1/8/25 at 8:25 AM, an interview was conducted with LPN 1. LPN 1 stated that sometimes if a medication was accidentally pushed through the backing, then the nurse would tape it, so the medication was not lost. LPN 1 stated she was unsure how the staff would know if the medication was still clean or if the correct medication had been taped back into the medication card. LPN 1 stated she was unsure why there was tape on the medication cards in the cart. On 1/8/25 at 10:19 AM, an interview was conducted with the Administrator (Admin). The Admin stated the nurses were not supposed to tape the back of the narcotic cards, they were expected to waste the narcotic in the sharps container. The Admin stated the staff would not know if the medication was clean or if the medication was the correct medication if it had been taped back into the medication card. On 1/8/25 at 1:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there should be two witnesses to waste narcotics. The DON stated the nurses do not waste the medication if it had not touched anything or if the resident refused to take it. The medication could be taped back into the medication card, and they would hopefully be able to use it again. The DON stated the risks of taping medications back into the medication cards where the medications could potentially fall out, the medications could be dirty, and there was a chance for medication diversion.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, for 1 out of 39 sampled residents, a resident's medication was not discontinued per pharmacy and provider recommendations. Resident identifier: 17. Findings included: Resident 17 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, protein calorie malnutrition, dementia, unsteadiness on feet, foot drop of right foot, adult failure to thrive, sexual dysfunction, bilateral primary osteoarthritis of hip, and insomnia. Resident 17's medical record was reviewed on 1/6/25 through 1/9/25. A review of resident 17's physician orders revealed, hydrOXYzine HCl [hydrochloride] Oral Tablet 25 MG [milligrams] (Hydroxyzine HCl) Give 25 mg by mouth every 6 hours as needed for antianxiety. The physician's order was initiated on 10/24/24 and discontinued on 12/10/24. A review of resident 17's Patient Recommendations Summary - Practitioner recommendations documented on 11/24/24. This resident has a current order for Hydroxyzine 25 mg as needed (PRN) every 6 hours for anxiety since 10/24/24. This PRN medication has been utilized 12 times in the past 30 days. Of note, the resident has had 20 documented falls in this same month. There were notes documenting behaviors of the resident wanting to give other residents a hard time and was subsequently given hydroxyzine. If an agent was truly needed for anxiety, buspirone may be a better alternative, with less cognitive side effects than hydroxyzine. The following intervention had been preapproved by the attending medical team through verbal communication and/or protocols: 1. Discontinue hydroxyzine 2. Replace with Buspirone 5 mg PRN Review of resident 17's November 2024 Medication Administration Record (MAR) revealed that the Hydroxyzine 25 mg was administered when it should have been stopped on 11/28/24 at 9:17 PM; 11/29/24 at 6:22 AM, 12:10 PM, 6:08 PM; 11/30/24 at 12:26 AM, 7:46 AM, 3:58 PM, and 11:58 PM. Review of resident 17's December 2024 MAR revealed that the Hydroxyzine 25 mg was administered when it should have been stopped on 12/1/24 at 6:42 AM, 1:17 PM, 7:18 PM; 12/2/24 at 3:35 PM; 12/4/24 at 7:41 AM; 12/5/24 at 7:36 AM, 5:11 PM; 12/6/24 at 5:26 AM, 5:37 PM; 12/7/24 at 5:28 AM; 12/8/24 at 3:40 PM; 12/9/24 at 5:46 AM and 6:06 PM. A secure text message revealed the medical provider was made aware of the medication change on 11/25/24, by the pharmacist and agreed to the immediate discontinuation of the Hydroxyzine and the initiation of the Buspar. A written physician phone message dated 11/29/24, revealed, I had previously approved changing the Hydroxyzine to buspar, (but watch for insomnia getting worse after the change), the change didn't happen when I rounded the following day . On 1/8/24 at 10:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they have a corporate pharmacist who went through each resident's medications monthly. The DON stated herself and the Assistant Director of Nursing would then go through the recommendations and contact the doctor. The DON stated the pharmacist had usually already talked with the doctor about the recommendations. The DON stated it took about one week for the recommendations to be put into effect. The DON stated resident 17's Hydroxyzine was not discontinued as recommended because the doctor was on vacation and communication was limited.

Based on interview and record review, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 39 sampled residents, a resident who had experienced a significant weight loss did not have recommendations from the Registered Dietitian (RD) implemented. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, pneumonia, type 2 diabetes mellitus (DMII), asthma, essential hypertension, major depressive disorder, chronic pain, legal blindness, and adjustment disorder with depressed mood. Resident 4's medical record was reviewed on 1/7/25 through 1/9/25. A care plan Focus initiated on 4/14/21 and revised on 12/26/24, documented [name redacted] has nutritional problem or potential nutritional problem r/t [related to], therapeutic diet. She has DMII, she is legally blind, has major depression and disease of stomach and duodenum. She is very picky with her meals. She thinks the meat is not real unless it has a bone in it. Significant WT [weight] loss. The care plan Interventions initiated on 4/14/21, included: a. Encourage her to not hoard food especially perishable foods. b. Provide and serve diet as ordered. c. RD to evaluate and make diet change recommendations as needed. d. Set up plate in clock so she knows where her food is during meals. A Prospective Payment System 5-day scheduled Minimum Data Set assessment dated [DATE], documented that resident 4 had a Brief Interview for Mental Status (BIMS) score of 9. A BIMS score of 8 to 12 indicates moderate impaired cognition. On 9/27/24, a Diet: Nutritional Assessment documented At nutritional risk related to being blind and inadequate PO [by mouth] intake evidence by use of a plate guard to ensure PO intake and leaving more than 25% of food uneaten. On 11/24/24, a Diet: Nutritional Assessment documented At nutritional risk related to being blind, altered mental status and inadequate PO intake evidence by use of a plate guard to ensure PO intake, Dx [diagnosis]: Depressive disorder and leaving more than 25% of food uneaten. On 11/20/24, resident 4 had a documented weight of 133.4 pounds (lbs). On 12/15/24, resident 4 had a documented weight of 124 lbs. With these reference weights, resident 4 experienced a documented significant weight loss of 7.05 % during a one month interval. On 12/14/24 at 10:58 AM, a Nutrition/Dietary Note documented Note Text: Current WT: 126.2 lbs (12/1/24), WT: 137.6 lbs (11/3/24), WT: 141.6 lbs (9/2/24), WT: 143.2 lbs (6/2/24), BMI [Body Mass Index]: 24.3, current dietary order Reg [regular] /Reg, current PO intake is around 50%, resident has been refusing meals the last couple of days, has experienced a -8.3% WT change at 30 days, -10.9% WT change at 90 days and -11.9% WT change at 180 days which is a significant WT loss, BMI is WNL [within normal limits], encourage high kcal [kilocalorie] supplement Mighty Shake or Ensure if resident refuses a meal, continue to observe and f/u [follow up] prn [as needed]. The Order Summary was reviewed and a high kcal supplement Mighty Shake or Ensure was not ordered. On 12/26/24, a Diet: Nutritional Assessment documented At nutritional risk related to GI [gastrointestinal], distress, inadequate PO intake, altered mental status evidence by Dx: Constipation and Major Depressive Disorder, leaving more than 25% of food uneaten and Blind. On 7/7/24, resident 4 had a documented weight of 142.4 lbs. On 1/5/25, resident 4 had a documented weight of 124.4 lbs. With these reference weights, resident 4 experienced a documented significant weight loss of 12.64 % during a six month interval. On 10/6/24, resident 4 had a documented weight of 137.8 lbs. On 1/5/25, resident 4 had a documented weight of 124.4 lbs. With these reference weights, resident 4 experienced a documented significant weight loss of 9.72 % during a three month interval. On 1/7/25 at 8:52 AM, a Nutrition/Dietary Note documented Note Text: Current WT: 124.4 lbs (1/5/25), WT: 126.2 lbs (12/1/24), WT: 137.8 lbs (10/6/24), WT: 142.4 lbs (7/7/24), current dietary order Reg/Reg, current PO intake is around 50%, has been refusing meals, has experienced a -1.5% WT change at 30 days, -9.8% WT change at 90 days and -12.6% WT change at 180 days, WT changes at 90 and 180 days are significant, current BMI is WNL and experienced no significant WT change at 30 days, encourage staff to offer a Ensure or other substitute when resident refuses a meal, continue to observe and f/u prn. The Order Summary was reviewed and Ensure or other substitute was not ordered. On 1/7/25 at 10:34 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated if a resident was receiving Ensure or a supplement it would be documented on the resident's Medication Administration Record. On 1/8/25 at 8:32 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that yes they had skin and weight meetings but it had been hard to have them because the Director of Nursing (DON) needed to be oriented. The ADON stated the skin and weight meetings were not formal yet but they were trying. The ADON stated that the skin and weight meetings use to be every Wednesday. The ADON stated they would talk with the dietary manager every week and they would talk to the physician to add supplements. The ADON stated that supplements were added immediately if the resident had a low weight on admission. The ADON stated the RD would send recommendations and would monitor the enteral feedings and the physician did those things also. The ADON stated that resident 4 got sick with the flu and resident 4 was very picky about her weight. The ADON stated that she thought the 120's would be resident 4's new baseline. The ADON stated that resident 4 would not do supplements but the ADON was unsure if that was resident 4's choice. The ADON stated that the RD was not there in the facility and would email recommendations. The ADON stated that resident 4 was happy with her weight loss. The ADON stated that resident 4 looked good and did not look to skinny. The ADON stated that they looked at the recommendations from the RD and would talk with the resident prior to implementing the recommendations. The ADON stated the RD was putting the orders in but the orders had to be approved and the orders would be missed. The ADON stated that staff put the orders in if it was going to work for the resident and we give the recommendations to the physician to see if it was okay. The ADON stated nutrition recommendations were wrote on paper and given to the physician to sign. On 1/8/25 at 9:17 AM, an interview was conducted with the RD. The RD stated that he did a report with the resident name, recommendations, and follow up plan. The RD stated he would forward the report to the DON and ADON. The RD stated in the past he would put the orders in the resident's electronic medical record but his access had been limited and he did not know why. The RD stated that resident 4 had been refusing a few meals. The RD stated that resident 4's weight had been stable the past 30 days. The RD stated that he would expect the staff to implement the dietary recommendations because that was the process. The RD stated that since he did not have access to put the orders in the resident's electronic medical record he would expect the staff to input those orders. The RD stated that the last couple months resident 4 had been stable with her weight and he would be okay if resident 4 maintained the current weight. On 1/8/25 at 10:03 AM, an interview was conducted with the DON. The DON stated that recommendations were emailed to her by the RD but she was unsure on how the recommendations were implemented. The DON stated that she would print the RD recommendations and would forward the recommendations to the dietary manager. The DON stated they also got recommendations from the Speech Therapist. The DON stated that herself and the ADON would work together for the skin and weight meetings. The DON stated they would talk about weights and if wounds were healing. On 1/8/25 at 10:14 AM, a follow up interview was conducted with the ADON. The ADON stated resident 4 would request an alternate meal if she did not like what was served. The ADON stated there was a template for the skin and weight meeting that listed any resident under 100 lbs, new admissions, pressure sores, and residents that triggered for significant weight loss. The ADON stated that residents were weighed weekly on admission and after four weeks if the resident had no triggers then the resident would be weighed monthly. The ADON stated the skin and weight meetings were documented in her head.

Based on interview and record review, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director (MD), and the Director of Nursing (DON) were acted upon. Specifically, for 1 out of 39 sampled residents, a pharmacy recommendation to discontinue hydroxyzine was not acted upon timely. Resident identifier: 17. Findings included: Resident 17 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, dementia, unsteadiness on feet, foot drop of right foot, adult failure to thrive, sexual dysfunction, bilateral primary osteoarthritis of hip, and insomnia. Resident 17's medical record was reviewed on 1/6/25 through 1/9/25. A review of resident 17's physician orders revealed, hydrOXYzine HCl [hydrochloride] Oral Tablet 25 MG [milligrams] (Hydroxyzine HCl) Give 25 mg by mouth every 6 hours as needed for antianxiety. A review of resident 17's Patient Recommendations Summary - Practitioner recommendations documented on 11/24/24, This resident has a current order for Hydroxyzine 25 mg as needed (PRN) every 6 hours for anxiety since 10/24/24. This as needed medication has been utilized 12 times in the past 30 days. Of note, the resident has had 20 documented falls in this same month. There were notes documenting behaviors of the resident wanting to give other residents a hard time and was subsequently given hydroxyzine. If an agent was truly needed for anxiety, buspirone may be a better alternative, with less cognitive side effects than hydroxyzine. The following intervention has been preapproved by the attending medical team through verbal communication and/or protocols: 1. Discontinue hydroxyzine 2. Replace with Buspirone 5 mg PRN The interventions on the patient recommendations summary were noted to be with the verbiage circled Verbal Order next to it. A secure text message revealed the medical provider was made aware of the medication change on 11/25/24, by the pharmacist and agreed to the immediate discontinuation of the Hydroxyzine and the initiation of the Buspar. A written physician phone message dated 11/29/24, revealed, I had previously approved changing the Hydroxine to buspar, (but watch for insomnia getting worse after the change), the change didn't happen when I rounded the following day . On 1/8/24 at 10:00 AM, an interview was conducted with the DON. The DON stated they have a corporate pharmacist who went through each resident's medications monthly. The DON stated herself and the Assistant Director of Nursing would then go through the recommendations and contact the MD. The DON stated the pharmacist had usually already talked with the doctor about the recommendations. The DON stated it took about one week for the recommendations to be put into effect. The DON stated resident 17's Hydroxine was not discontinued as recommended because the doctor was on vacation and communication was limited.

Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 39 sampled residents, a resident taking an anticonvulsant medication for behavioral disturbance had not received a GDR on that medication since 2023, and the medication was not clinically contraindicated. Resident identifier: 24. Findings included: Resident 24 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, senile degeneration of brain, dementia, essential hypertension, atrial fibrillation, and mood disorder. Resident 24's medical record was reviewed on 1/7/25 through 1/9/25. On 9/11/23, a physician's order documented CarBAMazepine Tablet 200 MG [milligrams] Give 1 tablet by mouth two times a day for behavior disturbance. A physician documented clinical contraindication was unable to be located. On 1/8/25 at 3:30 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated for the psychotropic meeting they would talk with the pharmacy, go through the resident behaviors, the pharmacist would recommend stuff, and we take the recommendations to the physician for approval. The ADON stated the physician would approve the recommendation by signing the form but the pharmacist had already spoken with the physician prior to us sending the recommendations. The ADON stated the Director of Nursing would put in the orders from the recommendations after the approval of the physician. The ADON stated the first year they had to do two GDRs and yearly after that. The ADON stated the pharmacist would tell us when the medications were up for a GDR.

Based on observation and interview, the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, two vials of insulin were open and available for use past the expiration date. Findings included: On [DATE] at 7:40 AM, an observation was made of the Team 2 medication cart with Licensed Practical Nurse (LPN) 1, the following medications were located in the medication cart: a. A bottle of Lantus 100 units/milliliter (ml) was open and available for use and labeled with an open date of [DATE], wrote on the vial and a date of ,d+[DATE], written on the box. The vial was opened 8 days past the 28 day open date. b. A bottle of Tresiba 100 units/ml was open and available for use and labeled with an open date of [DATE], wrote on the vial and a date of ,d+[DATE], wrote on the box. This vial was opened 6 days past the 28 days open date. An immediate interview was conducted with LPN 1. LPN 1 stated the insulin that was in the cart was being used for the residents. LPN 1 stated the insulin was good for 14 days after it was pulled out of the fridge from the medication room. LPN 1 stated the nurses were supposed to write the date on the insulin when it was taken out of the fridge. LPN 1 stated she was unsure why there was a ,d+[DATE], date wrote on the outside of the box and a different date wrote on the vial, LPN 1 stated it was not like that the day prior. An observation was made of LPN 1 as she placed the insulin vials back into the medication cart for future use. On [DATE] at 9:45 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation of the facility was for the nurses to administer the correct medications to the correct residents. The DON stated insulin was good for 30 days after being opened. The DON stated the medications should not be expired and the nurses were supposed to date the insulin when they got a new one out of the fridge from the medication room. The DON stated she was unsure why the insulin had two different dates wrote on them.

Based on interview and record review, the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, for 1 out of 39 sampled residents, a resident had a urinalysis (UA) ordered and the urine was not collected for five days after the order was given. Resident identifier: 17. Findings included: Resident 17 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, protein calorie malnutrition, dementia, unsteadiness on feet, foot drop of right foot, adult failure to thrive, sexual dysfunction, bilateral primary osteoarthritis of hip, and insomnia. Resident 17's medical record was reviewed on 1/6/25 through 1/9/25. A physician's order revealed, Urine to reflex to culture ordered on 9/25/24 and discontinued on 9/26/24. The progress notes revealed: a. On 9/25/24 at 1:20 PM, .2) UA with reflex to Cx [culture]. b. On 9/30/24 at 4:40 PM, UA collected on resident with clean urinal. UA sent to labs and awaiting results. c. On 10/1/24 at 11:40 AM, [Staff name redacted] from [Provider's name redacted] office called to let us know that resident's recent UA shows UTI [urinary tract infection]. She stated that order for Bactrim DS [double strength] was sent to the pharmacy. Will Pick it up when ready. On 1/7/25 at 2:56 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated they had standing orders for the UA, if needed. LPN 1 stated the staff would text the doctor and let them know about the symptoms the resident was experiencing and collect the sample. LPN 1 stated the sample was usually collected within 24 hours. LPN 1 stated the Medical Records watched for the results of any lab work. On 1/8/25 at 10:10 AM, an interview was conducted with the Medical Records (MR). The MR stated she was in charge of getting results to the staff after they returned to the facility. The MR stated the nurse on duty was in charge of putting the order in the computer and collecting the sample, if needed. On 1/8/25 at 1:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the resident was peeing in the sink and that they could not get the urine sample. The DON stated after they moved the resident to another room, so the resident could not pee in the sink, they were able to obtain the sample. The DON stated that it took them five days to get the urine, in a hat. The DON stated she thought the staff put the hat in the sink to catch the urine. The DON stated he was a difficult resident, and they did not want to use other measures to collect the urine. The DON stated it was not routine to wait five days to collect a urine sample after it was ordered by a provider.

Based on interview and record review, the facility did not maintain medical records on each resident that were accurately documented. Specifically, for 2 out of 39 sampled residents, a resident's medical record contained another resident's appeal discussion. Resident identifiers: 246 and 247. Findings included: 1. Resident 246 was admitted to the facility on [DATE] with diagnoses which included paraplegia, chronic obstructive pulmonary disease, spinal stenosis, anxiety disordered, intraspinal abscess, and granuloma. Resident 246's medical record was reviewed on 1/8/25. The review revealed that a medical record for resident 247 labeled KEPRO_5.23.23.pdf was in resident 246's medical record. 2. Resident 247 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, dementia of brain, spinal stenosis, anxiety disorder, and senile degeneration of the brain. Resident 247's medical record was reviewed on 1/8/25. On 5/23/23, resident 247's medical record had patient identifying information including resident's name and appeal status. On 1/8/25 at 2:10 PM, an interview with the Medical Records (MR) was conducted. The MR stated that she attached the documents to the medical record. The MR stated that she would do regular audits, that included making sure the correct documentation was attached to the correct resident's medical record. The MR stated that if she did find that a resident's documentation was in the wrong medical record, she would remove the document and place it in the correct medical record. The MR stated that as long as she remembered you should never put another resident's name or information in someone else's chart. On 1/8/25 at 2:57 PM, an interview was conducted with the Administrator (Admin). The Admin stated that when documenting in a resident's chart, you could write their name in the chart, but you could not write another resident's name in the chart or have records with another residents identifying information, due to a Health Insurance Portability and Accountability Act.

Based on interview and record review, it was determined, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, for 1 out of 23 sampled residents, facility staff did not: promptly respond with the resident presented with signs and symptoms of a UTI; ensure the resident received an antibiotic susceptible to organism causing the UTI; and, obtain antibiotic order clarification when a disparity existed. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, senile degeneration of brain, dementia, atrial fibrillation, essential hypertension, insomnia, and cellulitis. Resident 10's medical record was reviewed on 3/14/23. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 10 was occasionally incontinent of bladder and always continent of bowel. In addition, resident 10 required limited assistance of one person for toileting. A care plan Focus initiated on 2/11/23, documented 2/11/23: [Resident 10's name removed] is on antibiotic therapy Cefadroxil r/t [related to] infection UTI. Interventions included, but were not limited to, Report pertinent lab results to MD [Medical Doctor] Date Initiated: 02/13/2023. On 2/7/23 at 12:35 PM, a Nurses Note documented Note Text: CNA [Certified Nursing Assistant] notified LN [Licensed Nurse] that pt [patient] had blood in her urine this morning. LN assessed and found Gross Hematuria and reported it to MD [name removed]. Vitals are stable and pts behaviors are baseline normal. No new orders at this time. On 2/8/23 at 9:49 AM, a Nurses Note documented Note Text: U/A was collected and sent to [name removed]. [Note: A U/A was collected the day after resident 10 present with signs and symptoms of a UTI.] An MD note dated 2/8/23 at 11:35 AM, documented a chief complaint of possible UTI. Assessment/Plan Patient presents with symptoms of UTI. Results of dipstick were positive for UTI. Advised to drink clear fluids, Tylenol for pain and take prescribed medications as instructed. Patient encouraged to follow up within 1 week if not improving. 1. Acute urinary tract infection - patient had a urine culture submitted. Empiric cefadroxil. Nursing home staff continue to monitor. cefadroxil 500 mg [milligram] capsule - Take 1 capsule(s) twice a day by oral route. The February 2023 Medication Administration Record (MAR) documented: a. On 2/8/23, U/A one time only for Hematuria for 1 Day. b. On 2/11/23 at 7:15 PM, Cefadroxil Oral Capsule 500 MG (Cefadroxil) Give 1 capsule by mouth two times a day for uti until 02/17/2023 13:00 [1:00 PM]. [Note: The cefadroxil was started three days after the MD note dated 2/8/23.] c. On 2/11/23, Event/Alert Charting following Event, Document every shift until resolved: UTI ABX [antibiotics] cefadroxil 500 mg BID [twice a day] x 7 days every shift for uti for 10 Days. On 2/8/23 at 4:52 PM, a Nurses Note documented Note Text: U/A results received: Positive nitrite and other infection markers. MD [name removed] notified and no new orders at this time. A Urine Culture collected on 2/8/23 and reported on 2/13/23, documented that resident 10 had the organism Escherichia coli (E coli) in her urine. [Note: Cefadroxil was not listed on the sensitivity report. An additional antibiotic was not initiated to treat the organism.] A review of the February 2023 MAR documented that resident 10 received the last dose of cefadroxil on 2/17/23, during the morning flex administration. On 2/19/23 at 7:12 PM, an Event/Alert Charting note documented Type of Event: UTI ABX Assessment /Observation: Patient UTI resolved . Resident Reaction to Interventions: UTI resolved, no C/O [complaints of] Urinary pain Pain Management: PRN [as needed] Improvement/Decline: improvement . The Infection Report Form documented that resident 10 had a healthcare associated UTI with an onset date of 2/7/23. The UTI had a resolved date of 2/19/23. The signs and symptoms included blood in urine, abnormal labs, lethargic, agitation, confusion, and odor. No organism was documented. On 2/20/23 at 11:06 PM, an Event/Alert Charting note documented Type of Event: ABX for UTI Assessment /Observation: Patient completed ABX a few days ago. Aide [CNA] reports of urine with minimal pyuria and blood noted earlier today. Assessment put up for MD to further evaluating [sic] in the morning. Continue to encourage fluids. Call light in easy reach. Interventions: Observation. [sic] Resident Reaction to Interventions: Cooperative with care thus far. Pain Management: Denied any pain and discomfort this evening. Improvement/Decline: Decline. Notifications: n/a [not applicable]. A MD note dated 2/21/23 at 8:11 AM, documented a chief complaint of possible UTI. Assessment/Plan 1. Dysuria - patient will have urinalysis and CNS [culture and sensitivity] will be done if the nitrite is positive. Follow up with results . PAINFUL URINATION (DYSURIA): CARE INSTRUCTIONS. On 2/21/23 at 2:32 PM, a Nurses Note documented Note Text: U/A collected and sent to [name removed]. On 2/21/23 at 5:32 PM, a Nurses Note documented Note Text: Lab results: negative for nitrites; however, there was plus 4 bacteria, and the lab indicated it would be ideal for running culture and sensitivity even with nitrite negative. LN contacted MD and agreed to add it to the order. A review of the February 2023 MAR documented on 2/21/23, U/A one time only for Hematuria for 1 Day. On 2/27/23 at 6:43 AM, a Nurses Note documented Note Text: Aide reports to LN dark red blood noted in commode this morning. Blood was about 1/4 cup with foul smelling odor. A Urine Culture collected on 2/21/23 and reported on 2/27/23, documented that resident 10 had the organism E coli in her urine. On 2/28/23 at 8:30 AM, a Nurses Note documented Note Text: Culture and sensitivity report received, MD [name removed] notified and new order for Nitrofurantoin 100 mg BID for 10 days for UTI started. A MD note dated 2/28/23 at 8:48 AM, documented a chief complaint of possible UTI. HPI [history of present illness] Lower Urinary Tract Symptoms (LUTS) Reported by patient. Notes: [AGE] year-old female nursing home resident who has had lethargy as well as foul-smelling and off colored urine. Patient does not have a chronic indwelling Foley catheter. She has not had nausea vomiting or fever. Patient has had recurrent urinary tract infections that have been treated recently. On 2/28/23 at 9:34 AM, a Nurses Note documented Late Entry: Note Text: Pt vomited and [sic] hour after taking her new medication Macrobid. PT took medication with her breakfast, MD [name removed] notified no new orders at this time. On 3/1/23 at 7:28 PM, an Event/Alert Charting documented Type of Event: UTI Assessment/Observation: resident up for am meal took po [by mouth] antibiotic became ill and vomited. [Doctor name removed] was here and was notified stated to wait short while then repeat the po antibiotic no vomiting this time but refused to eat at noon meal has rested this afternoon. Interventions: ongoing monitoring Resident Reaction to Interventions: vomited this am but was able to take second dose Pain Management: no c/o pain voiced Improvement/Decline: stable Notifications: On 3/1/23 at 11:15 PM, an Event/Alert Charting documented Type of Event: UTI; ABX Assessment /Observation: Patient continue to have some discomfort during urination. Patient on ABX therapy. No a/e [adverse effects] noted from ABX therapy. Continue to encourage water. On 3/2/23 at 9:52 AM, a Nurses Note documented 'Note Text: Pt vomited approx [approximately] 1 hour after admin [administration] of Macrobid 100 mg after breakfast. MD notified no new orders at this time. On 3/3/23 at 1:00 PM, a Nurses Note documented Note Text: Aid reported resident vomited to LN. LN contacted MD and has received no new orders at this time. A MD note dated 3/4/23 at 11:49 AM, documented a chief complaint of a possible UTI. Assessment/Plan 1. Acute urinary tract infection - Urine culture was positive for E coli sensitive to Macrobid. continue Macrobid twice daily for 14 days. if patient continues to vomit or is not improving may need hospitalization for IV [intravenous] antibiotics. A review of the nursing progress notes revealed that resident 10 had no further episodes of vomiting after 3/4/23. The antibiotic, nitrofurantoin, based on documentation was stopped after the last dose on 3/9/23. The nitrofurantoin was initially ordered on 2/28/23, for 10 days. No documentation was located that the nursing staff obtained clarification from the MD note dated 3/4/23, regarding the continuation of the Macrobid (nitrofurantoin) for 14 days. On 3/14/23 at 1:25 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the MD would call the facility with orders or the MD would check the resident assessments daily and write an order while at the facility. RN 1 stated if the MD wrote an order in the MD note the MD would write the order on a script. RN 1 stated that she would review the MD notes because she was unable to follow the MD for resident rounds. RN 1 stated the laboratory would fax the urine culture and sensitivity to the facility and if the staff did not see the report the staff would call the laboratory for the results. RN 1 stated the MD would start the resident on an emergency antibiotic until the culture and sensitivity was received. RN 1 stated when the culture and sensitivity was received the MD would change the antibiotic if necessary. On 3/15/23 at 11:52 AM, an interview was conducted with RN 2. RN 2 stated the Alert Event Charting was completed during every shift and was initiated so the staff were aware of what was happening with the resident. RN 2 stated the Alert Event Charting could be for a new medication or behaviors and the staff should also write a progress note. RN 2 stated the facility had an emergency medication system that they could pull medications from, so there would not be a reason for resident 10's antibiotic delay. RN 2 stated if there was a revision in the medication order, the revision would discontinue the prior order and there may be a delay in starting the medication. RN 2 was unable to locate an order for the cefadroxil prior to 2/11/23. RN 2 stated that Medical Records would receive the resident lab reports and would give the lab reports to the floor nurse. RN 2 stated the nurse would sign the lab indicating that it had been reviewed and the MD had been contacted. RN 2 stated the urine culture and sensitivity report for resident 10 received on 2/13/23, was not signed indicating the MD had not been contacted. On 3/15/23 at 12:04 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated there was a laboratory book to write the resident cultures in. The ADON stated Medical Records would call the laboratory to get the reports because the laboratory would not send the reports to the facility. The ADON stated there was a delay in resident 10's cefadroxil. The ADON stated that she missed the antibiotic for resident 10 and should have caught it since she was the staff member that tracked resident infections for the Monthly Infection Surveillance Log.

