Every finding on record at H & J Vonderlieth LVG CTR, The

Based on observation, interview, and record review the facility failed to ensure injectable medications for two residents (R1 and R38) were labeled and dated when opened, and failed to ensure a multidose tuberculin vial was discarded after the expiration date when opened. These failures have the potential to affect all 55 residents residing in the facility.Findings include: The Storage of Medication Policy dated [DATE] documents Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Expiration Dating G. All expired medication will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. The Insulin Storage Chart printed [DATE] documents Generic Name: Insulin Glargine, Stability: Room Temp for 28 days, Insulin Lispro Vial, Cartridge, Pen: 28 days Pump Reservoir: 6 (six) days. Vaccines - Tuberculin PPD (Purified Protein Derivative), Expiration Notes Refrigerate, discard 30 days after opening. The Tuberculin Multi-Dose Vial Label documents Discard opened product after 30 days.The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated [DATE] and signed by V1 (Administrator) documents 55 residents currently reside within the facility. R1's Order Summary Report, dated [DATE], documents R1 has a Physician order to receive Insulin Lispro100 unit/ml (milliliter) inject as per sliding scale subcutaneously before meals related to Type Two Diabetes Mellitus.R38's Order Summary Report, dated [DATE], documents R38 has a Physician order to receive Lantus 100 unit/ml inject 30 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus with Hyperglycemia.On [DATE] at 11:09 AM V5 (Licensed Practical Nurse) was standing at the medication cart. V5 opened the top left drawer of the medication cart where resident's opened insulin injector-pens were stored. In this drawer R1's Insulin Lispro 100unit/ml multi-dose pen was opened (3/4 full) and undated and R38's Lantus 100 unit/ml multi-dose pen was opened (1/2 full) and undated. V5 verified at this time R1 and R38's injector pens were not labeled with an open date and were only good for 28 days after opening and at room temperature. V5 stated all opened multi-dose insulin pen injectors should be labeled with an open date after opening.On [DATE] at 11:17 AM V5 opened the refrigerator located in the north medication room. Two vials of Aplisol (Tuberculin) 5TU (Tuberculin Units) 0.1 ml were in the medication room refrigerator. Both (Tuberculin) vials were opened, 1/4 full, and was labeled with an open date of [DATE]. V5 verified the (Tuberculin) vials were opened and dated with an open date of [DATE] and stated, The (Tuberculin) is used for all residents residing in the facility. (Tuberculin) should be discarded after 30 days of opening. Both (Tuberculin) vials are expired.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and surgical wounds for six of six residents (R2, R8, R9, R18, R26, and R31) reviewed for EBP in the sample of 45. Findings include: The Enhanced Barrier Precaution Protocol dated 4/8/24 documents Enhanced Barrier Precautions (EBP) expands the use of Personal Protective Equipment (PPE) beyond situations in which exposer to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug-Resistant Organisms (MDROs) to staff hands and clothing. If Enhanced Barrier Precautions are required, a sign should be placed outside the resident's room to assist in educating staff, residents, and visitors on appropriate personal protection. When required, Enhanced Barrier Precautions apply to everyone caring for the resident. Personal Protective Equipment PPE (e.g. (example), gloves and gowns) should be used during high-contact resident care activities. Examples of high-contact resident care activities requiring gown and glove use include Dressing, Bathing/showering, Transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and or/wound care: any skin opening requiring a dressing. Enhanced Barrier Precautions May Be Indicated for Residents with Any of The Following: Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., (adhesive covering) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.The CDC (Centers for Disease Control) and Prevention Enhanced Barrier Precautions sign, provided by the facility, documents Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, and/or Wound Care: any skin opening requiring a dressing.The facility's Weekly Pressure Wound Report dated 12/8/25 documents that R8 has a stage two pressure wound to her coccyx that requires a dressing. The facility's Non-Pressure Wound Report dated 12/8/25 documents that R2, R9, and R26 have Moisture Associated Skin Damage/MASD, R18 has three surgical wounds, and R31 has Vascular wounds. All these wounds require a dressing. On 12/10/25 at 10:50 AM, V10 (Infection Preventionist) stated that there are five residents in EBP. They all have an indwelling catheter. There are residents in the facility that have wounds but none of these residents are in EBP. Residents that have wounds do not require EBP unless the wounds are infected or not healing. On 12/10/25 at 11:25 AM, V11 (Certified Nursing Assistant/CNA) and V12 (CNA) provided incontinent care for R8 and did not wear a gown. R8 has a stage two pressure wound to her coccyx. V11 stated that EBP was not required while caring for R8. On 12/10/25 at 11:30 AM, V9 (Registered Nurse) provided pressure ulcer treatment to R8's coccyx and did not wear a gown. V9 stated that EBP is not required for R8's pressure ulcer because it is not a stage three or four, not infected, and is not nonhealing. On 12/10/25 at 11:40 AM, a tour of the building was done. During this tour R2, R8, R9, R18, R26, and R31's doors did not have signs indicating they were in Enhanced Barrier Precautions. On 12/10/25 at 11:50 PM V2 (Director of Nursing/DON) stated that R2, R8, R9, R26, and R31 have open wounds that are getting a dressing. R18 has surgical wounds. None of these residents are in EBP and EBP is not required for any of these residents. EBP is only required for wounds that are infected or non-healing. On 12/10/25 at 12:42 PM, V2 (DON) stated that she was not aware that EBP was required for any skin opening that required a dressing. V2 also stated after reading the policy and the sign that is to be posted on the door that EBP should be worn when providing care for residents with wounds.

