Every finding on record at Idaho State Veterans Home - Boise

Based on staff interviews, policy, and record review, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 4 of 7 residents (#84, #71, #27, and #26) reviewed for abuse and neglect. The facility failed to prevent resident to resident altercations resulting in harm between Resident #84 and #71; failed to ensure wound care needs were met for Resident #27; and failed to prevent verbal abuse and neglect for Resident #26. Findings include: The facility's Freedom for Abuse, Neglect, Mistreatment, and Exploitation policy, revised 6/24, documented: Residents of the facility have the right to be free from all forms of abuse, neglect, exploitation, involuntary seclusion, injuries of unknown origin, misappropriation of property, and any crime.1. Resident #84 was admitted to the facility on [DATE], with multiple diagnoses including dementia, anxiety, and ADHD (attention-deficit hyperactivity disorder). Resident #84's care plan documented: -Directed staff that he wandered and was an elopement risk, and to distract him from wandering, initiated 6/11/25. -Directed staff to anticipate his needs and monitor his non-verbal communication (facial expression and gestures), and to monitor/report his risk for harm to others (increased anger, agitation, feeling threatened), initiated 6/12/25. Resident #71 was admitted to the facility on [DATE], with multiple diagnoses including PTSD, dementia, depression, repeated falls, and weakness. Resident #71's care plan, initiated 12/6/23, documented: -He had the potential for severe anxiety related to his BPSD (behavioral and psychological symptoms of dementia), and overall poor understanding of his deficits, including anxiety around others or which effects his sleep causing a full-blown anxiety attack/anger. -He had impaired cognition/dementia, or impaired thought process, which required moderate to significant assistance with all decision making as he did not have a good understanding of his deficits or limitations. a. An Abuse report was filed with the Idaho State Long-Term Care reporting portal on 10/14/25, which documented a nurse heard shouting at the end of the hallway and observed Resident #84 and Resident #71 in the doorway of Resident #71's room. Resident #84 was observed in his wheelchair throwing punches with his left hand toward Resident #71. Resident #71 was observed standing and striking Resident #84 with his left- and right-hand multiple times in a downward motion; at least six punches connected with Resident #84's head and face. Both residents were immediately separated by staff. The report documented the following injuries: -Resident #84 received a nursing assessment which identified bruising to the nose (1 cm x 1 cm), left forehead (1 cm x 1 cm), an outer portion of the left eye socket (2 cm x 2 cm, raised approximately .5 cm). Neurological checks were initiated with no concerns noted at that time. -Resident #71 received a nursing assessment and no concerns were noted. The report documented the following immediate steps were taken: -Resident #84 was moved away from Resident #71's room, assessed and treated for injuries. -Resident #71 agreed to go back to his room. -Staff sat with Resident #84 to ensure safety and prevent further intrusive wandering into Resident #71's space. -Resident's representative, facility staff, and physician were notified. -LCSW #2 interviewed staff witnesses to help determine antecedents and possible plans to prevent further altercations. -Resident #71 was temporarily transferred to another unit shortly after the incident and provided a Roam Alert bracelet as he expressed a desire to find that guy to the writer of the report. The report further documented the following investigation: -LCSW #2 interviewed Resident #71 within minutes of the incident: Resident #71 stated, [Resident #84] came into my room. I told him to leave. He came at me and started punching me (mimicking getting punched in the chest), I gave [Resident #84] a good one. I'm not hurt. -Resident #84 was interviewed by LCSW #2, who was unable to describe what had happened. -Staff interviewed reported they had seen Resident #84 in the hallway as he had come back from an activity, and Resident #71 was last seen in his room resting. -LCSW #2 interviewed other residents related to concerns with their safety or people coming into their rooms that were not supposed to be there; no concerns voiced. -LCSW #2 spoke with Resident #71's guardian and corroborated that Resident #71 will be aggressive if he feels others are in his space. They discussed the possibility of a transfer off the secured unit as there would be less likelihood of other confused residents in his personal space. -LCSW #2 spoke with Resident #84's wife to discuss a possible room change to minimize intrusive wandering at the end of the SCU hall. -The physician reviewed Resident #71's medication and added a low dose of as needed Risperdal for the next two weeks. -LCSW #2 met with staff from both units to determine if the current plan would be safer for both residents. Staff reported that Resident #71 continued to ask about that guy and wanted to make sure that guy was not bother the staff or others. -LCSW #2 and [staff], spoke with staff about the usual wandering habits of Resident #84 and staff expressed that Resident #84 rarely enters the rooms of others but will go up to doorways and look in; specifically, often times the doorway at the end of the hall where the altercation occurred. The report concluded the following corrective actions: -After review, Resident #71 was transferred off the secured unit to 2W unit to reduce possibility of other residents intrusively wandering into his room and to prevent any further altercations between Resident #71 and Resident #84. -The physician reviewed both residents for possible medical issues (bowels, infections, medications) with none noted. The physician added a low dose twice daily as needed Risperdal for Resident #71 that had not been needed (other than on the same day, shortly after the incident, when Resident #71 was still worked up and anxious from the altercation and room change.) -Resident #84 had not shown any fear or concerns around other residents and appeared to show no recollection of events. -Team evaluating possible room change for Resident #84, as discussed above, to reduce intrusive wandering into other spaces. -Unit meeting was held on the secured unit, 10/16/25, with staff from multiple shifts to review plans to reduce Resident #84's potential for intrusive wandering on the secured unit. Staff were encouraged to offer input on residents needs and well-being. -2W staff had a unit meeting on 10/16/25 to discuss cares and safety needs for Resident #71. On 8/20/26 at 2:21 PM, LCSW #2 stated Resident #71's room was at the end of the hall where Resident #84 would stop and turn around during his wandering. LCSW #2 stated the facility confirmed abuse occurred between both residents, with Resident #84 being harmed by Resident #71. b. An Abuse report was filed to the Idaho State Long-Term Care reporting portal on 9/28/25, which documented an incident on 9/27/25, where Resident #84 without provocation, swung his fists in the stomach region of Resident #71 punching him in the stomach. Resident #71 responded by punching Resident #84 in the left forehead area once. Facility staff intervened and removed Resident #84 away to his room for a nap, where he was assessed as having a very slight bruise from the strike to his head. Resident #71 was moved into the common area, directed to sit down, and to have a soda, while being assessed for a slightly sore right hand. The abuse report documented the facility completed the following immediate steps: -Residents were separated and assessed for injury. -Residents were assisted to separate areas of unit and provided with snacks to help distract and redirect to another activity of interest. -Appropriate individuals for resident and facility staff were notified. -Witness statements were collected. -LCSW #2 interviewed staff involved and spoke with family. -Staff were provided with instructions to keep Resident #84 from engaging with Resident #71 when agitated. -The physician adjusted medications. -A review identified overstimulation might have been a factor, in addition to Resident #84's advancing dementia, and efforts made to increase music on unit and reduce television usage, unless TV is providing therapeutic benefits. The report documented the following corrective actions were taken: -Resident #84's seated area in the dining room was causing agitation due to the confined space, which required more staff support during and after meals. -An in-service related to the calming aspects of music versus television for individuals with dementia was provided, and Resident #84's care plan was updated to identify his preferred music choice. -The physician reviewed recent medications for Resident #84 and increased morning Risperdal from .25 mg to .5 mg, with monitors for sign/symptoms and efficacy. Resident #84 had been receiving .5 mg twice per day. -The physician reviewed Resident #84's medications and added a noon dose of Risperdal .25 mg to .5 every morning and bedtime dosing. -Staff noted a reduction in agitation with an opportunity for Resident #84 to rest in bed between breakfast and lunch. -On 10/1/25, a unit meeting with staff from multiple shifts reviewed the plan to prevent further altercations between Resident #84 and Resident #71. Staff were encouraged to offer input on residents' needs and well-being. On 8/20/26 at 2:14 PM, LCSW #2 stated residents were being relocated due to the construction that was happening at the facility. Resident #84 was roaming more frequently. During this incident Resident #84 flayed his arms at Resident #71 and we didn't know until later that contact was made by Resident #84 to Resident #71's abdominal area. Resident #71 responded by punching Resident #84 on the forehead. Both residents were immediately separated, redirected, and assessed for injuries. We interviewed residents, and staff, educating staff about how to help both residents. LCSW #2 stated the facility confirmed abuse occurred between both residents. 2. Resident #26 was admitted to the facility on [DATE], and re-admitted on [DATE], with multiple diagnoses including muscle weakness, inflammatory polyarthropathy (inflammation affecting five or more joints), and lumbar spinal stenosis (narrowing of the spinal canal in the lower back). A review of the State Agency's Long-Term Care Reporting Portal, documented Resident #26 experienced verbal abuse and neglect from the staff as follows: A facility investigation report received on 1/2/26, documented on 12/31/25, Resident #26 came in after breakfast and asked CNA #6 to be laid down when they got a minute. CNA #6 replied to Resident #26 That sucks to want and walked off. Resident #26 went around the unit to find other staff members to help lay them down. On 1/1/26, after Resident #26 returned from having a cigarette, Resident #26 asked CNA #6 to be laid down when they got a minute. CNA #6 replied to Resident #26, I'm going to go take a break and smoke. I'll think about it when I get back. Resident #26 reported the incident to CNA #7. CNA #7 immediately notified the administrator. An investigation was conducted and staff and residents were interviewed. Five residents on the floor where CNA #6 primarily worked were interviewed. Four of the five residents interviewed recognized CNA #6 but denied ever being abused by CNA #6. One resident did not recognize CNA #6 but stated they felt safe at the facility. The investigation report documented that staff members who worked with CNA #6 were interviewed and all the staff members voiced concerns about the way CNA #6 spoke to the residents and reported CNA #6 did not speak to residents nicely and was short-tempered. The investigation report substantiated the allegation CNA #6 verbally abused and neglected Resident #26. On 8/20/26 at 3:00 PM, LCSW #1 confirmed CNA #6 was put on administrative leave during the investigation and was not allowed to return to the building. LCSW #1 confirmed the allegation was substantiated and CNA #6's last day in the building was 1/1/26. 3. Resident #27 was readmitted to the facility on [DATE], with multiple diagnoses including pressure ulcer of the left heel, absence of lower right leg below the knee, and anxiety disorder. A review of the Long-Term Care Reporting Portal, documented the facility reported an allegation of neglect on 10/20/25. A review of the facility's neglect investigation was conducted with the following findings: The facility's investigation dated 10/20/25, documented the allegation was reported to the nursing home administrator on 10/20/25. The allegation alleged LPN#1 refused to provide a wound dressing for Resident #27 on 10/17/25. The facility Administrator and Director of Nursing placed LPN #1 on administrative leave and initiated the investigation process. The investigation documented Resident #27's representative was informed and interviewed regarding the allegation but had no concerns. LPN #1 provided a statement to the facility stating she acknowledged seeing Resident #27 heel in the bathing room on 10/17/25 and delegated the application of the dressing to a certified nursing assistant (CNA). The investigation included CNA #1's statement documenting Resident #27 requested to have a mepalex dressing placed on his left heel however when CNA#1 reported the concern to LPN #1 she stated, I don't feel like it right now, I'll do it later. CNA #1's statement documented she informed LPN #1 several times about Resident #27's need for a dressing. She started on 10/18/25 Resident #27 still didn't have a dressing on his left heel. CNA #1 then reported the issue to the night shift nurse who applied the dressing immediately. On 10/22/26 LN #1 provided a statement confirming she applied the wound dressing to Resident #27's left heel on 10/18/25. The facility's investigation included six resident interviews. Five resident statements documented no concerns. One resident statement when asked about LPN #1 documented, I don't like her. She has a sassy attitude. The investigation included multiple staff interviews. Staff were asked if they had any concerns with LPN #1's implementation of treatment for residents. Unit Manager #2's statement documents a concern with treatment administration for 21 residents signed out of the Medication Administration Record (MAR) within 7 minutes by LPN #1. Based on the information gathered during the investigation the facility concluded the allegation of neglect was confirmed. On 8/20/26 at 2:56 PM, LCSW #1 confirmed the investigation identified neglect when LPN #1 did not provide wound care treatment to Resident #27.

Based on observations, record review, review of incident and accidents (I&A), review of the State Agency's Long-Term Care Reporting Portal, and staff interviews, it was determined the facility failed to ensure adequate supervision and the use of required assistive devices were used to prevent accidents. This was true for 1 of 11 residents (#21) reviewed for accidents. This deficient practice resulted in actual harm to Resident #21 who sustained a fall with a significant injury requiring emergency medical transport. Findings include:1. Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including muscle weakness, osteoarthritis, and displaced intertrochanteric fracture of right femur.Resident #21's care plan initiated on 2/6/26 and revised on 6/23/26, directed staff to assist Resident #21 with a gait belt and walker for all transfers.An I&A report dated 4/30/26 at 1:22 PM, documented the nurse was alerted to Resident #21's room by staff after a fall. Resident #21 was lying on the right side of the bed on his back. CNA #8 reported Resident #21 was trying to transfer from his wheelchair to his bed, tripped on the rug, and fell. Resident #21 hit the back of his head on the bedside table and landed on his right hip. Resident #21 was wearing proper footwear. The I&A report further documented Resident #21 was assessed for injury and was unable to move his right lower extremity without severe pain. EMS and the MD were called for urgent transport to the ER for further evaluation.The fall report included a statement from CNA #8 documenting maintenance came to pick up Resident #21's chair. Resident #21 stood up, started walking towards his bed, CNA #8 had Resident #21's catheter bag when Resident #21 tripped on the rug and fell to the floor. CNA #8 yelled for help.A review of the facility's Investigation Into Fall with Injury & Neglect report, dated 4/30/26-5/7/26, documented CNA #8 that witnessed the fall was interviewed. CNA #8 stated Resident #21 had complaints of his wheelchair not working and maintenance came to fix the wheelchair. CNA #8 stated Resident #21 was sleeping in his chair and CNA #8 explained to Resident #21 that maintenance was there to fix the wheelchair. CNA #8 stated Resident #21 stood up, CNA #8 grabbed the catheter bag, Resident #21 turned and CNA #8 had the wheelchair in one hand. CNA #8 further stated Resident #21 tripped on a rug, hit his head on the overbed table and Resident #21's right hip hit hard on the floor. Resident #21 complained of breaking his hip and CNA #8 notified the nurse. When asked if CNA #8 was aware of what Resident #21's care plan stated for transfers, CNA #8 stated he was not aware but knew Resident #21 had been transferring independently. When asked if CNA #8 used a gait belt, CNA #8 stated no.The investigation report substantiated the allegation of neglect based on CNA #8 not reviewing Resident #21's care plan and failed to use a gait belt during transfer which was indicated in Resident #21's care plan.On 8/20/26 at 3:42 PM, the DON stated CNA #8 had been with the company for more than 10 years and was terminated because of the incident. The DON stated gait belt audits were conducted, and a gait belt was placed in every resident's room. The DON further stated education was provided to staff on gait belt use.

