Every finding on record at Good Samaritan - Villisca

Based on observation, interview and policy review the facility failed to ensure safe food storage. In an initial observation of the kitchen, observed the opened food packages without dates when opened. The facility reported a census of 34 residents. Findings include: The initial observation of the kitchen completed on 1/26/26 at 10:00 AM, revealed the following food items without an opened date: A bag of shredded cheeseA bag of cauliflowerA crock pot of cheese.On 1/27/26 at 3:00 PM, the Dietary Manager said they expected the staff to date the food items at the time they open them. They explained unopened items in the refrigerator would be good for 7 days but opened items were good for no longer than 3 days. The described the crock pot of cheese as from a staff party over the weekend and not used by residents. A facility policy titled: Date Marking, dated 4/4/25, instructed to date time/temperature control foods items with the received date. When they opened the food but kept it in storage, the employees would clearly label the date/time when they opened the container.

Based on observation, interview, and record review the facility failed to safely secure controlled substances for 13 of 13 residents reviewed. An observation of the medication administration revealed the staff failed to store controlled substances under extra security. The facility reported a census of 34 residents. Findings include: On 1/27/26 at 7:32 AM observed Staff A, Licensed Practical Nurse (LPN), prepare medications for Resident #33. She pulled the clonazepam (anti-anxiety medication) out of the same drawer as the scheduled medication. When asked why they didn't have the controlled substance under a double lock, she replied she didn't know. She added they had the as needed (PRN) controlled substances under a double lock. On 1/27/26 at 7:44 AM the observation of the narcotic drawer revealed the facility had the PRN lorazepam's and clonazepam's double locked, but not the scheduled ones. The review of the Medication Review Reports (MRR) printed on 1/28/26 at 10:25 AM revealed 4 residents received clonazepam scheduled (Residents #21, #27, #30, and #33). According to the United States Drug Enforcement Administration (DEA) website article regarding Drug Scheduling retrieved 1/28/26 identified drugs, substances, and certain chemicals used to make drugs are classified into 5 distinct categories or schedules depending up the drugs acceptable medical use and abuse or dependency potential. Schedule I drugs have a high potential for abuse, as the schedule changes, so does the abuse potential, schedule V drugs represent the least potential for abuse. The article listed diazepam, tramadol, alprazolam, phenobarbital and Xcopri as Schedule IV (low potential for abuse and low risk of dependence).The Controlled Substances Alphabetic Order listed clonazepam as a Schedule IV medication.On 1/27/26 at 3:30 PM, the Director of Nursing (DON) said as long as she worked at the facility, they only double locked the PRN controlled medications and not the ones scheduled. On 1/28/26 at 7:00 AM, the DON said she talked to the pharmacy. They directed the facility to double lock the scheduled controlled substances as well as the PRN. She said they educated the staff and moved all the controlled substances. The facility policy labeled Medications: Controlled, dated 4/8/25, defined controlled medications as a substance that have an accepted medical use, have a potential for abuse, ranging from low to high and may also lead to physical or psychological dependence. The access system used to lock Schedule II medication could not be the same access system used to lock non-controlled medications.

Based on interview, record review, and policy review the facility failed to follow physicians' orders for blood pressure parameters. In addition, the facility failed to retake blood pressure measurements for readings outside of normal range for 1 of 1 resident reviewed (Resident #38). The facility reported a census of 34 residents.Findings include:Resident #38's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 12/13/25. The MDS identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure higher than 130/80), respiratory (lungs) failure, disorder of electrolyte and fluid balance. The Care Plan Focus initiated 12/13/25 reflected Resident #38 had hypertension. The Interventions directed the staff to monitor her for disorientation (a form of confusion), lethargy (extreme tiredness), difficulty breathing. Resident #38's Blood Pressure Exceptions Report printed 1/28/26 listed the following low blood pressures (blood pressure less than 90/60) on:12/14/25 at 3:53 PM: 75/56The chart lacked documentation of a repeat blood pressure result or consultation of the doctor.12/15/25 at 7:03 PM: 64/34. No documented blood pressure until 12/15/25 at 11:48 PM. 12/15/25 at 11:48 PM: 96/58.The chart lacked blood pressure measurements on 12/16/2512/20/25 at 9:34 PM: 84/70.Resident #38's December 2025 Medication Administration Record (MAR) included an order dated 12/13/25 at 7:00 PM for metoprolol 25 milligrams (mg) two times a day. The order changed on 12/17/25 at 7:15 AM, to give 25 mg metoprolol, two times a day, and hold if the systolic reading (top number) was less than 100 or the heart rate was less than 50. On 12/20/25 documentation reflected Resident #38 received the evening dose of metoprolol with a blood pressure of 84/70. On 1/28/26 at 9:49 AM, the Director of Nursing (DON) said the nurses should take another blood pressure measurement if/when they have a result outside of normal range. The DON acknowledged the staff gave Resident #38 metoprolol outside the normal range after they had established parameter orders. On 1/28/26 at 10:43 AM, Staff A, Licensed Practical Nurse (LPN), said that if a resident received metoprolol and had a low BP, she would hold the medication, retake the BP, and call the doctor. The Vital Signs-Blood Pressure policy, dated 11/12/25, instructed staff to report if a blood pressure above 139/89 or below 90/60. The Physician Orders policy, dated 4/6/25, defined the purpose of the policy as to provide individualized care to each resident by obtaining appropriate, accurate, and timely physician's orders.

Based on observation, interview and policy review the facility failed to serve the therapeutic menu as ordered for 3 of 34 reviewed residents reviewed (Residents #25, #23, and #20). The facility reported a census of 34 residents. Findings include: 1. Resident #25's Medication Review Report (MRR) printed 1/28/26 included diagnoses of muscle weakness, dementia, psychotic disturbance, and anxiety. The MRR included a diet order dated 1/27/26 of a regular diet with regular texture, thin consistency, and ground meat. 2. Resident #23's MRR printed 1/28/26 included diagnoses of kidney disease, malnutrition, and vitamin deficiency. The MRR included a diet order dated 1/27/26 of a no added salt (NAS) diet with soft and bite-sized texture with a mildly thick consistency.3. Resident #20's MRR printed 1/28/26 included diagnoses of hypertension (blood pressure higher than 130/80), vascular dementia (forgetfulness caused by changes in the brain), anxiety and muscle weakness. The MRR included a diet order dated 2/21/25 of a regular texture diet. On 1/27/26 at 12:00 PM, observed the lunch service. Resident #25 received the regular stir fry meal with an egg roll (the meat was not minced, and the egg roll was not pureed). Resident #23 received ground noodles and stir fry with no gravy. Resident #20 received a half scoop of noodles as they only had that left in the pan. On 1/27/26 at 3:00 PM, the Dietary Manager (DM) said Resident #23 should have received gravy on his meal, especially with the noodles being so sticky. She said Resident #25 had somewhat confusing and changing diet specifics. The Week at a Glance Menu, Week 4, showed the #5 diet to be beef and broccoli stir fry, minced with thick gravy, minced fettuccini noodles with thickened broth, pureed egg rolls and pureed brownie. The Week at a Glance Menu, Week 4, listed the #6 diet as soft and bite-sized beef and broccoli stir-fry with thick gravy, soft and bite sized buttered fettuccini noodles, pureed egg rolls, and a pureed brownie. According to a facility policy titled: Texture-Modification Diets, dated 5/12/25, directed the food and nutritional services to provide prescribed texture-modified diets by the resident's attending physician. They should serve texture-modified diets attractively. In addition, they should prepare the texture-modified diets by methods that conserve nutritional value, flavor and appearance. They would use a standardized process for all prepared texture-modified menu items to ensure the resident received the appropriate nutrient content in every menu item.

Based on Electronic Health Record review, Medication Administration Records - Treatment Administration Records (MAR-TAR) and staff interviews the facility failed to receive necessary treatment to prevent developing avoidable pressure ulcers for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 37 residents.Finding include:The Minimum Data Set (MDS) dated [DATE] for Resident #5 documented a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS documented diagnosis of two stage 2 pressure ulcers.Review of Resident #5's MAR-TAR documented a physician's order for daily wound data every day shift for wound observation. Right sacral region dressing change. Cleanse with soap and water, skin prep, med honey, cover with 2x3 or 4x4 proximal border foam dressing once a day for skin treatment started 5/9/25. Weekly skin observation one time a day every Thursday for skin observation.Review Resident #5's EHR's titled, Wound Data Collection from 5/5/25 - 5/31/25 documented no measurements of Resident #5's wound on the right sacral region.Review document titled Nurse's Notes for Resident #5 documented by Staff A, Certified Wound Nurse assessed Resident #5's wound on 5/8/25 and 6/3/25 with description and measurements. On 10/16/25 at 9:54 AM Staff A stated she was contracted for wound care and assessment for a pressure wound on Resident #5 right sacral region. Staff A stated Resident #5 was supposed to come to the wound clinic weekly. Staff A stated she spoke with Resident #5's daughter about weekly visits to the wound clinic. Staff A discovered Resident 5 was uncomfortable with coming to the clinic so Staff A started going to the facility. Staff A stated she visited on 5/15/25. Staff A stated every time she went to the facility Resident #5 would be lying on her side. Staff A stated the area on Resident #5's right sacral region was unavoidable. Staff A stated the dressing appeared to be changed as ordered.On 10/15/25 at 11:43 AM Staff B, Registered Nurse (RN) / wound nurse stated she had time off work from the last day of April of 2025. Staff B stated she returned in June. Staff B stated when she went on leave from the facility Resident #5's right sacral region only had a bruise and when she returned in June the area was open. On 10/16/25 at 11:30 AM the Director of Nursing (DON) stated Staff B was on medical leave the month of May. The DON explained Staff B completed the wound assessments with measurements weekly. The DON acknowledged wound assessment was not completed with measurements by the facility staff from 4/30/25 until 6/11/25. The DON stated Staff A from the wound clinic visited Resident #5 and completed a full assessment on 5/8, 5/15 and 6/3. The DON acknowledged Resident #5 did not have an assessment completed by RN with measurements and descriptions of the wound on Resident #5's right sacral region. The DON stated a wound assessment completed by an RN with measurements should have been completed weekly. The DON acknowledged the Staff A did not complete an assessment on Resident #5's right sacral region from 5/8 through 5/15 and 5/15 through 6/3. The DON explained an assessment with measurements should have been completed between these dates by a facility RN and that did not happen.On 10/16/25 at 1:14 PM the Administrator stated he would have expected an assessment with measurements completed weekly on all pressure ulcers. Review of policy revised 4/6/25 titled, Skin Assessment Pressure Ulcer Prevention and Documentation documented the purpose was to accurately document observations and assessments of residents. If a pressure ulcer was identified, cleanse the area prior to observations being made to allow the wound bed and depth to be more accurately observed. The Licensed nurse records the location of the area, the measurements, and the ulcer wound characteristics. The pressure ulcer should be assessed / evaluated at least weekly and documented on a Wound RN Assessment UDA.