Based on observation, interview, and record review, it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 2 out of 23 sampled residents, a staff member was observed to touch resident medications with bare hands with each medication administration. Resident identifiers: 2 and 22. Findings included: On 3/15/23 at 8:20 AM, an observation was made of Registered Nurse (RN) 1. RN 1 was observed to touch the desk chair, medication cart keys, medication cart, and computer immediately prior to resident medication administration. No hand hygiene (HH) was observed. RN 1 was then observed to place her ungloved fingers into a medication bottle and obtain a tablet. The tablet was then placed into a medication cup for administration. RN 1 was then observed to push a medication out of a bubble pack into her ungloved hand, pick the medication up with ungloved fingers, and place the medication into the medication cup for administration. This was observed four times with four different medications. These medications were then administered to resident 2 by RN 1. On 3/15/23 at 8:30 AM, an observation was made of RN 1. RN 1 was observed to brush her hair behind her ear, touch the medication cart keys, the medication cart, and the computer prior to directly touching four medications with ungloved hands. The medications were then placed in a medication cup and administered to resident 4 by RN 1. No HH was observed before or after the medication administration. On 3/15/23 at 10:11 AM, an interview was conducted with RN 2. RN 2 stated when passing medications it was important to pop the medications through the packaging without touching the medications and to keep it very clean. On 3/15/23 at 10:25 AM, an interview was conducted with RN 1. RN 1 stated she used HH before medication administration was started and in between each patient. RN 1 stated she did touch the medications when she placed them in the medication cups, if they were not easy to pop out. RN 1 stated she had a bad habit of touching the medications and that she touched all the medications she administered. On 3/15/23 at 10:53 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses were expected to make sure the resident's 5 rights were met, make sure the residents took the medications, use HH in between residents, and keep the medication carts locked. The DON stated the nurses were expected not to touch the medications they administer to the residents. The DON stated that was something that would need to be inserviced.

Based on interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 1 out of 23 sampled residents, a resident was not offered the pneumococcal immunization and the resident or the resident's responsible party was not provided information including the risks, benefits, and potential side effects of the pneumococcal immunization. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, late onset Alzheimer's disease, dementia, narcolepsy, obstructive sleep apnea, restless leg disorder, mood disorder, essential hypertension, wandering, and spinal stenosis. Resident 15's medical record was reviewed on 3/15/23. No documentation could be located or provided indicating that resident 15 was offered the pneumococcal immunization and had completed the immunization informed consent that included information on pneumococcal risks, benefits, and potential side effects. On 3/15/23 at 12:04 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 15 was not offered the pneumococcal immunization and resident 15 did not have an immunization informed consent completed. The ADON stated that the immunization was missed for resident 15. The ADON stated that the immunization informed consents were in the admission packet and Social Services was responsible for the consents. The ADON stated that the immunization informed consents were now included with the Nursing initial assessment packet. The ADON stated that the immunization informed consents were to be completed with new admissions and readmissions.

Based on observation, interview, and record review, it was determined, the facility did not ensure that the residents environment remains as free of accident hazards as was possible. Specifically, for 1 out of 23 sampled resident, a resident fell in the transportation vehicle during a transport. Resident identifier: 21. Findings Included: Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include end stage renal disease, vascular dementia, pulmonary fibrosis, essential hypertension, type 2 diabetes, dependence on renal dialysis, atherosclerotic heart disease, benign prostatic hyperplasia, gastro-esophageal, hyperkalemia, incontinence without sensory awareness, presence of coronary angioplasty. On 3/14/23, resident 21's medical record was reviewed. A significant change Minimum Data Set (MDS) assessment dated [DATE], was reviewed. The MDS revealed that resident 21 required one person physical assistance with limited assistance for bed mobility, transfers, dressing, eating, and toilet use. The MDS revealed that resident 21 required one person physical assistance with extensive assistance for walking. The MDS revealed that resident 21 had a Brief Interview for Mental Status (BIMS) score of 1. A BIMS score of 0 to 7 suggests severe impairment. A progress note dated 9/15/22 at 4:50 PM, revealed that resident 21 had a fall while in the transportation vehicle. The progress note revealed, Altered [sic] by RA [Resident Advocate] that she needed help in the parking lot and that the resident had fallen during transit from dialysis. Resident was observed sitting on the floor of the transport vehicle with his wheelchair tipped over and one shoe having fallen off. Resident was assisted to sit at the edge of the vehicle and was able to transfer c [sic] assistance into his wheelchair. Two small abrasions were noted to the R [right] side of pt's [patients] head with no active bleeding. Neuro [Neurological] checks and v/s [viral signs] monitoring were initiated as soon as resident was brought back into the facility. No other apparent injuries were noted and no changes to LOC [level of consciousness] at this time. MD [Medical Director], ADON [Assistant Director of Nursing], and family notified at 17:30 [5:30 PM]. Will continue to monitor. On 3/14/23 at 2:05 PM, an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated that the RA was typically the driver for the residents. RN 1 stated that the RA was not at the facility today and Certified Nursing Assistant (CNA) 1 was filling in as the driver for residents. RN 1 stated that she was the nurse who assisted resident 21 out of the transportation vehicle when he fell on [DATE]. RN 1 stated that resident 21 did not have any major injuries. RN 1 stated she did not know how resident 21's wheelchair tipped over in the vehicle. On 3/14/23 at 2:30 PM, an observation was made of a resident being loaded into a transportation van. CNA 1 pushed the resident into the van, CNA 1 attached a security strap from the floor of the van to the base of the wheelchair. CNA 1 stated each resident was secured with the straps in the van each time they were transported to keep them safe. On 3/15/23 at 8:44 AM, a phone interview with the RA was conducted. The RA recalled the incident on 9/15/22. The RA stated that she was bringing resident 21 back to the facility from his dialysis appointment. The RA stated that resident 21 was in his wheelchair behind the driver's seat facing the door of the vehicle. The RA stated that there were four straps that held the wheelchair down and the straps were in place. The RA stated that at the four-way stop, the RA made a left turn and resident 21's wheelchair slid backwards. The RA stated she then slowed down and attempted to reach back with one arm to hold resident 21's wheelchair, however the wheelchair tipped over on the right side. The RA stated she was unable to assist resident 21 back into an upright position, so she continued to drive back to the facility then called for help. The RA stated that resident 21 typically held onto the door during transport, and she believed resident 21 was not holding onto the door when his wheelchair tipped over, which could have contributed to the fall. The RA stated that other residents did not hold onto the door during transport. The RA stated she did not know how the wheelchair tipped over because the straps of the wheelchair were in the correct position. The RA stated that resident 21's break locks were not working very well that day and could have contributed to the wheelchair falling. On 3/15/23 at 9:00 AM, an interview with the Maintenance Supervisor (MS) was conducted. The MS stated that resident 21's wheelchair breaks were tightened about once a week. The MS stated that resident 21 typically moved around in his wheelchair when the breaks were locked, so throughout the week the breaks would become loose. The MS stated he was unaware that resident 21 had fallen in the transportation vehicle. The MS stated that even if the locks on the wheelchair were not locked at the time of the incident, the wheelchair should not have moved if the wheelchair was strapped down properly.

Based on interview and record review, it was determined, the facility did not ensure that residents did not receive psychotropic drugs pursuant to an as needed (PRN) order unless the PRN order for psychotropic drugs were limited to 14 days. If the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order. In addition, PRN orders for anti-psychotic drugs were limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Specifically, for 2 out of 23 sampled residents, a resident had a PRN order for Haldol that was not limited to 14 days, and the physician had not evaluated the resident for the appropriateness of the medication. In addition, a resident had a PRN order for an anti-depressant used for insomnia that extended past 14 days without a documented rationale for use. Resident identifiers: 10 and 15. Findings included: 1. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, senile degeneration of brain, dementia, atrial fibrillation, essential hypertension, insomnia, and cellulitis. Resident 10's medical record was reviewed on 3/14/23. A Medical Doctor (MD) note dated 2/4/23 at 8:47 AM, documented a chief complaint of sleep problems. Assessment/Plan 1. Initial Insomnia - patient will be placed back on trazodone 50 mg [milligrams]. Nursing home staff will continue to monitor. Follow-up as needed. INSOMNIA: CARE INSTRUCTIONS trazodone 50 mg tablet - Take 1 tablet(s) every day by oral route. Qty [Quantity]: (30) tablet Refills: 11 . A physician's order dated 2/4/23, documented traZODone HCl [hydrochloride] Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth every 24 hours as needed for Insomnia at bed time. The trazodone had an end date documented as indefinite. [Note: The MD note documented the trazodone was to be administered every day. The physician's order documented a PRN administration.] A physician's order dated 2/21/23, documented monitor # [number] hours of sleep due to use of trazodone every shift for use of trazodone. The February 2023 Medication Administration Record (MAR) documented that resident 10 had requested 7 doses of trazodone out of 25 opportunities. The following number hours of sleep were documented: [Note: Sleep monitoring did not occur when the trazodone was initiated on 2/4/23 until 2/21/23.] a. On 2/21/23, two hours during dayshift and two hours during night shift. b. On 2/22/23, two hours during dayshift and 6-8 hours during night shift. c. On 2/23/23, two hours during dayshift and 4-6 hours during night shift. Trazodone was administered. d. On 2/24/23, 3-4 hours during dayshift and 4-6 hours during night shift. e. On 2/25/23, 3-4 hours during dayshift and 6-8 hours during night shift. f. On 2/26/23, two hours during dayshift and 4-6 hours during night shift. Trazodone was administered. g. On 2/27/23, 1-2 hours during dayshift and four hours during night shift. h. On 2/28/23, two hours during dayshift and four hours during night shift. The March 2023 MAR documented that resident 10 had requested 5 doses of trazodone out of 13 opportunities. The following number hours of sleep were documented: a. On 3/1/23, two hours during dayshift and 6-8 hours during night shift. Trazodone was administered. b. On 3/2/23, two hours during dayshift and 4-6 hours during night shift. c. On 3/3/23, 3-4 hours during dayshift and 6-8 hours during night shift. Trazodone was administered. d. On 3/4/23, 3-4 hours during dayshift and 4-6 hours during night shift. e. On 3/5/23, two hours during dayshift and 6-8 hours during night shift. f. On 3/6/23, 1-2 hours during dayshift and four hours during night shift. g. On 3/7/23, 1-2 hours during dayshift and 6-8 hours during night shift. h. On 3/8/23, 3-4 hours during dayshift and 6-8 hours during night shift. i. On 3/9/23, 1-2 hours during dayshift and 6-8 hours during night shift. Trazodone was administered. j. On 3/10/23, 1-2 hours during dayshift and 6-8 hours during night shift. Trazodone was administered. k. On 3/11/23, 1-2 hours during dayshift and 6-8 hours during night shift. Trazodone was administered. l. On 3/12/23, 3-4 hours during dayshift and 6-8 hours during night shift. m. On 3/13/23, 1-2 hours during dayshift and 6-8 hours during night shift. The physician rationale for the PRN order of trazodone to be extended beyond 14 days was unable to be located within the medical record. On 3/14/23 at 1:25 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the MD would call the facility with orders or the MD would check the resident assessments daily and write an order while at the facility. RN 1 stated if the MD wrote an order in the MD note the MD would write the order on a script. RN 1 stated that she would review the MD notes because she was unable to follow the MD for resident rounds. On 3/15/23 at 11:40 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that Medical Records would read the MD notes and alert the nurses if the MD mentioned new orders. The DON clarified that the trazodone was an input error and should have been administered daily. 44640 2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included late onset Alzheimer's disease, dementia, narcolepsy, obstructive sleep apnea, restless leg disorder, mood disorder, essential hypertension, wandering, and spinal stenosis. A review of resident 15's physician's orders revealed the following: a. Haloperidol lactate concentrate 2 milligrams/milliliter (mg/ml), administer 2.5 ml (milliliters)by mouth every 12 hours PRN for agitation. The medication was initiated on 12/24/22, with an end date documented as indefinite. b. Haloperidol lactate 5 mg/ml, inject 2.5 ml intramuscularly every 12 hours PRN for agitation and aggression. The medication was initiated on 1/4/23, with an end date documented as indefinite. A review the MAR for December 2022, January 2023, and February 2023 revealed haloperidol was administered to resident 15 numerous times. Review of resident 15's medical record revealed no documentation of a physician evaluation, every 14 days, documenting the appropriateness of the haloperidol. On 3/15/23 at 11:26 AM, an interview was conducted with the DON. The DON stated the MD was made aware of any behaviors a resident had and would write an order for a medication if needed. The DON stated the nurses put the orders and end dates in the computer and she reviewed them. The DON stated the orders for psychotropic medications were written for 15 days and the doctor would come in and reevaluate the resident at the end of the 15 days. The DON stated it was sometimes difficult to get the MD to come in and reevaluate the residents every two weeks, but she had been working on it and had been keeping a record and would keep reminding them to come in. The DON stated it was necessary to have an end date for psychotropic medications and to have the medication reevaluated so the resident was kept safe and the medication was monitored appropriately.