Based on record review, resident interview, and staff interview, it was determined the facility failed to provide resident consents for assistive devices. This was true for 4 of 4 residents (#2, #8, #10, and #16) whose records were reviewed for notification of assistive device use. This deficient practice created the potential for harm if residents were not allowed to be informed in advance and participate in their treatment. Findings include: 1. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness, diabetes, Alzheimer's, dementia, depression, and PTSD (Post Traumatic Stress Disorder).On 8/17/26 at 11:55 AM, Resident #2's bed was observed with a perimeter mattress on his bed.A review of Resident #2's medical record did not include a consent form signed by the resident or resident's representative for the use of the perimeter mattress.On 8/19/26 at 2:30 PM, the DON confirmed there were no consents on file for Resident #2 for the perimeter mattress. 2. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including Parkinsonism, weakness, diabetes, depression, and repeated falls.On 8/17/26 at 8:45 AM, Resident #16 was observed near the nurse's station in a broda wheelchair.Resident #16's care plan directed and educated staff about the following:-Wheelchair: Resident #16 is not able to propel, initiated 3/23/26.-Utilize a tilt-in-space or broda wheelchair at approximately 45 degrees tilt during seated periods for pressure relief/offloading and reduction of sacral shearing forces, initiated 5/6/26.A review of Resident #16's medical record did not include a consent form signed by the resident or resident's representative for the use of the broda chair.On 8/19/26 at 2:34 PM, the DON confirmed there was not a consent form for the use of the broda chair. 3. Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, diabetes, PTSD, and low back pain.On 8/17/26 at 2:08 PM, Resident #10 was observed with a roam alert bracelet on his wrist.Resident #10's care plan directed and educated staff to:-Check roam alert operation and placement every evening shift, initiated 3/18/26.A review of Resident #10's medical record did not include a consent form for a roam alert bracelet. On 8/19/26 at 2:36 PM, the DON confirmed Resident #10 did not have a consent form for the roam alert bracelet. 4. Resident #8 was admitted to the facility 5/11/21, and readmitted on [DATE], with multiple diagnoses including Parkinsonism, diabetes, bipolar disorder, PTSD, anxiety, depression, and pain.On 8/21/26 Resident #8 was observed with a wheelchair alarm.Resident #8's care plan documented: -Wheelchair and bed pad alarms which would sound at the nurse's station, initiated 6/25/26.-A roam alert bracelet on his right wrist, initiated on 11/29/24.A review of Resident #8's medical record did not include a consent form signed by the resident or resident's representative for the use of the roam alert bracelet, wheelchair and bed pad alarm.On 8/21/26 at 8:25 AM, the DON confirmed there were no consents on file for Resident #8's device use.

Based on observation, record review, policy review, review of the FDA Food Code, and staff interviews, it was determined the facility failed to ensure food was stored, dated, and maintained according to safe food handling standards for ready to eat foods and refrigerated items. This was true for 1 of 1 dry food storage and 1 of 7 refrigerators observed. This deficient practice had the potential to affect all residents who consumed foods or drinks stored and prepared by the facility and had the potential to result in foodborne illness. Findings include: The facility's Food Storage policy, dated 2013 documented:-Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41 degrees Fahrenheit.-Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 degrees Fahrenheit. Temperatures for refrigerators should be between 35 to 39 degrees Fahrenheit. Thermometers should be checked at least two times each day. Check for proper functioning of the unit at the same time.-Each nursing unit with refrigerator/freezer unit will be supplied with thermometers and monitored for appropriate temperatures.-Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed.-All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 1. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.a. On 8/21/26 at 2:25 PM, during the final kitchen inspection, two 3 pound 2 ounce cans of Campbells Cream of Celery Soup were observed in the dry food storage room on the middle bottom storage rack with a date of [DATE] circled in black ink.On 8/21/26 at 2:30 PM, when asked about the date, [NAME] #1 with the DON present stated it might be the manufacture date. The DON stated it looked like an expiration date and would contact the dietary manager to clarify.On 8/21/26 at 3:30 PM, the DON confirmed the date on top of the soup cans were the expiration date and stated the cans would stay in her office to give to the Dietary Manager on Monday when she returned to the facility. b. On 8/21/26 at 2:35 PM, during the final kitchen inspection, three half gallons of Meadow Gold Half and Half were observed in the 2nd fridge with a best by date of 8/20/26.On 8/21/26 at 2:40 PM, [NAME] #1 with the DON present, confirmed the half and half expired on 8/20/26 and needed to go in the expired bin for a return credit from the supplier. 2. The FDA Food code Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding documented: Time/Temperature control for safety food shall be maintained at 41 degrees Fahrenheit or below.On 8/17/26 at 10:23 AM, the facility's refrigerator temperature log was observed fixed to the side of the refrigerator in the 1 west common area. The temperature log was dated August 2026. The temperature log indicated an area to record temperatures, comments/adjustments, and nurse initials. The temperature log was observed to be missing refrigerator temperatures for the following days:-8/9/26-8/10/26-8/11/26-8/12/26-8/13/26-8/14/26-8/16/26The refrigerator was also observed to contain an opened cup of applesauce dated 8/16/26 and a pitcher of red juice. No open date or use by date was observed on the pitcher of juice.On 8/17/26 at 10:35 AM, LPN #2 confirmed the refrigerator was used as a snack refrigerator for the residents. LPN #2 also confirmed the pitcher of juice did not contain a date, and the applesauce cup was dated 8/16/26. When asked about the applesauce cup, LPN #2 stated they do not usually keep anything open in the refrigerator and usually throw away opened food items. LPN #2 further stated the night shift staff were responsible for checking refrigerator temperatures.On 8/21/26 at 8:35 AM, the Unit Manager #2 confirmed night shift staff were responsible for checking refrigerator temperatures and should be checking temperatures nightly. The Unit Manager #2 accompanied the surveyor to the 1 west common area refrigerator and confirmed the temperatures for the refrigerator had not been done. When asked about dating the juice pitchers, the Unit Manager #2 stated, whoever is putting stuff in the fridge should be dating it.

Based on observation, policy review, record review, resident interviews, and staff interviews it was determined the facility failed to provide assistive device assessments to ensure residents were not restrained. This was true for 4 of 4 residents (#2, #8, #10, and #16) whose restraint devices were reviewed. This deficient practice created the potential for psychosocial harm if residents felt the facility was restraining them for purposes of discipline, convenience, and/or not treating their medical symptoms. Findings include:The facility's Motion Detection Device Identification policy, revised 12/15, did not include information related to assessing if a device would be a restraint when used for residents.No Restraint Device Policy was provided.1. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness, diabetes, Alzheimer's, dementia, depression, and PTSD.On 8/17/26 at 11:55 AM, Resident #2's bed was observed with a perimeter mattress on his bed.A review of Resident #2's care plan, initiated 6/24/26, documented pressure redistribution with perimeter overlay to identify edges of mattress to promote skin integrity is in place on my bed. Resident has been offered motor-less air mattress. Resident trialed and declined this. A physician's order, dated 6/24/26, documented Resident #2 was to have pressure redistribution with a perimeter overlay to identify edges of the mattress and to promote skin integrity.A review of Resident #2's medical record did not include a restraint assessment of the perimeter mattress.On 8/19/26 at 2:30 PM, the DON confirmed there were no restraint assessments on file for Resident #2's perimeter mattress. 2. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including Parkinsonism, weakness, diabetes, depression, and repeated falls.On 8/17/26 at 8:45 AM, Resident #16 was observed near the nurse's station in a broda wheelchair.Resident #16's care plan documented:-Wheelchair: Resident #16 is not able to propel, initiated 3/23/26.-Utilize a tilt-in-space or broda wheelchair at approximately 45 degrees tilt during seated periods for pressure relief/offloading and reduction of sacral shearing forces, initiated 5/6/26.A review of Resident #16's medical record did not include a restraint assessment for the use of the broda chair.On 8/19/26 at 2:34 PM, the DON confirmed restraint assessments are not being consistently completed for assistive devices, and Resident #16 does not have one. 3. Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, diabetes, PTSD, and low back pain.On 8/17/26 at 2:08 PM, Resident #10 was observed with a roam alert bracelet on his wrist.Resident #10's care plan documented:-Check roam alert operation and placement every evening shift, initiated 3/18/26.Resident #10's medical record did not include a restraint assessment for the use of the roam alert bracelet.On 8/19/26 at 2:36 PM, the DON confirmed Resident #10 did not have a restraint assessment for the roam alert bracelet. 4. Resident #8 was admitted to the facility 5/11/21, and readmitted on [DATE], with multiple diagnoses including Parkinsonism, diabetes, bipolar disorder, PTSD, anxiety, depression, and pain.On 8/21/26 Resident #8 was observed with a wheelchair alarm.Resident #8's care plan documented: -Wheelchair and bed pad alarms which would sound at the nurse's station, initiated 6/25/26.-A roam alert bracelet on his right wrist, initiated on 11/29/24.A review of Resident #8's medical record did not include restraint assessments for the use of the roam alert bracelet, or for the wheelchair and bed pad alarm.On 8/21/26 at 8:25 AM, the DON confirmed there were no restraint assessments on file for Resident #8's roam alert bracelet, or wheelchair and bed pad alarms.

Based on record review, policy review, and staff interview, it was determined the facility failed to report an allegation of abuse within two hours. This was true for 1 of 7 abuse reports reviewed. This deficient practice created the potential for further psychosocial and physical harm if resident's suspected abuse interactions were not reported in a timely manner for investigative purposes. Findings include:The facility's Abuse Policy, dated 2024, documented the facility must report no later than 2 hours after the allegation involving serious bodily injury. The covered individual and facility reporting requirement for reporting reasonable suspicion of a crime must be completed immediately, but no later than 2 hours after forming the suspicion if the suspicion involves serious bodily injury.An Abuse report was filed to the Idaho State Long Term Care reporting portal on 9/28/25 at 12:15 PM, which documented an incident on 9/27/25 at 2:32 PM, where Resident #84 without provocation, swung his fists in the stomach region of Resident #71 punching him in the stomach. Resident #71 responded by punching Resident #84 in the left forehead area once. Facility staff intervened and removed Resident #84 away to his room for a nap, where he was assessed as having a very slight bruise from the strike to his head. Resident #71 was moved into the common area, directed to sit down, and to have a soda, while being assessed for a slightly sore right hand. On 8/20/26 at 2:47 PM, LCSW #2 stated potential abuse is reported to the State within 2 hours. However, prior to March of 2026, we were not reporting abuse with physical altercations within 2 hours.Cross Reference F600

Based on observation, policy review, record review, and staff interview, it was determined the facility failed to develop and revise comprehensive person centered care plans that reflected the current needs and functional abilities of residents. This was true for 3 of 19 residents (#3, #6, and #47) reviewed for care planning. This deficient practice resulted in care plans that did not accurately guide staff in providing required care and implementing physician ordered interventions. Findings include: The facility's Care Plan Development policy, revised 8/18, documented: The interdisciplinary team will develop and implement a baseline and/or comprehensive care plan for each resident that includes the instruction needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of admission. In the event that the comprehensive assessment and care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the care plan, those changes shall be incorporated into an updated care plan provided to the resident and his or her representative, if applicable. 1. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses, including osteoarthritis (the most common form of arthritis, occurring when the protective cartilage that cushions the ends of your bones wears away over time), spondylosis (age-related wear and tear on the spine, which includes the breakdown of spinal disks), spinal stenosis (a narrowing of the spaces within your spine that puts pressure on the spinal cord and nerves), repeated falls, and dementia. Resident #6's care plan, initiated 11/6/23 and revised 7/7/25, documented Resident #6 required stand by assistance with close supervision to ensure safety of gait and to decrease risk of elopement with gait or wheelchair mobility in the facility per PT (physical therapy) recommendations for ambulation. Resident #6 was observed independently ambulating in the hallway without staff assistance for the following dates and times: -8/18/296 at 11:28 AM -8/19/26 at 9:45 AM -8/19/26 at 2:16 PM -8/20/26 at 5:46 PM On 8/20/26 at 5:48 PM, the DON confirmed Resident #6 independently ambulates and further stated sometimes Resident #6 gets tired and uses a wheelchair. When asked to clarify Resident #6's care plan, the DON reviewed Resident #6's care plan with the surveyor and stated the care plan needed updated. 2a. Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses, including nondisplaced fracture of base of neck of right femur, presence of left artificial hip joint, and dementia. A review of Resident #47's Physician Orders dated 8/17/26 documented: Call-light activating floor mat to left side of bed while resident is in bed to alert staff when resident may need assistance with mobility, transfers, or other needs. Check placement and function every shift. A review of Resident #47's care plan did not document the intervention for the fall mat alarm. On 8/19/26 at 10:54 AM, Resident #47 was observed lying in his bed covered with a blanket. A long gray colored rubber fall mat was noted on the floor to the left side of Resident #47's bed. On 8/20/26 at 12:53 PM, when asked about the fall mat/alarm intervention, the Unit Manager #2 stated the intervention was implemented on 8/17/26 when Resident #47 re-admitted to the facility from the hospital. When asked when care plans were updated when a resident re-admits to the facility, the Unit Manager #2 stated care plans should be updated within the first 48 hours of returning to the facility. When asked about Resident #47's care plan for the fall mat/alarm, the Unit Manager #2 confirmed the fall mat/alarm was not on the care plan and further stated the care plan should have been revised when Resident #47 re-admitted . b. A review of Resident #47's care plan, initiated 3/17/26, documented the following interventions: - Bed mobility: independent. -Transfer: IND (independent)-revised 5/4/26. -Ambulate: IND (independent)-revised 5/4/26. -Assistive devices include: FWW (front wheel walker)-revised 3/24/26. -ADL (Activities of Daily Living) independent. On 8/19/26 at 10:49 AM, CNA #3 and CNA #4 were observed to reposition and move Resident #47 up in bed and observed to hold a water cup with a straw to Resident #47's mouth to drink. When asked about the care provided to Resident #47, CNA #3 stated the staff help Resident #47 to the bathroom, provide peri-care, help with dressing, walking to and from the dining room, and help with putting in dentures. CNA #3 further stated Resident #47 was more of a fall risk now than he used to be. On 8/21/26 at 7:58 AM, CNA #5 was observed wheeling Resident #47 in a wheelchair to his room, obtained another staff member to assist with care, and closed the door. When CNA #5 exited the room, CNA #5 was asked about the care staff provide to Resident #47. CNA #5 stated Resident #47 required help getting up for meals, required assistance with eating, nail care, dressing, bathing, denture care, and changing of his brief. CNA #5 further stated Resident #47 was a two person transfer with a gait belt. On 8/21/26 at 8:22 AM, when asked if Resident #47 was independent with ADLs, the Unit Manager #2 stated Resident #47 was not independent with ADLs but it was the goal for Resident #47. When asked how staff know what care to provide if the care plan documented Resident #47 was independent with ADLs, the Unit Manager #2 confirmed the care plan did not reflect Resident #47's status and the care plan should have been revised. The Unit Manager #2 further stated staff are updated verbally on cares. 3. Resident #3 was readmitted to the facility on [DATE], with multiple diagnoses, including right below knee amputation, chronic pain, and right sided hemiplegia and hemiparesis following a stroke. Resident #3's care plan, dated 5/5/26, documented the use of a trapeze. A physician's order, dated 4/30/26, documented a trapeze bar to assist with bed mobility. Resident #3 was observed in bed in his room without a trapeze bar in place on the following dates and times:-8/18/26 at 9:17 AM-8/19/26 at 9:53 AM-8/20/26 at 11:54 AM On 8/20/26 at 11:59 AM, during a review of Resident #3's record, Unit Manager #1 stated that the physician order and care plan should have been revised when the trapeze was removed.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided respiratory services consistent with professional standards of practice. This was true for 1 of 4 residents (Resident #21) whose respiratory devices were not stored properly. This deficient practice created the potential for respiratory infections due to growth of pathogens (organisms that cause illness) in respiratory treatment equipment. Findings include:Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including displaced intertrochanteric fracture of right femur, COPD, and chronic respiratory failure with hypoxia.a. On 8/19/26 at 3:18 PM, Resident #21 was observed lying in bed wearing a nasal cannula attached to Resident #21's oxygen concentrator that was set to deliver 3 liters of oxygen per minute. Resident #21's portable oxygen nasal cannula was observed wrapped around the back of his wheelchair with the oxygen tubing running down the left side of the wheelchair with the nasal cannula dangling near the floor.On 8/19/26 at 3:25 PM, when asked about oxygen tubing storage, CNA #1 stated oxygen tubing should be stored in a bag. When asked if Resident #21's oxygen tubing was stored in a bag, CNA #1 confirmed Resident #21's oxygen tubing was not stored in a bag.On 8/19/26 at 4:29 PM, when asked about the oxygen tubing storage policy, the DON stated oxygen tubing should be stored in a bag and labeled with the resident's name and date.b. The facility's Equipment/Supplies Cleaning/Disposal Schedule Policy documented: Nebulizers will be changed on Monday of each week and PRN [as needed] and stored in a plastic bag. (Nebulizers shall be dated and change-over documented on Treatment Sheet.)Resident #21's physician's order, dated 7/27/26, documented: Nebulizers will be changed on Monday of each week and stored in a plastic bag. Nebulizers shall be dated. Every night shift every mon [Monday] for nebulizer usage.On 8/19/26 at 3:18 PM, Resident #21's nebulizer machine was observed on his nightstand table with the nebulizer mask observed resting on top of the nightstand with the tubing connected to the nebulizer machine. No bag or barrier was observed.On 8/19/26 at 3:25 PM, when asked about nebulizer storage, CNA #1 stated nebulizers were to be stored in a bag.On 8/19/26 at 4:29 PM, when asked about the nebulizer storage policy, the DON stated it was the same as oxygen. She further stated nebulizer masks or pipes should be rinsed and set out on a paper towel to dry and then put back in a bag.