Based on observation, interview, and record review the facility failed to ensure a resident who has a diagnosis of dementia was kept free from chemical restraints for one resident (R2) of six residents reviewed for antipsychotic medications in a sample of 45. Findings Include:The facility's Abuse policy dated 8/25/25 documents All residents have the right to be free of from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. This includes but is not limited to freedom from corporal punishment, and involuntary seclusion and physical or chemical restraints not required to treat the resident's symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time with ongoing re-evaluation and documentation of the need for restraints (42CFR483.12 (a) (2).The facility's Psychotropic Medication policy dated 7/14/25 documents Intent: residents are free from unnecessary psychotropic medication use. Psychotropic medication is any drug that affects brain activity associated with mental processes and behavior. These medications include but are not limited to, medication in the following categories: 1) Antianxiety, 2) Antidepressant, 3) Antipsychotic, 4) Hypnotic. These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the clinical record. Residents should only remain on psychotropic medications when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinically contraindicated. Additionally, medication should only be used to treat resident's medical symptoms and not used for discipline or staff convenience. B) Other indications for use: 1) Acute or Emergency Situations: a) When a psychotropic medication is being initiated or used to treat an emergency situation (i.e., acute onset or exacerbation of symptoms or immediate threat to health or safety of resident or others). Is related to a documented condition or diagnosis. 2) Enduring conditions: Psychotropic medication may be used to treat enduring, (i.e. (example), non-acute, chronic, or prolonged) condition. a) Symptoms and therapeutic goals must be identified and documented. b) Must ensure that the expressions or indications of distress are: Not due to medical condition or problem, not due to environmental stressors, not due to staff convenience, not due to psychological stressors. D) Dose, Duration, monitoring 4) Duplicated therapy is generally not indicated, unless current clinical standards of practice and documented clinical rational confirm the benefits of multiple medications from the same class or with similar therapeutic effects. 5) Documentation is necessary to clarify the rationale for each medication and the approach to monitor the benefits and any adverse consequences.R2's Care Plan dated 11/4/2025 documents R2 has medical diagnoses of Dementia, Anxiety, and Major Depressive Disorder.R2's Physician's order sheet dated 12/9/2025 documents, Olanzapine (antipsychotic medication) intramuscular solution reconstituted/5 mg (milligrams) every eight hours as needed, Olanzapine (antipsychotic medication) oral tablet/5 mg every eight hours as needed, Rexulti (antipsychotic) oral tablet/1 mg at bedtime, Valium (benzodiazepine medication) oral tablet/5mg four times daily, Hydroxyzine (antihistamine medication) HCI (hydrochloride) oral tablet/25 mg three times daily, Lithium Carbonate (mood stabilizer medication) oral tablet/150 mg at bedtime, and Depakote Sprinkles (anticonvulsant/mood stabilizer medication) delayed release oral tablet/125 mg four times daily.R2's POC (Point of Care) Transfer Chair/bed-to-chair status documentation dated 11/11/2025-12/10/2025 documents, R2 required substantial/maximal assistance from 11/11-11/17. This same sheet documents from 11/18-11/30 R2 began requiring full assistance with transfers and from 11/30-12/10, R2 was dependent with all transfers. R2's Progress note dated 11/9/2025 at 1:24 PM documents, Resident rude and condescending to writer at both med passes this shift. Resident attempting to throw herself out of her wheelchair after lunch in order to get put to bed sooner. Resident now resting in bed.R2's Progress note dated 11/9/2025 at 2:08 PM documents, Resident continues to yell out, curse out staff, and yell that she is calling the police and for people to get out of her house, even though nobody is in her room. PRN Olanzapine administered at this time. Resident continues to curse at writer. Resident's sitter arrived at facility at this time.R2's Progress note dated 11/9/2025 at 2:35 PM documents, PRN (as needed) Administration of Olanzapine 5 mg (milligrams) IM (intramuscular) was: Effective. Resident eventually stopped yelling and cursing at staff.R2's Progress note dated 11/11/2025 at 3:58 PM documents, Screaming you f---ing b.h several times. Trying to get out of bed.R2's Progress note dated 11/11/2025 at 7:10 PM documents, PRN Administration of Olanzapine 5 mg (milligrams) IM (intramuscular) was: Effective.R2's Progress note dated 11/12/2025 at 3:03 AM documents, Resident yelling, being disruptive and attempting to hit staff while staff provides care.R2's Progress note dated 11/12/2025 at 3:41 AM documents, PRN Administration of Olanzapine 5 mg (milligrams) IM (intramuscular) was: Effective.R2's Progress note dated 11/14/2025 at 3:40 PM documents, Hollering out at every person walking by room telling them to Get the F*** out of here. Non-pharm interventions: Staff attempted to approach and redirect, resident screamed for them to get the f*** out. Staff left room but was outside room to monitor her safety while resident continued to yell within room at no one in particular. She hollered for V13 (R2's Family Member) to get the f*** in here and take me out. Where the f*** are you V13, I know you are here. Staff attempted to redirect her and to reassure her that V13 is not here and that we could get her up and take her out of her room to confirm that she is not there. Resident refused and continued to holler out.R2's Progress note dated 11/14/2025 at 3:57 PM documents, PRN Administration of Olanzapine 5 mg (milligrams) IM (intramuscular) was: Effective.R2's Progress note dated 11/18/2025 at 5:26 PM documents, Cursing at others in the dining room, cursing at writer and calling staff the C word. Mocking writer when talking to other residents.R2's Progress note dated 11/18/2025 at 7:24 PM documents, PRN Administration of Olanzapine 5 mg (milligrams) IM (intramuscular) was: Effective.On 12/9/2025 at 10:30 AM, V6 (Certified Nurse Assistant) stated R2's behaviors are typically yelling, and screaming when she is upset and is typically in the afternoons after 2 PM. V6 also stated R2 is not physically abusive towards residents, R2 has seemed very drowsy these last few weeks and went from being a two person assist for transfers to a mechanical lift. V6 stated R2 can be redirected most of the time and stated she feels that R2 has the most verbal outbursts when she is bored or when she can hear people talking in the hallways. V6 stated R2 is not a danger to herself or other residents. On 12/9/2025 at 10:45 AM, V7 (Registered Nurse) stated R2's behaviors are typically screaming and yelling curse words towards staff members when it is time for cares. V7 stated R2 can be physical towards staff but only during cares when she is in a frustrated and confused state of mind. V7 stated R2 is not a harm to herself or other residents. V7 stated R2 is typically very pleasant and fun to talk to, and is easily redirected at times, but it depends on how you approach R2. On 12/9/2025 at 2:00 PM, R2 was in her room, in her bed laying, dressed and on her back. R2 appeared lethargic with her eyes hardly open. R2 stated she looks and feels tired all the time. R2 stated I want to live at home. On 12/9/2025 at 2:00 PM, V8 (Certified Nurse Assistant) stated R2 recently had a Urinary Tract Infection and V8 felt that R2 had more outburst than usual. V8 also stated sometimes R2 can be redirected by going to a different area, or by the fish or the birds. V8 stated R2 typically will be screaming and cussing and calling names towards staff, and that R2 typically does not yell at residents. V8 confirmed R2 is not a danger to herself or to other residents. On 12/10/2025 at 9:30 AM, V13 (R2's Family Member) stated she has been called by facility staff that R2 yells out for her, then R2 will become frustrated and starts cussing and screaming towards staff. V13 stated when she came to visit R2 on 11/25/2025 that R2 was very lethargic and was slouching over in her wheelchair and could not sit up or stay awake. V13 stated she is worried about all R2's psychotropic medications and feels that R2 does not need all of them.On 12/10/2025 at 10:50 AM, R2 was in her room, in her bed, dressed and laying on her back. R2 appeared lethargic and had her eyes closed. R2 would hardly open her eyes. R2 stated I do not want to be here. R2 stated she has no trouble with the staff here but does not want to live here. R2 stated she has felt weaker lately and cannot get up. On 12/10/2025 at 10:45 AM, V14 (Certified Nurse Assistant) stated R2 typically blurts out, cusses, screams, and that is how R2 shows her frustration. V14 stated R2 is not usually physical towards staff. V14 states most of R2's behaviors start after 2PM. V14 stated R2 has recently went from being a two person assist to a mechanical lift. V14 stated R2 is not a harm to herself or other residents. On 12/10/2025 at 11:24 AM, V2 (Director of Nursing) confirmed R2 does not have a diagnosis to warrant her antipsychotic medications. V2 stated R2 is not at risk for hurting other residents and she is on duplicate antipsychotic medication therapy. On 12/10/2025 at 1:41 PM, V18 (Physician) confirmed R2's Depakote, Olanzapine, Rexulti, Valium, and Lithium could be contributing to her lethargic appearance and decline in ability to transfer. V18 also confirmed that R2 receiving multiple Olanzapine injections on an as needed bases are too frequent, and her psychotropic medications should be reviewed.On 12/11/2025 at 11:24 AM V17 (V18's Certified Medical Assistant) stated V18 is aware of R2's psychotropic medications and he believes her behaviors are related to R2's dementia.

Based on observation, record review and interview, the facility failed to give medications as ordered by the physician for three of 15 residents (R22, R23 and R44) reviewed for medication pass in the sample of 45. This failure resulted in three errors out of twenty-six opportunities totaling an 11.5% medication error rate.Findings include:The facility's Medication Administration policy, dated 1/11/2010, documents Objective: To provide accuracy during medication pass to assure quality care for residents. Policy: It is the policy of this facility to accurately administer medication following physician's orders. Crush only medications that can be crushed, or physician has given orders to crush.The facility's Insulin Administration policy, dated 10/2009, documents Objective: Proper administration of insulin to promote control of blood glucose levels. This policy also documents Be sure there are no air bubbles in syringe.The facility's employee training guide (undated), provided by V2 (Director of Nursing), documents (for insulin pen administration) Remove protective tab from the pen needle and screw pen needle onto insulin pen. Turn the dosage knob to two units. With the needle end up, tap the insulin pen so any air bubbles collect at the tip. Push the injection button completely. Insulin should come out of the needle. If insulin is not released, repeat the priming process up to four more times until insulin appears. If insulin still does not appear, set pen aside and inform pharmacy; use a new pen. This same training guide documents Priming the pen every time a new needle is attached is vital to insulin pen administration. This ensures the pen is functioning properly and that the desired dose is administered with every injection.1. R22's Order Summary Report, dated 12/11/25, documents a Physician Order to receive Tylenol ES (Extra Strength) 500 milligrams (mg) three times a day for Pain Management.On 12/8/2025 at 11:45 AM V5 (Licensed Practical Nurse) prepared to administer R22 two tablets of Tylenol ES 500 mg (for a total of 1000 mg). At this time V5 confirmed R22's order and stated that she would've given a double dose.2. R23's Order Summary Report, dated 12/11/25, documents a Physician Order to receive Insulin Lispro (1 unit dial) 100 units/milliliter solution (rapid) pen-injector. Inject six units subcutaneously (SQ) in the afternoon related to Type Two Diabetes Mellitus with Hyperglycemia.On 12/8/25 at 1:00 PM, V9 (Registered Nurse) dialed R23's (rapid) insulin pen-injector to six units, applied a SQ needle and then, without first ensuring all air was expelled from the attached needle, injected R23 with insulin in her abdomen. On 12/8/25 at 1:05 PM, V9 stated she isn't sure if she was supposed to prime the needle and stated, It makes sense so that you don't have air in the needle. On 12/8/25 at 1:10 PM, V9 stated I verified with (V16 Licensed Practical Nurse/Minimum Data Set coordinator) and the needle should be primed with about a unit on the (rapid) insulin pen injections, or until we can see the liquid come out of the top of the needle.3. R44's Order Summary Report, dated 12/11/25, documents R44 has an order to receive Omeprazole Oral Capsule Delayed Release. Give 20 milligrams by mouth one time a day, 30 minutes before lunch related to Gastro-Esophageal Reflux Disease without Esophagitis.On 12/8/25 at 11:51 AM, V9 (Registered Nurse) took R44's Omeprazole capsule, sprinkled it into a medication cup and crushed the contents along with two other prescribed medications (Potassium Chloride and Loratadine). V9 then mixed the crushed medications with chocolate pudding and approached R44 who was sitting at a table in the dining room. At this time R44 had begun eating and had a plate in front of her with partially eaten fried chicken, potatoes and mixed vegetables. R44 finished chewing a bite of food, took a drink and then consumed the prepared pudding with medications (including Omeprazole) from V9.On 12/11/25 at 11:20 AM, V2 (Director of Nursing) stated R44 has had recent orders changed and she should be getting her Omeprazole 30 minutes before she eats lunch, not at the same time as her noon medications and not when she is eating food. V2 confirmed those instructions on R44's orders were implemented on 12/6/25.On 12/11/25 at 12:07 PM, V2 stated she spoke with the facility's pharmacy, who confirmed that R44 should be taking the prescribed Omeprazole on an empty stomach, away from other medications and that the capsule contents should not be crushed or administered with pudding. V2 stated I was told it can be sprinkled onto applesauce or yogurt but not pudding and the contents should not be crushed.