Based on Electronic Health Record (EHR) review, staff interviews, and policy review the facility failed to provide needed services in accordance with professional standards by receiving physician's orders to start physical therapy (PT) and occupational therapy (OT) and failed to start the orders for 1 of 3 residents (Resident #2). The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 documented a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. The MDS documented right below the knee amputation with right lower extremity prosthetic.Review of Resident #2's EHR document dated 8/4/25 titled, admission Orders to Nursing Home documented physician's orders for physical therapy and occupational therapy with rehab potential as fair. Review of document dated 9/3/25 titled, Physical Therapy PT Evaluation and Plan of Treatment documented certification period was 9/3/25 through 11/25/25. The document further explained physical therapy started 9/3/25.Review of document dated 9/3/25 titled, Occupational Therapy OT Evaluation and Plan of Treatment documented certification period was 9/3/25 through 11/25/25. The document further explained occupational therapy started 9/3/25.On 10/16/25 at 9:39 AM Staff C, Occupational Therapist Assistant stated Resident #2 was picked up for therapy in the beginning of September for improvement on standing, strengthening, and application of the prosthetic leg. Staff C explained the therapy department received an order on 8/27/25 to see Resident #2.On 10/16/25 at 11:30 AM the Director of Nursing (DON) acknowledged an order for Resident #2 dated 8/4/25 documented admission orders for physical therapy and occupational therapy. The DON acknowledged the orders were not followed and Resident #2 was not seen until 9/2/25 after Resident #2's primary care physician placed orders on 8/27/25 to be evaluated by PT and OT. The DON acknowledged Resident #2 should have been seen by PT and OT when orders were placed on 8/4/25. The DON stated the order was missed. On 10/16/25 at 1:14 PM the Administrator said the facility should have followed up better with the order for PT / OT for Resident #2. Review of policy revised 4/6/25 titled, Physician / Practitioner Orders - Rehab / Skilled documented the purpose was to provide individualized care to each resident by obtaining appropriate accurate and timely physician / practitioner orders. At the time of admission, the location will have physician orders for the resident to be admitted to a location. Each resident must remain under the care of a physician. The admitting orders are intended to provide guidance on appropriate resident care until a comprehensive assessment was conducted and the interdisciplinary care plan was developed. Required orders on admission include rehabilitation potential and therapy orders when appropriate.

Based on clinical document review, observation, resident interview, staff interview, and policy review the facility failed to provide a professional standard of quality by not following physician orders for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 37 residents. Findings include:Review of the Minimum Data Set (MDS) for Resident #2 dated 6/10/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of quadriplegia, seizure disorder, anxiety, and respiratory failure.Review of the Electronic Healthcare Record (EHR) page titled, Physician's Orders revealed an order for the lower extremities to be 1. washed with soap and water, 2. irrigate with normal saline, 3. apply skin prep to periwound, 4. apply nickel thick medicated cream, 5. Saline moistened fluffed gauze, 6. Cover with dry gauze, 7. Secure with rolled gauze and tape every day and evening shift for wound care with a start date of 7/21/25. The page further revealed an order for compression socks on in the morning and off in the evening for edema with a start date of 7/21/25.Review of a facility provided document titled, Provider Orders Form dated 7/21/25 revealed an order for compression hose as ordered by vascular.Review of a facility provided document titled, Clinic Referral dated 7/21/25 revealed an entry from an outside physician stating Resident #2 would need to start wearing compression stockings daily and to follow up as necessary. Review of another facility provided document titled, Certified Wound Care Nurse Assessment and Recommendations with a date of 8/20/25 revealed a note stating that Resident #2 reported not getting his new compression stockings, and that the wound nurse would reach out to the facility. Interview 9/2/25 at 2:35 PM with an outside provider revealed that she has been seeing Resident #2 since May of this year. The outside provider further revealed that Resident #2 was seen by vascular at an outside facility, and that Resident #2 has not had his stockings in the last 3 weeks that she has seen the resident. The provider then revealed that if Resident #2 was wearing his stockings as ordered wounds would be healing better on the lower legs. Observation 9/2/25 at 2:50 PM revealed Resident #2 to not be wearing compression stockings bilaterally to the lower extremities. Interview 9/2/25 at 2:57 PM with Resident #2 revealed that he does not have any stockings. Resident #2 revealed that stockings were ordered, and when they came in on August 29th or so of this year they were the wrong size. Resident #2 then revealed that if offered some stockings he would have put them on with the condition of his legs. Review of the Treatment Administration Record for the months of July, and August of 2025 revealed that between the dates of 7/21/25 through 8/31/25 compression stockings were documented that Resident #2 refused them 25 times, they were put on 6 times, and were unavailable 30 times. Interview 9/2/25 at 3:07 PM with Staff B Licensed Practical Nurse (LPN) stated that staff sometimes get click happy when entering/documenting on the Medication Administration Record (MAR), and may not be completing treatments as ordered. Staff stated she may be guilty as well as entering stockings donned when they were not. Staff B then revealed Resident #2 wanted specific stockings as the physician wanted a specific brand.Interview 9/2/25 at 3:15 PM with Staff C Registered Nurse RN revealed Resident #2 is very particular with his treatments, and that as far as Resident #2's compression stocking's he wanted to order his own. Staff C then revealed that Resident #2 did get some stockings in but they were the wrong size, and sent them back. Staff C further revealed that she would expect someone to follow up with the physician who ordered the stockings to be notified that they were not being worn. Interview 9/2/25 at 3:27 PM with Staff D LPN revealed that Resident #2 supposedly ordered his own compression stockings, and when they came in they did not fit. Staff D then revealed that she would expect that with a physician's order staff would follow up with the provider whether that be the primary care provider or the clinic that prescribed them if the supplies had not come in. Interview 9/2/25 at 4:15 PM with the Director of Nursing (DON) revealed that orders should be followed as written, and if the facility or resident was not wearing or did not have compression stockings that the facility should have followed up with the physician who ordered them.Review of a facility provided policy titled, Physician/Practitioner Orders with a revision date of 4/6/25 revealed:a. Physician/Practitioner orders are a critical component to providing quality care to residents. Accurate processing of physician/practitioner orders is important. The nursing services and health information management departments each have responsibilities for processing physician/practitioner orders in a timely and accurate manner. Teamwork and communication between the two departments is essential.

Based on clinical record review, observation, staff interviews and policy review the facility failed to protect a resident from a possible accident and injury by not following the prevention of fall interventions for 1 of 3 residents (#5). The facility failed to protect the resident with the completion of 3 movements using a dependent non-weight bearing mechanical lift with only 1 staff present. The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) for Resident #5 dated 8/19/25 identified a Brief Interview for Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment The document revealed the resident required total staff assistance for toileting hygiene and significant/maximal staff assistance for lower body dressing, sit to stand, chair/bed-to-chair transfer and toilet transfers. The document provided the resident was dependent for manual wheelchair mobility. The document provided the resident's diagnoses included cerebrovascular accident, Non-Alzheimer's Dementia and coronary artery disease. Resident #5's Care Plan printed 9/2/25 contained a focus area related to activities of daily living (ADL) with interventions of toileting with 2 staff assist and transfers with 2 staff assist with total lift using medium (yellow) sling. The document contained an additional focus area of impaired cognitive function/dementia and thought processes. Interventions for this focus area included reduction of distractions by turning off the television, radio, breaking tasks into single components, and providing simple direction sentences. The document contained a focus area of Enhanced Barrier Precautions (EBP) related to a pressure ulcer with interventions of applying/removing gown and gloves while performing high contact areas of transferring, checking and changing.On 9/2/25 at 12:00 PM observed an EBP sign on Resident #5's door, a storage container labeled EBP supplies and a disposal container for used products. On 9/2/25 at 3:15 PM observed Staff A, Certified Nurse Assistant (CNA), complete transfer and toileting tasks with Resident #5. The staff took a dependent mechanical non-weight bearing lift into the resident's room and told the resident she was going to get up, use the bathroom, and get into her wheelchair (w/c). The staff completed hand hygiene, donned gloves and approached the resident who was seated on her recliner. The staff prepared the resident for the transfer and toileting by lowering adaptive pants and placing the sling under the resident. Staff A connected the resident to the dependent lift. The staff then picked up a wash basin that was sitting on an arm chair, took it to the bathroom, and returned with a plastic bag in it. The staff proceeded to lift the resident from the recliner, place the wash basin on the recliner, lowered the resident onto the basin, told the resident she could go potty, and placed her blanket over her lap. While Resident #5 was sitting on the wash basin, the staff obtained peri care supplies and a clean brief. When the resident indicated she was finished, the staff lifted the resident off of the basin, completed peri cares and initiated the clean brief. Staff A proceeded to move the resident using the dependent mechanical non-weight bearing lift to the resident's w/c. The staff lowered the resident onto the w/c and completed the dressing tasks. On 9/2/25 at 12:44 PM Staff E, Clinical Care Coordinator, stated Resident #5 used a sit to stand/weight bearing lift in the bathroom. The staff stated if a dependent mechanical non-weight bearing lift was used with the resident a bedside commode was used. On 9/2/25 at 2:50 PM Staff B, Licensed Practical Nurse (LPN), stated the resident transfers with a dependent non-weight bearing mechanical lift and transfers to a bedside commode for toileting. On 9/2/25 at 3:08 PM Staff A stated the resident used a dependent non-weight bearing mechanical lift for transfers and used a commode pot.On 9/2/25 at 3:30 PM Staff A acknowledged there should have been 2 staff present for the use of the dependent non-weight bearing lift. When asked about EBP, the staff stated she utilized gloves. The staff stated Resident #5 was the only resident who utilized a non-weight bearing lift and completed toileting tasks. The staff stated that's how they had always toileted the resident when using the lift. On 9/3/25 at 8:30 AM Staff F, CNA, stated there should be 2 staff present when operating a dependent non-weight bearing mechanical lift. On 9/3/25 at 9:10 AM Staff G, CNA, stated there should be 2 staff present and engaged to use the dependent non-weight bearing lift. The staff stated the 2 staff work together hooking the sling to the lift, ensuring the loops match on both sides, stop and do a time out to ensure safety, the staff ensure no one turns their back on the resident, and work as a team to move the resident from one location to the next. On 9/2/25 at 3:45 PM the Director of Nursing (DON) stated that staff should utilize PPE as required with EBP for all direct contact cares, including transfers and toileting. The staff expected that 2 staff should be present during the use of non-weight bearing lift and transfers. The staff acknowledged a resident was never left alone when connected to the lift and completing toileting tasks.On 9/2/25 at 4:00 PM the Administrator concurred 2 staff should be used with the use of non-weight bearing mechanical lift. The facility's Safe Resident Handling Program Resource Packet reviewed 7/7/25 included the TIME OUT safety stop while a resident is in a sling and over the surface transferring from to ensure all straps were secure before moving away from the surface. The document further provided that residents who require full weight bearing support the total lift would be used with 2 staff.

Based on observation, interview and record review the facility failed to practice safe transfer techniques for 1 of 3 residents reviewed. On 12/3/24, Staff I transferred Resident #36 to and from the toilet without the use of a gait belt. The facility reported a census of 42 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #36 had a Brief Interview for Mental Status (BIMS) score of 4 (severe cognitive deficit.) He required partial assistance for bed to chair and toilet transfers, and he was occasionally incontinent of urine and always continent of bowel. His diagnoses included, cancer, Anemia, renal insufficiency, Non-Alzheimer's Dementia and anxiety disorder. The care plan updated on 5/3/24, showed that Resident #36 had falls related to poor balance and unsteady gait on 4/18, 5/12, 8/15, 9/11, 9/25 and 9/29. An audio monitor was used to alert staff of any movement for safety. He had limited weight bearing ability due to a right patella fracture, required one person assist with toilet use, transfers and he did not use his call light due to decreased cognitive ability. Staff were directed to use assistive devices with transfers. In an observation on 12/03/24 at 6:57 AM, Staff I, Certified Nurse Aide (CNA), pushed Resident #36 down the hallway and to his restroom in a wheel chair. The resident was very anxious to go the bathroom and as he tried to rise out of the wheel chair, Staff I grabbed onto his right arm and pants to stand him up. When he was done on the toilet, she grabbed his arm and shirt to help him stand. He couldn't bear weight for long and sat down quickly into the wheelchair, on his side with left hip on the seat. The CNA then pushed him out of the bathroom and assisted him to sit up straight in the wheel chair. On 12/05/24 at 6:28 AM, Staff H, CNA, said that the residents have their own gait belts kept in the room or sometimes in the pocket on the back of the wheel chairs. On 12/05/24 at 8:35 AM, The Director of Nursing (DON) said that she expected staff to follow the care plan and know how a resident was to be transferred. She said that staff were taught to use a gait belt with every transfer where a resident required the assistance of staff for transfers and ambulation. According to the facility policy titled: Gait-Transfer Belt, last reviewed on 5/2/24, The purpose of gait belt use was to safely stabilize a transfer, to ambulate with residents and to aid resident in maintaining balance. The gait belts were used with assisted ambulation unless medically contraindicated.