Based on interview and record review, it was determined the facility failed to ensure opioid monitoring was developed and implemented for 1 of 6 residents (Resident #74) whose records were reviewed for opioid medications. This failure had the potential for unmonitored adverse effects, such as respiratory depression, sedation, constipation, or increased fall risk. Findings include: Resident #74 was readmitted to the facility on [DATE], with multiple diagnoses, including chronic pain, dementia, and repeated falls.Review of Resident #74's care plan identified a pain focus area; however, the care plan did not include monitoring related to opioid use.Resident #74's record included a physician order for a Buprenorphine transdermal patch (an opioid pain medication):- 5 micrograms per hour; apply one patch transdermally every 7 days for pain control and remove per schedule.A review of Resident #74's record revealed no documentation of opioid monitoring for adverse effects.On 8/20/26 at 12:49 PM, Unit Manager #2 stated that Resident #74's record did not include opioid monitoring.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure medications were stored securely and managed according to physician orders and manufacturer expiration dates. This was true for 1 of 1 resident (Resident #1) whose medication was observed at the bedside. This deficient practice created the potential for inappropriate administration of medication, decreased medication effectiveness, and failure to maintain safe medication management practices. Findings include:The facility's Medication Storage/Disposal Policy, revised 12/15 documented:Resident MedicationsAll medications brought by a resident will be sent home with families. If no family is available, medications will be stored and given to residents upon dismissal from the facility. If the medications are stored for over 30 days, they will be destroyed with proper witness and documentation by the Director of Pharmacy.If it is determined that there is a compelling reason to use the resident's own medication, a physician's order is required. Examples of valid justification may be unusual medications which the pharmacy has difficulty obtaining.The physician order shall specify that the resident's own medication is to be stored and the name of the drug, the dose and the directions/reason for use.The prescription must be identified by the pharmacist and it must be properly labeled. The pharmacist will affix another identifying label certifying the contents.The nurse will store the authorized medication with other routine medications.The nurse will administer the medication(s) and record use on the medication administration record.If the medication is anticipated to be accessible to the resident then a self-medication assessment needs to be completed.The facility's Self-Administration of Medication Policy, revised 6/20 documented:-Medications to be administered in the self-administration program must be kept in a locked drawer at the individual resident's bedside.-The Licensed Nurse assigned to a resident on a self-administration program shall check the inventory of the medications kept at the bedside and document the use of the medications on the resident's eMAR (electronic Medication Administration Record) on a shift/daily basis.-For those residents using hand-held nebulizers/MDI (Metered-Dose Inhaler), the nurse will maintain nebulizer/MDI medications at the med cart.Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including COPD, asthma, and hypoxemia (a lower-than-normal level of oxygen in the blood).Resident #1's care plan, initiated 6/5/25 documented: The doctor has given me permission and orders are placed for me to self-administer my own eye drops and inhalers.A review of Resident #1's physician orders did not contain an order to self administer inhalers or contain a physician order for an inhaler.Resident #1's Self Administration of Medications Assessment, dated 8/4/26, documented under section C question 2, Resident has not been granted approval to self-administer medications was check marked.A review of Resident #1's August 2026 MAR/TAR did not include documentation of an inhaler being administered.On 8/20/26 at 5:23 PM, a yellow colored inhaler with an orange cap was observed sitting on Resident #1's overbed side table next to a box of straight catheters. The inhaler was not observed to be in a locked drawer.On 8/20/26 at 5:30 PM, the DON reviewed Resident #1's physician orders with the surveyor and stated she did not see an order for an inhaler. The DON reviewed Resident #1's Self Administration of Medications Assessment with the surveyor and confirmed the resident had not been approved to self administer medications.On 8/20/26 at 5:43 PM, the DON accompanied the surveyor to Resident #1's room. The DON removed the inhaler from Resident #1's room and stated the inhaler was albuterol (a fast-acting rescue medication used to quickly open the airways in the lungs and relieve symptoms like wheezing, coughing, and shortness of breath). The DON then removed the inhaler cartridge and showed the surveyor the albuterol expiration date which read [DATE]. The DON stated she would have to look to see when Resident #1 had orders for the albuterol and further stated she did not know why Resident #1 still had the albuterol.On 8/21/26 at 10:00 AM, the DON showed the surveyor an Order Audit Report with an order date of 4/21/25 which documented the following order:-Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 6 hours as needed for SOB (shortness of breath)/Asthma/COPD unsupervised self-administration **wait 1 min b/t [between] puffs**Okay for resident to keep this at bedside and self administer as directed.-The order status on the Order Audit Report documented, Discontinued.The DON stated the medication had been discontinued in February 2026.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 7 of 11 residents (#11, #26, #28, #29, #38, #46, and #52) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The RAI, revised 10/1/2024, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR level II screening determines a resident has a serious mental illness and/or mental retardation, or related condition. 1. Resident #26 was admitted to the facility on [DATE], with a diagnoses of dementia with agitation, PTSD, and Major Depressive Disorder. Resident #26's Admission MDS assessment, dated 12/11/23 and Significant Change MDS dated [DATE], documented under A1500 in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR level II found in his electronic medical record dated 12/5/23. 2. Resident #52 was admitted to the facility on [DATE] with diagnoses of anxiety and PTSD. Resident #52's Annual MDS assessment, dated 8/20/24 documented under A1500 in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR level II found in his electronic medical record dated 8/2/23. On 5/15/25 at 2:25 PM, the MDS Coordinator stated Resident #26 and #52's MDS assessments were coded that the resident did not receive a PASRR level II screening because she misinterpreted the meaning of the MDS A1500 question. 48402 3. Resident #38 was readmitted to the facility on [DATE] with multiple diagnoses including dementia and mild cognitive impairment. Resident #38's Annual MDS assessment, dated 5/19/24 documented under I5950 in section I, yes for question, Does the resident have a psychotic disorder other than schizophrenia? However, on review of Resident #38's record no diagnoses were identified to meet the criteria for a psychotic disorder. On 5/15/25 at 3:09 PM, the MDS coordinator stated she had no evidence to support the decision for marking yes for psychotic disorder as Resident #38 did not have a psychotic disorder in May of 2024. 4. Resident #46 was readmitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, PTSD, anxiety, and Major Depressive Disorder. Resident #46's Annual MDS assessment, dated 3/8/25 documented under A1500 in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and or intellectual disability or related condition? However, Resident #46's record included a PASRR level II, dated 8/20/21. On 5/15/25 at 2:43 PM, the MDS Coordinator stated she misinterpreted question A1500 and should have indicated yes. 50603 5. Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including PTSD, Major Depressive Disorder, and anxiety. Resident #11's Admission MDS assessment, dated 9/9/24 documented under A1500, no selection to the question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? However, a PASRR level II, dated 9/9/24, was completed and on file in Resident #11's electronic health record (EHR.) On 5/15/25 at 2:24 PM, the MDS Coordinator stated Resident #11 did have a PASRR level II completed, and the MDS assessment should have been coded yes at A1500. 6. Resident #28 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including delusional disorders, Major Depressive Disorder, anxiety, and PTSD. Resident #28's Admission MDS assessment, dated 10/26/24 documented, No at A1500, as a response to question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? However, a PASRR level II, dated 11/3/23, was found in Resident #28's EHR. On 5/15/25 at 2:24 PM, the MDS Coordinator stated a PASRR level II was completed, and it should have been coded yes at A1500. 7. Resident #29 was admitted to the facility on [DATE], and readmitted on [DATE] with multiple diagnoses including anxiety disorder, Major Depressive Disorder, and PTSD. Resident #29's Admission MDS assessment, dated 3/17/25 did not document at A1500, Resident #29 had a PASRR level II completed. However, a PASRR level II, dated 8/22/24 and 12/2/19 were found in Resident #29's EHR. On 5/15/25 at 2:24 PM, the MDS Coordinator stated a PASRR level II was completed, and it should have been coded yes at A1500.

Based on record review, medication error reports, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 15 of 39 residents (#3, #12, #15, #16, #27, #33, #37, #39, #44, #46, #52, #57, #64, #73, and #281) reviewed for medication errors. This deficient practice created the potential for harm when residents received the wrong dosage of medications or did not receive their prescribed medications. Findings include: The facilities Procedure for Medication Errors/Omissions revised December 2015, documented a medication and treatment error report will be completed upon identification of any of the following: -wrong resident -wrong medication -wrong dose -wrong frequency -wrong route -omitted medication(s) 1. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, chronic pain syndrome, and rheumatoid arthritis. Resident #3's physician's order was for Oxycodone (opioid pain medication) 5 mg tablet by mouth twice per day for arthritic pain. a.) A Medication Error Report documented a medication error occurred on the evening of 5/31/24, when the nurse discovered she had administered 30 mg of Morphine (opioid pain medication) to Resident #3 instead of his ordered 5 mg of Oxycodone. On 5/14/25 at 11:35 AM, the DON confirmed the nurse administered Resident #3 the wrong medication when Morphine was given instead of Oxycodone. b.) A Medication Error Report documented a medication error occurred on the morning of 9/12/24, when the nurse administered Lacosamide (anti-seizure medication) 100 mg instead of the ordered Oxycodone 10 mg to Resident #3. The resident was noted to be suffering from blurry, double vision as a result of the error. On 5/14/25 at 11:40 AM, the DON confirmed the nurse administered Resident #3 the wrong medication when Lacosamide was given instead of Oxycodone. c.) A Medication Error Report documented Resident #3 did not receive the following medications on the morning of 2/25/25: -Aerobika 10-15 (treatment used to clear airway secretions) -Albuterol 2.5 mg/3 ml (nebulizer treatment to prevent or treat airway spasms) -apixaban 5 mg (anticoagulant - prevents blood clots) -baclofen 5 mg (a skeletal muscle relaxant) -Bupropion 75 mg (antidepressant) -cranberry 500 mg (herbal product) -finasteride 5 mg (used to treat enlarged prostate) -lactase 9000 units (a supplement used to treat lactose intolerance) -oxycodone 5 mg (opioid pain medication) -prazosin 2 mg (antihypertensive) -simvastatin 40 mg (lower cholesterol) -Tylenol 1000 mg (pain and fever reducer) On 5/14/25 at 11:45 AM, the DON confirmed the nurse failed to administer Resident #3 the entirety of his morning medications on 2/25/25. 2. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including mild cognitive impairment, fracture of left hip, and gout. Resident #12's physician's order was for Oxycodone 5 mg tablet by mouth twice per day for pain. The Medication Error Report documented a medication error occurred on 9/5/24, when Resident #12 did not receive his pain medication in the morning as ordered. On 5/14/25 at 11:50 AM, the DON confirmed the nurse did not administer Resident #12's morning dose of Oxycodone. 3. Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including dementia, hypertension, testicular hypofunction (a condition where the testes do not produce sufficient amounts of testosterone and/or sperm), and edema. Resident #15's physician's order was for Furosemide (Lasix) 10 mg one time a day for lower extremity edema. The Medication Error Report documented several nurses made a medication error on 5/10/24, 5/11/24, 5/12/24, 5/13/24, 5/14/24, and 5/15/24 when Resident #15 was administered Lasix 20 mg for each of the daily scheduled doses instead of the Lasix 10 mg that was ordered. On 5/14/25 at 11:55 AM, the DON confirmed the nurses administered the wrong dose of Lasix to Resident #15 for six days. 4. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, hypertension, and heart disease. The Medication Error Report documented a medication error occurred on 3/5/25, when the nurse administered Resident #16 another resident's medications. Resident #16 was noted to be suffering from drowsiness as a result of the medication error. The medications administered were: -Oxycodone 5 mg -tamsulosin 0.4 mg ( used to treat enlarged prostates in men) -gabapentin 400 mg (anti-convulsant) -Tylenol 1000 mg On 5/14/25 at 12:00 PM, the DON confirmed the nurse administered Resident #16 the wrong medications when she received another residents medications. 5. Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia and diabetes. Resident #27's physician's order was for Insulin glargine (long acting insulin) 25 units in the morning. The Medication Error Report documented a medication error occurred on 2/5/25, when the nurse administered Resident #27 Insulin NPH (70/30) (intermediate acting Insulin) in the morning. On 5/14/25 at 12:05 PM, the DON confirmed the nurse administered Resident #27 the wrong insulin on the morning of 2/5/25. 6. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (the upper chambers of the heart beat irregularly) and diabetes. Resident #33's physician's order was for diltiazem (heart medication) 90 mg for treatment of atrial fibrillation. The Medication Error Report documented a medication error occurred on 3/31/25, when the nurse failed to administer Resident #33 his diltiazem medication in the morning. On 5/14/25 at 12:10 PM, the DON confirmed the nurse failed to administer Resident #33 his prescribed dose of diltiazem on the morning of 3/31/25. 7. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, pain in knee, and Major Depressive Disorder. Resident #37's physicians order was for lorazepam (antipsychotic) 1 mg every day. The Medication Error Report documented a medication error occurred on 3/31/25, when the nurse failed to administer Resident #37 Oxycodone 5 mg instead of his ordered lorazepam. On 5/14/25 at 12:15 PM, the DON confirmed the nurse failed to administer Resident #33 his prescribed dose of lorazepam 1 mg and administered oxycodone 5 mg instead on the morning of 3/31/25. 8. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including stroke and sciatica (nerve pain that travels the longest nerve in the body). Resident #39's physician's order was for Oxycodone 2.5 mg every 6 hours as needed for pain. The Medication Error Report documented multiple medication errors occurred on 12/20/24 and 12/21/24 when multiple nurses administered Resident #39 Oxycodone 5 mg instead of the ordered 2.5 mg. On 5/14/25 at 12:20 PM, the DON confirmed the nurses failed to administer Resident #39 his prescribed dose of oxycodone 2.5 mg on 3 separate occasions between the dates of 12/20/24 and 12/21/24. 9. Resident # 44 was admitted to the facility on [DATE], with multiple diagnoses including fracture of the bone around a prosthetic hip and chronic pain. Resident #44's physician's order was for Oxycodone 5 mg every 6 hours as needed for pain. The Medication Error Report documented a medication error occurred on 5/9/24, when the nurse administered Resident #44 Oxycodone 2.5 mg instead of the ordered 5 mg. The resident was noted to be suffering from anxiety from pain and unable to rest as a result of the error. On 5/14/25 at 12:25 PM, the DON confirmed the nurse failed to administer Resident #44 his prescribed dose of Oxycodone 5 mg on 5/9/24. 10. Resident #46 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, diabetes and history of substance abuse. Resident #46's physician's order was for Oxycodone 2.5 mg three times a day for pain. The Medication Error Report documented the nurse reports she may have given Resident #46 an extra dose of Oxycodone 2.5 mg by mistake on 3/7/25. The nurse reported she had a missing dose at end of shift that day. On 5/14/25 at 12:30 PM, the DON confirmed the nurse may have given Resident #46 an extra dose of oxycodone 2.5 mg on 3/7/25. 11. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including severe dementia and diabetes. Resident # 52's physician's order was for Lantus (long acting Insulin) 25 Units in the morning. The Medication Error Report documented a medication error occurred on 2/5/25, when the nurse administered Resident #52 Insulin NPH (70/30) 25 Units. On 5/14/25 at 12:35 PM, the DON confirmed the nurse administered Resident #52 the wrong insulin on the morning of 2/5/25. 12. Resident # 57 was admitted to the facility on [DATE], with multiple diagnoses including pain in the left leg and pain in the lower back. Resident #57's physician's order was for Oxycodone 7.5 mg three times a day. The Medication Error Report documented a medication error occurred on 3/7/25, when the nurse failed to administer Resident #57 her Oxycodone 7.5 mg dose. On 5/14/25 at 12:40 PM, the DON confirmed the nurse did not know if she gave Resident #57 her scheduled dose of oxycodone 7.5 mg on 3/7/25. 13. Resident #64 was admitted to the facility on [DATE], with multiple diagnoses including Major Depressive Disorder and PTSD. Resident #64's physician's order was for bupropion 160 mg every day. The Medication Error Report documented a medication error occurred on 1/4/25 through 1/11/25 (8 days) when multiple nurses administered Resident #64 bupropion 300 mg every day instead of the ordered 150 mg. On 5/14/25 at 12:45 PM, the DON confirmed multiple nurses administered Resident #64 the wrong dose of bupropion over the span of 8 days before the error was discovered. 14. Resident #73 was admitted to the facility on [DATE], with multiple diagnoses including rhabdomyolysis (a condition that causes muscle pain) and low back pain. Resident #73's physician's order was for Oxycodone 5 mg three times a day. The Medication Error Report documented a medication error occurred on 3/7/25, when the nurse reported she was missing an extra dose of Oxycodone 5 mg, and she may have given the extra dose to Resident #73. On 5/14/25 at 12:50 PM, the DON confirmed the nurse suspected she gave Resident #73 an extra dose of his Oxycodone 5 mg on 3/7/25. 15. Resident #281 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, diabetes, and fracture of the femur. The Medication Error Report documented a medication error occurred on the morning of 10/9/24, when the nurse administered Resident #281 another residents medications. Resident #281 was noted to be suffering from somnolence as a result of the error. The medications administered were: -amlodipine 10 mg (lowers blood pressure) -Magnesium oxide 400 mg (supplement) -clopidogrel bisulfate 75 mg (antiplatelet) -wixela inhub inhalation aerosol powder 250-50 mcg/act (asthma treatment) -gabapentin 900 mg -leflunomide 20 mg (anti-inflamatory) -Risperdal potassium 2 mg (antipsychotic) -losartan potassium 50 mg (lower blood pressure) -sertraline 200 mg (antidepressant) On 5/14/25 at 12:55 PM, the DON confirmed the nurse administered Resident #281 the wrong medications on 10/9/24. On 5/14/25 at 1:00 PM, the DON stated the expectation was for the RN Manager assigned to each floor to provide education and training after a medication errror occured. She could not provide any documentation of training or education being provided after these errors.

