Every finding on record at Galeon

Based on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for change in condition, when R1 had a weight gain of 13 pounds in her first nine days at the facility, resulting in postpoing her scheduled surgery. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], indicated R1 had diagnoses of right humerus (arm bone from shoulder to elbow) fracture and coronary artery disease. A progress note, on 1/21/25 at 8:24 p.m., indicated R1 was admitted to the facility from the hospital following a fall on 1/18/25, at home causing a proximal humerus fracture. A progress note, on 1/22/25 at 11:21 a.m., indicated R1's weight was 200 pounds. A progress note, on 1/31/25 at 1:01 p.m., indicated R1 weighed of 213 pounds, and weighed 200 pounds on 1/22/25. A progress note, on 2/2/25 at 3:24 p.m., indicated R1 was short of breath and had a cough. A progress note, on 2/3/25 at 4:26 p.m., indicated R1 was short of breath with oxygen saturation of 90%, on room air. A progress note, on 2/4/25 at 5:52 p.m., indicated R1 was short of breath with activity and conversation and had a cough. R1 had +3 (moderate to severe level of fluid accummulation) edema from her mid-calf to her feet. R1's face and abdomen appeared puffier and her pants were tight. Weight gain since admission. Notified physician. Physician ordered STAT (immediate) dose of Lasix 40mg and labwork to be completed. A progress note, on 2/4/25 at 6:01 p.m., indicated R1's physician felt R1 was not medically stable for scheduled surgery on 2/5/25. A physician visit note, dated 2/5/25, indicated R1 was planned for surgery on 2/5/25 but due to fluid overload, the surgery was postponed. R1 had edema and wheezing in her lungs. R1 had an increase of 13 pounds since admission. Staff contacted the physician on 2/4/25 and started R1 on Lasix (a medication used to treat fluid retention) immediately. On 2/20/25 at 11:58 a.m., the director of nursing (DON) stated she wrote the progress note, on 1/31/25. The DON stated she wasn't paying attention when she entered the note. She did not address the weight gain with the physician or the interdisciplinary team. The DON stated she should have done an assessment, checked for edema, listened to R1's lung sounds, and notified the physician. On 2/20/25 at 2:55 p.m., the physician stated he expected to be notified when the facility noted R1 had gained 13 pounds from 1/22/25 to 1/31/25, but was not made aware until 2/4/25, when R1 was experiencing fluid overload. The physician stated R1 was not medically stable to proceed with surgery for her arm fracture on 2/5/25. The physician stated R1's arm would heal without surgery. A facility document, Change in a Resident's Condition or Status, dated 2/21, directed our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.

Based on interview and document review, the facility failed to investigate an allegation of abuse as required for 1 of 2 residents (R82) reviewed for abuse. Findings Include: R82's entry Minimum Data Set (MDS) included an entry date of 10/18/24. R82's Order Summary Report dated 10/30/24, included an order for Hospice. On 10/25/24, a report was filed with the State Agency which reported abuse was witnessed during a hospice aide visit on 10/25/24. The report indicated nursing assistant (NA)-B reported abuse to registered nurse (RN)-A. During interview on 10/29/24 at 5:29 p.m., RN-A confirmed NA-B reported witnessing rough cares provided to R82. RN-A confirmed she had not completed a body assessment after receiving the report. RN-A stated she would typically report concerns about abuse to either the director of nursing (DON), administrator, or social worker. RN-A confirmed she had not spoken with the alleged perpetrator after the report of abuse. During interview on 10/29/24 at 5:48 p.m., RN-B confirmed RN-A had not reported abuse to her. RN-B stated she was informed of the concern of abuse during a team meeting the following morning. RN-B stated it was passed on during report that NA-B felt NA-A was rough with R82. RN-B was unsure if any additional follow up was completed. RN-B stated it was standard procedure to take a staff member off the schedule after a report of alleged abuse. During interview on 10/29/24 at 6:18 p.m., director of nursing (DON) stated she received a call from RN-C who reported an aide witnessed rough cares from a facility employee. DON was unable to recall what day or time she received the call. DON stated she had spoken with the alleged perpetrator within the hour of receiving the phone call. DON stated she did not speak with any additional staff members or residents to complete a thorough investigation. DON confirmed she had not attempted to speak with the aide who reported the alleged abuse. DON stated she had completed a skin assessment of R82's but had not documented the assessment. DON stated she should have documented the assessment because if it wasn't documented, it did not happen. DON stated she had handwritten notes regarding the incident, but was not able to produce them at the time of the interview. DON confirmed the alleged perpetrator continued to work after the report of alleged abuse. DON produced an undated, handwritten one page sheet of paper on 10/30/24. During interview on 10/30/24 at 2:30 p.m., administrator stated a thorough investigation should have been completed with any concerns of abuse. Administrator stated a thorough investigation would take two to three days to complete and would include interviews with other residents, mood/behavior monitoring and removing the alleged staff member from the schedule. Facility schedules indicated NA-A worked 10/25/24, 10/26/24, 10/29/24, and 10/30/24. Facility abuse policy included all alleged violations involving abuse should be investigated immediately. The investigation should have included resident's statements, involved staff and witness statements of events, a description of the resident's behavior and environment at the time of the incident, injuries present, and observation of resident and staff behaviors during the investigation. The alleged individual would be immediately removed.

Based on interview and document review, the facility failed to report an allegation of abuse as required for 1 of 2 residents (R82) reviewed for abuse. Findings Include: R82's entry Minimum Data Set (MDS) included an entry date of 10/18/24. R82's Order Summary Report dated 10/30/24, included an order for Hospice. On 10/25/24, a report was filed with the State Agency which reported abuse was witnessed during a hospice aide visit on 10/25/24. The report indicated nursing assistant (NA)-B, a hospice nursing assistant, reported the abuse to registered nurse (RN)-A. During interview on 10/29/24 at 5:29 p.m., RN-A confirmed NA-B reported witnessing rough cares provided to R82. RN-A confirmed she had not completed a body assessment after receiving the report. RN-A stated she had spoken with someone at the facility about the alleged abuse, but did not remember who. RN-A stated she would typically report concerns about abuse to either the director of nursing (DON), administrator, or social worker. RN-A stated she could not remember reporting the concerns to any of the mentioned staff. During interview on 10/29/24 at 5:48 p.m., RN-B confirmed RN-A had not reported abuse to her. RN-B was informed of the concern of abuse during the team meeting the following morning. RN-B stated it was passed on during report that NA-B felt NA-A was rough with R82. RN-B was unsure if any additional follow up was completed. During interview on 10/29/24 at 6:18 p.m., DON stated she received a call from RN-C who reported an aide witnessed rough cares from a facility employee. DON was unable to recall what time she received the call. DON confirmed she did not file a report with the state agency about the alleged abuse. DON confirmed abuse should be reported within two hours of receiving the report. During interview on 10/30/24 at 2:30 p.m., administrator stated a thorough investigation should have been completed with any concerns of abuse. Administrator stated a thorough investigation would take two to three days to complete and the report of abuse should have been file prior to investigation. Facility abuse policy included all alleged violations involving abuse should be reported immediately, but no later than two hours after the allegation was made.

Based on observation, interview and document review, the facility failed to ensure staff were using proper personal protective equipment (PPE) according to the Centers for Disease Control (CDC). Further, the facility failed to prevent Covid positive staff from providing care to 2 of 11 residents (R2 and R15) not on precautions or covid positive and failed to update policies annually for COVID-19 and infection control practices. Findings include: The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personal During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated May 8, 2023, identified when using a NIOSH approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on droplet precautions), they should be removed and disgarded after the patient care encounter and a new one should be donned. During observations on 11/13/23, 11/14/23, 11/15/23, and 11/16/23, brown paper bags with goggles and N95 masks were sitting on benches on the south, east, and west wings. During an interview on 11/15/23, at 1:22 p.m., infection preventionist (IP) stated staff put the N95 masks in the brown paper bags for five days. There were staff that reused the N95 masks one to two days. During an interview on 11/16/23 at 12:19 p.m., trained medication aide (TMA)-A stated her practice was to switch out the masks every few days. She did not remember being told how often to change out masks during this COVID-19 outbreak. During an interview on 11/16/23 at 12:19 p.m., License practical nurse (LPN)-B stated her practice was to use the same N95 mask twice. During an interview on 11/16/23 at 12:20 p.m., director of nurses (DON) stated staff reused N95 masks for one day, and placed the N95 mask in a brown paper bag between uses. During an interview on 11/16/23 at 11:04 a.m., the administrator stated she was aware of the CDC guidelines that came out in May 2023. She stated staff could reuse N95 masks five times per day and then throw away the masks. Administrator reported the facility had enough masks. During an interview on 11/16/23 at 11:55 a.m., administrator stated she had verified with staff oredering supplies there were a sufficient number of masks available for staff to no reuse. Further, Infection Control Assessment and Response Program (ICAR) had reached out to the facility with an email inquiring on the facility Personal Protective Equipment (PPE) supply. However, she had not yet responded to the email. R2's quarterly Minimal Data Set (MDS) dated [DATE], indicated intact cogitation, history of hypertension, (elevated blood pressure), and cerebral palsy (weakness with using muscles). R2's progress note dated 11/15/23 at 4:44 p.m., indicated negative for COVID-19 from completed outbreak testing. R15's quarterly Minimal Data Set (MDS) dated [DATE], indicated R15 had severely impaired cognition with history of hypertension, (elevated blood pressure), and cardiopulmonary obstructive disease (COPD) (diseases that cause airflow blockage and breathing-related problems). MDS indicated R15 required oxygen therapy. R15's progress note dated 11/15/23 at 11:03 a.m., indicated R15 was negative for COVID-19 from completed outbreak testing. During observation and interview on 11/15/23 at 11:34 p.m., certified nursing assistant (CNA-C) stated she was just going into work with R15 quick and was observed donning and doffing PPE appropriately. CNA-C assisted R15 with personal cares and was in the room for under 10 minutes. During observation and interview on 11/16/23 at 9:11 a.m., CNA-C on west wing donned PPE and was about to enter the room of a COVID-19 positive resident. CNA-C stated that she had recently tested positive for COVID-19 on 11/13/23 and had been assigned to work with only covid-19 positive residents on the east wing. CNA-C stated that she had assisted yesterday with R15 on the east wing and recently with R2 on the west . She was aware that both were negative for COVID-19. CNA-C stated she had been told if she properly donned PPE, she could assist with non-positive COVID-19 residents now, and that previously she could only work with COVID-19 residents on the west wing. CNA-C could not recall who had told her this change. During an interview on 11/16/23 at 10:17 a.m., director of nursing (DON) stated she was not aware of COVID-19 positive staff working with non-positive COVID-19 residents. DON stated positive staff who were asymptomatic were allowed to work as they had qualified for crisis staffing, but they should not be working off the east wing behind the closed doors, where most of the COVID-19 positive residents were located. DON continued, I have just spoken with her, and we have reassigned her off the unit. DON stated scheduling was done by medical records (MR-D). During an interview on 11/16/23 at 10:30 a.m., MR-D stated that when she had covid positive asymptomatic staff who feel well enough to work they were assigned to the east wing and to work with only COVID-19 positive residents. MR-D stated that CNA-C should not have been working with residents not positive for COVID-19. MR-D stated that the rational for using the COVID-19 positive staff was because she had been told the facility was in crisis for staffing. During an interview on 11/16/23 at 11:04 a.m., the facility Administrator stated that they were in Crisis staffing and the reason for not working with a staffing agency was to provide better care and knowledge of residents. The administrator stated that the crisis staff had been reached through review of the CDC crisis staffing criteria, and that they do have contracts for agency or pool staff if needed. The administrator stated that those staff should be working on the east wing only, and that they do have a way of monitoring positive staff through testing and tracking. During an interview on 11/16/23 at 2:30 p.m., facility administrator showed surveyor facility tracking documents for all COVID-19 positive staff, indicated CNA-A was positive on 11/13/23. Upon request of the PPE policy, two polices were provided. One policy titled Donning PPE and Doffing PPE from 2020 which prompted staff to remove facemask/respirator and place in bag with name on it. This policy was on the doors of the isolation rooms. During an interview on 11/16/23 at 11:04 a.m., administrator was shown a copy of the policy from 2020 titled Donning PPE Doffing PPE. Administrator verified that this was the most recent policy that the facility was using. Administrator verified that last time the policy was reviewed was on 8/10/21. Administrator reported her expectations would be to review policies yearly. A second policy from the MED-PASS April 2020, titled Personal Protective Equipment-Contingency and Crisis Use of Facemask (COVID-19 Outbreak), was obtain stating to place masks in a waste container after use. The facility was not abiding to this policy. 48740