Based on record review and interview the facility did not develop and implement a comprehensive person-centered care plan for 3 of 18 sample residents, that included measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident's care plan regarding assisting with dining was not implemented as written, and two residents did not have care plans developed regarding their need for assistance with dining. Resident identifiers: 9, 14, and 33. Findings include: 1. Resident 9 was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 9's medical record was reviewed on 6/14/21. An annual Minimum Data Set (MDS) for resident 9 dated 3/17/21 was reviewed. Staff assessed resident 9 as being totally dependent on staff for eating, dressing, bed mobility, transfers, personal hygiene, bathing, and toilet use. Review of resident 9's Care plan dated 1/3/19 revealed that resident 9 was totally dependent on staff for eating. On 6/15/21, the lunch meal was observed in the main dining room. Resident 9's meal was delivered at 12:11 PM. Resident 9 was not assisted with dining until 12:20 PM, approximately 9 minutes after being served. On 6/16/21, the lunch meal was observed in the main dining room. At 12:12 PM resident 9 was served his meal. He was observed to enter the dining room earlier with a burrito from a fast food restaurant prior to be served his meal from the facility. At 12:18 PM, resident 9 told Certified Nursing Assistant (CNA) 3, Ok sit down. Hurry it up will ya?! Resident 9 was assisted with his burrito at 12:19 PM. This was seven minutes after being served the facility meal, but several minutes after resident 9 had entered the main dining room with his burrito. [Note: The observation indicated that the facility did not implement the care plan they had developed regarding resident 9's total dependence on staff for eating.] 2. Resident 33 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/16/21 the breakfast meal was observed in the main dining room. Resident 33 was served at 7:45 AM. At 7:51 AM, resident 33 placed his right hand in a bowl of hot cereal, and then licked his hand. At 7:53 AM, resident 33 was assisted with his meal, approximately 8 minutes after being served his meal. Resident 33's medical record was reviewed on 6/14/21. A quarterly MDS was completed for resident 33 on 5/17/21. Staff assessed resident 33 as requiring extensive one person physical assistance with eating. Resident 33's care plan was reviewed. A care plan had not been developed to address resident 33's need for assistance with eating. 3. Resident 14 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/16/21 the breakfast meal was observed in the main dining room. Resident 14 was served at 7:45 AM. Resident 14 was not assisted with his meal until 7:52 AM, approximately 7 minutes after being served his meal. Resident 14 did not make any attempts to feed himself during the observation period. Resident 14's medical record was reviewed on 6/14/21. A quarterly MDS was completed for resident 14 on 3/23/21. Staff assessed resident 14 as requiring extensive one person physical assistance with eating. Resident 14's care plan was reviewed. A care plan had not been developed to address resident 14's need for assistance with eating. On 6/16/21 at 4:15 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that she was unsure why care plans were not developed that addressed resident 14 and resident 33's need for assistance with eating. The MDS Coordinator stated that she would immediately add more specific interventions the residents' care plans.