Based on observation, interview and record review the facility failed to document appropriate indications to warrant the use of an antipsychotic medication (R46) and attempt a gradual dose reduction (R19) for 2 of 5 residents reviewed for unnecessary medication in a sample of 23. Findings include: A Psychotropic Medication policy dated 11/28/17 gives as its intent, Residents are free from unnecessary psychotropic medication use. This policy states that antipsychotic medication may be indicated for use if behavioral symptoms present a danger to the resident or others; expressions or indications of distress that are significant distress to the resident; if not clinically indicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are presenting a danger or significant distress; and /or a gradual dose reduction (GDR) was attempted, but clinical symptoms returned. In addition, this policy states that a GDR must be attempted annually, unless contraindicated. 1. R46's list of current diagnoses includes Unspecified Dementia, Unspecified Severity, with other behavioral disturbance, Depression, and Anxiety disorder. R46's physician's order (POS) dated 6/20/23 documents R46 was prescribed the antipsychotic medication Seroquel 25 mg (milligrams) two times daily for the diagnosis of Unspecified Dementia, Unspecified Severity, with other behavioral disturbance. R46's physician's visit notes dated 6/2/23 instructs staff to use the diagnosis, Dementia (with) behaviors for her Seroquel. R46's Physical Device/Psychoactive Medication Initial and Quarterly Evaluation dated 6/20/23 documents R46 has the mental status of being alert, disoriented, with a short attention span. This same evaluation documents that R46 has the emotional, environmental, and social considerations of toileting difficulties, dependence on staff for turning and repositioning, and feelings of anger, loneliness, and abandonment. This same evaluation includes an area for defined recommendations/alternatives and individualized alternatives to administering psychoactive medications to R46, however, the only recommendation made was for family visits which, this evaluation documents, have been effective as an alternative to medications. In addition, R46's psychoactive medication evaluation documents the indication to warrant R46's use of an antipsychotic medication as dementia with behavior disorder. R46's Antipsychotic Medication Consent dated 6/20/23 documents R46 has the diagnosis or medical symptom of dementia with behaviors as an indication for the use of Seroquel. R46's care plan dated 2/28/23 documents that R46 was prescribed an antipsychotic medication. This same care plan instructs for staff to monitor R46 for the target behaviors of pacing, disrobing, inappropriate response to verbal communication, violence/aggression towards others. R46's care plan dated 3/29/23 documents R46 has the behaviors of hitting and slapping at staff during cares and using abusive language, screaming, crying out, and hollering. R46's Behavior Monitoring and Interventions Report dated 4/1/23 to 8/2/23 documents R46 had behaviors on four dates which included physical and verbal behaviors directed towards others, sad, tearful, agitated, refusing care, R46's Minimum Data Set (MDS) assessment dated [DATE] documents R46 is severely cognitively impaired and had no behaviors during the look-back period of this assessment. This same assessment documents R46's behavior was unchanged from the previous assessment. On 7/31/23 at 1:35 p.m. R46 was seated in a wheelchair in the activities room drinking a cup of coffee surrounded by other residents. R46 was confused but calm and relaxed with a pleasant demeanor. R46 was able to answer some simple questions and stated she was tired that morning. On 8/2/23 at 9:25 a.m. R46 was seated in a wheelchair in the activities room waiting for the activity of 50's music to begin. R46 was surrounded by other residents but remained calm and relaxed with a pleasant demeanor. At 9:26 a.m. V6 (Certified Nurse Aide/ CNA) stated that R46 sometimes has behaviors which usually occur while staff are providing R46 with care. V6 stated R46's behaviors during care are usually yelling and crying. V6 stated that one way to prevent R46 from having behaviors is for staff to wait until R46 decides she is ready to get up in the morning by watching for R46 to sit up at the side of the bed. V6 stated another way to help prevent R46 from having behaviors is to give R46 a cup of coffee stating, She loves coffee. V6 stated that R46's behaviors are unchanged since R46's admission 2/28/23. On 8/2/23 at 9:35 a.m. V5 (Licensed Practical Nurse/LPN) stated that he is R46's nurse and also serves as the MDS Coordinator. V5 verified that R46's diagnosis for the use of Seroquel is behavioral disturbances with Dementia. V5 stated that R46's behaviors include physical and verbal behaviors towards staff during cares. V5 stated when R46 has behaviors, staff will try to reapproach R46 at another time, try using soothing speech to talk with R46, provide snacks or leave R46 in a safe area to relax. 2. R19's list of current diagnoses includes Alzheimer's disease, Major Depressive disorder, single episode; Delusional disorder, Dementia with behavioral disturbances. R19's physician's order (POS) dated 8/2/22 documents R19 was prescribed the antipsychotic medication Seroquel 25 mg (milligrams) 1/2 tablet every Monday, Tuesday, Thursday, Friday, Saturday in the evening for the diagnosis of Delusional Disorder. A pharmacy comprehensive list of R19's psychotropic orders dated 7/1/23 to 7/24/23 documents R19's original physician's order for Seroquel 25 mg 1/2 tablet every evening five times per week was written 1/26/18 with the most recent gradual dose reduction attempted 8/2/22. R19's Minimum Data Set (MDS) assessment dated [DATE] documents that R19 is rarely or never understood and rarely or never understands. This same MDS documents R19 is moderately cognitively impaired and displayed no behaviors during the MDS look-back period. R19's Physical Device/Psychoactive Medication Initial and Quarterly Evaluation dated 7/17/23 documents R19's most recent gradual dose reduction of Seroquel occurred 8/2/22. R19's Behavior Monitoring and Interventions Report dated 4/3/23 to 8/2/23 document that during those dates, R19 did not have any behaviors. On 8/02/23 at 9:20 a.m. V6 (Certified Nurse Aide) stated that R19 does not usually have behaviors and is cooperative with cares. On 8/02/23 at 9:38 a.m. V5 (Licensed Practical Nurse/ MDS Coordinator) and V4 (Social Services Director) were standing next to the nurses' station. V5 stated R19 has behaviors towards staff during cares and is prescribed the antipsychotic medication Seroquel. V4 stated R19 has delusions, hallucinations, and has conversations with an invisible person. V4 stated that R19's delusions and hallucinations are not distressing to R19. On 8/3/23 V2 (Director of Nurses) stated she manages psychoactive medications for the facility. V2 stated the facility does not have a specific protocol for performing GDRs for antipsychotic medications but, instead, they rely on their pharmacy to recommend when GDRs should be attempted. V2 stated that residents who have been taking an antipsychotic one year or more do not necessarily require an annual GDR. V2 stated that the R46's indications of Dementia with behaviors used to warrant the use of the antipsychotic Seroquel were appropriate.