Based on observation, interview and document review, the facility failed to follow standards of practice related to medication administration for 1 of 1 residents (R7) observed to receive an inhalation medication. Findings include: R7's Admission Record printed 11/16/23, indicated diagnoses of chronic obstructive pulmonary disease (a condition that blocks airflow and make it difficult to breathe), mild cognitive impairment, heart failure, obesity, and weakness. R31's Order Summary Report printed 11/16/23, included Pulmicort (also known as budesonide) inhalation suspension (medication used to prevent swelling in the lungs) 0.5 mg (milligram)/2ml (milliliter) inhale via nebulizer two times a day, rinse mouth well after nebs. During observation on 11/15/23 at 8:11 a.m., licensed practical nurse (LPN)-C set up R7's nebulizer medication and left the room. During interview on 11/15/23 at 8:11 a.m., LPN-C stated staff cannot go in R7's room when the nebulizer is running due to resident being positive for COVID-19. Staff must stay out of the room for 30 minutes following completion of medication. During interview on 11/16/23 at 10:27 a.m., R7 reported being comfortable with taking nebulizer on her own. She states she does not do anything after completing the nebulizer other than turn off the machine. No one has ever told her to rinse her mouth after and she does not rinse her mouth. During interview on 11/16/23 at 12:19 p.m., consulting pharmacist stated it is standard practice to have the resident rinse their mouth after using this type of nebulizer. It is important to avoid the resident getting thrush (a yeast infection of the mouth). During interview on 11/16/23 at 1:46 p.m., director of nursing (DON) stated it is important for the resident to rinse their mouth after using this type of nebulizer medication to prevent a sore from forming in the resident's mouth. All parameters and guidelines for administering medications should be on the medication administration record (MAR) and the staff should follow them. Facility policy Nebulizer Therapy dated 9/2023 failed to include guidance on rinsing mouth after administration of this kind of nebulizer.

Based on observation, interview, and document review the facility failed to honor the resident's choice to go to bed at preferred time. This affected 1 of 1 residents (R3) reviewed for self determination. Findings include: R3's Minimum Data Set (MDS) dated [DATE], indicate assistance of one staff with grooming, dressing, transfers. R3 was to be involved with decisions related to ADL tasks. MDS indicated resident's cognitive performance assessment, Brief Interview for Mental Status (BIMS) was a 4/15, indicating severe cognitive impairment. During observation on 12/19/22, at 6:56 p.m. nursing assistant (NA)-A was observed exiting R3's room. NA-A stated R3 was awake in her recliner. On 12/19/22 at 6:57, p.m., R3 was moaning and calling out for help. R3 was seated in reclined chair and dressed in a hospital gown with a blanket covering her body. R3 stated she wanted to go to bed, but NA-A had told her she had to be in the chair. R3 stated she could not sleep like this because of pain in her left shoulder. NA-B entered R3's room and assisted R3 to bed. During interview on 12/19/22, at 6:59 p.m. NA-A stated the rule was residents were not to be assisted to bed before 7:00 p.m. this applied to all residents. NA-A stated she assisted R3 with evening cares and into the recliner. She confirmed R3 had requested to go to bed, however she did not comply. During an interview on 12/19/22, at 6:59 p.m. NA-B stated there was no rule residents were not allowed to go to bed before 7:00 p.m. During an interview on 12/20/22, at 1:36 p.m. NA-C stated there were no rules regarding what time residents got up in the morning or what time they went to bed at night. She stated we do what they request. During an interview on 12/20/22, at 3:00 p.m. licensed practical nurse (LPN)-A stated staff encouraged residents to stay up until about 7:00 p.m. During an interview on 12/20/22, at 3:10 p.m. Director of Nursing (DON) stated residents have the right to choose what time they want to get up in the morning and when they go to bed at night. Further, they encouraged healthy sleep habits. She stated when residents wanted to go to sleep they let them, regardless if it was prior to 7:00 p.m. or not.

Based on interview and document review, the facility failed to ensure the drug regimen reviews were completed by a licensed pharmacist at least once a month for 1 of 1 residents (R15) reviewed for unnecessary medications. Findings include: R15's pharmacy reviews indicated a 43-day gap between drug regimen reviews conducted by a licensed pharmacist. Pharamicists review occurred on 8/31/22 and then again on 10/13/22, resulting in a 43 day gap between pharmacy review of medication. During an interview on 12/21/22, at 12:02 p.m. director of nursing (DON) indicated that drug regimen review was missing for the month of September for R15. During an interview on 12/21/22, at 12:36 p.m. consultant pharmacist (CP) stated September drug regimen review was not completed for R15 due to illness. She stated their contract stated review may be delayed up to ten days, or more frequently than monthly. She stated there should be a back-up pharmacist for instances of absence. She stated pharmacy consults were completed on 8/31/22 and on 10/13/22. She stated the review should have been completed on 9/30/22. Policy titled Drug Regimen Review Policy/Procedure reviewed 12/21/22. Policy indicated consultant pharmacist will review each resident's drug regimen, at least once a month or as deemed appropriate by the pharmacy consultant, either in person or remotely. The consultant pharmacist may need to conduct the medication regimen review more frequently depending on the resident's condition, review short term stay resident's and/or if risk of adverse consequences. Procedure indicated the pharmacy consultant will perform monthly drug regimen review on each resident, unless the resident's condition/risk will indicate a more frequent schedule that is individualized and communicated between the facility clinical staff and the pharmacy consultant.

Based on observation, interview and document review, the facility failed to properly disinfect a glucometer after resident use. This had the opportunity to affect 1 of 1 residents observed for proper disinfection of equipment. Findings include: Record review of medical diagnosis list on 12/20/22 indicated R8 had a diagnosis of diabetes mellitus type 2. During an observation on 12/19/22, at 6:34 p.m. Licensed practical nurse (LPN)-B conducted a blood glucose test for R8 with an Assure Platinum 106 glucometer. She wiped the glucometer with an alcohol wipe after use. However, failed to disinfect the device. During an interview on 12/19/22, at 6:36 p.m. LPN-B stated the glucometer was designated for R8 and each resident had their own. She stated they wiped down meters with alcohol wipes every time they go in and out of the cart. During an interview on 12/21/22, at 9:50 p.m. Registered nurse (RN)-B stated the glucometers were not shared equipment. She stated the glucometers were cleaned with the cleansing wipes and contact was for a designated amount of time, depending on the product. RN-B stated alcohol wipes were not sufficient as a disinfectant. Facility policy titled Glucometer Cleaning and Disinfecting Policy/Procedure, facility issued the Assure platinum glucometer. It was policy to clean and disinfect the blood glucose meters after each use to avoid cross-contamination issues. Blood glucose meters were at a high risk of becoming contaminated with blood borne pathogens such as Hepatits B, Hepatitis C, and HIV per the CDC and by cleaning/disinfecting between resident use it can prevent the transmission of these viruses through indirect contact. To clean the blood glucose meter you may wipe the meter down the soap and water or isopropyl alcohol. To disinfect the blood glucose meter you may use an EPA registered disinfectant detergent or germicide approved for healthcare settings such as super Sani-cloth germ disposable wipe, Sani-cloth HB germ disposable wipes or 1:10 concentration of bleach. Directions continue to wipe all surfaces.