Based on interview, and record review the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 6 sample residents. Specifically (1) The facility staff did not assess a resident abdomen or bowel sounds, after the resident complained of abdominal pain, resulting in resident being admitted to the hospital, and (2) The facility staff did not send a resident to the hospital for an evaluation after complaints of rib pain. Resident identifiers: 3 and CL 1. Findings include: 1. Resident CL 1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident CL 1 medical record reviewed on 7/17/12. Review of the Minimum Data Set (MDS) assessment completed by facility staff on 6/25/12 revealed that resident CL 1 was alert and oriented. The facility staff assessed resident CL 1 has having had constant pain that limited resident CL 1's day to day activities of daily living. Review of the CL 1's care plans revealed the following care plans: 1. A care plan for "Pain" was developed on 6/28/12. The "Problem/Need/Strength" was documented as "Resident is at risk for pain r/t (related to): dx (diagnosis): Regional Enterititis NOS (nonspecific), Rheumtiod (sic) Arthritis, Migrne (Migraine) Unsp (unspecified) Wo (without) Nrtc (Narcotic) Mgrm (management), Hypertension, Abnormality of gait, Epilep ([MEDICAL CONDITION]) Nos, [MEDICAL CONDITION], and [MEDICAL CONDITION] Reflux. The goal(s) developed was "Resident will have pain under control with meds by next review date as evidenced by verbalization or free of s&s (signs and symptoms) of pain (moaning, grimacing, restlessness). The approaches developed to achieve the goal was: "[MEDICATION NAME] as ord (ordered) prn (as needed), and ...Observe effectiveness of meds." 2. A care plan for "GI (Gastrointestinal) Distress" was developed on 6/28/12. The "Problem/Need/Strength" was documented as "Resident is at risk for GI distress r/t Dx: [MEDICAL CONDITION] reflux." The goal developed was "Resident will be free of signs & symptoms of GI distress by next review date". The approaches developed to achieve the goal were: "Keep MD (medical doctor) advised of changes, meds as ordered, observe effectiveness of meds, observe residents for signs & symptoms of GI distress (nausea, vomitting (sic), diarrhea, constipation, [MEDICAL CONDITION] pain, blood in stool)..." Review of the "Nurse's Notes" revealed the following entries by the facility licensed nurses: a) 6/18/12: "...Pt. (patient) c/o (complained of) pain 8/10 and requested prn (as needed) medication. it was provided per doctors orders. ..." b) 6/19/12 at 4:00 PM: "Pt. states she did not sleep well. Pt. states she is intense (sic) pain. Pt. requests pain meds (medications) on regular basis." c) 6/21/12: "...Pt. continues to ask on a regular basis for a [MEDICATION NAME] (sic) stating that she is in pain. ..." d) 6/22/12: "(Resident CL 1) mindful of when her meds are due, requests [MEDICATION NAME] for pain in midline chest from 'my surgery.'" e) 6/23/12: "To nurses station to request [MEDICATION NAME] about every 5 1/2 to 6 hrs (hours). Said her back and surgical site hurt. ..." f) 6/24/12: "...came to nurse's station to get her noon meds. [MEDICATION NAME] given then for pain mid chest (incisional or operative site). [MEDICATION NAME] given @ (at) 1800 (6:00 PM) per pt. request for pain (upper) abd (abdomen) into back. ..." g) 6/25/12: "Pt. c/o pain continually and request (sic) pain medication on a regular basis. ..." h) 6/26/12: "Pt. continues to complain about not sleeping well at night for various reasons. She continues to complain about an abdominal pain and request pain medications on a regular basis. ..." i) 6/27/12: "...She continually asks for pain medications. CN gives [MEDICATION NAME] Q6H (every 6 hours) as ordered. ..." j) 6/28/12: "...She continues to have pain & (and) ask (sic) for a pain pill. Pt. given pain medications as per dr. (doctor) orders. ..." k) 6/29/12: "[MEDICATION NAME] given X 1 (once). ..." l) 6/30/12 at 5:45 PM: "Has been asking for pain medication for abd pain when ask (sic) when her last BM (bowel movement) was states every day. I had my last one yesterday morning. ..." m) 7/1/12 at 9:00 AM: "Has been asking for pain pills every 3 1/2 - 4 hours. No BM yet today. Explain to her when pain meds are due. Continues to come back every 15 minutes until she can have one. 8 AM [MEDICATION NAME] was given at 0610 (6:10 AM) because she said she was in pain. ..." n) 7/2/12: "pt. in bed until this afternoon. Meds given per orders. pt. c/o pain throughout shift. Meds given per orders. pt. c/o pain at incision site on stomach. ..." o) 7/3/12: "New order to D/C (discontinue) [MEDICATION NAME]." p) 7/3/12: "pt. in & out of bed. pt. c/o pain throughout shift @ incision site. ..." q) 7/4/12: "...pt. c/o pain in abdomen throughout shift. Medication given as ordered. ..." r) 7/4/12: "new order: TUMS (one) tab (tablet) PO (by mouth) TID (three times a day) PRN (as needed)." s) 7/5/12: "new order: V/S (vital signs) changed to daily BP (blood pressure) & full set of V/S on Wednesday & Saturdays." t) 7/7/12 from 7:00 PM to 7:00 AM: "pt. took noc meds. Requested [MEDICATION NAME] at 19:30 (7:30 PM). stated she has had abd pain all day where surgery was done and has had soft BMs but not any diarrhea. Request [MEDICATION NAME] which was given PO 30 cc (cubic centimeters). Request sleeping pill given @ 2330 (11:30 PM) pt. said she had not eaten all day. But did not want anything to eat. C/O gas and hoped [MEDICATION NAME] would help. Tums given PO (one) pt. request. Ask for [MEDICATION NAME] nurse told her she would have to wait for a while longer D/t (due to) only could have it q (every) 6 (hours) and was given @ 19:30 and it was only 0030 (12:30 AM). Nurse said it may also upset stomach, but she could have it @ 01:30 (1:30 AM) if she needed it. pt. understood and said thank you. Helped pt. pull up her hair which she said was hot on her neck. Said she was sorry to be a bother. Pt. told she was no bother and to let nurse know if she could do anymore to help her at this time." u) 7/8/12 at 1:35 AM: "pt. c/o abd pain et request [MEDICATION NAME] @ this time. Pt in bed trying to rest @ this time. Will monitor." v) 7/8/12 at 3:30 AM: "pt continue's to c/o abd pain et requesting [MEDICATION NAME]. CN asked pt if she has had any BM in the last day. Pt. stated 'yes, 4 soft BM yesterday'. [MEDICATION NAME] given per order. Pt thinks it gas/heartburn et needs [MEDICATION NAME] @ this time. Will continue to monitor." w) 7/8/12 at 4:00 AM: "Patient turned on call light, aide went down to patients room to answer call light. Patient told aide, 'she fell in bathroom but didn't get hurt'. aide reported patient fall to CN et reported that patient was back in bed already, upon entering the room. Patient body assessment was WNL (within normal limits) @ 0400 (4:00 AM). NOC Aides proceeded (with) neuro (neurological) checks @ this time. Will continue to monitor." 1. Review of the "Neurological Check Sheet" dated 7/8/12, revealed: a) 4:00 AM: Alert/wakefulness, strong facial muscle movement, strong left and right upper extremity movement/grasps, strong right and left lower extremity movements, pupil size of 3 mm (millimeters) that were round and brisk, clear speech and that resident CL 1 responded to her name, the environment and stomach pain. The facility staff documented the initial vital signs (VS) as blood pressure 134/78, heart rate 78, temp (temperature) 96.9, respirations 24 with an oxygen saturation of 97%. b) 4:15 AM: Alert/wakefulness, strong facial muscle movement, strong left and right upper extremity movement/grasps, strong right and left lower extremity movements, pupil size of 3 mm that were round and brisk, clear speech and that resident CL 1 responded to her name, the environment and stomach pain. The facility staff documented the vital signs as blood pressure 90/68, heart rate 68, temp 96.9, respirations 24 with an oxygen saturation of 97%. c) 4:30 AM: Alert/wakefulness, strong facial muscle movement, strong left and right upper extremity movement/grasps, strong right and left lower extremity movements, pupil size of 3 mm that were round and brisk, clear speech and that resident CL 1 responded to her name, the environment and stomach pain. The facility staff documented the vital signs as blood pressure 115/84, heart rate 83, temp 96.9, respirations 24 with an oxygen saturation of 96%. d) 4:45 AM: Alert/wakefulness, strong facial muscle movement, strong left and right upper extremity movement/grasps, strong right and left lower extremity movements, pupil size of 3 mm that were round and brisk, clear speech and that resident CL 1 responded to her name, the environment and stomach pain. The facility staff documented the vital signs as blood pressure 102/75, heart rate 75, temp 96.9, respirations 24 with an oxygen saturation of 96%. e) 5:15 AM: Lethargic/drowsy, weak facial movement, weak right and left extremity movement/grasps, weak right and left lower extremity movement, pupil size of 4 mm that were round/sluggish, unclear speech and that resident CL 1 responded to her name, the environment and stomach pain. The facility staff documented the vital signs as blood pressure 86/61, heart rate 105, temp 96.7, respirations 24 with an oxygen saturation of 94%. (Note: The facility licensed nurse did not document notifying resident CL 1's attending physician with the change in vital signs or that resident CL 1 was assessed as being "Lethargic/drowsy.) f) 5:45 AM: Lethargic/drowsy, weak facial movement, weak right and left extremity movement/grasps, weak right and left lower extremity movement, pupil size of 4 mm that were round/sluggish, unclear speech and that resident CL 1 responded to her name, the environment and stomach pain. The facility staff documented the vital signs as blood pressure 147/39, heart rate 26, temp 96.2, respirations 16 with an oxygen saturation of 90%. (Note: The facility licensed nurse did not document notifying resident CL 1's attending physician with the change in vital signs or that resident CL 1 was assessed as being "Lethargic/drowsy.) x) 7/8/12 at 5:55 AM: "Pt. turned on call light. CN went down to answer call light. Pt. was sitting @ edge of bed et insisting to be taken to hospital. CN told patient, she will go down in about 5 - 10 min (minutes) d/t (due to) paper needs to be copied et sent with patient. 0600 (6:00 AM) CN call patient's sister, (name documented) et that she would be sent to ER (emergency room ) at (local hospital). At the same time team CN #3 came in et was given report about patient's status et was getting ready to be sent to ER. Aide forgot to get resparations (sic) , et 02 (oxygen) wasn't taken yet, so team CN #3 volunteared (sic) to go get VS. y) 7/8/12 at 6:00 AM: "CN was going down to complete vital signs and neuro checks. Pt. was found laying limp horizontal in bed. She was cold and clammy and blue in color. Did sternal rub to try and arouse pt with no response. CN called down hall for help. Secondary CN came down with crash cart. CNA (certified nurse assistant) was told to call 911. We layed (sic) the pt on the ground. She did not have a palpable pulse at this time and pt. was gasping for air every 30-40 seconds. She remained unresponsive and lifeless, her eyes were fixed and dilated. CN bagged pt until paramedics arrived on the scene. CN assisted paramedics as needed. CN assisted until pt. transported to hospital." z) 7/8/12 at 6:00 AM: "New order monitor for any new injuries D/T fall X 3 days." (Note: The licensed nursing staff did not notify the attending physician of resident CL 1's fall until two hours after the fall had occurred.) aa) 7/8/12 at 6:30 AM: "New order transfer to (local hospital) by ambulance @ 0630 (6:30 AM)." bb) 7/8/12 at 10:00 AM: "(Director of Nursing (DON)) and (Administrator) notified of pt. condition and situation." Review of the "Pain Management Flowsheet" revealed that facility licensed nurses documented administering [MEDICATION NAME] 5 mg to resident CL 1 from 6/18/12 to 6/25/12 for complaints of "general pain," chest pain and back pain. The facility staff further documented administering [MEDICATION NAME] 5 mg for the following: a) 6/25/12 at 12:00 PM - "C/O back and ABD pain." b) 6/26/12 at 1:40 PM - " CO back and abd pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. c) 6/26/12 at 7:30 PM - "c/o rib, abd and back pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. d) 6/27/12 at 1:30 AM - "c/o rib and abd pain." The facility licensed nurse documented "resting" after the [MEDICATION NAME] was administered. e) 6/28/12 at 9:15 AM - "c/o rib and abd pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. f) 6/28/12 at 11:15 PM - "c/o rib and abd pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. g) 6/29/12 at 1:00 PM - "c/o rib, back and abd pain." The facility licensed nurse documented that the [MEDICATION NAME] had "...helped." h) 6/29/12 at 7:30 PM - "c/o rib and abd pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. i) 6/30/12 at 3:30 AM - "c/o rib and abd pain." The facility licensed nurse documented "(No) c/o." j) 6/30/12 at 9:30 AM - "c/o rib and abd pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. k) 6/30/12 at 3:00 PM - "c/o abd pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. l) 6/30/12 at 9:15 PM - "pt. request for pain." The facility licensed nurse documented "sleeping" after the [MEDICATION NAME] was administered. m) 7/1/12 at 8:15 AM - "pt. request." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. n) 7/1/12 at 3:15 PM - (No documentation as to why [MEDICATION NAME] 5 was administered.) The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. o) 7/1/12 at 9:15 PM - "pt. request for pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. p) 7/2/12 at 3:15 AM - "pt. request for pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. q) 7/2/12 at 10:00 AM - "pt. request for pain in stomach." The facility licensed nurse documented "helped pt. sleeping." r) 7/2/12 at 10:00 PM - "pt. request for pain." The facility licensed nurse documented "pt. sleeping" after the [MEDICATION NAME] was administered. s) 7/3/12 at 4:00 AM - "pt. request." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. t) 7/3/12 at 10:30 PM - "pt. request in section of abdomen." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. u) 7/4/12 at 5:00 AM - "pt. request for pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. v) 7/5/12 at 4:00 AM - "pt. request for pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. w) 7/5/12 at 10:00 AM - "pt. request for pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. x) 7/5/12 at 4:00 PM - "pt. request for pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. y) 7/5/12 at 11:00 PM - "pt. request pain legs hurt." The facility licensed nurse documented "sleeping (1:00 AM)" after the [MEDICATION NAME] was administered. z) 7/6/12 at 5:00 AM - "pt. request pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. aa) 7/6/12 at 12:00 PM - "pt. request for pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. bb) 7/6/12 at 7:40 PM - "pt. request for pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. cc) 7/7/12 at 1:40 AM - "pt. request for pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. dd) 7/7/12 at 7:00 AM - "pt. request." The facility licensed nurse documented "sleeping" after the [MEDICATION NAME] was administered. ee) 7/7/12 at 1:15 PM - "abd pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. ff) 7/7/12 at 7:30 PM - "abd pain from surgery." The facility licensed nurse documented "some relief" after the [MEDICATION NAME] was administered. gg) 7/8/12 at 1:25 AM - "c/o abd pain." The facility licensed nurse did not document the effectiveness of the [MEDICATION NAME] after it was administered. In addition, the licensed nursing staff documented administering [MEDICATION NAME] 5 mg on the "Narcotic and Hypnotice Record" that was not documented on the "Pain Management Flowsheet." a) 6/18/12 at 2:00 PM; b) 6/19/12 at 4:00 PM; c) 6/22/12 at 3:00 AM; d) 6/23/12 at 6:00 AM; e) 6/25/12 at 6:00 AM; f) 6/25/12 at 6:30 PM; g) 6/25/12 at 12:30 AM; h) 6/26/12 at 7:30 AM; i) 6/27/12 at 9:30 AM; j) 6/27/12 at 9:30 PM; k) 6/28/12 at 3:45 AM; l) 6/28/12 at 5:40 PM; m) 6/29/12 at 5:30 AM; n) 7/2/12 at 4:00 PM; o) 7/3/12 at 10:30 AM; p) 7/3/12 at 4:30 PM; q) 7/4/12 at 2:00 PM; and r) 7/4/12 at 8:38 PM On 7/17/12 at 3:05 PM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that she had asked the night CNA's to obtain CL 1's vital signs at 5:15 AM and 5:45 AM. LPN 1 stated that the CNA's did not report the vital signs obtained until after 5:45 AM. LPN 1 stated that she did not notify CL 1's physician or responsible party until she was transported by the ambulance at 6:30 AM. LPN 1 further stated that if the CNA's had reported the vital signs obtained at 5:15 AM to her immediately, she would have notified the physician and family at 5:15 AM. LPN 1 stated that she did not assess resident CL 1's abdominal status or bowel sounds. Review of the facility policy and procedure for a "Change in a Resident's Condition or Status" revealed the following: "Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc. (et cetera). Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a. An accident or incident involving the resident; ... d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; ... g. a need to transfer the resident to a hospital/treatment center; ...and/or i. Instructions to notify the physician or changes in the resident's condition. 2. A "significant change" of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; ... 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychosocial status; ... e. It is necessary to transfer the resident to a hospital/treatment center. ..." On 7/18/12 at 3:45 PM, the facility Director of Nursing (DON) was interviewed. The DON was unable to provide additional information as to why the facility licensed nursing staff did not document assessing resident CL 1's abdomen, bowel sounds, the effectiveness of pain medications or continued complaints of pain when the [MEDICATION NAME] was not effective. 2. Resident 3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's medical record was reviewed on 7/17/12. Review of the "Physician's Orders" for resident 3 included: a) [MEDICATION NAME] 600 mg (milligrams) TID (three times a day); and b) [MEDICATION NAME] 325 mg 2 tablets by mouth every 4 hours. Review of the "Nurse's Notes" revealed the following entries by the facility licensed nurses: a) 7/14/12 at 10:45 AM: "unwitnessed fall, orderly to report fall et resident was on floor, lying on R (right) side, body audit found. Skin tear (ST) to R elbow, pain to R knee, R mid-ribs, R shoulder. R shoulder pain at ROM (range of motion) to extension to side but pain denied when arm raised above head et crossing chest. C/O R mid ribs painful upon palpaling (sic) surrounding site. Vitals taken q 15 min (minutes), for 30 minutes to 45 minutes, slight change in B/P (blood pressure) decrease, resp (respiration) shallow while down in bed, sm (small) bruising on left are adjacent to ST (skin tear) et wrist. No discoloring to shoulder or hip or knee. Nero (sic) check found no abnormalities. Denies pain to head, neck or back." b) 7/14/12 at 11:15 AM: "pt up in elec (electric) chair. about facility, questioned pain et site discomforts, is alert, et denied except at rib site. Will continue to monitor." c) 7/14/12 at 12:05 PM: "denies further pain except at rib site, flinches when touched, vitals taken BP 122/80, P (pulse) 74, R (respirations) 28, temp 97.8. Alert et able to care for ADL's (activities of daily living) et up for lunch, fair appetite. d) 7/14/12 at 12:15 PM: "family notified, (responsible party), primary contact et as per request resident will be sent to (local hospital) for x-ray (x-[MEDICAL CONDITION]). Resident will have lunch et preped (sic) for transport after. (Note: The family was not notified of the incident until resident 3 requested the staff to notify his family.) e) 7/14/12 at 1:35 PM: "to (local hospital) for possible need for x-ray. Transported by CNA. ..." (Note: A physician was not notified of the incident until resident 3 was seen at the emergency room .) f) 7/14/12 at 1:40 PM: "New orders: 1) monitor x 3 days for further injuries. 2) Bruises R elbow et wrist, monitor q day until healed. 3) monitor ST drg (dressing) for placement. 4) ST R elbow, cleanse with NS (normal saline) et DSD (dry sterile dressing), prep skin with skin prep et apply opsite until healed et PRN." g) 7/14/12 at 5:30 PM: "returned from (local hospital), called came from hospital, no breaks et x-ray was done." Review of incident report dated 7/14/12 completed by facility staff revealed resident 3 had an "unwitnessed fall" at 10:30 AM. The facility staff documented that resident 3 was "found on the floor." Review of radiological reports completed at the hospital on [DATE] revealed a subacute fracture involving the lateral aspect of what appears to be the left 10th rib. Some bone callus was identified which indicated that the fracture was likely to be subacute. No acute fractures were evident. On 7/17/12 at 9:20 AM, resident 3 was interviewed. Resident 3 stated that his pain was at a "5" (on a scale of 1 - 10 with 1 being very mild pain and 10 being severe pain). Resident 3 stated that he had received his pain medication that morning but that he had "cut back" on his physical therapy related to his pain. On 7/17/12 at 9:45 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that the charge nurse was suppose to monitor and document the effectiveness of the pain medication administered to a resident. RN 1 stated that she would wait 1 to 1 1/2 hours after administering pain medications to evaluated if the resident's pain was "better or worse." RN 1 stated that she would have the resident provide a numerical number of their pain or assess the facial expressions when the resident was unable to verbally communicate. RN 1 stated that the nurse administering the medications should also document the medication administration in a nurse's note. RN 1 further stated that residents were assessed every four hours if they were receiving narcotic pain medication. RN 1 stated that if the resident's pain was not resolved, the primary care physician should have been notified.