Based on interview and record review the facility failed to accurately document (breathing machine) refusals for one resident (R1) out of three residents reviewed for oxygen therapy in the sample of four. Findings include: The Resident Care Policy and Procedure dated 5/2022, documents It is the policy of this facility to maintain current physician orders to provide treatment according to the attending physician for each resident of the facility. a) All medications and treatments shall be given only upon the written order of the physician. All such orders shall be written in the medical record and shall be given as prescribed by the physician at the designated times. g) If for any reason, a physician's medication or treatment order cannot be followed, the physician shall be notified as soon as is reasonable, depending upon the situation, a notation of this will be made into the medical record. The Job Description for Licensed Practical Nurses dated 11/10/17, documents Essential Job Function: Responsible for nursing care of assigned residence in accordance with new nursing facility and nursing service policies and procedures. Chart medications and treatments according to procedure. R1's current Medical Record, documents R1 was admitted to the facility on [DATE] with diagnoses which included Primary Central Sleep Apnea and Chronic Obstructive Pulmonary Disease. R1's Physicians Order dated 2/10/23, at 11:08 AM, documents (Breathing machine) per home settings on at all times when sleeping or napping. R1's Care Plan dated 1/24/23, documents that R1 has chronic obstructive pulmonary disease and OSA (Obstructive Sleep Apnea). The intervention is that R1 will use a (breathing machine) as ordered when napping and in bed at night. On 6/30/23 at 9:55 AM, V2 (Director of Nursing) stated that V12 (R1's Family Member #1) complained that the (breathing machine) was not being used as ordered for R1, however the nursing documentation showed that the (breathing machine) was being used as ordered. V12 brought in a Sleep Therapy Report that showed the use of the (breathing machine). There were days that the report showed the (breathing machine) was not used and it did not match the facility Treatment Administration Records (TAR) documentation. There were also a couple of nursing notes written by V8 (Licensed Practical Nurse) that documented the (breathing machine) was used on her shift that did not match the Sleep Therapy Report. V8 was asked about the documentation and stated that she would check off the breathing machine task before she applied the machine to R1. When V8 went to R1's room to apply the (breathing machine) mask R1 would refuse the treatment sometimes, and V8 would forget to go back and change the documentation to show that R1 refused the treatment. V2 stated that an In-Service was done with all nurses about the (breathing machine) and correct documentation. On 6/30/23 at 12:30 PM, V2 (Director of Nursing) and V1 (Administrator) reviewed R1's Sleep Therapy Report previously provided by V12 (R1's Family Member #1) and compared it to the Treatment Administration Record (TAR) and agreed that the report indicated the (breathing machine) was not used by R1 on 6/05, 6/06, 6/20, and 6/21/23 On 6/30/23 at 1:35 PM, V1 (Administrator) stated that she is aware that the Therapy Report for R1's (breathing machine) that V12 (R1's Family Member #1) presented to the facility had days that there was no usage documented for R1. V1 was also aware that the Treatment Administration Record (TAR) and the Nursing Notes had documentation that R1 received the (breathing machine) treatment on days the Therapy Report showed the machine was not used. R1's Nursing Note dated 6/5/23 at 11:33 PM, documents (R1) Resting quietly Arouses easily voices no C/O (Complaints of) keeping (breathing machine) mask on this night. (R1's Sleep Therapy Report documents No usage for the (breathing machine) on 6/5/23.) R1's Nursing Note dated 6/6/23 at 22:07 PM, documents (R1) Resting quietly Arouses easily voices no C/O keeping (breathing machine) mask on this night. (R1's Sleep Therapy Report documents No usage for the (breathing machine) on 6/6/23.) On 6/30/23 at 7:50 PM, V8 (License Practical Nurse) stated that she usually works the night shift from 6:00 PM to 6:00 AM, and she knows it is important for R1 to use her (breathing machine) when sleeping. V8 would mark off the task on the Treatment Administration Record (TAR) for the (breathing machine) before going in to apply the mask to R1. There were times that R1 refused to have the mask applied. V8 did not go back and correct the TAR to show that R1 refused the treatment. I am guilty about not thinking to change the documentation when R1 refused. V8 was asked about the nursing notes dated 6/5/23 and 6/6/23 that she wrote documenting that R1 had used the (breathing machine) during the night when she didn't. V8 stated I got in a hurry and copied and pasted the notes not paying attention to the details. I was wrong for doing that. Now I realize the information in the Nursing Notes are not correct. I know that's not a good excuse. There is no good excuses. R1's Sleep Therapy Report dated 5/31/23 - 6/29/23, documents that there were 16 days there was no usage recorded. This report was compared to R1's Treatment Administration Record (TAR) dated 6/1/23- 6/30/23. There are four days (6/5, 6/6, 6/20, and 6/21/23) that there is no documentation charted that R1 was refusing the (breathing machine). V8 (Licensed Practical Nurse) worked on all four days from 6:00 PM - 6:00 AM. On 7/1/23 at 9:20 AM, V1 (Administrator) stated that the information documented in the nursing notes should be accurate. V1 also stated that there is no policy on accurate documentation.

Based on observation, interview, and record review the facility failed to apply foot pedals to a wheelchair (R22) or ensure two staff assisted during bed mobility and transfers (R24) to reduce injury risk for two of two residents (R22, R24) reviewed for accidents in a sample of 30. Findings include: A Fall Assessment and Management policy dated as revised 4/2019 states, It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. In addition, this policy states, Each resident will be assessed using the Minimum Data Set (MDS) upon admission, quarterly and with any significant change assessment. 1. R24's list of current diagnoses includes [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction affecting left non-dominant side. R24's MDS dated [DATE] documents R24 requires the extensive assistance of two people for bed mobility, dressing, and toilet use; and is totally dependent on two staff for transfers. On 6/28/22 at 1:50p.m. R24 was lying in bed. R24 stated she has difficulty using her arms and legs because of weakness. R24 stated that she requires staff assistance to reposition in bed. On 6/29/22 at 8:10a.m. R24 was seated in a wheelchair in the dining room being fed by facility staff. At 8:26a.m. V4(Certified Nurse Aide/CNA) pushed R24 back to her room and used a mechanical lift to transfer R24 from the wheelchair to the toilet. R24's fall risk assessment dated [DATE] documents that R24 is at high risk for falls because R24 overestimates or forgets limits, has fallen before, and has multiple diagnoses which could contribute to the risk of falls. R24's current care plan documents that R24 has or is at risk for an activities of daily living (ADL) self-care performance deficit related to R24's activity intolerance, confusion and impaired balance. This care plan documents that R24 requires the assistance of two people for transfers using a mechanical lift and that R24 is, slightly able to reposition, herself once R24 is in bed. In addition, R24's care plan documents that R24 needs extensive assistance from two people with ADL care because of R24's decreased cognition and weakness. R24's Occurrence Report dated 5/1/22 documents that while one CNA (V5) was providing ADL care to R24, R24 rolled too far to the side of the bed and slid off. This report documents that V5 was able to ease R24 to the ground during which time R24 received a three-inch-long scratch/bruise. This report documents that when R24 was asked what happened she stated, I just rolled out of bed. In addition, this report documents that V5 stated that while V5 was providing R24 care, V5 rolled R24 to the right side at which time R24 began sliding off the bed. The Occurrence Report documents the root cause to R24's fall was that V5 should have rolled R24 towards V5 instead of away from her while providing cares. This report's recommendation to prevent future falls was to instruct staff to, Always roll resident towards you when you are changing (R24). On 6/28/22 at 1:28p.m. V2 (Director of Nurses) stated that she investigated R24's fall on 5/1/22. V2 stated that when R24 fell , she was being cared for by only one staff member, (V5), who rolled R24 in the bed away from V5 which led to R24 sliding off the side of the bed. V2 stated that the facility does not necessarily follow residents' MDS assessments to determine how many staff provide ADL care. V2 stated that CNA staff decide whether one or two staff are needed to provide R24's ADL care. 2. R22's electronic medical record documents he has the current diagnoses of Dementia with Behavioral Disturbance, Diabetes Mellitus and Fatigue. R22's Minimum Data Set assessments, dated 2/04/22 and 5/04/22, document R22 has functional limitation in range of motion in both lower extremities and is dependent on staff for wheelchair mobility. R22's current Plan of Care documents R22 uses a wheelchair for mobility and will safely use assistive devices for mobility through the next review date. A Nursing Progress note, dated 4/29/2022, documents CNA (Certified Nursing Assistant) reported new skin tear to (R22's) right third toe. Writer assessed. Skin tear measures 1 cm (centimeter) x 1.5 cm, skin peri wound (clean, dry and intact). Moderate amount of blood noted to area. No (signs)/symptoms of pain noted at this time. (Vital Signs Stable). Area cleansed, (triple antibiotic) and bordered gauze dressing applied. Resident placed on incident status. (Physician and Power of Attorney) updated. An Incident Report, dated 4/29/22 at 1:30 pm, documents CNA stated that (R22) scraped his toe on the floor while she was propelling him in his (wheelchair) to his room. The Incident Report also documents, Other action taken, educated CNAs on use of leg pedals when propelling (R22) as an immediate intervention and Root Cause: CNA pushing (R22) in (wheelchair) and resident had only slipper socks on at the time and (R22) scraped toe on floor causing a skin tear. Staff educated that resident is to have shoes on at all times when in wheelchair. On 6/27/22 at 11:45 am and 6/30/22 at 11:40 am, R22 was sitting in the dining room in his wheelchair with his feet resting on foot pedals wearing slipper socks. On 6/30/22 at 9:32 am, V6 (Certified Nursing Assistant) stated R22 always uses foot pedals when he is propelled in the wheelchair, because he can't hold his feet up. On 6/30/22 at 9:25 am, V2 (Director of Nursing) stated R22 impulsively lifts his legs and feet, but R22 is unable to do so on command. V2 stated, at the time R22 sustained the injury to his right third toe, the facility was replacing the flooring throughout the building and there was some texture to the exposed concrete, which caught R22's foot causing the skin tear. V2 stated proper footwear and wheelchair foot pedals were not utilized by the CNA at that time, resulting in R22's injury.