Based on interview and document review, the facility failed to conduct ongoing surveillance for the infection control program to ensure tracking and trending of [CONDITION(S)] infections and illnesses in the facility. This deficient practice had the potential to affect all 30 residents currently residing in the facility. Findings include: A line list for infection surveillance was requested from 6/1/21, through 8/31/21. Additionally, a line listing was requested for the current month of 9/21. The line list provided consisted of two separate forms. The Community Memorial Home Infection Log identified resident name, room number, date of onset, location/type of infection, symptoms, whether it was cultured and the identified organism, the antibiotic treated with, if it was facility acquired and date resolved. The Resident Non-Antibiotic Symptom Tracking form identified the resident name, date, symptoms, temperature and date resolved. The Resident Non-Antibiotic Symptom Tracking form indicated All residents who are not on antibiotics with symptoms (ex: cough, emesis, diarrhea, temp, etc.) must be tracked!!. The line lists from 6/1/21, through 9/12/21, were blank. The logs lacked documentation of illnesses caused by viruses or other organisms which did not require antibiotic treatment. During an interview on 9/16/21, at 2:45 p.m. with the director of nursing (DON) and licensed practical nurse (LPN)-A (infection preventionist in training) stated all symptoms were discussed in a stand-up huddle every morning and they kept a mental note of what was happening. The infections treated with antibiotics were placed on the Community Memorial Home Infection Log. The infections which were not treated with antibiotics were documented on the Resident Non-Antibiotic Symptom Tracking form. The DON confirmed the Resident Non-Antibiotic Symptom Tracking form was in a book at the nurse's station and had not been used since January 2021. The DON verified they should have been tracking all symptoms to have a comprehensive view of infections in the facility and to watch for patterns of infection which could have led to an outbreak. The facility's undated Galeon Infection Control Policy-Surveillance indicated ongoing surveillance would identify infections that were causing or have the potential to cause an outbreak. The facility was to closely monitor all residents who exhibited signs/symptoms of infection through ongoing surveillance.

Based on observation, interview, and document review, the facility failed to maintain the resident snack refrigerator in a safe operating condition. This had the potential to affect all 29 residents who consumed food from the refrigerator. Findings include: On 9/13/2021, at 1:00 p.m. an initial tour of the kitchen and dining room was completed. The resident snack refrigerator's temperature indicated a reading of 41 degrees Fahrenheit (F). On 9/16/2021, at 10:37 a.m. cook (C)-A stated the resident snack refrigerator should have been kept at 35 F. Further, when the refrigerator was above 41 F maintenance were to be notified and it was expected the refrigerator temperature would be re-checked the next day. C-A stated the facility utilized a building management platform designed for Senior Living with integrated Asset Management, Life Safety, and Maintenance solutions (TELS) system, however stated handwritten notes received faster responses. On 9/16/21, at 12:05 p.m. head of maintenance (HM)-A stated concerns of equipment not functioning properly were reported through the facility's TELS system. HM-A verified the refrigerator temperature was out of range. He was unaware of the refrigerator malfunctioning. HM-A stated residents and staff had access to the refrigerator at all times. On 9/16/2021, at 1:18 p.m. C-A stated she documented temperatures after she finished serving for the night. C-A stated staff were expected to document the temperature twice a day and confirmed the morning temperatures had not been documented for the month of September 2021. On 9/16/21, at 2:14 p.m. administrator stated properly functioning refrigerators were extremely important. She expected they would be cleaned and temperatures documented twice daily. The administrator stated the acceptable temperature range was 35 to 40 F which was identified at the top of the documentation form. She expected staff to utilize the facility TELS system to notify maintenance of improperly functioning devices in the building. The administrator stated food refrigerators required immediate attention when not functioning properly and expected staff to contact the dietary manager when maintenance was not in the building. The administrator stated food holding temperatures of 41 and 42 F were unacceptable. Monthly temperature logs for the resident snack refrigerator, dated September 2021, identified 6 documented temperatures of 42 F which were outside the acceptable range. Facility policy related to monitoring the operational status of refrigerators for food was requested and not provided. Facility policy related to staff training on the TELS system was requested and not provided.

Based on interview and document review, the facility failed to ensure the pharmacy consultant identified and reported an irregularity related to a lack of [CONDITION(S)] stimulating hormone (TSH) laboratory test for 1 of 5 residents (R16) reviewed for unnecessary medication and who was on [MEDICATION(S)] (medication for [CONDITION(S)] hormone replacement). Findings include: R16's 5/13/21, annual Minimum Data Set (MDS) indicated R16 admitted to the facility in June 2020. Diagnoses included a [CONDITION(S)] disorder. R16's 9/15/21, Order Summary Report identified on 6/11/20, active order for: [MEDICATION(S)] 50 mcg by mouth one time daily for [CONDITION(S)] (a disorder of the endocrine system in which the [CONDITION(S)] gland does not produce enough [CONDITION(S)] hormone). The manufacturer's information @rxabbvie.com directed to monitor serum (blood) TSH levels in patients on a stable and appropriate replacement every 6-12 months and whenever there was a change in the patient's clinical status. R16's medical record lacked a TSH laboratory result. During an interview on 9/15/21, at 12:30 p.m. the consulting pharmacist (CP)-B stated it was the standard to check [CONDITION(S)] labs annually for residents on [CONDITION(S)] hormone replacement medication, as long as everything was stable with no signs of [CONDITION(S)] or [CONDITION(S)], and as long as the person was not on any other medication that may interfere with the [CONDITION(S)] medication. CP-B stated the last documented TSH for R16 was in March 2020 (prior to admission). CP-B stated she reviewed R16's medical record monthly and during the spring of 2021 missed that R16 was due for an annual TSH. Therefore, a recommendation to the provider to order a TSH to check for the effectiveness of the current dose of [MEDICATION(S)] was not done. The facility's policy titled Drug Regimen Review Policy/Procedure, updated 4/16/21, indicated the consultant pharmacist would review each resident's drug regimen at least monthly. The pharmacist consultant would report in writing or via email, any irregularities to the attending physician, the facility's Medical Director and the Director of Nursing, and were to be acted upon.

Based on interview and document review, the facility failed to provide written hospital transfer notices to the resident and/or resident's representative who had a facility-initiated hospital transfer for 2 of 2 residents (R11, R17) reviewed for hospitalization s. Findings include: R11 R11's 6/3/21, quarterly Minimum Date Set (MDS) indicated R11 required staff supervision for eating. R11's undated Admission Record included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note on 7/10/21, at 11:03 p.m. indicated R11 was audibly congested. R11 was unable to expectorate (cough up) anything when encouraged to cough. Oxygen saturations 83% on room air (normal 90% and above). Oxygen was applied via nasal cannula at 2 liters/minute (LPM). Oxygen saturations slowly improved to 88-90% with oxygen. Rhonchi (continuous gurgling or bubbling sounds typically heard during both breathing in and breathing out) present in bilateral upper lobes of lungs. Crackles present bilaterally to lower lungs as well as audible wheezing. Family updated as well as physician via the phone. Both family and physician agreed to send R11 to the hospital for evaluation and treatment. The ambulance arrived to the facility and transferred R11 to the hospital at at 10:33 p.m. A progress note on 7/10/21, at 11:53 p.m. indicated R11 was admitted to the hospital with aspiration pneumonia (inhaling food, drink, vomit, or saliva into the lungs). A progress note on 7/14/21, at 2:03 p.m. indicated R11 returned from the hospital. R11's medical record lacked evidence of written notification and/or reason regarding the transfer to R11 and/or R11's representative. Findings include: R17's significant change MDS, dated [DATE], indicated R17 utilized tube feedings for nutritional maintenance. R17's face sheet, printed 9/15/21, indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note, dated 7/11/21, at 7:33 a.m. R17 had bile colored vomit (emesis) and a fever of 101.7 degrees Fahrenheit. Respiratory rate was 28 to 38 respirations per minute with coarse breath sounds (low-pitched moist-sounding breathing). On-call physician was updated and R17 was sent to emergency room . A progress note, dated 7/11/21, at 1:14 p.m. emergency room R17 was admitted to hospital due to aspiration pneumonia. A progress note, dated 7/15/21, at 2:49 p.m. indicated R17 had been readmitted . R17's medical record lacked evidence of a written notification and/or a reason regarding the transfer to R17 and/or R17's representatives. During an interview on 9/15/21, at 11:29 a.m. registered nurse-case manager (RN)-A stated she was unaware if the facility provided written notification to the resident and/or representative of the reasons for a hospital transfer adding, social worker (SW)-A may provide the notice. During an interview on 9/15/21, at 11:37 a.m. SW-A stated she did not provide a written notice of hospital transfers to the resident and/or resident's representative. SW-A stated the nurses on the floor at the time of the transfer provided the notice. During an interview on 9/15/21, at 11:46 a.m. registered nurse (RN)-B stated she transferred residents to the hospital when their condition warranted. RN-B stated many times those transfers were an emergency. RN-B stated she updated the family of the reason for transfer via the phone and obtained a verbal physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-B reviewed R11's and R17's medical record and was unable to locate a written hospital notice provided to the residents or the residents' representative. A facility's policy Transfer or Discharge, Emergency, reviewed 5/12/21, directed staff Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility would .Notify the representative (sponsor) or other family member. The policy lacked direction to provide notification in writing to the resident and/or resident's representative of the transfer and the reason for the move in writing.

Based on observation, interview, and document review, the facility failed to ensure a care plan was revised to reflect occasional bowel and bladder incontinence for 1 of 2 residents (R8) reviewed for activities of daily living. Findings include: R8's significant change Minimum Data Set (MDS), dated [DATE], indicated R8 required extensive assistance with toileting, was always continent of bowel and bladder, and was cognitively intact. R8's Care Plan, dated 7/31/19, identified R8 as continent of bowel and bladder. Interventions included: -assist of 1 staff with the sit to stand lift on and off the toilet. Reinforce to use call light for assistance to bathroom when needed. Check/offer toileting assistance upon rising, before/after meals and before bed. -assist with pericares, hygiene after toileting. -uses urinal at bedside. Staff need to empty. During observations and interview on 10/2/19, at 7:14 a.m. incontinent briefs were observed in R8's bathroom. R8 stated Oh I just wear those inside my underwear to keep my underwear clean. When asked if he had times of incontinence R8 laughed and did not answer the question. R8 stated he uses his call light and gets staff assistance when needed onto the toilet. The room was free of bowel and bladder odors. R8's Toileting documentation in the electronic medical record (EMR) point of care (P[NAME]) between 9/4/19 and 10/3/19 revealed: -9/6/19, 9/8/19, 9/27/19, and 10/1/19 incontinent of urine one time each day. -9/12/19 and 9/20/19, incontinent of urine twice each day. -9/20/19, 9/26/19, 9/29/19, and 10/1/19 incontinent of bowel once each day. During an interview on 10/2/19, at 1:05 p.m. registered nurse case manager (RN)-B stated a significant change MDS was completed 7/20/19 related to a decline in R8's activities of daily living. RN-B reviewed the 7-day look-back documentation related to bowel and bladder and R8 was continent of bowel and bladder. RN-B stated R8 was toileting independently and began requesting more assistance. RN-B stated since the MDS, she has been made aware R8 is occasionally incontinent of bowel and bladder. RN-B reviewed R8's care plan and stated R8's care plan should have been, but was not updated to identify the incontinence. During an interview on 10/3/19, at 11:19 a.m. the director of nursing (DON) stated resident changes are discussed, most often in morning report. The newly identified problems are then added to the care plan with interventions. The facility's policy Care Plan, undated, indicated the purpose of the resident care plan is to plan an outline of the specific nursing care that is to be provided to the resident. It is a tool for communicating the resident's health problems and the specific nursing care measures that are to be instituted to solve those problems. It is the means by which the nursing staff can provide for individualize resident care. All problems/issues which arise prior to the 90-day review shall be entered in the care plan on a timely basis.