Based on review of staff schedules, policy review, license review, and staff interview, it was determined the facility failed to ensure nursing staff possessed a license within the state where they provided care. This was true for 3 of 28 CNAs (CNA #4, CNA #5, CNA #6) and 2 of 22 Licensed nurses (LPN #1, and LPN #2) whose certifications and licenses reviewed. This deficient practice had the potential to affect all 77 residents in the facility. This failure created the potential for harm if residents received inappropriate care due to a staff lacking the required credentials to provide nursing care. Findings include: The facility's policy for Licensed Nurse Credentialing and License Verification, dated [DATE], documented the following: - Credentials and license are evaluated annually for performance appraisal for each licensed nurse. - Reverification of license is required at the intervals set by the Board of Nursing of this State. Licensed nurses are required to renew their license prior to the expiration of their license. - If the licensed nurse has not renewed their license prior to the expiration date, the nurse may not work past midnight of the expiration date of his/her current license. Review of the CNA's certification and licensed nurses currently employed documented the following: - CNA #4's certificate expired [DATE]. - CNA #5's certificate expired [DATE]. - CNA #6's certificate expired [DATE]. - LPN #1's license expired [DATE]. - LPN #2's license expired [DATE]. On [DATE] at 8:15 AM, the Administrator and DON confirmed CNA #4, CNA #5, and CNA #6's, certifications were expired, and LPN #1 and LPN #2's licenses were expired, and they should not have been working in the facility.

Based on observation, record review, policy review, I&A report review, review of Quality Assurance Performance Improvement (QAPI) meeting minutes, and staff interview, it was determined the facility failed to ensure a QAPI plan was developed and implemented. This failure impacted 15 of 39 residents (#3, #12, #15, #16, #27, #33, #37, #39, #44, #46, #52, #57, #64, #73, and #281) whose records were reviewed for medication errors and had the potential to affect the other 38 residents residing in the facility. This created the potential for harm if residents received substandard quality of care from lack of identification and correction to quality deficiencies such as medication errors, staff training, and staff certification and licensure. Findings include: The facility's QAPI Plan, undated, documented: -Use quality assurance and performance improvement to make decisions to guide day-to-day operations. -Improve the quality of care and quality of life of residents with the outcome of QAPI. -QAPI includes all employees, all departments, and all services provided. -QAPI focuses on systems and processes to identify system gaps versus individuals. -Decisions are based on data which includes the input and experiences of caregivers, residents, health care practitioners, families, and other stakeholders. -Goals are set for performance and measured progress towards those goals. The facility's QAPI Plan, dated October 2024, documented the facility's QAPI Performance Improvement Plan (PIP) goals for the 2024-2025 fiscal year. These PIP goals included: 1. Facility will reduce for Moderate/Severe pain national percentile of 93% to 80% with a final goal of 75% by 12/31/25. 2. Facility acquired pressure ulcers (PU) will be below 2% monthly by 12/31/25. 3. Facility will reduce or eliminate psychotropic medications on new admissions within 14-days post admit except when it is documented to be medically inappropriate by 12/31/25. The following records were reviewed: A. I&A reports May 2024 through May 2025: -Thirty-nine medication errors reviewed, and 15 were identified as significant medication errors. B. Staff Licensure and Certification: - Three of 28 CNAs (CNA #3, CNA #4, and CNA #5) did not have current certification. - Two of 22 Nurses (LPN #1 and LPN #2) did not have a current license. C. CNA training requirements: -Two of 28 CNAs (CNA #8 and CNA #9) did not have the 12-hr annual training. QAPI meeting attendance was reviewed, documenting monthly meetings were attended by the Medical Director, Administrator, DON, IP, Pharmacist, Activity Director, and other facility staff. On 5/16/25 at 12:59 PM, the Administrator, with the DON present, stated QAPI meetings were held monthly. The Administrator stated any concerns in the facility were brought to and discussed in the QAPI meeting. At each meeting, the Administrator stated the QAPI reports were reviewed which identified trending patterns in multiple areas including facility-initiated discharges, facility incident reports (i.e. falls, falls with injury, medication errors), wounds, catheters, elimination, infection control, antibiotic stewardship, physical restraints, mobility and ADL (activities of daily living), resident mobility safety, and therapy. The April 2025 QAPI report, reviewed at the 5/14/25, QAPI meeting documented trends from January 2025 through April 2025: -Medication errors for 2025: January - 3 errors; February - 6 errors; March - 5 errors. No PIP or QAPI Plan was documented for the medication errors. -Human resources: No documented concerns with employee certification or licensure were noted. There were no documented concerns regarding required annual nurse aid training. A review of the May 2025 meeting minutes documented: -New business updates for PIP related to UTI's and PU's to be provided the week of 5/19/25. On 5/16/25 at 1:16 PM, the DON, with the Administrator present, was asked how the QAPI meeting used the QAPI report if the metrics were not addressing the identified PIPs approved in October 2024. The DON stated, We review the [monthly] trends, medication type of error, and educate staff individually, if needed, and address the concerns immediately. However, I did not document those [trainings]. Recently, I had an Administration Medication Error in-service, but I cannot remember the date it was provided. The DON stated she should be documenting these monthly corrective action plans and staff education. The DON stated there was no documented record on file for any monthly corrective action plans. Surveyors exited the facility on 5/16/25 at 3:00 PM. No additional information was provided regarding the Administration Medication Error in-service training which had been provided to the nursing staff. The facility's QAPI program failed to provide sufficient monitoring and oversight to sustain regulatory compliance as evidenced by the citations the facility received.

Based on observation and staff interview it was determined the facility failed to ensure appropriate infection control measures were maintained. This was true when CNA #7 failed to remove personal protective equipment after coming in contact with a resident on enhanced barrier precautions, and RN#1 failed to perform hand hygiene prior to application of a clean dressing. This failed practice created the potential for adverse outcomes including infection due to cross contamination. Findings include: 1. The CDC website's article titled Consideration For Use Of Enhanced Barrier Precautions accessed on 5/23/25, documented effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care. On 5/13/25 at 9:34 AM, during a resident to staff interaction observation CNA #7 was observed leaving the shower room to take a resident back to his room while wearing a gown and a mask. CNA #7 took the resident to his room and removed her gown in his room before exiting. She then proceeded to enter the following room with her mask on to talk to another resident. On 5/13/25 at 9:40 AM, CNA #7 stated she had not been informed of the proper location to remove her gown and mask after bathing a resident on enhanced barrier precautions. She also stated her understanding of utilizing enhanced barrier precautions was to protect others if the resident may have had a contagious infection in his wound, and she should have removed the gown and mask prior to leaving the shower room. 2. The CDC website's article titled Hand Hygiene for Healthcare Workers accessed on 5/23/25, documented hand hygiene is recommended before moving from working on a soiled body site to a clean body site on the same patient. On 5/15/25 at 11:22 AM, during a wound care observation RN #1 was observed to performed hand hygiene with application of gloves. She then proceeded to remove the dirty dressing on Resident #8's left lower leg by soaking it with normal saline to discard the dressing. After the dressing was removed RN #1 cleansed the site and used gauze to pat dry. She then proceeded to apply gauze soaked in briotech (a solution used to target and eliminate bacteria as well as help new skin cell growth on wounds). RN #1 was not observed performing hand hygiene before applying the briotech. RN #1 removed her dirty gloves, performed hand hygiene, and proceeded to remove the dirty dressing from Resident #8's right lower leg. After removing the dirty dressing and cleansing with normal saline RN #3 then applied gauze soaked in briotech around the right lower leg. RN #1 was not observed performing hand hygiene before applying the briotech. RN #1 was observed once again removing her gloves performing hand hygiene and applying clean gloves. She returned to Resident #8's left lower leg removed the soaked gauze and applied the clean dry dressing around the left lower leg. RN #1 removed her gloves, performed hand hygiene, and applied gloves, she then proceeded to Resident #8's right lower leg. She removed the soaked gauze and applied the clean, dry dressing. On 5/15/25 at 12:01 RN #1 stated briotech is a clean dressing and hand hygiene should be performed prior to applying the dressing.

Based on personnel record review and staff interview it was determined the facility failed to ensure an effective training program was maintained. This was true for 3 of 5 personnel records reviewed for training requirements. This failure created the potential for adverse outcomes including harm when staff were not educated on abuse protocols and did not have the minimum required training to provide direct care to residents in the facility. Findings include: 1. On 5/15/25 at 1:17 PM, during a personnel record review CNA #8's training record documented a total of 11.80 hours was completed out of the minimum annual 12-hour requirement. 2. On 5/15/25 at 1:21 PM, during a personnel record review CNA #9's training record documented a total of 1 hour was completed out of the minimum annual 12-hour requirement. CNA #9's record did not include training for abuse and neglect, dementia care, resident rights, and effective communication. On 5/16/25 at 10:01 AM, the Staff Development Coordinator stated CNA #8 and CNA #9 did not complete the training required and should have. 3. On 5/16/25 at 10:45 AM, Housekeeper #1 stated she had been employed with the facility for 2 years and had not received any abuse and neglect training. She also stated if she witnessed or heard a resident being abused, she would not intervene but would notify a supervisor or the nurse on shift. The facility was unable to provide documentation Housekeeper #1 received abuse and neglect training. On 5/16/25 at 11:28 AM, the DON stated Housekeeper #1 did not have any abuse and neglect training but she should have.

Based on policy review, record review, review of the State Agency's Long-Term Care Reporting Portal, review of I&As, and staff interview, it was determined the facility failed to ensure a resident was free from abuse. This was true for 1 of 5 residents (Resident #56) reviewed for abuse. This failure created the potential for residents to experience ongoing abuse and potential harm. Findings include: The facility's Freedom from Abuse, Neglect and Exploitation policy, revised February 2020, documented each resident has the right to be free from exploitation, verbal, sexual, physical and mental abuse, serious bodily injury, corporal punishment, and involuntary seclusion. A review of the State Agency's Long-Term Care Reporting Portal, documented Resident #56 experienced abuse from the staff as follows: 1. A facility investigation report, received on 11/26/24, documented that on 11/19/24 at 10:15 PM, CNA #1 was observed standing in front of Resident #56 with his hands on Resident #56's upper arms and pushed him forcefully back down into the recliner and yelled Sit down. The facility's investigation report documented the facility's Abuse Response Team conducted an investigation where five staff where interviewed. One of the staff interviewed reported that [name of the CNA #1] does overall want to make sure everything gets completed, and everyone is cared for, I believe. He can get flustered when residents may not wish to do what he has asked of them. I think he doesn't always have the creativity to think of a different approach, as he gets focused on getting the cares done. The investigation report substantiated the abuse of Resident #56 and CNA #1 was not allowed to return to the facility. A review of CNA #1's record documented CNA #1 resigned from his employment from the facility effective 12/15/24. 2. A facility investigation report, received on 1/30/25, documented CNA #2 physically restrained Resident #56 who was attempting to self-transfer. Investigation was conducted and staff and residents were interviewed. One of the staff who witnessed the incident reported CNA #2 yelled that Resident #56 was going to fall and he needed help moving him over to his recliner. The staff stated she helped CNA #2 to sit Resident #56 in his chair. When Resident #56 was seated to his recliner, he tried to get up out of the recliner. CNA #2 pushed Resident #56 back to his recliner and used the controls to elevate the footrest and recline the chair. CNA #2 then sat down next to Resident #56 and when Resident #56 continued to try to get up out of the chair CNA #2 put his elbow and arm over Resident #56's left arm to keep him down in the chair. Another staff reported [name of CNA #2] was not good with 1:1 situations. We all know this. The investigation report substantiated the allegation CNA #2 restrained Resident #56. On 5/15/25 at 12:43 PM, the DON stated CNA #2 was put on administrative leave, and after the investigation the abuse was substantiated. The DON stated even though the intention of CNA #2 was to prevent Resident #56 from falling, he restrained Resident #56. The DON stated CNA #2 was no longer working in the facility. On 5/15/25 at 2:50 PM, the Administrator stated he was the abuse coordinator. He stated abuse training was being provided to the staff upon hire and annually thereafter. The Administrator stated CNA #1 and CNA #2 were no longer employed in the facility. A review of CNA #2's record documented he was dismissed from his employment in the facility effective 2/18/25. Based on the corrective action taken by the facility and no incidents of staff to resident abuse and neglect after 2/18/25, the facility was cited for past non-compliance.