Based on observation, interview and record review, the facility failed to document behaviors to justify the use of antipsychotic medications, document target behaviors, document non-pharmacological approaches, accurately complete quarterly [CONDITION(S)] evaluations, and failed to attempt a gradual dose reduction (R36) for two of four residents (R19, R36) reviewed for antipsychotic medications in the sample of 30. Findings include: The facility's [CONDITION(S)] Medication policy dated 11/28/17, states Intent: Residents are free from unnecessary [CONDITION(S)] medication use. [CONDITION(S)] medication is any drug that affects brain activity associated with mental processes and behavior. These medications include but not limited to: 1. Antianxiety 2. Antidepressant 3. Antipsychotic 4. Hypnotic. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, mental, behavioral, psychosocial needs. 1) Indications for use of [CONDITION(S)] medication may include but not limited to 1) Expressions or indications of distress 2) Symptoms are clinically significant that is causing a functional decline 3) non-pharmacological approaches were implemented and not effective or were clinically contraindicated. Additionally, Antipsychotic medication may be indicated for use if 1) behavioral symptoms present a danger to the resident or others; 2) Expressions or indications of distress that are significant distress to the resident; 3) If not clinically indicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are presenting a danger or significant distress; and/or 4) GDR (Gradual Dose Reduction) was attempted, but symptoms returned. B) Dose, Duration, Monitoring 1) Evaluation of pharmacological ongoing effectiveness towards therapeutic goal; 2) Evaluation of the effectiveness of the non-pharmacological approaches prior to medication administration; 3) Quarterly evaluation or more frequent if needed to determine if a reduction is warranted. C) Gradual Dose Reduction 1) Resident's should receive the lowest effective dose of [CONDITION(S)] medication for the resident's physical, mental, and psychosocial well-being; 2) GDR is to be attempted within the first year in two separate quarters, unless contraindicated. 3) If treating expressions or indications of distress related to dementia, the GDR may be contraindicated for the following reasons a) Target symptoms returned or worsened after a recent attempt of GDR, AND b) Physician has documented rationale why a reduction would impair residents function or increase distressed behavior. 1. On 6/27/22 at 12:10 p.m. and 6/28/22 at 9:33 a.m., R19 had no observed mood or behavior issues. R19's current Physician Orders document R19 receives [MEDICATION(S)] (antipsychotic medication) 12.5 mg (milligrams) daily. R19's Behavior Tracking and Progress Notes dated 10/29/21 through 6/28/22, do not document any behaviors to justify the use of an antipsychotic medication. R19's Care Plan dated 5/27/22, does not document R19's use of [MEDICATION(S)], R19's target behaviors for the use of [MEDICATION(S)] or non-pharmacological approaches to be used. R19's Physical Device/Psychoactive Medication Initial and Quarterly Evaluation dated 1/28/22 and 5/2/22, document R19's behavioral factors present are Toileting difficulties and (R19) has a diagnosis of Alzheimer's/Dementia. This same evaluation does not document Recommendations/Alternative to Psychoactive Medications, Effectiveness of alternatives tried or Medical Diagnosis or Indication for use. 2. On 6/27/22 at 12:00 p.m. and 6/28/22 at 10:00 a.m., R36 had no observed mood or behavior issues. R36's current Physician Orders document R36 receives [MEDICATION(S)] 12.5 mg twice a day for Delusional Disorder with expressions or indications of significant distress to R36. R36's Behavior Tracking and Progress Notes dated 6/1/21 through 6/28/22, do not document R36 has behaviors to justify the use of [MEDICATION(S)]. These same Behavior Tracking and Progress Notes do not document R36 has delusions and/or indications of significant distress. R36's current Antipsychotic medication Care Plan initiated on 8/28/20, does not document R36's target behaviors or non-pharmacological approaches to be utilized. R36's Physical Device/Psychoactive Medication Initial and Quarterly Evaluations dated 8/3/21, 11/29/21, and 2/24/22, document R36's behavioral factors present are Hearing difficulties, toileting difficulties, and (R36) has a diagnosis of Alzheimer's/Dementia. This same evaluation does not document Recommendations/Alternative to Psychoactive Medications or Effectiveness of alternatives tried. R36's Note to Attending Physician/Prescriber form dated 1/27/22, documents the Pharmacist requested a dose reduction on R36's [MEDICATION(S)]. This same form is blank and does not document any response from R36's physician. R36's Medical Record does not document a GDR has been attempted or physician documented clinical contraindication for a GDR from 6/1/21 through 6/28/22. On 6/30/22 at 9:20 a.m., V2 (Director of Nursing) stated R36's dose reduction request for [MEDICATION(S)] dated 1/27/22, has not been addressed by R36's physician. V2 stated V2 was not aware if R36's physician received the request or not. V2 stated R36's [MEDICATION(S)] should have been reduced or have a physician documented rationale for not reducing the [MEDICATION(S)] in the past 12 months. V2 stated there was no additional documentation of R19 or R36's behaviors to justify their use of [MEDICATION(S)]. V2 stated R19 and R36's care plans do not document their target behaviors or non-pharmacological approaches that staff are to utilize. V2 stated R19 and R36 are not a danger to themselves or other residents.

Based on observation, interview and record review, the facility failed to implement contact isolation precautions for one of three residents (R253) reviewed for transmission based precautions in the sample of 24. Findings include: Facility [CONDITION(S)] ([CONDITION(S)]) Protocols revised 4/30/19 documents It is the protocol of this facility to prevent the spread of all MDROs. Upon diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Place appropriate transmission based precaution sign on the resident's door. R253's medical record documents R253 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/30/21 at 9:50 AM, R253's room did not have signage to indicate isolation precautions. On 3/30/21 at 10:00 AM, V4 (Registered Nurse/RN) stated R253 was not on isolation precautions. On 3/31/21 at 11:25 AM, R253's room had contact isolation precaution signage posted. On 3/31/21 at 12:10 PM, V6 (Licensed Practical Nurse/LPN) stated R253 was placed on new admission COVID droplet isolation precaution on 3/12/21 and taken off isolation on 3/27/21. R253's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R253's POS dated 3/12/21 documents Left Foot - Apply Xeroform to incision line, cover with gauze, wrap with kerlix and secure with Ace Wrap. Change every Monday, Wednesday and Friday and as needed. On 04/01/21 at 08:20 AM, V1 (Administrator) stated that R253 was initially placed on contact droplet isolation due to being a new admission to the facility and verified R253 was taken out of isolation from 3/27/21 to 3/30/21 but should have remained on contact isolation due to his MRSA infection. V1 also stated, I spoke to the agency nurse and she verified she didn't wear contact isolation PPE (Personal Protective Equipment) while changing (R253)'s bandage on 3/29/21 because he was not on contact isolation precautions at that time.

Based on interview and record review, the facility failed to obtain an Advanced Directives order for one of 16 residents (R203) reviewed for Advanced Directives in a sample of 24. Findings include: The facility's Advance Directives policy revised 6/16 documents, Policy: 1) All residents will be given information regarding Advanced Directives upon admission, in accordance with Self determination Act. 2) Residents will be afforded the opportunity upon admission to the facility to submit an Advanced Directive regarding their care in this facility, thereby informing the facility of each resident's desires regarding medical decision making and end of life care. R203's Order Summary Sheet dated 3/30/21 at 1:44 PM documents an admitted [DATE] and does not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/30/21 at 2:10 PM V4 (Registered Nurse/RN) stated, Well the code status is supposed to be here, but it's not. I don't see it anywhere in the record; let me check the hard chart. Well, there should be a Practitioner Order for Life-Sustaining Treatment (POLST) in here, but it's not. Well he is a full code until we have an order. I will take care of that now.

Based on interview and record review, the facility failed to provide quarterly assessments to warrant the continued use of [CONDITION(S)] medications for two of four residents (R42, R46) in the sample of 24. Findings include: The facility's [CONDITION(S)] Medication policy (revised 11/28/17) documents monitoring will be provided by Quarterly evaluation or more frequent if needed to determine if a reduction is warranted. 1. R42's Physician Order Summary Report dated 4/1/21 documents diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder, and orders for Lorazepam 0.5 (five) mg (milligrams) at bedtime Monday, Wednesday, Friday, and Sunday; and [MEDICATION(S)] 50mg every evening. R42's last quarterly [CONDITION(S)] assessment was dated 8/20/2020. 2. R46's Physician Order Summary Report dated 4/1/21 documents diagnoses of Alzheimer's Disease, Major Depressive Disorder, Auditory Hallucinations, and Visual Hallucinations and orders for [MEDICATION(S)] 25mg twice a day and [MEDICATION(S)] SR Extended Release 12 hour, 150mg twice a day. R46's last quarterly [CONDITION(S)] assessment was dated 8/26/20. On 4/01/21 at 1:07 PM V5 (Registered Nurse/Corporate Nurse Consultant) stated there are no other quarterly [CONDITION(S)] assessments for R42 and R46, and [CONDITION(S)] assessments are to be done quarterly.