Based on clinical record review, staff interviews, and policy review the facility failed to obtain bed hold notifications for 2 of 2 residents (Residents #3, Resident #20) reviewed. The facility reported a census of 40 residents. Findings Include: 1. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] revealed a most recent reentry date from a short-term general hospital on 5/14/24. Review of Resident #3's Clinical Census in the Electronic Health Record (EHR) provided a Paid Hospital Leave from 5/11/24 to 5/14/24. Review of the Progress Notes in the EHR dated 5/11/24 revealed Resident #3 fell while at home and was transferred to the hospital where she was admitted with a right fractured hip. Review of the Notice of Transfer Form to Long Term Care Ombudsman for 5/24 revealed Resident #3 was transferred to the hospital on 5/11/24. On 12/4/24 at 12:05 PM Staff E, Social Worker, indicated the facility did not have a signed bed hold for the resident. The staff stated she was not present when the resident left the facility for completion of the document. 2. Review of Resident #20's MDS dated [DATE] revealed a most recent reentry date from a short-term general hospital on 10/24/24. Review of Resident #20's Clinical Census in the EHR provided a No Pay Hospital Leave from 10/19/24 to 10/24/24. Review of the Progress Notes in the EHR dated 10/19/24 at 10:43 AM revealed the resident was found on the floor in the living room. The Emergency Management System (EMS) and Primary Care Physician (PCP) were notified and the resident was transferred to the hospital. The resident was admitted with a right hip fracture. Review of the Notice of Transfer Form to Long Term Care Ombudsman for 10/24 revealed Resident #20 was transferred on 10/19/24 to the hospital. On 12/4/24 at 12:05 PM Staff E, Social Worker, indicated the facility did not have a signed bed hold for the resident. The staff stated she was not present when the resident left the facility for completion of the document and a nurse was supposed to complete the document. On 12/4/24 at 2:00 PM the Director of Nursing (DON) stated bed holds were primarily completed by Social Services or other administrative personnel. The DON stated charge nurses have not completed bed holds in the past but could be trained to complete them. When asked about the process after hours, the DON indicated it had been discussed but no clear answer/plan had been developed. The DON acknowledged in both instances a bed hold should have been completed. On 12/4/24 at 2:15 PM the Administrator stated nurses (charge) could likely complete the bed hold forms after hours, and they could contact the Social Worker or other administrative personnel for assistance. The facility provided document, Bed-Hold Policy, reviewed/revised 12/7/23, revealed that the facility is to ensure the resident/resident ' s representative is made aware of the bed hold and reserve bed payment policy before and upon transfer to the hospital. The document further revealed that in the case of an emergency transfer the Notice of Bed-Hold Policy is sent with other papers accompanying the resident to the hospital, and should be provided to a family member/representative within 24 hours of transfer. The policy indicated the document should be mailed if the family member or representative does not come to the facility to receive a copy. The document provided that the charge nurse is responsible for completion of notification procedures if the Social Worker/designee is not available, and the Social Worker/designee will contact the resident/representative regarding the decision for holding a bed.

Based on observation, interview and record review the facility failed to ensure that residents consented to the use of a restraint and obtained a physician's order for the restraint, for 1 of 1 resident reviewed. Resident #33 had a diagnoses of epilepsy and profound intellectual disabilities with limited mobility. Staff were using bilateral foot straps on her wheel chair for safety; they failed to get consent from the family and physician orders. The facility reported a census of 40 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #33 had a Brief Interview for Mental Status (BIMS) score that required staff completion and indicated severe impairment. The resident was totally dependent on staff for transfers, dressing, locomotion, and hygiene. She used a wheelchair for mobility. The MDS indicated that the resident had a trunk restraint used daily on her wheelchair. The MDS did not reference the foot restraints. The Care Plan updated on 6/3/24 showed that Resident #33 had epilepsy with limited mobility, she was chair fast, did not ambulate, and required the use of a dependent non weight bearing mechanical lift for transfers. The document identified a Focus Area of physical restraints in the wheelchair related to epilepsy exhibited by seizure activity. The Interventions for staff guidance included: discussion and recording with the family the risks and benefits of the restraint, application of a seatbelt every time the resident uses the wheelchair and releasing every 2 hours, and monitor/document to the health care provider any changes regarding the effectiveness of the restraint. The Care Plan did not reference the foot restraints. The Physician Orders revealed an order dated 1/10/24 for a seatbelt in current tilt in space wheelchair for safety related to epilepsy. The seatbelt will be released when repositioned in bed every 2 hours. Review of Resident #33's Consent Documents noted a signed consent by the resident's Power of Attorney for the use of a seatbelt on the tilt in space wheelchair. The document did not reflect the use of foot restraints. Observation on 12/2/24 at 12:41 PM revealed Resident #33 positioned in a tilt in space wheelchair with a seatbelt and bilateral foot restraints. Observation on 12/2/24 at 6:33 AM revealed Staff H, Certified Nursing Assistant (CNA), and Staff J, CNA, completing a transfer of Resident #33 from her bed to the tilt in space wheelchair using a dependent mechanical non weight bearing lift. Upon positioning in the wheelchair, Staff H fastened the seatbelt and foot straps. On 12/4/24 at 1:50 PM the Director of Nursing (DON) stated a restraint is considered anything that inhibits any body part from movement. The DON further stated a restraint needs to be released every 2 hours and requires physician orders and consent. On 12/4/24 at 1:54 PM the MDS Coordinator with the DON stated when Resident #33 transferred to the facility from a State Facility the resident had the foot straps and seatbelt in place on the tilt in space wheelchair. The MDS Coordinator stated consent and orders were not obtained for the foot straps upon entry as it was not thought to be a restraint as the resident could not reach her feet. The MDS Coordinator did acknowledge that anything that restricted a resident's movement would be considered a restraint. The DON and MDS Coordinator revealed the foot straps were released every 2 hours with the seat belt as the resident was repositioned from wheelchair to bed every 2 hours. The facility provided document, Restraints - R/S, LTC, Therapy and Rehab Policy, reviewed/revised 10/29/24 revealed a physical restraint is any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily that restricts freedom of movement. Examples of restraints contained in the document included leg or ankle restraints,and waist belt or safety belt if the resident was unable to remove them. The document further revealed the facility should receive consent for the restraint, physician's order, remove every 2 hours, and document in the Care Plan.

Based on clinical record review, staff interview and policy review, the facility failed to provide a resident and family with adequate notification of financial responsibility when Medicare Part A services were scheduled to be discontinued for 1 of 3 residents reviewed (Resident #32). The facility reported a census of 42 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #32 had a Brief Interview for Mental Status (BIMS) score of 1 (severe cognitive deficit.) He had diagnoses that included; cancer, anemia, renal insufficiency and Cerebrovascular Accident (CVA). The Care Plan updated on 2/8/24, showed that Resident #32 had self-care performance deficits related to acute transverse myelitis in demyelinating disease of the central nervous system. He required one staff assistance with ambulation, toileting and transfers. According to the census tab in the electronic record, on 9/16/24 Resident #32 qualified for Medicare A services and on 9/24/24, he was self pay. The chart lacked a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055. On 12/03/24 at 1:17 PM, the Social Worker (SW) said that therapy services had initiated the paperwork to discharge Resident #32 from Medicare Part A. The resident was not cognitive enough to participate or make decisions. The SW was unable to locate a 10055 form and did not see where the information had been offered or signed by the family. According to the facility policy, dated 2/14/23, titled: Advance Beneficiary Notice of Non-Coverage (ABN). The advance Beneficiary Notice of Noncoverage informs the beneficiary of potential none-coverage and shift of financial liability for those items or services, if Medicare denied the claim. The Medicare Administrative Contractor may hold any provider financially liable who either failed to give notice when required or gave an valid notice. The ABN must be issued prior to delivery of the service in question. The provider must allow enough time for the beneficiary to make an informed decision on whether or not to receive the service in question and accept potential financial liability.