Based on State Operation Manual Appendix PP, record review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a new major mental illness. This was true for 1 of 11 residents (Resident #46) reviewed for PASRR level II evaluations. This deficient practice had the potential to cause harm if the residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority to provide coordinated care. Findings include: The State Operation Manual Appendix PP revised on 8/8/24, documented if a PASRR level I identified a major mental illness, an in-depth evaluation, known as a PASRR level II evaluation is completed by the state-designated authority, which must be completed prior to admission to a nursing facility. Resident #46 was readmitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, PTSD, anxiety, and Major Depressive Disorder. Resident #46's PASRR level I, dated 8/20/21, documented PTSD disorder as a major mental illness. It also documented depression as a mental disorder. However, the PASRR level I did not document bipolar disorder as a major mental illness or anxiety as a mental disorder. On 5/16/25 at 10:25 AM, the Social Worker #1 stated a new PASRR level I should have been completed to reflect Resident #46's diagnoses and have him properly evaluated for further mental health services.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 2 of 18 residents (#17 and #52) whose care plans were reviewed. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The CMS SOM, Appendix PP, dated 8/8/24 documented a resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. 1. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including dementia, anxiety, and PTSD. Resident #52's physician's orders documented: -Quetiapine (antipsychotic) was discontinued on 2/24/25. -Trazodone (antidepressant used as a sleep aid) was discontinued on 2/24/25. Resident #52's care plan, initiated on 8/29/23 and revised on 8/29/24, documented resident used the psychotropic drug Quetiapine. Resident #52's care plan initiated on 2/14/25 documented resident used the psychotropic drug Trazodone. On 5/15/25 at 4:11 PM, RN Manager #1 confirmed Resident #52's care plan should have been updated to reflect a change in physician's orders when Quetiapine and Trazodone were discontinued, and it did not. 50603 2. Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including obesity and below the knee amputation. On 5/13/25 at 11:30 AM, Resident #17's bed was observed parallel to the window with the headboard facing the wall. There was an 18-inch gap between the side of the bed and the window. A physical restraint consent, dated 6/23/23, and 9/26/23, documented the right side of the bed should be placed against the wall. Resident #17's care plan, dated 6/23/23, documented Resident #17 had mobility and fall risk interventions to include having the right side of the bed against the wall so the resident would feel safe and comfortable. On 5/15/25 at 3:35 PM, RN Manager #2 stated Resident #17 had moved rooms on 4/7/25, where his bed was placed parallel to the window. RN Manager #2 confirmed Resident #17's care plan had not been updated since his move to the new room on 4/7/25.

Based on record review and staff interview it was determined the facility failed to ensure professional standards of practice were followed for 2 of 2 residents (Resident #38, #43) reviewed for bowel management. This failure created the potential for adverse outcome when standards of practice were not followed for bowel management. The CDC website's article titled, Guidelines on Bowel Care, accessed on 5/21/25 recommended that long-term care facilities prioritize bowel care and implement practices to prevent and manage constipation and other bowel-related issues, especially in residents at risk. This includes proactive strategies for residents with bowel incontinence or constipation. 1. Resident #38 was readmitted to the facility on [DATE], with multiple diagnoses including mild cognitive impairment and hemorrhoids. Resident #38's care plan, revised 11/25/19, directed staff to offer bowel interventions and encourage Resident #38 to sit on the toilet to promote bowel movements. Resident #38's MAR, dated 3/1/25 - 5/14/25 documented the following physician's order: - Colace capsule 100 mg by mouth in the morning for constipation and hemorrhoids. Discontinued on 5/14/25. - Senna oral tablet give 17.2 mg by mouth every 12 hours for constipation. Discontinued on 5/14/25. - MiraLax Oral powder give 1 scoop by mouth as needed for constipation one time a day. - Bisacodyl oral tablet give 10 mg by mouth as needed for no documented bowel movement following administration of milk of magnesia. Resident #38's MAR did not include a physician's order for milk of magnesia. Resident #38's bowel record, dated 3/1/25 - 5/14/25, documented no bowel movement on the following dates: 3/1- 3/3 (3-days) 3/6-3/9 (4-days) 3/13-3/16 (4-days) 3/18-3/23 (6-days) 3/26-3/29 (4-days) 4/4-4/7 (4-days) 4/26-4/29 (4-days) 5/6-5/13 (8-days) Resident #38's record did not document additional bowel management interventions when Resident #38 did not have a bowel movement for 3 or more consecutive days. 2. Resident #43 was readmitted to the facility on [DATE], with multiple diagnoses including dementia and constipation. Resident #43's care plan, revised 8/3/24, directed staff to monitor bowel movements and offer dietary bowel interventions. Resident #43's MAR did not include physician's orders for bowel management. Resident #43's bowel record, dated 3/1/25 - 5/14/25 documented no bowel movement on the following dates: 3/10-3/12 (3-days) 3/18-3/22 (5-days) 3/26-3/29 (4-days) 4/1-4/4 (4-days) 4/25-4/27 (3-days) 5/11-5/13 (3-days) On 5/15/25 at 9:01 AM, the DON stated the Licensed Nurse should obtain an order for bowel management and implement the order into the residents MAR for documentation. On review of Resident #38 and Resident #43's records, the DON stated there was no documentation Resident #38 and Resident #43 received bowel interventions when they did not have a bowel movement for 3 or more consecutive days.

Based on record review, policy review, and staff interview, it was determined the facility did not ensure residents were free from chemical restraints. There was no documented evidence a systematic process of evaluation and care planning was utilized for staff to first implement resident-specific focused non-pharmacological interventions should residents demonstrate aggressive behaviors. This resulted in harm to 1 of 6 residents (Resident #261) reviewed for [MEDICAL CONDITION] drug use. Resident #261 was harmed when he experienced increased somnolence, sedation, and a decline in ADL's as a result of multiple [MEDICAL CONDITION] medications. Findings include: A facility policy, Mood and Behavior Medication Review Committee, undated, documented the committee identified and evaluated residents use of medication for behaviors or mood and the committee would determine the appropriate interventions and ensure consents, orders, and care plans were completed. The facility's ADL Behavior Monitor flowsheets documented the following behaviors for each resident in the facility, wandering, verbal abusive, physical abusive, socially inappropriate behavior, resistive or rejection of care, or there were no behaviors. The facility's ADL Mood Symptoms Monitor flowsheets documented the following behavior for each resident in the facility, little interest or pleasure in doing things, feeling or appearing down/depressed, trouble falling asleep or staying asleep, feeling tired, poor appetite or overeating, feeling bad about themselves, trouble concentrating, moving extremely slow and speaking slow so that others notice, suicidal ideation's, and short tempered. The facility did not identify resident specific behaviors for staff to monitor. Resident #261 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A significant change MDS assessment, dated 6/7/18, documented Resident #261 was severely cognitively impaired and he was totally dependent or required extensive assistance from one to two staff members with cares. The MDS documented Resident #261 had signs and symptoms of mild depression and he exhibited delusions and hallucinations. The MDS documented Resident #261 had physical, verbal, and other behaviors 4-6 days a week. The MDS documented he did not wander or reject cares. Resident #261's (MONTH) (YEAR) Physician order [REDACTED]. Scheduled medications: [REDACTED] - [MEDICATION NAME] (anticonvulsant) 500 mg by mouth one time a day for Lewy bodies dementia with hallucinations and agitation, ordered on [DATE] and discontinued the same day. - [MEDICATION NAME] (antidepressant) 15 mg at bedtime for depression and [MEDICAL CONDITION], ordered on [DATE] and discontinued on 6/1/18. - [MEDICATION NAME] (antipsychotic) 200 mg at bedtime for dementia with hallucinations, ordered on [DATE] and discontinued on 5/23/18. - [MEDICATION NAME] 100 mg two times a day for dementia with hallucinations, ordered on [DATE] and discontinued on 5/23/18. - [MEDICATION NAME] 300 mg at bedtime for dementia with hallucinations, ordered on [DATE] and discontinued on 5/31/18. - [MEDICATION NAME] (anticonvulsant) 25 mg at bedtime for unstable mood, ordered on [DATE] and discontinued on 6/12/18. - [MEDICATION NAME] (antidepressant) 200 mg one time a day for depression, ordered on [DATE] and discontinued on 6/1/18. PRN medications: [REDACTED] - [MEDICATION NAME] (sedative and antianxiety) 1 mg intramuscularly (IM) one time only for extreme anxiety, ordered on [DATE]. - [MEDICATION NAME] 1 mg IM one time only for Lewy bodies dementia related to [MEDICAL CONDITION], ordered on [DATE]. - [MEDICATION NAME] 1 mg IM one time only for Lewy bodies dementia related to [MEDICAL CONDITION], ordered on [DATE]. - [MEDICATION NAME] 0.5 mg IM one time only for extreme anxiety, ordered on [DATE]. - [MEDICATION NAME] 1 mg intramuscularly every 24 hours PRN for agitation, ordered on [DATE] and discontinued on 6/4/18. - [MEDICATION NAME] (narcotic) 5 mg every 6 hours PRN for pain, ordered on [DATE] and discontinued on 6/12/18. - [MEDICATION NAME] 100 mg one time only for dementia with hallucinations, ordered on [DATE]. - Trazadone (sedative and antidepressant) 25 mg every 8 hours PRN for anxiety, ordered on [DATE] and discontinued on 5/23/18. - Trazadone 50 mg every 8 hours PRN for anxiety, ordered on [DATE] and discontinued on 6/12/18. Resident #261 received 2 antidepressant medications, [MEDICATION NAME] and [MEDICATION NAME], daily from 4/2/18 to 6/1/18, and 1 antipsychotic medication, [MEDICATION NAME], daily from 4/24/18 to 5/31/18. Two medications, [MEDICATION NAME] and [MEDICATION NAME], were prescribed for hallucinations according to the MAR indicated [REDACTED]. Additionally, the medications [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME] had sedative effects. Resident #261's (MONTH) (YEAR) Physician order [REDACTED]. Scheduled medications: [REDACTED] - [MEDICATION NAME] 1 mg/ml by mouth three times a day for agitation, ordered on [DATE] and discontinued on 6/6/18. - [MEDICATION NAME] 1 mg/ml by mouth two times a day for agitation, ordered on [DATE] and discontinued the same day. - [MEDICATION NAME] 1 mg/ml by mouth every eight hours for agitation, ordered on [DATE] and discontinued on 6/14/18. - [MEDICATION NAME] (antianxiety) 0.5 mg by mouth two times a day for comfort and [MEDICAL CONDITION] control, ordered on [DATE] and discontinued on 6/6/18. - [MEDICATION NAME] extended release 500 mg by mouth at bedtime for Lewy bodies dementia with hallucinations and agitation, ordered on [DATE] and discontinued on 6/12/18. - [MEDICATION NAME] 50 mg two times a day for dementia with hallucinations, ordered on [DATE] and discontinued on 6/12/18. - [MEDICATION NAME] 200 mg at bedtime for dementia with hallucinations, ordered on [DATE] and discontinued on 6/12/18. - [MEDICATION NAME] 25 mg at bedtime for unstable mood, ordered on [DATE] and discontinued on 6/12/18. PRN medications: [REDACTED] - [MEDICATION NAME] 0.5 mg by mouth every 2 hours PRN for agitation, ordered on [DATE] and discontinued on 6/5/18. - [MEDICATION NAME] 0.5 mg by mouth every hour PRN for agitation, ordered on [DATE] and discontinued on 6/14/18. - [MEDICATION NAME] 1 mg IM every 24 hours PRN for agitation, ordered on [DATE] and discontinued on 6/4/18. - [MEDICATION NAME] 1 mg IM every 24 hours PRN for agitation, ordered on [DATE] and discontinued on 6/14/18. - [MEDICATION NAME] (narcotic) 10 mg sublingually every 2 hours PRN for pain and air hunger, ordered on [DATE] and discontinued on 6/14/18. - [MEDICATION NAME] 5 mg every 6 hours PRN for pain, ordered on [DATE] and discontinued on 6/12/18. - Trazadone 50 mg every 8 hours PRN for anxiety, ordered on [DATE] and discontinued on 6/12/18. Resident #261's antidepressants, [MEDICATION NAME] and [MEDICATION NAME], were discontinued and he had 2 antianxiety medications added to be taken daily, [MEDICATION NAME] and [MEDICATION NAME]. He also had PRN orders for [MEDICATION NAME], and a new order for [MEDICATION NAME] for pain. Additionally, the medications [MEDICATION NAME], [MEDICATION NAME], and Trazadone had sedative effects. Resident #261's care plan did not include specific behaviors and did not identify or include depression and anxiety. Resident #261's care plan addressed cognition, dated 3/27/18, and documented he had impaired cognition related to [DIAGNOSES REDACTED] and was rarely understood and had difficulty understanding. The care plan did not document how his dementia presented. Resident #261's care plan area addressing elopement risk, dated 4/13/18, and documented he verbalized wanting to leave the facility and wandered the facility. Interventions included Resident #261 had a roam alert bracelet on his wheelchair, dated 4/13/18, and staff were to provide 1:1 supervision until Resident #261 stopped attempting to leave the facility, dated 5/26/18. The care plan did not include identification of behaviors associated with the 1:1 intervention initiated on 5/26/18. The care plan area addressing Resident #261's behaviors and mood, dated 6/28/17, documented he was cognitively impaired and had dementia. The care plan documented he had behavioral issues with hallucinations and delusions. The care plan documented Resident #261 had suicidal ideation, hit staff, and screamed. Resident #261's care plan did not identify if Resident #261's hallucinations and or delusions were tactile (touch), visual, auditory, and olfactory (smell)), was not resident specific and did not document clearly how his hallucinations or delusions presented. The care plan did not document if his hallucinations or delusions were harmful to him. Resident #261 did not have a care plan for his anxiety or his depression. The facility did not identify how Resident #261's anxiety, agitation, or depression presented. Resident #261's Sleep Monitors, MAR, and Progress Notes documented Resident #261's hours of sleep increased as the medications were added, and he experienced falls and increased confusion with the medication changes. Examples include: - Resident #261's Sleep Monitor for 5/2/18 MAR indicated [REDACTED]. Resident #261's Trazadone was ordered for anxiety and not sleep. - A Progress note, dated 5/14/18 at 9:39 PM, documented Resident #261 was agitated and continued to ambulate without his wheelchair or assistance and PRN Trazadone was provided at 2:53 PM. The note documented Resident #261 needed 1:1 staff supervision from 1:00 PM to 9:00 PM and a light duty staff member was only available from 4:00 PM to 6:00 PM. Resident #261's care plan was not updated to include the need for 1:1 staff supervision on 5/14/18, and it was unclear if he was to have a 1:1 CNA present for the duration of time between 1:00 PM and 9:00 PM. - A Progress Note, dated 5/19/18 at 5:15 AM, documented Resident #261 experienced an unwitnessed fall in his room while attempting to walk in his room. - A Progress Note, dated 5/22/18 at 1:39 PM, documented Resident #261 had increased behaviors of hitting staff, aggression, paranoia and was not redirectable. The note documented he spoke in word salad (gibberish) and appeared in distress. The note documented pharmacy recommended increasing his [MEDICAL CONDITION] medications, [MEDICATION NAME] and Trazadone, and Resident #261's spouse agreed. Resident #261's clinical record did not document an episode of physical abusive behaviors occurring on 5/22/18. The behavior monitoring documented he experienced one behavior of being physically abusive for the month of May, on 5/21/18. - A Progress note, dated 5/22/18 at 2:43 PM, documented Resident #261 was easily frustrated and angry at nursing staff. The note documented he wanted to leave the facility and attempted to pick up items off the floor that were not there. The note documented he yelled at staff when they attempted to assist him to the restroom during the day, and later in the evening he was unable to bear weight to transfer onto a toilet and was resistive when they attempted to assist him into bed due to sleepiness. - A Progress Note, dated 5/23/18 at 5:45 AM, documented Resident #261 experienced a witnessed fall in the TV room. The note documented Resident #261 was sitting in his wheelchair and he was leaning to the side and fell out of his wheelchair before the staff member sitting next to him could stop it. The note documented Resident #261 was up all night and was assisted into a recliner chair using a Hoyer lift, and he immediately fell asleep. Resident #261's 5/23/18 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. There was 13 minutes between the PRN [MEDICATION NAME] and PRN [MEDICATION NAME], and Trazadone doses. According to the Nursing 2019 Drug Handbook, [MEDICATION NAME] by IM injection take up to 60 minutes to take effect. According to the Nursing 2019 Drug Handbook [MEDICATION NAME], Trazadone, and [MEDICATION NAME] side effects include sedation, confusion, [MEDICAL CONDITION], dizziness, and drowsiness. The staff did not provide adequate time for the anxiety medication administered to take effect before administering another two [MEDICAL CONDITION] medications and a pain medication. - A Progress Note, dated 5/23/18 at 11:05 PM, documented Resident #261 was provided PRN [MEDICATION NAME] at 2:25 PM and at 10:06 PM and they were effective with relieving pain from his fall. The note documented he was anxious the majority of the shift and rested for a few hours after dinner while his 1:1 supervision CNA was with him. Resident #261's care plan was not updated to include the need for 1:1 staff supervision on 5/23/18, and it was unclear if he was to have a 1:1 CNA. The 5/23/18 note documented the IM [MEDICATION NAME] was not initially effective and PRN Trazadone, [MEDICATION NAME], and [MEDICATION NAME] were administered. The same note documented at 10:30 PM Resident #261 was asleep and snoring in the common area. The note documented Resident #261 required the assistance of 2 staff members with a Hoyer lift for all transfers during the remainder of the shift. - A Progress Note, dated 5/27/18 at 3:00 AM, documented Resident #261 woke up and he was calling out he wanted to use the bathroom and go home. Resident #261 was unable to stand up and comprehend instructions with using the mechanical lift and required 3 CNAs to assist with the transfer. He was given a dose of PRN Trazadone related to anxiety, which was ineffective. Resident #261 was moved to the nurses' station and continued to call out. The note documented a 1:1 sitter was not available for the night shift and a staff member assigned to a different unit volunteered to assist as Resident #261's 1:1 for 1-2 hours. Resident #261 was administered a PRN IM [MEDICATION NAME] dose at 3:22 AM. There was no documentation describing how Resident #261's anxiety presented. - A Progress Note, dated 6/1/18 at 8:15 AM, documented Resident #261 experienced a witnessed fall in the common room. The note documented Resident #261 was attempting get out of a recliner chair and sat on the footrest causing it to collapse to the floor. The note documented a new care plan intervention was implemented of a 1:1 staff member. It was unclear if Resident #261's 1:1 staff was near him at the time of the fall, or if the 1:1 was currently in place as care planned on 5/26/18. - A Progress Note, dated 6/2/18 at 10:38 AM, documented a conversation between Resident #261's physician and nursing staff from 5/31/18 through 6/1/18. The note documented Resident #261's [MEDICAL CONDITION] medications were adjusted. The note documented on 5/31/18 at 11:52 AM, Resident #261 had not slept for 2 days and an IV [MEDICATION NAME] was provided per the physician's orders [REDACTED]. - A Progress Note, dated 6/4/18 at 10:41 AM, documented Resident #261 had increased confusion and was restless and picked up unseen items on the floor. The note documented he had a change in his previous normal pattern of behavior with an increase in negative behaviors and increased confusion and agitation. Resident #261's 6/4/18 MAR indicated [REDACTED]. According to the Nursing 2019 Drug Handbook, [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME] side effects include anxiety, irritability, agitation, hostility, anger, sedation, confusion, [MEDICAL CONDITION], dizziness, and drowsiness. - A Progress Note, dated 6/5/18 at 3:00 AM, documented Resident #261 was with a 1:1 staff member for safety. The note documented he was agitated and fidgety. The note documented Resident #261 was rubbing his knees for possible pain and attempted to rise from his bed frequently. The note documented he was provided PRN [MEDICATION NAME] for possible pain and later PRN [MEDICATION NAME] for cont (inued) wakefulness/agitation. Resident #261's 6/5/18 MAR indicated [REDACTED]. Resident #261's (MONTH) (YEAR) MAR indicated [REDACTED]. Examples include: - On 5/2/18, the MAR indicated [REDACTED]. Resident #261's Trazadone was ordered for anxiety, not sleep. - Resident #261's MAR indicated [REDACTED]. - Resident #261's MAR indicated [REDACTED]. - Resident #261's MAR indicated [REDACTED]. - Resident #261's MAR indicated [REDACTED]. Resident #261's (MONTH) (YEAR) MAR indicated [REDACTED]. Examples include: - Resident #261's Sleep Monitor for 6/4/18 documented he slept 8 hours during the 24 hour period. - Resident #261's Sleep Monitor for 6/5/18 documented he slept 9 hours during the 24 hour period. - Resident #261's Sleep Monitor for 6/6/18 documented he slept 16 hours during the 24 hour period. - Resident #261's Sleep Monitor documented he slept 11 hours on 6/7/18, 16 hours on 6/8/18, 21 hours on 6/9/18, 16 hours on 6/10/18, 21 hours on 6/11/18, and 24 hours on 6/12/18 and 6/13/18. On 11/9/18 at 10:19 AM, LMSW #1 stated Resident #261 was actively delusional, he experienced hallucinations, and was paranoid of people trying to do bad things to him. LMSW #1 stated the medications were managed by a psychiatrist. LMSW #1 stated he received alerts from staff when a resident was experiencing increased behaviors and the GDR committee evaluated the residents from the alerts. LMSW #1 stated the CNA behavior monitors did not include hallucinations and delusions, but staff documented these in the MDS and throughout the progress notes. LMSW #1 stated [MEDICAL CONDITION] medications could increase a resident's fall risk and the facility did not provide PRN [MEDICAL CONDITION] medications when a 1:1 staff member was unavailable. LMSW #1 stated staff provided PRN medications when a resident's behavior exhibited. LMSW #1 stated the specific behavior the resident exhibited should be documented in their clinical record for any PRN [MEDICAL CONDITION] medication administration. LMSW #1 stated the care plan should identify resident specific behaviors for dementia, hallucinations, and delusions and if they were harmful. The LMSW #1 stated the current behavior monitors were helpful with gathering information in addition to the alerts he received along with the resident MDS. On 11/9/18 at 12:23 PM, the DON stated according to the care plan Resident #261 was to have a 1:1 staff member with him on 5/26/18. The DON stated he may have been provided a 1:1 for short durations before that time. The DON stated the facility did not provide PRN [MEDICAL CONDITION] medications when a 1:1 staff member was unavailable, only when residents' behaviors increased. The DON stated the behavior monitors were not resident specific and the staff documented specific instances throughout the progress notes. The DON stated when the GDR team met the team reviewed each resident's behaviors and evaluated items such as sleep and what the team discussed was documented on the GDR note.