Based on interview and record review, the facility failed to provide residents written notification of reason for transfer for five of five residents (R39, R60, R26, R41, and R37) reviewed for transfers in a sample of 24 Findings include: On 6-19-19 at 3:00 pm, V1 (Administrator) stated the notice of transfer is not given at the time of transfer to the resident and/or representative but is mailed to the POA and/or representative the next day. 1. R26's Written Notice of Resident Transfer form documents R26 was sent to the hospital on 3-29-19 and the notice was sent to R26's resident's POA/representative on 3-31-19. No notice was given to R26. 2. R39's Written Notice of Resident Transfer form documents R39 was sent to the hospital on 5-9-19 and the notification was sent to R39's resident's POA (power of attorney)/or representative on 5-10-19. No notice was given to R39. 3. R60's Written Notice of Resident Transfer documents R60's was sent to the hospital on 3-28-19 but the notification was not sent to the resident's POA/representative until 3-29-19. No notice was given to R60. 4. The Facility Written Notice of Resident Transfer Form, dated 4/12/19, documents that R27 was transferred to a local hospital. 5) R41's Written Notice of Resident Transfer dated 6/14/19 documents R41 was sent to a local hospital for evaluation.

Based on interview and record review the facility failed to ensure a safe handling method was used during a resident transfer for one of three residents (R1) reviewed for accidents and incidents in a sample of three. Findings include: A Safe Resident Handling Program policy dated 3/18/18 states, Resident transfer status will be listed on the resident plan of care (P[NAME]). R1's Care Plan dated 1/28/17 states, Transfer: Full body mechanical lift x (times) two person physical assist. R1's Minimum Data Set (MDS) assessment dated [DATE] documents that R1 is totally dependant on two people for transfers between surfaces. R1's incident investigation dated 4/18/19 documents that on 4/17/19 V4 (Certified Nurse Aide/CNA) stated that she had transferred R1 from the wheelchair to the bed on 4/16/19 during the night shift using a mechanical lift and with the assistance of a second CNA. This same investigation documents that V4 provided a second statement in which V4 stated that on 4/16/19 V4 did not use a second person to transfer R1 but instead, She (V4) picked (R1) up using a cradle hold and placed her into the bed. On 4/22/19 at 11:50a.m. V1 (Administrator) stated that V4 originally stated that on 4/16/19 V4 had transferred R1 from the wheelchair to the bed using a mechanical lift with the assistance of another CNA. V1 stated that V4 told V1 a few days later that V4 did not use a mechanical lift and there was not a second CNA assisting when V4 transferred R1 to bed on 4/16/19. V1 stated that V4 physically lifted R1 out of the wheelchair using a cradle hold to transfer R1 to the bed. V1 verified that V4 did not use a safe handling method to transfer R1. V1 also verified R1's care plan documents for R1 to be transferred using a mechanical lift and two people. On 4/22/19 at 2:00p.m. V4 stated that V4 was R1's CNA on the night shift on 4/15/19 to 4/16/19 from 6:00p.m. to 6:00a.m V4 stated that at approximately 1:00a.m. on 4/16/19, V4 transferred R1 to bed without the assistance of a second person. V4 stated that she physically picked R1 up from the wheelchair then cradled R1 in her arms like a child during the transfer. V4 verified that R1 is supposed to be transferred using two people and a mechanical lift.

Based on observation, interview and record review the facility failed to keep a resident free from verbal and mental abuse. This affects one of three residents reviewed for Abuse. Findings: The document Abuse and Neglect Prohibited, dated 3/15/18, states, All residents have the right to be free from verbal and mental abuse. An employee shall not abuse a resident. Mental abuse includes humiliation. The document Resident Rights dated 7/22/14 and signed by V4, Certified Nursing Assistant (CNA), on 10/31/18, states, All residents will be permitted respect and privacy. The document, State Report, dated 3/27/19 states, On 3/23/19 at 6:30 PM V4, Certified Nursing Assistant, made comments in the residents dining room about one resident (R1) of the two residents that were present. The comments were sensitive and embarrassing regarding his (R1's) personal conduct. On 4/01/19 at 12:20 PM V5, Dietary Employee, stated during a phone interview, Me and V6, Dietary Employee, were in the dining room wiping off tables. R1 and R2 were sitting at different tables eating and V4 and V8 CNA were sitting at another table between R1 and R2. V4 got up and pulled R1 away from the table and said, You' re going to go to your room now. R1 made some noise about wanting to finish eating. Then, V4 got some sanitary wipes and started cleaning R1's walker saying that V4 didn' t want to touch it because it had (semen) on it. V4 said she sees R1 (masturbating) in his room and who knows where that goes. R1 made some noises like maw maw maw while V4 was talking. On 4/01/19 at 3:34 PM, V6, Dietary Employee, stated during a phone interview, V5, Dietary Employee, and I were cleaning up in the Dining Room when V4, Certified Nursing Assistant (CNA), grabbed R1's chair and pulled it away from the table. R1 screamed NO, that he wanted to eat but V4 ignored R1. V4 took sanitation wipes and cleaned off R1's walker. She was saying that it had (semen) on it. Then she started telling V8, CNA, about it walking into R1's room when he was masturbating and stuff like that. R1 just looked down at the floor, maybe he was embarrassed, I don't know. I think he was saying something but it didn' t make a lot of sense. V8, Certified Nursing Assistant that was in the dining room at the time of the event on 3/23/19, was unavailable for interview. On 4/01/19 at 8:45 AM V1, Administrator stated, It happened on a Saturday evening, (3/23/19) when V5 and V6, Dietary Employees, heard V4, Certified Nursing Assistant (CNA) talking inappropriately to R1. V5 immediately reported the incident. I called the Charge Nurse and had her walk V4 out of the facility. I started investigating as soon as I was able to that night. I talked to V4 on Monday morning. I don't think it was that V4 was intentionally trying to cause any harm. I think she is just immature and said those things without thinking. After the investigation concluded, we terminated V4's employment with the facility. The document Employee Disciplinary Action Form, no date, states, Type of violation and violation description: V4 violated the facility's abuse policy (by) making derogatory and humiliating comments within ear shot of a resident (R1) and another resident (R2). This document was signed by V1, Administrator and V4, Certified Nursing Assistant on 3/27/19. On 4/01/19 at 9:40 AM, R1 was observed in his room, awake, laying on the bed. An interview with R1 was attempted to discuss the incident. R1 repeated questions asked him and then would say, Why? I don' t know. Who are you? What are you going to do for me? Should I know? Why? I don't know. After a couple of questions R1 became more confused and agitated and the interview concluded. On 4/01/19 at 11 AM R2, who was in the dining room at the time of the incident, was observed sitting in his room. R2 stated, When I'm in the cafeteria I mind my own business. I'm there to eat, I don't pay much attention to anything else so I'm not going to say I heard anything.