Based on interview, observation, and document review the facility failed to ensure a system was in place for reconciliation of controlled substance medications in 1 of 1 medication storage rooms to prevent potential loss or diversion. This had the potential to affect all 32 residents residing in the facility. Findings include: A tour of the locked medication storage room was conducted with the director of nursing (DON) on 9/30/19, at 3:30 p.m. The double locked cabinet on the inside of the medication room door did not have any narcotics in the locked cabinet. The Certificate of the Inventory and Destruction of Controlled Substances Form 8-1, undated, indicated prescription number 6, [MEDICATION NAME] 100 milligram (mg)/5 milliliter (ml) strength, with 43.25 ml quantity remaining was placed in the double locked cabinet. The Drug Destruction Record for R13 lacked any evidence that [MEDICATION NAME] 100 mg/5 ml was moved or placed in another storage area. The DON stated she took R13's [MEDICATION NAME] 100 mg/5 ml from the double locked cabinet on the wall and placed it in medication safe on the counter in the medication storage room. The DON stated she did not check or document on the destruction record prior to putting R13's [MEDICATION NAME] 100mg/5ml in the lock box on the counter for destruction. The facility policy Scheduled II Drug Recording, Counting and Destruction dated 9/19/19, indicated on the resident's individual medication destruction log page in the black book in the med room, write the date, prescription number, the drug name, strength, and quantity that will be destroyed by the pharmacist at a later date.

Based on observations, interview, and document review, the facility failed to ensure bathing preferences were honored for 1 of 1 residents (R29) reviewed for choices. Findings include: R29's admission Minimum Data Set (MDS), dated [DATE], indicated R29 required 1 staff physical assist for physical help in part of bathing. R29 required extensive assist with transfers, dressing, and personal hygiene. R29 was moderately cognitively impaired. R29's Care Plan, dated 9/10/19, directed R29 required assistance of 1 staff in and out of the tub and to wash/dry body and to give choices regarding when to bathe. During an interview on 9/30/19, at 6:36 p.m. R29 stated she would like to have 2 showers a week, but is only provided with 1 bath weekly. Observations on 10/2/19, at 10:17 a.m. identified a Bathing Schedule posted on the wall behind the nursing station. The schedule listed Monday, Tuesday, Wednesday, Thursday, Friday, with resident names below each day. R29's name was listed under Tuesday and Thursday. R29's Bathing documentation in the electronic medical record (EMR) point of care (P[NAME]) for the week 9/2/19 to 9/8/19 revealed: -Received a bath on Tuesday, 9/3/19. Physical assist of 1 staff. -Documentation lacked a second bath. Documentation under Resident Refused was blank. R29's Bathing documentation in the EMR-P[NAME] for the week of 9/9/19 to 9/15/19 lacked documentation of R29 receiving or refusing baths. R29's Bathing documentation in the EMR-P[NAME] for the week of 9/16/19 to 9/22/19 revealed: -Received a bath on Thursday 9/19/19. Physical assist of 1 staff. -Documentation lacked a second bath. Documentation under Resident Refused was blank. R29's Bathing documentation in the EMR-P[NAME] for the week of 9/23/19 to 9/29/19 revealed: -Received a bath on Wednesday 9/23/19. Physical assist of 1 staff. -Documentation lacked a second bath. Documentation under Resident Refused was blank. During an interview on 10/3/19, at 11:27 a.m. activity staff (AS)-A stated when a resident admits to the facility the resident is asked about preferences. AS-A stated a form is filled out that includes a residents' preference between a bath, shower, or bed bath. AS-A stated the resident is verbally asked about the frequency of bathing and this information is verbally communicated with the bath aide, nursing assistant (NA)-C. During an interview on 10/2/19, at 11:05 a.m. NA-C stated when a resident admits to the facility she discusses bathing preferences, including frequency with the resident. NA-C stated she adds the resident's name to the bath schedule based on those preferences. NA-C stated she documents the completion of the bath in P[NAME] and documents any resident refusals in P[NAME] as well. NA-C stated she has enough time to complete the baths as scheduled. NA-C stated R29 receives 2 baths weekly. NA-C stated R29 may have refused a bath one time, but could not remember. NA-C reviewed the bathing P[NAME] documentation for (MONTH) 2019. NA-C stated She may have only had one (a week) and was not sure why. R29 stated she could have refused adding she documents when a resident refuses and she had not documented any refusals for R29. During an interview on 10/3/19, at 11:19 a.m. the director of nursing (DON) stated residents are bathed according to the residents preference. The resident chooses the frequency. The aide documents whether the bath was given or refused. The facility's policy Scheduling of bathing Times, dated 5/17/17, directed. All residents will receive at least one bath weekly or more per resident preference. Procedure: 1) Activities will complete an activity interview which includes their preference of bathing and how often within 48 hours of admission to the facility. 2) Activities will inform the bathing assistant the resident's bathing preferences and frequency of bathing. 3) Bathing assistant will then place resident on the bathing schedule to accommodate resident preferences. 4) If the resident is ill on bath day or refuses to be bathes, the bathing assistant will offer the resident a different day or time for bathing and place this information on the schedule. 5) if resident refuses or is ill and bathing has to be rescheduled the bathing assistant will document this in PCC under the Point of Care.

Based on observation, interview, and document review, the facility failed to implement a comprehensive infection control program to include day to day tracking of signs and symptoms of infections not requiring antibiotics, this had the potential to affect all 35 residents. In addition, the facility failed to follow proper hand hygiene practice for one of one residents (R29) and failed to disinfect the same residents glucometer when checking a residents blood sugar. And failed to follow proper hand hygiene for 1 of 3 residents (R14) when providing personal care. Findings include: The facilities infection control data from (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) identified the following information: The facilities infection control line by line log for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) indicated areas to document resident name, admitted , room number, body system of infection, dates of symptoms, types of symptoms, collection date, type of test, specimen source, results, and antibiotics. However, did not include an area to track illness or symptoms of infection that did not require antibiotic treatment. Although the facility line by line infection control logs identified all the required areas for infections requiring antibiotics, the facility failed to track infections not requiring antibiotics. During interview on 11/29/18, at 10:33 a.m. registered nurse (RN)-A stated the facility does not have a system in place for documenting non antibiotic signs, symptoms or illnesses. RN-A stated all non antibiotic illness and symptoms are all reported verbally during report each morning. RN-A stated non antibiotic illness are not tracked. Rn-A stated she is known as the infection control preventionist in the facility but she was not certified and has not trended or tracked any residents if they are not on an antibiotic. The facility policy, dated (YEAR), titled Infection Control Program indicated the infection control program exits to assure a safe, sanitary and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of disease and infection. R29's Minimal Data Set MDS dated , 10/25/18 indicated R29 was diagnosed with [REDACTED]. On 11/27/18, at 10:59 a.m. licensed practical nurse (LPN)-C was observed to gather the glucometer, a blood glucose strip, lancet and gloves and entered R29's room. LPN-C washed her hands and donned gloves. LPN-C swabbed R29's finger with an alcohol wipe, after it was dry, used the lancet to poke R29's finger, placed the glucose strip in the glucometer and obtained a sample of R29's blood. LPN-C gave R29 a cotton ball for his finger, LPN-C placed the lancet and the used glucose strip into a plastic Dixie cup. LPN-C doffed her gloves, did not wash her hands and grabbed the plastic Dixie cup opened R29's door and proceeded back to the medication cart. LPN-C disposed of the used lancet into the sharps container on the medication cart. LPN-C unlocked the medication cart and placed the glucometer in a basket with R29's insulin pens, locked the medication cart then used hand sanitizer. LPN-C indicated she did not think the glucometer needed to be wiped down after each use since R29 was the only one using it. LPN-C stated she was not aware if there was a policy for cleaning the glucometer. LPN-C did state she should have used hand sanitizer after glove removal. When interviewed on 11/27/18, at 2:57 p.m. the director of nursing (DON) stated technically the glucometer is designated for that one individual, they would only need to clean it if visible with blood. DON stated there is a cleaning policy, but couldn't remember what kind of wipe they are suppose to use. The DON went on to say the nurses and certified nursing assistants have hand sanitizer available to them, hand hygiene needs to be completed after removing gloves. The Glucometer Cleaning and Disinfecting Policy/Procedure dated 11/16 indicated it is the facilities policy to clean and disinfect the blood glucose meters after each use. R14's quarterly Minnimum Data Set (MDS), dated [DATE], included [DIAGNOSES REDACTED]. The MDS also identified R14's cognition could not be assessed, however, long and short term memory were intact. Also included in the MDS, R14 required extensive assistance with toileting and personal hygiene, was frequently incontinent of urine, and always continent of stool. During an observation on 11/28/18, at 8:33 a.m. nursing assistant (NA)-C assisted R14 back to her room, from the dining room, via wheelchair. NA-C locked the wheels of the wheelchair and placed a transfer belt around R14's waist. R14 stood up and then pivoted to sit on the toilet with guidance provided by NA-C. NA-C assisted R14 with pulling down pants and brief. R14 made a low throaty sound until the transfer belt was removed. R14 sat on the toilet and stood up when finished. NA-C gloved right hand and used pre-moistened cloth to wipe R14's bottom. NA-C removed the glove, and disposed it into the trash. NA-C assisted R14 with pulling up brief, and placed a transfer belt around R14's waist. R14 made verbal noises and NA-C stepped back, which allowed R14 to wash her hands at the sink. R14 pulled a paper towel to dry hands and reached to drop it in the wastebasket but missed. NA-C picked up the used paper towel with a bare hand and placed it in the trash. Without performing hand hygiene, NA-C assisted R14 to walk to the recliner. R14 pivoted and pulled on the transfer belt until NA-C removed it. R14 adjusted clothing and sat down. NA-C ensured R14 had the call light and, without performing hand hygiene, NA-C walked out of R14's room and headed down the hall toward unit 100 to answer a call light. NA-C walked into the resident's room and touched the resident's shoulder and arm of wheelchair when she spoke. NA-C was stopped and asked to step into the hallway. When interviewed on 11/28/18, at 8:51 a.m. NA-C indicated that hand hygiene should be performed when removing gloves, however, stated that she had not done so after removing her glove after doing peri-care for R14, and verified that R14 had a bowel movement. NA-C immediately left to wash her hands. The Hand Hygiene Policy undated, indicated hand hygiene must be performed immediately after gloves are removed.