Based on observation, resident and family interviews, staff interviews and record review the facility failed to treat each resident with respect and dignity during care for 1 of 1 resident reviewed. Resident #8 reported that a staff member refused to put him to bed until he went to the bathroom, then she tried to pry his hand off of the mechanical lift. The facility reported a census of 42 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #8 was admitted to the facility on [DATE]. He had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) Resident #8 did not exhibit verbal or physical behavioral symptoms toward others nor did he reject care from staff. The resident required substantial assistance with toileting, lower body dressing, showers, sit to stand, and toilet transfers. His diagnoses included; lymphedema, muscle weakness, need for assistance with personal care, depression and chronic pain. The Care Plan for Resident #8, updated on 4/26/24, showed that he had a communication problem related to a hearing deficit, staff were to turn off the television during cares and speak clearly and slowly. Resident #8 had impaired mobility, was unable to ambulate and required extensive assistance for toilet use. Staff transferred him with the use of a mechanical lift; Sit to Stand, at times, he was able to pivot transfer to and from the toilet and wheelchair. The resident had bladder incontinence, chronic pain and he was on diuretic therapy related to edema. On 12/02/24 at 12:13 PM, observed Resident #8 sitting in a wheel chair in his room watching television. He was wearing shorts, and was found to have swelling in his legs and feet. When asked if the staff were treating him respectfully, Resident #8 said that there was just one staff member that he'd had trouble with. I needed to go to the bathroom. He went on to said that he put his call light one evening around 6:30 and when he didn't get help, he transferred himself from the wheel chair to the toilet. Later that evening, when he was ready to go to bed, he put his call light on again and Staff G brought the mechanical lift, Sit to Stand in the room. She told him she wouldn't transfer him to bed until he first went to the bathroom. She tried to pull my arm off the lift, and argued that she was not going to transfer him to bed until he went to the bathroom. The resident said that he needed to put his feet up because he had a lot of swelling and he just wanted to be put in bed. Resident #8 was holding onto the arms of the Sit to Stand machine and Staff G tried to get his hand off by prying and pulling on his fingers. The resident said that Staff G got on the walkie and asked for help. Soon after, another aide came into the room and put him in bed. He said that the Administrator, and the DON failed to come and talk to him about the allegations. On 12/02/24 at 12:51 PM, a family member (FM) for Resident #8 said that the resident told her that he thought his rights had been violated. He told her that on the evening of 11/8/24 he put his call light on at around 6:30 PM. Staff G came in and said that it would be a while before she could help him and then left the room. He took himself to the bathroom and then put the light back on when he was ready to go to bed. Staff G came back into the room around 7:45 PM and said that she wanted him to go to the bathroom first, and would not transfer him until he went to bathroom. The FM said that Resident #8 told her, she tried to pull his hands off the lift. The FM wrote up a grievance on 11/9 and called the facility on 11/11 to tell the Social Worker (SW) that she did not want Staff G to take care of the Resident #8 until the incident had been investigated. She found out on 11/13 that Staff G had been in his room on 11/12. The FM said that she did not get a call back from the facility or talk to the DON or Administrator about the incident until about a week later. On 12/3/24 at 10:10 AM, Staff C Licensed Practical Nurse (LPN) said that she was the nurse working the evening of 11/8/24. She said that she gave Resident #8 his medications earlier that evening and there wasn't anything unusual about him at that time. Around bedtime, Staff D came and told her that Resident #8 and Staff G weren't getting a long, so she put the resident to bed herself. She hadn't learned about the details of the incident until the following day from the FM. A couple of days later, she had gone into the resident's room and talked to Resident #8 and the FM and they described what happened. The FM said that it seemed that the administration wasn't doing anything about it and Staff G hadn't been suspended. Staff C said that she had not been interviewed by Administrator or the DON about the events of that evening. On 12/03/24 at 12:22 PM, Staff D, CNA was getting ready to leave for supper break on the evening of 11/8/24 when she got a message on the Walkie-Talkie that Staff G needed assistance in the room for Resident #8. Staff D said that she went to the resident's room could tell there was tension. Usually, Resident #8 would be friendly and talkative but he was upset, and his facial expressions showed he was angry. Staff D asked what was going on and Staff G responded that Resident #8 was being difficult and rude. The resident did not say anything. She asked Staff G to leave the room and continued with his care, and asked him if everything was okay. Staff D said that he did not want to talk about it. The Sit to Stand was in front of the resident who was sitting in his wheel chair. His feet were on the lift, and the sling was hooked up to the machine. She said that she asked him if he needed to use the bathroom and he responded that he had gone earlier and just wanted to get into bed. The resident didn't need anything else. he goes to restroom every couple of hours. Staff D said that neither the DON nor the Administrator interviewed her related to this incident. On 12/03/24 at 2:38 PM, the DON said that she learned about the incident between Resident #8 and Staff G the following day, 11/9/24. The resident didn't have any marks on his hands and arms and Staff G didn't work with him over that weekend so she dealt with it on Monday, 11/11/24. She said that she trusted the nurses on duty and none of them expressed concerns of suspected abuse. The DON maintained that she had interviewed Staff C and Staff D and she did not report the incident to the state authorities or complete an incident report because the resident did not have any marks, and they didn't believe that it rose to the level of abuse. On 12/3/24 at 5:02 PM, the DON said they did not talk to the resident about the incident, but had relied on the Social Worker to complete an interview and had assumed that she had. She said that she hadn't talked to Resident #8 specifically about the interactions with Staff G, but the resident was not shy about coming to them with concerns. On 12/04/24 at 8:08 AM, the Social Worker (SW) said that she was responsible for resident grievances. She said that the department heads along with DON and Administrator determined if/when the issues had been resolved. She said that it was over the weekend that the FM for Resident #8 completed a grievance so she dealt with it on the following Monday (11/11/24). The SW acknowledged that she hadn't actually talked to the FM, and didn't talk to Resident #8 about the situation until 11/19/24 at which time he said that it was just a moment of frustration. The SW said that she gave the grievance to the DON, and then Staff G had been interviewed by the DON. On 12/04/24 at 9:21 AM, Staff A RN, said that the FM for Resident #8 told her about an incident the previous evening and she directed her to fill out the grievance form. Staff A and Staff F were in the Resident's room providing care while the FM discussed the detailed with the resident. Staff A said she didn't see any marks on the resident's hands or arms. The resident said that he just wanted to go to bed and didn't need to use the restroom. The resident told Staff A that she grabbed his arm and forcefully pulled his hand off the lift. On 12/04/24 at 9:51 AM, Staff F, Registered Nurse (RN), said that she provided care to Resident #8 on the morning of 11/9/24. The FM was in with the resident and she and Staff A, RN came in the middle of the conversation. They talked about an incident that happened the night before and the FM was examining the resident's hands. Staff F also looked over his hands and didn't see any marks or bruises. The resident said that Staff G wanted him to go to the bathroom and he had already gone. Staff G got upset and left. He did mention she had walked by the room a couple of times while his call light was on. Watched her walk by the room. He said she forcefully moved his hand off the sit and stand and he thought there were scratches. Staff F said that the resident was grumpy that morning because he hadn't slept well. The FM said she was going to talk to the DON and SW about the details. Staff F said that she did not get interviewed by the DON or Administrator regarding this situation. The backside of the grievance form also included a second, hand-written note, dated 11/11/24, signed by the DON. The note indicated that the DON spoke to Staff G, and the CNA admitted that on the evening of 11/8, Resident #8 wanted to go to bed but she tried to get him to go to the bathroom so he wouldn't need to get up shortly thereafter. He told her that he already went to the bathroom and he just wanted to get into bed. They argued a little and he told Staff G to get the nurse. She called for help and tried to remove the lift from the room but the resident held on to the lift. She told him she couldn't leave it in the room for safety reasons and tried to remove his left hand, with no luck, then tried to remove the other. A second CNA came into the room and took over the cares. The DON discussed with Staff G that she should not have tried to pry his hand off of the lift. Staff G agreed that she would refrain from providing cares to resident #8, unless necessary. According to a Grievance Log summary that included a list of resident grievances, on 11/9/24 the grievance for Resident #8 concerning CNA problems had been resolved. According to a form titled: Suggestion or Concern, dated 6/19/24. Resident #8 reported to a family member that the evening before, he put on his call light to get assistance to the bathroom and Staff G wanted him to use the urinal. The resident did not like to use the urinal because he was concerned that he would make a mess in the chair. He was able to get assistance from a different staff member.