Based on observation, record review, and interview, the facility did not ensure that the residents' environment was free of accident hazards and that 6 sample residents received adequate supervision and assistive devices to prevent accidents. Specifically, residents experienced falls that required hospital visits and/or resulted in injuries and pain. Resident identifiers: 8, 16, 27, 42, 52, and 79. Findings include: 1. Resident 79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 79's medical record was reviewed on 8/1/11. Resident 79's Nurses Notes dated 6/8/10 documented that resident 79 was admitted to the facility that day and was "alert and responsive but has confusion/forgetfulness . . . Pt (patient) has been (name of acute care hospital) d/t (due to) subdural hematome (with) evacuation. Pt has 2 incisions on (right) side of head where burr holes were . . . Pt is fall risk as he has not been using call light (and) up several times without assist. Pt has generalized weakness and gait is not steady. Has been instructed multiple times on call light use, but does have problems (with) short term memory. Bed alarm placed . . ." A document entitled "Fall risk assessment" for resident 79 dated 6/8/10 documented the resident had intermittent confusion, one to two falls in the last three months, was chair bound, and required the use of assistive devices. Resident 79's total fall risk score was 16. According to the document, a score of 10 or more represented someone at high risk for falls. Resident 79's admission orders bed alarm d/t hx (history) of falls/poor safety awareness." Nurses notes dated 6/8/10 documented resident 79 was "found wandering around in room. Urinated on floor by his bed. . . reminded to use call light." Nurses notes dated 6/9/10 documented resident 79 "tried to get up out of bed on own a few times today but was noticed (and) assisted (before) any injury could occur." A document entitled "Resident Accident/Incident Report" for resident 79 dated 6/10/10 was reviewed. The incident report documented that resident 79 was "found. . sitting on floor by bed. Commode tipped over (with) urine all over floor. . . No bruises, no laceration noted. . ." The incident report documented that resident 79 had attempted to use the bedside commode at the time that he fell to the floor. No interventions were listed to prevent further falls. Nurses notes dated 6/10/10 documented resident 79 was "confused" and was getting out of bed without assistance. . . "can't remember that he is fall risk or won't admit it. . . becomes agitated (with) (name of staff member) when he tells pt to use call light." Nurses notes dated 6/11/10 documented resident 79 was getting out of bed without assistance. An incident report for resident 79 dated 6/14/10 was reviewed. The incident report documented that the resident was "put in shower chair (and) he got out (and) ambulated (and) fell , sustained 1 cm (centimeter) laceration behind (right) eye socket bone and 1.5 cm dia (diameter) skin break" on his knee. The incident report also documented that resident 79 was "confused" at the time of the fall and that the resident was "put in shower chair (and) told to stay but while (name of staff member) was getting his clean clothes to wear. Pt got out of w/c (wheelchair) (and) ambulated (and) fell in rm (room) in middle of rm. Called (name of staff member) who was a door down giving medication. Noted pt on floor on (right) side (with) spots on (sic) blood on floor." The incident report documented that after the fall, resident 79 was experiencing "dizziness, headache, blurry vision" and was "unable to see." The incident report also documented that resident 79 was sent to the emergency room of the local acute care hospital. No interventions were listed to prevent further falls. A document entitled "Physician Orders" for resident 79 dated 6/14/10 from the acute care hospital emergency room was reviewed. The document revealed that resident 79 was admitted to the hospital for a "23 hour observation" with [DIAGNOSES REDACTED]. Interdisciplinary Team (IDT) notes dated 6/15/10 for resident 79 were reviewed. The IDT notes documented that resident 79 "Transferred from (name of acute care hospital) s/p (status [REDACTED]. . Client wont use call-light -- gets agitated when re-oriented by staff. 6/10 found on floor in room -- tipped BSC (bed side commode) (no new injury). 6/14/11 witnessed fall in room -- sustained laceration (Right) outer eye -- taken to (name of acute care hospital) -- observed overnight." A document entitled "Restraint Assessment" dated 6/15/10 for resident 79 documented that resident 79 was using a soft waist seat belt due to "inability to consider own lack of independence". . . fall mats ineffective because "pt attempts to stand on own (and) forgets to use call light even (with) multiple reminders." The assessment also documented that resident 79 had a "memory problem" with "impaired decision making". physician progress notes [REDACTED]." 2. Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 27's medical record was reviewed on 8/1/11. Resident 27's Activities of Daily Living (ADL) flow sheets for the month of April 2011 were reviewed. The ADL flow sheets revealed that resident 27 required "total dependence" on facility staff for dressing, toilet use, bathing, transfer, and bed mobility. Resident 27's care plan dated 12/23/10 was reviewed. The care plan documented that resident 27 was "at risk of injury r/t (related to) dementia, [DIAGNOSES REDACTED], seizure disorder needs total assist with bed mobility and transfers of two people." Resident 27's Interdisciplinary Team (IDT) meeting notes dated 6/15/11 were reviewed. The notes documented that on 4/4/11 resident 27 had a right ankle x-ray and had reported "legs buckling during a transfer." A physician's visit for resident 27 dated 4/4/11 documented that resident 27 had experienced an "ankle injury" and that "Severity level is moderate. The problem is stable. Location: right ankle. The pain is sharp. Associated symptoms include bruising, swelling, and tenderness. Additional information: Sat on foot awkwardly and has diffuse right ankle pain." A document entitled "Resident Accident/Incident Report" dated 4/4/11 for resident 27 was reviewed. The incident report documented that on 4/4/11 "(resident 27) told me (name of Certifed Nurse Aide (CNA)) I went backward (and) landed on my (right) foot. My foot was hurting. happened 2 days ago 4/2/11. Don't remember where it happened or who was there to help me. But a nurse was there, to help me get back up. There were other people there. But don't know who were there. Pt (patient) c/o (complains of) increase (sic) pain to (right) foot when touched . . . . . X-ray (right) ankle per (physician name) (fracture noted in x-ray)." Another entry on the incident report was recorded by the administrator who documented "Talked (with) CNAs, nobody remembers (resident 27) landing on the floor or even landing on his legs. (Resident 27)'s account is unchanging, he said his legs buckled when transferring but didn't land on the floor. Does not remember the CNA or if it was male or female." On 8/4/11 at 3:45 PM an interview was conducted with resident 27 in his room. Resident 27 stated that he remembered the incident on 4/4/11 and that his ankle was injured "while some aides were transferring me." Resident 27 then stated that he was being transferred from his wheelchair and his "foot got caught" but that he did not remember which staff members were involved. Resident 27 stated that he could not transfer himself in his wheelchair or get out of bed without assistance from staff. On 8/4/11 at 3:20 PM an interview was conducted with the facility administrator regarding the incident involving resident 27. The administrator confirmed that resident 27 was completely dependent on staff for transfers. The administrator also stated that the entire investigation into the incident on 4/4/11 was listed on the incident report. The administrator further stated that she did not recall which staff members she had interviewed during the investigation. The administrator also stated that following resident 27's injury, she had not done any inservices or training of staff to prevent further injuries during transfers. 3. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8's medical record was reviewed on 8/3/11. On 8/4/11 at 8:41 AM, resident 8 was interviewed. Resident 8 stated that "a couple of weeks ago" he went on a shopping activity provided by the facility. He stated that Certified Nurse Aide (CNA) 10 attempted to load him in the facility van using the mechanical lift on the van. He stated CNA 10 bumped his left leg several times against an empty wheelchair. He stated CNA 10 was "rough with him and irritable". Resident 8 stated that when he was placed in the van, his geri-chair was not secured in any way to prevent it from moving when the van was moving. Resident 8 stated that he was "sliding out of the chair" and noticed that the facility van was "veering off to the right side of the road". He stated that the vehicle went over the rumble strips on the road and that CNA 10 jerk the vehicle back onto the road. Resident 8 stated that when CNA 10 jerk the vehicle to the left, an unsecured oxygen tank and wheelchair that was placed to the resident's left side, fell on his left knee. Resident 8 stated that there was a "pop" sound from the left knee. He stated that CNA 10 pulled the vehicle over and secured the wheelchair and oxygen tank. Resident 8 stated that CNA 10 commented, "I bet you're glad you have a morphine pump now". Note: Per documentation on a facility incident report, the incident occurred on 7/19/11. Resident 8 stated that when he returned to the facility, at approximately dinner time, he reported the incident to the nurse. He stated that his pain was severe at 10 on a 1 to 10 rating scale, with 10 being the most severe. He stated that the nurse kept giving him Tylenol and one dose of Dilaudid but that he was in such severe pain that he requested to go the hospital for an evaluation. Resident 8 stated that the facility Administrator asked him on 7/20/11 if he could rotate his knee or bend his knee enough to be placed in a geri-chair. Resident 8 responded by saying "No, not with the severe pain I have". He stated that the Administrator stated that she "hated" to call an ambulance but finally realized that he was in a lot of pain and an ambulance was called. Resident 8 stated that he had some fluid removed from his knee and that he received a "knee sprain" from the incident. Resident 8 stated the facility waited too long to transfer him to the hospital. Resident 8 was evaluated at the emergency roiagnom on [DATE] at 7:30 AM. The hospital emergency room personnel documented "(Resident 8) c/o (complains of) pain in left hip, femur and knee.." with additional documentation that included "left knee is swollen, unable to move left leg for evaluation d/t (due to) pain and contractures... Pt. yelling out in pain with minimal movement". The hospital records revealed that resident 8 received Dilaudid 2 mg IM (intramuscular). Resident 8's left knee was aspirated and Kenalog/Lidocaine injection was administered. On 8/1/11 at 2:16 PM, the facility Administrator was interviewed. The Administrator stated that resident 8 was alert and oriented and was a good historian. She stated that "that if he said it happened then it happened and she took his word for it". The Administrator was asked about the incident that occurred on 7/19/11. The Administrator stated that she had not documented the investigation but that resident 8 was evaluated at the emergency room and had no fractures. On 8/5/11, the facility Administrator provided a written investigation into the incident that occurred on 7/19/11. The investigation was documented following the surveyor's interview with the Administrator on 8/1/11. The Administrator documented that she interviewed (resident 8) regarding an allegation of being "rough". She documented that the resident stated that his knee was "...twisted in a funny way and that (CNA 10) didn't make sure that his leg was safe. When they were closing the lift, his leg got twisted by an adjacent wheelchair. He told them to stop, that his leg was hurting and they did stop the lift and readjusted him". The Administrator's investigation did not include allegations that CNA 10 "veered" off the road resulting in a wheelchair and oxygen tank landing on his leg. On 7/20/11 at 4:30 PM, approximately 24 hours after resident 8 reported the incident, a facility nurse completed an "Incident Report". The incident report included documentation that resident 8 reported his knee was bumped when being loaded into the van and that he felt a "pop". 4. Resident 16 was admitted to the facility on [DATE] for a twelve day respite stay. Resident 16's medical record was reviewed on 8/2/11. A "Non-Pressure Skin Condition Report" form was completed at the time of admission and revealed multiple bruises sustained prior to admission to the facility related to a fall. An care plan for "Risk for poor mobility and falls" was developed at the time of admission to the facility. Goals for this identified problem included: "Will regain prior level of function and be free from falls or injury for 90 days". The care plan approaches included: physical therapy consult, physical therapy designed rehabilitation plan when physical therapy is continued, assist with all mobility and transfers, monitor gait if ambulatory, monitor for falls or injury. The facility nurses documented in the "Nurse's Notes" the following: 5/9/11 (no time): "...was waiting for drink of water. she went to sit down and tripped over her feet fell face forward hematoma on rt (right) side of forehead. Skin tears on left arm and rt arm. assessment done. call Grandson. Called (emergency department at hospital). to hospital per facility van". 5/9/11 (no time): "returned from ER (emergency room ) with instructions 1) keep dressing dry and intact, 2) change outer dressing daily. leave steri-strips in place, 3) call for redness around skin tear, watch for signs and symptoms of infection, 4) call for any change in mental status from baseline, 5) follow up as needed with primary care provider". On 5/12/11 (no time) a facility nurse documented in the nurse's notes "...amb (ambulated) with staff assist as pt. (patient) (at) risk for falling". On 5/12/11 at 11:45 PM: "slipped out of w/c (wheelchair) while visiting with another resident (at)nurses station. Pt. was laying on right side on floor. Pt. was lifted off floor and put in w/c by both (nurses). Pt. was checked for injuries. No visible injuries found. Pt. unable to verbalize to how she got to the floor. After pt. sat in w/c for a minute she started c/o (complain of) leg pain and mid thigh. Would not raise her foot when asked. Pt. was then transported to (hospital) for x-rays". Resident 16 was admitted to a hospital with a [DIAGNOSES REDACTED]. Resident 16's care plan for "Risk for poor mobility and falls" was not revised or changed to include further interventions to prevent further falls from occurring. On 8/2/11 at 3:33 PM, the facility Director of Nursing was interviewed. The DON stated that the facility did not initiate additional interventions after resident 16 fell on [DATE]. 5. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Multiple observations or resident 52's room were made between 8/1/11 and 8/4/11. At each observation, a nebulizer with tubing was observed to be on the floor, near the doorway. A quarterly MDS, dated [DATE], indicated resident 52 moved independently and had not had any falls. A Fall Risk Assesment, dated 6/8/11, indicated resident 52 scored 12, a high risk for falls. The Care Plan for resident 52 for accidents listed a fall on 3/9/1 and her right foot run over by a wheelchair on 5/13/11. No interventions were noted. Incident reports from December 2010 were reviewed for resident 52. They were as follows: 3/9/11: "pt reports she tripped on the cord to her nebulizer and fell on to her right knee earlier today, says she bumped toes on both feet. Does have a bruise on right knee and lateral edge of left 2nd toe." No interventions were made except to monitor. 5/13/11: "pt came to nurses station told charge nurse someone ran over my bad foot. Said he rolled back in his motorized wheelchair and she was behind him and stepped forward with the wheel running over the top of my right foot. Right foot is only slightly swollen on top . . .no discoloration." The intervention was to "monitor daily". On 8/3/11 at 1:47 PM, RN 1 was interviewed. RN 1 stated resident 52 used the nebulizer once or twice a week. RN 1 stated resident 52 had a few accidents. RN 1 stated resident 52 purposely ran over her own foot with another residents wheelchair. RN 1 stated resident 52 purposely fell at times so she could get attention and get pain medication. On 8/3/11 at 2:47 PM, CNA 1 was interviewed. CNA 1 stated resident 52 did not use a nebulizer and had not noticed one in her room. On 8/4/11 at 2:20 PM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated resident 52 used the nebulizer as needed and the last time was on 8/3/11. The ADON stated resident 52 had unsafe behavior. The ADON reported resident 52 ran over her own foot with another residents wheelchair. The ADON was asked what interventions were put in place after resident 52 fell over the nebulizer tubing in March 2011. The ADON stated resident 52 put her nebulizer on the floor. The ADON stated: "She does what she wants to do." On 8/4/11 at 9:16 AM, the Resident Advocate (RA) was interviewed concerning resident 52's behaviors. The RA stated there was not a behavior care plan in place for staff to deal with resident 52's behavior to prevent accidents. 6. Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated resident 42 needed a one person assist to transfer, walk in her room or in the hall and her balance was not steady without assistance. The MDS indicated resident 42 did not have any falls since the prior assessment. A fall risk assessment for resident 42 indicated on 12/19/10 and 3/6/11 resident 42 scored 17, a high risk for falls and on 6/6/11 resident 42 scored 15, a high risk for falls. The care plan for resident 42 listed 5 falls since 2/8/11. The actions and approaches were to monitor injuries. Interventions to prevent further falls were not listed. Incident reports for resident 42 since December 2010 were reviewed: 1/7/11: "found sitting on floor no injuries resident comment I was rolling over in bed and rolled out of bed. I'm fine just get me back in bed." Interventions were to monitor. 1/26/11: "client found on floor- reports she fell client too upset to tell charge nurse what happened wouldn't talk to RA . . . later her arm and abdomen hurt from hitting into her dresser but later recanted and said it only hurt where 'that man' picked me up referring to the orderly who helped her off the floor no injuries". No interventions were documented. 1/31/11: "CNA found her sitting on floor in room Charge Nurse found her in wheelchair didn't have brakes applied. . . Encouraged to use call light. States I was trying to get into wheelchair and I slipped to floor." The intervention was to monitor. 2/16/11: "pt was found lying on floor by sink in her room fell while ambulating from bathroom pt was upset/crying bruise/hematoma found on right lower back and Left knee pt also reported left shoulder sore no bruising pt has been asked many times to use the call light for assist.. . pt stated I'm going to kill myself, then stated I'm sick of you people." No interventions were documented. 7/15/11: "pt found lying on right side in room head towards foot of bed feet towards bathroom found by resident and family member. Patient denies pain CNA responded . . . pt stated she was picking up cans when she fell says she didn't hurt anything c/o (complains of) slight pain in inner right thigh complains of dizziness." No interventions were documented. 7/23/11: "pt found lying on her back in her room aide reports she was preparing for a shower and aide went to check on pt and found pt on floor aides reported they did not hear the pt fall from the next room 18:15 (6:15 PM) aide reports pt was found kneeling beside bed says she fell and requires assistance aid (sic) reported pt behavior c/o headache finished shower free from bruising." No interventions were documented. A Nurses Note dated 7/11/11 indicated the charge nurse found resident 42 on her right side on the floor of her doorway with her head towards the hall. Resident 42 stated she had bumped her head trying to move one of her bags from under her table by the doorway and lost her balance. An incident report for this fall was not located. A Physicians Progress Note dated 5/22/11, indicated resident 42 had left hand pain with a moderate severity level. The note indicated resident 42 hit her left hand on the doorway as the wheelchair was going through on 5/21/11. The hand had bruising, swelling and tenderness. An incident report was not located for this accident and the hand injury was not in resident 42's nursing notes. An Inter-departamental Team (IDT) note dated 3/9/11 reported for housekeeping: "room crowded- but resident won't let us de-clutter." For Nursing the IDT note indicated: frequent falls with minor injuries bumps/bruises working with therapy." The last Resident Advocate quarterly assessment, dated 12/8/10, did not mention any behaviors for resident 42. On 8/1/11 at 11:00 AM, a staff interview was conducted. The staff member stated resident 42 fell while trying to find things in her room because she "had a lot of stuff in it." On 3/3/11 at 2:08 PM, RN 1 was interviewed about resident 42. RN 1 stated resident 42 "acted out" a little bit. RN 1 stated that when there were visitors in the facility resident 42 "supposedly" fell twice. Resident 42 was found on her back one time and on her knees another time. RN 1 stated that if a lot of people were around, resident 42 would make sure she was getting a lot of attention. RN 1 reported resident 42 would state she was going to have a seizure and if staff did not do what she wanted she would throw herself on the ground. On 8/3/11 at 2:47 PM, CNA 1 was interviewed. CNA 1 stated she was not aware of any accidents for resident 42. On 8/4/11 at 9:16 AM, the RA was interviewed. The RA stated resident 42 tended to do things on her own without asking for help. The RA stated that resident 42 stated her knees go weak and then she would fall. The RA stated resident 42 would fall when getting to the bathroom or getting onto the bed from the wheelchair. On 8/4/11 at 2:20 PM, the ADON was interviewed. The ADON stated physical therapy got an electric wheelchair for resident 42 and staff decluttered her room. The ADON did not know why an incident report was not completed when resident 42 hit her hand on 5/22/11. Accident Hazards: 1. On 8/2/11 at 8:56 AM, a can of paint and another unidentified chemical were observed to be unsecured in the bathroom of room 407. 2. On 8/2/11 from 7:30 AM through 11:00 AM, a container of a wax stripper was observed to be unattended outside of room 402. 3. On 8/3/11 at 4:45 AM an observation was made of tub room 6. The door to the room was unlocked and ajar. Inside the tub room was a bottle of disinfectant spray and three boxes of disposable razors that were not secured. 4. On 8/1/11 at 8:05 AM, a disinfectant spray bottle was observed on the hand rail by the door in shower number 5. The shower door was unlocked.