Based on observation, interview and documentation review the facility failed to ensure a residents wheel chair was clean and sanitary for 1 of 1 residents (R30) reviewed for environment. Findings include: R30's admission Minimum Data Sets ((MDS) dated [DATE], indicated R30 had severely impaired cognition, hypertension (elevated blood pressure), dysphasia (inability to communicate), [MEDICAL CONDITION] (paralysis of all 4 limbs), and had a gastrostomy (surgical opening into the stomach) for feedings and medications. R30 required a wheel chair for mobility with staff to propel to all locations. R30's physician's orders [REDACTED]. During observation on 11/28/18, when observing R30's wheel chair, it was noted to have the appearance of food, dirt and a cream/white substance on the wheels, spokes and frame. During observation on 11/29/18, at 9:00 a.m. R30's wheel chair continues to have cream/white substance on the wheels, spokes and frame, along with chunks of food particles in several different places on frame of wheel chair. During interview on 11/29/18, at 10:16 a.m. nursing assistant (NA)-D stated the night shift staff clean the wheel chairs and they have a schedule, although she does not know what their schedule is. NA-D stated they should be cleaning all parts of the wheelchair. NA-D stated R30's wheel chair is not clean and can see food particles, dirt and milk on the tires and both sides of the wheel chair. NA-D stated the wheel chair needs to be cleaned. During interview on 11/29/18, at 10:22 a.m. licensed practical nurse (LPN)-A stated the wheel chairs are supposed to be cleaned weekly on night shift. LPN-A stated the chair is not clean as she could see some kind of food, and white stuff like dried milk all over the wheels and wheelchair spokes. LPN-A stated R30's wheel chair needs to be cleaned. LPN-A removed R30's wheel chair from his room and brought it to an area for house keeping to be cleaned. During interview on 11/29/18 at 10:29 a.m. registered nurse (RN)-A stated R30's wheel chair is not clean as she saw white substance and food particles on wheel, spokes and frame of wheel chair. RN-A stated its horrible and needs to be cleaned. The facilities Weekly Wheelchair Washing Schedule was obtained and R30's wheelchair was scheduled to be cleaned on Monday nights. Documentation verifying R30's wheelchair was cleaned per the schedule was requested but not received. A facility policy for Medical Equipment Maintenance/Nursing Policy and Procedure dated 10/2017, indicates all equipment used for patient care will function properly and safely by inspecting, maintaining, and cleaning medical equipment on a routine basis.

Based on interview and document review, facility failed to notify the physician of a newly acquired pressure ulcers for 1 of 5 residents (R18) reviewed for pressure ulcers. Findings include: R18's annual Minimum Data Set ((MDS) dated [DATE], identified R18 was moderately cognitive impaired. R18 required extensive assistance for transferring, toileting, bed mobility, dressing, personal hygiene. R18 had no pressure ulcers. R18 was at risk for pressure ulcers R18's quarterly MDS, dated [DATE], indicated R18 had no pressure ulcers, but was at risk. Interventions included a pressure reducing mattress and wheelchair cushion. R18's Comprehensive Skin Assessment, dated 10/3/18, indicated R18 had no pressure ulcers. R18 was at moderate risk for pressure ulcer development. R18 did not have redness over bony prominences after 2 hours of sitting/laying. Interventions included 2 hour repositioning. A Progress Note dated 11/18/18, indicated R18 to had an open area to the lower buttocks measuring 0.3 centimeters (cm) x 0.5 cm. Additionally, a wide slit measuring 2.5 cm x 1 cm to the right gluteal fold. Areas were cleansed and registered nurse notified. A Wound Assessment/Monitoring form, dated 11/18/18, idenfied the areas as stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed) pressure ulcers. Scant amount of bleeding from both areas and no signs of infection. Protective ointment applied. Interventions included to have R18 lay down twice daily, apply protective ointment to the areas, and to ensure the elastic from the incontinent brief was not on the areas. A Wound Assessment/monitoring form, dated 11/23/18, identified 3 pressure ulcers, all at a stage 2. 1. Left gluteal fold measured 0.2 cm x 4 cm x 0.1 cm. 2. Left gluteal fold measured 0.3 cm x 0.7 cm x 0.1 cm. 3. right gluteal fold measured 0.2 cm x 2.5 cm x 0.1 cm. wound bed pink with no signs or symptoms of infection. No drainage. Area cleansed and protective cream applied. R18's medical record lacked physician notification and treatment orders for the pressure ulcers. Standing orders direct wounds and skin breakdown will be managed in compliance with skin protocols unless the resident has other medical orders. *in all cases, the physician will be contacted for all continued problems. During observation at 1:22 p.m. on 11/29/18, registered nurse (RN)-A assessed R18's pressure ulcers. R18's had no open areas to the buttocks. RN-A stated the areas were healed as of today. The skin was pink and blanchable. During an interview at 1:27 p.m., on 11/29/18 RN-A stated the 2-stage 2 pressure ulcers were identified and assessed on 11/18/18. RN-A stated the ulcers were a result of pressure from the incontinent brief. RN-A stated she verbally reported to the aides to apply protective ointment to the areas more frequently and encourage R18 to lay down twice daily. RN-A stated the physician was not notified of the pressure ulcer development. RN-A stated the physician is to be notified when a pressure ulcer is identified. RN-A stated the physician was not notified of the pressure ulcer development and wound orders were not obtained as it was the weekend and missed. During an interview at 2:07 p.m. on 11/29/18, the director of nursing (DON) stated nursing assistants inform the nurse when skin changes. The nurse then completes an assessment and notifies the physician for treatment orders. A facility policy Wound Management/Skin Integrity/Ulcers, dated 11/9/15, indicated treatment/management of resident who have a loss of skin integrity will receive the appropriate treatment/services which may include specific physician ordered medication/treatment. A policy related to physician notification was requested and not provided.

Based on observation, interview, and document review, the facility failed to implement intervention of timely repositioning to prevent and heal a pressure ulcer for 1 of 5 residents (R18) reviewed for pressure ulcers. Findings include: R18's annual Minimum Data Set ((MDS) dated [DATE], identified R18 was moderately cognitively impaired. R18 required extensive assistance for transferring, toileting, bed mobility, dressing, personal hygiene. R18 had no pressure ulcers. R18 was at risk for pressure ulcers R18's quarterly MDS, dated [DATE], indicated R18 had no pressure ulcers, but was at risk. Interventions included a pressure reducing mattress and wheelchair cushion. R18's Comprehensive Skin Assessment, dated 10/3/18, indicated R18 had no pressure ulcers. R18 was at moderate risk for pressure ulcer development. R18 did not have redness over bony prominences after 2 hours of sitting/laying. Interventions included 2 hour repositioning. R18's care plan dated 10/29/18, identified a pressure reducing mattress and wheelchair cushion. The care plan indicated R18 was able to turn and reposition self in bed. The care plan directed staff to remind and assist R18 to reposition every 2 hours and required assistance of 1 to 2 staff for repositioning. A Progress Note dated 11/18/18, indicated R18 had an open area to the lower buttocks measuring 0.3 centimeters (cm) x 0.5 cm. Additionally, a wide slit measuring 2.5 cm x 1 cm to the right gluteal fold. Areas were cleansed and registered nurse notified. A Wound Assessment/Monitoring form, dated 11/18/18, idenfied the areas as stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed) pressure ulcers. Scant amount of bleeding from both areas and no signs of infection. Protective ointment applied. Interventions included to have R18 lay down twice daily, apply protective ointment to the areas, and to ensure the elastic from the incontinent brief was not on the areas. A Wound Assessment/monitoring form, dated 11/21/18, identified both pressure ulcers remained at a stage 2. Measurements remained unchanged. Scant bleeding at both areas. Protective ointment applied. Areas are superficial. Wound beds are clean and pink. No signs or symptoms of infection. A Wound Assessment/monitoring form, dated 11/23/18, identified 3 pressure ulcers, all at a stage 2. 1. Left gluteal fold measured 0.2 cm x 4 cm x 0.1 cm. 2. Left gluteal fold measured 0.3 cm x 0.7 cm x 0.1 cm. 3. right gluteal fold measured 0.2 cm x 2.5 cm x 0.1 cm. wound bed pink with no signs or symptoms of infection. No drainage. Area cleansed and protective cream applied. R18's care plan lacked updates related to the development of the pressure ulcers or new interventions to heal and prevent pressure ulcers. R18's medical record lacked physician notification of the pressure ulcer or orders for treatment. During continuous observations starting at 10:14 a.m. on 11/29/18, the following was observed. -10:14 a.m. R18 was in the activities room, sitting in a wheelchair. A black cushion was in the wheelchair. -11:00 a.m. exercise technician (ET)-A moved R18 to the television room. ET-A did not offer or provide repositioning. -11:31 a.m. ET-A moved R18 to the dining room for lunch. ET-A did not offer or provide repositioning. -12:24 a.m. licensed practical nurse (LPN)-B assisted R18 to her room. LPN-B did not offer or provide repositioning. 12:41 a.m. LPN-B applied Apercream to R18's knees and shoulders. LPN-B did not offer or provide repositioning. No staff offered or repositioned R18 between 10:14 a.m. and 1:05 a.m. ( 2 hours and 51 minutes). At 1:08 p.m. surveyor approached nursing assistant (NA)-B and nursing assistant (NA)-C. Both stated they follow the resident's care plan/kardex located in each resident bathroom. Additionally all residents are repositioned every 2 hours unless the kardex directs differently. Both NA's stated they were done repositioning all but one resident after lunch. The remaining resident was not R18. Both NA's stated R18 is repositioned every 2 hours. When asked the last time R18 was repositioned both stated R18 was to be repositioned at noon, but was not. -1:15 p.m. NA-B and NA-C toileted R18 with a sit/stand lift, then used the sit/stand lift to lay R18 in bed. -1:22 p.m. registered nurse (RN)-A assessed R18's pressure ulcers. R18's had no open areas to the buttocks. RN-A stated the areas were healed as of today. The skin was pink and blanchable. During an interview at 1:27 p.m. on 11/29/18, RN-A stated the 2, stage 2 pressure ulcers were identified and assessed on 11/18/18. RN-A stated the ulcers were a result of pressure from the incontinent brief. RN-A stated she verbally reported to the aides to apply protective ointment to the areas more frequently and encourage R18 to lay down twice daily. RN-A stated the physician was not notified of the pressure ulcer development. RN-A stated the physician is to be notified when a pressure ulcer is identified. RN-A stated the physician was not notified of the pressure ulcer development and wound orders were not obtained as it was the weekend and missed. RN-A stated staff are to assist with repositioning every 2 hours. During an interview at 2:07 p.m. on 11/29/18, the director of nursing (DON) stated nursing assistants inform the nurse when skin changes occur. The nurse then completes an assessment and notifies the physician for treatment orders. The DON stated staff are to follow the resident's care plan. A facility policy Wound Management/Skin Integrity/Ulcers, dated 11/9/15 indicated all residents are preventatively placed on pressure reduction mattresses and cushions in wheelchairs based on the skin assessment. Those residents who represent a high risk will have futher preventative interventions put in place. Appropriate turning and repositioning schedules will also be put in place per assessment. An initial/immediate care plan will be initiated. Residents with risk for or who have a loss of skin integrity will receive the appropriate treatment/services, and residents who are determined to be at risk for or who have loss of skin integrity will receive the appropriate treatment/services which may include. Specific physican ordered medication/treatment. Repositioning or off-loading as per resident assessment and care plan.