Based on record review, facility investigative file review, surveillance footage, resident and staff interview and policy review the facility failed to ensure 1 of 3 resident (Resident #1) was free from abuse. The facility reported a census of 37 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool, with a reference date of 7/2/24, documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 11. A BIMS score of 11 suggested moderate cognitive impairment. The MDS documented Resident #1 displayed no physical, verbal or other behavioral symptoms during the review period. The MDS indicated he had bilateral upper and lower extremity impairment on both sides and utilized a wheelchair. The MDS documented the following diagnoses for Resident #1: hypertension, renal failure, obstructive uropathy, stroke, hemiplegia, depression, and spinal stenosis. The Care Plan focus area with a revision date of 7/26/2023 documented Resident #1 had an activities of daily living (ADLs) self-care performance deficit related to impaired mobility. The care plan documented Resident #1 required the assistance of one staff for bathing. A second Care Plan focus area with a revision date of 7/18/2023 documented the resident had behavior symptoms related to anger and frustration as evidenced by pinching and attempting to hit staff during cares. The care plan instructed staff to: intervene as necessary to protect the rights and safety of others and staff are to approach/speak in a calm manner. A third Care Plan focus area with a revision date of 10/16/2023 documented the resident is resistive to care related to adjustment to the nursing home as evidenced by refusal of cares, eating, treatments, and bathing at times. The care plan instructed staff to leave and return 5-10 minutes later and try again if the resident is resistant with ADLs. The following Progress Notes documented the following: - 8/27/24 at 11:38 AM called the Primary Care Provider (PCP) to report possible abuse. Described new physical injuries, see Skin Assessment. Resident is reporting pain, especially to his 5th finger on left hand. When asked how he obtained injuries the resident stated, she hit me! Active bleeding to small lacerations under both eyes was stopped with light pressure. The primary care provider (PCP) gave order to send Resident #1 to the emergency room (ER) for evaluation. - 8/27/24 at 4:09 PM the ER nurse called with report. Diagnostic studies were performed including CT scan of his c-spine, CT scan of his head, chest x-ray and x-ray of his left hand. There were no acute fractures noted. Resident returned to the facility via facility vehicle with transport staff at 3:20 PM. - 8/28/24 at 3:21 PM resident denies any pain this shift. Resident out for all meals, good appetite. Resident pleasant mood today and no behaviors noted. - 8/29/24 at 2:08 AM resident cooperative with cares. Voiced no complaints of pain or discomfort at this time. Call light is in reach but resident chooses to tap chew can on bedside table when needing assistance. Resident was in a good mood. - 8/30/24 at 1:43 PM resident chooses to stay in his room for breakfast. Stated that he was tired and was being lazy. Resident denied any pain or discomfort this shift. He did get up for lunch and came out to the dining room. No negative behaviors noted. The following Skin Assessments documented the following: - 8/22/24 no skin conditions observed/skin condition resolved. - 8/27/24 at 10:22 AM skin observations noted: face: 3 centimeter (cm) x 2.5 cm abrasion under R eye with 1 cm x 0.1 cm shallow laceration. Slight amount of bleeding noted. Face: 1 cm x 0.1 cm shallow laceration noted to under L eye. Scant amount of bright red blood noted. Other: 5th finger on left hand and all joints very swollen and painful for Resident. Purple bruising noted to entire finger up to proximal joint. Chest: 8.5 cm x 4 cm area of bruising to L chest. Within area is 5 cm x 4 cm yellow fading bruising, and 3.5 cm x 4 cm bright purple bruising with marked swelling, warmth, and tenderness. Comments: Resident sent to ER for evaluation and treatment, per PCP. Family notified via phone. - 8/29/24 skin observations noted: face: abrasion under right eye measuring 0.8 cm x 1.0 cm. Face: abrasion under left eye measuring 1.0 cm x 0.1 cm. Chest: Yellowish bruising measuring 7 cm x 4.5 cm. Other: dark purple bruise on left 5th finger and knuckles measuring 7 cm x 6 cm - 9/5/24 skin observations noted: face: abrasion under right eye is resolved. Only small area of pink new skin remains where abrasion was. Face: abrasion under left eye is resolved, with the exception of a 0.1 cm x 0.1 cm dark red scab area where abrasion was is pink in color and shiny. Chest: yellow/green bruising remains to left chest. Swelling and heat has resolved. Other: 5th digit on left hand remains edematous but much less than previous assessment. Knuckle is most swollen and painful. 3rd, 4th, and 5th digit have yellow/green bruising in healing stages. Left hand is contracted. - 9.12.24 skin check completed-no skin conditions observed/skin condition resolved. Bruises on chest and hand have resolved. - 9.19.24 skin check completed-no skin conditions observed/skin condition resolved. Review of the resident's clinical record revealed a hospital document titled Physician Clinical Report with an arrival date and time of 8/27/2024 at 12:03 PM. The report documented a chief complaint of reported physical abuse. Location of injuries-face and left hand and left ring finger. This occurred just prior to arrival. Occurred at a nursing home. He has dementia at baseline by reportedly went into the shower with an aid and came out with new bruises, telling staff that the aid hit him while in the shower. He does not give much detail to physician during exam. He only answers yes and no questions and is confused with orientation questions. This was reported to be baseline. Noted to have a scratch to the left side of his nose, with mild swelling over the bridge of his nose, new bruising to his chest, left hand, and elbow. He reports pain with palpitation of the bridge of his nose and hand. He had a previous stroke and has contractures of the left hand and elbow. Wheelchair bound and use of a mechanical lift to get up. Physical exam: extremities- left elbow small abrasion with controlled bleeding and bruising. Left forearm medium sized bruising. Left little finger: moderate tenderness and swelling and medium sized ecchymosis. Eyes: right periorbital area: small ecchymosis (small scabbed abrasion to upper check). Ears, Nose Throat (ENT): left ear small abrasion behind the ear. Nose: mild tenderness and swelling and small abrasion with controlled bleeding. Neurologic: altered mental status: confused (at baseline mental status per nursing home). Chest x-ray: no trauma. Left hand x-ray: no trauma. Head CT: no trauma. C-Spine CT: no trauma. The facility provided the following statements from their investigation: - On 8/27/24 Staff B Certified Nursing Assistant (CNA) wrote while she was walking up Hall 300 to the dining room to assist with breakfast, she heard from the shower room Resident #1 yell you're hurting me, followed by Staff A CNA saying I am just washing our f****** face. Resident #1 was known to yell out frequently and would say you are hurting me when touched. Staff B did not think anything of it until the resident was brought to the breakfast table by Staff A. His face was swollen and discolored around his nose, eyes and a sore under his right and left eyes. Blood seemed to be draining from the area between his eyes and nose. Staff B then immediately reported to the Staff C Registered Nurse (RN) charge nurse and the MDS Coordinator. Her hand-written statement was signed and dated 8/27/24. - On 8/27/24 the MDS Coordinator typed Staff B CNA came to her and reported that she had heard Staff A in the bathhouse with Resident #1. Staff B reported she heard Resident #1 state stop you are hurting me. Staff A then stated to Resident #1 I am just washing your face. Resident #1 stated again stop it you are hurting me. Staff A stated I am just washing your f****** face. Staff A came out of the bathhouse with the resident and took him to the dining room for breakfast. The MDS Coordinator went to assess the situation and observed Resident #1 at the dining room table. His face and eyes were red. He had a small area on the left side of his nose/eye area with small amount of blood on it. The MDS Coordinator took Resident #1 into the family room and asked him about his bath and the situation that had just occurred. Resident #1 stated to her that Staff A was washing his face too hard and asked her to stop but she didn't stop. He stated she was too rough even though he asked her a couple times to stop. Staff A told him I am just washing your f****** face. The MDS Coordinator asked Resident #1 if he was harmed in any other way or was hurting, he denied any other pain and stated she is always rough when she moves me. He did not visibly have any other signs of injuries so she asked Staff C to complete a head to toe assessment then he was taken to his room by Staff C for that assessment. Staff A was in the dining room at this time with another CNA assisting residents with breakfast. The MDS Coordinator asked Staff A not to start any further baths and that the Director of Nursing (DON) will be here in a few minutes to speak with her. Prior to this she had notified the DON and Administrator of the potential abuse situation. The MDS Coordinator signed and dated the typed statement on 8/27/24. - On 8/27/24 Resident #1 was interviewed. What happened in the bath today? Resident #1 stated she washed my face too hard and wouldn't stop. Did Staff A hit you? Resident #1 said no. Did the girl that gave you a bath hit you. Resident #1 said no. Did Staff A pinch you? Resident #1 said no. Did Staff A put your head in the water? Resident #1 said no. Did Staff A push you? Resident #1 said no. Did Staff A harm or hurt you in any other way? Resident #1 stated she was always rough when she moved him. How is she rough? Resident #1 stated she doesn't listen. Are you hurting anywhere? Resident #1 stated no. Do you need to go to the hospital? Resident #1 stated no reason to. Do you feel safe? Resident #1 stated yes. - On 8/27/24 Staff A wrote she was giving Resident #1 his bath. As she was undressing him he asked her over and over what are you doing and to stop it. Staff A kept explaining she was giving him a shower. She turned on the water and grabbed a wash rag to wash his face. As she was doing that he was grabbing my arm saying what are you doing. She explained she was washing his face trying to get the dry boogers out of his eyes. He kept saying what are you doing, that hurt, pounding on the shower chair and grabbing her. She hurried and finished the shower, got him dressed and took him out to breakfast. She signed her statement. - During resident interviews the following residents stated: Resident #4 was asked how staff treat her and she stated good except Staff A. Review of Staff A's employee file revealed the following disciplinary actions: - 5/1/24 discussed tone of voice and approach to residents - 5/14/24 discussed approaching residents differently and/or having another aide to bath specific resident. - 6/1/24 had discussion with charge nurse at nurse's station. Witnesses stated both were unprofessional. - 6/4/24 the DON and MDS Coordinator sat down with Staff A to discuss recent complaints from residents, staff and family members. Staff A admitted to having a bipolar disorder and that since she is currently taking fertility drugs, she hasn't been great about taking her medications. She also reported not always being aware of her tone, she has difficulty recognizing when she needs to watch her tone. She agreed to be receptive to coaching from her co-workers when they recognize an increase in her stress level affect her tone of voice. - 6/30/24 heated discussion at nurse's station with charge nurse. Witnesses stated that the charge nurse did not de-escalate the situation, but seemed to escalate it when Staff A was trying to calm down after being asked to by the other charge nurse. - 7/25/24 heated discussion at nurse's station with charge nurse regarding Staff A's care given to charge nurse's mother who is a resident. Several residents complain that she is rude and hurried while giving them their baths. Discussion: Staff A was calm and receptive to concerns voiced regarding tone of voice (rudeness), making the residents feel as if she did not want to take care of them and altercations that continue with her charge nurses at the nurse's station in front of residents and families. She stated that she has not been getting much sleep lately and could see why she appears to not want to be here or to take care of the residents. We revisited the discussion about not making the residents feel rushed while she is doing their cares. Regarding the heated discussions with the charge nurse, the DON instructed her that from now on if she believes the discussion is going to be heated, if she cannot walk away, please take it away from the nurse's station to be in private. The DON asked her to repeat what we discussed and she was able to state watch my tone, slow down and take it away from the station. Staff A stated that she felt like she is not doing anything right and so she just does not say anything at all. The DON informed Staff A she would be submitting a formal verbal warning regarding performance/behavior. She acknowledged understanding. Expectations: to slow down with resident cares, choose words wisely and walk away if things begin to escalate at the nurse's station or in front of residents/families. With all of the discussions they have had with Staff A since hire, she has shown improvement, but continues to require guidance. - On 8/27/24 an employee overheard a resident yelling from the shower room you are hurting me. This employee stated it is not unusual for that resident to yell during his cares. That employee then heard Staff A yell I am just washing your f****** face. When the resident came out of the shower, this employee noted that the resident's face was swollen and discolored around his eyes and near left eye appeared to have some blood draining. The CNA reported this and Staff A was suspended. The resident was questioned after he came out of the shower about this and confirmed Staff A provided rough care in the shower. The resident was sent out for evaluation due to some concerns about his finger as well. Staff A denied that she said the word f****** to the resident but states the resident was asking her over and over what she was doing, he was pounding on the shower chair saying that hurts and she had to keep explaining that she was giving him a shower. We have been addressing on-going behavior concerns with Staff A for concerns with her attitude toward staff and her approach with residents. As a result of these on-going concerns and this egregious concern with resident care, we have made the decision to end Staff A's employment, effective immediately. On 9/20/24 at 1:26 PM reviewed the facility's security camera footage from 8/27/24 with the DON. The footage revealed at 6:34 AM Staff A walked out of Resident #1's room with wheelchair and clothes on it. She walked up the hall to smaller that led to the 300 hall (per the DON) to the bath house. Per the DON there is not camera footage from the 300 hall. At 6:38 AM Staff A went back to Resident #1's room with a mechanical lift and exited the room with Resident #1 in the wheelchair at 6:46 AM. Staff A then propelled the resident up the 200 hall to the adjoining hall that led to the 300 hall. No other staff members were observed to enter or exit the resident's room other than Staff A between 6:34 AM and 6:46 AM. At 7:03 AM Staff A assisted Resident #1 out of the 300 hall by the nurse's station and to the dining room table with peers and Staff B present. Unable to see Resident #'1 face clearly on the video footage. On 9/20/24 at 10:36 AM Resident #1 was observed to be sitting in his recliner watching television. Noted a bruise to his left hand between his index finger and thumb. The bruise was deep purple/maroon in color. No skin issues noted to his face or under his eyes. Resident #1 agreed to speak with surveyor and for his door to be shut. He then offered a chair to sit on. Resident #1 stated he had breakfast and it was pretty good. When asked what happened a few weeks ago while he was receiving a bath he stated he fell . When asked how that happened he stated the floor was wet. When asked if he had any injuries from that fall he stated his ribs hurt but that was it. Eye contact was made during this part of the conversation. When asked what else happened in the bath house he stated nothing. When asked how the staff are with him during his baths he stated fine. He was asked if anyone was ever rough with you during your bath he stated no. When asked how are staff are when they are washing his face he stated he had no concerns. When asked if staff had ever washed his face in a rough manner he stated no and denied staff being rough during his bath. Resident #1 was asked if anyone had ever hurt him in any way, he stated no. When Resident #1 was informed of bruising and open areas to his face documentation in his file from last month, he stated he did not know what happened. Resident also denied knowing why he had bruising on his chest and hands. During this part of the conversation he made no eye contact with me. When asked how things were going here at the facility and he stated it's very peaceful here. When asked if he wanted to talk about anything else he stated no. Resident #1 was thanked for his time and to have a great day. On 9/20/24 at 12:34 PM the MDS Coordinator stated Staff B came to her about what she heard in the bath house. She heard Resident #1 say you are hurting me and Staff A said I am washing your face. Resident #1 said it again and Staff A said I am just washing your f****** face. Staff B had asked her to come look at Resident #1 because she was concerned about his face. When she went to the dining room, Staff A was assisting other residents with their meal with other staff members present. When she saw Resident #1, she asked Staff A which baths she had left. She wanted to get a game plan on how to talk with her because Staff A has a history of blowing up when confronted. So she told Staff A the DON wanted to speak with her before she completed more baths. She asked Staff B not to leave the area where Staff A was at. The MDS Coordinator did not want Staff A blowing up in front of residents so she made sure Staff B knew to basically supervise her until they figured out a plan. She then called the DON and Administrator to come in. When she went back to the dining room, Resident #1 was done eating so she pulled him into the conference room, closed the door and talked with her for a bit. About the same time the DON had arrived and had Staff A at the front of the building. When asked what happened-he said she was washing his face too hard and could not breath. She noticed a scratch on his face, when asked if he scratched himself he stated she washed my face too hard. Resident #1 said Staff A was rough with him. He denied other physical occurrences while she was washing his face The MDS Coordinator also noted his eyes were reddened, blood shot. But did not see other injuries because the DON and Administrator had arrived and Staff C had completed the head to toe assessment upon request. She has been with Staff A when she has assisted Resident #1 before. He is contracted and would say he was in pain while assisting him and he would yell. She also has had to sit in while the DON talked with her before about concerns and she would do good after speaking with her. She never thought Staff A would be mean with residents as she seemed to care about them. She had been educated previously on slowing down with residents. Staff A did tell them she has mental health issues and stopped taking her medications because she is currently doing fertility injections. When asked how Staff A was as an employee she indicated she can be loud and boisterous. Resident #1's behaviors can be combative at times; swat at staff, nice out of nowhere then back to pinching staff out of the blue. The MDS Coordinator indicated Staff A had told her she gets overstimulated and is task oriented, so what she thinks happened was Resident #1 was saying stop you are hurting me. Staff A may not have understood what she was doing and just wanted to get his eye burgers out, not realizing he has sensitive skin. The MDS Coordinator indicated she has sat in when Staff A would be educated on not rushing residents, slowing down with them. Staff A would be remorseful when spoken to. She did call in a lot, would pick up extra shifts and stay over to help. On 9/20/24 at 1:07 PM Staff C RN stated she was told by Staff B she walked by the bath house and heard Resident #1 yelling. Staff B stated she then heard Staff A tell Resident #1 to shut up, I am trying to wash your f****** face. When he came to the dining room Staff C noticed he had two black eyes, cuts under his eyes, with brand new bruising on his chest, and the left side of his hand was swollen. Resident #1's pinky on his left hand was 3 times bigger than normal and had bruising originating at the joint. She completed a full head to toe assessment to make sure she saw everything. When she asked happened he stated she hit me then five seconds later he could not remember what happened. But that was normal for him. He was sent to the ER for a full evaluation and they noted no broken bones. Staff C indicated she had given him his medications prior to his bath and did not notice these injuries at that time. When asked about Staff A as an employee, she stated she is very loud, can be disrespectful with other residents. Staff C stated she reported these concerns before. Staff A would yell at residents, was always on her phone when giving baths or supposed to be doing other things. When assisting residents, she would yell at them to hurry up, or would not pay attention at all. When asked to describe his behaviors she stated he would pinch or hit staff's butt, yell a lot. When asked how Resident #1 has been since this she stated good, appears much happier now since she is gone, coming out of his room more often. On 9/20/24 at 1:37 PM Staff B CNA stated she was working on the 300 hall that day. She indicated that is where the bath house is located. When she walked by the bath house she heard Resident #1 tell Staff A to stop hurting my face. Then she heard Staff A say I am just washing your f****** face. Staff B reported the resident tends to yell in pain so she did not think anything of it. She continued to go to the dining room to assist residents with their breakfast. When Staff A brought Resident #1 to the dining room table where those that need assistance sat, she thought his nose looked crooked so she called another staff member over to look. Staff C came over and Staff B stated below his eye was bleeding and under both of his eyes the skin appeared dark in color and puffy. Staff B went and got the MDS Coordinator because it looked like someone punched him in the face. She came to the dining room and took over after that. Staff B indicated the corner of his left eye was rubbed raw with blood in the corner of it. Both of his eyes were dark and puffy. When asked if the resident said anything to her she stated no. When asked how he was while in the dining room during his breakfast she stated he seemed ok but was more shaky than normal. He ate his breakfast then they sent him to the hospital to be evaluated. When she left at 2:00 PM he was still gone. Since then he appears to be fine and never said anything to her about Staff A or that day. When asked how Staff A was as an employee she stated she is rude and acts like she does not care, rough around the edges type of person. She had never witnessed her being rough with residents but were times where she was in a hurry and rushing with residents. When asked if Resident #1 had any behaviors she stated he was not good at expressing himself without yelling out. When she has assisted with his baths he would grab her hair, with cares assist he would smack at them. But if you talk him through what is going on he would stop. Residents have reported to her that Staff A was rude and acted like she did not care. Staff B stated she has noticed other residents appear happier since Staff A was let go. On 9/24/24 at 10:39 AM Staff A CNA stated she was completing Resident #1's shower and he became very combative: hitting, screaming, and pinching her. So, she rushed through his shower to get him out and to breakfast. He had a bunch of gunk in his eyes that she was trying to get out. As she was rubbing his eyes, he was hitting her, she acknowledged to being overstimulated at that point in time. Staff A admitted she rubbed his eyes with the washcloth too rough and she feels really bad about it. She indicated the bruising to his chest and fingers were there before the bath. When asked if she had told anyone about the bruising on his chest and fingers she stated she let Staff C know about it when she brought him to the dining room that morning. Staff A also stated she told the DON during her interview about the bruising on his chest and finger, during her interview. She brought him to the dining room for breakfast she saw a little mark on the side of his nose, she knew she rubbed too hard to get the gunk out of his eyes. When asked what staff are to do when he has these behaviors she stated she would report them the nurses were supposed to do behavior charting but not sure if they were. She added staff just dealt with Resident #1's behaviors. When explained to her his care plan advised staff to step away from 5-10 minutes she indicated she did not know that. She indicated she would normally step out to get another aide but did not do that, that day because everyone was busy. She denied using foul language with Resident #1 or any resident for that fact. Staff A stated at the time of this incident she was taking a lot of fertility treatments and would get overwhelmed. Staff A also stated she has Polycystic Ovarian Syndrome (PCOS), with the extra hormones, plus anxiety/depression medications, it all made her overstimulated and overwhelmed. Staff A stated she did not mean to hurt him at all, she feels really bad. She stated she again was just overwhelmed/overstimulated that day. When asked what time she gave Resident #1 his bath she stated he was usually done first thing in the morning, so about 6:30 AM-7:00 AM (ish). She indicated Staff D CNA had assisted her with his transfer from his bed to the wheelchair that morning. Staff A acknowledged she had been talked to about rushing prior to this incident. Before she started working at the facility she had worked for a facility that was very short staffed, so she was used to rushing to get things done. She indicated she never stepped back and just relaxed while working at this facility. Staff A admitted to becoming overwhelmed at work and would go speak with the DON about it for guidance and she would tell her to breath. On 9/24/24 at 10:46 AM Resident #2 was sitting in her room working on a diamond art photo. Resident #2 was asked how staff are with her and she stated better now that one is gone. When asked what was going on she stated Staff A would put her socks on and was very rough about it. When Resident #2 would ask her to stop she would not. Resident #2 stated her feet are very tender/sensitive but Staff A would not listen when she asked her to stop. Resident #2 also would not help her when she wanted to move about in her room. She indicated she required assistance of staff when moving out of her chair/bed and with walking. Staff A stood in the doorway while she tried to get up but would not come to help her. Resident #2 indicated she told Staff A she needed help and her doctor had filled out paperwork that stated this. Resident #2 also stated she was using the restroom before she had to leave the facility for an appointment. She activated her bathroom light and could hear Staff A talking outside of her room but would not come in to assist her off the toilet and assist her with getting ready for her appointment. Resident #2's daughter came in for her appointment and had to assist her off the toilet to get ready for the appointment. They ended up being late that day. When Staff A came in to Resident #2's room the next day, she asked Staff A why she did not help her when she heard her talking outside of her room, Staff A did not say anything. Resident #2 indicated she has not had further issues since Staff A was let go. On 9/24/24 at 1:55 PM the DON stated when she got here Resident #1 was out of the dining room. She indicated staff made a comment that Resident #1's nose was cricked so she pulled up his picture from his Electronic Health Record (EHR) and his nose was cricked in the picture as well. She did not notice any redness or bruising when she arrived. The ended up sending him to the ER because of other bruising that was noted during his head to toe assessment. She let Staff A know she was suspended pending investigation. She did not talk to Resident #1, the MDS Coordinator interviewed him. When they spoke to Staff A about the incident with Resident #1 Staff A stated she did not want to hurt him. She was washing his face and he was not letting her do so. Staff A stated she honestly did not see him bleeding. When asked what happened to his left pinky Staff A did not say anything to that. Staff A told them she was overstimulated that day. The DON indicated they had previously provided education to Staff A before and wanted to believe in her that things would change. The told her she needed to slow down with residents and ask for help. They had formally completed did some disciplinary actions for her attendance, behavior and performance. The DON was asked if Staff D was working that day, she indicated she was scheduled to work but called in. The DON stated Staff A never reported that Resident #1 had bruising to his chest that day. If he was having behaviors during his bath, she should have stepped away from the situation and asked for help. The facility provided a document titled Abuse and Neglect with a revision date of 7/22/24 documented the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies service the individual, family members or legal guardians, friends or other individuals. The resident has the right to be free from abuse. The facility provided a document titled Resident-Dignity with a revision date of 11/16/2023 documented the purpose of the policy was to maintain the dignity of all residents and to assist with respecting and ensuring resident rights. The location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Ideas for maintaining a resident's dignity may include, but not be limited to: a. Grooming residents as they wish to be groomed f. Treating residents with respect