Based on observation, staff interview, record review, and facility policy review, it was determined the facility failed to a) attempt GDR of [MEDICAL CONDITION] medications, b) monitor behavioral symptoms, c) obtain informed consents for the medications, and d) identify resident specific behaviors on the care plan. This was true for 4 of 6 residents (#2, #30, #87, and #261) reviewed for unnecessary medications. This resulted in harm to Resident #261 when he experienced increased somnolence, sedation, and a decline in ADL's as a result of multiple [MEDICAL CONDITION] medications. This deficient practice also had the potential for harm of other residents if they receive unnecessary [MEDICAL CONDITION] medications which were not adequately monitored. Findings include: A facility policy Mood and Behavior Medication Review Committee, undated, documented the committee identified and evaluated residents use of medication for behaviors or mood and the committee would determine the appropriate interventions and ensure consents, orders, and care plans were completed. The facility's ADL Behavior Monitor flowsheets documented the following behaviors for every resident in the facility, wandering, verbal abusive, physical abusive, socially inappropriate behavior, resistive or rejection of care. The facility's ADL Mood Symptoms Monitor flowsheets documented the following behavior for every resident in the facility, little interest or pleasure in doing things, feeling or appearing down/ depressed, trouble falling asleep or staying asleep, feeling tired, poor appetite or overeating, feeling bad about themselves, trouble concentrating, moving extremely slow and speaking slow so that others notice, suicidal ideation, and short tempered. The facility did not have resident specific behaviors for staff to monitor. a. Resident #261 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A significant change MDS assessment, dated 6/7/18, documented Resident #261 was severely cognitively impaired and he was totally dependent or required extensive assistance from one to two staff members with cares. The MDS documented Resident #261 had signs and symptoms of mild depression and he exhibited delusions and hallucinations. The MDS documented Resident #261 had physical, verbal, and other behaviors 4-6 days a week. The MDS documented he did not wander or reject cares. i. Resident #261's (MONTH) (YEAR) Physician order [REDACTED]. Scheduled Medications: - [MEDICATION NAME] (anticonvulsant) 500 mg by mouth one time a day for Lewy bodies dementia with hallucinations and agitation, ordered on [DATE] and discontinued the same day. - [MEDICATION NAME] (antidepressant) 15 mg at bedtime for depression and [MEDICAL CONDITION], ordered on [DATE] and discontinued on 6/1/18. - [MEDICATION NAME] (antipsychotic) 200 mg at bedtime for dementia with hallucinations, ordered on [DATE] and discontinued on 5/23/18. - [MEDICATION NAME] 100 mg two times a day for dementia with hallucinations, ordered on [DATE] and discontinued on 5/23/18. - [MEDICATION NAME] 300 mg at bedtime for dementia with hallucinations, ordered on [DATE] and discontinued on 5/31/18. - [MEDICATION NAME] (anticonvulsant) 25 mg at bedtime for unstable mood, ordered on [DATE] and discontinued on 6/12/18. - [MEDICATION NAME] (antidepressant) 200 mg one time a day for depression, ordered on [DATE] and discontinued on 6/1/18. PRN Medications: - [MEDICATION NAME] (sedative and antianxiety) 1 mg intramuscularly (IM) one time only for extreme anxiety, ordered on [DATE]. - [MEDICATION NAME] 1 mg IM one time only for Lewy bodies dementia related to [MEDICAL CONDITION], ordered on [DATE]. - [MEDICATION NAME] 1 mg IM one time only for Lewy bodies dementia related to [MEDICAL CONDITION], ordered on [DATE]. - [MEDICATION NAME] 0.5 mg IM one time only for extreme anxiety, ordered on [DATE]. - [MEDICATION NAME] 1 mg intramuscularly every 24 hours PRN for agitation, ordered on [DATE] and discontinued on 6/4/18. - [MEDICATION NAME] (narcotic) 5 mg every 6 hours PRN for pain, ordered on [DATE] and discontinued on 6/12/18. - [MEDICATION NAME] 100 mg one time only for dementia with hallucinations, ordered on [DATE]. - Trazadone (sedative and antidepressant) 25 mg every 8 hours PRN for anxiety, ordered on [DATE] and discontinued on 5/23/18. - Trazadone 50 mg every 8 hours PRN for anxiety, ordered on [DATE] and discontinued on 6/12/18. Resident #261 received 2 antidepressant medications, [MEDICATION NAME] and [MEDICATION NAME], daily from 4/2/18 to 6/1/18, and 1 antipsychotic medication, [MEDICATION NAME], daily from 4/24/18 to 5/31/18. Two medications, [MEDICATION NAME] and [MEDICATION NAME], were prescribed for hallucinations according to the MAR documentation. He also had orders for 2 antianxiety medications PRN, [MEDICATION NAME] and Trazadone. Additionally, the medications [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME] had sedative effects. Resident #261's (MONTH) (YEAR) Physician order [REDACTED]. Scheduled Medications: - [MEDICATION NAME] 1 mg/ml by mouth three times a day for agitation, ordered on [DATE] and discontinued on 6/6/18. - [MEDICATION NAME] 1 mg/ml by mouth two times a day for agitation, ordered on [DATE] and discontinued the same day. - [MEDICATION NAME] 1 mg/ml by mouth every eight hours for agitation, ordered on [DATE] and discontinued on 6/14/18. - [MEDICATION NAME] (antianxiety) 0.5 mg by mouth two times a day for comfort and [MEDICAL CONDITION] control, ordered on [DATE] and discontinued on 6/6/18. - [MEDICATION NAME] extended release 500 mg by mouth at bedtime for Lewy bodies dementia with hallucinations and agitation, ordered on [DATE] and discontinued on 6/12/18. - [MEDICATION NAME] 50 mg two times a day for dementia with hallucinations, ordered on [DATE] and discontinued on 6/12/18. - [MEDICATION NAME] 200 mg at bedtime for dementia with hallucinations, ordered on [DATE] and discontinued on 6/12/18. - [MEDICATION NAME] 25 mg at bedtime for unstable mood, ordered on [DATE] and discontinued on 6/12/18. PRN Medications: - [MEDICATION NAME] 0.5 mg by mouth every 2 hours PRN for agitation, ordered on [DATE] and discontinued on 6/5/18. - [MEDICATION NAME] 0.5 mg by mouth every hour PRN for agitation, ordered on [DATE] and discontinued on 6/14/18. - [MEDICATION NAME] 1 mg IM every 24 hours PRN for agitation, ordered on [DATE] and discontinued on 6/4/18. - [MEDICATION NAME] 1 mg IM every 24 hours PRN for agitation, ordered on [DATE] and discontinued on 6/14/18. - [MEDICATION NAME] (narcotic) 10 mg sublingually every 2 hours PRN for pain and air hunger, ordered on [DATE] and discontinued on 6/14/18. - [MEDICATION NAME] 5 mg every 6 hours PRN for pain, ordered on [DATE] and discontinued on 6/12/18. - Trazadone 50 mg every 8 hours PRN for anxiety, ordered on [DATE] and discontinued on 6/12/18. Resident #261's antidepressants, [MEDICATION NAME] and [MEDICATION NAME], were discontinued and he had 2 antianxiety medications added to be taken daily, [MEDICATION NAME] and [MEDICATION NAME]. He also had PRN orders for [MEDICATION NAME], and a new order for [MEDICATION NAME] for pain. Additionally, the medications [MEDICATION NAME], [MEDICATION NAME], and Trazadone had sedative effects. ii. Resident #261's 5/1/18 through 6/14/18 MAR documented he was administered a PRN [MEDICAL CONDITION] medication, Trazadone or [MEDICATION NAME], within 0 to 15 minutes of a PRN pain medication, [MEDICATION NAME] or [MEDICATION NAME], being administered. Examples include: - [MEDICATION NAME] and Trazadone were administered together on 5/23/18 at 2:25 PM and 10:06 PM, 5/24/18 at 3:45 PM, 5/30/18 at 12:33 AM, and 6/4/18 at 3:30 AM. - [MEDICATION NAME] and [MEDICATION NAME] were administered together on 6/2/18 at 1:12 PM, 6/3/18 at 10:45 AM, and 6/5/18 at 3:03 PM. - [MEDICATION NAME] and Trazadone were administered together on 6/6/18 at 4:00 AM. - [MEDICATION NAME] and [MEDICATION NAME] were administered together on 6/1/18 at 1:30 PM, 6/3/18 at 1:40 PM, 6/3/18 at 4:10 PM, 6/4/18 at 6:30 AM, 9:35 AM, and 12:15 PM, 6/6/18 at 3:07 PM, 5:07 PM, and 9:15 PM, 6/10/18 at 10:01 PM, 6/11/18 at 3:32 PM, and 6/12/18 at 1:50 PM. According to the Nursing 2019 Drug Handbook, [MEDICATION NAME] by IM injection takes 15-30 minutes to take effect and when given orally it takes 1 hour. Additionally, the Nursing 2019 Drug Handbook stated [MEDICATION NAME], Trazadone, and [MEDICATION NAME] side effects include sedation, confusion, [MEDICAL CONDITION], dizziness, and drowsiness. This occurred 21 times on 12 days, from 5/23/18 to 6/12/18. The staff did not allow adequate time for the pain medication or the antianxiety medication administered to take effect. It was unclear if Resident #261 was anxious or in pain. According to the Nursing (YEAR) Drug Handbook the side effects for [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME] included sedation, confusion, [MEDICAL CONDITION], dizziness, and drowsiness. The progress notes for Resident #261 for the above listed dates and times included documentation he received [MEDICATION NAME] or Trazadone PRN for agitation and/or anxiety. The progress notes did not include documentation of how Resident #261's agitation and/or anxiety presented or specific behaviors related to his agitation and/or anxiety. iii. Resident #261's (MONTH) (YEAR) Behavior flowsheet documented he experienced the following behaviors: - Wandering- 3 episodes on 5/6/18, 5/17/18, and 5/20/18 - Physically abusive- 1 episode on 5/21/18 - Resistive or rejection of care- 2 episodes on 5/22/18 and 5/23/18 Resident #261's 6/1/18 through 6/13/18 Behavior flowsheet documented he experienced the following behaviors: - Physically abusive- 1 episode on 6/3/18 - Resistive or rejection of care- 1 episodes on 6/2/18 Resident #261's progress notes did not correlate with his Behavior Monitoring flowsheets for (MONTH) and (MONTH) of (YEAR). Examples include: - A Progress note, dated 5/14/18 at 9:39 PM, documented Resident #261 was agitated and continued to ambulate without his wheelchair or assistance and a PRN Trazadone was provided at 2:53 PM. The note documented Resident #261 needed 1:1 staff supervision from 1:00 PM to 9:00 PM and a light duty staff member was only available from 4:00 PM to 6:00 PM. Resident #261's care plan was not updated to include the need for 1:1 staff supervision on 5/14/18, and it was unclear if he was to have a 1:1 CNA present for the duration of time between 1:00 PM and 9:00 PM. - Progress Notes, dated 5/23/18 at 2:25 PM, documented Resident #261 was provided a PRN Trazadone for anxiety and calling out and excessive movement in his wheelchair, PRN [MEDICATION NAME] for pain, and [MEDICATION NAME] was given early to help with calming anxiety. There was no documentation of Resident #261 calling out or other behaviors related to anxiety in the behavior monitor flowsheet. Additionally, the progress note did not include a description how his anxiety presented. A subsequent Progress Note, at 11:05 PM on 5/23/18, documented Resident #261 woke up at 8:50 PM and was combative, agitated, and refused his bedtime medications by spitting them out at the nurse. The note documented Resident #261 was also kicking and hitting the nurse and CNAs. Resident #261 refused drink and food and was assisted to the common area to sit in a recliner for better observation by staff. The note documented he required 1:1 supervision because Resident #261 attempted to transfer himself and was constantly repositioning himself in the recliner. The note documented Resident #261 was anxious during most of the shift and rested for a few hours after dinner while his 1:1 supervision CNA was with him. The note documented IM [MEDICATION NAME] was not initially effective and PRN Trazadone, [MEDICATION NAME], and [MEDICATION NAME] were administered to help settle his [MEDICAL CONDITION]/anxiety. The note did not include a description of how Resident #261 presented with [MEDICAL CONDITION] or anxiety. The Behavior Monitoring flowsheet documented Resident #261 was resistive to cares, there was no documentation related to his [MEDICAL CONDITION], anxiety, or hitting and kicking at staff. The MAR documented he was administered a PRN dose of [MEDICATION NAME] IM at 9:53 PM and at 10:06 PM, 13 minutes later, he was administered a dose of PRN Trazadone and PRN [MEDICATION NAME]. At 10:13 PM, 7 minutes later, he was administered a dose of PRN [MEDICATION NAME]. The staff did not provide adequate time for the antianxiety medication to take effect before administering another 2 [MEDICAL CONDITION] medications and a pain medication. - A Progress Note, dated 5/24/18 at 10:53 PM, documented Resident #261 was pleasant and cooperative for most of the shift. The note documented he was administered a PRN pain and antianxiety medication for an increase in symptoms/suspected pain, with successful result. The note documented at 6:45 PM, Resident #261 was restless, yelled and hit staff, and attempted to self-transfer out of his chair, and his scheduled [MEDICATION NAME], and [MEDICATION NAME] did not decrease his anxiety. The note documented the physician ordered a one-time dose of IM [MEDICATION NAME] which was given and he calmed down afterwards and was observed sleeping in a recliner chair. There was no documentation in his Behavior Monitoring flowsheet Resident #261 hit staff or he exhibited other behaviors. - A Progress Note, dated 5/27/18 at 3:00 AM, documented Resident #261 woke up and he was calling out he wanted to use the bathroom and go home. Resident #261 was unable to stand up and comprehend instructions with using the mechanical lift and required 3 CNAs to assist with the transfer. He was given a dose of PRN Trazadone related to anxiety, which was ineffective. Resident #261 was moved to the nurses' station and continued to call out. The note documented a 1:1 sitter was not available for the night shift and a staff member assigned to a different unit volunteered to assist as Resident #261's 1:1 for 1-2 hours. Resident #261 was administered a PRN IM [MEDICATION NAME] dose at 3:22 AM. There was no documentation describing how Resident #261's anxiety presented. - A Progress Note, dated 6/4/18 at 10:41 AM, documented Resident #261 had increased confusion and was restless and picked up unseen items on the floor. The note documented he had a change in his previous normal pattern of behavior with an increase in negative behaviors and increased confusion and agitation. Resident #261's 6/4/18 MAR documented he was administered a dose of PRN [MEDICATION NAME] and PRN [MEDICATION NAME] at 12:15 PM, a dose of PRN Trazadone at 2:00 PM, and a dose of PRN IM [MEDICATION NAME] at 2:40 PM. The Behavior Monitoring flowsheet did not include documentation of behaviors or an increase in behaviors. There was also no documentation in the Behavior Monitoring flowsheet about how Resident #261 exhibited agitation. iv. Resident #261's care plan did not include specific behaviors and did not identify or include depression and anxiety. Resident #261's care plan addressed cognition, dated 3/27/18, and documented he had impaired cognition related to [DIAGNOSES REDACTED] and was rarely understood and had difficulty understanding. The care plan did not document how his dementia presented. Resident #261's care plan area addressed elopement risk, dated 4/13/18, and documented he verbalized wanting to leave the facility and wandered the facility. Interventions included Resident #261 had a roam alert bracelet on his wheelchair, dated 4/13/18, and staff were to provide 1:1 supervision until Resident #261 stopped attempting to leave the facility, dated 5/26/18. The care plan did not include identification of behaviors associated with the 1:1 intervention initiated on 5/26/18. The care plan area addressing Resident #261's behaviors and mood, dated 6/28/17, documented he was cognitively impaired and had dementia. The care plan documented he had behavioral issues with hallucinations and delusions. The care plan documented Resident #261 had suicidal ideation, hit staff, and screamed. Resident #261's care plan did not identify if Resident #261's hallucinations and or delusions were tactile (touch), visual, auditory, and olfactory (smell)), was not resident specific and did not document clearly how his hallucinations or delusions presented. The care plan did not document if his hallucinations or delusions were harmful to him. Resident #261 did not have a care plan for his anxiety or his depression. The facility did not identify how Resident #261's anxiety, agitation, or depression presented. v. Resident #261's MAR and Progress Notes documented his hours of sleep increased as medications were added. The care plan area addressing Resident #261's sleep cycle, dated 6/19/17, documented he was taking medications daily to assist him with sleep. The care plan documented staff were to monitor Resident #261's hours of sleep at night and staff were to encourage him to maintain his home routine of going to bed at 8:00 PM and waking at 6:00 AM. Resident #261's (MONTH) (YEAR) MAR documented he was sleeping from 3 hours to 16 hours a day and averaged 9 hours daily. Examples include: - On 5/2/18, the MAR documented he slept 11 hours. A progress note, dated 5/2/18, documented Resident #261 was administered a PRN Trazadone as he was unable to sleep and settle down. Resident #261's Trazadone was ordered for anxiety, not sleep. - Resident #261's MAR documented he slept 9 hours during the 5/8/18 evening shift. - Resident #261's MAR documented for the night shift on 5/23/18 he slept 7 hours, and during the day shift on 5/24/18 he slept for 4 hours. - Resident #261's MAR documented for the night shift on 5/27/18 he slept 7 hours, and during the day shift on 5/28/18he slept for 4 hours. - Resident #261's MAR documented he slept for 10 hours on 5/29/18, on 5/30/18 he slept 7 hours, and on 5/31/18 he slept 10 hours during the 24 hour period. Resident #261's (MONTH) (YEAR) MAR documented he was sleeping from 7 to 24 hours a day and averaging 15 hours daily. Examples include: - Resident #261's Sleep Monitor flowsheet for 6/4/18 documented he slept 8 hours during the 24 hour period. - Resident #261's Sleep Monitor flowsheet for 6/5/18 documented he slept 9 hours during the 24 hour period. - Resident #261's Sleep Monitor flowsheet for 6/6/18 documented he slept 16 hours during the 24 hour period. - Resident #261's Sleep Monitor flowsheet documented he slept 11 hours on 6/7/18, 16 hours on 6/8/18, 21 hours on 6/9/18, 16 hours on 6/10/18, 21 hours on 6/11/18, and 24 hours on 6/12/18 and 6/13/18. vi. Resident #261's GDR did not review specific behaviors or evaluate his sleeping habits. Resident #261's Quarterly GDR review, dated 6/6/18, documented Resident #261 was on [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME]. The GDR review documented he was on these medications for sleep and behavioral disturbances with [DIAGNOSES REDACTED]. The review documented Resident #261 had hallucinations, increased paranoia, and was on hospice and the committee recommended no changes to his medication regime. The review did not evaluate Resident #261 for how many episodes/behaviors of hallucinations, depression, and or anxiety he experienced during the look back period. The GDR review did not include an evaluation of the increase in the hours he slept. The review did not include an evaluation what his hallucination or paranoia looked like or identify what other behaviors he was experiencing and how they were harmful to him. On 11/9/18 at 10:19 AM, LMSW #1 stated Resident #261 was actively delusional and paranoid of people trying to do bad to him. LMSW #1 stated the medications were being managed by a Psychiatrist and he experienced hallucinations as well. b. Resident #30 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 8/13/18, documented Resident #30 was severely cognitively impaired and had no signs and symptoms of depression. The MDS documented he did not exhibit inappropriate behaviors, hallucinations, delusions, rejection of cares, or wandering. Resident #30's (MONTH) (YEAR) Physician order [REDACTED].>- [MEDICATION NAME] 5 mg by mouth in the afternoon and evening for dementia, ordered 10/22/18. - Trazadone 100 mg at bedtime for [MEDICAL CONDITION], ordered 4/2/18. - Trazadone 25 mg in the afternoon for anxiety, ordered 10/19/18. - [MEDICATION NAME] 5 mg twice daily for arthritis pain, ordered 9/28/18. The care plan area addressing Resident #30's sleep cycle, dated 3/9/17, documented he was taking medications daily to assist him with sleep. The care plan documented staff were to monitor Resident #30's hours of sleep at night. The care plan area addressing Resident #30's behaviors/cognition, revised 5/23/18, documented he was cognitively impaired and had dementia. The care plan documented Resident #30 was angry and frustrated at times. It did not specifically describe how Resident #30's dementia presented. Resident #30's care plan did not include specific goals and interventions related to his anxiety and did not describe how his anxiety presented. Resident #30's Quarterly GDR review, dated 9/13/18, documented Resident #30 was receiving [MEDICATION NAME] and Trazadone. The GDR review documented he was taking the medications for sleep and dementia. The review documented Resident #30 had poor safety awareness and had several falls. The review documented he exhibited anxiety by leaning forward in his Broda chair. The review documented the committee recommended decreasing Resident #30's [MEDICATION NAME] to 5 mg in the afternoon and 2.5 mg before bed. This was completed and then the medication was increased back to 5 mg twice daily on 10/29/18, when the physician discontinued another [MEDICAL CONDITION] medication ([MEDICATION NAME], an antidepressant). Resident #30's GDR did not include a review of specific behaviors or evaluate his sleeping habits. Resident #30's 8/1/18 through 11/7/18 Behavior Monitoring flowsheets documented he did not exhibit behaviors. The review did not evaluate the number of behaviors and/or symptoms of anxiety Resident #30 experienced during the look back period, to assess the ongoing need for the medications. Resident #30's 10/1/18 through 11/6/18 MAR documented he was sleeping from 11 to 21 hours a day and averaging 16 hours daily. On 11/6/18 from 9:50 AM to 10:39 AM, Resident #30 was observed sitting in his Broda chair (tilt-in-space positioning chair) asleep and snoring. Resident 30 was observed asleep in his Broda chair on 11/6/18 at 2:28 PM, 11/7/18 at 11:00 AM and 4:20 PM, and 11/8/18 at 7:00 AM. On 11/9/18 at 9:56 AM, LMSW #1 stated Resident #30's specific behavior was wandering into other residents' rooms. LMSW #1 stated Resident #30's dementia presented as confusion and increased anxiety. LMSW #1 stated Resident #30 should have a care plan for anxiety and his dementia care plan should describe how his behaviors presented. LMSW #1 stated missing information in Resident #30's care plan made it difficult for contracted agency staff to observe for those behaviors and document them. c. Resident #2 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #2's quarterly MDS assessment, dated 7/21/18, documented his cognition was severely impaired, and family or representative participated in the assessment. The MDS documented Resident #2 received antipsychotic and antidepressant medications on a routine basis and documented target behaviors. The MDS target behaviors included delusions, physical, verbal, and other behaviors 1-3 days a week. Resident #2's care plan related to his behavior and mood, dated 5/3/17, did not identify resident specific behaviors or include interventions related to Resident #2's depression, [MEDICAL CONDITION], and anxiety. The care plan included Resident #2's dementia, dated 2/20/18, but did not document how his dementia presented or interventions related to the dementia. Resident #2's physician's orders [REDACTED]. The orders included monitoring the number of hours of sleep every shift for [MEDICAL CONDITION], and to observe Resident #2 for side effects every shift related to the use of antidepressant and antipsychotic medications. Resident #2's Quarterly Mood/Behavior Medication Review, dated 8/7/18, listed his [DIAGNOSES REDACTED]. The review included a section for antidepressant medications and the date initiated. Under this section [MEDICATION NAME] Oxalate and Trazadone were listed. The review documented Trazadone was used for anxiety and [MEDICAL CONDITION]. Under another section for antipsychotic medications [MEDICATION NAME] was listed. The Trazadone was indicated for [MEDICAL CONDITION] not anxiety according to his physician orders. The Quarterly Review documented Resident #2 had an increase in aggression directed toward other residents and staff over the past few weeks. There was no documentation how it was determined his aggression increased. The Quarterly Review documented the IDT was unable to determine other causes for Resident #2's increased aggression beyond dementia and [MEDICAL CONDITION]. Resident #2's record did not include a [DIAGNOSES REDACTED]. Resident #2's Behavior and Mood Monitoring Flowsheets, dated 10/1/18 through 11/8/18, monitored each shift for general behaviors and mood symptoms. The flowsheets included a section for response to interventions and effectiveness of the interventions, but they were not specific to Resident #2. The flowsheets did not document the effectiveness of Resident #2's use of [MEDICAL CONDITION] medications and did not identify the behaviors to monitor related to the use of [MEDICAL CONDITION] medications. d. Resident #87 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS assessment, dated 9/29/18, documented Resident #87 had severe cognitive impairment. Resident #87's physician orders, dated 11/7/18, documented his medication duloxetine (a medication used to treat depression and pain) was increased from 20 mg orally every day to 60 mg each day. Resident #87's current care plan documented he experienced pain, difficulty concentrating, fear of others causing him harm, and changes in sleep patterns. Resident #87's care plan lacked specific behaviors staff were to monitor Resident #87 for and lacked interventions related to the use of the psychoactive medication, duloxetine. On 11/8/18 at 1:25 PM, the Pharmacist confirmed the facility failed to develop and implement a resident specific care plan that described resident specific behaviors and included inventions related to Resident #87's use of duloxetine. On 11/8/18 at 10:44 AM, the DON stated she looked for resident specific behaviors and where they may be located. The DON stated residents' sleep habits were evaluated in the GDR meetings verbally and a resident's behaviors were discussed. The DON stated the current GDR form did not document the conversation that took place for the residents. On 11/9/18 at 10:19 AM, LMSW #1 stated he received alerts from staff when a resident was experiencing increased behaviors and the GDR committee evaluated trends from the alerts. LMSW #1 stated the CNA Behavior Monitoring flowsheets did not include hallucinations and delusions, but staff documented these in the MDS and throughout the progress notes when they were seen by staff. LMSW #1 stated [MEDICAL CONDITION] medications could increase a resident's fall risk and the facility did not provide PRN [MEDICAL CONDITION] medications when a 1:1 staff member was unavailable. LMSW #1 stated staff provided the PRN medications when a resident exhibited behaviors. LMSW #1 stated the specific behavior the resident exhibited should be documented in their clinical record for any PRN [MEDICAL CONDITION] medication administered. LMSW #1 stated the care plan should identify resident specific behaviors for dementia, hallucinations, and delusions and if they were harmful. LMSW #1 stated the current behavior monitors were helpful with gathering information in addition to the alerts he received and the MDS. On 11/9/18 at 12:23 PM, the DON stated according to the care plan Resident #261 was to have a 1:1 staff member with him on 5/26/18. The DON stated he may have been provided a 1:1 for short durations before that. The DON stated the facility would not provide PRN [MEDICAL CONDITION] medications when a 1:1 staff member was unavailable, only when residents' behaviors increased. The DON stated the behavior monitors were not resident specific and the staff documented specific instances throughout the progress notes. The DON stated in the GDR meeting the team reviewed each residents' behaviors and evaluated items such as sleep, and what the team discussed was documented in the GDR note