Based on observation, interview, and document review, the facility failed to accurately assess gastrostomy tube placement for 1 of 1 residents (R30) prior to administering medications. Findings include: R30's admission Minimum Data Set (MDS), dated [DATE], indicated R30 received nutrition via a feeding tube. During observations at 7:57 a.m. on 11/28/18, licensed practical nurse (LPN)-A prepared seven medications for R30 by crushing the medication individually and placing the medication in seven separate medication cups. LPN-A mixed 10 cc of tap water to each of the medication cups. LPN-A put air in a 60 cc syringe and attached the syringe to R30's gastrostomy tube ([DEVICE]). LPN-A opened the clamp. LPN-A pushed on the syringe plunger, administering air through the [DEVICE], while listening with a stethoscope on the abdomen near the tube insertion site. LPN-A clamped the tube and removed the syringe. LPN-A did not pull back on the syringe to check for gastric contents. LPN-A administered 60 cc's of tap water via [DEVICE], prior to administering each medication individually via gravity, flushing with 10 cc of tap water between all medications. LPN-A flushed the [DEVICE] with 60 cc of tap water once all medication were administered and clamped the [DEVICE]. Upon completion of medication administration LPN-A stated she did not use any other method for checking [DEVICE] placement other than auscultation (listening). R30's physician orders [REDACTED]. Check placement of tube by inserting 10 cc of air and auscultate (listen). Then remove 10 cc of air. Check for gastric residual. During an interview at 2:06 p.m., on 11/29/18 the director of nursing (DON) stated facility's practice is to check placement of [DEVICE] by auscultation of air. The DON went onto say staff are to follow physician orders. The facility's policy Confirming Placement of Feeding Tubes, undated, indicated the purpose of this procedure is to ensure proper placement of the feeding tube to prevent aspiration during feedings. To Confirm Placement of Tube: 1. Observe for change in the external tube length marked at the time of the initial insertion X-ray. 2. Observe for signs of respiratory distress (if applicable). 3. Observe for changes in residual volume: a. A sharp increase in residual volume may indicate that a small bowel tube has moved into the stomach; b. Little to no residual volume may suggest that the tube has migrated from the stomach to the esophagus 4. If feeding has been interrupted for a few hours, observe (nasogatric, gastric, jejunostomy tubes): a. Fasting stomach contents will have a clear, colorless or green appearance. b. Respiratory secretions may look similar to gastric contents. c. Post-pyloric/intestinal contents cam be bile-stained, light to dark yellow or greenish-brown. 5. If the above suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician .

Based on observation, interview, and document review, the facility failed to ensure 4 of 4 residents, (R44, R50, R34, and R53) who exhibited combative behaviors were not physically abused when the resident(s) were restrained by staff providing necessary cares. The failure of the facility to ensure combative residents were assessed, interventions developed/monitored to ensure appropriate interventions were in place and were implemented by staff, the lack of investigation and oversight of staff who acknowledged restraining residents while providing personal cares, which resulted in bruising to residents, resulted in an immediate jeopardy for R44, R50, R34, and R53. These residents were identified by staff as residents who were combative with cares and as a result staff restrained them. The immediate jeopardy began on 4/15/14, at 4:47 p.m. when the facility failed to comprehensively assess, investigate, and implement interventions to ensure combative residents were not restrained or injured by staff during the performance of personal cares. The administrator and director of nursing (DON) were notified of the immediate jeopardy (IJ) for R44, R50, R34, and R53 on 4/15/13, at 4:47 p.m. The IJ was removed on 4/17/13, at 4:20 p.m. but noncompliance remained at a pattern scope and severity level, with potential for actual harm. Findings include: R44's admission record identified [DIAGNOSES REDACTED]. R44's Behavior Care Area Assessment (CAA) dated 5/21/14, identified resident "has a [DIAGNOSES REDACTED]. She has memory and judgement deficits. She is resistive to cares, and unpredictable in her reaction to staff when they are providing personal cares. Typically once the task is completed, she is pleasant and cooperative..." However, the CAA failed to comprehensively assess R44's ongoing behaviors to ensure interventions were in place related to R44's behaviors to direct staff on how to provide cares to the resident. During interview on 4/15/14, at 8:50 a.m. licensed practical nurse (LPN)-C reported R44 can be a "difficult" resident for staff to provide cares related to combative behavior. LPN-C stated at times it took up to 3 staff to provide cares to the resident, 2 staff to change the resident's brief (incontinence product) and one staff to hold R44's hands down. LPN-C stated it is "just easier" on R44 to quickly "get the cares done" because it was difficult to redirect the resident once she became agitated. During observation on 4/15/14, at 4:00 p.m. R44 was observed quietly sitting in a wheelchair in the dayroom watching the birds. On 4/15/14, at 5:35 p.m. R44 was in the dining room being assisted by a (unknown) nursing assistant (NA) and was cooperative. R44's care plan, last updated on 1/24/14, identified the resident had behaviors, which included her restiveness with personal cares and could become physically and verbally aggressive. She also had a history of [REDACTED]. The interventions directed staff, " ...when doing cares, check/ change in bed; may work better if one person holds her hands and engages her with explanations/ soothing words/ conversation to distract from the cares..." On 4/14/14, the facility provided R44's injury reports from January 1, 2014, to present time. The DON reported all injury reports prior to January 1, 2014 had been shredded and therefore not available. An injury report dated 1/10/14 indicated R44, "...was combative with HS (hour of sleep) cares noted to have grabbed staffs wrist. Staff stated, 'She grabbed my wrist with my watch on it. When I pulled my arm out her grasp and looked the top of her hand was bleeding noted resident to have an abrasion to the top of her right hand...' wound cleansed, 3 steri strips and [MEDICATION NAME] applied, and wrapped with cling wrap." No further investigation was found regarding the incident or evidence of further assessment/additional interventions being implemented. An injury report dated 2/13/14, identified R44 "...cares were being performed and resident swung arm at staff running right hand across nametag of staff and obtained a 1.7 x 1.7 abrasion to top of right hand... wound cleansed, [MEDICATION NAME] and gauze applied, will continue to monitor daily." No further investigation was found regarding the incident or evidence of further assessment/additional interventions being implemented. An injury report dated 3/2/14, indicated R44, "...had incontinent BM (bowel movement) and was combative with AM (morning) cares. Was hitting out at staff. Staff was holding onto her hands to prevent her from digging into BM and striking out at staff. At lunch bruises were noted. Resident was unaware." A wound assessment/ monitoring form dated 3/2/14, identified R44 had left wrist bruising which measured 3.5 cm (centimeter) x 5.2 cm and right wrist bruising which measured 3.6 cm x 2.8 cm. The assessment indicated the specific interventions being used were, "Try to calm and reapproach resident when combative." No further investigation/interventions were found. An injury report for R44 dated 3/14/14, indicated " ...When NA (nursing assistant) were assisting resident with her A.M. cares they noted resident to have 2 bruises to her left forearm. Author observed bruises to be dark purple in color measuring 6 cm x 3 cm and 3 cm x 3 cm. NOC (night) nurse reported resident was very combative during cares and hitting staff with her hands and arms. Is likely bruising is from residents combativeness." No further investigation was found regarding the incident or evidence of further assessment/additional interventions being implemented. A review of R44's progress notes from 9/13- present was completed and the following were noted: 9/11/13- "Resident had an abrasion to left forearm. NA noticed abrasion during HS cares. Inside of residents left sleeve noted to have old dried blood as well. Author observed a wide C shaped abrasion covered in moderate amount of old dried blood. On lateral side of arm near abrasion contains a blue/ dark purple hematoma. Resident unable to describe what happened ... abrasion measuring 4.5 cm x 0.8 cm. Hematoma approximately 5 cm x 3 cm x 1 cm." There was no further investigation or explanation of this injury found in the medical record. 10/3/13- "Occasional episodes of combative behavior are effectively managed by nursing home staff as per POC (plan of care)." 10/8/13- "RN manager reports some combative behaviors during PM cares ..." 11/5/13- "...is still intermittently combative with care, most at HS." 11/25/13- "...combative with HS cares but nothing unusual ..." 12/25/13- "... was combative with cares. Assist of 3 to provide HS cares and assist into bed ..." 12/27/13- " ... has been very combative and resistive this shift ..." 1/5/14- " ...Resident was hitting and pinching staff with peri cares this AM." 1/10/14- " Resident was combative with HS cares ..." 2/19/14- " ...was combative with AM cares today. She was combative again this afternoon, scratching a staff member's wrist. " 3/3/14- "...staff report increased hitting out behaviors. Both forearms badly bruised. She states she doesn't remember how it happened. " 3/7/14- " Combative with 10:00 p.m. rounds, verbal with HS rounds. Redirected behavior with minimal success." 3/10/14- ..."resident did become combative and pinched NA during brief change during the night. Resident is usually resistive/combative with brief changes during the night shift ..." 3/12/14- " ...noted to be combative and have verbal outbursts during HS cares." 3/13/14- "...noted to be combative and have verbal outbursts during HS cares. Was also combative during night every 2 hour rounds." 3/14/14- " ...combative and have verbal outbursts during HS cares ..." 3/16/14- " ...Combative with HS cares ... was combative hitting, scratching, pinching and attempting to bite at staff during 10:00 p.m., midnight, 2:00 a.m., and 4:00 a.m. cares...." 3/19/14- " Combative and agitated with NA assisting her with HS cares. Was compliant and cooperative with author. Author excused NA from the room and finished assisting resident with HS cares ..." 4/3/14- " ...There has been no significant improvement with her behaviors with the increase (in anti-psychotic medication). She continues to be combative with most personal cares, and is not redirect able with this. Change in caregiver may be helpful, at times not." Although R44's progress notes identified the resident was consistently combative with staff while providing cares which resulted in the resident receiving bruising, the facility was unable to provide any investigation, tracking, or any assessments completed regarding R44's combative behaviors or staff interventions being used to ensure interventions were appropriate and being implemented. During an interview on 4/15/14, at 9:05 a.m. NA-A reported R44 was combative when staff is providing cares. NA-A indicated it would often take 3 staff to change R44's brief, however, the resident was "smaller" so it can often be done with 2 staff; one staff to change the resident's brief and one to hold her hands down to prevent the resident from hitting staff or herself. NA-A also reported that if R44 needed cares provided it worked best if " we just try to get her changed and get it over with." During an interview on 4/15/14, at 9:35 a.m. NA-D indicated R44 was combative with staff when they are providing cares to her (the resident). NA-D reported R44 only required one staff assist with cares, but usually 2 staff were required to help so one staff can "hold the resident's hands down when cares are being done." NA-D stated she knew staff had caused bruising to R44's wrists, arms, and ankles from holding them down when staff were trying to get personal cares done, but "the residents" are so resistive and staff are just trying to get the residents cares done as quickly as possible. NA-D indicated she felt "horrible" when residents had developed bruising from holding them down to perform cares, but she stated, "They are just so fragile and struggling with us so much when we are holding them." NA-D stated about a month ago R44 needed to have her brief changed and was resistive. NA-D stated staff had to hold the resident's wrists/ hands so the resident could be cleaned up. NA-D reported about 2-3 hours later staff observed R44's wrists were bruised "like perfect hand prints." NA-D stated that made her feel "horrible." R50's admission MDS dated [DATE], indicated [DIAGNOSES REDACTED]. R50's CAA dated 2/18/14, identified resident, "Has dementia, that has progressed to where she is essentially nonverbal, dependent upon staff for ADL's. She is unable to express her needs, and staff needs to anticipate/ be aware of nonverbal indicators. She is still able to propel her wheelchair, and does so aimlessly about the facility. She is combative with cares, and may act out towards others near her- especially if in the path of where she is going. This puts her at risk for injury for self or others." However, the CAA failed to comprehensively assess R50's ongoing behaviors and to ensure interventions were in place related to R50's behaviors to direct staff on how to provide cares to the resident. R50's care plan updated 4/14/14, identified the resident was resistive with cares, wandered, verbal and physical resistance with cares, and may reach out and grab at other people in her path. The interventions included allow time for thought process when providing cares, keep her warm during cares, and attempt to distract with music or items to manipulate her hands. During observation on 4/15/14, at 6:30 p.m. R50 was observed in the bird room and was pinching another resident (R34) in the upper left arm. R34 repeatedly said, "Stop, get the hell out of here!" With no communication to R50, an (unknown) staff member grabbed the back of R50's wheelchair and pulled her backwards out of the bird room into the hallway. The resident was left sitting in the hallway alone. On 4/14/14, the facility was asked to provide R50's injury reports from January 1, 2014 to present. The DON indicated R50 had no injury reports/ investigations during that time period. A review of a Wound Assessment/ Monitoring form, dated 4/3/14, identified R50 had left forearm bruising measuring approximately 6 cm in length and 1 cm wide; reddish/ purple in color. No investigation was found regarding the bruise of unknown origin or any further assessment/ care plan revisions. Review of R50's progress notes identified the following: 2/12/14- "Not alert or orientated x 3 or able to communicate needs...Combative with HS cares, not able to redirect." 2/13/14- "Combative with HS cares." 2/13/14- "In AM she was noted to be verbal and combative... 2 assist with cares due to being combative..." 2/15/14- "NAs noted resident to be combative with HS cares." 2/16/14- "NAs noted resident to be combative with HS cares." 2/16/14- "Resident very combative this morning with AM cares; would hit out and pull staffs hair. When up has been scooting around facility in wheelchair and runs into other residents and walls continuously." 2/17/14- "Hit at staff with each attempt (at care). NAs noted resident to be combative with HS cares." 2/18/14- "Combative throughout shift, hitting, pinching, and squeezing arms of personnel." 2/18/14- "During AM cares resident was noted to be combative towards NA. NA explained each task before and during, this did improve behaviors." 2/21/14- "was combative and verbal with AM cares... has been wandering in halls and running her wheelchair into residents, staff, and other objects." 2/22/14- "Combative with AM cares." 2/24/14- "Wheeling into other resident's wheelchair in bird room... hitting out at staff during HS cares. Resistive with cares, grabbing clothes, wash cloth, towel and bedding." 2/25/14- "Running into other resident's wheelchairs and also wandering into other residents rooms... combative during HS cares. Also combative while being repositioned on rounds during the night." 2/26/14- "Combative with reposition during the night." 2/27/14- "Found in other resident's rooms. Was also running into other resident's wheelchairs. NAs noted resident to be very combative during HS cares." 3/2/14- "Combative with cares... was found to be wandering into other resident's rooms. Redirected with some results." 3/3/14- "Resident was noted to be wandering through the facility at the beginning of the shift. Was found multiple times in other residents' rooms, digging in drawers, garbage... She was also noted multiple times to be running into other residents' wheelchairs, squeezing fell ow resident's leg- staff had to remove her hand. Staff attempted redirecting resident multiple times during PM shift- all attempts failed. Noted to be very combative during HS cares." 3/4/14- "Noted to be wandering in and out of other resident rooms. Combative with HS cares. Noted to be hitting out at staff during HS cares. Resistive... Staff explained procedure to her, and she continued to be resistive and combative. Total assist of 2..." 3/5/14- "Wanders into other resident's rooms. Does not leave other residents' rooms even if being yelled at by that resident. Several attempts were made by staff to redirect, without success... combative and resistive with staff during HS cares." 3/14/14- "Has been noted to be combative with cares in AM." 3/15/14- "Grabbed another resident in the chest. Staff assistance required to get her to let go." 3/16/14- "Was observed by staff that she had grabbed another resident in the chest. Attempting to hit another resident. Author stopped her as she was about to run another residents feet over with her wheelchair. Aggressive with HS cares." 