Based on employee file review, facility policy review, and staff interviews the facility failed to provide in-service training to nurse aides at least 12 hours yearly. The facility reported a census of 39 residents. Finding include: Review of a document titled Completion Report for Staff C revealed only 9.92 hours of training had been completed in the last 12 months. On 9/14/23 at 8:27 AM Staff D stated the facility's expectation is that the end of the month report was sent by September 1st with the employee that needed to complete training. Staff D stated she emails the facility's exception report to the DON, and the Administrator. Staff D stated an exception report was emailed on September 1st to the facility with the number of hours that needed completed by all employees. On 9/14/23 at 9:24 AM the Administrator stated all employees are responsible to complete training. The Administrator stated emails are sent to employees with needs to complete hours. The Administrator stated he tried to follow up with those who are behind in the needed training hours. The Administrator stated computers are available all the time for the employees to use. The Administrator stated the facility's expectation is that all employees complete the required 12 hours of training yearly. Review of policy titled Competency and Mandatory Education Requirements revised 5/22/23 revealed that [NAME] is responsible to provide processes for ongoing education and competency achievement. Employees are responsible to attain and maintain competency and complete mandatory education required within their specific job description. [NAME] requires organizational mandatory education. Additional mandatory education may be required at the department/clinic or the specific job level.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food and failed to maintain essential kitchen equipment. The facility reported a census of 39 residents. Findings include: During an initial kitchen observation on 9/11/23 at 8:50 AM, the following findings were identified. a) An accessed, undated carton of Orange Juice. b) An accessed, undated half-gallon of chocolate milk. c) An accessed, undated carton of Apple Juice thickener. d) An unlabeled, small, pink pitcher containing white liquid. e) An opened bag inside an opened box of fish strips. During a follow-up kitchen observation on 9/12/23 at 7:45 AM, the pink pitcher of white liquid was still in the refrigerator with no label. On 9/12/23 at 8:00 AM, the Dietary Manager (DM) stated all stored food should be sealed or closed and dated. A policy titled Food-Supply Storage- Food and Nutrition Services revised 5/11/23 indicated foods that have been opened or prepared were to be placed in an enclosed container, dated, labeled and stored properly. During a dishwashing observation on 9/12/23 at 9:38 AM, the temperatures of the heat sanitation dishwasher were 148 degrees during the wash cycle and 176 degrees during the rinse cycle. On 9/13/23 at 12:11 PM, the dishwashing machine representative stated the manufacturer's specifications required two (2) wash and rinse pre-cycles before dishes were washed. He stated the wash cycle temperature was set at 140 degrees and the rinse cycle temperature was set at 180 degrees. An excerpt from the dishwashing machine representative's sales support indicated the manufacturer recommended three (3) warm-up cycles as part of a typical daily start-up to ensure all of the cold water was out of the equipment system. On 9/14/23 at 8:45 AM, the DM stated the expectation was the dishwasher temperatures should meet the 150 degree wash cycle and 180 degree rinse cycle requirements.

Based on observation, clinical record review, facility policy review, and staff interviews the facility failed to provide replacement tracheostomy device for emergent unplanned extubation for 1 of 1 residents reviewed (Resident #141). The facility reported a census of 39 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #141 documented a Brief Interview of Mental Status (BIMS) of 13 out of 15 indicating no cognitive impairment. The MDS documented diagnoses of acquired absence of larynx. On 9/11/23 at 1:39 PM an observation in Resident #141's room revealed no emergency tracheostomy equipment present. On 9/13/23 at 2:36 PM Staff A stated there was not an emergency tracheostomy appliance available in Resident #141's room. Staff A stated she did not know where another appliance would be located to reinsert if needed. On 9/13/23 at 2:38 PM Staff B stated there was no emergency trach appliance present in Resident 141's bedroom. Staff B stated the facility's expectation is that there would be an emergency trach appliance available in Resident #141's room. Review of policy titled Tracheostomy, Suctioning, Dressing Change and Reinsertion of Tube revealed decannulation is an emergency situation. The Tracheostomy tube must be reinserted quickly to maintain a patent airway. A licensed nurse who has undergone training or a respiratory care practitioner performs this procedure.