Based on interview, record review, review of facility abuse policy, State of Idaho Contract, and review of contracted agency policies, it was determined the facility failed to ensure all employees received appropriate training of abuse protocols in a timely manner; This failure to ensure all staff had been trained in abuse prevention, identification, response, and reporting, placed all residents of the facility in immediate jeopardy for possible abuse. The immediate jeopardy was identified 1/22/16 and was on-going. On 2/3/16, the facility provided an acceptable abatement plan, and on 2/5/16 at 10:50 am, an onsite visit to the facility confirmed the jeopardy was abated. Findings included: 1. On 1/19/16 at 1:15 pm, a Housekeeper (E8) identified she had not received education upon hire regarding abuse protocols. E8 revealed she was unable to differentiate between physical abuse and neglect. On 1/21/16 at 10:30 am, the DSS stated Housekeeping was a contracted service and the facility was not responsible for training contracted employees on abuse. On 1/21/16 at 11:30 am, the contracted Director of Housekeeping stated abuse in-servicing was provided annually and was due in February 2016. He said he did not provide abuse training upon hire, but employees received an employee handbook explaining resident rights. Review of the Employee Handbook at identified that it did not address regulatory requirements for abuse training. The Employee Handbook contained one page addressing consideration, dignity and respect, privacy, use and quiet enjoyment of his/her room, planning of total care and medical treatment, resident council, resident financial affairs, and confidentiality. None of the documents contained information related to the identification, prevention, response, or reporting of instances of potential abuse or neglect. On 1/21/16 at 2:10 pm, the HRA stated the facility did not maintain abuse training records for contracted employees as that this was the responsibility of the contracted company rather than the facility. On1/21/16 at 2:25 pm, the Administrator stated, The contracted employees are not the responsibility of this facility. On 1/21/16 at 3:00 pm, E5 stated he was provided an Employee Handbook upon hire in June 2015, but received no formal abuse training. When asked to define various forms of abuse, E5 stated he did not know the definition of mental abuse. E5 stated he was concerned because minutes before this interview he received a brief abuse training, but could not remember it. He stated he had been asked to sign a paper attesting that he received the Employee Handbook when he had only just been given a copy. E5 stated he could not recall the information when asked about it by a surveyor. The contract between the Idaho Department of Administration and the Department of Veterans Services, documented The contractor shall ensure that Contractor's staff is trained in the following: The Contractor and Contractor's employees are required to physically participate in and attend all in-services provided by the Home that concern subject relevant to the scope of work under the Agreement. Contract shall provide translator or trainer acceptable to the Home, at Contractor's sole cost and expense, if the Contractor's staff cannot participate in and understand training conducted in English. The Home shall, in its sole discretion, identify the in-services that concern subject relevant to the scope of work under the Agreement. Attendance at such in-services shall be at the Contractor's expense. The facility's Policy for Abuse documented, The (facility) is committed to protecting our residents from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual. (The facility) has a zero tolerance policy for resident mistreatment, neglect, abuse, or misappropriation of resident property. On 1/22/16 at 2:00 pm, the HRA said the facility could not provide a list of contracted staff working in the facility because the facility did not maintain records on any contracted personnel. The facility's Policy for Abuse documented, The (facility) conducts a through screening of all new employees before they are hired. (The facility) will not knowingly employ any individual who has been convicted of a crime that could adversely affect their relationship with fell ow employees, residents, or families. All new staff personnel, volunteers, and potential admission(s) will be screened. Training on issues related to abuse prevention practices commences with the employee's orientation and continues on a regular basis throughout the employee's tenure at (the facility).