Based on observation, interview, and record review the facility failed to supervise a known wandering resident which allowed this resident to wander unattended in an intrusive manner into other residents' rooms throughout the facility and repeated attempts to exit the building. These failures have the potential to affect all 63 residents in the facility. Findings include: A Wandering Resident/Elopement policy dated 10/2011 states, It is the policy of this facility to provide a safe environment for all residents. R22's Exit Seeking/Wandering Screener form dated 6/20/18 documents that R22 is physically able to leave the building on her own, is disoriented to place, has impaired decision making, has a history of wandering as well as currently wanders. R22's current care plan documents R22 has the [DIAGNOSES REDACTED]. R22's care plan also states that R22 has, Problems associated with wandering throughout the facility, in and out of other resident's rooms. (The Facility) is hoping (R22) becomes acclimated to a new environment that the wandering will subside. R22's medical record indicates R22 was admitted to the facility 3/2018. On 8/20/18 at approximately 10:30a.m. R42 and V16 (R42's family) were seated in R42's room which is on the opposite side of the building from where R22 lives. R22 wandered into R42's room at which time both R42 and V16 told R22 to , Get Out! R22 walked out the room and continued to wander down the hallway unattended. R42 and V16 stated that R22 frequently enters R42's room unsupervised by staff. On 8/20/18 at 12:58p.m. R59 stated that R22 frequently wanders into her room without knocking and without permission, and without supervision by staff. R59 stated that R22 is cognitively impaired, independently mobile using a walker, and often wanders in the middle of the night. R59 stated that recently while R59 was in bed asleep, R59 had the feeling that someone was standing over her. R59 stated that when she opened her eyes, R22 was standing over R59 trying to put R59's glasses on her face. R59 stated that she saw that R22 had something in R22's hand and asked R22 what it was. R22 opened her hand which contained R59's hearing aid. R59 stated that a nurse came into R59's room and guided R22 out. R59 stated that even though R22 usually just wants to look out the window when she enters R59's room, R22 is walking into R59's private space without permission or supervision. R59 stated that the facility has not tried any measures to prevent R22 from entering her room. On 8/21/18 at approximately 10:00a.m. R47, who's clinical record documents a severely cognitively impaired resident who requires extensive assistance for bed mobility and is totally dependent for all other activities of daily living, was laying in bed with tube feeding solution infusing through a tube attached to R47's abdomen. R22 attempted to enter into R47's room which was located on the other side of the building from where R22 resides. A visitor noted that R22 was unsupervised and entering the wrong room. The visitor redirected R22 back out into the hallway where R22 continued to wander unattended down the hallway. On 8/21/18 at 3:00p.m. R44 and R39 were attending the resident council meeting. During the meeting both R44 and R39 complained that R22 is cognitively impaired and frequently wanders into their room without knocking and without supervision. R44 and R39 stated that they do not like R22 entering their home without permission and feel like their, Space is being invaded. R44 and R39 stated that the facility has not tried any measures to keep R22 out of their room. On 8/22/18 at 2:32p.m. R32 was in R32's room calling out for help. R32 stated that there was a woman in the empty bed across from his. R22 was in the bed across from R32 with the covers pulled up around her face. V5 ( Licensed Practical Nurse) entered R32's room and escorted R22 out of the bed and back down to the other end of the building to R22's own hallway. R22's nurse's notes dated 7/16/18 to 8/20/18 document multiple entries describing R22's wandering and exit seeking. R22's nurse's note dated 7/16/18 at 12:37a.m. states, Resident awake all night and wandering in hall has attempted to open door times two thus far has gone into other residents' rooms several times and messes with their things. Nurse's notes dated 7/17/18 at 3:37a.m. state, (R22) pushed roommate in her wheelchair across the hall into another room causing the residents of that room to call out for staff assistance. Nurse's note dated 7/17/18 at 5:37p.m. state, Exit seeking, did get out one door but was witnessed, wouldn't sit down for supper, constant wandering. Nurse's notes dated 7/19/18 at 9:03p.m. state, Continues to exit-seek. Went out door x 1. Nurse's note dated 8/7/18 states, Resident observed another employee punch code on door to exit and got up from chair and pushed a number on the pad and opened door exited the building and was a few feet out when staff was able to encourage her to come back in. On 8/22/18 at 2:40p.m. V4 (Certified Nurse Aide) stated, R22 likes to wander all over the facility and she also likes to go into rooms and get in other residents' beds. On 8/20/18 at 10:59a.m. R22 was walking down the 200 wing hallway using a walker. R22 walked into the room next to where R22 resides without permission and while no one was present in that room. On 8/21/18 at 10:30a.m. V1 (Administrator) stated that the facility knows that R22 wanders and that she has a history of wandering into other residents' rooms. V1 stated that the facility usually puts up a stop sign across residents' doorways to deter R22 from entering but stated there was currently only one resident with a stop sign on their door in the facility. On 8/22/18 at 3:45p.m. V1 stated that residents' rooms are their homes and should not be entered or their belongings touched without permission.

Based on observation, interview, and record review the facility failed to ensure residents' rooms were not entered without permission for three of 16 residents (R32, R59, R42) reviewed for resident rights in a sample of 21, and two residents (R39, R44) not on the sample. Findings include: A Resident Dignity policy dated 9/2011 states as its purpose, To ensure the respect of the right of privacy and dignity for residents of the facility. All residents have the right to have their privacy maintained irrespective of their functional and cognitive status. The policy further states, Knock on room door prior to entry and request permission to enter. A Wandering Resident/Elopement policy dated 10/2011 states, It is the policy of this facility to provide a safe environment for all residents. A Resident Rights Information policy dated 2/2017 states, The facility does everything possible to ensure that resident rights will be honored to their full extent. On 8/20/18 at 12:58p.m. R59 stated that R22 frequently wanders into her room without knocking and without permission. R59 stated that R22 is cognitively impaired, independently mobile using a walker, and often wanders in the middle of the night. R59 stated that recently, while R59 was in bed asleep, R59 had the feeling that someone was standing over her. R59 stated that when she opened her eyes, R22 was standing over R59 trying to put R59's glasses on her face. R59 stated that she saw that R22 had something in R22's hand and asked R22 what it was. R22 opened her hand which contained R59's hearing aid. R59 stated that a nurse came into R59's room and guided R22 out. R59 stated that even though R22 usually just wants to look out the window when she enters R59's room, R22 is walking into R59's private space without permission. R59 stated that the facility has not tried any measures to prevent R22 from entering her room without permission. On 8/20/18 at approximately 10:30a.m. R42 and V16 (R42's family) were seated in R42's room which is on the opposite side of the building from where R22 lives. R22 wandered into R42's room at which time both R42 and V16 told R22 to , Get Out! R22 walked out the room and continued to wander down the hallway unattended. On 8/21/18 at 3:00p.m. R44 and R39 were attending the resident council meeting. During the meeting, both R44 and R39 complained that R22 is cognitively impaired and frequently wanders into their room without knocking and without permission. R44 and R39 stated that they do not like R22 entering their home without permission and feel like their, Space is being invaded. R44 and R39 stated that the facility has not tried any measures to prevent R22 from entering their room without permission. On 8/22/18 at 2:32p.m. R32 was in R32's room calling out for help. R32 stated that there was a woman in the empty bed across from his. R22 was in the bed across from R32 with the covers pulled up around her face. V5 ( Licensed Practical Nurse) entered R32's room and escorted R22 out of the bed and back down to the other end of the building. On 8/22/18 at 2:40p.m. V4 (Certified Nurse Aide) stated, R22 likes to wander and she also likes to go into rooms and get in other residents' beds. On 8/20/18 at 10:59a.m. R22 was walking down the 200 wing hallway using a walker. R22 walked into the room next to where R22 resides without permission. V7(Certified Nurse Aide) witnessed R22 entering another resident's room and directed R22 back out into the hallway. On 8/21/18 at 10:30a.m. V1 (Administrator) stated that the facility knows that R22 wanders and that she has a history of wandering into other residents' rooms. V1 stated that the facility usually puts a stop sign across residents' doorways to deter R22 from entering, but V1 stated she had not put up any stop signs across R59, R39, R44, or R32's doorways. On 8/22/18 at 3:45p.m. V1 stated that residents' rooms are their homes and should not be entered or their belongings touched without permission.

Based on observation, record review and interview, the facility failed to include turning and repositioning in the revised plan of care for skin impairment, for one of four residents (R1) reviewed with pressure ulcers, in a sample of 21. Findings include: The facility policy, titled Wound and Ulcer Policy and Procedure (1/10/18), documents It is the policy of this faciity to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. and Approaches will be placed in the resident care plan. A 7/16/18 Skin Risk Assessment identifies R1 as at moderate risk for skin breakdown. A Plan of Care, updated 8/15/18, documents R1 is at risk for impairment to skin integrity related to fragile skin, medication use, decreased mobility, cognitive impairment, incontinence and poor oral intake. Nursing Progress Notes, dated 8/19/18, document staff observed an open area on R1's coccyx, measuring 1 cm (centimeter) by 0.4 cm by 01 cm, and the physician ordered a dressing of Duoderm to be changed every three days and for staff to Continue to turn and reposition every 2 hours and PRN (as needed). The 8/15/18 Plan of Care for R1 fails to identify any turning and repositioning program for R1, even after the onset of the Stage II Pressure Ulcer to the coccyx. On 8/22/18 at 10:30 am, V10 (Certified Nursing Assistant) removed a dressing from R1's coccyx, which was covering a red area directly on the bony prominence of the coccyx with an open center. V10 stated at that time, the nursing staff had found something on R1's coccyx a few days prior, so they were to reposition R1 every two hours. On 8/23/18 at 1:00 pm, V2 (Director of Nursing) confirmed R1's Plan of Care was updated to identify the presence of a Stage II Pressure Ulcer on the coccyx, but the frequency of repositioning was not included.