Based on clinical record review, facility policy review, and staff interviews the facility failed to implement gradual dose reductions (GDR) instead continued psychotropic medications without review and failed to ensure as needed (PRN) orders for psychotropic medications did not exceed 14 days without physician review for 3 of 5 residents reviewed (Resident #10, #11, and #31). The facility reported a census of 39 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #10 documented a Brief Interview of Mental Status (BIMS) of 15 out of 15 indicating no cognitive impairment. The MDS documented diagnoses to include generalized anxiety and depression. Review of document titled Consultant Pharmacist's Medication Regimen Review (MRR) dated 4/25/23 for Resident #10 revealed a request for mandated dosage decrease attempt on the orders of Alprazolam 0.5mg TID, Mirtazapine 7.5 mg at bedtime, and Sertraline 50mg at bedtime. Review of document titled Note To Attending Physician/Prescriber for Resident #10 related to the 4/25/23 MRR revealed the physician response portion was incomplete. Review of Resident #10's electronic health records (EHR) for the month of April revealed orders for Alprazolam 0.5mg TID, Mirtazapine 7.5 mg at bedtime, and Sertraline 50mg at bedtime. Review of Resident #10's electronic health records (EHR) for the month of May revealed orders for Alprazolam 0.5mg TID, Mirtazapine increased to 15 mg at bedtime on 5/26/23, and Sertraline 50mg at bedtime. On 9/13/23 at 9:15 AM Staff B stated April's GDR for Resident #31 was sent by the pharmacy. Staff B stated the physician did not return a fax. Staff B stated she was not sure the fax was sent to the physician. Staff B stated all faxes should be sent to the physician in a timely manner. Staff B stated not sure about the time frame for refaxing the order recommendations but initial fax should have been sent that day. Staff B stated the clipboard has hall one and hall two. Staff B stated it is the facility's expectation that nurses should be going through faxes every couple days and refaxed recommendations that were not returned. 2. The MDS dated [DATE] for Resident #31 documented a BIMS of 4 out of 15 indicating severe cognitive impairment. The MDS documented diagnosis of schizoaffective disorder, depression, anxiety, mood disorder, and dementia. Review of a document titled Consultant Pharmacist's Medication Regimen Review dated 8/19/23 for Resident #31 revealed a request for mandated dosage decrease attempt on the orders of Seroquel 25 mg BID, Trazadone 50 mg BID, and Buspirone 15 mg TID. Review of document titled Note To Attending Physician/Prescriber for Resident #31 related to the 8/19/23 MRR revealed the physician response portion was incomplete. Review of Resident #31's electronic health records (EHR) revealed current orders for Seroquel 25 mg BID, Trazadone 50 mg BID, and Buspirone 15 mg TID. On 9/13/23 at 9:45 AM Staff B stated she was unaware if August's GDR recommendations were sent. Staff B stated facility's expectation is that GDR recommendations for August would have been sent by 9/13/23. Staff B stated the clipboard with documents that have been faxed that are awaiting return fax had no documents from August GDR recommendations. Staff B stated the facility's expectation is that a response to GDR recommendations from 8/19/23 would have been received prior to 9/13/23. Staff B stated GDR recommendations for Resident #31 were refaxed 9/13/23. Staff B stated she could not find a returned fax with physicians response to recommendations. Review of policy titled Medication Drug Regimen Review (DRR) revised 2/10/23 revealed The pharmacist will complete a written report noting any drug irregularities or issues of concern for each resident reviewed. The pharmacist will also complete the Medication Regimen Review Summary for the QAPI Committee document. Both reports will be given to the director of nursing services upon completion of each monthly DRR. The reports must be shared with the attending physician and the location ' s medical director, and these reports must be acted upon. 47079 3. A review of Resident #11's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 06 out of 15, indicating severe cognitive impairment. The MDS also included diagnoses of Non-Alzheimer's dementia and Bipolar disorder. It revealed the resident had hallucinations and received antipsychotic medications within the 7-day look-back period. The Care Plan for Resident #11 initiated 6/5/23 indicated the resident was on antipsychotic medication related to the Bipolar disorder and directed staff to administer the medication as ordered by the primary care physician. On 9/11/23 at 11:36 AM, a review of the resident #11's electronic health record (EHR) revealed an active order dated 6/7/23 for Seroquel (an antipsychotic medication) one (1) tablet by mouth every 8 hours as needed (PRN) for agitation or aggression with no end date. On 9/12/23 at 11:07 AM, a review of Resident #11's Progress Notes revealed the Pharmacist consultant documented recommendations for the PRN antipsychotic medications on 6/23/23, 7/20/23, and 8/18/23. The progress notes also revealed no contact attempts to the primary care physician were documented by the facility staff. On 9/13/23 at 4:29 PM, a review of documents for Resident #11 titled Consultant Pharmacist's Medication Regimen Review dated 6/23/23, 7/20/23, and 8/18/23 indicated the consultant pharmacist noted the 14-day limitation for PRN antipsychotic medications and recommended the physician either discontinue the medication or provide documentation every 14 days to support the continued use. On 9/13/23 at 4:51 PM, a document titled Note to Attending Physician/Prescriber dated 6/23/23 for Resident #11 indicated no response or signature from the physician. Resident #11's Medication Administration Record for June, July, August, and September revealed the PRN antipsychotic medication was administered on 6/8/23, 6/11/23, 6/13/23, 7/14/23, 7/15/23, 7/17/23, 8/14/23, 9/1/23, and 9/6/23. On 9/14/23 at 9:30 AM, the MDS Coordinator, acting on behalf of the Director of Nursing (DON) stated the pharmacist's antipsychotic medication recommendations should be faxed to the physician every 24 hours. The physician should have been called when no response was received after the second fax was sent. A document titled Medication: Drug Regimen Review revised 2/10/23 indicated the pharmacist's monthly Medication Regimen Review (MRR) must be shared with the DON and drug irregularities were to be reported to the medical director and attending physician by the director of nursing services or designee.

Based on clinical record review and staff interviews the facility failed to follow the comprehensive care plan for 1 of 3 residents reviewed (#1). The facility reported a census of 27 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 6/28/21, Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had severely impaired cognitive skills. The MDS also documented she required total assist of 2 staff for bed mobility, transfers, dressing, bathing and toilet use. The Care Plan revised 7/1/21 documented Resident #1 had a nutritional problem related to variable meal intakes and dementia and directed staff on 12/3/20 to weigh the resident weekly. The Weights and Vitals Summary for Resident #1 documented staff obtained weights on 12/3/20, 3/3/21, 4/6/21, 5/1/21, 6/2/21 and 7/3/21 only. During an interview with the Director of Nursing on 7/20/21 at 2:45 PM, she stated that if the care plan directs staff to weigh a resident weekly then staff should do that.

Based on clinical record review, staff and resident interviews, the facility failed to provide baths in accordance with resident preferences for 2 of 3 residents reviewed (Resident #1 and #2). The facility reported a census of 27 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 6/28/21 Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident displayed severely impaired cognitive skills. The MDS also documented she required total assist of 2 staff for bed mobility, transfers, dressing, bathing, and toilet use. The Care Plan revised 7/6/21 documented Resident #1 indicated demonstrated an activities of daily living (ADL) self-care deficit related to dementia and revealed the resident dependent on staff for bathing needs. The care plan lacked any interventions related to bathing frequency. The Bathing Documentation Report revealed Resident #1 did not have a bath or shower the week of 6/20/21 or 6/27/21. During an interview with the Director of Nursing on 7/20/21 at 2:45 PM she stated the facility had been short of staff leading to holes in the staff bathing schedule. She added she expected staff to provide baths for the residents 1-2 times per week, but she knows that had not always occurred. 2. According to the quarterly Minimum Data Set (MDS) assessment tool dated 4/8/21 Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 out of 15 on the Brief Interview of Mental Status indicating she is cognitively intact. The MDS also documented she required total assist of 2 staff for transfers, is not able to walk, and requires extensive assist of 2 staff for dressing, hygiene, toileting and bathing. The Care Plan with the revision date 6/10/21 documented Resident #2 has an ADL self-care deficit related to [CONDITION(S)] with left sided weakness. It listed an intervention that the resident is dependent on staff to provide a bath twice a week and as necessary. The Bathing Documentation Report revealed Resident #2 did not have a bath the week of 6/27/21 and went up to 13 days without a whirlpool or shower. During an interview on 7/20/21 at 3:30 PM with Resident #2 she stated there have been 1-2 week gaps recently where she has not gotten a bath.