Based on a complaint from the general public, record review, staff interview, and a review of the facility's [MEDICAL CONDITION] screening procedure, it was determined the facility failed to ensure physician orders [REDACTED]. This was true for 2 of 24 residents sampled (#s 12 and 23). Resident #23 was not given [MEDICATION NAME] ordered on [DATE] until 12/11/10. Resident #12 was admitted to the facility with orders for a chest x-ray to rule out [MEDICAL CONDITION], however the facility failed to ensure the resident was assessed as ordered and the resident was discharged from the facility nearly three weeks later without the x-ray having ever taken place. This failure to follow physician orders [REDACTED]. Findings include: 1. A complaint from the general public filed 12/14/10 with the Idaho Department of Health and Welfare, Bureau of Facility Standards, alleged that the facility failed to adequately manage [MEDICAL CONDITION]. Resident #23 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident's 5-day admission MDS assessment, dated 11/29/10, documented the resident did not receive any diuretic medications in the preceding seven days. The resident's Nutritional Status CAA, dated 11/22/10 and signed by the facility's Registered Dietitian on 12/6/10, documented, "[MEDICAL CONDITION]/HTN ([MEDICAL CONDITION]/Hypertension)-treated with therapeutic diet and medication. May have fluid/weight shifts." An Admit Assessment/Nursing form, dated 11/22/10 at 12:00 p.m., documented that Resident #23 had [MEDICAL CONDITION] to the "BLE (Bilateral Lower Extremities)," however the area reserved to record a measurement of the resident's [MEDICAL CONDITION] was left blank. Resident #23's handwritten Admission Physician order [REDACTED]. A Preliminary Care Plan, dated 11/22/10 at 12:30 p.m., did not include "problem, goal, or approaches (interventions)" documentation related to "fluid/weight shifts," [MEDICAL CONDITION], or diuretic therapy. The resident had been ordered upon admission on 11/22/10 to receive a NAS/NCS (no added salt/no concentrated sweets) diet. A comprehensive Resident Plan of Care, dated 12/7/10, did not include documentation related to "fluid/weight shifts," [MEDICAL CONDITION], or diuretic therapy. Daily (except 11/24/10) Medicare A Skilled Charting forms, dated 11/23/10 through 12/10/10, documented the resident was assessed with [REDACTED]. The following was documented on the Medicare A Skilled Charting forms: * 12/1/10: "2+ BLE. Refusing to elevate LE's." * 12/2/10: "2+ BLE. Refuses to elevate BLE's." * 12/7/10: "2+ BLE. Ref(uses) to elevate BLE. Refusing to talk about compression type stockings. 'I don't wear those.'" Nursing Progress Notes (NPN) reviewed in the resident's medical records at the facility documented the following: * 11/22/10 - 1:00 p.m.: "Lung sounds have crackles and are diminished throughout.... no SOB (shortness-of-breath)." * 11/22/10 - 3:00 p.m.: "Admit skin assessment performed today.... 1+ [MEDICAL CONDITION] noted to BLE. Res(ident) denies use of compression stockings." * 11/26/10 - 1:00 a.m.: "No c/o (complaints of) SOB." NOTE: A Physician's Progress Note, dated 12/1/10, documented, "Lungs: no wheezes today. No definite crackles. Asthma. Really not wheezing right now and this does not seem to be the cause of her dry cough or oxygen requirement at present." NPN, continued- * 12/3/10 - 11:00 a.m.: "(No) c/o SOB." * 12/4/10 - 9:00 p.m.: "1+ to 2+ (bilateral) pedal [MEDICAL CONDITION] noted." * 12/5/10 - 9:45 a.m.: "Rsdt (Resident) on no routine [MEDICATION NAME] regimen. Does have PRN APAP order (with one) dose used in past 5 days. Dose used was for LE (lower extremity) discomfort." NPN, continued- * 12/9/10 - 3:10 p.m.: "Noted some expiration wheezing of (right) upper lobe (after Physical Therapy) this a.m. Order received from (resident's physician/facility medical director) for [MEDICATION NAME] 20 mg PO QD (daily).... Will monitor X72 (hours after) start of meds for a/e (adverse effects), [MEDICAL CONDITION], SOB, wheezing." A Physician Telephone Order, dated 12/9/10, documented that the physician ordered the resident to receive [MEDICATION NAME], 20 mg, daily, and potassium-chloride 10 mEq (miliequivalents) daily. * 12/10/10 - 11:45 a.m.: "Unable to provide or administer newly ordered meds as (pharmacy name) has not delivered ordered meds." NOTE: Resident #23's December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No [MEDICATION NAME] was given on 12/10/11. This constituted a 40-hour delay in implementing the [MEDICATION NAME] order. NPN, continued- * 12/11/10 - 1:20 a.m.: "Cont(inue) on [MEDICATION NAME] (without) adverse effects." * 12/11/10 - 9:15 a.m.: "2+BLE [MEDICAL CONDITION] noted." * 12/11/10 - 10:10 a.m.: "Rec'd (Received) phone call from (hospital) re: (Resident #23) was in ER (emergency room ) (with) family to be evaluated by ER physician .... (hospital) staff did tell me resident was being evaluated by (hospital physician) for 'falls and [MEDICAL CONDITION].'" * 12/11/10 - 1:10 p.m.: "Rec'd phone call from (hospital), resident will be admitted to (hospital).... for [MEDICAL CONDITIONS]." On 1/4/11, Resident #23's hospital medical records for 12/11/10 through 12/13/10 were requested from the hospital by surveyors. The following documents were reviewed: emergency room Report: * 12/11/10 - 9:42 am.: The report documented vital signs; tests ordered, and chest x-ray to determine [MEDICAL CONDITION] status; resident's weight; ambulatory oximetry; and "[MEDICATION NAME], 40 mg," by "SIVP (slow intravenous push)." emergency room Physician Assessment Note: * 12/11/10 - 10:00 a.m.: "Extremities: Massive BLE [MEDICAL CONDITION] pitting below knees, fullness above knees, symmetric." * 12/11/10 - 10:08 a.m.: Assessment: [MEDICAL CONDITION] due to diastolic dysfunction. Weight increased 12 lb since discharge on 11/22 ... I am recommending that she be admitted now to stabilize her [MEDICAL CONDITION]." NOTE: Though the Nutritional Status CAA, dated 11-22-10, stated "May have fluid/weight shifts" there was no evidence in NPNs that the resident's weight increase of 12 pounds in 21 days had been noted. On 12/30/10, at 12:15 p.m., the DON was interviewed about management of the resident's [MEDICAL CONDITION]. No further information was received. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Also, he was noted to have an allergy to PPD (purified protein derivative) [MEDICATION NAME], a [MEDICAL CONDITION] (TB) skin test. Resident #12's Admission physician's orders [REDACTED]." Resident #12's clinical record was reviewed; however, a chest x-ray report was not found. On 1/3/11 at 2:20 p.m., Resident #12 was observed ambulating independently in his room, a 4 bed ward with 3 other residents living in the room. On 1/4/11 from 7:30 to 7:40 a.m., the resident was observed eating breakfast in the main dining room. At 8:55 a.m., he was observed ambulating independently in the hallways by the main dining room. And, at 11:55 a.m., he was also observed in the main dining room. On 1/4/11 at 2:00 p.m., the resident was observed in his room. Resident #12 said he was going to take a nap and that he found out that he was "moving out sometime tomorrow." On 1/5/11 at 9:25 a.m., the 2-West Unit Manager (UM) was interviewed regarding the chest x-ray to rule out TB. The 2-West UM stated that when Resident #12 was admitted , a chest x-ray was requested at the specified medical center. The 2-West UM stated however, that the specified medical center "does not and will not" accept chest x-ray orders for a resident living in the facility. The UM also stated that a chest x-ray request was sent to another local medical center but because the resident was scheduled to transfer to a residential care center they "did not proceed with it." The 2-West UM stated the resident had no signs or symptoms, such as a cough, and they "felt it was the best route because (the specified medical center) will do the chest x-ray once he is in the residential care." The surveyor requested the facility's TB policy and procedure. On 1/5/11, Resident #12 was transferred to Residential Care. On 1/6/11, the 2-West UM provided the facility's Residents-[MEDICAL CONDITION] procedure. It documented in part: "1. Residents shall be screened for infection with M. ([DIAGNOSES REDACTED])[MEDICAL CONDITION] on admission. ... B. Residents with a history of a positive skin test shall be screened by a chest x-ray..." On 1/6/11 at 4:30 p.m., the 2-West UM provided a chest x-ray report, dated 6/24/10, that concluded, "Normal chest examination, without [MEDICAL CONDITION]." The UM stated she had received the report that day, from a "sister" facility (in another town). She stated that because the resident "has not been out of our system" the report was acceptable. The 2-West UM stated, "I don't know why we didn't think of this before." On 1/6/11 at 5:00 p.m., the Administrator, Assistant Administrator, and DON were informed of the issue. No further information was received from the facility. Resident #12, who moved about independently among other residents, including 3 residents with whom he shared a room, was in the facility for 20 days without having a chest x-ray done, as ordered on admission, to rule out TB.