4/3/14- Resident "is combative with her personal cares, wanders throughout the building in her wheelchair; difficult to redirect." 4/13/14- "Irritable, striking out when approached to change her direction or remove from other resident areas. Striking out at those she was near..." Although the review of the progress notes in R50 medical record indicated consistent ongoing documentation of R50's restiveness with personal cares, there was no further investigation, tracking, or assessment of these combative behaviors to ensure appropriate interventions are in place. During interview on 4/15/14, at 9:05 a.m. NA-A stated R50 is combative "all the time" when staff is attempting to provide cares to the resident. She stated when providing cares to R50 it requires 2 staff, one to provide the cares, and one to hold the resident's hands and feet so cares can be provided. NA-A stated she reported R50's behavior to the nurse "every day," but she does not know what the nurse did with the information as the resident's combative behavior never improved. During interview on 4/15/14, at 9:35 a.m. NA-D reported R50 was combative "all the time" with "any cares" staff attempted to provide. NA-D also reported staff tried to redirect the resident by talking with her, but R50 could not be redirected. NA-D stated sometimes it takes 3 staff to change the residents brief because the resident is "pretty big and strong." She stated the resident's bed was against the wall and one staff stands above R50's head to hold her arms down, and the other two staff get the resident's cares done. NA-D stated, "We have to hold her down to get her cares done or we would never get done." NA-D stated she reports this to the charge nurse "all the time" but nothing is ever done to help caring for R50 any easier. NA-D stated, "I know it isn't right (to hold residents down); but how else do you do cares?" R34's quarterly MDS dated [DATE], identified the resident had [DIAGNOSES REDACTED]. She had moderate cognitive impairment, required extensive assistance with ADLs, and rejected care 1-3 days of the 7 day look back assessment period. R34's CAA dated 11/21/13 identified the resident, "Has [DIAGNOSES REDACTED]. She is alert, orientated to self, recognizes staff, facility locations. She is unaware of time of day, month. She is easily/ quick to have mood changes from pleasant to angry and reverse. She does have a hearing deficit with hearing aids which she refuses to wear (similarly her glasses's) which could impact her interpretation of her surroundings. At risk for isolation, misunderstandings." However, the CAA failed to comprehensively assess R34's ongoing behavior to ensure interventions were in place related to R34's behaviors to direct staff on how to provide cares to the resident. R34's care plan dated 2/27/14, identified the resident is verbally aggressive and resistive to cares. Staff were instructed to reapproach with different staff if resident was refusing cares, report to nurse cause and effect relationship when behavior is exhibited, assure good communication was maintained and resident understands what was happening, and set limits for behavior with resident. If non-compliant and safe, staff were directed to leave situation until behavior stops. They were to reapproach later and "verbally demand behavior stop." During an observation on 4/15/14, at 6:30 p.m. R34 was seated in her wheelchair in the bird room. Another resident (R50) wheeled next to her and began pinching her in the upper left arm. R34 kept saying, "Stop, get the hell out of here!" A (unknown) staff member grabbed the back of R50's wheelchair and pulled her backwards out of the bird room into the hallway. R34 was left sitting in the bird room and was not approached by staff to ask the resident what happened or if she had any injuries. On 4/14/14, the facility provided R44's injury reports from January 1, 2014, to present time. The DON reported all injury reports prior to January 1, 2014, had been shredded and therefore not available. An injury report dated 1/20/14, indicated, "Noted to have bruising to bilateral arms and wrists, has had increased physical behaviors with staff during cares, including hitting at staff and hitting PAL lift with fists, bare hands typically during cares and transfers. The immediate action taken was, "Monitor bruising until healed. Leave and re approach when angry with cares." There was no further investigation of this incident nor was there any identification of which staff had been caring for the resident. Review of R34's Wound Assessment Monitoring identified the following: 12/28/13- Right forearm bruising 3.5 cm x 2.3 cm. Right forearm bruising 9.5 cm x 5 cm x 0.2 cm (depth). The monitoring form identified the bruising was dark purple. There was no further assessment or investigation regarding the bruising. 1/6/14- Multiple bruising to left arm. Bruising to left hand (back) measuring 4 cm x 6 cm. The appearance indicated, "Bruising to hand and multiple to left arm. Bruises are dark blue/ purple in color. Discontinue mobility bars in bed. Resident may be bumping her arms on these." 1/11/14- Right forearm bruising. "Dark purple around the edges of bruising. Appears to be fading in the middle. Yellow color to middle of bruise." There was no further investigation or explanation of the bruising. 1/20/14- Left back hand bruising and left arm bruising. "Has one penny sized bruise present on the left hand and has multiple bruises present on her forearm." There was no further investigation or explanation of the bruising. Review of R34's progress notes revealed the following: 12/23/13- "Had one brief episode of verbal and physical behaviors during AM cares." 1/4/14- "Was rude and combative with cares this AM. She grabbed one of the staff's hair when being assisted to the bathroom." 1/15/14- "Resident noted to be very verbal and combative with staff this shift. Hitting, kicking, and scratching staff during HS cares. Also calling staff inappropriate names and swearing at them. Resistive with transfers during HS cares. 1/17/14- "...noted to be hollering out/swearing at staff. Was noted to be slapping, pinching, reaching out, and punching at staff, as well as PAL lift. Continues with multiple bruises to forearms and hands..." 1/22/14- "Resident noted to both verbal and physical with staff throughout shift... was also hitting with HS cares and during (night) every 2 hour rounds." 1/25/14- "...was verbal and combative with her AM cares..." 2/4/14- "... very resistive and physical with cares this shift. Both HS cares and (night) rounds. Was noted to be hitting at/ slapping staff..." 2/6/14- Resident "verbal and combative at start of shift. Yelling '[***] ; your stupid; just go to hell.' Combative with HS cares." 2/16/14- "Resident noted to be verbal and combative with HS cares... Also hit at staff while being repositioned during (night) every 2 hour rounds." 2/20/14- "Verbal and combative with HS cares. Hit and yelled at staff while being repositioned during (night) every 2 hour rounds." 2/21/14- "Combative with AM cares this morning." 2/27/14- "Verbal towards other residents and staff throughout shift. Was also combative during repositioning during the night..." 3/13/14- "During toileting this AM resident sustained [REDACTED]." There was no further assessment or investigation of how the abrasion happened. Although R34's progress notes identified the resident was consistently combative with staff while providing cares which resulted in the resident receiving bruising, the facility was unable to provide any investigation, tracking, or assessments related to R34's combative behaviors or staff interventions being used to ensure interventions were appropriate and being implemented. During interview on 4/15/14, at 8:50 a.m. LPN-C reported R34 was combative with cares. LPN-C stated staff would sometimes try to reapproach the resident later to provide cares, but, if that didn't work, it would take an extra staff to assist with holding the residents arms and legs to provide the cares. LPN-C indicated often holding R34's arms and legs down was the only way to get cares done on the resident. During interview on 4/15/14, at 9:05 a.m. NA-A stated R34 is often combative with cares. NA-A stated it will often take "a few of us" to provide cares because one has to "hold her hands" while the other staff is providing the cares. NA-A stated R34 is very combative when males provide cares because she doesn't like men to take care of her. R53's annual MDS, dated [DATE], identified resident [DIAGNOSES REDACTED]. The resident had moderate cognitive impairment, required extensive assistance with ADLs, and rejected care 1-3 days of the 7 day look back assessment period. R53's CAA dated 1/9/14, identified the resident, "Has [DIAGNOSES REDACTED]. He is aware of his location, recognizes family, his judgement and reasoning are impaired. He does not recognize his own limitations, potential hazards, or social restraints. His cognition losses have become more apparent in the past year..." However, the CAA failed to comprehensively assess R53's ongoing behaviors to ensure interventions were in place related to R53's behaviors to direct staff on how to provide cares to the resident related to his hallucinations or paranoia. R53's plan of care dated 4/14/14, identified the resident hollered and yelled and indicated if "painful (did not identify what painful referred to), wants attention, or for no reason...not always redirectable..." The interventions directed the staff to ask the resident why he is yelling. He was also an assist of one staff for personal cares but if not cooperative, 2 staff were to be used. During observation on 4/15/14, at 6:45 p.m. R53 was observed in the hallway outside of the dining room. The resident had his arms spread out with one hand on the wall and the other hand on the medication cart blocking the hallway. Several resident's were lined up behind him waiting to get by him down the hall. An (unknown) staff asked the resident to put his arms down so other resident's could get through. R53 did not respond to the staff or move his arms, so the staff member took the resident's arm and physically moved it, and pushed R53 into the dayroom. During interview on 4/15/14 at 9:05 a.m. NA-A stated R53 was often combative with cares. NA-A stated she does not work with R53 often, but when she has, extra staff had to hold the residents arms down to allow staff to provide cares. On 4/14/14 the facility provided R53's injury reports from January 1, 2014, to present. The DON stated injury reports prior to January 1, 2014 had been destroyed. The facility provided one injury report for R53 dated 3/2/14, with a revision date of 4/14/14, which identified the resident was "Combative with HS cares, to thrashing arms in PAL. Abrasion noted to left arm after HS cares completed... Checked PAL and bed for sharp edges." A Wound Assessment and Monitoring Report identified R53 had (2) left antecubital (forearm) abrasion(s) measuring 1.3 cm x 0.7 cm and 1 cm x 0.3 cm. The interventions listed were, "Check for any sharp edges." Review of R53's Progress Notes from 12/1/13 to present identified the following: 1/14/14- "Resident noted to be hitting another resident in the back of the head today, NA quickly removed (R53) from room and told him this behavior was inappropriate." 1/20/14- "Behaviors have improved from the very resistive, paranoid, yelling. He continues to refuse cares, be irritable but there is the possibility of getting him distracted or talked into the task you wish him to do..." 2/10/14- "Noted to be sitting in the TV room with other residents. Staff heard another resident hollering out for help. When staff approached the TV room, resident was noted to be holding on the back of the other resident's wheelchair and preventing her from leaving the area. Took several attempts to redirect resident before he let go of the wheelchair... When staff attempted to reposition resident he became resistive and hollering. Also was noted to be combative and pulled female NA's hair. Resident was not redirectable or able to be distracted." 3/5/14- "Was resistive with HS cares." 3/20/14- "Noted to be combative and resistive during HS cares." This was the last documented note regarding the resident being resistive with cares. Although R53's progress notes identified the resident was combative with staff while providing cares which resulted in the resident receiving bruising, the facility was unable to provide any investigation, tracking, or assessment related to R53's combative behaviors or staff interventions being used to ensure interventions were appropriate. During interview on 4/15/14, at 9:35 a.m. NA-D stated R53 was combative with cares and "just about anytime you try to do something with him." NA-D also reported two staff can usually "handle him," but if he was combative staff try to walk away and reapproach him later. NA-D indicated if staff comes back and R53 was still combative, staff would need to restrain him (hold his hands/ legs) to do cares. NA-D stated, "We do what we have to do" to complete cares. During interview on 4/15/14, at 8:50 a.m. LPN-C stated if a resident was noted with bruising she would ensure the bruising was monitored to ensure healing. LPN-C stated she was aware staff needed to hold combative residents down to provide cares and was aware bruising had resulted from staff restraining residents. LPN-C stated she did not think the bruising required investigation or reporting because she was aware the bruising was related to the resident being combative while staff was assisting the resident with cares. LPN-C stated an injury/ incident report is not always filled out for bruising, especially if it was known where the bruising came from. During interview on 4/15/14, at 12:10 p.m. DON stated she was aware staff needed to restrain combative residents to do personal cares. The DON stated if a resident was combative or resistive with cares staff should leave the resident safe, and reapproach. DON stated, "The cares have to get done for these resident's and there are just some resident's who are difficult." She stated when a resident had dementia, there was a risk the resident may be resistive with cares and staff needs to get "cares done as quickly as possible for these residents, you can't just leave them in a soiled brief and not get cares done." DON stated, "There is a point we have to provide cares and I know that residents are held down by staff to provide the needed cares." DON stated staff were restraining resident's for their own safety to make sure the resident's were not striking staff or injuring themselves. DON verified injury reports of bruising were documented at times for some residents as related to "combative with cares." She stated this bruising was not suspicious and did not require a full investigation because the facility was aware where the bruising came from and knew the residents weren't being abused. The DON verified the facility did not complete assessments on residents with behaviors or who were combative with cares to ensure individualized interventions were in place; nor did the facility have any investigations or tracking of staff who were providing cares to the residents when they were combative with cares and received br