Based on clinical record review, facility policy review, observation, and interview, the facility failed to adequately supervise and develop and implement interventions to prevent a fall with injury for 1 of 1 residents reviewed with a fall resulting in a major injury (Resident #140). The facility reported a census of 40 residents. Findings: 1. The MDS (Minimum Data Set) assessment tool, dated 10/3/18, listed [DIAGNOSES REDACTED]. (causing tremors and an unsteady gait), and [MEDICAL CONDITION] polyarthropathy (which caused pain in multiple joints). The resident required the limited assistance of 1 staff for walking and extensive assistance of 1 staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The resident had unsteady balance and could stabilize with staff assistance when moving from a seated to standing position, walking, turning around, moving on and off the toilet, and transferring between the bed and chair or wheelchair. The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 15 out of 15, indicating intact memory and cognition. A 7/3/18 annual Fall Tool assessment recorded Resident #140 had a medium risk for falls. An Incident Report dated 1/1/18 at 10:00 a.m. documented staff found the resident sitting on the bathroom floor and he stated he tried to get onto the toilet but was unable to make it so he lowered himself to the floor. A 1/5/18 6:50 p.m. Incident Report documented the resident's wife reported Resident #140 was on the floor and very confused all evening about the time and surroundings. The wife stated the resident leaned forward and slid out of the wheelchair onto the floor. The Incident Report dated 1/26/18 at 7:10 p.m. recorded the resident's wife reported the resident was on the floor and staff found him on his knees with blood on the floor. Resident #140 hit the side of his face on the bedside table and also hit his back and ear; he sustained a small laceration under the earlobe and bruises on the face and did not call for help. The Incident Report of 1/29/18 at 3:22 p.m. documented Resident #140's wife reported he fell during a home visit when he tried to get into bed by himself. The resident did not receive an injury. A 3/18/18 3:18 p.m. Incident Report documented the resident's wife reported he fell outside. Resident #140 stated he opened the door of his car, the wind caught his hat, he tried to pick it up and fell from the car seat and hit his head on the car door and then the ground. The resident sustained [REDACTED]. The Incident Report dated 3/29/18 4:21 p.m. recorded staff found the resident sitting on the floor. The resident stated he tried to transfer himself from the bed to the chair but could not make it. A 4/3/18 4:45 p.m. Incident Report documented the resident's wife reported he slipped out of the wheelchair onto the floor. The resident stated he wanted to get into bed to take a nap. A 5/18/18 4:08 p.m. Incident Report documented staff found Resident #140 sitting half on, half off the recliner. The resident informed staff he did not fall; he was trying to reach his call light. Staff recorded it looked like the resident self-transferred after using the bathroom. Progress Notes documented the following information: a. 6/6/18 12:38 p.m. - Resident #140 was noncompliant with use of the call light. At 3:21 p.m., he got up without calling for help and required assistance of 1 staff for transfers. b. 6/29/18 9:35 a.m. - The resident continued to self-transfer. c. 7/3/18 1:41 p.m. - The resident stated he knew he broke the rules by not using the call light and self-transferring. d. 7/11/18 10:36 p.m. - Staff found the resident up walking from the chair to the bed behind his wheelchair. e. 8/22/18 5:25 p.m. - The resident continued to transfer himself without help even after staff reminded him to call for help. f. 9/19/18 5:11 p.m. - The resident was noncompliant with calling for help. Staff found him up walking. He is able to make his wishes known. g. 10/2/18 10:37 a.m. - Resident #140 still self-transferred in his room therefore did not meet this goal. The facility continued educating the resident and his family and stated this was the primary intervention. h. 10/3/18 5:41 p.m. - The resident was forgetful and needed reminders to call for help with transfers; he did not comply with call light use. An Incident Report dated 10/9/18 7:30 a.m. documented Resident #140 reported he fell last night and got up himself. The resident had a light purple bruise on the left hip measuring approximately 4.2 centimeters (cm) and could not move the left lower extremity fully. The facility sent the resident to the hospital. Progress notes documented he left the facility at 12:22 p.m. A 10/9/18 3:20 p.m. radiology report documented a CT (Computerized Tomography, or type of X-ray) scan revealed a [MEDICAL CONDITION]'s left greater trochante r(an upper portion of the thigh bone). A 10/9/18 4:15 p.m. hospital report stated the resident admitted to the emergency room from the nursing home with uncontrollable left hip pain. The report stated the resident reported he possibly fell recently and a CT scan revealed a [MEDICAL CONDITION]. The report stated the physician admitted the resident for the night to obtain pain control and stated the resident received [MEDICATION NAME] (a narcotic used to control pain). A Progress Noted dated 10/9/18 at 4:28 p.m. recorded Resident #140's wife reported the hospital admitted him due to a [MEDICAL CONDITION]. The resident returned to the facility on [DATE] at 3:53 p.m. Progress Notes continued as follows: a. 10/12/18 at 5:04 a.m. - Resident #140 had increased confusion. b. 10/14/18 at 2:00 p.m. - Resident #140 remained confused. c. 10/15/18 at 10:10 a.m. - Resident #140 was more delusional over the weekend. d. 10/10/18 at 11:16 a.m. - The resident admitted to Hospice services. An Incident Report dated 10/13/18 incident report stated staff found the resident sitting on the floor. The resident stated he slid out of bed reaching for a snack. The resident's care plan documented the following interventions: a. 7/3/17 - Resident #140 and his spouse were non-compliant with asking or waiting for assistance with transfers. b. 7/3/17 - Staff will provide activities that promoted exercise and strength building when possible. c. 7/5/17 - The resident's bed should remain in the lowest position. d. 7/14/17 - He had impaired cognitive function/dementia and poor safety awareness and would be safe by not self-transferring. e. 8/17/17 - Staff to educate/instruct the resident and family to not self-transfer. f. 1/9/18 - Ensure the resident's clothing was not too loose or long. g. 1/4/18 - Establish a toileting plan based on the resident's needs. h. 1/29/18 - Staff should monitor the resident for significant changes in gait, mobility, positioning, standing/sitting balance, and lower extremity joint function. i. 4/2/18 - Staff to utilize an audio monitor in the room to alert staff to any movement for fall prevention. j. 10/15/18 - Place a fall mat beside the resident's bed. The care plan lacked any further interventions implemented during the period of 4/3/18 - 10/13/18 which related to the circumstances following the resident's falls to prevent him from having further falls. The facility policy Fall Prevention and Management, revised 10/2017, instructed the facility would identify risk factors and implement interventions before a fall occurred and prevent further injury. On 3/5/19 at 10:22 a.m., Staff A LPN (Licensed Practical Nurse) stated at times the resident was more with it than at other times. He was at times confused and thought he could get up on his own. The facility had an audio monitor in his room but he would be quiet when he got up and staff wouldn't hear him. She stated the receiving end of the audio monitor was located at the nursing station so if staff weren't at the desk, they wouldn't hear it. She stated during the night he sometimes was not oriented and wouldn't be cognitively stable enough to push the call light. During an interview on 3/5/19 at 10:57 a.m., Staff B CNA (Certified Nursing Assistant) stated she observed the resident up in his room alone and on one occasion he was up rearranging the furniture and as she opened the door he fell . During an interview on 3/5/19 at 12:31 p.m., Staff C LPN stated the resident was non-compliant with using the call light and she saw him up alone moving his furniture around. She stated his cognition would be OK one minute but not OK the next. She stated the morning they discovered his fracture, he told her he fell but no staff observed a fall. On 3/5/19 at 2:02 p.m., Staff E CNA stated the resident self-transferred so they reiterated to him to use the call light. During an interview on 3/5/19 at 2:23 p.m., Staff F LPN stated the resident was non-compliant with his transfers. She stated the facility implemented a fall mat after the resident had the fall with the fracture. She stated after the fracture when the resident returned to the facility he was in a lot of pain. He slowly stopped eating and drinking as well. She stated he went through a similar period after a previous fall when he sustained a hematoma but eventually came out of that decline. During an interview on 3/5/19 at 2:32 p.m., Staff D CNA stated the resident got up on his own without calling for help. She stated they had an audio monitor staff could hear if they were close to the nursing station. On 3/5/19 at 2:51 p.m., the DON (Director of Nursing) stated Resident #140 was very non-compliant and it was a constant battle. The facility carried out constant education regarding the self-transfers. The facility should place a new intervention on the care plan after each fall and she would search for additional interventions to provide the survey team. During an interview on 3/6/19 at 8:19 a.m., the Administrator stated the resident was a frequent fall risk and the facility carried out education with him at various times. He stated they tried to think of creative ways to prevent him from falling. He stated the falls at night were difficult and the facility did a few things but they could not restrain him and stated that was the only way they could have kept him from falling. During an interview/observation on 3/6/19 at 11:11 a.m., the Administrator showed the surveyor which room Resident #140 occupied at the time he sustained the fracture. The room was located towards the end of the hallway, the third room furthest from the nursing station. Three resident rooms, a linen closet, a soiled utility, and a bathroom were located on the hall between the resident's room and the nursing station.

Based on clinical record review, observations and staff, family and resident interviews, the facility failed to adequately supervise Resident #1 to ensure against hazards from self and the health service supervisor failed to adequately revise the written care plan to meet the needs of the resident. The sample consisted of 4 residents and the facility identified a census of 40 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 7/31/2012 identified [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of one staff person for bed mobility, transfers, ambulating in the halls, toileting and supervision/set up help for, eating, and personal hygiene. The MDS revealed the Brief Interview for Mental Status (BIMS) score of 7. A score of 0-7 identified severely impaired cognitive status. The MDS reflected the resident as incontinent of bowel/ bladder. The assessment revealed no major injuries. The same MDS revealed Resident #1 received antipsychotic medications on a daily basis, placing the resident at significant risk of falling. The Resident Care Plan dated 5/30/2012 and revised on 7/23/12 recorded Resident #1 had a problem of mobility related to ataxia, blindness in his/her right eye and a history of falls while at home. The approaches directed staff to transfer and stand by assistance of one staff person for safety, personal alarm to the resident's bed and wheelchair. The Care Plan indicated the alarm box was changed to make it more difficult for the resident to reach and turn the alarm off. The Care Plan reflected the resident required ambulation assistance of 1 to 2 staff and used a wheeled walker prior to the fall on 7/19/12. After the fall, the Care Plan directed staff to transfer the resident using the mechanical lift/total body lift. Keep the bed in its lowest position when the resident is in the bed and non-skid strips placed on the floor next to the bed and in front of the toilet. The Care Plan did not include interventions to address risk factors related to blindness in the right eye. The care plan documented that following falls on 2/24/12 and 4/22/12 the approaches directed staff to re-educate the resident to use the call light, lock the wheelchair brakes and request help for transfers. The Care Plan revealed severely impaired cognition making it difficult for the resident to follow directions when re-educated with call lights, using the chair brakes or remembering to request help. Review of the Incident Details report dated 2/24/12 at 12:20 AM identified the alarm had sounded, the staff found the resident on the floor next to the bed, barefoot and an abrasion/scab found on the left elbow. The staff instructed the resident about the use of the call light and to ask for assistance. Review of the Incident Details report dated 3/1/12 at 7:10 PM revealed the staff found the resident on the floor. The alarm had sounded. The report documented the resident stated he/she tripped on the wheelchair pedals when going to the toilet. The staff removed the wheelchair pedals for safety. Review of the Incident Details report dated 4/4/12 at 8:00 AM revealed the staff found the resident on the bathroom floor, lying on back. The report documented the resident turned the alarm off on the wheelchair and took self to the toilet and fell while trying to pull up pants and lost his/her balance. The approach to reduce a risk for reoccurrence indicated the facility changed the alarm to a box alarm with a switch on the bottom of the box to deter the resident from shutting the alarm off. Review of the Incident Details report dated 4/22/12 at 1:15 PM revealed Resident #1 as found on the floor on buttocks by the bathroom door. The personal alarm did sound, no injury revealed on document. Staff instructed to re-educate to the resident on the importance of locking h/her wheelchair brakes and to ask for assistance for safety. Resident #1 severely cognitively impaired. Review of the Incident Details report dated 7/19/12 at 1:15 PM revealed Resident #1 found on the floor in his/her room, lying on right side and with knees bent. The resident's personal alarm system did not sound; the resident had rubber soles on feet and no apparent unsafe conditions. Staff documented the resident went to the emergency room and the report instructed staff not to leave the resident in the restroom unattended. Review of the History and Physical dated 7/19/12 revealed past medical history of [REDACTED]. The Diagnostic Radiology Report dated 7/19/12 documented the resident had a displaced comminuted intertrochanteric fracture of the right femur (thigh bone) and a chest x-ray revealed multiple healing rib fractures on the left side. On 8/7/12 at 11:20 AM, observation revealed the resident in bed. Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA assisted the resident into the mechanical lift sling and transferred the resident into the wheelchair. On 8/9/12 at 1:30 PM, the MDS Coordinator was interviewed and stated she has had so many interventions in her head and it ' s hard sometimes to come up with something that will work for that person. The MDS Coordinator stated she had just been told last week to individualize the care plans more. On 8/9/12 at 3:40 PM, the room mate of Resident #1 was interviewed and stated he/she called for help when Resident #1 fell on the floor when coming out of the restroom. The roommate stated staff had just been in the room and assisted the roommate to the restroom. The roommate further stated the alarm had not sounded. On 8/13/12 at 1:02 PM, the resident's spouse stated the facility told her/him they had taken Resident #1 to the restroom, put the resident on the toilet, left alone and he/she fell when left alone. The spouse stated the resident would do that at home as well, when she/he cared for the resident. At times, the resident's leg would not move and other days the resident would do fine. On 8/13/12 at 1:35 PM, the Director of Nursing (DON) was interviewed and stated the staff hadn't identified interventions specific to blindness but had been serving the resident's meals to the left side, kept his/her wheelchair away and against the wall, kept a nightlight on and kept the room clutter free. On 8/13/12 at 1:15 PM, Staff E, Registered Nurse (RN) was interviewed and stated she worked the day Resident #1 fell and she sent the resident to the emergency room . Staff E stated she found the resident on the floor on the right side. She stated she thought an aide helped the resident to the restroom but it had been awhile and she could not be sure. Staff E stated she had caught the resident removing the alarm earlier that day and the resident had a history of [REDACTED]. At that time, the resident's roommate came up the hall and informed Staff E and Staff C, at the nurse's station. .