Based on observation and interview, it was determined the facility did not have a Quality Assessment and Assurance (QAA) committee that identified concerns and developed and implemented appropriate plans of action to correct identifiable quality deficiencies. The QAA committee did not identify concerns in the areas of abuse, pain, pressure ulcers, accidents and falls, infection control and nutrition which affected all residents and specifically for 6 sample residents. Resident identifiers: 8, 16, 27, 43, 50 and 79. Findings include: During the State Survey and Certification review, from 8/1/11 through 8/4/11, the following concerns were identified: 1. The facility's QAA Committee did not ensure that staff intervened with resident 16 in a manner that promoted resident choice and prohibited abuse when she was taken against her will to the Administrators office. (see F 223) 2. The facility's QAA Committee did not ensure resident 8's pain was assessed and managed timely. (See F 309) 3. The facility's QAA Committee did not ensure resident 43 received care and treatment to prevent a facility acquired pressure ulcer. (See F 314) 4. The facility's QAA committee did not ensure resident 8 was safe while being transported in the facility van which was driven by an impaired employee who did not secure the resident's wheelchair or other items in the van. The QAA committee did not ensure residents 16, 27 and 79 were free from repeated falls and injuries. (See F 323) 5. The facility's QAA Committee did not ensure residents 16 and 50 were free of significant, avoidable weight loss. (See F 325) 6. The facility's QAA Committee did not ensure there was an infection control program that monitored and prevented facility acquired infections. (See F 441) On 8/1/11, during an initial entrance conference, the Administrator stated the facility had a QAA committee that met quarterly with the Medical Director and Department Heads. In addition, the Administrator stated department heads met daily in "stand up" meetings as part of their QAA process. The Administrator stated that given the issues identified by survey, the facility's QAA committee had been ineffective.

Based on interview and record review the facility did not ensure that one sample resident maintained acceptable parameters of nutritional status, specifically body weight. Resident 16. Findings include: Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 16's medical record was reviewed on 8/1/11. A weight report provided by the facility documented the following weights (in pounds (lbs)) on the corresponding dates: a) 5/22/11 101 lbs b) 6/5/11 99 lbs c) 6/12/11 96 lbs d) 7/10/11 95 lbs e) 7/17/11 94 lbs Resident 16 experienced a 7% weight loss from 5/22/11 through 7/17/11. Resident 16's admit care plan documented that resident 16 was at "risk for poor nutrition and weight loss." However, the nutrition care plan for resident 16 dated 5/28/11 did not document that resident 16 was at risk for weight loss. On 6/24/11 a "Dietary Progress Note" was completed for resident 16 by the facility Registered Dietitian (RD). The RD documented that resident 16 had experienced a significant weight loss and recommended that facility staff "determine need to start TF (tube feeding) d/t (due to) inadequate . . . intake (and) wt (weight) loss. (Decreased) alb ([MEDICATION NAME]). RD to f/u (follow up) monthly or prn (as needed)." The RD note did not document other interventions to be attempted by facility staff to increase resident 16's intake. In addition, the RD did not make any recommendations to increase resident 16's [MEDICATION NAME] level. Resident 16 was observed in the dining on 8/2/11. The following was noted: a) At 7:31 AM, resident 16 was pushed into the dining room and placed at her assigned table. A facility staff member gave resident 16 a cup of what appeared to be 4 ounces of Med Pass. b) At 7:45 AM, resident 16's table mates were eating with the assistance of two staff members. Resident 16 had not been served her breakfast. c) At 7:50 AM, resident 16's breakfast was served. The facility staff member cut the pancakes. d) At 7:54 AM, facility staff had not attempted or encouraged resident 16 to eat. e) At 8:00 AM, the facility Administrator sat next to one of resident 16's table mates and assisted another resident to eat breakfast. The Administrator did not encourage or assist resident 16 to eat. f) At 8:01 AM, the facility Administrator gave resident 16 a cup of yogurt. Resident 16 was observed stirring her hot cereal but had not taken a bite to eat. g) At 8:06 AM, a staff member attempted to assist resident 16 to eat. Resident 16 pushed the staff member's hands away multiple times. h) At 8:11 AM, the facility Administrator offered resident 16 a banana. Resident 16 was at the dining room table for 19 minutes before being served breakfast and an additional sixteen minutes before offering assistance with eating breakfast. On 8/3/11 at 4:00 PM an interview was conducted with the facility Dietary Manager (DM). The DM stated that resident 16 received snacks and a high calorie supplement frequently throughout the day, but that it was not documented. When asked about the Nutrition At Risk (NAR) meetings, the DM stated that resident 16's weight had not been discussed since 6/25/11. The DM also stated that NAR meetings were supposed to be held once a week, but that it had been two weeks since the last meeting. On 8/3/11 at 5:00 PM an interview was conducted with the facility Director of Nursing (DON) and Administrator. The DON stated that facility staff were aware of the weight loss, but that the family had decided not to place a feeding tube with resident 16, so facility staff would "try and get extra med pass (high calorie supplement) in her." Activities of Daily Living (ADL) flow sheets were reviewed for resident 16. The flow sheets did not indicate whether a PM snack was offered or refused. On 8/3/11 at 4:00 PM Certified Nurse Aide (CNA) 13 was interviewed. CNA 13 stated that when he offered the PM snack to resident 16, resident 16 was asleep, but that he did not indicate that on the ADL flow sheets. On 8/3/11 an interview was conducted with the facility RD. The RD stated that resident 16 needed assistance with eating, and that she was aware of resident 16's weight loss. The RD stated that she was supposed to be seeing resident 16 every month, but confirmed that she did not have any documentation for resident 16 after 6/24/11. When asked about interventions the RD had put in place to address resident 16's weight loss, the RD stated that staff members offered resident 16 "med pass" throughout the day, the resident was on an [MEDICATION NAME] diet, and the option of a feeding tube placement was discussed with resident 16's family. The RD stated that resident 16 received "med pass" throughout the day, but that she had no way of monitoring how much resident 16 received from various staff members. The RD stated that because the family did not want to place a feeding tube, resident 16's weight loss was unavoidable. The RD stated that there was a snack cart that residents could pick a snack from every night. The RD stated that in spite of resident 16's [DIAGNOSES REDACTED].

Based on interview, record review and observation the facility did not ensure that one sample resident who entered the facility without a pressure sore did not develop a pressure sore. In addtion, a second sample resident's wound was not given appropriate treatment for [REDACTED]. Findings include: 1. Resident 43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 43's medical record was reviewed on 8/1/11. A document entitled "Wound/Skin Healing Record" was reviewed. The wound sheet, documented that on 6/6/11 facility staff identified a stage II wound that was 1 centimeter (cm) in diameter on resident 43's "coccyx". Per the wound sheet, a stage II wound was described as "partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater." On 6/6/11 a physician's telephone order regarding resident 43's "stage II DQ (decubitus/pressure sore) coocyx" was received. The telephone order documented that resident 43 should have her pressure sore cleased with normal saline, have wound gel applied and then covered. On 6/16/11 facility staff documented on the wound sheet that resident 43's stage II pressure sore was "completely healed". On 6/28/11 the facility physician documented that resident 43's "skin break to coccyx is healing." A Minimum Data Set ((MDS) dated [DATE] documented that resident 43 was totally dependent on staff for bed mobility and transfers. In addition, the MDS documented that resident 43 had "impairment on both sides" of both the lower and upper extremities. The MDS also documented resident 43 as having no restraints in place. A care plan dated 5/4/11 for resident 43 was reviewed. The care plan documented that resident 43 was "at risk for skin breakdown of pressure ulcers (sores) related to decreased mobility bed mobility bladder (and) bowel incontinence needs extensive help with ADL's (sic) (and) transfers." A physician's telephone order dated 3/21/11 was in place for resident 43 to "add Cardiac chair w/ (with) easy release seatbelt (and) add pommel cushion. . . for positioning/safety." Interdisciplinary Team (IDT) notes dated 7/20/11, 4/20/11 and 1/1911 documented that resident 43 had a self-release seat belt in place as an "enabler" but not a restraint. In addtion, the IDT notes dated 7/20/11 documented that resident 43 had a stage II pressure sore, but that it had healed. On 7/20/11, 4/29/11 and 3/21/11 facility staff documented on a "Physical Restraint Assessment" that resident 43 was "unable to reposition self or get out of her w/c (wheelchair)." The document further stated that resident 43 had a "partial or total loss of voluntary movement" and a "partial or total loss of ability to position." Activities of Daily Living (ADL) flow sheets for resident 43 for the month of June 2011 were reviewed. The flow sheets documented that resident 43 was totally dependent on two staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene/grooming, and bathing. On 8/1/11 during the lunch meal and 8/2/11 during the breakfast meal, observations were made of resident 43. On both occasions, resident 43 was observed in a "cardiac chair" with a self release seat belt in place. On 8/3/11 at 6:40 AM resident 43 was observed while seated in her "cardiac chair" in the hallway. At 6:44 AM resident 43 was wheeled into the dining room for breakfast. Resident 43 remained in the "cardiac chair" with the self release seat belt in place throughout the breakfast meal. On 8/4/11 at 8:25 AM an interview was conducted with Certified Nurse Aide (CNA) 4 regarding resident 43. CNA 4 stated that resident 43 was unable to remove the seat belt due to her severe contractures, and that staff members were responsible for removing the seat belt at appropriate intervals. On 8/4/11 at 8:40 AM an interview was conducted with CNA 5 regarding resident 43. CNA 5 stated that resident 43 was unable to remove the seat belt due to her severe contractures, and that staff had to both remove the seat belt and assist resident 43 with repositioning. On 8/4/11 at 9:20 AM an interview was conducted with the Assistant Director of Nursing (ADON) regarding resident 43's pressure sore. The ADON confirmed that resident 43 had a pressure sore in June 2011. The ADON stated that she was unsure how the resident aquired the pressure sore, but that facility staff noticed it on 6/6/11 during pericare. On 8/4/11 at 9:44 an interview was conducted with Licensed Practical Nurse (LPN) 2 regarding resident 43. LPN 2 confirmed that resident 43 aquired a stage II pressure sore on her coccyx in June 2011. LPN 2 stated that she had treated the pressure sore, and that the wound was open and was located on the "bony" part of resident 43's coccyx. LPN 2 stated facility staff discussed resident 43's pressure sore and decided that resident 43 was up in her cardiac chair "too much so we started laying her down more." LPN 2 confirmed that resident 43 could not reposition herself or remove the self release seat belt. 2. Resident 19 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/3/11 at 10:45 AM, Licensed Practical Nurse (LPN) 1 was observed during a dressing change procedure for resident 29's Stage IV sacral/coccyx pressure sore. Resident 19 was observed to have a large amount of loose stool in her brief and down her thighs. LPN 1 pulled the brief down and tucked the top under to expose the pressure sore, but did not remove the soiled brief. There was no dressing covering the pressure ulcer. LPN 1 did not cleanse resident 19's buttocks before she cleansed inside the pressure sore with clean, moistened gauze pads. LPN 1 completed the dressing and covered the pressure sore with two adhesive Opsite bandages. After she had finished resident 19's dressing, LPN 1 asked a CNA for assistance to change the soiled brief.