Based on interview and record review the facility failed to ensure a resident and resident's Power of Attorney (POA) were provided with the facility's bed-hold policy at the time of transfer to the hospital for three of three residents (R30, R58, R213 ) reviewed for bed-holds in a sample of 21. Findings include: A Bed-Hold Notification form (undated) states, The bed-hold notification will be issued at the time of transfer and in cases of emergency transfer; notice will be given within 24 hours of the leave. 1. R30's nurse's notes dated 8/8/18 document that on that date R30 was transported to the hospital for evaluation. R30's medical record does not document that R30 or R30's POA were given a notice of bed hold policy upon or after R30's transfer to the hospital. On 8/22/18 at 1:23p.m. V1 (Administrator) verified that R30 was transferred to the hospital on [DATE]. V1 also verified that notice of bed hold policy was not given to R30 or R30's POA upon or after R30 was transferred to the hospital 2. R58's nursing progress note, dated 7/18/18 at 1:40 PM, document R58 was transferred to the hospital. R58's medical record does not document that R58 was given a notice of bed hold policy upon or after R58's transfer to the hospital. 3. R213's nursing progress note, dated 7/20/18 at 2:21 PM, document R213 was transferred to the hospital. R213's medical record does not document that notice of bed hold policy was given to R213 upon or after transfer to the hospital. On 8/23/18 at 10:00 AM, V1 Administrator confirmed that notice of bed hold policy was not given to R58 or R213 when they were transferred to the hospital.

Based on observation, record review and interview, the facility failed to provide activities to enhance a resident's well-being and and facilitate interaction with others, for one of six residents reviewed for activities in a sample of 21. Findings include: A Minimum Data Set assessment, dated 7/20/18, documents R47 as having significant cognitive impairment and requiring total dependence of staff for all Activities of Daily Living. A Plan of Care, dated 8/04/18, documents R47 requires staff assistance to move throughout the facility, activity staff visits her daily and have 1:1 visits, conversations she thoroughly enjoys and generally will have a verbal response, but at times she will not interact with activity staff, her church news letter is read to her along with the newspaper. Conversations consist of talking about the birds, family, church, sports. She does like to sit and loot at the birds in the facility aviary. The Plan of Care instructs staff to introduce resident to residents with similar interests, facilitate interaction. On 8/22/18 at 8:15 am, R47 was lying in bed awake. R47's television was not on and R47 was watching people walking past her door, which is located right outside of the TV/activity area of the 100 Hall. R47 was continuously observed from 8:15 am - 10:00 am, and was not engaged by any staff during that time. At 10:00 am, V14 (Assistant Director of Nursing) went into R47's room and administered medication. At that time, V14 was questioned about the high back reclining wheelchair next to R47's bed. V14 stated the wheelchair belonged to R47 and that R47 is to get up throughout the day. R47 continued to be observed in her bed in her room at 10:30 am, 11:00 am, 12:00 pm, 12:30 pm, 1:00 pm, 1:30 pm, 2:00 pm , 2:30 pm, 3:30 pm and 3:45 pm, awake and looking out her doorway, with no TV or music on. On 8/22/18 at 3:53 PM, V20 (Certified Nursing Assistant) stated R47 was her patient for the current shift (2:00 pm - 10:00 pm) and that R47 is to be up for most of the day, so she will be in her room for the night, we can turn on the TV or music for her.

Based on interview and record review the facility failed to provide written notification to a resident and resident's Power of Attorney (POA) explaining the reason for a hospital transfer for three of three residents (R30, R58, R213 ) reviewed for transfer notifications in a sample of 21. Findings include: 1. R30's nurse's notes dated 8/8/18 document that R30 was transported to the hospital for evaluation. R30's electronic medical record does not document that written notice of transfer was given to R30 or R30's POA. On 8/22/18 at 1:23p.m. V1 (Administrator) verified that R30 was transferred to the hospital on [DATE]. V1 also verified that written notice of transfer was not given to R30 or R30's POA. 2. R58's nursing progress note, dated 7/18/18 at 1:40 PM document R58 was transferred to the hospital. R58's medical record does not document that written notice of transfer was given to R58 or R58's family. 3. R213's nursing progress note, dated 7/20/18 at 2:21 PM document R213 was transferred to the hospital. R213's medical record does not document that written notice of transfer was given to R213 or R213's family. On 8/23/18 at 10:00 AM, V1 Administrator confirmed that written notice of transfer was not given to R58, R213 or their families.

These failures resulted in two deficient practices: A. Based on interview and record review the facility failed to use a mechanical lift as careplanned during a transfer for one (R11) of seven residents reviewed for a fall in the sample of 15. This failure resulted in R11 sustaining an impacted medial tibial plateau fracture. B. Based on interview and record review the facility failed to investigate and determine root cause analysis and implement fall interventions to prevent falls for one of seven residents (R19) reviewed for falls in the sample of 15. Findings include: A. Facility Fall Assessment, Risk Identification and Management Policy (Revised 3/20/12) documents: that the policy will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess, and ultimately reduce injury risk; factors related to risk will be addressed and care planned; each resident will be assessed using the Minimum Data Set (MDS) upon admission, quarterly and any significant change assessment; and all staff providing care to the resident will have access to the care plan and interventions. R11's Physician order [REDACTED]. R11's MDS, dated [DATE], 3/28/17 and 6/20/17, documents R11's cognition as severly impaired and unable to assess. Facility Occurrence Report (dated 2/26/17, 1:02 pm) documents that Z1 (Agency Certified Nursing Assistant/CNA) was the assigned caregiver to R11. Z1 assisted R11 to the bathroom, R11's knees buckled, and R11 tripped on her own feet. Z1 then lowered R11 to the ground. R11's Progress Note (dated 2/26/17, 8:45 pm) documents Since supper, (R11) has progressively indicated she has pain in her right knee. At bedtime whimpered when put into bed. Right knee larger than left. R11's Progress Note (dated 2/27/17, 11:30 am) documents that bruising to R11's right lower extremity is larger, covering the majority of the anterior portion, below knee and to upper ankle, dark purple in color, knee to foot with pitting edema, and that R11 complained of knee pain. R11's Care Plan (initiated 1/17/17), documents that R11 is a mechanical lift for transfers. R11's MDS (1/3/17), documents that R11's Transfer and Toilet Use as extensive assistance with two person physical assist. R11's Fall Scale Assessment (dated 1/3/17) documents that R11 is a high risk for falls. R11's Radiology Imaging Patient Report (dated 2/27/17) documents an impacted medial tibial plateau fracture. Z2's (R11's Attending Physician) Order (dated 2/27/17) documents an order for [REDACTED]. Z2's Order (dated 3/6/17) documents an order for [REDACTED]. On 7/13/17, at 2:15 pm, E2 (Director of Nursing/DON) stated that on 1/17/17, R11 became a mechanical lift (sit-to-stand) due to an illness. On 7/13/17, at 12:00 pm, E4 (Licensed Practical Nurse/LPN) stated that on 2/26/17, right after lunch, Z1 (Agency CNA) was attempting to transfer R11 to a commode that was located in the whirlpool bathroom. Z1 called for E4 to come to the bathroom and assist with R11. E4 stated that, when I got there, (Z1) was the only staff present and (R11) was on the floor on her bottom, with her back against the toilet. E4 stated that, (Z1) told me that (R11) was holding onto the grab bar and (R11's) legs gave out and (R11's) feet got tangled and I had to lower her to the ground. On 7/13/17, E4 (LPN) stated that Z1 (Agency CNA) was the only staff member that was performing R11's transfer. On 7/14/17, at 10:10 am Z1 (Agency CNA) stated that, I was taking (R11) to the bathroom and all of the sudden (R11) just fell on me and went down. I pulled the call light for help. Z1 also stated, that, (R11) was a one person transfer to the bathroom and then after the fall they made her a mechanical lift. On 7/14/17, at 10:10 am, Z1 verified that Z1 had been an agency CNA at the facility for approximately 3 months and that no formal training is provided by the facility. Z1 stated that, I did not look at the Care Plan and all the others girls just tell me how people transfer and tell me what to do. B. On 7/14/17 at 11:30 am, E7 Corporate Nurse stated the Full Occurrence Report is used to investigate root cause analysis and is where interventions for resident falls are documented. E7 stated root cause analysis should be listed under Conclusion Statement, and interventions should be documented under Recommendations on the Full Occurrence Report. E7 also stated, all resident falls and interventions are to be documented on each resident care plan. The Progress Note, dated 7/8/17, documents R19 was found in (R19's) room lying on (R19's) left side. CNA (Certified Nursing Assistant) found the resident approx (approximately) 15 minutes after she had toileted the resident and repositioned (R19) in (R19's) (geriatric chair), and one on one supervision provided to the resident at this time. The Full Occurrence Report, dated 7/8/17, does not include a root cause analysis of R19's fall. The Progress Notes, dated 7/10/17 documents Called to resident room, resident on floor lying on (R19's) right side, slid out of recliner. There is no documented root cause analysis and no fall interventions documented. The Full Occurrence Report, dated 7/10/17, does not include a root cause analysis or any interventions for R19's fall. R1's current Care Plan, dated 6/20/17 does not document or include interventions for R19's 7/8/17 and 7/10/17 falls. On 7/14/17 at 11:00 am, E5 LPN (Licensed Practical Nurse) Care Plan Cordinator, stated she was not made aware of (R19's) 7/8/17 or 7/10/17 falls, therefore there is no root cause analysis or interventions for R19's falls.