Based on observation, interview and record review, it was determined the facility did not provide necessary care and services to attain or maintain the highest pradticaly physical, mental and psychosocial well-being for 2 sample residents. Resident identifiers: 8 and 52. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/19/11, while on a facility van ride, resident 8 sustained injuries to left lower extremitity. Cross-Refer to F-323, example #3. Resident 8's medical record was reviewed on 8/4/11. On 7/19/11 at 8:00 PM, a "Nurse's Note" for resident 8 was documented by Licensed Practical Nurse (LPN) 3. LPN 3 documented that resident 8 complained of hitting his LLE (left lower extremity) while on a van ride and that he was experiencing a lot of pain to his left femur area. LPN 3 documented that resident 8's LLE was repositioned by a nurse aide at the resident's request and that the resident experienced moderate leg spasms. LPN 3 documented that resident 8 wanted an x-ray of his leg and that the LPN wrote a note for the physician to evaluate resident 8 in the morning. LPN 3 documented that resident 8 was given [MEDICATION NAME] for pain as needed. LPN 3 documented at 4:30 AM resident 8 experienced increased muscle spasms to his LLE and that Bengay ointment was applied. On 7/20/11 at 6:30 AM, LPN 3 documented that resident 8 had increased pain and spasms to his LLE but that no swelling or deformity was noted. LPN 3 documented that an order to transfer resident 8 to an acute care hosptial emergency room by ambulance was obtained. On 8/4/11 at 8:41 AM , resident 8 was interviewed. Resident 8 stated that when his left leg was injured, during the van ride on 7/19/11, it was painful and that he had requested pain medication from the facility Activity Director (AD). He stated that the AD gave him some Tylenol. Resident 8 stated that when he returned to the facility, at approximately dinner time, he reported the incident to the nurse. He stated that his pain was severe at 10 on a 1 to 10 rating scale, with 10 being the most severe. Resident 8 stated that he requested to go to the hospital for x-rays and evaluation and was told by the nurse that the physician was scheduled to do rounds at the facility in the morning and that she would make sure the resident was seen. He stated that he requested multiple times during the night to be evaluated at the hospital but was denied. Resident 8 stated that the pain became so unbearable with pain and muscle spasms that he was finally sent to the hospital around 7:00 AM on 7/20/11. The Physician order [REDACTED]. Resident 8's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"as needed" doses of [MEDICATION NAME] 4mg on 7/19/11 at 6:00 PM and again on 7/20/11 at midnight. LPN 3 documented the reason for the additional doses of [MEDICATION NAME] was, "Pt (patient) req (request)". LPN 3 did not document the effectiveness of the "as needed" [MEDICATION NAME]. On 8/4/11 at 8:00 AM, LPN 3 was interviewed. LPN 3 stated that it was facility policy to assess a resident's complaint of pain as to where the pain was, the nature of the pain and the cause. She stated that she would then check the physician orders [REDACTED]. She stated that she would usually administer nonnartic pain medications before administering narcotic pain medications. LPN 3 stated that if the resident did not receive relief from pain, that the physician would be notified and if the resident could not "tolerate" the pain, that the resident would be transported to the emergency room for an evaluation. LPN 3 stated that resident 8 "wanted to wait until the morning to talk to the physician" but that he "couldn't tolerate the pain any longer" and was eventually sent to the emergency room for an evaluation. LPN 3 stated that resident 8 did not have any swelling or deformities outside of his normal limits when he was sent to the emergency room . Despite complaining of severe pain when he returned from the van ride at approximately dinner time on 7/19/11, resident 8 was not evaluated at the emergency room until 7:30 AM on 7/20/11. The hospital emergency room personnel documented "(Resident 8) c/o (complains of) pain in left hip, femur and knee.." with addiitonal documentation that included "left knee is swollen, unable to move left leg for evaluation d/t (due to) pain and contractures... Pt. yelling out in pain with minimal movement". The hospital records revealed that resident 8 received [MEDICATION NAME] 2 mg IM (intramuscular). Resident 8's left knee was aspirated and [MEDICATION NAME]/[MEDICATION NAME] injection was administered. 2. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/1/11 at 2:59 PM, resident 52 was asked if she had any pain. Resident 52 responded that she did experience pain and that Registered Nurse (RN) 1 would not give her pain medication when she requested. Resident 52 stated if she were to request pain medication from RN 1, RN 1 would not administer the pain medication until all the other resident medications had to be administered. Resident 52 stated she had to sign a paper saying she would not ask for her pain pills any more than every 8 hours. Resident 52 stated she could not handle the pain in her fractured pelvis. Resident 52 stated that 6 hours after her pain pill, she was hurting again. A quarterly MDS dated [DATE], indicated resident 52 had pain occasionally that made it hard to sleep with an intensity of 8. Interdisciplinary Team Meeting notes, dated 6/8/11, indicated resident 52 had mild to moderate pain in her feet, back and tooth. The note indicated resident 52 received [MEDICATION NAME], Tylenol and routine [MEDICATION NAME]. Resident 52's Multidisciplinary Resident Care Plan did not include pain issues. A Pain Evaluation, dated 9/17/09, indicated numerous nonverbal/noncognitive signs of pain such as grimacing/distorted face, tightly shut lips, wrinkled brow, gasping and rubbing body parts. The evaluation stated the pain was due to a rib fracture. No further documentation for the assessment of resident 52's pain was located in the medical record. The July 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a) [MEDICATION NAME] 50 mg four times a day at 12 AM, 6 AM, 12 PM and 6 PM. b) [MEDICATION NAME] 10 mg three times a day as needed. c) Tylenol 650 mg three times a day as needed for one week. The MAR indicated Charge Nurse to be sure and take all medications to resident in her room to lessen the chance for socially disruptive behavior." Review of the July 2011 MAR indicated [REDACTED]. The Pain Management Flowsheet for 7/15/11 through 8/4/11 for resident 52 was reviewed. The effect of the pain medication before resident 52 received a pain medication was documented by a numbered pain rating. The pain after the intervention was not documented. Nurses Notes dated 6/14/11 indicated: "pt complains of pain R (right) hip requests 'my big pain pill'. Also wants her R hip x-rayed." Nurses Notes revealed that on 6/17/11 an x-ray and a nerve conduction test were scheduled for resident 52. On 6/19/11 the note indicated resident 52 was constantly asking the nurse for pain pills for constant hip and foot pain. Nurses Notes on 6/24/11 indicated resident 52 had requested [MEDICATION NAME] several times and sat by the nurses medication care grunting, and moaning and saying her right hip, foot and back hurt. Nurses Notes dated 7/9/11 indicated resident 52 had pelvic insufficiency fractures. The physician was asked for more pain medications for resident 52. The physician stated no, resident 52 had enough to cover her. The Nurses Notes for resident 52 had no further documentation of pain. Physicians Progress Notes were reviewed and contained the following entries: a) On 6/17/11, the progress note indicated the back pain was worsening, occurred persistently and radiated to the right foot. The note indicated there was severe sciatic pain on the right side of resident 52's back and chronic right foot pain. b) On 7/18/11, the physician's progress note indicated resident 52 had [MEDICAL CONDITION], was at risk for an atraumatic fracture and had a family history of pelvic insufficiency fractures. c) On 7/26/11, the physician's progress note indicated resident 52 had a pelvic insufficiency fracture and had [MEDICAL CONDITION]. On 8/3/11 at 1:47 PM, RN 1 was interviewed. RN 1 stated that resident 52 had [MEDICATION NAME] ordered every 8 hours and it was difficult to keep her to every 8 hours. RN 1 stated: "I have to keep explaining over and over to her why I can't give it to her." RN 1 stated that resident 52 sometimes fell on purpose so she could get pain medication. On 8/4/11 at 2:20 PM, the Administrator was asked about resident 52's pain. The Administrator stated resident 52 did have pain. The Administrator stated the pain was assessed on a pain numbered scale and documented on the Pain Management Flow Sheet. The Administrator noted the flow sheet did not document resident 52's pain after the pain medication was given.

Based on observation and interview the facility did not protect one sample resident from abuse. Specifically, facility staff used physical force to take a resident from one area of the facility to another, against the resident's expressed desire. Additionally, during two confidential resident interviews the residents expressed fear of retaliation by facility staff. Resident identifier: 16. Findings include: 1. Resident 16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/1/11 at 2:00 PM observations were made of resident 16. Resident 16 was sitting in a "cardiac chair" near the nurses' station. The chair was made of plastic piping, allowing the resident to stand, walk, and sit freely. Resident 16 was sitting quietly and without signs of agitation. At 2:07 PM Certified Nurse Aide (CNA) 9 approached resident 16 and, without speaking to the resident, started pulling on the front of resident 16's cardiac chair, attempting to pull resident 16 in her chair down the hallway. Resident 16 began yelling out "No! No!" repeatedly. Resident 16 then began pulling against CNA 9, resisting CNA 9's efforts to pull her chair down the hallway. CNA 9 then began to pull resident 16's chair harder, saying "Come on. You have to go to the administrator's office." Resident 16 planted her feet and was pulling backward, using her legs to resist the efforts of CNA 9. At that point, CNA 9 turned resident 16's cardiac chair around and pulled resident 16 in her cardiac chair backward down to the administrator's office. Resident 16 was grabbing the handrails yelling "No! No! Someone help me! Please! I don't want to go! Help! Help!" Despite resident 16's protests, CNA 9 continued to pull resident 16 in the chair backwards to the administrator's office. When resident 16 arrived at the administrator's office, several staff in the office began pulling resident 16 in her cardiac chair into the office, while CNA 9 pushed resident 16 in her cardiac chair into the office. Resident 16 was holding on to the door jambs yelling "Please help me! No! No! Stop it! Leave me alone!" Resident 16 was agitated. On 8/1/11 at 2:15 PM an interview was conducted with CNA 9 regarding the occurrence with resident 16. CNA 9 stated that resident 16 was "really aggressive" and gets "angry." When asked how she cared for residents who became resistive to cares, CNA 9 stated that "you try to talk to them to calm them down while you are doing the cares." When asked why resident 16 was taken to the Administrator's office CNA 9 stated that it was per the Director of Nursing's (DON) request. CNA 9 further stated that "you don't go against what the DON says. . . so it didn't matter what the resident was saying." At 8/4/11 at 8:40 AM an interview was conducted with CNA 5 regarding resident 16. CNA 5 stated she had worked with resident 16 on multiple occasions and that resident 16 often resisted cares. CNA 5 stated that if resident 16 began to resist cares, it was most effective to "leave her (resident 16) alone and approach her again. She (resident 16) will forget she was resisting cares." CNA 5 further stated if resident 16's behaviors got "really bad" CNA 5 would "let her be alone and calm down" before attempting to provide cares again. On 8/4/11 at 8:35 AM an interview was conducted with the facility Administrator regarding the incident that occurred with resident 16 on 8/1/11. The Administrator stated that she had not only witnessed the incident, but that "there were a few of us in my office trying to pull her (resident 16's) chair into my office." The Administrator further stated that she had witnessed CNA 9's treatment of [REDACTED]. The Administrator stated that she "didn't have any problem" with resident 16's treatment and stated "I don't know what else we could have done. Her family is fine with it anyway." 2. Two residents, who requested anonymity, were interviewed individually during the survey. The residents each stated they had been yelled at by staff, had been treated roughly, did not feel they were treated with respect by certain staff, and did not feel they received appropriate interventions by administrative staff. One of the anonymous residents stated that he/she had been threatened by administrative staff and the resident was afraid to talk to surveyors about concerns.